THE USE OF PROJECTIVE TECHNIQUES IN RISK ASSESSMENT OF PSYCHIATRIC EMERGENCIES IN CHILDREN AND ADOLESCENTS
Some of the projective techniques have proven their utility over time in diagnosing the risk of psychiatric emergencies. This article will focus on ways of assessing suicidal risk and that of paroxysmal discharges of aggressive energy. with the help of three projective techniques: Roerich Psychodynamic Inventory, Thematic Apperception Test and Szondi Test.
Used correctly, these three techniques provide conclusive indications of suicidal risk, which allows avoiding suicide attempts.
In the paroxysmal discharges of aggressive energy, they can be predicted quite accurately by using the Szondi test. The formulas to indicate the trend of destruction of others, sadistic structure, the weak control of emotions and of aggressiveness, the imminent paroxysmal discharges of aggressive energy., are clear indications that a paroxysmal discharge of aggressive energy. can occur at any time. This allows an effective intervention to stabilize emotionally and behaviourally the persons who are in this situation.
Even if projective techniques do not allow a very precise prognosis of the moment a situation / disorder that constitutes a psychiatric emergency appears, some of these techniques provide very important information on the risk of such emergencies. This means that one can establish that there is a serious risk for a given situation / disorder to trigger, but one cannot specify exactly when (how many days or hours will pass until) it will happen.
One cannot make a prediction on the occurrence of all types of psychiatric emergencies, but at least for suicidal / autolytic risk and for paroxysmal discharge of aggressive energy. some of the projective techniques provide decisive information.
The fact that some of projective techniques provide such information is due to clearly superior coding as compared to other concurring diagnostic tools, which reduces considerably the risk of simulation.
Regarding the prognosis of the risk of triggering a psychotic episode, the exclusive use of projective techniques is counterproductive because some atypical responses may be considered psychotic, which is totally wrong.
Projective techniques that can be used in assessing suicidal / autolytic risk and that of aggressive discharge are Thematic Apperception Test (TAT), Szondi Test, Roerich Psychodynamic Inventory (RPI) Luscher Test and Rorschach Test. These tests can be supplemented as needed with other projective techniques, e.g. drawing tests.
It is desirable to use a battery of projective techniques for at least three reasons:
– The results obtained from one test are most often insufficient for achieving a precise prognosis;
– Correct interpretation of atypical responses or of symptomatic formulas;
– Diminished risk of misinterpretation due to possible attempts to simulation.
If, for time reasons, there is impossible to apply several projective techniques, the most relevant test to the respective case will be chosen. In this situation, one will take into account the reason for carrying out the assessment, the subject’s level of intellectual development and understanding, the existing data about the subject and the available time. Data obtained from the administration of projective techniques should be corroborated with other data on the subject obtained by other methods.
In most cases, following the administration of projective techniques, especially when there are definite clues of auto and heterolytic risk (suicidal risk, paroxysmal discharge of aggressive energy., etc.) the request for additional information is mandatory – from the subject, the carers, the school, etc. – helping to establish a correct diagnosis, and also to achieve adequate intervention / prevention.
During the administration of the tests, special attention should be given to simulation attempts. Attempts to simulation are based on five factors:
lack of interest in evaluation,
lack of trust in/rejection of the evaluator,
fear of results – in particular the fact that the subject could be diagnosed with a mental illness or that he/she will be open to ridicule, –
fear of losing control of the situation
desire to mislead the evaluator (this issue appears particularly in aggressive subjects, especially if they have antisocial traits). Simulation methods are determined by the level of intelligence, life experience – the higher the level of intelligence/ experience of living of the subjects, the more refined the simulation attempts are – and, less often, information that subjects have about the tests used. However, given that projective techniques are better coded, simulation possibilities are limited (they are described for each test presented here).
In the case of subjects with auto and heterolytic risk, prevention is customized for each case, according to the following guidelines:
Elimination or reduction of the causes (where possible) that led to the problem, this could largely solve the problem;
Psychological intervention (aimed at the eventual associated pathology), extended to family members / close persons – where necessary and possible. Psychological intervention is useless in children / adolescents with sadistic traits;
Psychological monitoring from time to time; these intervals are set depending on the type and severity of the problem;
Surveillance, even permanent in children / adolescents with suicidal / self-destruct ideation, but which does not show a high risk of acting out;
Following a psychopharmacological therapy, especially therapy for reducing aggressive energy. and that of the associated pathology;
Emergency admission to hospital for more serious cases – for example in case of an impending paroxysmal discharge of aggressive energy. or of suicide, thus avoiding the acting-out.
Roerich Psychodynamic Interview (RPI)
Adapted after R. M. Roerich, 2002
Robert M. Roerich – member of the American Association for the Study of Mental Imagery (New York), introduced this projective technique of mental imagery in 2002, in the USA.
In Romania is known as the “Road Interview”. This technique has been built to evaluate five sub-themes:
An overview of the subject on his life at the same time revealing the spiritual condition in general, the difficulties and problems that he/she faces;
Feelings about sexuality and / or intimacy with others;
Inner self image, self-esteem, support systems and relationships with parents, strength of support systems and of emotional connections;
The relationship of fidelity and honesty in a relationship; this cannot be considered in children, it being relevant only in people who are experiencing or have experienced a couple relationship;
Current or previous problem that bothers the subject, having major influence on his/her life, how it can be overcome, as well as the belief that life will change or stay the same. Here the suicide risk can be assessed, but this will only be done by corroborating the data obtained during the description of the road and at the “house of support”.
The technique can be used both as assessment evidence and as psychological intervention, because the subjects accept it easily, as it is not perceived as intrusive.
Description of the test
There are two types of questions: the standard ones (15 in number) and the optional ones, which are addressed in the manual, but without being included in the standard inventory. According to the description / replies of the subject (some subjects smoothly describe what they imagine, others respond only to questions they have been asked) other clarifying questions can be asked further, too.
Instructions are given throughout the test.
Instructions and standard questions:
The general perception of the road:
Imagine that you are driving along a road …
Record everything you see and hear, like a camera. Overfly the landscape, noting what you see in the distance, the background, and what surrounds you. Feel the earth under your feet. You are the one who contemplates the journey.
1. What colour is the road?
2. What is the road surface like?
3. What is the firmness of the road?
The perception of sexuality:
Keep walking until you reach a river that has to be crossed.
In front of you, there is a river; the width and depth of the river are your choice. You cannot by-pass it, you have to imagine a way to cross it. Everything you need to cross the river is already in your mind just imagine how you will proceed.
` 4. How do you cross the river?
5. What does the water look like?
6. How fast is the water flowing?
7. Is there anything in the water? If so, what is it?
“House of support”:
You have crossed the river and you continue walking. You arrive at a house. Take a good look at the house. Note the impression that you have on it.
8. What colour is your house?
9. In what state is the house?
10. Does anyone live there? If yes, who?
Perception of fidelity:
We continue our mental journey and come to an open space. On the ground, there is a vessel and you stop to look at it. It can have any size and shape. Describe the vessel. Focus on its appearance, on its condition and on its content.
11. What colour is the vessel?
12. In what state is the vessel?
13. Is there anything in the vessel?
Keep walking along the road and you come across something that blocks your way. It stops you and prevents your walking forward. This is the obstacle.
14. What obstacle is it? Can you overcome the obstacle? If so, how?
15. What do you see beyond the obstacle?
In children with speech difficulties, for whatever reason, they can draw the road, but with coloured pencils.
Indices of suicide:
Cumulating the following clues is necessary:
– Black, grey, or red road, which is very rough, broken or with ravines, deep pits, high walls – regardless of their type – which can be crossed with difficulty or not at all;
– A house where no one lives / is abandoned, possibly in disrepair;
– Inability to pass the (obligatory) obstacle and the absence of a road beyond it; without this element, the suicidal risk is very low or absent. Another suicidal clue is the obstacle in the form of a gate. This type of barrier is almost as relevant as the inability to move beyond the obstacle and the absence of the road behind the obstacle.
– Since the obstacle cannot be overcome, but the house is inhabited and possibly in good condition, the suicidal risk is low because there is a support person, but, in this situation, parasuicide is not excluded or the risk of self-injury.
In this technique, there are two possible ways of simulating; either, for various reasons, the subject does not imagine what he/she is asked and answers all questions formally, or the subject says something different from what he/she imagines.
Simulation can be countered by additional questions asked during the interview, because in case of a desire of simulation mismatches will appear between answers or while describing the journey. The subject’s refusal to imagine what he/she is asked is considered a form of simulation only if the subject has no mental retardation. In subjects who have mental retardation, use of this test is contraindicated because it leads to erroneous conclusions.
In practice, the subjects do not simulate at this test, considering it nonintrusive.
Thematic Apperception Test (TAT) Henry A. Murray
TAT is a projective technique that aims to assess patterns of thinking, attitudes toward self and others, the subject’s emotional responses, defences, his/her needs and response patterns (including the level of aggressiveness) to a softly structured material. With its help, one can get significant information about the suicidal risk and about its possible motivation.
Another aim of the test is its use in psychological intervention.
Description of the test
TAT’s material consists in 30 black and white picture cards and one completely blank card.
The pictures contain characters of different ages and both sexes. The actions that characters are engaged in and the facial expressions are rendered ambiguously, in a way so that they can be interpreted in terms of needs, interests, emotions, conflicts characteristic to the age of the subjects and to their life experience. Of the 30 picture cards (plus the blank card), 10 are valid for all categories of subjects while the others are more specific. The symbols from the picture codes have the following meanings:
B – pictures for boys aged up to 14 years;
G – pictures for girls aged up to 14 years;
M – pictures for men over 14 years of age;
F – pictures for women over 14 years of age;
GF – pictures for girls under 14, and women over 14;
BM – pictures for boys under 14 and men over 14;
MF pictures for men and women over 14.
Pictures marked only with numbers are for all ages and both sexes.
The administration of the test
The subject is asked to develop a story about each card that is offered; the subject should include in the story to the following aspects: what happens in the respective scene on the picture card, the events that have preceded the respective situation, what the characters on the picture feel and think and how that particular story ends. Depending on what the subject says, clarifying questions may be asked throughout the story, which would allow the subject to expand the story. Questions should be such that they do not suggest an answer and do not involve moral judgments. After the subject ends the story, it is advisable that he/she would be asked the following questions: “What comes to your mind when you look at this picture?”, “How do you feel when you look at this picture?” “Do you associate the characters in the picture with anyone?” The last question is not addressed in case of pictures where there are no characters.
Some authors recommend two stages in administering the test: association stage (actual administration of the test) and the investigation stage in which the subject is asked about the source of the story. After the administration of the picture cards, it is necessary to discuss the responses with the subject, these discussions having a clarifying role. (Aronow; Weiss, Reznokoff, 2001; Bellak, 1991; Brelet- Foularde, 2003; Popescu, 2011)
The level of aggressiveness is assessed mainly with the help of two picture cards: 8BM and 9BM. However, in practice, responses that contain a high level of aggressiveness can be obtained from the other pictures, for example 13MF or 17GF, so it is useful to administer the entire test. This is necessary because aggressive responses may be obtained from those cards whose pictures the subject associates with different situations related to his/her experience of life or towards which he/she has some aggressive fantasies.
It is considered that the subject has a high level of aggressive energy. only if the character with which he/she identifies (the one who is most spoken about, whose subjective feelings and ideas are the most discussed) has aggressive manifestations (e.g. it beats or kills other characters, destroys things, etc.). To these, the subject’s own aggressive manifestations during testing can be added (e.g. pounding his fist on the table). If, during the test, the subject has aggressive manifestations, the paroxysmal discharge of aggressive energy. is imminent, especially if these symptoms are combined with “s +!” in Szondi Test. The subject is not considered aggressive if the character he/she identifies with is assaulted, abused, etc.
The suicidal risk is much better assessed using TAT.
The basic picture cards are 3BM, 14 and 17BM, but answers that contain suicidal ideation may exist in other cards, too. For example, card 15 – with this picture both types of content may be obtained – both suicidal ideation and aggressive energy. – therefore, in this situation, it is better to administer the complete test, based on the same considerations as for the assessment of aggressiveness.
Suicidal ideation consists in the fact that the character from the picture, which the subject identifies with, either commits suicide or is willing to do so.
Depending on the circumstances leading to the suicide of the main character and his/her desire to do so, the stories can be classified as follows (without claiming that this classification is complete):
1. Stories describing situations that have no equivalent in reality (e.g., “the woman commits suicide because her child was kidnapped by aliens”).
Suicidal ideation in such stories is inconclusive and require further investigation, at most, as the risk of suicide is absent.
2. Stories where the character commits suicide or is willing to do so due to situations that the subject might meet along his/her life and that he/she expects (e.g. loss of a parent).
In these cases, suicidal ideation is structured and it usually indicates situations where the subject may commit suicide. Although in these cases suicidal risk is low, psychological intervention is necessary, having a preventive goal.
3. Stories where the character commits suicide or is unwilling to do so due to a situation that the subject has lived in. In these situations, the suicidal ideation is consistent, suicidal risk depending on whether the situation is overcome or not. If the situation has been overcome, the suicidal risk at the time of testing is low, otherwise, the risk is increased. Whatever the case, the subject remains potentially suicidal, any traumatic event that will not be overcome, could lead to suicide. In these cases, both a deeper psychological assessment accompanied obviously by psychotherapy and psychiatric assessment is necessary.
4. Stories in character commits suicide or unwilling to make due to situations where the subject is facing at the time of testing. This topic describes major suicide risk, suicide may occur at any time, these cases represent psychiatric emergencies – especially if the data obtained with TAT’s are confirmed by other tests.
5. Stories where the character commits suicide due to self- depreciation /the fact that he/she feels lonely. In such cases, suicide is not imminent, but it may occur at any time, this depends on other factors, such as situations where the subject cannot handle emotionally. Subjects who offer such stories are often depressed.
6. Stories where the main hero wants to commit suicide, but does not, and the story ends as it the subject wishes. In this situation, it is not real suicidal ideation, but possibly a risk of superficial self-harming. The motivation of the possible self-harming is the most often the emotional blackmail of the person concerned in achieving the subject’s goals. This is especially true with subjects who have a histrionic personality structure.
In the last two cases, it has to be established whether there are also other mental disorders besides suicidal ideation.
Especially with type “4” story, in suicidal risk assessment one must take into account other factors, too:
– Fear of death: if the subject has a strong fear of death, suicide is unlikely, unless it presents emotional explosions, possibly doubled by histrionic behaviour. In this situation, the subject’s behaviour is unpredictable and suicide may occur at any time.
– Emotional explosions: if the subject displays affective explosions, suicidal risk is amplified, the subject’s being behaviour being unpredictable, especially when such explosions are doubled by histrionic behaviour.
– Histrionic conduct: it amplifies the parasuicidal risk. This behaviour has two purposes: either the subject wants to draw attention on him/her or to obtain desired behaviours the from persons concerned.
– Emotional instability: a factor that increases the suicidal risk because at a certain moment, the subject may understand and be able to overcome the problem he/she faces and the next moment he/she may change into the opposite mood and go further to acting – out.
– The level of self-control: if the subject has strong self-control, suicidal risk is amplified. In the same situation, in case of weak self-control, suicide risk is diminished because it is highly probable that even if the subject has built a plan to commit suicide, he/she will not have the resources to implement it.
It is advisable that both for suicidal risk and for aggressiveness, the results from TAT should be corroborated with results from other projective techniques.
In the case of TAT, simulation may consist either in that the subjects tell something different from what they see or think, or they tell incomplete stories about what they see and think. Some picture cards facilitate simulation because of the embarrassment or discomfort that subjects feel when they look at them or because of very strong emotions that the pictures evoke, which the subjects wish to repress or hide.
The methods to counteract simulation consist in asking the subjects clarifying questions during the administration of the cards and in monitoring the subjects’ behaviour and psychological condition during the test.
If the during the storytelling of one or several pictures, the subjects have motor restlessness, move their eyes or avoid eye contact with the examiner, smile, but their smile is not consistent with what they say, it is evident that they want to hide certain things. In this situation, the examiners can ask the subjects further questions and can suggest that they have realized that the subjects want to hide something and that it is to their advantage to give up the attempt. If they are approached tactfully, subjects change their attitude and become cooperative if they realize that they cannot hide what they think and that the examiner is not hostile. Other questions may be asked, too, to determine the subjects to say whatever they think in connection to a particular picture, but these questions should be formulated according to the context, there is no standard recipe. In these situations, children and adolescents feel the need to reassure themselves on the confidentiality of the psychologists, some of them needing emotional support when they tell the story of certain pictures, typically of those pictures have a strong emotional impact on them.
Aim of the Test
Assessment of Pulsions and of Pulsional Dynamics.
The test is designed to assess four pulsions, each having two tendencies:
1. Sexual Vector (S)
It reflects the intensity and the expression of sexual and aggressive needs of the subject, hence the sexual identification of the individual, on his two facets: femininity and masculinity. Femininity is associated with a softer, more passive spirit, with gentleness and tenderness, while masculinity is associated with incisive, active, domineering, aggressive spirit. Any person contains an alloy composed of the two elements, but one is predominant. Analysing this vector, one may find the intensity of the person’s erotic-sexual, aggressive needs as well as the ability of sublimation of libido. h factor (represented by pictures of homosexuals) reflects the need for tenderness, eroticism, and the s factor (represented by pictures of sadists) measures the need for physical activity, effective domination and manipulation of objects in the environment.
2. Paroxysmal Vector (P)
It shows the degree of imbalance or stiffness in affective censorship, i.e. the modality of control of the emotional manifestations. e factor shows to what extent the subjects want to control their harsh emotions, like anger, irritability and to adopt an ethical attitude of helping others and do good. hy factor reflects the intensity of moral censorship, respectively the control of expressing gentle, non-aggressive emotions.
3. Schizophrenic, or Ego Vector (Sch)
It shows the ego strength, the complexity of the defence mechanisms, general control of the behaviour of the subject. k factor reflects the tendency of the body to differentiate from the environment, to be independent and p factor reflects the trend of emotional fusion with the environment and the burst of ego boundaries, within a contact that should annul the distance between object and subject.
4. Contact Vector(C)
It shows how stable and satisfying the object relationships of the individual are. d Factor refers to the necessity to search objects in the environment that should be invested emotionally, and the m factor refers to the tendency to cling to objects.
It consists of 48 photographs, each showing the face of a mentally ill patient. They are displayed into six groups of eight each. Each group contains the photo of a person whose personality had been classified as homosexual, a sadist, an epileptic, a hysteric, a catatonic schizophrenic, a paranoid schizophrenic, a manic-depressive in the depressive phase and a manic-depressive in the manic phase.
Test administration and coding
It has two stages: the stage of the actual choice and the stage of association, the association stage in children is not applicable.
In the stage of actual choice, the subjects are asked to choose two most appealing, then two most repulsive photos from each group (for the foreground profiles), and then another two repulsive photos (for the background profile).
The appealing photos (including the two remaining ones) are denoted “+” and the repelling ones are denoted by “-”.
Useful Szondi formulas and indices in assessing aggressivveness. and suicidal risk
|s+!||Sadistic tendencies (very high energy.)|
|h+/s+!||Sexual drive with aggressiveness|
|H0/s+!||Tendency to destroy the others|
|H0/s-!||Tendency towards self-destruction|
|e-||Poor control of emotions; unstable emotional balance indicated by the frequency with which e- factor switches to e0|
|s+/e-||Paroxysmal discharge of aggressive energy; lack of aggressiveness control|
|Hy+||The desire to stand out; histrionic behaviour|
|h0/s+!/e- sau e0/m-||Imminence of paroxysmal discharge of aggressive energy.|
|S+/e-/m-||Antisocial personality structure|
|h0/s-!/k-!/d0||Serious risk of suicide|
|h0/s-!/hy+/k-!/d0||Major risk of parasuicide|
|h0/s-!/k+/p-||Risk of suicide|
The formulas to indicate the tendency to destroy the others, the sadistic structure, the weak control of emotions and of aggressiveness, the imminence of paroxysmal discharges of aggressive energy, are clear indications that a paroxysmal discharge of aggressive energy can occur at any time. These statements do not constitute psychiatric emergencies, but both psychopharmacological therapy and psychotherapy are absolutely necessary to improve the state of these people. In the absence of psychopharmacological therapy, any other type of intervention is useless, since people with high levels of aggressiveness do not suffer, but make others people suffer, so they have no good reason to want to be healed.
There are three situations where Szondi profiles are null:
1. The subject makes choices after a certain algorithm, i.e. choose the pictures located in the same positions. This has four possible causes: strong anxiety at the test / examiner, a possible mental blockage, misunderstanding of the instructions and desire to simulate.
2. The subject chooses the pictures without looking at them. This situation is caused by the desire to simulate and the disinterest in the test, ADHD, and, less often, by the misapprehension of the instructions.
Apparently, the person chooses the pictures in compliance with the instructions, but his choices are not according to what he thinks and feels. This is an obvious form of simulation. Subjects who do so are highly intelligent and usually want to hide a high level of aggressiveness or of antisocial / pathological behaviour. It is very difficult to detect such a situation. The only clues come from the inconsistency of the profiles with existing data on the subject and with results obtained from other tests and eventually from possible behavioural manifestations during the test showing a simulated behaviour, such as avoiding eye contact, a certain anxiety, etc. (Adapted from Szondi, 1952 Deri, 1949 Melon, 1997 Dumitraşcu 2005 www.szondiforum.org)
Slavonic Love Story -2
Translation after Djos V., 2011
On the side of a full-flowing impetuous river, there lived a girl, Luba (L) by name. She was ripe for a great love, but only married, disabled, or alcoholic men lived around her. Had she agreed to throw in her lot with one of them, her fate might have turned out to be different.
However, she did not want to squander her dream on substitutes.
Demitry (D), her ubiquitous neighbour, who offered her various candidates, also acquainted her with Sergey (S), who lived on the opposite side of the river. Sergey once saw her swimming in the river and wanted to take possession of her. He sent old Marya (M), the matchmaker, and she did her best praising Sergey and made Luba believe that Sergey was the only intended husband for her. The desire to be with him was getting stronger, but the river was flowing between them; besides, it was also the state border.
There was a narrow footbridge across the river. Konstantin (K), the frontier guard, was staying there on point duty and allowed only those he liked to cross the bridge. Luba asked him to let her go to the opposite side. But he did not like her and he refused. Then Luba applied to her ubiquitous neighbuor Dmitry, for whom, frankly speaking, no frontiers existed. Dmitry promised to find the way for her to get onto the other side of the river. Days and weeks passed.
In despair, the girl rushed to Colonel Petrov (P), the guards’ commander and asked him to let her go to the other side. Colonel Petrov was surprised and asked her to explain why she was striving to get there. She told him about her love. It was night and her story reminded him of
his youth, his unhappy love that destroyed his marriage and he ordered Konstantin to let Luba go; however, he wanted to think everything over first. Seeing that the colonel started hesitating, she rushed to the other side before he could change his mind.
On the other side of the bridge, there was another guard, Eugene (E). He was deeply suffering as the day before his wife was unfaithful to him. Had Luba walked slowly he might have not noticed her. But she was running. Eugene stopped her and asked whom she was hurrying to
at such a late hour. She told him about her love. Eugene felt anger that Sergey was loved so much and that his own wife was unfaithful.
“It’s not fair!” – he thought. Eugene fell upon Luba and using force raped her. After that, he felt a bit better and let her go. It was dark and no one saw it. However, Istratiy (I), who was making his usual evening stroll, heard something while walking past the bridge and even saw Luba putting her clothes in order. And he told everyone, including Sergey, in vivid colours, adding so many details to this sexual episode that it looked like wild lechery. Luba went to Sergey to explain everything hoping that he would understand and protect her. But Sergey met her with hatred. He said, “I needed all of you, I don’t want any leftovers! I would ask prostitutes to stay away from me!” Luba felt as if a heavy hammer fell down onto her head. She lost the future. Her life lost its meaning. While she was walking along the river, she recalled that she would have to pass by Eugene and she jumped, plunging into the river, and was drowned.
Who, in your opinion, is “the most guilty” out of the 8 participants in the tragedy described above?
Write down the first letter of the character’s name into the first cell of the table below:
Now, who among the remaining characters is “the guiltiest”? Write down the first letter of the character’s name into the second cell of the above table, and so on, until all the participants of the tragedy are analysed. (Write down only the first letter of the character’s name.)
N.B.: the test should be administered to persons whose age is 14 or older, but it is contraindicated in persons with mental retardation or borderline intellect because they do not understand it.
After reading the story, the subject is asked to arrange all the characters according to their culpability, starting from the most guilty to the most innocent.
Scoring: all the characters are scored in the order noted by the subject from one point for the most guilty to 8 points for the most innocent.
Two indices are of interest:
1. The crime index (CI): This indicates a possible predisposition of the subject to commit a crime.
Calculation formula: CI = Σe + hy / Σk+ p.
An index between 0 and 1 is considered normal; if more than 1, the higher the CI is, the higher criminal potential the subject has; the latter situation indicates the subject’s high level of aggressiveness.
2. The orientation rate (index) – to the past or the future (O): it indicates the predominance of the subject’s orientation, either to the past or to the future. A person who is oriented mainly towards the past has a higher risk of suicide than one mainly oriented towards the future.
Calculation: O = Σk + p + d + m / Σh + s + e + hy.
An index between 0 and 1 shows a person oriented towards the past, and one located above 1 indicates a person oriented towards the future. In the latter case, the higher the index, the more the person is future oriented.
N.B.: Each case will be considered only in terms of suicide risk, the level of aggressiveness and associated matters related to these issues.
A 16-year-old girl coming from a family with a very poor background and with absent moral norms. She became a prostitute since she was 13 years old, being encouraged by her mother whom she gave some the money thus earned. The girl gave up this practice one year and a half before because she has started a relationship with a boy.
Roerich Psychodynamic Interview
1. What colour is the road? Black.
2. What is the road surface like? Straight, smooth.
3. What is the firmness of the road? It is hard.
House of support
8. What colour is your house? Pink.
What material is the house made up of? From bricks.
9. In what state is the house? In good condition.
10. Does anyone live there? If yes, who? No one lives there.
14. What obstacle is it? A large tree fell and cannot move further.
Can you overcome the obstacle? If so, how? I cannot because it is too large.
15. What do you see beyond the obstacle? A house.
Go ahead and you arrive at another obstacle. What is that obstacle? I have broken my leg.
Can you overcome that obstacle? If so, how? I cannot.
What do you see beyond the obstacle? A hospital.
N.B.: in this case, the interview also contains more questions than the standard ones.
Interpretation: the absence of suicidal risk, but risk of self – harm in order to receive help, to capture the attention of others and to get the desired behaviour from the person concerned. (The house that lies beyond the first obstacle signifies the need for support, and the hospital from the second obstacle means the need for material aid to be in the centre of attention.)
– Both female and male behaviour, “s” having both “+” and “-”, tendencies.
– S+e-: poor control of aggressiveness, especially since s + transforms each time into s0, which indicates a paroxysmal discharge of aggressive energy.
– Frequent fluctuations factor “e” indicates poor control of emotions.
– Hy + / + -: histrionic structure. In 8 out of the 10 profiles hy is either “+” or “+ -”. This, in conjunction with the poor control of emotions, leads to unpredictable behaviour, which may consist both in paroxysmal discharges of aggressive energy, and in superficial self – harming.
– Frequent fluctuations of factors in the “Sch” vector indicate a weak ego structure and the risk of the possible emergence of a pathological process.
– M-: the absence of attachment person, m + occurs only in 3 consecutive profiles, this indicating a transient form of attachment. This is reinforced by the fact that m- is accompanied by d + and d0.
– The existence of s + e- m- indicates the risk of antisocial personality, and this is also reinforced by the presence of m- in 7 of the 10 profiles. This risk depends very much on the social environment where the girl will live from that moment on.
Girl with both male and female behaviour, with poor control of emotions and of aggressiveness, with histrionic behaviour, in the absence of attachment person, has the potential for paroxysmal discharges of aggressive energy, development of antisocial personality and self-harm – she harms herself only if she wishes to obtain certain behaviour from the person concerned.
Thematic Apperception Test
3BM. A boy broke up with his girlfriend because she cheated on him with his best friend and when he broke up with her, in the street, he saw a pillar with a stone, sat there, put his head on the stone, and wept. What else is there in the picture? A knife. Why is a knife there? He wanted to kill himself because his girlfriend cheated. What happens next? The boy decided to give another chance to the girl and be together again and forget everything and be happy, although this can never be forgotten. What comes to your mind when you look at the picture? I think of Flavius, but I have not deceived him, it was he who cheated on me, she is not my best friend, with a girl and he still keeps telling me “I have not cheated on you”. What do you feel when you look at the picture? Sadness. Do you liken the boy in the picture with anyone? Yes, with me.
3GF. A boy is standing at the door. The boy wants to open the door, he is crying because his mother is ill in bed, she wanted to commit suicide and closed the door so that no one could find her, because, God forbid, she had stomach cancer and did not want to suffer, neither she nor her child and thought that maybe it was better like that for her child, too. What happens next? His mother finally decided to kill herself because she has suffered too much and does not want to suffer any longer, neither she nor her child. Did she manage to kill herself? Yup. What comes to mind when you look at the picture? Death. I take it that you are afraid of death? Yup. Is it possible that I may inherit anything? My grandfather had eye cancer and Aunt Viorica had in the belly and died. What do you feel when you look at the picture? Great sadness. Do you liken the boy in the picture to anyone? Yes, to my uncle.
8BM. There are 4 people. One is on the table, lying on his back and a man cut him with a knife in the belly. The other man from the back is looking at them and this other man is sad because why does this guy cut that man’s belly. Where are they? In a room. Near the man on the table there is a rifle. Who cuts him and why ? I do not know, maybe he did something evil. What evil has he done? He was with them in the gang and he wanted to come out and they said no, he should not go away, he should stay with them. What gang is that? In a music band. What happens next? The man who wants to cut him says: “Will you stay with us or we kill you?” The man said, “I remain with you, but on one condition: you take my brother, too.” and tells the man that wants to cut says: “Yes, we take him, too but he must do what I say”. “What did he want to tell him to do? To listen to him, to sing what music he wants, to go wherever he sends him. Why would they kill him if he does not want to be in the same gang with them? Because he knows a lot, that they killed before, that they are drug dealers. Will they take his brother, too? Yes, and the boy’s brother says, “You shall deal only with drugs “ What comes to mind when you look at the picture? Nothing. What do you feel when you look at the picture? Nothing. Do you liken the characters in the picture to anyone? No.
15. (resistance) A man dressed in black goes to the cemetery at midnight and breaks the crosses. He is Satanist, goes to the cemetery, takes drugs, does crap out there. (sigh). What happened before? He has been a good man, labourer, lived in the countryside, but when he came – he moved in town – he saw what life is like here, befriended some Satanists, he took after them and got like them. What is mood like? Of a demon. What happens next? He will remain the same, he will still stand by his friends, will move with them. What comes to mind when you look at the picture? Nothing. What do you feel when you look at the picture? Nothing. (low voice) Do you liken the man in the picture to anyone? Perhaps he is like me, but I’m not a demon.
– The story of 3BM card is placed into group 6, it is actually a faithful reproduction of her relationship with a partner. In this situation, it is not a real risk of suicide or suicidal ideation, but a potential risk of self-harm for the emotional blackmail of the target person.
– The story in 3GF card is placed into group 2. Suicidal ideation is related to the situation in which she would suffer from a disease that would not allow her to care for herself. In this situation, it is highly likely for her to resort to suicide.
– From the stories of the pictures 8BM and 15 one can see very high levels of aggressiveness, predisposition to antisocial behaviour and criminal activities.
Conclusion: It is a person with suicidal risk only in the situation of an incurable disease, risk of self-harming the body, but with a very high level of aggressiveness, a tendency to antisocial behaviour and criminal activities.
1. Girl with poor control of emotions and of aggressiveness, tendency to antisocial behaviour and susceptible to illicit activities on the background of a histrionic personality structure.
2. Suicidal risk only in case of an illness that would not allow her to care for herself.
3. Risk of self-harm, but only to impress / as emotional blackmail of the partner (to whom she is not attached).
4. This case is not a psychiatric emergency, the girl needs long-term psychotherapy and psychological monitoring, otherwise, her evolution will be extremely unfavourable.
Boy of 18, from a single-parent family, his mother has never had authority over him and his brother. He has a high level of aggressiveness, which he tries to hide in front of teachers. After the first administration and after the interpretation was offered to him, the student has never come back for the next administration.
H + s + !: sexual drive with aggressiveness (this thing considering that the inquiry revealed that the last sexual relationship happened in morning of the testing);
S +! e: paroxysmal discharges of aggressive energy;
S +! e-m-: antisocial personality structure;
s + e-hy-: less interested in how their actions affect others; pursuing of their own selfish advantage.
N.B.: after the administration of the test, the same day, the boy physically assaulted his partner.
Conclusion: paroxysmal discharge of aggressive energy, against the background of following his own selfish advantage and of his antisocial personality structure.
Girl, aged 17 years and a half, above average intelligence, coming from a family where the father and grandmother behave arbitrarily and in an authoritarian manner with her, claiming that they want to protect her. Both the behaviour of two relatives and her problems with her eyes have led to her lack of self-esteem and inferiority complex. Since the father drinks alcohol, he becomes uninhibited, most often threatening her, and, very rarely, assaulting her, even without a real reason. Stepmother is the only attachment person in the house and she no longer keeps in touch with her natural mother
– s-!: masochistic structure. In 8 of the 10 profiles, s- is at least with a “!”, which indicates that the masochistic structure is well defined.
– h0s- !: self-destructive tendency which usually contains suicidal ideation.
– s-! e-: from the first profile indicates rage turned against one’s own self, this behaviour is enhanced by histrionic structure.
-e + -: ambivalence in controlling aggressiveness and emotions; affective conflict that can lead to periodic choleric crises, but not to antisocial manifestations;
– hy + -: consciously perceived conflict; intra-psychic tension, reflecting indecision to express her own feelings; the component hy + from the structure h+ – indicates a histrionic personality, especially that hy + – is found in 7 of the 10 profiles.
Conclusion: It is a person with tendencies towards self-destruction and moments of directing the anger against her own self, against a background of masochistic and histrionic personality structure. In this situation, there is a real risk of suicide, but only in extreme situations, which she cannot manage emotionally, and emotional self-control and that of aggressiveness is absent.
Thematic Apperception Test
3BM. So! There is a man who lies – not lying there on the ground, but in a squat position – and with head resting on the seat. He is alone. Hmmm. What else is there in the picture? It is a bench, a chair, he is upset (motor restlessness). He thinks about what will happen with him, that is, if everything will be fine with him as before, what will become of him, if he is going to have a beautiful family. But, what’s down there? There is nothing. (Later laughs). Look carefully and tell me, do you notice anything else in the picture? There is a knife. Why is there a knife? He has forgotten it on the ground. On what purpose is the knife there? He wanted to tattoo his veins a little. Aren’t you stupid! Don’t you know what you want from life? (Laughs). Why did he want to “tattoo his veins”? He thought it’s good that way, but he stopped in time. What caused him to believe so? That way he thought it is better, but he realized that he has all the future in front of him and he realized that he would not have solved anything and he is trying to be more optimistic. Can you be more explicit why he thought it is better like that? (Hesitation) He had no one close to him. What happens next? (Motor restlessness) He will realize that everything will be fine and he will be very optimistic. You shall be optimistic, you stupid! (Throughout the whole interview, the motor restlessness persisted). I do not liken anyone with anyone else, he is in a good, optimistic mood, (statements made mechanically). I hate this TAT! I can’t believe it! (The test was performed at the request of the student) What comes to mind when you look at the picture? Nothing. That he’s stupid (laughs). But what about you, what do you remember? That I made, I would have made a big mistake if I did that thing when it was to happen. What do you feel when you look at the picture? (Long silence, resistance) Stupidity on his part, because he thinks so. (resistance, slight sadness). What did you mean when you said “That I made”? When I quarrelled with Daddy and I started to go to bars (this happened while I was in grade IX), Daddy, instead of talking nice to me, he hit me and I got angry and I wanted to do this stuff. What did you want to do? I took the knife and wanted to slit my wrists. If I were nervous, I would have done it, because I did not realize what I was doing, but as I realized and I stopped. There was another thing, too: I do not know what was phase about, he, instead of believing me, he believed that one (the girl in the village) and I quarrelled with them and hit the window with my fist, I broke the glass and I smashed my hand. When I broke it I did not realize what I did, after I cut my hand I realized what I did. This phase was in grade VI or VII. Lacri (father’s sister) is worse than me. When she gets angry, very often she breaks windows, cups, pots.
14. A dark room with the window open (laughs) and one guy playful –because he is perched on the window, the asshole! – he wanted to see what the weather is like from the top (laughs heartily). He sits up on the window and looks down, he is alone in the room. What mood is he in? (hesitation). A little upset. Why is he angry? Because he has no one with him and he has a bad feeling about him, why would he sit perched on the window? He is crouching. It is not what you think, stop insisting! Because he is a fool, he does not want to jump (laughs) so do not insist about this! He does not because he stops himself. What happens next? He realizes that if he does this thing, he is gonna be the biggest fool in this world and that it’s not worth sacrificing his life for all that bullshit. Or for the stupidity in his head, because he thinks that’s better and knows that this is not a solution, firstly, so that he should put an end to these stupid thoughts from his little brain and should enjoy life as he is part of it. I do not liken this character to anyone. What do you feel when you look at the picture? That he deserves another chance not to do that stupid thing.
– Obvious suicidal impulses, high risk of acting out in extreme situations, which she cannot manage emotionally, and emotional self-control and that of aggressiveness ares absent. This is doubled by the fact that in these situations, she no longer recognizes the consequences of her actions. The acting-out is enhanced by the histrionic and masochistic personality structure.
– In terms of rational thinking, the girl is aware of the danger of these impulses, of the fact that suicide is not a solution to any situation, which produces her a strong sense of discomfort.
– Apparently, suicidal impulses arise from time to time in her consciousness, their source is the feeling of loneliness and lack of self-esteem, all these on the background of her masochistic structure.
– The test showed that in an extreme situation she harmed herself and in another she had an attempt at suicide.
Conclusion: It is a person with suicidal impulses related to the feeling of loneliness and lack of self- esteem, real suicidal risk, but only in situations that she cannot handle emotionally. She weighs the situation where she is in rationally and concludes that suicide is not a solution in any situation, but in strong negative emotional moments, emotions rule the thinking so that she no longer realizes the consequences of her actions and moves on to acting-out.
1. The person presents a weak control of emotions and of aggressiveness, tendencies towards self-destruction, turning anger against herself amid histrionic and masochistic personality.
2. In cases that she cannot control herself emotionally, she loses her emotional control and that of aggressiveness, her thinking being subordinated to affections; this could lead to acting out. This means a real risk of suicide / self-harm risk, especially in the context of her histrionic and masochistic personality structure and of her self-destructive tendencies.
3. Although there is a potential suicidal / autolytic risk, the girl is not a psychiatric emergency, but she requires long-term psychotherapy, psychological monitoring and supportive family environment.
It is a nine-and-a-half -year-old girl, above average intelligence, who comes from a single-parent family with precarious financial situation and lives in an area where physical and verbal aggressiveness and alcohol consumption are highly frequent.
Mother is with a history of psychiatric disorders for which she had been admitted to the psychiatric clinic, but in recent years, she has had no hospitalization.
– s +: masculine structure with aggressive behaviour, particularly since out of 7 profiles where s +is present, 4 are s +!, which indicates a very high level of aggressiveness and sadistic inclinations. This male structure is also reinforced by h- and h + – which soften to some extent the very high level of aggressiveness.
– s + e-: paroxysmal discharge of aggressive energy, this situation is reinforced by the fact that s + e- from profile II turned into s0e0 in profile III. However, it should be noted that over the 10 profiles, there was a single paroxysmal discharge of aggressive energy (caused by the fact that the student was assaulted verbally), and this against a fairly high level of aggressiveness.
– Frequently changing the factor “e” indicates poor control of emotions.
– Frequent fluctuations of factors in vector “Sch” indicate a weak ego structure and a possible risk of psychotic process.
– Frequent fluctuations of factors in vector “C” indicate its disturbance, including a disturbance of attachment relationships.
– The fact that in two out of the 10 profiles there is the s + e-m- combination indicates an increased risk of developing antisocial personality, this risk is amplified by the harmful environment in which she grows.
1. She is a girl with a high level of aggressiveness, with some paroxysmal discharges (paroxysmal discharges occur only if she is subjected to physical and verbal aggressiveness.) against a weak control of emotions. The high level of aggressiveness is sometimes mitigated by the presence of h-, e + and hy- along the profiles.
2. High risk for antisocial personality development, especially because of the environment in which the girl grows.
Thematic Apperception Test
3BM. There is a lady who sits and cries. She stays in bed. She is complaining that her husband has died. Why did her husband die? He was sick. What disease did he have? Cancer. And she went to his grave. And she wanted to throw herself over the grave but she could not because no one had let her. Why did she want to throw herself over the grave? Because she loved him very much and wanted to let him buried there. What else is there in the picture? A carpet. And on the carpet? A knife, it seems. Why is a knife there? Then it means that she murdered her own husband. Why did she kill him? For he annoyed her or he did not want to do what she wanted. What annoyed her? (motor restlessness) The fact that he did not want to go to the hospital to see the baby. Why was the baby in hospital? Because it was sick. What disease did it have? It had a very bad cold, it had water on the lung. What could have been that he did not do as mother wanted? To take her to the hospital to her child by car. What happens next? The child came home from the hospital and mother is happy. She says that she has killed the father and why she killed him. And the child says, “Mom, but you should not have killed him!” Will anything happen to mother because she killed his father? No. What comes to mind when you look at the picture? That’s sad to kill your husband and tell this to your child when he comes home. It is a tragedy. What do you feel when you look at the picture? I feel bad, so it’s not good to kill your husband. Do you liken the woman in the picture with anyone? No.
7BM. Two men are talking about some girls. After talking about girls they went home, each sat on the bed, went to sleep, the next day they met again, talked, and found two beautiful girls that are good to work, to sweep, to wash away. They took on those two girls, raping them first, secondly they made them to do their work every day. What happens next? All the time other girls, other girls and the girls will gather. Where will they gather? At the job that these guys gave them. What job is that? Like a sort of tragedy to kill, but as if they go to their job and kill people and women stay at home, they cook, they work. What comes to mind when you look at the picture? That’s not good, it’s very, very, very bad to put these raped women to work and work until they are exhausted. What do you feel when you look at the picture? Nothing. Do you liken the men in the picture with anyone? No.
9GF. It is a woman who hides behind a tree and she is chasing the other a woman behind the tree. And the woman who was behind the tree caught the first ones. And took her to jail. After she took her to jail she said she wanted to kill her. And of course she killed her and she made her a coffin and buried her without anyone, she spoke only with the gravediggers and buried her. Is there any connection between the two women? Only they were at the same school, from here, and they quarrelled at school and the one that stayed behind the tree wanted to kill her. No one of our family had this happened to them, perhaps in other families. What caused the two women to quarrel? Over some money. They came on the first day at school. They were in grade V and this little girl asked for some money from the oldest woman at the school and said, “OK, I give you but I want it back tomorrow when we meet at school!” And the girl said “good”. The next day they met and she said “Now, come on, give me the money ‘cause we met, before we got to the class” and she said “what money?, I have not any money from you! What money do you need from me? “. The previous day she had asked for 100 lei. And she said, “if you don’t give me the money, I’ll tell you to my mother that I gave you so much money and I needed the money to buy myself clothes for the baptism ceremony.” She said, “ what money?, I asked for no money from you! “, So the little girl her. And then, the little girl thought to kill her and so she did. What happens next? The mother of the girl who died came to school and said why she killed her and she said that from some money, that she did not want to give her the money back. Will anything happen to the girl who killed her? No. What comes to mind when you look at the picture? That’s good to kill someone if they do not give you money back, not even the next day and third day. What do you feel when you look at the picture? That’s good to kill someone (easy smile) if they do you harm. Do you liken any of the girls in the picture with anyone? No.
17GF. There is a house with some warriors that fight. After they fought, they all died. All that’s left is a woman and the woman put all of them into the grave and all of a sudden a light appeared so big, big! Nobody saw it because everybody went to the grave. What light was it? The sun? Why did they fight? Because they were always arguing. Why were they arguing? Because of the money, that they were not able to share it. Where was the money from? They stole it. Has the woman any connection with them? No, but shethought to be kind enough to take them. What happens next? She buried them and she came home and warriors who were left, no more than two, woman has argued with them. Why did she quarrel with them? Because the two were in the other team, because they killed them and they were the best. What happens after the fight? Woman kills them, too. What comes to mind when you look at the picture? Nothing. What do you feel when you look at the picture? Sadness. Do you liken the characters in the picture with anyone? No.
Interpretation: From the answer to all the presented pictures, one may conclude that there is a very high level of aggressiveness, tendency toward antisocial behaviour (as indicated by Szondi test results), lack of remorse and awareness of legal consequences. The social environment, in which the subject lives, most likely causes this because in that environment socially undesirable acts occur, but are not sanctioned legally.
1. The little girl is strongly negatively affected by the social environment in which she lives, showing a high level of aggressiveness, with paroxysmal discharges amid poor emotional control, a lack of remorse for her deeds and her not realizing their legal sanctions .
2. High risk for antisocial personality development.
3. Even with a high level of aggressiveness, with paroxysmal discharges, the girl is not a psychiatric emergency, nor does she require psychopharmacological treatment; at this time is only monitoring and psychological counselling are very useful.
A Boy aged 19 years came from an orphanage, out of the social protection system at 18, previously undiagnosed psychiatrically but showing an obvious Borderline Personality Disorder and a liminal intellect. About his family we know that the father is an alcoholic, and his mother has rejected all her children, abandoning them to social protection system. Two of the student’s siblings (a brother and a sister) were diagnosed with behavioural disorders, his brother has improved significantly, but we have no data about his sister, but at the moment of the dropout (grade XI, she had average conduct disorder and a certain predisposition to antisocial personality disorder.
Results for Slavic Love Story
CI = Σe + hy / + Σk p = 5 + 6/3 + 4 = 11/7 = 1.57, increased index, showing a criminal potential
O = Σk + p + d + m / Σh + s + e + hy = 3 + 4 + 7 + 8/1 + 2 + 5 + 6 = 22/114 = 1.57, future oriented person
N.B.: As can be seen, the crime index (CI) is very high, indicating at that time a significant criminal potential. 5 months after sample administration, the student had attempted to injure or kill his partner, he was stopped by colleagues, so that the partner was not even hurt.
It should be considered that an increased CI will always be potentiated by Borderline Personality Disorder, and other psychiatric disorders.
Conclusion: Although with a CI indicating a high criminal potential and with Borderline Personality Disorder, the boy is not a psychiatric emergency at the moment but requires both psychopharmacological treatment and psychotherapy and psychological monitoring. In the absence of psychopharmacological treatment, any intervention is useless, because the subject is not aware of the disease, thus he may become a genuine psychiatric emergency at any time.
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