Rorschach Changes in Long-Term Short-Term Psychotherapy

Over a period of several years, repeat Korschach testing was done with two groups of patients receiving outpatient psychotherapy, a long-term group (n = 88) engaged in intensive, dynamically oriented psychotherapy and a short-term group (n = 88) involved in behavioral or gestalt therapy. Rorschach protocols were obtained at the beginning of the treatment and on three subsequent occasions, 1 year, 21/2 years, and 4 years later, when most of the long-term and all of the short-term patients had completed their therapy. The findings demonstrate generally beneficial effects of psychotherapy, greater change in long-term than in short-term therapy, and the validity of the Rorschach for measuring these effects and changes.     

Langzeitwirkungen psychoanalytischer und verhaltenstherapeutischer Langzeitpsychotherapien

The prospective study compares 31 patients in long-term behavior therapy with 31 patients in psychoanalytically oriented long-term therapy. A naturalistic design was applied within the German health system. All patients underwent a diagnostic interview (SCID) by an external interviewer. Only patients who fulfilled the DSM III-R criteria for a depression or an anxiety disorder were included in the study. Although the diagnoses of the patients undergoing long-term behaviour therapy and long-term psychoanalytical psychotherapy were comparable, we found that they differed in various ways. The differences arose in a number of characteristics, such as education, access to psychotherapy (recommended by professionals versus patients introducing themselves), usage of psychotropic medication, and the strain of symptoms. The average duration of long-term behavior therapy was 2.4 years and 64 sessions. The average duration of psychoanalytically oriented long-term therapy was 3.6 years and 209 sessions. Symptoms (SCL-90-R) and interpersonal problems (IIP) were examined at the beginning, after 1 year, 2.5 years, 3.5 years and after 7 years. Both groups showed significant degrees of improvement within the first 3.5 years and remained stabilized in the following 3.5 years regarding the symptomatic aspects. Focussing on the interpersonal problems, group PA showed further improvement after the 3.5-year period. The BT group however, showed no further improvement after 3.5 years but stabilized. The evaluated phase-model of psychotherapeutic change for short-term therapy was confirmed more clearly for long-term therapies of psychoanalytical orientation than for long-term therapies of behavioral orientation.     

Prognostic validity of the Rorschach

Fifty adult stutterers entering therapy at the UCLA Psychology Clinic were administered the Rorschach, with a Klopfer method inquiry, scoring, form level rating, and calculation of scores on the Rorschach Prognostic Rating Scale (RPRS). On the basis of independent clinician ratings of attitudinal or psychotherapeutic improvement, subjects were divided into groups of Improved Most (n = 21) and Improved Least (n = 29). Subjects were also divided into Continued (n = 43) and Dropped (n = 7). Logistic regression was employed to compare groups on the following Rorschach dimensions: Prognostic Score (RPRS); Human Movement; Animal Movement; Inanimate Movement; Shading; Color; Form Level. The Improved Most group was significantly higher in M, FM, Shading, and Productivity. The finding that M and FM discriminates between improvement groups corroborates results obtained in a previous study (Sheehan et al., 1954). The Rorschach movement variables, particularly M and FM, seem to be stable indicators of capacity for improvement in psychotherapy.     

Interviews of female patients with borderline personality disorder who dropped out of group psychotherapy

Premature termination from group psychotherapy continues to be a serious problem in the treatment of patients with borderline personality disorder (BPD). Qualitative research is regarded as an important means to shed light upon the complex dynamics leading to dropout. We conducted an interview study with patients having a diagnosis of BPD (n = 8) who dropped out from long-term group psychotherapy as a continuation therapy following intensive day treatment. The group therapists for these patients were interviewed as well (n = 12). The findings suggest the operation of many processes that contribute to dropout. Most significant appeared to be experiences of separation and loss of the day hospital that were not worked through and a failure of the group to regulate and contain the patients' affects. To integrate patients at risk of premature termination it seems necessary to pay attention to the strong negative emotions that they experience in the group. A higher treatment intensity than weekly group sessions may help to promote more beneficial group processes.     

Rorschach assessment of changes following psychotherapy: a meta-analytic review

I examined Rorschach assessment of personality changes following psychotherapy. I conducted a comprehensive literature search to find all studies using the Rorschach method at least twice for the same participant in connection with psychotherapy. I conducted meta-analyses for 38 samples, and I performed regression analyses to identify moderating factors. Across all Rorschach scores, the total weighted sample effect size was r = .26, and nearly half the variables obtained effect sizes higher than .30. Several moderating factors were found. Most important, effect sizes increased with longer and more intensive therapy. More concern for interscorer reliability was associated with larger effect sizes, whereas a higher degree of scorer blinding was associated with smaller effect size magnitudes. Predicted levels of change based on the regression models indicated substantial increases in effect size with longer therapies. The data indicate that many elements in the Rorschach are valid indicators of change despite the poor reputation the method has acquired within psychotherapy research.     

Evaluation of a cognitive behavioral group intervention program for spouses of stroke patients

This study investigated the effectiveness of a cognitive behavioral group program for spouses of stroke patients. The program consists of 15 bi-monthly 112h sessions. The goal of the intervention is to reduce the prevalence of mental disorders and burnout among care-giving spouses of stroke patients. The sample (stroke patients and their spouses) consisted of one intervention group (n=38 couples) and two different control conditions, those receiving informational support (n=35 couples) and those receiving standard care (n=51 couples). We used the following instruments to measure spouses' mental health and quality of life: Beck Anxiety Inventory (BAI), Beck Depression Inventory (BDI), WHO Quality of Life Questionnaire. Measurements were taken before the intervention (Time 1), directly following the intervention (Time 2) and 6 months after Time 2 (Time 3). Several regression analyses allowed for examination of the short-term and long-term effects of the intervention. The spouses' participation in the intervention program was associated with significant short-term changes in care-giving spouses' quality of life and with long-term changes in their quality of life and depression. The presented multi-component intervention appears to have an immediate effect on care-giving spouses' quality of life. In contrast, the intervention-related changes in more resistant mental-health-related variables did not appear until after a latent stage in the later post-intervention phase.     

Rorschach changes following brief and short-term therapy.

Two groups of 35 patients each, one treated with brief therapy, averaging 14.2 sessions on a once per week basis, and the other group, treated with a short-term type of therapy, averaging 47 sessions on a once per week basis were administered the Rorschach and the Katz Adjustment Scales-Form S three times. The first administration took place before entering therapy. The brief therapy group was tested a second time at termination of treatment and again 8 to 12 months following termination. The short-term therapy group was tested the second time at therapy termination and the third time 10 to 12 months after termination. Each group reported substantially fewer symptoms at termination and continued to report about the same level of symptom reduction at the second retest. The Rorschach data seem to provide an ample basis from which to argue that considerable improvement occurred in the psychological organization and/or operations of both groups, and this appears to have some confirmation in the self-report data.     

Rorschach test findings at the beginning of treatment and 2 years later, with a 30-year follow-up

In this article, I report a case containing 2 Rorschach assessments-the first (R1) 30 years ago at the beginning of a 4-year period of psychotherapy and the second (R2) 2 years later. I also recently contacted the patient to obtain information about his life during the 26 years since termination. This report examines the 2 Rorschach protocols-combining the Comprehensive System (CS; Exner, 2003) structural summaries with thematic content analysis-in relation to the patient's history, treatment, and 30-year outcome. I focus on the change between R1 and R2, particularly the shift from an introversive to an ambitent EB and a corresponding shift from 6 Y responses on R1 to 6 m responses on R2. In the clinical interpretation, I considered these shifts in a context of the patient's patterns of managing destabilization and overstimulation.     

The rorschach search for the borderline Holy Grail: an examination of personality structure, personality style, and situation

Much of the research on the use of the Rorschach to diagnose borderline disturbance has sought to discover a specific borderline pattern or Rorschach configuration. Given our increased understanding of borderline functioning representing a level of personality organization (or personality structure), this single pattern approach is excessively simplistic. It fails to consider the complex interaction between personality structure, personality style, and situational variables. An approach to the Rorschach assessment of borderline functioning is presented using a clinical example. The patient was tested at the onset of psychotherapy and then some 4 years into treatment. Results from the two testings were compared using Weiner and Exner's (1991) Rorschach variable clusters for assessing change in psychotherapy.     

Change after long-term psychoanalytic psychotherapy

Psychoanalytic psychotherapy in clinical practice is traditionally a long-term treatment conducted by well-trained psychotherapists. However, very few studies have been published that evaluate the effects of such treatment. To redress this lack of studies, 55 individuals selected for long-term psychoanalytic psychotherapy (average, 3 years) were invited to participate in a naturalistic study. The psychotherapists had a mean of 15 years of professional experience. The 36 patients who completed psychotherapy manifested a substantial reduction in symptomatic suffering and decreased levels of character pathology, as measured by the Karolinska Psychodynamic Profile (KAPP) and the Karolinska Scales of Personality. Generally, such changes were not found in the individuals who did not engage in treatment. In the therapy group, improvements were found on eight KAPP subscales defining different aspects of character: Intimacy and Reciprocity, Frustration Tolerance, Regression in the Service of the Ego, Coping with Aggressive Affects, Conceptions of Bodily Appearance and their Significance for Self-esteem, Sexual Function, Sexual Satisfaction, and Personality Organization. The results indicate that individuals who engaged in psychotherapy improved their capacity to handle crucial aspects of life and reduced their symptomatic suffering.     

Personality Dimensions in Two Types of Learning-Disabled Children: A Rorschach Study

Children referred for psychoeducational assessment of learning disabilities (LDs) commonly receive the Rorschach test. Yet little is known about the impact of LD on Rorschach response patterns. This study investigated Rorschach response patterns in two groups of 9- to 12-year-old children (n = 41) classified by their respective intellectual abilities. Another group of 9- to 12-year-olds (n = 143) served as a nonclinical comparison group. Rorschach variables indicative of personality dimensions failed to discriminate between the two LD groups. Compared to the nonclinical group, the LD group exhibited several Rorschach characteristics—including problems in perceptual accuracy, inefficient visual scanning and problem-soving strategies, and avoidance of affect-laden stimuli—having implications for successful socioemotional adaptation.     

Journeys through the valley of death: multimethod psychological assessment and personality transformation in long-term psychotherapy

The Psychodynamic Diagnostic Manual (PDM Task Force, 2006) is based on the assumption that an in-depth understanding of clients' underlying emotional, personality, and interpersonal patterns will facilitate their treatment. In this article I show how such an understanding can be achieved through multimethod psychological assessment, and how useful such information can be in long-term psychotherapy with high-achieving, successful clients who struggle with forming and maintaining intimate relationships. Such treatments are extremely difficult, because when these clients attach to their psychotherapists, many of them temporarily become more symptomatic. I illustrate these points with a detailed account of my long-term therapy with a resilient but highly traumatized young man. Repeated use of the Minnesota Multiphasic Personality Disorder-2 (MMPI-2; Butcher, Dahlstrom, Graham, Tellegen, & Kaemmer, 1989) and Rorschach with my client helped guide us in our work, and also helped create an important therapeutic "opening" into the underlying traumatic material. This and other experiences have convinced me that it is extremely useful for psychologists to have training in both assessment and psychotherapy.     

Personality dimensions in two types of learning-disabled children: a Rorschach study

Children referred for psychoeducational assessment of learning disabilities (LDs) commonly receive the Rorschach test. yet little is known about the impact of LD on Rorschach response patterns. This study investigated Rorschach response patterns in two groups of 9- to 12-year-old children (n = 41) classified by their respective intellectual abilities. Another group of 9- to 12-year-olds (n = 143) served as a nonclinical comparison group. Rorschach variables indicative of personality dimensions failed to discriminate between the two LD groups. Compared to the nonclinical group, the LD group exhibited several Rorschach characteristics--including problems in perceptual accuracy, inefficient visual scanning and problem-solving strategies, and avoidance of affect-laden stimuli--having implications for successful socioemotional adaptation. Suggestions for further research are discussed.     

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).     

Relationship between patient characteristics and treatment allocation for patients with personality disorders

Within a large multi-center study in patients with personality disorders, we investigated the relationship between patient characteristics and treatment allocation. Personality pathology, symptom distress, treatment history, motivational factors, and sociodemographics were measured at intake in 923 patients, who subsequently enrolled in short-term or long-term outpatient, day hospital, or inpatient psychotherapy for personality pathology. Logistic regressions were used to examine the predictors of allocation decisions. We found a moderate relationship (R(2) = 0.36) between patient characteristics and treatment setting, and a weak relationship (R(2) = 0.18) between patient characteristics and treatment duration. The most prominent predictors for setting were: symptom distress, cluster C personality pathology, level of identity integration, treatment history, motivation, and parental responsibility. For duration the most prominent predictor was age. We conclude from this study that, in addition to pathology and motivation factors, sociodemographics and treatment history are related to treatment allocation in clinical practice.     

Time-Limited Dynamic Psychotherapy as a Model for Short-Term Inpatient Groups

The present article proposes a method, practiced by the author, to adapt time-limited dynamic psychotherapy (TLDP), a short-term individual psychodynamic therapy, for use with inpatient psychotherapy groups. Characteristics of TLDP which suggest the usefulness of such an adaptation, including short-term duration, specific treatment focus, rapid conceptualizations and broad selection of patients, and emphasis on the here-and-now in therapy, are discussed. The general approach to treatment, a supportive stance that involves an identification of maladaptive interpersonal issues, and then working on these issues without directly confronting the patients, is described. Specific therapeutic techniques for common inpatient group situations are also discussed.     

Appraisal of suicidal risk among adolescents and young adults through the Rorschach test

The aims of this study are to investigate suicidal behaviors among adolescents and young adults and to test an index composed using Rorschach test responses related to an increased risk of suicide. Using a cross-sectional design, 4 groups were studied (according to criteria of the Columbia Classification Algorithm of Suicide Assessment [Posner, Oquendo, Gould, Stanley, & Davies, 2007]): A group with suicidal ideation (n = 30), a group with parasuicidal behavior (n = 30), a group with near-lethal suicide attempts (n = 26), and a control group (n = 30). Responses to the Rorschach test yielded 6 potential indicators of suicidal behavior (scored according to Exner's Comprehensive System and the Suicidal Index for Adolescents; Silberg & Armstrong, 1992 ). Rorschach scores including at least 4 of these 6 indicators selected 69% of the people who had committed serious suicide attempts. The Rorschach Suicidal Index reached an acceptable reliability and was related to other criteria of suicide risk, such as the Beck Depression Inventory (BDI; Beck, Ward, Mendelsohn, Mock, & Erbaugh, 1961) and Linehan Reasons for Living Inventory (RFL-I; Linehan, Goodstein, Nielsen, & Chiles, 1983). Moreover, the Rorschach Suicidal Index showed incremental validity over the BDI and the RFL-I to predict suicidal behavior. A path analysis additionally showed that low social support was an important mediator between the Rorschach Suicidal Index and the number of suicide attempts committed by participants.     

Therapeutic factors in two forms of inpatient group psychotherapy: Music therapy and verbal therapy

Therapeutic processes in one type of creative arts group psychotherapy, music therapy, were compared with verbal group psychotherapy. Sixty-one short-term inpatients ranked group psychotherapy curative factors and completed satisfaction ratings. Therapists rated 201 group therapy sessions— 109 music therapy and 92 verbal therapy. Statistical analysis revealed that patients highly valued both group formats. The mean curative factor rankings for both groups included cohesiveness, instillation of hope, and altruism among the most helpful factors. Therapists' ratings indicated qualitative differences between the two groups. Music therapy involved more therapeutic interaction among patients and emotional expression, whereas verbal therapy emphasized concrete problem solving.Supported in part by Biomedical Research Support Grant Program grant #S07-RR05755 from the Division of Research Resources, National Institutes of Health.