This article is adapted from a presentation I gave at the International Society for the Rorschach in Geneva, Switzerland, on July 13, 2022. The paper was part of a panel discussion on the use of the Rorschach in conjunction with the Thurston-Cardock test of Shame (TCTS) to illuminate the role of shame in symptom expression. I hope to illustrate the power of personality assessment and collaborative assessment in helping patients understand themselves and get better.
History and Background
I first met John (pseudonym) and his parents when they consulted me regarding John’s slipping performance in college and his oppositional and explosive behavior in the family. John was nineteen and struggling in his first year of college. He had done well in high school and presented as bright and articulate. John’s father wondered if John needed better time management and cited decreased motivation as sources of the problem. He wondered if this was all due to ADHD or something else. He described his son as being “off the rails” and wanted help in getting him back on track.
John’s mother described him as fidgety in grade school and recalled that it seemed to take him a long time to get assignments completed. After his first semester of college, he was diagnosed through a psychiatric interview with ADHD and prescribed 15mg of Adderall, but this had not seemed to help much.
John described himself as struggling to get started on school projects, but even when he got behind, he could make up work and get a decent grade. He described himself as “motivated,” but he said he has a hard time initiating tasks. He reported that habits tended to “fizzle out” and that he had always had difficulty focusing.
John is the youngest of three children in an intact family. He has a twenty-two-year-old brother and a twenty-five-year-old sister. He describes his sister as highly accomplished and able to sail through high school and college with ease. John’s brother reportedly had some difficulties when he first went to college, being overly social but ultimately settling in and earning his degree.
Collaborative/Therapeutic Assessment (C/TA) is a flexible but structured therapeutic intervention that leverages the powerful effects of personality assessment to engage clients’ curiosity and harness this energy to bring about change. In contrast to traditional assessment that tends to focus on diagnosis and relies on a top-down, expert role for the psychologist, C/TA works from the bottom up and starts with developing questions collaboratively with the patient. The focus is on what the patient wants to know and not a referral question. The first step in C/TA is for the psychologist and patient to develop assessment questions (AQs) together. Based on these questions, the psychologist selects assessment measures with a high probability of answering these questions in a meaningful way for the patient. Next, assessment measures are administered in a standard manner to obtain valid results. The psychologist and client next explore the data in extended inquiries and assessment intervention sessions designed to bring the patient’s core conflicts into the room in an experiential way without overwhelming the patient. This depends on an accurate case formulation that organizes the information into a hierarchy from easily digestible, level one information to more schema-challenging level two and three information. Once the entire process is complete, a letter is written to the patient summarizing all the work, offering answers to the assessment questions, and providing some recommendations for moving forward. Often current therapists are involved in the process, providing assessment questions of their own and participating in discussion sessions.
As a first step, I met with John and his parents separately to develop assessment questions. John’s mother asked: How can John be more motivated to succeed? How can he be successful? Is ADHD the right diagnosis, or is there anything else? John’s father asked: Is there an executive function issue? Can John use time management? These were John’s questions: Where did this start, and why is this happening now? How might my relationship with my parents affect how I behave with others and my inability to do things? How might my relationship with my parents affect my social relationships? Is this just a rough patch or do these strong feelings indicate deeper problems? Why do my parents and I get into so many fights? Can we as a family give feedback to each other without getting into fights?
What struck me about these questions was the qualitative difference between john’s questions and his parents’. Understandably, John’s parents were concerned with him being successful at college and moving into adulthood, but John’s questions struck me as much more psychologically rich and insightful. This was a sensitive kid with some awareness of his inner life.
In an individual session, John confided that when his parents give too much support, he feels like they “baby” him and he feels “micromanaged.” John had searched the internet and wondered if both he and his father had narcissistic traits. He experienced his dad as controlling and perfectionistic and described fights in which neither one was willing to concede any ground to the other to the point where neither could understand what the other was talking about or how the argument started.
According to John, “the first year of college didn’t go well.” This was the start of the pandemic, and classes were conducted over Zoom. He began to feel disconnected from the classwork, missed deadlines, and got farther and farther behind. He reported being ashamed about all of this: “I knew I needed help, but I didn’t like it when it was given.” He kept telling himself, “Next week will be different,” but he continued to slip behind and ultimately had to take incomplete grades. He hid his failures at school from his parents for as long as he could, but they eventually found out and forced him to return home and enroll in a local satellite campus of his university. He moved into the basement and became increasingly isolated and despondent.
For the assessment, John completed the Minnesota Multiphasic Personality Inventory -2 (MMPI-2), Crisi Wartegg System (CWS) for the Wartegg Drawing Completion Test, Adult Attachment Projective, Thurston-Craddock test of Shame, Rorschach (R-PAS), and the Difficulties in Emotion Regulation Scale.
John’s MMPI-2 showed elevations on clinical scales 7-4-2 and 8. John’s 7-4-2 profile suggested that he experienced significant tension, worry, rumination, and guilt and may act out to manage these feelings. His scale 2 and the Rorschach told me that he was also quite depressed. His K and S scales were low, and I wondered about damage to his self-esteem. I was also concerned about the quality of his thinking with an elevated clinical scale 8, RC8, and bizarre mentation scales.
John completed the Difficulties in Emotion Regulation Scale (DERS), a self-report measure tapping a client’s experience and management of emotion. John’s responses suggested that he was aware of his feelings but had difficulty regulating them and staying focused when he was flooded. John reported that his emotions “feel like a flood” and that he felt like “I have two brains constantly thinking of a million things.” He stated that Adderall made this worse rather than better.
On the Rorschach, John produced a complex protocol with signs of engagement (turning, pulls, blends, Synthesis). Like the MMPI, there were also signs of perceptual and thinking problems (EII-3, TP-Comp, WSumCog, SevCog). He could accurately interpret his environment but was prone to combinations and logical connections that were peculiar.
There were indications of stress on his Rorschach (shading, m, SC-comp) and his trauma content index (Armstrong & Lowenstein, 1990) at .39, particularly high. John produced seven achromatic color responses, a testament to both his distress and his resilience. Finally, his Rorschach was notable for his attempts to integrate all the information on each card. Of 28 responses, 25 were whole card responses, including all the complex, later cards. He really wanted to pull everything together, even when the cost of doing so was prohibitive.
At this point, it was clear to me that this was a sensitive, intelligent, distressed adolescent. I was leaning away from psychosis or thought disorder and more toward disruptions in thinking caused by intrusions of confusing effects. I also realized that ADHD symptoms, while present, did not explain the complexity of this presentation. So what was the effect that was consuming him and taking up so much bandwidth?
Thurston-Cradock test of Shame (TCTS)
The TCTS is a ten-card, performance-based story-telling task in which the client is asked to tell a story with a beginning, a middle, and an ending in response to visual pictures. There is a structured scoring procedure that examines the Presence or absence of shame content, defenses against shame, resolution in the stories (ambivalent, adaptive, maladaptive), and the presence of disguised shame.
John’s TCTS confirmed the presence of shame. One manifestation of this was indicated by the sheer length of his stories. The length of these stories and the rambling quality of them, often including negations and contradictions, were a mirror into the tangle of cognitive defenses he brought to bear in an attempt to manage his shame. As we know, shame is one of the most painful emotions in humans.
Four of Ten stories contained direct shame references, and 9 of 10 stories contained indirect shame. Shame themes in John’s stories included “Failing” at something, Pressure, and Impacts on the future. He also repeated phrases, included some bizarre content, and negated feelings (“he’s not sad”). John employed many defenses throughout his TCTS, but it didn’t seem to get him very far. Only three out of ten stories had adaptive endings, and two of those were only superficially adaptive. Seven more had maladaptive endings.
Also notable in John’s TCTS was the absence of competent adults who might have intervened to assist him but did not. In several of the pictures, adults are depicted, and these adults are often included in respondent stories as assistants who help the protagonist deal with shame leading to adaptive story endings. John’s efforts to contain and regulate shame were not effective, and this left him spinning and putting too much effort into staying regulated.
In his efforts to stay regulated in the face of his acute shame, John used cognitive defenses to contain his anger and sadness. This is what was winding him up and impacting the clarity of his thinking. When his defenses began to fail, his associations got looser, and he began to look a little psychotic. Using John’s assessment results on the Rorschach, I wanted to help him understand how his defenses were impacting his functioning.
Rorschach Extended Inquiry
John put a tremendous amount of effort into incorporating every bit of data (whole card responses) on the Rorschach cards. To explore this, John and I looked at his sequence of scores together. When a respondent uses the whole card in creating a response to the question “what might this be?” they need to assimilate a great deal of information. The Rorschach cards are intentionally constructed so that there are commonly used areas that lend themselves to seeing forms. A whole card response forces the respondent to integrate all these areas into a coherent response. This takes a lot of cognitive and organizational effort. A more economical approach would be to use the common areas when available and have some responses pull everything together but not every response.
John readily understood that it takes more effort on most of the cards to create a W response, especially the visually complex cards. John began to see that the choices he made influenced his efficiency. We wondered together if a similar process was affecting his academic work, and he thought that it did.
I asked john to read some of the responses with me, and I pointed out where the response contained common, good form quality content, but the elaboration confused things. I asked him to stick with the popular response and try to ignore other details. He did it, but he didn’t like it. He stated that it was “kind of difficult because I keep finding new layers.” He said, “I try to integrate everything.” John said that many times on the Rorschach, he “could feel it but not describe it. Then I over-think, and it gets jumbled. It’s like peripheral vision with thoughts.” I could not have said it much better myself. John did it for me. This is the goal in C/TA; to reach new levels of understanding experientially and open new doorways. Particularly in the context of colorful cards, John got overstimulated. He could “feel” what he saw but not articulate it. Then his defense stepped in to help him out, only it tied him up, “I overthink, and it gets jumbled.” We talked about how this might relate to his problems at school and his arguments with his father. We were able to use the metaphor of “Running Down Rabbit Holes” in our therapeutic work together. I could now ask him at the start of the session, “how were the rabbit holes this week?” and he would know what I meant. As we worked together, he was able to let go of some of the shame and see himself as less broken. He began to tolerate his feelings a bit more.
How is John today?
I am happy to report that John has made significant progress. He was able to return to the main campus of his college and has reconnected with his peers. This was a significant improvement and went a long way to correct his isolation in the basement. Academically, John is passing all his courses with A’s and B’s. he continues to struggle with deadlines a bit, but he has learned to rely more on his peers to keep him on track. When he is late on an assignment, it is no longer in the service of avoiding an uncomfortable feeling but more normative, age-appropriate prioritizing of fun over work.
I realize that some of the material above was technical, but I hope that some flavor of C/TA persisted. I would be happy to explore the assessment findings in more depth if anyone is interested. Please feel free to contact me if you are interested in making a referral for an assessment or wish to consult on personality assessment questions. Information about my work can be found at www.inkblotdoc.com. You can also email me directly at [email protected].