The Rorschach Suicide Constellation: assessing various degrees of lethality

Legal Admissibility of the Rorschach and R-PAS: A Review of Research, Practice, and Case Law

The special issue editors selected us to form an "adversarial collaboration" because our publications and teaching encompass both supportive and critical attitudes toward the Rorschach and its recently developed system for use, the Rorschach Performance Assessment System (R-PAS). We reviewed the research literature and case law to determine if the Rorschach and specifically R-PAS meet legal standards for admissibility in court. We included evidence on norms, reliability, validity, utility, general acceptance, forensic evaluator use, and response style assessment, as well as United States and selected European case law addressing challenges to mental examination motions, admissibility, and weight. Compared to other psychological tests, the Rorschach is not challenged at unusually high rates. Although the recently introduced R-PAS is not widely referenced in case law, evidence suggests that information from it is likely to be ruled admissible when used by a competent evaluator and selected variables yield scores that are sufficiently reliable and valid to evaluate psychological processes that inform functional psycholegal capacities. We identify effective and ethical but also inappropriate uses (e.g., psychological profiling) of R-PAS in criminal, civil, juvenile, and family court. We recommend specific research to clarify important aspects of R-PAS and advance its utility in forensic mental health assessment.

Serious Suicide Attempts

BACKGROUND

Suicidal behavior comprises a diverse set of behaviors with significant differences among several behavioral categories. One noteworthy category includes individuals who have made serious suicide attempts, epidemiologically very similar to those completing suicide. This behavioral category is important, since interviewing survivors of a potentially lethal incident of self-harm enables a detailed investigation of the psychological process leading to the suicidal act.

AIM

To achieve a consensus definition and operational criteria of serious suicide attempts.

METHOD

We reviewed studies that included the term serious suicide attempt or related terms (e.g., highly lethal), with a focus on the variety of operational criteria employed across studies.

RESULTS

More than 60 papers addressing various types of serious suicide attempt were explored. We found a large variety of operational definitions, reflecting the lack of consensus regarding terminology and criteria related to the term.

CONCLUSION

We undertook the challenge of developing an integrative and comprehensive set of criteria of serious suicide attempt and suggest a definition comprising three key dimensions: medical lethality, potential lethality of the method used, and severity of the objective circumstances of the suicide intent. Clinicians and researchers are strongly encouraged to consider using the term serious suicide attempt with its attendant components.

The Rorschach Comprehensive System (CS) Psychometric Validity of Individual Variables

Since the publication of the Rorschach Inkblot Method (Rorschach, 1921/1942 ), theorists, researchers, and practitioners have been debating the nature of the task, its conceptual foundation, and most important its psychometric properties. The validity of the Rorschach Comprehensive System (CS; Exner, 1974 , 2003; Exner & Weiner, 1995 ) has been supported by several meta-analyses that used different types of nontest external criterion for validating individual variables. In a recent meta-analysis, Mihura, Meyer, Dumitrascu, and Bombel ( 2013 ) found coefficients ranging from modest to excellent for most of the selected CS variables, with 13 of them reported as showing "little to no support." This article focuses on these variables. Although endorsing Mihura et al.'s mainly validating findings, we also suggest that the evidence presented for the little or no validity of these 13 variables is not quite compelling enough to warrant changing their definition or coding, or removing them from the system. We point to some issues concerning the description and interpretation of these variables and the appropriateness of the external criteria used for exploring their validity, and suggest considering these issues in further CS research. Implications of Mihura et al.'s meta-analysis for clinical and forensic practice are discussed.

"Why am I so stuck?": A Collaborative/Therapeutic Assessment Case Discussion

Assessors from 3 continents worked together on a single multimethod case study. Their goal was to hold the client at the center and forefront of their attitudes and thinking as each assessor focused on a specific measure or group of measures. The adult client requested a neuropsychological assessment and completed a full battery of cognitive measures as well as the MMPI-2, the Rorschach, and the Wartegg. A basic tenet of collaborative/therapeutic assessment holds that the client is a full partner in the assessment process; he or she is also seen as the final arbiter of the usefulness of the ideas derived. With that in mind, the client worked with the lead assessor to create 6 questions she wished answered by the assessment. Feedback and discussion occurred in a number of ways: through discussion sessions with the lead assessor that included extended inquiry; individualized letters from the other assessors, each addressing her 6 questions; a summary letter from the lead assessor; and a metaphorical, therapeutic story that stressed key findings from the assessment. Results converged powerfully, with similar findings from each assessor. The client stated that she felt heard and understood in the process, even by individuals who she had never met personally.

A review of suicide risk assessment instruments and approaches

Introduction:

Conducting an accurate suicide risk assessment (SRA) is no simple task as there are a number of factors that influence an individual's level of suicidality and his/her willingness to share this information. Therefore, it is imperative that practitioners adopt a systematic approach to conducting and documenting the foreseeability that a patient will commit suicide.

Methods

PubMed was used to search for articles published in MEDLINE journals using the following keywords: suicide, risk assessment, measure, scale. Randomized trials and pilot, proof-of-concept publications investigating the use of specific SRA measurements were included in the review. The scales are described based on the prevailing opinions in psychiatry from the American Psychiatric Association's Textbook of Suicide Assessment and Management (2nd ed., 2012).

Results

Although various SRA scales exist, experts in the field have repeatedly concluded that there is not any one scale that can predict who will commit suicide to any useful degree. However, when used along with the clinical interview, standardized suicide risk factor components of clinical and research scales remain crucial to gaining information often omitted by patients regarding thoughts and preparation for suicide. A summary of the most widely cited scales and approaches used in SRA is provided.

Discussion

SRA remains a challenge largely due to the fact that suicidal behavior is multifactorial. As a result, risk formulation is a process that should involve both standardized measures and detailed clinical interviews repeated over time.

Identification of suicidal ideations with the help of projective tests: a review

Identification of the presence of suicidal ideations in an individual is crucial for the timely intervention. However, these ideations may remain unidentified as an individual with serious intentions of self-harm may not express them explicitly. Various projective tests can provide crucial clues to clinicians about the presence of suicidal ideations in an individual's mind. The present review is intended to update clinicians working in the field of suicide prevention about salient findings on these tests which can serve as a ready reckoner for them. We also highlight the status of research in this domain.

Risk stratification using data from electronic medical records better predicts suicide risks than clinician assessments

BACKGROUND

To date, our ability to accurately identify patients at high risk from suicidal behaviour, and thus to target interventions, has been fairly limited. This study examined a large pool of factors that are potentially associated with suicide risk from the comprehensive electronic medical record (EMR) and to derive a predictive model for 1-6 month risk.

METHODS

7,399 patients undergoing suicide risk assessment were followed up for 180 days. The dataset was divided into a derivation and validation cohorts of 4,911 and 2,488 respectively. Clinicians used an 18-point checklist of known risk factors to divide patients into low, medium, or high risk. Their predictive ability was compared with a risk stratification model derived from the EMR data. The model was based on the continuation-ratio ordinal regression method coupled with lasso (which stands for least absolute shrinkage and selection operator).

RESULTS

In the year prior to suicide assessment, 66.8% of patients attended the emergency department (ED) and 41.8% had at least one hospital admission. Administrative and demographic data, along with information on prior self-harm episodes, as well as mental and physical health diagnoses were predictive of high-risk suicidal behaviour. Clinicians using the 18-point checklist were relatively poor in predicting patients at high-risk in 3 months (AUC 0.58, 95% CIs: 0.50 - 0.66). The model derived EMR was superior (AUC 0.79, 95% CIs: 0.72 - 0.84). At specificity of 0.72 (95% CIs: 0.70-0.73) the EMR model had sensitivity of 0.70 (95% CIs: 0.56-0.83).

CONCLUSION

Predictive models applied to data from the EMR could improve risk stratification of patients presenting with potential suicidal behaviour. The predictive factors include known risks for suicide, but also other information relating to general health and health service utilisation.

Rorschach score validation as a model for 21st-century personality assessment

Recent conceptual and methodological innovations have led to new strategies for documenting the construct validity of test scores, including performance-based test scores. These strategies have the potential to generate more definitive evidence regarding the validity of scores derived from the Rorschach Inkblot Method (RIM) and help resolve some long-standing controversies regarding the clinical utility of the Rorschach. After discussing the unique challenges in studying the Rorschach and why research in this area is important given current trends in scientific and applied psychology, I offer 3 overarching principles to maximize the construct validity of RIM scores, arguing that (a) the method that provides RIM validation measures plays a key role in generating outcome predictions; (b) RIM variables should be linked with findings from neighboring subfields; and (c) rigorous RIM score validation includes both process-focused and outcome-focused assessments. I describe a 4-step strategy for optimal RIM score derivation (formulating hypotheses, delineating process links, generating outcome predictions, and establishing limiting conditions); and a 4-component template for RIM score validation (establishing basic psychometrics, documenting outcome-focused validity, assessing process-focused validity, and integrating outcome- and process-focused validity data). The proposed framework not only has the potential to enhance the validity and utility of the RIM, but might ultimately enable the RIM to become a model of test score validation for 21st-century personality assessment.

Risk factors for medically serious suicide attempts: evidence for a psychodynamic formulation of suicidal crisis

This study explored a psychodynamic model for suicide risk by examining risk factors for medically serious suicide attempts, including assessments of affect flooding, negative self-schema / fragmentation, and impaired reality testing, closely approximating Maltsberger's psycho-dynamic formulation of suicide crisis. Baseline risk factors including age, gender, psychiatric symptoms, high-risk behaviors, and the Implicit Risk for Suicide Index (IRSI) were used to detect medically serious suicide attempts monitored for up to a year after the assessment. Twenty-five psychiatric inpatients who made life-threatening suicide attempts after assessment were compared to 25 inpatients and 25 psychotherapy outpatients who made no suicide attempts during follow-up. Statistical analysis revealed that a history of at least one suicide attempt and elevated IRSI scores accounted for 60 percent of the variance in detecting medically serious suicide attempts. Elevated IRSI accurately identified suicide attempt status above and beyond past suicide attempts and other empirically validated risk factors. Results are discussed in light of psychodynamic formulations of suicide risk.

Developing Continuous Variable Composites for Rorschach Measures of Thought Problems, Vigilance, and Suicide Risk

Using a multiple regression approach with a large developmental sample ( N = 460) of Rorschach protocols from psychiatric, forensic, and nonclinical control groups, the authors created continuous multivariable Composite scores corresponding to the Comprehensive System (CS) Perceptual-Thinking Index, Hypervigilance Index, and Suicide Constellation. Within a validation sample ( N = 230), these three new scores, called the Thought and Perception Composite, Vigilance Composite, and Suicide Concern Composite were strongly associated with the three original CS Indices. Additional analyses suggest that the new Composite scores were more reliable than and at least as valid as the original Indices. Interpretive guidelines are offered.

Depression and Vulnerability As Assessed by the Rorschach Method

We examined clinically depressed (CD; n = 16), previously depressed (PD; n = 19) and never depressed (ND; n = 18) individuals on 13 theoretically selected Rorschach (Exner, 1993; Rorschach, 1942) variables and on the Beck Depression Inventory (BDI; Beck, Rush, Shaw, & Emery, 1979). The group assignment was made according to the criteria of Diagnostic and Statistical Manual of Mental Disorders (4th ed.; American Psychiatric Association, 1994). We tested 2 contradictory models for depressive vulnerability, Beck's (Clark & Beck, 1999) and Miranda and Persons's (1988; Persons & Miranda, 1992), in a planned comparison design with focused contrasts. The CDs significantly contrasted the combined group of NDs and the PDs in a pathological direction on 8 of the 13 Rorschach variables and on the BDI. However, the combined group of CDs and PDs also significantly contrasted the NDs in a pathological direction on 3 of these Rorschach variables and on the BDI. In addition, logistic regression analyses indicated that Rorschach indexes significantly improved the prediction of major depression above and beyond that achieved by the BDI. The findings show that the Rorschach method was able to identify (a) cognitive and aggressive disturbances that are present in individuals who are actively depressed but not in individuals who have been depressed in the past or never been depressed and (b) affective and coping disturbances that are present in depressed individuals and to some degree in PD individuals but not in individuals who have not experienced depression. We discuss the scanty evidence of psychological disturbances in PD individuals, as measured with the Rorschach, in relation to the mood-state dependent hypothesis of Miranda and Persons (1988; Persons & Miranda, 1992).

Test de Rorscharch: respuestas diferenciales entre pacientes con y sin intento suicida

Este estudio tuvo como objetivo identificar respuestas diferenciales entre grupos de No-pacientes, pacientes diagnosticados con Depresión, pacientes diagnosticados con Trastorno de Personalidad y con Depresión y pacientes con intento suicida a través de los indicadores de la Escala de Potencial suicida, propuesto por Passalacqua, Herrera y Orcoyen (1997). La muestra total fue de 70 sujetos de sexo femenino, con grupos de aproximadamente 18 personas cada uno. Se encontró diferencia significativa en seis indicadores entre los cuatro grupos y en diez indicadores entre los pacientes con intento suicida y los demás participantes. Con estos indicadores se realizó un análisis discriminante, encontrándose una alta capacidad para diferenciar los diferentes subgrupos, en especial a grupo de pacientes con intento suicida y el resto de las personas. Se entrega una formula para calcular la probabilidad de pertenencia al grupo de intento de suicidio.

An examination of the construct validity of the Rorschach Mutuality of Autonomy (MOA) Scale

Using 100 clinical cases, we examined the construct validity of the Mutuality of Autonomy (MOA) Scale (Urist, 1977) using Westen and Rosenthal's (2003) r(contrast - construct validity (CV)) procedure for quantifying a pattern of convergent-discriminant relationships between a target measure and a set of criterion variables. Our 15 criterion variables included the Comprehensive System (CS; Exner, 2003) variables, a CS-based measure of ego strength (Resnick, 1994), and 3 subscales from the Social Cognition and Object Relations Scale (Westen, Lohr, Silk, Kerber, & Goodrich, 1990). We generated the r(contrast - CV) coefficients to test 2 competing hypotheses: that the MOA Scale primarily measures object relations (OR) quality or that it primarily measures psychopathology. Results suggest that the MOA Scale is an equally potent measure of OR and psychopathology regardless of the MOA Scale index used.

Rorschach variables and Big Five scales as predictors of military training completion: a replication study of the selection of candidates to the naval special forces in Norway

We tested 140 male candidates at the Naval Special Forces (NFS) of Norway on the Rorschach (Exner, 2003; Rorschach, 1921/1942) and the Norwegian version of the Big Five personality dimensions (Engvik & Føllesdal, 2005). Rorschach variables significantly correlated with training completion (effect sizes of r(e) = .14-.25), whereas none of the Big Five factors or facets did. The combination of Rorschach and Big Five variables framed in the illusory mental health concept provided strong predictive ability. Testing under stress produced slightly higher predictive validity coefficients between the Rorschach variables and pass-fail than under calm testing. The findings support the results of Hartmann, Sunde, Kristensen, and Martinussen (2003), indicating that Rorschach variables and indications of good mental health may be valid predictors of NFS training.

Convergence of self-report scales and Rorschach indexes of psychological distress: the moderating role of self-disclosure

In this study, we addressed the weak associations found in research between self-report measures and the Rorschach test (Exner, 1978, 1991), from the perspective of Bornstein's (2002) "process dissociation framework." Specifically, in the study, we focused on the associations between self-report measures of psychological distress and their corresponding Rorschach indexes while inspecting the moderating role of self-disclosure. A total of 59, nonpatient Israeli adults participated in a 2-session study. In the first session, they completed self-report scales measuring self-disclosure and psychological distress (suicidality, depression, and loneliness). In the second session, the Rorschach test was administered and coded. The participants were divided into high and low self-disclosure groups. A convergence between self-report and Rorschach measures of psychological distress was found only among high self-disclosers. In the discussion, we address the theoretical and clinical implications of these findings.

Rorschach correlates of adolescent self-mutilation

The present study examined various Rorschach variables of aggression, dysphoric affect, and disordered thinking in relation to self-mutilation in samples of self-mutilating (SM; n=16) and nonself-mutilating (N-SM; n=26) adolescent inpatients. Categorical comparisons indicated that SM patients had significantly higher mean scores for Aggressive Past (AgPast), but not for Aggressive Content (AgC), Aggressive Movement (AG), Morbid Content (MOR), Inanimate Movement (m), Sum Shading (SumY), and the Perceptual-Thinking Index (PTI), than N-SM patients. Additionally, logistic regression results suggested that PTI and AgPast were the most robust predictors of group membership. The authors propose that self-mutilating adolescents may struggle with internally directed aggression and victimized sense of self that, when coupled with disordered thinking, significantly predicts self-mutilation.

Assessing normal and abnormal personality functioning: strengths and weaknesses of self-report, observer, and performance-based methods

Assessing personality characteristics; distinguishing the boundaries between normal and abnormal functioning; identifying impairment in the domains of work, interpersonal relationships, and emotional state due to maladaptive personality traits; and translating these findings into effective, appropriate treatment interventions is a complicated endeavor. Valid, reliable conclusions about an individual's personality functioning and adjustment cannot be reached unless one has accurate information about that person's patterns of behavior, cognitions, emotions, and interpersonal relationships. I discuss strengths and weaknesses of assessment approaches utilizing explicit assessment methods, such as self-report measures and clinical interviews; information obtained from knowledgeable observers; and performance-based, implicit assessment methods such as the Rorschach Comprehensive System (Exner, 2003). In contrast to explicit methods of assessment, implicit methods can provide salient information about a personality construct whether or not individuals have accurately conceptualized that construct, have weighed how the construct describes them, are self-aware, and are willing to openly provide information relevant to that construct. I propose that the accuracy of conclusions about an individual's personality style, problems in adjustment, and treatment needs may be improved if conclusion are based on a multimethod assessment approach that incorporates information gathered using explicit assessment methods, information provided by significant others, and data from performance-based or implicit measures of personality.

The status of the Rorschach in clinical and forensic practice: an official statement by the Board of Trustees of the Society for Personality Assessment

This statement is intended for psychologists, other mental health professionals, educators, attorneys, judges, and administrators. Its purpose is to present a summary of the issues and evidence concerning the Rorschach. This statement affirms that the Rorschach possesses reliability and validity similar to that of other generally accepted personality assessment instruments, and its responsible use in personality assessment is appropriate and justified.

CSF 5-HIAA and the rorschach test in patients who have attempted suicide

Two independent measures, 5-HIAA and the Rorschach Suicide Constellation (S-CON), both related to suicide, were studied in an attempt to explore any relationship between the two. Lumbar puncture and the Rorschach were performed in standardized manner on 38 consecutive psychiatric inpatients, who had made a recent suicide attempt. Low CSF 5-HIAA was significantly related to the S-CON (rs = -.517, p = .033) and the Vista variable in the S-CON appeared to play an important role for the correlation. The results indicate that suicide attempters with low CSF 5-HIAA in this sample tended to experience more discomfort and pain during self-inspection. These results raise questions whether shame may be involved in the psychobiology of suicide.

A Consideration of Challenges to Psychological Assessment Instruments Used in Forensic Settings: Rorschach As Exemplar

In this brief primer, we provide an outline of key issues that will help psychologists organize and prepare their expert testimony. These issues include the need to obtain essential sources of research, a review of the actual legal standards regarding admissibility of test data in expert testimony, the nature of the expert relative to the assessment instrument in expert testimony, the nature of legal versus scientific debate, and the examination of appropriate qualifications of expertise when offering legal testimony. In addition, we use a summary of information contained in several recent articles to address challenges directed against forensic psychological testing. We use the empirical literature on the Rorschach as an exemplar in discussing these issues, as the admissibility of the Rorschach in particular has been challenged, and the issues frequently focused on with the Rorschach are equally applicable to other psychological measures. In this article, we provide essential sources of Rorschach research regarding several empirical studies that summarize important information and directly address previous criticisms of the measure.

The LSARS-II: Lethality of Suicide Attempt Rating Scale-Updated

The concept of lethality is essential to the assessment of suicide risk; yet operational definitions of lethality for purposes of its measurement have been loose and varied. A number of scaling measures have been published in the literature, with no relative consensus on the best of these. In addition, only a few of these scales have published data on their psychometric properties. Of these, we argue that the best is the Lethality of Suicide Attempt Rating Scale (LSARS; Smith, Conroy, & Ehler, 1984). Presented here is a significantly revised and redesigned listing of drugs and chemicals and lethal ranges of ingestion (in caps, tabs, or ounces) by body weight to update that scale.

Psychological measures as predictors of military training performance

The predictive validity of 7 ability tests, the Big Five, and the Rorschach method administered to 71 male applicants at the Naval Special Forces (NSF) of Norway was evaluated based on pass/fail results in training. The findings showed: (a) small correlations between the ability tests, the Big Five scales, and the success criterion; (b) Rorschach variables measuring stress tolerance, reality testing, cognition, and social adjustment correlated significantly (r =.25 to.48) with pass/fail results in training, and (c) logistic regression analysis revealed that 3 of the Rorschach variables accumulated incrementally in the prediction of training completion when entered after the ability tests and the Big Five scales, thus supporting the merit of using Rorschach variables for predicting NSF training performance

An examination of interrater reliability for scoring the Rorschach Comprehensive System in eight data sets

In this article, we describe interrater reliability for the Comprehensive System (CS; Exner. 1993) in 8 relatively large samples, including (a) students, (b) experienced re- searchers, (c) clinicians, (d) clinicians and then researchers, (e) a composite clinical sample (i.e., a to d), and 3 samples in which randomly generated erroneous scores were substituted for (f) 10%, (g) 20%, or (h) 30% of the original responses. Across samples, 133 to 143 statistically stable CS scores had excellent reliability, with median intraclass correlations of.85, .96, .97, .95, .93, .95, .89, and .82, respectively. We also demonstrate reliability findings from this study closely match the results derived from a synthesis of prior research, CS summary scores are more reliable than scores assigned to individual responses, small samples are more likely to generate unstable and lower reliability estimates, and Meyer's (1997a) procedures for estimating response segment reliability were accurate. The CS can be scored reliably, but because scoring is the result of coder skills clinicians must conscientiously monitor their accuracy.