Some Comments on the Idiographic Interpretation of Rorschach Findings Carl B. Gacono & Jason M. Smith

        The utility of the Comprehensive System Rorschach rests in the proven relationships between its variables/indices, personality functioning, and real-world behaviors. While the reliability and validity of Comprehensive System data (CS; Exner, 2003; also CS-R; Fontan & Andronikof, 2022) is well established (Gacono & Evans, 2008), other supplemental Rorschach scoring systems also add to understanding our patients (Meloy, Acklin, Gacono, Murray, & Peterson, 1997). Previously, we discussed the importance of anchoring all Rorschach data within a nomothetic context (Gacono & Smith, 2021b). In this article, we discuss a strategy for interpreting the individual protocol.

Introduction:

        Consistent with Rorschach’s (1921/1942) intent, “an attempt is made to get at least one answer to every plate, though suggestion in any form is, of course, avoided” [p.16]), the Comprehensive System (CS; Exner, 2003; Comprehensive System-Revised [CS-R]; Fontan & Andronikof, 2022) administration procedures are ideally suited for allowing the natural variation in R needed for interpretation (Gacono, 2019). While most responses are scored during the administration, the final scoring may require comparison with data in the CS Workbook (Exner, 2001). The CS coding is used to generate a sequence of scores and structural summary1 that provide patterns for understanding the patient’s personality functioning.

        Various core indices such as R, Lambda, and EB aid in understanding the personality of the patient, provide a template for interpreting other variables, and establish the limits of a protocol’s validity. Elevated R is expected in several sexually deviant samples where internal dysphoria presses for expression. High Lambda (mostly Pure F) may reflect characterological constriction, emotional impoverishment or even defensiveness (Gacono & Gacono, 2008). An ambitent EB style predicts that the patient will become overwhelmed when confronted with internal or external stressors. In-depth analysis begins after variations in R and Lambda are understood and fully explained.

        While all CS and other supplemental systems have been validated with external criteria (real world behavior; Exner, 2003) many also contain a certain amount of “face” or “mathematical” validity. For example, the relationship between reflections/egocentricity ratio and self-focus was validated through several studies (Exner, 2003; Gacono, 1988, 1990). Subjects who produced greater numbers of reflection responses produced higher scores on the Self-Focus Sentence Completion test, tended to look at themselves in the mirror more often, and belonged to groups where narcissism was evident (Exner, 2003; see also Gacono & Meloy, 1994; Smith, Gacono, & Cunliffe, 2019). Face validity linking reflections (mirroring) to self-focus is found in the myth of narcissus who languished by a pool of water unable to pull himself away from his own reflection (see Gacono & Meloy, 1994). Some Vistas being associated, in certain clinical groups, with failed narcissism (Gacono, Meloy, & Heaven, 1990) is also apparent. The Vista (shading with

        1 Supplemental systems have included object relations (Blatt & Lerner, 1983; Fisher & Cleveland, 1958; 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; Gacono & Smith, in press), and thought organization (Athey, 1974; Meloy & Singer, 1991). Also see Bornstein and Masling (2005), Kissen (1986), Kwawer, Lerner, Lerner, and Sugarman (1980), Lerner and Lerner (1988), and Lerner (1991).

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depth) involves an internal self-focus, albeit an unpleasant one--gazing inward in a painful manner. It is less expected in personalities with normal self-esteem regulation or in those whose grandiosity is effective in warding off threats to esteem. It is not a stretch to conceptualize MOR content responses as being associated with something unpleasant, such as depression, and from an object relations perspective, in some cases, representing a damaged sense of self.

        The critical Lambda variable contains both face and mathematical validity (Gacono, 2019). Lambda is computed as L = F/(R-F). Consequently, the higher the Lambda the lower the occurrence of determinants other than Pure F (simple math). While many interpretations have been offered for high Lambda (Gacono, & Gacono, 2008), other than conscious defensiveness, most can all be couched in terms of difficulties with and/absence of/or avoidance of emotion. Face validity is also present in the Pure F response as representing perceptual accuracy minus affect. Note that historically, the F+% (no longer provided in the CS or CS-R; see Table 2) offers a variable where perceptual accuracy without emotions can be quickly compared to perceptual accuracy with affect (X+%).

        All idiographic findings are anchored within a nomothetic context (comparison with relevant clinical and non-clinical groups; Exner, 2003; Gacono & Evans, 2008; Gacono & Smith, 2021b). For example, how does this “depressed” patient compare to inpatient depressives (DEPI)? To non-patients? What does the protocol data reveal about this patient’s uniqueness within various clinical groups? This comparison with both clinical and non-patient groups allows for hypotheses concerning both the nature and position of the patient’s personality issues. As Rorschach wrote, “It must be noted that there has been constant checking of the observations on normal subjects against observations of patients and vice versa.” (p.13). In this regard, the CS/CS-R, unlike the R-PAS, has both an extensive research base and more than adequate normative, clinical2, and forensic comparative data3 (Exner, 2001, 2003, 2007; Gacono & Evans, 2008; Smith et al., 2021). The CS has also 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, 2015) as compared to any other Rorschach system.

In this article, we discuss how one interprets the Rorschach.

Underlying Scientific Principles of Interpretation:

        In order to integrate Rorschach data into the evaluation process, the examiner must determine which variables and indices are associated with the personality issues relevant to a referral question or clinical issue. Will the nature of thinking difficulties (X-%; WSum6) aid in diagnosis and treatment? Does impulsivity or poor affect modulation (FC:CF+C; Pure C) contribute to the patient’s behaviors? Is depression present (DEPI) and indicate the need for a psychiatric consultation? The examination of Rorschach data continues the process of hypothesis formation begun during record review and clinical interview. In a reciprocal fashion, confirmation of the Rorschach findings is found within the history of the patient and statements during the clinical interview. The relationship between Rorschach data and real-

        2 The CS Workbooks (4th & 5th edition; Exner, 1995, 2001) include 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 available for over 2061 CS administered forensic protocols (Gacono & Evans, 2008; Gacono & Meloy, 1994; Gacono & Smith, 2021a; Smith et al., 2021).

        3 The CS is the only Rorschach System with adequate nomothetic data for applied usage. 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.

world behavior becomes uniquely apparent when providing test feedback during a process like Therapeutic Assessment (Finn, 2020).

Essential caveats for Rorschach interpretation include:

1. All disorders are inherently dimensional (comprised of cluster[s] of specific traits). When present in sufficient quantities and the proper combinations these traits reach a threshold that constitute a category (syndrome or disorder; diagnosis). For the most part, Rorschach variables measure traits, not disorders or diagnoses (i.e., Reflection responses do not equal psychopathy but rather self-focus). Specific disorders emerge from a composite of Rorschach variables4.

1. The interpretation of Rorschach variables 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, Gacono & Smith, 2021).

1. Rorschach data means what it means (Weiner, 2003), it does not lie. However, the relative health or pathology of a variable must be assessed within the context of the entire protocol with considerations for gender and developmental issues. For example, FD (introspection) produced with FQ- and an accompanying ALOG in a protocol with poor reality testing and thinking difficulties, would not suggest healthy introspection. In the same fashion, a FC:CF+C of 1:5, while normative for a 5-year-old, is not for an adult. Yet in both cases the ratio, it suggests poor affect modulation.

1. Rorschach patterns aid in ferreting out sub-groups within any clinical syndrome. For example, while reflection responses may be present in one sub-group of male psychopaths (all of which are narcissistic as measured by PCL-R Factor 1), not all psychopaths produce reflections (Gacono & Meloy, 1994; Gacono, Meloy, & Bridges, 2008; Gacono & Smith, 2021a).

1. The accuracy of Rorschach findings is dependent on proper administration (Gacono, Evans, & Viglione, 2008; Gacono & Smith, 2021a). Poor administration, particularly inquiry, can result in reliable scoring within a compromised protocol. Poor inquiry is particularly impactful on the production of shading variables, tending to reduce their frequency (see also Gacono, Evans, et al., 2008; Ritzler & Nalesnik, 1990).

Interpreting the Individual Protocol: Where to Start?

        While various search strategies have been offered (Exner, 2003; Weiner, 2003), the most efficient is guided by the referral question or clinical/forensic issue. These vary dependent on the assessment context. Clinical contexts include issues such as the presence of a thought disorder, affective issues (including depression), interpersonal functioning, treatment planning, and so forth. Forensic contexts seek information related to psycho-legal issues occur within a forensic context (criminal or civil) to aid the trier of fact in determining a

4 A recent article demonstrates the importance of anchoring findings within comparative non-patient data (Gacono & Smith, 2021c). MPs (male psychopaths) had less indices of affect then FPs (female psychopaths). Both groups were found to be emotionally explosive (Pure C, MP, M = 0.70; FP, M = 1.07; non-patients, 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.

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specific outcome. The Rorschach has been used extensively with issues such as competency to stand trial (Gray & Acklin, 2008), mental state at the time of the offense (Acklin, 2008), violence risk assessment (Gray, Meloy, & Jumes, 2008), tort and employment litigation (Smith, 2008), death penalty mitigation (Kaser-Boyd, 2008), professional fitness to practice (Stacy, Graham, & Athey, 2008), personality functioning related to parenting (Evans & Schutz, 2008; Singer, Hoppe, Lee, Olesen, & Walters, 2008), and aiding the attorney in the case presentation. Regardless of the context, the examiner determines what personality issues are relevant to the referral question and then, examines those Rorschach variables and patterns that provide information relevant to personality issues.

        When a parole board requests an assessment of violence risk, after examining records, administering a Hare Psychopathy Checklist-Revised (PCL-R, Hare, 2003), and conducting a clinical interview, which includes a thorough analysis of past behavioral patterns, what might the Rorschach contribute? A glance at R and Lambda will provide some clues as to whether overcontrol or under control are issues. R can also provide an indication that affect is creating an internal press toward acting out. An analysis of es, blends, and the sequence patterns elucidate the nature of the stressors that facilitate a loss of control. Low Lambda suggests poor boundaries and a propensity to be sucked into emotionally charged situations.

        Examining EA, D, and Adj D will provide an indication of the psychological resources available, the degree of control, and the chronicity of the Rorschach patterns. Should the EB be ambitent the patient is prone to feeling overwhelmed and exhibits problem solving skills that shut down when confronted with internal and external stress--a precursor to impulsivity. Introversiveness and Extratensiveness styles will guide other fine-tuned hypotheses.

        Additional information relative to the referral question might include an assessment of thinking difficulties (X+%, X-%; WSum6), ability to tolerate and modulate affect (FC:CF+C, Afr), presence of internal stressors (blends, C’, Sum Shading), aggression prevalence (AG, S, S-%, AgC, AgPot, AgPast), impulsivity (C), while other supplemental scores will aid in understanding level of personality organization and primary defense utilized (Acklin, 1997). When integrated with the history and other assessment data, the Rorschach data enhances our understanding of the patient’s ability or inability to delay/avoid actions, suggests possible intervention strategies (Relapse Prevention), and adds to the identification of circumstances that are of high risk.

CS Structur

al Summary

The CS Structural Summary (CSSS) provides a portrait of the patient’s personality functioning. As noted by Fontan et al. (2013), we consider that the Structural Summary provides a visual and dynamic representation of the psychological functioning of a person. This is the same kind of experience that the engineer has when looking at mechanical designs and “seeing” the pieces moving together, or when the architect looks at blueprints and “sees” people living and working in the building, or the musician when looking at multiple instruments scores and “hearing and feeling” the movements of a piece of music. One of the major purposes of CHESSSS is to promote this experience of the Structural Summary (p. 62).

The CSSS allows for the perusal of the entire personality without having to search through pages of individual data points, organize the data, and then interpret them. It allows the examiner to view Rorschach patterns of great interpretative value.

In a patient prone to impulsively, one might quickly scan the CSSS finding a low Lambda, high number of dysphoric blends, in an extratensive style. This patient experiences a push (blends) and pulls (low Lambda) and is wired for environmental engagement. They are unable to separate from emotionally stimulating situations. Combined with poor reality testing, cognitive issues, problems with affect modulation, and

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interpersonal deficits this pattern is a template for real-world boundary issues, impulsivity, and interpersonal misjudgments. This rapid glimpse into personality functioning is not possible in systems where individual data points must be searched, and then organized into essential patterns.

        Variations in Lambda provide clues into impulsivity related to aggressive acting out (Exner, 2003; Weiner, 2003). High Lambda individuals (constricted) are susceptible to experiencing difficulties with affect. When overwhelmed their limited resources (EA) may result in explosive behavior when considered in the context of other variables such as Pure C, X-%, FC:CF+C and the various indices of aggression. The low lambda subject may have the tendency to find themselves too easily ensnared within affectively charged situations where they become overwhelmed and act out. The examiner can readily scan the CSSS to fine tune hypotheses generated by Lambda.

        Readily identifiable patterns occur related to other areas of personality functioning such as self-esteem regulation. An EGOI elevated by reflections combined with MORs, Vistas and PERs, suggests the defensive use of grandiosity to compensate for a damaged inner self. In female psychopaths the defensive nature of Hx, AB etc. highlight the way hysteria is integral to self-esteem regulation. Interpersonal variables such as spoiled COP will reveal the impact of poor affect modulation and a damaged self-image on interpersonal functioning.

        The following structural summary produced by Brinkley, a 31-year-old, male Caucasian sexual murderer provides some intriguing interpretative issues. This reduced response protocol (R = 13) may not provide a full presentation of the patient’s personality functioning and is likely not completely valid related to some of the constellations (see Table 1). However, is it clinical useful? RIAP-5, in misguided fashion, does not generate the ratios, percentages and derivatives for a 13-response protocol. Consequently, the Structural Summary from the original RIAP is presented (some minor inconsistencies between the CSSSs may result as we could not update the scoring for the original RIAP).

Table 1: Brinkley Structural Summary from RIAP-5.

        Does this 13-response protocol accurately describe an individual who committed a sexual homicide? How does one interpret the low R and Lambda (in Table 2)? Given the patient was evaluated over several days, the protocol was administered by the CBG, and cooperation was listed as excellent (patient fully engaged & rapport established) conscious defensiveness can be ruled out. High task engagement is supported by the low Lambda (0.18; Table 2) and abundant DRs (13), suggesting an over-engagement in the task. Of note since only experienced examiners have administered our research protocols only 4% or less of the cases constitute abbreviated protocols (Gacono & Evans, 2008; Gacono & Meloy, 1994; Smith et al., 2021).

        Low R in a protocol with very low Lambda and a plethora of blends represents characterological constriction (Gacono & Gacono, 2008; Gacono & Meloy, 1994). Not due to defensiveness, it accurately reflects some aspect of the patient’s functioning and therefore warrants interpretation. Comparing the W: D and W:R ratio in nonpatient adults (Exner, 2007) is 8.28/12.88 (64%) and 8.28/22.32 (37%), with Brinkley’s ratios (8:5 (1.6) & 8:13 (61%)) one discovers an overproduction of Ws. What does an elevated W mean in the case of a psychopathic sexual murderer? The original CS structural summary is included here (see Table 2).

Table 2: Structural Summary for Brinkley from RIAP

        The presence of 3 reflections (elevated EGOI) in this abbreviated protocol is telling. Whenever a low base rate variable (T, Fr, etc.) is produced in a low R protocol, attributing its clinical meaning to the patient rests on safe grounds. Conversely, the absence of a variable in a short protocol may constitute a false negative. In this case the W:M being near the 3:1 ratio, which indicates the presence of aspirations that exceed real world abilities (Weiner, 2003), supports the presence of grandiosity. Given the 3 MORs and 9 PERs (associated with omnipotence in male psychopaths; Gacono & Meloy, 1994) the hypothesis that this individual manifest a malignant narcissism where grandiosity compensates for inner damage is justified. His grandiosity was also evident throughout the assessment. It began at the onset when after a formal introduction of the examiners, the patient stated, “Carl, you can call me [Brinkley]”, and then sat down and propped his feet up on the examination table. While the EB may or may not be valid due to the low R, the extratensive style is consistent with an individual who has great difficulty disengaging from stimulating environmental stimuli in this case idealized women who fit his victim fantasy (note his Mp > Ma suggesting an abuse of fantasy). The sexual murder itself becomes a component of the offender’s self-esteem regulation.

        Extensive verbiage is evident (DRs). Disordered thinking (WSum6 = 71) lies beneath Brinkley’s mask of sanity (adequate perceptual accuracy, X+% & F+%). In a grandiose fashion, Brinkley expends much energy producing each perfect response. Not likely evidence of insightfulness on his part, he states on Card X response 13, “That’s a Rorschach original.” The fact that his protocol continues to be used for educational purposes suggests, however, that indeed his protocol continues to be “a Rorschach original.” In predatory fashion, Brinkley scans the entire blot (W), a correlate of his perpetual environmental scanning as he searches for prey while in a paranoid fashion, he identifies potential predators. These latter interpretations are supported by plethora of extended Ag scores (including SM, AgC, AgPot, AgPast; Gacono & Meloy, 1994) and indices indicating an underlying paranoid personality structure (PERs).

Sequence of Scores:

        At times individual responses provide rich imagery that provide a microcosm of the patient’s personality functioning. In Card 1, response 1 offered by a Karen a psychopathic female serial killer (Gacono & Meloy, 1994; Smith & Gacono, 2021) one is struck by abundance of aggressive imagery, primitive defenses, an admixture of sexual and aggressive content, and a hysterical-paranoid style the hallmark of psychopathic women (Smith et al., 2021).

        Karen stated, (FA) A Wiley coyote in an aggressive mode (AgC, AG). Wiley coyote is the one that chases the road runner on the cartoons. My initial impression is a carnivore (AgC). Is that an unusual response? He needs eyeballs.” (Inquiry) S: These look like eyes that are hostile, angry, white orbs (white space). These look like pupils, appear to be ears. E: (Hostile?) S: Without going into details of cartoons (denial), there is a way of drawing the eyes that looks angry. My first impression was aggression. Wiley coyote about to attack the road runner (AgPot). Yes, there is a large aggressive part of me (PER). He looks like a carnivore ready to strike (AgPot, projective identification). All I see is the eyes and a hostile mouth, what else is there to see? I wish I could see doves mating (splitting). Something soft and gentle. Something that's not hostile (Gacono & Meloy, 1994, p. 129).

        (FA) Or a filet of fish ready to put on a frying pan” (Inquiry) S: I'm not seeing the tail with Indian feathers. Just the filet of fish. E: (Filet?) S: Side by side. It's been deboned, (SM, AgPast; Laughs) sorry I shouldn't have said that term. He'll be ready to go into the frying pan or perhaps is already in the pan. E: (Deboned?) S: I knew you were going to hit me on that. No spine, no substance, no form, a blob! A piece of fish to be cooked. Or perhaps a fudgsicle that's been allowed to set in the sun and melt.” Of note is that Karen beheaded one of her victims with fish deboning knife (note food imagery with aggressive & sexual contamination in this unconsciously chosen phrase) (p. 132).

Beyond content analysis essential information is provided when examing the responses in their CS/CS-R generated sequence. Basic to sequence analysis is the understanding of impulses (poor form, special scores) and defenses (good form; Meloy et al., 1997; Rapaport, Gill, & Schafer, 1946; Schafer, 1954). The following can be obtained from sequence analysis.

1. How does the patient react to an unstructured stimulus (Card 1) or affect (color shock)?
2. What dynamic issues cause disruptions? Analysis of the determinants and content proceeding and occurring on responses with minus, unusual form, and special scores should provide answers.
3. What is the nature of the disruption? Examine determinants/content occurring with cognitive slippage, perceptual inaccuracy, affect based disturbance.
4. How does the patient react to disruptions? Do they recover in subsequent response with good form absent special scores or do they continue to remain disorganized? If they recover, how do they do so? (i.e., do they produce a popular [conventionality]?)
5. How does the patient hold up during the administration from response 1 to the final response? Are they consistent with good form throughout? Do they demonstrate disruptions and recover by the end of Card X? Do they regress and never recover? These patterns are likely a microcosm of their real-world resiliency in difficult or complex situations.

Conclusion:

         The CS/CS-R Rorschach provides a completed portrait--sometimes bland and colorless, sometimes rich and colorful--of a patient’s personality functioning. While supplemental scoring significantly enriches the clinical yield of the canvass, much is provided by the Structural Summary and Sequence of scores. R, Lambda, and EB are particularly useful in establishing the protocol’s validity and providing a basis for interpreting other Rorschach data.

        The variations in R allowed by CS administration are not only sufficient but ideal, allowing R to be treated as a dependent measure of the populations studied or patient assessed. Allowing for variations in R is not only ideal but consistent with Rorschach’s intentions. Abbreviated CS protocols are rare (< 4%) when the CS is administered by experienced raters who are patient, astute and able to establish rapport. Claims to the contrary are not justified or scientific. As noted by Gacono and Meloy (1994) related to assessing antisocial and psychopathic subjects:

        “We have found, contrary to our expectations, that psychopaths generally produce a normative amount of Rorschach responses, at least in a research setting. We have purged our group samples of protocols with less than 14 responses without great heartache, because they were few in number. (p. 5).”Patience has limits, however, and should be anchored in clinical judgement. This is in contrast to one case where a schizophrenic patient fell asleep sitting next to the examiner who exercised extraordinary restraint, remaining client centered, and non-directive, as he, unfortunately, was not being able to see the patient’s closed eyes. As with criticisms of administration time being too lengthy for the Rorschach and PCL-R (not justified), there is a repeated pattern in psychology to reframe problems with incompetent or inexperienced examiners as negative attributes of the test itself, confusing poor clinical practice with test psychometrics (i.e., statements concerning a 10% production rate of shortened protocols are most likely an attribute of the examiners). This difficulty acknowledging limitations is left to the interpretation of the reader.

        Encouraging for psychologists and Rorschach enthusiasts is the fact that the CS/CS-R Rorschach is alive and evolving, not frozen in time (Kivisto, Gacono, & Medoff, 2013). It continues to undergo creative adjustments and improvements (see Fontan et al., 2013). Well trained examiners should not fear using the CS, when appropriate to the referral question or clinical issue, in applied contexts. In this regard, we refer users and potential users to the Handbook of Forensic Rorschach Assessment (Gacono & Evans, 2008) and offer this brief overview as a resource for competent Rorschach usage.

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