David Ephraim. Rorschachiana. Volume 25, Issue 1. 2002.
The United Nations High Commissioner for Refugees estimated in 1999 that there were about 11.6 million political refugees worldwide (UNHCR, 2000). The proportion of refugees who are also survivors of torture is estimated to be between 5% and 35% (Baker, 1992). Torture has been defined by the United Nations Declaration on the Protection of All Persons from Torture (December 9, 1975) in the following terms:
Torture means any act by which severe pain or suffering, whether physical or mental, is intentionally inflicted by or at the instigation of a public official on a person for such purposes as obtaining from him or a third person information or confession, punishing him for an act he has committed or is suspected of having committed, or intimidating him or other persons.
Clinicians experienced in the assessment and treatment of survivors of torture and state violence have stated that the goal of torture is not to extract confessions or punish the opponent but to destroy his or her personality (Elsaas, 1997). For example, Ritterman and Simon (1990) affirmed that the actions of politically repressive regimes would resemble an upside-down version of therapy’s goals, as such regimes “intend to constrict people’s worlds rather than enlarge them … demoralizing individuals, families and communities in order to make them easier to control” (p. 277).
The psychological assessment materials presented in this chapter were collected through forensic evaluations of survivors of torture applying for refugee status in Canada. The assessment reports were requested by the refugee’s immigration lawyer, who typically asked from the psychologist the following referral questions: (1) Does this client present symptoms of a traumatic condition? (2) Is the clinical picture consistent with the traumatic events reported by the client? (3) Does a traumatic condition interfere with the client’s ability to recount the traumatic events? This last question is particularly relevant since severely traumatized refugees experience difficulty in providing a detailed and fully consistent report of the traumatic events, both in writing and at the time of their oral hearing. Such difficulty in reporting the traumatic experiences may lead to a rejection of the refugee claim on the basis of lack of credibility.
The refugee claimant was typically interviewed on two occasions for a total of 5 to 6 hours. Other than collecting trauma-related interview observations and self-report data, the Rorschach and some Thematic Apperception Test (TAT) cards were routinely administered. The Rorschach and TAT provided key information regarding the traumatic condition, which was often included in the report as corroborating evidence. Both methods were found extremely useful for establishing credibility, and above all, for understanding the psychological state of each individual in terms of his or her traumatic condition. It is important to keep in mind that decision-makers often expect from the psychological report an individualized picture of the person, and not merely a list of symptoms shared by the client with a clinical group.
This chapter presents a conceptually based clinical approach to Rorschach trauma assessment of extremely traumatized adults. Since trauma issues have not been the focus of contemporary Rorschach approaches, the chapter also underlines the need for changes in some current Rorschach scoring and interpretation guidelines when assessing cases of extreme victimization. Before the discussion and illustration of such issues through clinical vignettes, the following topics are briefly covered: (1) clinical diagnosis of victims of prolonged and repeated trauma, and (2) advantages of projective methods for trauma assessment.
Clinical Diagnosis of Survivors of Prolonged and Repeated Trauma
The diagnostic criteria of a posttraumatic stress disorder (PTSD) identify some of the trauma manifestations suffered by traumatized survivors of torture, such as intrusive thoughts, avoidance and numbing, and increased arousal symptoms (American Psychiatric Association, 1994). Additionally, survivors of torture may display the more complex clinical picture associated with disorders of extreme stress (van der Kolk, 1997a) or complex trauma (Herman, 1992a, 1992b). These last clinical diagnoses aim to identify the multifaceted symptoms and trauma adaptations developed by individuals who experienced repeated and prolonged atrocities in domestic, sexual or political contexts, such as extended child abuse, chronic spouse abuse, torture, or captivity as a concentration camp internee or prisoner of war. As described by Herman (1992a): “In contrast to the circumscribed traumatic event, prolonged repeated trauma can occur only where the victim is in a state of captivity, unable to flee and under the control of the perpetrator” (p. 377). Herman’s diagnosis of complex trauma identified three broad areas of disturbance which transcend the PTSD diagnosis: (1) a more diffuse and tenacious symptom-picture which includes symptoms of somatization, dissociation, and trauma-related depression, (2) posttraumatic personality alterations involving changes in both identity and relatedness, and (3) a vulnerability to repeated harm.
The PTSD and other DSM trauma-related diagnosis as well as the disturbances associated with complex trauma are relevant for the clinical and/or forensic assessment of survivors of torture and other cases of adult extreme victimization. Nevertheless, many trauma-related difficulties do not fit easily into any specific diagnostic category (Briere, 1997). Also clinicians should be aware of the deficiency of the concept of posttraumatic stress when dealing with victims of human rights violations (Becker, 1995). According to Becker, the term post is frequently inadequate (survivors often experience cumulative and continuous trauma) as well as the term stress (trauma would be qualitatively different from stress). The term disorder is the most problematic for Becker, who quoted in this regard the title of an article by Eissler published in 1963: “The assassination of how many of his or her children does a human being have to experience without producing symptoms in order to show that he or she has a healthy psychic constitution?”
Advantages of Projective Methods for Trauma Assessment
A variety of structured interviews and self-report measures are used for adult trauma assessment (Briere, 1997; Weathers & Keane, 1999; Wilson & Keane, 1997). Projective methods, such as the Rorschach and the TAT, offer some distinct contributions for assessing traumatic states. They are often less direct and intrusive than clinical interviews, which helps to circumvent the avoidance and guardedness of trauma survivors (Levin & Reis, 1997). Also, projective methods generate more experiential data when compared with structured interviews and self-report measures, allowing the symptoms to “come to life” (Lating, Zeichner, & Keane, 1995). Coping and defense mechanisms can be detected at work reflecting individual differences.
A pioneer article by van der Kolk and Ducey (1989) regarding Rorschach patterns in PTSD remains a significant conceptual contribution to the field despite its methodological limitations (Cohen & de Ruiter, 1991). According to Ducey and van der Kolk, the Rorschach protocols from traumatized people reveal the biphasic cognitive processing of traumatic experiences of rigidity and constriction versus intrusive reliving. Incidentally, the survivors of torture on which this chapter is based did not display two distinct phases, but rather the simultaneous presence of both constricted and intrusive phenomena.
The following issues regarding Rorschach assessment in cases of extreme adult victimization will be presented and illustrated through clinical vignettes:
- Cognitive disturbances associated with intrusive recollections
- Distinction between avoidance and numbing defense-patterns
- Posttraumatic changes in identity and relatedness
- Self-regulation and dissociation in cases of concurrent early trauma
Cognitive Disturbances Associated with Intrusive Recollections
Repeated re-experiencing of the traumatic events through recollections, nightmares or flashback experiences has been described as the hallmark feature of a posttraumatic stress disorder (Simon, 1995). Such intrusive and distressing experiences severely interfere with the cognitive processes set in motion by the Rorschach task, particularly with the capacity to perceive events objectively and to think clearly and logically. As described by Carlson and Armstrong (1995), “for traumatized patients, tests like the Rorschach can cease to be a projective measure and become instead a traumatic trigger” (p. 169). The following response to Card II by a 26-year-old male refugee from a Middle East country illustrates such kind of cognitive disturbances:
This one looks like … blood on a dirty wall, somewhere. This one doesn’t look really nice. (Inquiry) Dirty, black, dark, spots. Splashed on the wall. Like in your hand you had blood and just splashed it on the wall. Even before the dirt there was blood behind too …. Not that someone drew something. It’s dirt black. Where dirty hands or people kicked on the wall.
The loss of objectivity and clear thinking is blatant at the last phrase: “Not that someone drew something. It’s dirt black. Where dirty hands or people kicked on the wall.” Incidentally, Card II often stimulates associations to being harmed because of its areas of bright red color, which are easily seen as blood (Weiner, 1998); such is often the case with survivors of torture. The particular traumatic events evoked by the previous Rorschach response took place approximately 10 years before the assessment. It is worth mentioning that the refugee status was initially denied to this person because of some inconsistencies between his written and oral testimonies. A psychological report was useful to reopen and reconsider the client’s claim of refugee status, which was finally granted. Certainly, the loss of distance and objectivity revealed by the previous Rorschach response reflects his difficulty in providing a detailed and fully consistent narrative of his traumatic experiences. Regarding the accuracy of reporting, Mollica and Caspi-Yavin (1996) pointed out that “survivors of trauma and torture constantly change the details of their reports” (p. 277). Such observation is consistent with van der Kolk’s (1997b) description of traumatic memories as “timeless and ego-alien,” because they return as emotional and sensory states with limited verbal representation.
Another illustration of trauma-related cognitive disturbances refers to a single 49-year-old female refugee from Central America, who worked selling clothes at the market of her rural town. This woman was repeatedly harassed, hurt, and raped by police officers that visit her every week at her workplace demanding a quota of her sales. She gave the following response to Card IV, a card that often evokes associations to a powerful male authority figure:
“Oh, I don’t know what is this! Like a shadow. I don’t know what is this! (Inquiry) It looks as if it were glued to the wall … A shadow affixed to the wall. (Shadow?) Because it looks like when you throw something and it stays affixed to the wall. It doesn’t have any shape.”
This response would be scored as deviant (DR) according to the Comprehensive System. The “shadow” described is certainly strange in logical terms. It is a mobile, frightening shadow that someone threw at the wall and stayed affixed there, but could also bounce back from the wall. Although the common response of a male figure to which she reacted is easy to perceive, she stated, “it doesn’t have any shape.”
As revealed by the previous illustrations, the Rorschach method not only allows to identify the presence of traumatic memories, but also to document how such memories radically interfere with the capacity to perceive objectively and think clearly and logically. As described by Herman (1992b), the trauma survivors’ anxiety, somatic or depressive symptoms are not the same as ordinary anxiety, somatic, or depressive disorders. The loss of distance and cognitive impairment at the Rorschach of severely traumatized individuals is not ordinary cognitive impairment. Consequently, it should be scored and interpreted as trauma-related.
Distinction Between Avoidance and Numbing Defense Patterns
The DSM diagnosis of PTSD identifies as Criterion C a cluster of symptoms reflecting behavioral, cognitive and emotional strategies by which individuals attempt to reduce the likelihood of reexperiencing intrusive emotions associated to the traumatic memories. Such strategies include the persistent avoidance of thoughts, feelings or activities associated with the trauma as well as a numbing of emotional responsiveness. This last defensive strategy consists of affective constriction and feelings of estrangement from others. Briere (1997) distinguished defensive avoidance strategies, which usually reflect conscious, intentional processes, from largely unconscious defensive alterations such as numbing and other dissociative defenses. According to van der Kolk and McFarlane (1997), despite the fact that they are grouped together in the DSM, avoidance and numbing response patterns probably have a different underlying pathophysiology:
Many people with PTSD not only actively avoid emotional arousal, but experience a progressive decline and withdrawal, in which any stimulation (whether it is potentially pleasurable or aversive) provokes further detachment. To feel nothing seems to be better than feeling irritable and upset (p. 12).
Rorschach trauma assessment allows to set apart avoidance and numbing defensive strategies in strictly psychological terms, as illustrated by the following vignettes. The first vignette refers to a 35-year-old male refugee from Iran, who left his home country with his family after two decades of persecution, which included years in prison and several episodes of torture, such as mock executions and attending the execution of close friends and fellow prisoners.
At the clinical interviews, he displayed a variety of intellectual and emotional resources. Despite his psychological resourcefulness, he had lost any capacity for self-regulation when approaching trauma-related past memories or current concerns. For example, he suffered a panic attack when questioned about the date of his upcoming immigration hearing. Projective testing confirmed the previous interview findings regarding both his access to significant psychological resources and the severity of his traumatic condition. At the TAT, he made up stories that reflected both the complexity of his internal representations of people and his sense of being psychologically damaged. When administered the Rorschach, he gave the following five responses to the first two cards:
- I think it is a butterfly
- I see a human being. She’s looking to the other side. I see her hands and her feet, and her skirt. These other parts I don’t know
- I see two dancers. Cossacks dancing a Russian dance
- I see an airplane, or jet, in the middle. A fighter jet
- I see two bears, Grizzlies
The five previous responses are ordinary in terms of their Form Quality; two of them are Populars and another two are good human movement responses (M), one of which (R. 3) is a synthesized response (DQ +) and probably also a cooperative response (COP). Given the absence of intrusive and/or constriction features, such responses would be found in an intact personality in terms of trauma manifestations.
After the previous responses, this person turned up Card II and suddenly recollected the circumstances of a friend’s execution while both were in prison (“If I take the card this way, I see a mask. A bad person behind the mask. I don’t know if this is a good time to talk about it. Can I talk about the most repulsive face I ever saw in my life? Because this reminds me exactly that face”). Subsequent associations to this traumatic memory provoked such acute distress that the Rorschach administration had to be interrupted. His extreme reaction illustrates well this person’s severe difficulty in implementing conscious and intentional avoidance strategies as a way of managing his traumatic state. Conversely, he did not report or display any evidence of emotional numbing or constriction, and/or feelings of estrangement from others.
Our second clinical vignette contrasts with the previous one in terms of the kind of coping and defense strategies used for managing posttraumatic stress. It involves another refugee from Iran: a 39-year-old male technician, who also spent long periods of time in prison and experienced several torture episodes.
Clear symptoms of avoidance as well as emotional constriction and feelings of estrangement from others were evident during the interviews. He reported the traumatic events in an extremely detached way, as if describing another person’s experiences. While he tried to give a factual and detailed report, his body showed an intense physiological reaction. As his face became red, he felt very cold and had to interrupt the session and leave the room for a while before we could continue with the interview. He also described his feelings of detachment and inability to get close to people, which contrasted with his previous social behavior: “In my profession I used to be very outgoing. I was very well known as a friendly person. But now I can’t. I try but I can’t.”
This person’s desperate attempts to view his world and himself with an overly narrow focus of attention were evident in his Rorschach response pattern. In contrast with the previous case, the key feature of this protocol was its extreme constriction in terms of information processing. Ten of his twelve responses were pure Form. The Rorschach contents were animals, anatomy, X-ray, and only one human content referred to “a foot.” On four occasions, it took him more than one minute to give a response. In brief, a poor and stereotyped protocol revealing a severe deterioration.
The previous response pattern might indicate that he did not want to do the Rorschach. Nevertheless, his comments as well as test behavior revealed rather that he could not do anything better with the inkblots. As he said after a trauma-related response, “I have to think too much about these inkblots. It makes me crazier. When I think too much those incidents come back to my mind.” As an indirect confirmation of such a statement, two of the three Rorschach responses in which he displayed a more complex level of cognitive processing in terms of its organizing effort (DQ+) were trauma-related (for example, “X-ray of the side ribs … with blood” at Card III).
Could this person be described as displaying a High Lambda personality style? That is, in Weiner’s (1998) terms: “a person who prefers to be in familiar circumstances, find simple solutions to problems and ignores anything that might be distressing”? (p. 255). Such description corresponds closely to Rorschach data as well as interview observations, but to describe his condition solely as a personality style would imply that he has a stable, ego-syntonic condition, overlooking his active struggle and helplessness in dealing with a posttraumatic extreme vulnerability to disordered arousal.
Defensive constriction in traumatized people is not easily recognized through diagnostic clinical interviews. The previous case vignettes illustrate Rorschach’s potential for identifying different kinds of inhibitory posttraumatic strategies. Incidentally, the previous comparison between Rorschach protocols from individuals belonging to a non-Western culture allows speculation about issues of cross-cultural validity regarding trauma assessment. On the one hand, just the fact that such comparison has been possible seems to confirm that there might be universal features regarding Rorschach trauma manifestations that could be identified across cultures. On the other hand, there are probably culture-specific trauma symptoms and alterations that could be identified only by assessors who are deeply familiar with the particular culture.
Post-traumatic Changes in Identity and Relatedness
The International Classification of Diseases (World Health Organization, 1990), includes the diagnosis of “Persistent personality transformation following catastrophic experiences.” As mentioned before, the diagnosis of disorders of extreme stress or complex trauma includes character or personality alterations in identity and relatedness.
Regarding changes in identity, severely traumatized individuals often report permanent damage in their self-perception. Such alterations can often be identified at their Rorschach responses through thematic analysis of projected material. As proposed by the Comprehensive System (Exner, 1993), distorted, movement and/or embellished responses might be particularly revealing of self-perception features.
The case of a 35-year-old Nigerian male refugee illustrates the kind of posttraumatic changes in identity experienced by some survivors of torture. This person reported radical changes in his self-experience following torture, prison, and the assassination of family members in his home country: “I’m not my usual self anymore … My world has fallen apart … I don’t feel like I am a human being anymore.” The last phrase is particularly significant. Niederland (1968) reported profound alterations in self-experience in concentration camp survivors, and described that the most severely destroyed stated that they did not experience themselves as persons anymore. In the Rorschach protocol of this refugee, there were no whole and real human responses (H). The following sequence of distorted percepts took place at the first four Rorschach cards: at Card I, a cockroach; at Card II, an ant and a cockroach; at Card III (upside down), a fly and half of a human being; at Card IV, a snail and an ameba.
This sequence of distorted responses converged with his comments during the Rorschach administration as to an extremely low opinion of himself. Such Rorschach responses and test behavior contrasted with this person’s dignified attitude and depth of feelings as revealed during the interviews.
A second illustration regarding posttraumatic alterations in identity refers to a 23-year-old female refugee from Latin America: when attending her university classes three years before, she was kidnapped, punched, and raped by secret police officers who wanted to punish her for being a political activist. Although she was not physically restrained, she remained for more than a year under the absolute control of her persecutors, who threatened to punch and rape her again—and they did it on two other occasions—if she did not collaborate in acting as an informer of her schoolmates.
Some of her projected Rorschach contents involved vulnerable small animals or human beings (“small birds,” “a baby,” “small animals”). The elaboration of such responses revealed an extreme sense of helplessness. In Card II, she described: “The part of the uterus where the baby is guarded, where it is protected and cushioned, but it is as if it were injured and bloody.” In Card VIII, she described two small animals like raccoons climbing to the top to hold them up better, but “the rocks tend to fall when you hold yourself from them.” The self-perception of this refugee as a weak, fragile, and helpless individual is consistent with her traumatic experiences, and qualifies as a posttraumatic change in personality.
Regarding posttraumatic changes in relatedness, they can be detected through interpersonal thematic imagery as well as structural Rorschach variables from the interpersonal cluster. In the previous protocol there were no cooperative (COP) or active aggression responses (AG) and the Isolation Index was high (0.37) because of various landscape and nature responses. Also some thematic content suggested social and interpersonal isolation. The two most elaborate whole and real human figures (H) involved lonesome individuals (at Card IX, the silhouette of a person leaving from the light and the life part towards the death part, and at Card X, a person looking at the horizon). This case also illustrates the Rorschach usefulness in precisely identifying personality features that have been affected by traumatic experiences. Other than posttraumatic changes in identity and relatedness, this person did not display in her protocol any rigidity regarding information processing, as happened with the constricted protocol of the Iranian refugee presented above.
Self-Regulation and Dissociation in Cases of Concurrent Early Trauma
The majority of people who present PTSD intrusive and avoidant symptoms also develop other problems, such as symptoms of dissociation, somatization and affect dysregulation; these PTSD-associated features tend to occur more often when the person has experienced repeated and prolonged trauma in childhood (van der Kolk, Pelcovitz, Roth, Mandel, McFarlane, & Herman, 1996). Regarding affect dysregulation, its lack or loss has been described as “possibly the most far-reaching effect of psychological trauma in both children and adults” (van der Kolk, 1997a, p. 187). Self-regulation difficulties are involved in the criterion D for the PTSD diagnosis, which refers to various persistent symptoms of increased arousal. Individuals suffering from disorders of extreme stress or complex trauma would also experience a variety of other chronic severe problems with affect regulation, such as difficulty modulating anger, self-destructiveness, suicidal behavior, and/or unmodulated sexual involvement (van der Kolk et al., 1996).
The lack or loss of self-regulation of severely traumatized individuals may be recognized through the sequence analysis of their Rorschach responses. According to Weiner (1998), after identifying a distressing theme or concern, sequence analysis focuses on how the person attempts to regain his or her psychological equilibrium. The key question in assessing defensive recovery would be “how adequate are the responses subjects produce following anxiety-provoking Rorschach experiences, and how long does it take them to reestablish adequate responding” (p. 234). Sequence analysis reflects individual differences in trauma survivors regarding defense capacities that are relevant in terms of diagnosis and treatment planning. Defenses against the anxiety and disorganization produced by trauma associations and images are invariably limited in severe trauma cases. In the most extreme cases there might not be signs of recovery throughout the entire protocol.
The Rorschach protocol of the female refugee from Latin America discussed in the previous section revealed both severe trauma symptoms and considerable defense resources. Regarding the latter, the sequence analysis showed positive features, such as a variety of contents and successful defenses in some trauma-related responses. For example, the frightening male figure in Card IV, a difficult stimulus for victims of abusive authorities, was reluctantly approached at the beginning (“Oh, I don’t know, this one is so difficult!”), but she ended up with neither a highly distorted nor a thinking disordered response and described the monster as “funny” because of his “pointy shoes.” In brief, distortions in reality testing and loss of coherence in thinking were limited in her trauma-related responses.
The sequence of Rorschach responses of a 16-year-old Latin American female refugee stands in clear contrast with the previous case. This youth was threatened and sexually abused when she was 14 by secret police officers that surprised her distributing protest leaflets in her neighborhood. Her severe anxiety and depression was evident at the clinical interviews. The complete lack of support from her parents after the traumatic events took place as well as some of her shared childhood memories suggested a history of early trauma.
In contrast with the previous case, the Rorschach protocol of this adolescent did not show much in the way of recovery. His responses to the first three cards were: at Card I, the war and people dead, and the face of a frightening animal; at Card II, someone crying, and a sad face; at card III, two men detaining someone—a trauma memory—and a bad face. Her responses to the last three cards were: at Card VIII, a skeleton and someone sick, dying; at Card IX, fire from houses burning; and at Card X, a destroyed village. Consistent with her inability to recover from extremely distressing associations during the Rorschach administration, at the time of her assessment this youth presented a high suicidal risk and seemed entirely unable to move forward with her life because of her extreme anxiety and depression.
Dissociation was evident in the Rorschach protocols of some severely traumatized female refugees who had also experienced interpersonal abuse at or before the preadolescent years. Such was clearly the case with a 42-year-old female Latin American refugee, who escaped from her country of origin after being persecuted and threatened to be killed by the authorities at her workplace. Following some routine questions, she revealed an eight yearlong history of severe domestic abuse, and memories of sexual abuse as a child. There was a manifest continuity, which she was entirely unconscious about, between the kind of abuse she was subjected to during her marriage and the persecution experienced at her workplace.
Her life history was a clear case of vulnerability to harm, as she seemed unable to defend herself from dangerous situations. Several sequences of Rorschach responses dramatically suggested such vulnerability. For example, her first three responses entailed a collage of fragmented images of danger, terror, and helplessness: at Card I, she started describing a vampire with fangs “who clutched two things, heads.” Her next response to this card was “a mouth screaming.” Then, she reported at Card II: “splashed blood, and a crash, as if something were crashing.” Keeping in mind this sequence of responses, one might suspect that she would handle a dangerous situation by fragmenting it into pieces. In the context of such responses, her inability to defend herself comes as no surprise.
The Rorschach protocols of female refugees who also experienced early trauma differed from those of female refugees who were severely traumatized only as adults by showing more diffuse trauma-related thematic contents. In cases of concurrent early trauma, responses of dangerous and morbid contents that also involved loss of objectivity and clear thinking were often not directly identifiable with specific traumatic memories.
A striking feature in some cases of concurrent early trauma is the apparent neutrality or lack of concern that accompanies frightening trauma-related responses. It should be taken into account that prolonged and repeated early trauma implies not only “conditions marked by intense surprise but also those marked by prolonged and sickening anticipation” (Terr, 1991, p. 11). According to Terr, individuals who experience repeated and prolonged early trauma display massive efforts in order to survive and protect their psyche, which involve defense mechanisms such as massive denial, dissociation, self-anesthesia, identification with the aggressor, etc. The Rorschach method often identifies such chronic adaptations to trauma, as in the following response to Card VIII from the same protocol. The striking feature to keep in mind is that she smiled while reporting the following terrifying response:
Water (D5). Like with fishes or dolphins (shading). They look big. But the water looks as if blown away with great force. Look. Here’s the mouth (D2) and here’s the water. I feel like it’s someone like saying: “I’m going to drown” (returns the card). Inquiry: Water. This is like water. Very strong. That blows away (smiles). Here is the fish, its fin. The water is hooked at the mouth (Dd29) … There is too much water. That’s why I said he is going to die drowned. I don’t know what’s happening with the water. (Going to die?) Or could be that I’m going to die drowned.
Regarding sequence analysis, this protocol alternated frightening images of this type with non-trauma-related and common responses, such as elephants dancing, a butterfly flying, an ultrasound image of a baby, angels, dogs on their heads, an airplane, and a bunch of flowers. The alternation of frightening traumatic and nontraumatic neutral images paralleled this person’s capacity, even if restricted, to work and take good care of her daughter despite her severe trauma-related symptoms and personality alterations.
Closing Remarks
Rorschach protocols of severely traumatized survivors of torture support statements about the ultimate goal of torture being the destruction of the victim’s personality. Trauma survivors not only retain distressing memories of their traumatic experiences, but keep recreating internally the torture and psychological destruction they experienced in the hands of their perpetrators (J. Armstrong, personal communication, December 10, 2000). As illustrated in this chapter, the internal transformation that replaces terror and helplessness experienced under the absolute control of others may involve a variety of manifestations, such as posttraumatic intrusive experiences, severe affect dysregulation, changes in representations of self and others, personality alterations, somatic symptoms, etc.
As a wide band instrument, the Rorschach method seems particularly appropriate for assessing the broad range of psychological functions affected by trauma. The method’s sensitivity to a variety of PTSD and complex trauma posttraumatic symptoms and trauma adaptations has been illustrated throughout this chapter. The chapter also emphasized the need for changes in some current Rorschach coding and interpretation guidelines when assessing cases of extreme victimization. For example, regarding the survivor’s cognitive disturbances associated to intrusive recollections, their trauma-related nature should be directly acknowledged by the scoring system and interpreted accordingly. Similarly, posttraumatic emotional constriction should be recognized and validated as such. Current Rorschach interpretive strategies might miss the survivors struggle by reducing constriction to a personality style or an ego-syntonic character trait.