A Commentary on “Developments in the Rorschach Assessment of Disordered Thinking and Communication” (Kleiger & Mihura, 2021)

Free AccessA Commentary on “Developments in the Rorschach Assessment of Disordered Thinking and Communication” (Kleiger & Mihura, 2021)Lindy-Lou Boyette and Arjen NoordhofLindy-Lou BoyetteLindy-Lou Boyette, Department of Clinical Psychology, University of Amsterdam, Nieuwe Achtergracht 129D, 1001 NK Amsterdam, The Netherlands, E-mail l.l.n.j.boyette@uva.nl Department of Clinical Psychology, University of Amsterdam, The Netherlands Search for more papers by this author and Arjen Noordhof Department of Clinical Psychology, University of Amsterdam, The Netherlands Search for more papers by this authorPublished Online:September 15, 2021https://doi.org/10.1027/1192-5604/a000145PDF ToolsAdd to favoritesDownload CitationsTrack Citations ShareShare onFacebookTwitterLinkedInRedditE-Mail SectionsMore“Why on earth would one use the Rorschach to assess disordered thinking?” was the almost Pavlovian reaction of the second author to the request to write this commentary. This uninformed response was markedly changed after reading the excellent contribution by Kleiger and Mihura (2021), as well as the research they cite. The authors convincingly argue for the reliability and validity of a set of Rorschach scales that assess thought disorder. Hence, we see no reason why one shouldn’t use these scales for this purpose.Apart from reliability and validity, the question “why use the Rorschach?” encompasses utility. This deserves attention if one wishes to convince new researchers and clinicians to start using the instrument. We will review current instruments for disordered thinking and communication and discuss the hypothetical (incremental) utility of the Rorschach in research and in clinical practice.Other Research InstrumentsWe concur with the authors that the Rorschach is at the moment (unfortunately!) not valid for the assessment of the negative dimension of thought disorder and therefore will focus only on the assessment of the positive dimension. Four different methods of assessment have been used for this purpose: (1) clinician ratings of free-speech, (2) semistructured interviews, (3) questionnaires, and (4) performance-based or projective tasks, such as the Rorschach itself.The standard research instrument for disordered thinking and communication is the Scale for the Assessment of Thought, Language and Communication (TLC; Andreasen, 1986). The TLC is most commonly used in research and is generally included in the assessment of convergent validity of other instruments. The TLC consists of 18 clinician-rated items concerning communication disorders (e.g., tangentiality, perseveration), language disorder (e.g., word approximations, neologisms) and thought disorder (e.g., poverty of speech and illogicality). Clinicians base their assessment on observations of spontaneous speech, for instance a standard psychiatric interview. The TLC has been critiqued for being less sensitive to subtle, subclinical gradations of disturbance as found in the speech of nonaffected relatives of patients with psychotic disorders and individuals without a psychiatric disorder (Docherty et al., 1997).An interesting alternative to the TLC is the Thought and Language Disorder (TALD) scale (Kircher et al., 2014). Just like the TLC it uses clinician ratings of spontaneous speech (25 items based on a 50-minute unstructured interview). Additionally, the TALD assesses the patient’s own perspective through a semistructured interview concerning five more internal and subtle symptoms. Clinician-rated symptoms had strong convergence with other clinician-rated scales and clear divergence from ratings of depression and mania. Correlations between self-reported and clinician-rated positive symptoms were either nonsignificant (TALD, SAPS/SANS) or low (r = .22 with TLC linguistic control).1An alternative attempt at assessing the patient’s perspective is the Formal Thought Disorder Scale (FTD; Barrera et al., 2008), which is the only questionnaire we are aware of that is specifically directed at disordered thinking and communication.2 Both a self-report and an informant version are available. Both showed adequate reliability. Total scores showed moderate convergence (r = .30 for self-report and r = .52 for informant-report) with clinician-rated symptoms assessed by the Comprehensive Assessment of Symptoms and History (CASH) (Andreasen et al., 1992), while self-report and informant-report were uncorrelated.The final class of instruments use performance-based or projective tasks to elicit speech from subjects, which is then rated by an observer. The Thought Disorder Index (TDI) (Solovay et al., 1986) is based on verbatim scripts of responses to the Rorschach inkblots (Rorschach, 1942) and, potentially, any observed deviant verbalizations as noted by the observer during completion of the verbal subtests of the Wechsler Adult Intelligence Scale (WAIS-R; Wechsler, 1981). The Thought and Language Index (TLI; Liddle et al., 2002) uses either the Rorschach or Thematic Apperception Test (TAT; Murray, 1943) cards to elicit speech but is much briefer than the TDI, collecting eight 1-minute speech samples. The Bizarre-Idiosyncratic Thinking Scale (BIT; Marengo et al., 1986) is also quite quick to administer, as it employs only the WAIS Comprehension subtest and a 12-item proverb test.Of the performance-based or projective instruments, the Rorschach is the only instrument with meta-analytic support for reliability and validity. In regard to its most recent version, the Rorschach Performance Assessment System (R-PAS; Meyer et al., 2011), a second strong and unique quality is the inclusion of age-based norms. This is important as the frequency and severity of disordered thinking and communication is higher in children and adolescents (Roche et al., 2015). The most notable limitation to the Rorschach/R-PAS is the time and effort needed to learn how to administer, score, and interpret the instrument. It is therefore positive that the R-PAS team is working on shortened versions and further simplified, perhaps automated coding.Research UtilityFirst some thoughts on research utility of the Rorschach. In general, we believe multimethod to be preferable to monomethod assessment. A major disadvantage of the latter is the conflation of phenomena with their measurement. If one attempts to assess the same phenomenon with different methods, there are likely to be substantial divergences between methods. This is clearly demonstrated by the aforementioned covariance patterns of the perspectives of clinicians, informants, and patients. This does not necessarily indicate a lack of validity as different informants (self, clinician, carer) have different perspectives and contexts and hence should not necessarily converge (Noordhof et al., 2008). Performance-based tests like the Rorschach add another source of divergence to this puzzle. For research, such divergent findings are crucially important. They may indicate that one or both methods are unreliable or invalid, but often they instead point towards the fact that the phenomena under consideration are complex, multifaceted, and not yet fully understood. Such acknowledgement is extremely important for any genuinely scientific project.So why add a performance-based task? One advantage of performance-based tasks is that they do not rely on introspection or outside observation. Hence, they may tap into domains that are not easily captured by observation or introspection and which may otherwise remain unknown or dynamically unconscious (Finn, 1996). A second possible advantage of performance-based tasks is that they can have demonstrable incremental predictive utility (Shedler et al., 1993). We are not aware of any research demonstrating incremental predictive utility with the Rorschach scales reviewed here, for instance in regard to transition to clinical disorder or psychotic relapse or remission, and this would be a fruitful line for future research. Third, as performance-based tests are less transparent, they can add value to the assessment of malingering. There is an historic interest in the Rorschach as a measure of malingering psychosis and although there is support for this use (Kleiger, 2017), a specific malingering pattern has not yet established (Perry & Kinder, 1990). The R-PAS, which is more standardized than older versions of the Rorschach in terms of number of responses, could be of interest for this topic.Furthermore, as mentioned, the TLC has been critiqued for not capturing the more subtle aspects of disordered thinking and communication. The Rorschach is a likely candidate to improve on this as the sumscale (WSumCog) is based on the frequency of both mild and more severe indications. The TALD and FTD may be used for the same purpose. We do not know of any research comparing these approaches in terms of their utility for capturing mild disturbances but would certainly be very interested in the outcomes.Clinical UtilityThe Rorschach is not only a research instrument. It is also promoted very much as a clinical tool. Hence, we wondered what clinical utility might be obtained if nonusers learn to use the test. Utility is very dependent on the context and goals of use (Kamphuis et al., 2020), so we will discuss possible uses in three contexts that we deem most relevant: the clinic for psychotic disorders, assessment of personality (disorder), and psychoanalytically oriented structural diagnosis.Based on our personal experience (LLB conducted assessment for a psychosis department for over 10 years), none of the aforementioned instruments – including the Rorschach – are currently routinely used in the clinical care of patients with psychotic disorders or individuals with at-risk mental states. Eblin et al. (2018) argue that the Rorschach may have incremental validity for (1) assessing psychosis when used in conjunction with neuropsychological and neuroimaging tasks, (2) for identifying individuals at risk for psychosis, and (3) for assessing social and functional deficits. In the psychosis clinic, assessment of functioning is currently generally limited to cognitive functioning, for which purpose neuropsychological test batteries are conducted. Neuropsychological and neuroimaging tasks are not utilized for identifying or assessing psychosis. Instead, semistructured interviews containing multiple symptom dimensions of psychosis, such as the CASH (Andreasen et al., 1992) and PANSS (Kay et al., 1989) or the CAARMS for at-risk states (Yung et al., 2003), are standard. These interviews all contain a few observational, clinician-rated items of disordered thinking and communication (in case of the CASH, this is a small subset of TLC items). By definition, these items will not capture the full range of disordered thinking and communication. However, in order to convince clinicians to include the Rorschach, empirical evidence on its incremental validity for assessing factors relevant for the clinical care of patients with psychotic disorders or individuals with at-risk mental states, of which several have been discussed, is needed.Current use of the Rorschach is more frequent in care settings that are not specific to psychosis. In these contexts, it could very well be of help in detecting subtle forms of disordered thinking and communication, which are commonly encountered in patients with a diverse range of primary diagnoses (Van Os & Reininghaus, 2016). At the core of the alternative model for personality disorders (AMPD) in section 3 of DSM-5 (APA, 2013), there is a hierarchical structure of personality traits consisting of five broad domains and disordered thinking and communication pertain to the broad domain of psychoticism. The Rorschach might be used in a multimethod approach to the assessment of facets in the domain of psychoticism. The AMPD cannot only be applied to severe personality disorders, but also to mildly problematic features of personality in many other patients. This potentially opens up a vast area of possible uses of the Rorschach, although, on a more skeptical note, we have not encountered evidence that this would result in substantial treatment utility (nor did we find evidence to the contrary).Finally, the processes Kleiger and Mihura (2021) discuss are often inscribed in a psychoanalytic orientation towards how the mind works. From this perspective it can be argued that primary process thinking is not an exclusive property of overtly psychotic people but is generally repressed in neurotic subjects leading to compromise formations like dreams, slips, and symptoms. Such formations and secondary defense mechanisms are the typical result of neurotic resolutions to the Oedipus complex. Primary processes become mainly unconscious, and their libidinal force expresses or erupts in, for example, jokes or permitted transgressions. If these defenses are strongly developed, one would expect Rorschach responses that are reflective of specific secondary defenses (e.g., isolation of affect or humor) rather than primary process responses. In psychotic structures (Kernberg, 1984) the oedipal constellation is not resolved by general repression, and primary process thinking and primary defenses are thus much more prominent and overt, which would presumably result in primary process (or uncensored) responses on the Rorschach. This would certainly be the case in manifest psychosis, but people with psychotic structures are often capable of adapting to neurotic expectations and thereby appearing rather “normal.” It stands to reason, and is an interesting hypothesis for research, that especially for the group that is not manifestly psychotic the Rorschach would be useful. Furthermore, in people who have mainly developed neurotic compromises primary process thinking may still be present in a way that is not easily detectable and for which the Rorschach might be a useful diagnostic tool. Likewise, primary process thinking in people diagnosed as borderline (Kernberg, 1967) seems like an area for which the Rorschach can also be useful. For example, it could help to distinguish between people with borderline disorder characterized by mainly neurotic structure but much traumatic reactivity, acting out, and unmitigated transference on the one hand, and people with borderline disorder for whom primary process thinking is a rather important feature of the general structure of their personality on the other. Such distinctions have important clinical implications for how analytically informed therapies should proceed (e.g., McWilliams, 2011). However, as a cautionary note: In order to have incremental utility, the Rorschach should outperform clinical judgment on the basis of the development of speech and transference, which remains to be demonstrated.ConclusionKleiger and Mihura have convinced us that the Rorschach is valid and reliable for the assessment of disordered thinking and communication, and we do now think that the instrument deserves a more prominent place in research. We have made some recommendations for further areas of study. We have also presented ideas for how its use in clinical practice may be helpful. The Rorschach should no longer be harshly judged on criteria that are not typically met by alternatives. Nevertheless, solid evidence for utility is the royal road towards broader adoption of the instrument.1Another clinician-rated interview is the CLANG (Chen et al., 1997) which we have omitted due to space constraints. The currently discussed instruments all follow a definition of disordered thinking and communication broadly comparable to Andreasen (1986). The CLANG is based on a highly different conceptualization, namely psycholinguistic concepts.2There are also several self-report omnibus tests that include scales related to these phenomena, but we omit these for lack of space.References American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorder (DSM 5) First citation in articleCrossref, Google Scholar Andreasen, N. C. (1986). Scale for the Assessment of Thought, Language, and Communication (TLC). Schizophrenia Bulletin, 12(3), 473–482. https://doi.org/10.1093/schbul/12.3.473 First citation in articleCrossref, Google Scholar Andreasen, N. C., Flaum, M., & Arndt, S. (1992). The Comprehensive Assessment of Symptoms and History (CASH): An instrument for assessing diagnosis and psychopathology. Archives of General Psychiatry, 49(8), 615–623. https://doi.org/10.1001/archpsyc.1992.01820080023004 First citation in articleCrossref, Google Scholar Barrera, A., McKenna, P. J., & Berrios, G. E. (2008). Two new scales of formal thought disorder in schizophrenia. Psychiatry Research, 157(1–3), 225–234. https://doi.org/10.1016/j.psychres.2006.09.017 First citation in articleCrossref, Google Scholar Chen, E. Y. H., Lam, L. C. W., Kan, C. S., Chan, C. K. Y., Kwok, C. L., Nguyen, D. G. H., & Chen, R. Y. L. (1997). Language disorganization in schizophrenia: Validation and assessment with a new clinical rating instrument. Hong Kong Journal of Psychiatry, 6(1), 4–13. First citation in articleGoogle Scholar Docherty, N. M., Miller, T. N., & Lewis, M. A. (1997). Communication disturbances in the natural speech of schizophrenic patients and non-schizophrenic parents of patients. Acta Psychiatrica Scandinavica, 95(6), 500–507. https://doi.org/10.1111/j.1600-0447.1997.tb10138.x First citation in articleCrossref, Google Scholar Eblin, J. J., Meyer, G. J., Mihura, J. L., Viglione, D. J., & O’Gorman, E. T. (2018). Development and preliminary validation of a brief behavioral measure of psychotic propensity. Psychiatry Research, 268, 340–347. https://doi.org/10.1016/j.psychres.2018.08.006 First citation in articleCrossref, Google Scholar Finn, S. (1996). Assessment feedback integrating MMPI-2 and Rorschach findings. Journal of Personality Assessment, 67(3), 543–557. https://doi.org/10.1207/s15327752jpa6703_10 First citation in articleCrossref, Google Scholar Kamphuis, J. H., Noordhof, A., & Hopwood, C. J. (2020). When and how assessment matters: An update on the Treatment Utility of Clinical Assessment (TUCA). Psychological Assessment, 33(2), 122–132. https://doi.org/10.1037/pas0000966 First citation in articleCrossref, Google Scholar Kay, S. R., Opler, L. A., & Lindenmayer, J. P. (1989). The Positive and Negative Syndrome Scale (PANSS): Rationale and standardisation. The British Journal of Psychiatry: Supplement, 13(7), 59–67. First citation in articleCrossref, Google Scholar Kernberg, O. F. (1967). Borderline personality organization. Journal of the American Psychoanalytic Organization, 15, 641–685. First citation in articleCrossref, Google Scholar Kernberg, O. F. (1984). Severe personality disorders, psychotherapeutic strategie. Yale University Press. First citation in articleGoogle Scholar Kircher, T., Krug, A., Stratmann, M., Ghazi, S., Schales, C., Frauenheim, M., Turner, L., Fährmann, P., Hornig, T., Katzev, M., Grosvald, M., Müller-Isberner, R., & Nagels, A. (2014). A rating scale for the assessment of objective and subjective formal thought and language disorder (TALD). Schizophrenia Research, 160(1–3), 216–221. https://doi.org/10.1016/j.schres.2014.10.024 First citation in articleCrossref, Google Scholar Kleiger, J. H. (2017). Rorschach assessment of psychotic phenomena: Clinical, conceptual, and empirical developments. Routledge/Taylor & Francis. First citation in articleCrossref, Google Scholar Kleiger, J. H., & Mihura, J. L. (2021). Developments in the Rorschach assessment of disordered thinking and communication. Rorschachiana, 42(2), 265–280. https://doi.org/10.1027/1192-5604/a000132 First citation in articleAbstract, Google Scholar Liddle, P. F., Ngan, E. T. C., Caissie, S. L., Anderson, C. M., Bates, A. T., Quested, D. J., White, R., & Weg, R. (2002). Thought and language index: An instrument for assessing thought and language in schizophrenia. British Journal of Psychiatry, 181(4), 326–330. https://doi.org/10.1192/bjp.181.4.326 First citation in articleCrossref, Google Scholar Marengo, J. T., Harrow, M., Lanin-Kettering, I., & Wilson, A. (1986). Evaluating bizarre-idiosyncratic thinking: A comprehensive index of positive thought disorder. Schizophrenia Bulletin, 12(3), 497–511. https://doi.org/10.1093/schbul/12.3.497 First citation in articleCrossref, Google Scholar McWilliams, N. (2011). Psychoanalytic diagnosis. Understanding personality structure in the clinical process (2nd ed.). The Guilford Press. First citation in articleGoogle Scholar Meyer, G. J., Viglione, D. J., Mihura, J. L., Erard, R. E., & Erdberg, P. (2011). Rorschach performance assessment system: Administration, coding, interpretation, and technical manual. Rorschach Performance Assessment System, LLC. First citation in articleGoogle Scholar Murray, H. A. (1943). The Thematic Apperception Test manual. Harvard University Press. First citation in articleGoogle Scholar Noordhof, A., Oldehinkel, A. J., Verhulst, F. C., & Ormel, J. (2008). Optimal use of multi-informant data on co-occurrence of internalizing and externalizing problems: The TRAILS study. International Journal of Methods in Psychiatric Research, 17(3), 174–183. https://doi.org/10.1002/mpr.258 First citation in articleCrossref, Google Scholar Perry, G. G., & Kinder, B. N. (1990). The susceptibility of the Rorschach to malingering: A critical review. Journal of Personality Assessment, 54(1–2), 47–57. https://doi.org/10.1207/s15327752jpa5401&2_5 First citation in articleCrossref, Google Scholar Roche, E., Creed, L., Macmahon, D., Brennan, D., & Clarke, M. (2015). The epidemiology and associated phenomenology of formal thought disorder: A systematic review. Schizophrenia Bulletin, 41(4), 951–962. https://doi.org/10.1093/schbul/sbu129 First citation in articleCrossref, Google Scholar Rorschach, H. (1942). Lemkau, P., & Kronenberg, B. Psychodiagnostics: A diagnostic test based on perception. Hans Huber. First citation in articleGoogle Scholar Shedler, J., Mayman, M., & Manis, M. (1993). The illusion of mental health. American Psychologist, 48(11), 1117–1131. https://doi.org/10.1037/0003-066X.48.11.1117 First citation in articleCrossref, Google Scholar Solovay, M. R., Shenton, M. E., Gasperetti, C., Coleman, M., Kestnbaum, E., Carpenter, J. T., & Holzman, P. S. (1986). Scoring manual for the thought disorder index. Schizophrenia Bulletin, 12(3), 483–496. https://doi.org/10.1093/schbul/12.3.483 First citation in articleCrossref, Google Scholar Wechsler, D. (1981). Wechsler Adult Intelligence Scale manual: Revised form. Psychological Corp. First citation in articleGoogle Scholar Van Os, J., & Reininghaus, U. (2016). Psychosis as a transdiagnostic and extended phenotype in the general population. World Psychiatry, 15(2), 118–124. https://doi.org/10.1002/wps.20310 First citation in articleCrossref, Google Scholar Yung, A. R., Yuen, H. P., Phillips, L. J., Francey, S., & McGorry, P. D. (2003). Mapping the onset of psychosis: The Comprehensive Assessment of At Risk Mental States (CAARMS). Schizophrenia Research, 60(1), 30–31. First citation in articleCrossref, Google ScholarFiguresReferencesRelatedDetailsCited byCelebrating 100 YearsKari Carstairs15 September 2021 | Rorschachiana, Vol. 42, No. 2Related articlesDevelopments in the Rorschach Assessment of Disordered Thinking and Communication15 Sep 2021Rorschachiana Special Issue: The Rorschach Test Today: An Update on the ResearchVolume 42Issue 2September 2021ISSN: 1192-5604eISSN: 2151-206X Published onlineSeptember 15, 2021 InformationRorschachiana (2021), 42, pp. 281-288 https://doi.org/10.1027/1192-5604/a000145.© 2021Hogrefe Publishing