James H. Kleiger, PsyD, ABPP, ABAP
Thinking About Thought Disorder on the Rorschach
The major Rorschach systems, past and current, include procedures for identifying and scoring individual examples and composite measures of disordered language and thinking. Special Scores and Indices capture diverse forms of disordered verbalization and thought that, with proper training, can be reliably scored. However, despite some effort to group scores into broad categories, according to levels of severity or whether they pertain to language, reasoning, or visual image combination, to date there has been little attempt to organize existing scores in a manner that is both conceptually coherent and consistent with what is known clinically about thought disorder.
From a conceptual perspective, a deeper understanding of what different categories of thought disorder might signify about an individual’s internal world, in terms of cognitive functioning, typical modes of reasoning, and experiences of self and others, is lacking. Too often, diagnosticians become stuck at the level of test scores or indices and have difficulty linking these test-based metrics to broader conceptual and clinical reference points concerning the nature of thought disorder or broader aspects of the patient’s functioning. The scores become reified to the point that we often settle for the knowledge that a patient has a DR or tends to give FABS or INCS. These labels become endpoints in our psychodiagnostic thinking, instead of serving as starting points for trying to understand the psychological, developmental, clinical, and even psychodynamic concepts that might be associated with the test scores. In this sense, typical approaches of assigning different “thought disorder” scores to Rorschach responses often leads to the circular conclusion that the respondent has a thought disorder. Useful diagnostic questions such as what might these scores suggest about our patients’ abilities to focus and filter their thoughts, how they organize information, or what kinds of errors they make when they reason with complex and ambiguous information are left unexplored.
To move beyond static score-bound thinking, diagnosticians can organize Special Scores in terms of three dimensions of thought disorder: (1) Disorganization, (2) Illogicality, and (3) Impoverished Speech and Thinking. Disorganization describes what is often referred to as “formal thought disorder” or “disorganized thinking (speech)” in the DSM 5. The Disorganization dimension provides a way of understanding DV’s and DR’s.
Illogicality reflects the inferential and reasoning process that silently takes place, as the patient tries to form conclusions and attribute meaning to the inkblots. Illogical thinking, or “errors in reasoning,” is represented by combinative responses (INC and FAB), certain types of embellished or over-interpreted DR’s, ALOG’s, and CON responses.
Finally, Impoverished Speech and Thinking, which can be found in the Rorschachs of psychotic patients who suffer from negative forms of thought disorder or cognitive impairment, is more difficult to capture by individual scores alone. However, when examiners begin to understand the nature of these symptom dimensions of psychosis, it becomes possible to identify manifestations of speech and cognitive impoverishment in Rorschach responses.
This excerpt is from Disordered Thinking and The Rorschach: A Second Look, due to be released in 2017 by Routledge. Jim Kleiger, with Ali Khadivi, is author of Assessing Psychosis: A Clinician’s Guide (Routledge, 2015) and Disordered Thinking and the Rorschach: Theory, Research and Differential Diagnosis (Analytic Press, 1999).
TIME TO REGISTER FOR REMAINING 2016 PROGRAMS
FIVE DAY BEGINNING PROGRAM- JUNE 27-JULY 1
The last 2016 Five Day Beginning Program for the Rorschach Comprehensive System is being offered at the University of Hartford, West Hartford, Connecticut Monday through Friday, July 27-July 1, 2016. This Program offers 35 contact hours of training in administration, coding and interpretation of the Rorschach. It is the equivalent of a semester’s training. There is no better way to learn the foundational structure of the Rorschach. The Program takes participants through a series of case protocols that increase in complexity. Practice in administration and inquiry are included because these facets of the Rorschach are vital to standardized administration. To obtain the graduate student discount send your request in an email to email@example.com or go to “contact us” on the website. Full details are published under Beginning Training Programs at www.rorschachtraining.com.
TWO DAY ADVANCED PROGRAM- AUGUST 11 & 12
Thursday August 11 and Friday August 12, 2016, a two Day Advanced Program, Enhancing Your Rorschach Skills, is being planned for psychologists who are already familiar with the Rorschach. Drs. Barry Ritzler and David Shmerler will be presenting challenging case protocols and discussing coding and interpretation. This is an opportunity to improve your Rorschach skills and enjoy the offerings of the “Big Apple”. The Program will be held at the NYC Health+Hospitals|Kings County, 451 Clarkson Avenue, Brooklyn, NY, 11203, and will be providing 12 Category 1 CE credits for this Program. All information and details for registration are published on www.rorschachtraining.com.
For over-night accommodations hospital personnel suggest a Comfort Suites Hotel, 599 Utica Avenue, Brooklyn,, NY, 11203, (within a mile of the hospital). The hotel is holding a discounted room block. To take advantage of the discount call the hotel at 718-774-0018, ask for “Christi” and mention “Kings County Training.” She will offer the best rate possible. Summer dates fill quickly so make your reservation as early as possible. You can always cancel if plans change.
We look forward to seeing many of you at the upcoming Programs and hearing from you via email. We have three E-Newsletters remaining for 2016 – July/August, September/October and November/December. Guest contributors for each of these newsletters will be writing on topics of interest to assessment psychologists.