Case 67: Using the Rorschach Trauma Content Index (TCI) with Incarcerated Women

Using the Rorschach Trauma Content Index (TCI) with Incarcerated Women

Jason M. Smith, Carl B. Gacono and Ted B. Cunliffe

        Based on findings from prior research studies, trauma histories have been found to be ubiquitous in psychopathic women. In this study, the Rorschach Trauma Content Index (TCI) was used to better understand the trauma histories of incarcerated women (N = 180). The TCI was significantly correlated with total reported trauma events, reported sexual abuse, other Rorschach scores (AgPast, ROD), and scales on both the Personality Assessment Inventory and the Trauma Symptom Inventory-2. The TCI may be related more to sexual abuse than physical abuse and the traumatic intrusions appear to be related to borderline features and dependency in this sample. These results suggest that the TCI facilitates our understanding of trauma in the lives of incarcerated women.

        While the number of incarcerated prisoners has declined, the percentage of female offenders has increased slightly (Carson, 2018; Green et al., 2016). Female offenders have exhibited higher rates of psychopathology (including mood and anxiety disorders), trauma, and borderline personality disorders than male offenders (Bronson & Berzofsky, 2017; Fazel, Hayes, Bartellas, Clerici, & Trestman, 2016; Smith, Gacono, Kivisto, & Cunliffe, 2019).

        Females tend to have higher rates of Posttraumatic Stress Disorder (PTSD) than males (Prins, 2014). Incarcerated females have even higher rates of PTSD (from 12% to as high as 54%; Green et al., 2016) than both incarcerated males and non-incarcerated females (Briere, Agee, & Dietrich, 2016; Harner, Budescu, Gillihan, Riley, &Foa, 2015). High incidents of sexual abuse and interpersonal violence are common traumatic historical events related to the development of PTSD and substance use within female offenders (Bowles, DeHart, & Webb, 2012; Briere et al., 2016; DeCou, Lynch et al., 2016; Rowan-Szal, et al., 2012;MacDonald, 2013;Tolin&Foa, 2006; Tripodi & Pettus-Davis, 2013).

Rorschach Measures of Trauma

Personality assessment measures for trauma are common and the Comprehensive System (CS) Rorschach (RIM) variables have been

used extensively (Armstrong,2002; Armstrong & Loewenstein, 1990; Ephraim, 2002; Gacono

& Meloy, 1994; Gravenhorst, 2002; Kaser-Boyd & Evans, 2008; Piotrowski, 2017; Sloan, Arsenhault, & Hilsenroth, 2002; Viglione, Towns, & Lindshield, 2012). The RIM assesses psychological variables beyond those measured by self-report. The interpersonal nature of the testing situation also allows the respondent to indirectly communicate trauma issues (Gacono & Meloy, 1994; Levin & Reis, 1997). The Trauma Content Index (TCI; Armstrong & Loewenstein, 1990) has been used specifically as a Rorschach measure to assess trauma.

        The TCI is correlated with personal traumatic history and intrusive traumatic imagery (Armstrong & Loewenstein, 1990; Zukerman, Ben-Itzchak, Fostick, & Armony-Sivan, 2017). 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). This score is divided by the total number of Rorschach responses. Exner’s (2003) Comprehensive System is used to calculate the TCI. Recently, another Rorschach scoring system, (Rorschach Performance Assessment System; R-PAS; Meyer, Viglione, Mihura, Erard, & Erdberg, 2011) was proposed whereby a Critical Contents (CritCont%) score. While, some investigators have questioned the validity of the TCI, stating the traumatic content categories of the TCI are broad, encompass images related to other types of psychopathology or non-traumatic issues, and are related to exaggerating (Viglione et al., 2012), most research has supported its validity (Armstrong & Loewenstein, 1990; Zukerman et al., 2017).

        High scores on the Trauma Content Index have been related to sexual abuse, dissociation, physiological responses, higher levels of arousal, and those diagnosed with PTSD produce high scores (Armstrong & Loewenstein, 1990; Arnon, et al., 2011; Brand, et al., 2009; Goldfinger, Amdur, & Liberzon, 1998; Nordström & Carlsson, 1997; Zukerman et al., 2017). 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 has been proven to differentiate traumatized and non-traumatized patients (Armstrong, 2002; Arnon et al., 2011; Kamphuis, Kugeares, & Finn, 2000; Kamphuis et al., 2008; Smith et al., 2010).Investigators have also found that the TCI and Aggressive Past responses (AgPast; tendency to view selfas a victim; Gacono & Meloy, 1994) are highly correlated in traumatized patients (Kamphuis et al., 2000). With offenders, TCI scores have been higher in debt collectors than those that have committed homicides or had low levels of violence (Nørbech, Grønnerød & Hartmann, 2016). Females high in psychopathy (M = 0.37; Smith, Gacono, Cunliffe, Kivisto,& Taylor, 2014) and female sexual offenders tend to have had high TCI scores as well (M = 0.23; Smith, Gacono, Kivisto, & Cunliffe, 2019).

Method:

Participants:

        We used archival data in this study. The females (N = 180) were part of separate research projects conducted by Doctoral Level Psychologists at various medium sized state prisons in the United States (California, Wyoming, and Kentucky). Due to the nature of female prisons in the USA, the security levels of the women ranged from camp to maximum. Instant offenses for the population were: 72% (130), were drug related, 10 % (18) had a

violent crime, 5% had a sex offense (9), 13%

(23) had another type of crime. All participants randomly received a flyer requesting their participation and all inmates volunteered for participation in the various studies. They signed informed consent forms to be included in research. They did not receive any monetary incentives and participation did not affect their sentence. The research studies were approved by the various institutions.

Table 1. Descriptive Statistics for Entire Sample

Note. M = mean; SD = standard deviation; TSI = Trauma Symptom Inventory; PAI = Personality Assessment Inventory; CritCont%; = Critical Contents; TCI = Trauma Content Index; ROD = Rorschach Oral Dependency; AgPast

= Aggressive Past; IE = Intrusive Experiences; DA = Defensive Avoidance; DIS = Dissociation; ICN = Inconsistency; INF = Infrequency; NIM = Negative Impression Management; PIM = Positive Impression Management; SOM = Somatic Complaints; AA-H = Hyperarousal; TRB = Tension Reduction Behavior; DEP = Depressive Symptoms; BOR

= Borderline Features; ALC = Alcohol; DRG = Drugs; AGG = Aggression; PAR-H = Hyperarousal; ARD-T = Traumatic Stress; BOR-A = Affective Instability; BOR-I = Identity Problems.

The ethnicities for the entire sample (N = 180) were White (N = 112; 62.2%), Black (N = 47; 26.1%), Hispanic (N = 15; 10.98.3%), Asian

(N = 3; 1.7%), Native American (N = 2; 1.1%), and Other (N = 1; 0.6%). Diagnoses were part of the archival records and had been provided by a Clinical Psychologist. Overall, 80 (44.4%) met criteria for PTSD and 19 (10.6%) met criteria for Unspecified Trauma- and Stressor-Related Disorder (UTSRD; 55% had a trauma-related diagnosis). In terms of Personality Disorders, 107 (59.4%) were diagnosed with Antisocial Personality Disorder (ASPD) and 68 (37.8%) were diagnosed with Borderline Personality Disorder (BPD). Age, IQ, Rorschach responses, and Lambda scores are available in Table 1. Further, mean, standard deviations, and ranges for all variables included in the correlational analyses are available in Table 1. Those diagnosed with PTSD had a TCI of 0.27.

Measures:

        The Shipley Institute of Living Scale (SILS; Shipley & Zachary, 1986) or the Shipley-2 (Shipley, Gruber, Martin, & Klein, 2009), Trauma Symptom Inventory-2 (TSI-2; Briere, 2011),Personality Assessment Inventory (PAI; Morey, 1991), Stressful Life Events Screening Questionnaire (SLESQ; Goodman, Corcoran, Turner, Yuan, & Green, 1998), and Rorschach Inkblot Test (Exner, 2003; Rorschach, 1921/1942) were administered in accordance with procedures outlined in the test manuals. 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 was used to provide an estimate of intelligence. The Shipley measures crystallized intelligence with the Vocabulary scale and fluid intelligence with either the Abstraction or Block Pattern scale. The Shipley has been shown to correlate with the WAIS-R Full Scale IQ between .85 and

.87 (Shipley & Zachary, 1986). It is important to utilize a cognitive measure when using the Rorschach as low IQ can contribute to a constricted Rorschach protocol (Gacono, 2019; Smith, Gacono, Fontan et al., 2018).

The Stressful Life Events Screening Questionnaire (SLESQ; Goodman et al., 1998) is a 13-item self-report measure to assesses lifetime exposure to traumatic events which was used to identify traumatic events. It has been found to have good test-retest reliability and appropriate levels of concurrent and discriminant validity (Goodman et al., 1998).

        The Trauma Symptom Inventory-2 (TSI-2; Briere, 2011) is a 136 item self-report measure. It measures trauma-relevant symptomology with two validity scales, four factor scores, 12 clinical scales and 12 clinical subscales. The TSI-2 has shown to have concurrent, discriminant, construct, criterion, and factorial validity as well as high test-retest reliability and internal consistency (Briere, 2011). It has been validated on incarcerated women (Briere, 2011). Protocols were considered valid if they had T scores below 75 on the Response Level (RL) scale and had a raw score below 15 on the Atypical Response (AR) scale.

        The Personality Assessment Inventory (PAI; Morey, 1991) is a 344 item self-report measure. It examines psychopathology and personality characteristics. It contains validity, clinical, treatment, and interpersonal scales. When examining the validity of a protocol, participants were retained for analyses only if they obtained an Infrequency (INF) score below 75T, an Inconsistency (ICN) score below 73T, and a Negative Impression Management (NIM) score lower than 77T (Morey, 1991).

        All the Rorschach protocols were administered and scored per the Exner Comprehensive System Guidelines (Exner, 2003). Exner’s (2003) Comprehensive System was used to calculate the TCI. All Rorschach variables (TCI, CritCont%, ROD, & AgPast) were scored using CHESSSS (Fontan et al., 2013). All have shown to have good reliability and validity (Armstrong, 2002; Bornstein & Masling, 2005; Gacono & Meloy, 1994; Viglione et al., 2012). Kappa coefficients for the Rorschach scores ranged from .75 to 1.00 (all in the excellent range [Meyer, 1999]). Twenty protocols were scored by two raters and inter-rater reliability was calculated from these protocols.

Procedure:

        The total sample consisted of 180 incarcerated females. Thirty-six of the 180 were excluded as 24 had PAI INF, INC, and/or NIM scores above the cutoff and 12had an IQ < 80. The following were used in the correlational analyses: 1) total traumatic events; total physical abuse events; total sexual abuse events; 2) Rorschach: TCI; CritCont%; ROD; AgPast; 3) TSI-2 scales: IE (Intrusive Experiences); DIS (Dissociation); AA-H (Hyperarousal); DA (Defensive Avoidance); SOM (Somatic Preoccupations); TRB (Tension Reduction Behavior); TRAUMA (Constellation of TSI-2 Trauma Scales); 4) PAI scales: SOM (Somatic Complaints); DEP (Depressive symptoms); BOR (Borderline features); AGG (Aggression); ALC (Alcohol); DRG (Drug); PAR-H (Hypervigilance); BOR-A (Affective Instability); BOR-I (Identity Problems); ARD-T (Traumatic Stress).

The Statistical Package for Social Sciences (SPSS) version 22, was used for all calculations. The data were analyzed for means, standard deviations, and ranges. Due to the nature of the Rorschach variables selected (unequal distribution, J-Shaped curves; Exner, 1995), these variables were examined with non-parametric statistics (Spearman rho; Viglione, 1995).

Results:

Table 2. TCI Correlational Analyses

Note.Correlations = ρ (Spearman); * = p < .05; ** = p <

.01. TSI = Trauma Symptom Inventory; PAI = Personality Assessment Inventory; TCI = Trauma Content Index; CritCont%; = Critical Contents; ROD = Rorschach Oral Dependency; AgPast = Aggressive Past; IE = Intrusive Experiences; DA = Defensive Avoidance; DIS = Dissociation; SOM = Somatic Complaints; AA-H = Hyperarousal; TRB = Tension Reduction Behavior; DEP

= Depressive symptoms; BOR = Borderline Features; ALC = Alcohol; DRG = Drugs; AGG = Aggression; PAR-H

= Hyperarousal; ARD-T = Traumatic Stress; BOR-A = Affective Instability; BOR-I = Identity Problems.

The TCI correlational analyses found 10 significant correlations (see Table 2). These included total traumatic events (ρ [107] =

.294, p = .002), total sexual abuse events (ρ [106] = .299, p = .002), CritCont% (ρ [168] =

.955, p < .001), ROD (ρ [166] = .178, p =

.022), AgPast (ρ [167] = .482, p < .001), TSI-2

DA (ρ [73] = .279, p = .017), PAI BOR (ρ [92]

= .333, p = .001), PAI BOR-A (ρ [92] = .325, p

= .002), PAI BOR-I (ρ [92] = .239, p = .022), and PAI AGG (ρ [92] = .296, p = .004).

Though there was not a significant correlation

with the TSI-2 TRAUMA scale, there was a positive  trend  (ρ  [73]  =  .209,  p  =

.062).CritCont% was significantly correlated with the TSI-2 TRAUMA scale (ρ [73] = .261, p = .026).

Discussion:

         In our study, the TCI had several noteworthy correlations. The TCI was significantly correlated with the total number of reported traumatic events and total reported sexual abuse events but not total reported physical abuse events. This suggests that the index may be tapping into intrusive traumatic imagery from these events (there was a positive trend with m responses which measures intrusive intrusions). However, it appears that it may be more related to sexual rather than physical abuse as previously seen (Kamphuis et al., 2000; Nordström & Carlsson, 1997). Not surprisingly, the CritCont% was highly correlated with the TCI. The CritCont% was significantly correlated with a constellation of TSI-2 trauma scales suggesting it is measuring trauma symptomology (TCI had a positive trend). Though the overall sample had a TCI with a mean of 0.26 (less than the .30 signifying traumatic intrusions; Armstrong, 2002), it does appear the individuals within the sample are suffering from traumatic intrusions. For forensic populations, clinicians need to be mindful of exaggeration or malingering which is a possibility on the TCI (Viglione et al., 2012). However, in this forensic sample, none of the validity scales on the self-report measures were significantly correlated with the TCI.

        When examining the TCI components, the contents suggest aggression, a damaged sense of self, sexual preoccupations, blood, and anatomy responses. The significant relationship between AgPast and the TCI suggests that the female offenders identify with a damaged view of self in part due to the fact that they were victims of aggression or traumatic events (also PAI AGG scale). In our sample, the victims of aggression become the victimizers (prone to aggression; Gacono & Meloy, 1994; Goldenson, Geffner, Foster, & Clipson, 2007; Smith, Gacono, & Cunliffe, in press [a]) which would relate to Rorschach Aggressive Movement (AG) responses (part of the TCI). Avoidance is a key symptom of  PTSD  and  from  clinical experience, this unhealthy coping strategy is common among female offenders with past traumatic experiences. Therefore, the TCI appears to be related to their use of avoidance, specifically intentional effort to deter and fend off unwanted internal experiences and physical environments that could trigger a memory (TSI-2 DA).

        While trauma, PTSD, and Borderline Personality Disorder (BPD) differ, they overlap in central symptomology (Cloitre, Garvert, Weiss, Carlson, & Bryant, 2014). The TCI is significantly correlated with the PAI Borderline features scales in our sample. Both PTSD and BPD are prominent within incarcerated women, with 49 (27.2%) having a trauma diagnosis (PTSD or UTSRD) and a co-morbid BPD diagnosis in this sample (Bronson &Berzofsky, 2017; Fazel et al., 2016; Prins, 2014; Smith et al., 2019). Perhaps the measures are assessing symptoms from both disorders. Examining the PAI BOR scales, BOR-A examines affective instability and heightened emotionality which has been described as a differentiating factor between male and female offenders/psychopaths (Cunliffe & Gacono, 2005, 2008; Cunliffe et al., 2016; Gacono, 2016; Gacono & Meloy, 1994; Smith, Gacono, & Cunliffe, 2018). This leads the female offender to be prone to dissociation, avoidance, and traumatic intrusions and the emotionality may be the driving force of symptom presentation and antisocial behavior (Smith, Gacono, Kivisto et al., 2019).

The TCI and ROD scales were also significantly correlated suggesting that traumatic intrusions may relate to higher levels of dependency in the sample. Abnormal attachment/bonding is common with victims of sexual abuse especially in early childhood (common in incarcerated women; Smith, Gacono,  &  Cunliffe,  in  press  [b]).

Consequently, it is not surprising our women would have higher levels of dependency related to an excessive need for nurturance (ROD & PAI BOR scores).

        The findings show that when validating a Rorschach variable, externally assessed criteria (e.g., diagnoses; real-world data [traumatic events]) may be better than introspectively assessed criteria (e.g., self-report measures). Research findings have found externally assessed criteria rather than introspectively assessed criteria are better at validating Rorschach indices (Mihura, Meyer, Dumitrascu & Bombel, 2013; Smith, Gacono, Fontan et al., 2018; Smith, Gacono, & Cunliffe, 2019). This may, in part, explain the lack of significant correlations between the TCI and many of the TSI-2 and PAI scales assessing traumatic events.

Conclusions:

        The Rorschach remains a valuable instrument in psychological assessment. Though it is not meant to make diagnoses, it can provide information about personality characteristics not accessible with self-report measures. This provides clinicians with a more thorough understanding when it comes to trauma especially in forensic contexts. A multimethod assessment approach including the Rorschach is recommended. This is paramount since the high levels of psychopathology in forensic settings necessitates treatment. Future trauma-related research with the Rorschach would benefit by investigating the relationship between the TCI and other popular measures of PTSD (see Piotrowski, 2020).

References:

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. Journal of Nervous and Mental Disease, 178, 448–454.

Arnon, Z., Maoz, G., Gazit, T., & Klein, E. (2011). Rorschach indicators of PTSD: A retrospective study. Rorschachiana, 32(1), 5-26.

Bornstein, R. F., & Masling, J. M. (2005). The Rorschach Oral Dependency Scale. In R. F. Bornstein & J.

1. Masling (Eds.), Scoring the Rorschach: Seven validated systems (pp. 135-157). Mahwah, NJ: Lawrence Erlbaum Associates Publishers.

Bowles, M.A., DeHart, D. & Webb, J.R. (2012). Family influences on female offenders’ substance use: The role of adverse childhood events among incarcerated women. Journal of Family Violence, 27(7), 681-686.

Brand, B. L., Armstrong, J. G., Loewenstein, R. J. & McNary, S. W. (2009). Personality differences on the Rorschach of dissociative identity disorder, borderline personality disorder, and psychotic inpatients. Psychological Trauma: Theory, Research, Practice, and Policy, 1(3), 188–205. doi:10.1037/a0016561

Briere, J. (2011). Trauma Symptom Inventory–2 (TSI–2). Odessa, FL: Psychological Assessment Resources.

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. http://dx.doi.org/10.1037/tra0000107

Bronson, J., &Berzofsky, M. (2017). Indicators of mental health problems reported by prisoners and jail inmates, 2011-12 (Bureau of Justice Statistics Bulletin). Washington, DC: U.S. Department of Justice.

Carson, E.A. (2018). Prisoners in 2016 (Bureau of Justice Statistics Bulletin). Washington, DC: U.S. Department of Justice.

Cloitre, M., Garvert, D.W ., Weiss, B., Carlson, E.B., & Bryant, R.A. (2014). Distinguishing PTSD, Complex PTSD, and Borderline Personality Disorder: A latent class analysis. European Journal of Psychotraumatology, 5 (1). DOI: 10.3402/ejpt.v5.25097

Cunliffe, T.B., & Gacono, C.B. (2005). A Rorschach investigation of incarcerated antisocial personality disordered female offenders. International Journal of Offender Therapy and Comparative Criminology, 49, 530-547.

Cunliffe, T.B., & Gacono, C.B. (2008). A Rorschach understanding of antisocial and psychopathic women. In C. B. Gacono, F.B. Evans, N. Kaser-Boyd, & L.A. Gacono (Eds.), The handbook of forensic Rorschach assessment (pp. 361-378). New York, NY: Routledge.

Cunliffe, T.B., Gacono, C.B., Smith, J.M., Kivisto, A.J., Meloy, J.R., & Taylor, E.E. (2016). Assessing psychopathy in women. In C.B. Gacono (Ed.), The clinical and forensic assessment of psychopathy: A practitioner’s guide (2nd ed., pp. 167-190). New York, NY: Routledge/Taylor & Francis Group.

DeCou, C.R., Lynch, S.M., DeHart, D.D., & Belknap, J. (2017). Evaluating childhood and adulthood victimization as predictors of psychotic disorders: Findings from a nationwide study of women in jail. Psychosis, 9(3), 282-285. DOI: 10.1080/17522439.2017.1325512

Ephraim, D. (2002). Rorschach trauma assessment of survivors of torture and state violence. Rorschachiana, 25(1), 58-76.

http://dx.doi.org/10.1027/1192-5604.25.1.58

Exner, J. E. (Ed.). (1995). Issues and methods in Rorschach research. Mahwah, NJ: Erlbaum.

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

Fazel, S., Hayes, A. J., Bartellas, K., Clerici, M., & Trestman, R. (2016). Mental health of prisoners: prevalence, adverse outcomes, and interventions. The Lancet: Psychiatry, 3(9), 871-

881.

Fontan, P., Andronikof, A., Nicodemo, D., Al Nyssani, L., Guilheri, J., Hansen, K. G., Kumasaka, S., & Nakamura, N. (2013). CHESSSS: A free software solution to score and compute the Rorschach Comprehensive System and Supplementary Scales.   Rorschachiana,   34(1),   56-82.

http://dx.doi.org/10.1027/1192-5604/a000040

Gacono, C.B. (2016). Introduction. In C. B. Gacono (Ed.), The clinical and forensic assessment of psychopathy: A practitioner's guide (pp. 3-13). 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.

Goldenson, J., Geffner, R., Foster, S.L., & Clipson, C.R. (2007). Female domestic violence offenders: Their attachment security, trauma symptoms, and personality organization. Violence and Victims, 22, 532-545.

Goldfinger, D.A., Amdur, R.L., & Liberzon, I. (1998). Psychophysiologic responses to the Rorschach in PTSD patients, noncombat and combat controls. Depression and anxiety, 8 (3), 112-20.

Goodman, L., Corcoran, C., Turner, K., Yuan, N., & Green, B. (1998). Assessing traumatic event exposure: General issues and preliminary findings for the Stressful Life Events Screening Questionnaire. Journal of Traumatic Stress, 11(3), 521-542.

Gravenhorst, M. C. (2002). Rorschach psychodiagnosis of psychic trauma in sexually abused children. Rorschachiana, 25(1), 77-85.

http://dx.doi.org/10.1027/1192-5604.25.1.77

Green, B. L., Dass-Brailsford, P., Hurtado de Mendoza, A., Mete, M., Lynch, S. M., DeHart, D. D., & Belknap, J. (2016). Trauma experiences and mental health among incarcerated women. Psychological Trauma: Theory, Research, Practice, and Policy, 8(4), 455-463.

Harner, H. M., Budescu, M., Gillihan, S. J., Riley, S., & Foa, E. B. (2015). Posttraumatic stress disorder in incarcerated women: A call for evidence-based treatment. Psychological Trauma: Theory, Research, Practice, and Policy, 7(1), 58-66.

Kamphuis, J.H., Kugeares, S.L., & Finn, S.E. (2000). Rorschach correlates of sexual abuse: Trauma content and aggression indices. Journal of Personality Assessment, 75, 212–224.

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. DOI: 10.1080/00223890802388558

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). New York, NY: Routledge.

Levin, P., & Reis, B. (1997). Use of the Rorschach in Assessing Trauma. In J.P. Wilson & T.M. Keane (Eds.), Assessing psychological trauma and PTSD (pp. 529–541). New York: Guilford.

MacDonald, M. (2013). Women prisoners, mental health, violence and abuse, International Journal of Law and Psychiatry, 36 (3–4), 293-303.

Meyer, G. J. (1999). Simple procedures to estimate chance agreement and kappa for the interrater reliability of response segments using the Rorschach Comprehensive System. Journal of Personality Assessment, 72, 230-255.

Meyer, G., Viglione, D.J., Mihura, J.L., Erard, R.E., & Erdberg, P. (2011). A Manual for the Rorschach Performance Assessment System. Toledo, OH: R-PAS.

Mihura, J.L., Meyer, G.J., Dumitrascu, N., & Bombel, G. (2013). The validity of individual Rorschach variables: Systematic reviews and meta-analyses of the comprehensive system. Psychological Bulletin, 139, 548-605.

Morey, L. C. (1991). Personality Assessment Inventory professional manual. Odessa, FL: Psychological Assessment Resources.

Nørbech, P.C.B., Grønnerød, C., & Hartmann E. (2016). Identification with a violent and sadistic aggressor: A Rorschach study of criminal debt collectors. Journal of Personality Assessment, 98 (2), 135-145.

Nordström, K., & Carlsson, A. M. (1997, March). Rorschach comparison of borderline patients with and without a history of childhood sexual abuse. Paper presented at the annual meeting of the Society for Personality Assessment, San Diego, CA.

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

Prins, S.J. (2014). Prevalence of mental illnesses in US state prisons: A systematic review. Psychiatric Services, 65(7), 862-872.

Rorschach, H. (1921/1942). Psychodiagnostik. Bern: Bircher (translation Hans Huber Verlag, 1942).

Rowan-Szal, G.A., Joe, G.W ., Bartholomew, N.G., Pankow, J., & Simpson, D.D. (2012). Brief trauma and mental health assessments for female offenders in addiction treatment, Journal of Offender Rehabilitation, 51(1-2), 57-77.

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

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

Sloan, P., Arsenault, L., & Hilsenroth, M. (2002). Use of the Rorschach in the assessment of war-related stress in military personnel. Rorschachiana, 25(1), 86-122.

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. (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. (in press[a]). Female psychopathy and aggression: A study with incarcerated women and Rorschach aggression scores. Journal of Aggression, Maltreatment, and Trauma.

Smith, J.M., Gacono, C.B., & Cunliffe, T.B. (in press[b]). Trauma and dependency in incarcerated women. Criminal Justice & Behavior.

Smith, J.M., Gacono, C.B., Cunliffe, T.B., Kivisto, A.J., & Taylor, E.E. (2014). Psychodynamics in the female psychopath: A PCL-R/Rorschach investigation. Violence and Gender, 1(4), 176-187.

Smith, J.M., Gacono, C.B., Fontan, P., Taylor, E.E., Cunliffe, T.B., & Andronikof, A. (2018). A scientific critique of Rorschach research: Revisiting Exner's (1995) Issues and Methods in Rorschach Research. Rorschachiana, 39(2), 180-203.

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.

Smith S.R., Chang, J., Kochinski, S., Patz, S., &Nowinski,

L.A. (2010). Initial validity of the logical Rorschach in the assessment of trauma. Journal of Personality Assessment, 92(3), 222-231. DOI: 10.1080/00223891003670174

Tolin, D. F., &Foa, E. B. (2006). Sex differences in trauma and posttraumatic stress disorder: A quantitative review of 25 years of research. Psychological Bulletin, 132(6), 959-992.

Tripodi, S.J., & Pettus-Davis, C. (2013). Histories of childhood victimization and subsequent mental health problems, substance use, and sexual victimization for a sample of incarcerated women in the US, International Journal of Law and Psychiatry, 36 (1), 30-40.

Viglione, D.J. (1995). Basic considerations regarding data analysis. In J.E. Exner (Ed.), Issues and methods in Rorschach research (pp. 195-226). Hillsdale, NJ, US: Lawrence Erlbaum Associates, Inc.

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(2), 135-144. http://dx.doi.org/10.1007/s12207-012-9128-5

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.