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Journal of Contemporary Psychotherapy, Vol. 30, No. 3, 2000

Suicide Signs on the Rorschach

John Bishop, M.S., Andrew Martin, M.S., Scott Costanza, Psy.D.,
and Robert C. Lane, Ph.D.

This paper reviews the literature concerning the assessment of suicide using the
Rorschach and updates the important developments since Goldfried, Stricker, and
Weiner’s comprehensive review of the literature in 1971. Special attention is given
to those indicators which show the most support in the literature and are most
efficient to use. The presence or absence of any of these signs in a patient’s record
should not be taken to signify the presence or absence of suicidal ideation. However,
the presence of even one of these indicators does provide a warning to the clinician,
indicating that further exploration in this area may be warranted. Knowledge of
the many suicidal indicators on projective tests places the clinician in a better
position to predict such destructive behavior and intervene appropriately.
KEY WORDS: suicide; suicidal ideation; Rorschach; cross sectional responses; transparencies; color
shading responses.

INTRODUCTION

The prediction of suicide is one of the most important challenges facing a

clinician, due to its fateful consequences. The myriad of factors that underlie the
act of suicide make its prediction difficult. These causative factors typically are
psychological, social, cultural, economic, medical or situational. Psychological
tests often play a role in the prediction of such behavior, as thoughts of suicide are
not always readily admitted to by the patient. Frequently, the patient may with-
hold, knowingly or otherwise, personal information, which makes it more difficult
for the clinician to understand the personality dynamics of the individual. Un-
like self-report measures, projective tests such as the Rorschach and the Thematic
Apperception Test (TAT) are best suited for this purpose since the patient is un-
aware of exactly what is being measured. Consequently, the ability to under- or
Address correspondence to: John Bishop, M.S., Psychodynamic Concentration, Nova Southeastern
University, Center for Psychological Studies, 3301 College Avenue, Fort Lauderdale, FL 33314.

289
0022-0116/00/0900-0289$18.00/0 °
C 2000 Human Sciences Press, Inc.
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290 Bishop, Martin, Costanza, and Lane

over-report symptoms is markedly diminished with projective measures of assess-

ment. Additionally, self-report measures do not address the causative factors that
may underlie the pathological symptoms of the patient.
Research on the use of psychological tests to identify suicidal patients has
proven to be problematic. Persons who successfully commit suicide are often
grouped with individuals who make suicidal gestures or voice suicidal thoughts.
Not only does the attempted suicide group differ from the successful suicide group,
but there may also be differences in both groups in diagnosis, as well as the length
of time prior to the attempt that the test protocol was taken from the patient.
The use of projective tests, such as the Rorschach and Thematic Appercep-
tion Test, to identify suicidal patients does not escape these research difficulties.
Due to methodological inconsistencies, the results found in studies are often dif-
ficult to evaluate, and replication in general has been unsuccessful. Neuringer
(1965) reviewed the literature on the use of the Rorschach in identifying suicidal
potential and found that the apparent lack of support derives mainly from the in-
comparable nature of the studies and the various definitions of suicidal behavior.
He found that samples are small, experimental conditions not identical, statistical
procedures vary, judges are often used with different degrees of reliability, defini-
tions of terms are sometimes difficult to comprehend, and cut-off scores are not
sufficiently spelled out. In other problems, sometimes test protocols from many
different sources are pooled together in which there are different examiners with
varying levels of skill, and different scoring procedures or systems.
With the growth of cognitive and/or behavioral psychology during the sev-
enties and eighties, the use of the Rorschach for the assessment of suicide or
otherwise has steadily declined. Critics charge that the Rorschach is too theoreti-
cally based, too lengthy and time consuming, too subjective, and based on poorly
controlled research studies. Seeking greater objectivity and quicker methods of
assessment, many psychologists have begun to rely on self-report measures of
personality functioning, such as the Minnesota Multiphasic Personality Inventory
(MMPI).
While such self-report measures may prove to be more statistically sound, they
often fail to capture the richness and depth of the individual in question, qualities
which are better apprehended through consulting multiple sources of information.
The clinician exercises crucial clinical judgement in marshalling data from nu-
merous sources, including the clinical interview, the patient’s history and current
situation, and projective tests, such as the Rorschach, which in the hands of an
experienced clinician can sensitively assess emotional and personality dynamics.
This paper reviews psychodynamic theory of suicide and how attention to
certain signs on the Rorschach may be revealing of these dynamics. While these
signs or indicators of suicide potential have received varying degrees of empirical
support, they all have been attested to clinically. In any test record, they may appear
singly or as a configuration of multiple signs, embodying different types of content.
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Suicide Signs on the Rorschach 291

THEORIES OF SUICIDE

The use of the Rorschach is closely tied to, and cannot be discussed apart from,
psychodynamic theory. In his paper “Mourning and Melancholia” (1917/1948),
Freud attempted to explain suicide as being a death wish originally directed to-
ward someone else which now is directed toward the self with the aim of killing
the introjected object. Other theorists such as Litman and Tabachnick (1968)
have speculated that the ego consists of a basic “action self” plus a number of
“subselves” acquired through experience by such processes as introjection, iden-
tification, loving imitation and the resolution of various basic conflicts. Under
stress, the ego tends to fragment and suicidal subselves may emerge. The sui-
cidal sub-self is frequently formed in a situation where the patient feels aban-
doned or cruelly treated and that the only way to gain love is by self injury and
death.
Many of the suicidal patient’s dynamics, feelings, and language can be de-
scribed with reference to disturbances in the sense of self, object relations, emo-
tionality, sexuality and fantasies (Lane, 1971). Familiarity with the disturbances in
each of these areas is helpful assessing suicide potential prior to the use of specific
techniques.

1. Disturbance in the Sense of Self—Beset by intense feelings of inadequacy

and worthlessness, and suffering severe body anxiety and preoccupation,
patients display symptoms of every psychosexual level. They are over-
whelmed by their problems, may be seeking punishment or a wish to
change their identity. They feel helpless, powerless, are narcissistically
preoccupied, and use self-references, referential and influential ideas and
personalizations. Another type of suicidal patient may display delusions
of omnipotence and power, invulnerability and the wish for contact with
God, or display some type of religiosity.
2. Extremely Disturbed Object Relationships—There are all types of feelings
of estrangement from the self, people and reality, with a diminished interest
in the external world, activities and people. Patients have murderous rage
which cannot be directed towards their significant objects, and is redirected
against the self. They blame themselves, and fantasize the masochistic
destruction of the hated part of the self. By destroying the self, they feel
they are getting back at the mother, while at the same time re-merging
with her.
3. Rigid to Impulsive Emotionality—Patients show flattened affect and de-
pression, yet vacillate from rigid control over emotions to impulsive acting
out with loss of control. Severe anxiety and guilt are nearly always present,
and associated with murderous rage and death wishes. Unbearable tension
and pain lead to agitation and general mood variation.
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292 Bishop, Martin, Costanza, and Lane

4. Disturbed Sexuality—A lack or diminishment of sexual drive is common

in many patients. Libido is turned inwards and body symptoms and preoc-
cupation replace sexual feelings toward objects. They feel sexually inade-
quate, unloved, unmasculine or unfeminine, and that to get close to them or
know them would mean hatred of them. Both men and women lack orgastic
potential and fantasize solving their problems through magic. Sometimes
there is frantic Don Juan-like activity in men, and very promiscuous ac-
tivity in women, in their search for contact prior to a suicide attempt.
5. Death Fantasies and Preoccupation with Fear of Separation from the Love
Object—There is excessive concern and preoccupation with dehumanized
concepts, the lifeless and the inanimate. These patients feel they are sur-
rounded by all kinds of frightening objects which can annihilate them.
There are references to shadows, transparencies, ghosts, spirits, invisi-
ble beings, dead things, corpses, and dissections. In addition, things are
smashed, mutilated, run over, stepped on, burned out, rotted away, and the
like. Death may be seen as a new life; an escape from an unbearable life
situation, heaven, paradise or perfection itself. Often present is an inability
to accept separation from a love object, along with a feeling of extreme
loss which cannot be tolerated.
The above dynamics and feelings are often found in the records and speech
of suicidal patients. The greater the number of these factors present, the greater the
likelihood of a suicidal potential. When using the Rorschach to detect for suicidal
potential, the clinician can look for signs in the test record that may tap into these
factors. The Rorschach is the obvious choice for such a task since it provides
insight into the personality dynamics of the individual, as well as ego strength,
ego defects, sexual drives/attitudes, degree of superego control, and the capacity
for empathy. As noted earlier, when assessing suicide potential it is important to
look for a constellation of signs and related phenomena because no single sign has
been found reliable.
There are also numerous external factors that may contribute to a person’s de-
cision to commit suicide including economic factors, social conditions/influences,
and family dynamics. Maltsberger (1992) lists a number of factors that have been
found to be statistically related to suicide risk, including age, sex, race, mari-
tal status, living arrangements, employment status, physical health, a psychiatric
condition (including substance abuse), medical care within the past six months,
previous suicide attempts or threats, recent loss, childhood losses, separations,
family history of mental illness, and a history of physical, sexual or emotional
abuse. These factors, plus any other factors that are clinically significant (e.g.,
anniversary reactions), must also be taken into account while interpreting the
Rorschach data. Let us now turn to the Rorschach content which provides us with
the most comprehensive and “in depth” examination of an individual’s personality
dynamics.
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INDICATORS OF SUICIDE

When the clinician suspects suicide potential, even if the patient has denied
suicidal ideation, specific techniques should be used to search for evidence of
this potential. The use of indicators in this assessment raises ethical questions
for the clinician. How many indicators should be searched for and which in-
dicators should be used—those that are well supported by the literature, or all
indicators whether they are well supported or not? How much time and energy
spent looking at indicators is enough to determine a course of action? To be thor-
ough, the authors have included all indicators from the literature, well-supported
or not, time-consuming or brief. We have elaborated, however, on only those in-
dicators which are moderate to simple to employ and are well supported by the
literature.

Indicators Based on Content

Morbid Content

The projection of morbid content has been seen by a number of researchers

as being indicative of suicidal potential (Broida, 1954; Crasilneck (1954); Exner,
1986; Hertz, 1948; Lane, 1971; Lindner, 1947; Sakheim, 1955; White and
Schreiber, 1952). Morbid content involves themes of death, dead things, disin-
tegration and decay. Fleischer (1958), in contrast to Hertz, reported that only one
morbid response may indicate suicidal potential. Exner (1993)1 found that three
or more morbid responses, when added to his criteria (the suicide constellation),
increased the identification of the suicidal group from 74% to nearly 80%. It
goes without saying, that the greater the number of signs, the greater the suicidal
risk.
Phillips and Smith (1953) noted that those percepts that were specifically
related to death were indicative of depression. Furthermore, they maintained that
when depressives provided a pure “C” response, which was rare, it was usually
that of a morbid percept such as “blood” to the colored area of Card II or III.

Costello’s Content Signs

Costello (1958) found that four signs were able to differentiate successfully
between a group of suicidal patients and a group of non-suicidal patients: winged
animal in flight to Card V, human response to Card V, map response to Card VII,
and a deer’s head to Card IX. The projection of a map (W or D) onto Card VII as an
1 Exner (1993) is the standard Rorschach textbook, and the reader is referred to this book to understand
all of the Exner signs.
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294 Bishop, Martin, Costanza, and Lane

indicator of suicidal potential was further supported by Phillips and Smith (1953).
The remaining three signs have not been supported in any subsequent research.
The above two signs (morbid content and Costello’s content signs) are sup-
ported in the empirical literature and relatively simple to use. Other content signs
with only limited support are listed below.

Sapolsky Sign

Sapolsky (1963) postulated that responding to area D6 on Card VII, com-

monly seen as the vaginal area on the so-called mother card, represented an un-
conscious wish to return to the maternal womb and would successfully differentiate
suicidal patients from a comparable control group. His results were questionable
and Cooper, Bernstein and Hart (1965), Cutter, Jorgensen and Farberow (1968),
and Drake and Rusnak (1965) all failed to produce significant results.

Lindner Sign

Lindner (1947, 1950) referred to Card IV as the “suicide” card. He hypoth-

esized that responses containing such projections as “a decaying tooth,” “a rotted
tree trunk,” or “a ball of black smoke,” (p. 83) all reflect severely depressed states
with suicidal overtones. Cutter, Jorgensen and Farberow (1968) tested this hy-
pothesis and found support, although weak, for its continued use. Sakheim (1955)
found that shock to Card IV (card rejection, blocking, delayed reaction time) dif-
ferentiated suicidal from non-suicidal hospitalized psychiatric patients.
Hertz (1948) pointed out that Lindner’s hypothesis “must be viewed with
extreme caution.” Her category, “ideational symptomatology” includes Lindner’s
sign, but she emphasized that, “one configuration alone is not sufficient to indi-
cate suicidal tendencies.” Furthermore, she pointed out that deteriorating content
on Card IV appears to be a very important sign of depression, but not neces-
sarily suicide. Hertz (1948) stated the following, “It should be emphasized that
depressed conditions in themselves do not reflect suicidal trends. Indeed many
patients in deep depression are not suicidal. They are too far gone to experience
inner struggle, to plan self-destruction, and to act and put any plans into effect”
(p. 54).

Two Angels Carrying Center Figure Up to Heaven (Card I)

Although there is no research to support the use of this indicator, it has been
found anecdotally among the records of suicidal individuals, and may be a clinically
significant indicator of suicidal ideation. Obviously this response contains strong
connotations of death, passivity, and a wish to escape to a better place.
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Multiple Signs/Configurations

Hertz’s Signs

Hertz (1948, 1949, 1965) conducted the most comprehensive and theoretically
based study to date. She viewed suicide as a violent, aggressive form of acting out
behavior resulting in self-destruction. Hertz’s approach best covers the diverse
factors underlying suicide, leading to better prediction. Her approach combines
both sign and content analysis, and identifies fourteen Rorschach configurations
suggestive of suicidal potential.
Her sample consisted of 229 clinical cases in three groups: 50 neurotic and
63 psychotic suicidal patients, 63 nonsuicidal neurotics and 53 non-suicidal psy-
chotics, and 96 normals. Ten of the fourteen configurations were found to distin-
guish between suicidal and non-suicidal groups. She found that the most important
combination of suicidal configurations included Depressed states, Deep anxiety,
Active conflict, Agitation and pathological Ideation characterized by hypochon-
driacal bodily delusions and ideas concerning the futility of existence. Thus, she
concluded that patients whose records indicate deep and anxious depression, in-
tense inner struggle and, in addition, tension, agitation and restlessness, appeared
to be the greatest suicidal risks. Her findings have been validated repeatedly and
her study appears to be the most comprehensive and influential to date.
In using her configurational approach, Dr. Hertz acknowledged that the
Rorschach does not predict suicidal behavior, but rather assesses the underlying
personality characteristics that may give rise to such behavior. She says, “It is then
the clinician’s job to integrate the Rorschach findings into the life history of the
individual taking a host of factors into consideration (situational and socio-cultural
factors, etc.) before making a prediction regarding suicidal risk.” Hertz was quick
to point out that regardless of whether or not the patient reported feeling better or
appeared clinically less depressed, the Rorschach signs should be heeded.
One of the main criticisms of her study was that the scoring criteria for each
configuration was complicated and required an inordinate amount of time to score.
Neuringer (1974) criticized Hertz for separating the subjects into suicidal and non-
suicidal groups and then examining them for the presence and absence of these
signs, which Neuringer believed contaminated the data. However, Sakheim (1955)
found that four of Hertz’ signs (Deep anxiety, Depressed states, Withdrawal from
the world, and Resignation trends—(Configurations 2,3,12 and 10) differentiated
his two groups in a similar study. Eyman and Eyman (1992) wrote that the config-
urational approach, especially that of Hertz (1948, 1949) and Martin (1952) offers
the best validity since it takes into account the multiple determinants of suicide
risk. The authors are quick to note, however, that suicidal behavior is complex and
should be corroborated by other clinical data regardless of whether you are using
a single sign or a configurational approach.
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Exner’s Suicide Constellation (S-CON)

Exner’s (1977, 1986) suicide constellation is one of the more widely used
methods for assessing suicide risk. Exner’s suicide constellation gained popu-
larity throughout the eighties and nineties and remains one of the more sig-
nificant research developments since Goldfried, Stricker and Weiner’s (1971)
review of the Rorschach literature concerning the assessment of suicidal
potential.
To develop the scale, the Rorschach records of individuals (S = 59) who
attempted suicide shortly after taking the test (within 60 days) were computer
searched for all combinations of variables and variable frequencies to detect those
appearing in at least 30 of the 59 records. Eleven variables were found to signifi-
cantly discriminate the suicidal subjects from three control groups. Using a cut-off
of eight or more variables, the S-CON was able to correctly identify 44 of the 59
suicide cases (75%).
Ultimately, the constellation included 12 variables, with the presence of eight
being suggestive of suicidal potential. Despite being able to identify correctly
83% of the target population (those subjects who had attempted suicide within
60 days of Rorschach administration), a cutoff score of eight produces a false
negative rate of 15% within the target group and a false positive rate of more
than 10% among depressive controls. The presence of eight or more variables
should be taken as a warning and further exploration of the possibility of self-
destructive potential should be pursued expeditiously. However, Exner cautions
against making the assumption that no suicide risk exists if the S-CON contains
fewer than eight positive variables.
The S-CON has been used with varying degrees of success among younger
subjects. It seems to have some degree of validity when used with 15-and 16-year-
olds, only because most of the normative data for these subjects is similar to those
for adults. It does not appear to be useful for younger children since many of the
variables are expected to be positive.
The Hertz and Exner signs are well supported in the literature. Other sign
configurations which are not as well supported are listed below.

Martin’s Checklist

Martin (1952), in an unpublished doctoral dissertation, empirically developed

a checklist consisting of 17 signs which he felt successfully differentiated ( p < .10)
suicidal patients from non-suicidal patients.
Subsequent research by Weiner (1961) found that two of Martin’s signs, 6
(Color and Color Form responses appear first on Cards VIII, IX, or X) and 16
(P less than 3, and F + % < 60) consistently differentiated between suicidal and
non-suicidal individuals ( p < .05). He also found support for signs 3 (CF responses
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Suicide Signs on the Rorschach 297

either 1 or 2) and 7 (C and/or CF responses appear in protocol, but sum shading-Y

and sum texture-T is 0) ( p < .10).
Four other studies (Cutter, Jorgensen and Farberow 1968; Daston and
Sakheim, 1960; Goldfried, Stricker and Weiner 1971; White and Schreiber, 1952)
found that Martin’s 6th sign indicated the potential for suicidal behavior. Daston
and Sakheim (1960) found that three signs (C or CF appear first on Cards VIII, IX
or X (6); Sum of shading-Y and Sum of texture-T is less than 1 (10); average time
first card responses less than 27 seconds (17)) successfully differentiated between
those that successfully committed suicide and a control group of non suicidal in-
dividuals. Using a cutoff of 7 or more signs they were able to correctly categorize
92% of the control group, 61% of the “suicide attempt” group, and 62% of the
“successful suicide” group.

Beck’s Configurations

Beck (1945) hypothesized that, “When a person of superior intelligence ex-

periences much inner conflict projected in a neurotic structure of compulsive form,
and much mulling over of deeply personal life experiences . . . the pattern is almost
always ominous with the threat of suicide.” Based on this hypothesis, Fleischer
(1958) and Sakheim (1955) outlined five suicidal indicators which they believe
best represent this hypothesis. They are: Oppressive Anxiety, Neurotic Structure,
Strenuous Inner Conflict, Mulling Over, and Shading Shock on Card IV.
Obviously there is a high degree of subjectivity involved with this system.
Inter-rater reliability has suffered as a result. Fleischer (1958) found that the pres-
ence of any four or more of Beck’s five signs was best able to differentiate between
those who committed suicide, those who attempted suicide, those who threaten
suicide, and a control group.

Piotrowski’s Signs

Piotrowski (1957) hypothesized that numerous shading responses, low F+%,

many W and a “powerful sum C” point to suicidal tendencies. Fleischer (1958)
and Sakheim (1955) tested these four signs and found that the use of three or more
signs failed to distinguish between suicidal and non-suicidal groups.

Single Signs

Shading Within a Colored Area

Appelbaum and Holzman (1962), in a controlled study, found that the color
shading response occurred with greater-than-chance frequency in both suicidal
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groups investigated and correctly identified 86% of the suicidal patients. The color
shading response was found with greater frequency in the group in which the
respondents had successfully committed suicide than in the group in which the
respondents had made an unsuccessful attempt. An example of this response might
be, “Card VIII, lower center half; shape and color of an iris: the velvety insides
because of the shading.”
Appelbaum and Holzman (1962) hypothesized that persons who give the
color shading response possess a greater sensitivity to subtle nuances of feeling
and may possess a keener eye for what is there. “Patients excessively concerned
with their difficulties and caught up in their anxieties may turn up the capacity to
penetrate beyond the obvious toward an inquiry into their own existence and the
purpose of their own being.” They speculate that individuals who provide a color
shading response might have a keener sense of reality and a capacity to see beyond
what most people see. They refer to Freud who noted the heightened awareness of
melancholic patients.
Rapaport, Gill and Schafer (1946) suggest that this response suggests a person
who has a tendency to fuse both affect and anxiety, “such as in the case of nostalgia
(sweet sorrow).” Mayman (1970) speculated that this response reflected not merely
an “immersion” into the color aspects of the blot, but rather an intellectualized
response which reflects the tendency of the perceiver to distance him/herself from
the horror of their suicidal action. Their tendency to “step aside” and do something
other than experience emotion is found in their responses not only to the color, but
also to the lines and gradations which make up the color.
The color shading response seems to be the single sign most supported in the
literature as indicative of suicidal risk. Other, less supported single signs are listed
below.

Transparency or Cross Sectional Responses

Basing their research on the findings of Roth and Blatt (1974) as well as
their own clinical experience, Blatt and Ritzler (1974) set out to demonstrate
that transparency and cross sectional responses occur primarily in patients with
suicidal intent. They found that these responses did occur with greater frequency
among suicidal patients. An example of a transparency response includes percepts
such as “a room divided into two by two glass partitions or layers of clothing
perceptible through a sheer fabric.” The authors were quick to note that the absence
of these signs was not contraindicative of suicidal potential, but rather, when such
responses do occur, the clinician should be alert to the possibility of suicidal
ideation.
The authors compared this type of response with the color shading response
described by Appelbaum and Colson (1968). They hypothesized that this re-
sponse also reflects a person’s unusual “differentiation and sensitivity to nuances of
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feeling—a searching beyond the given which turns into a penetrating questioning
of his or her own existence and purpose of being.” Roth and Blatt (1974) suggested
that this response represents a collapse of three-dimensional representations with
a consequent loss of object-subject differentiation, so that self and other become
intertwined as objects of aggression.
In keeping with Blatt and Ritzler’s results, Rierdan, Lang and Eddy (1978)
found that suicidal individuals gave a greater number of transparencies and cross
sectional responses than non-suicidal individuals. They reasoned that such re-
sponses may represent the individual’s fantasy that death is not truly the end of
life. Death is seen as a transitional phase rather then a definite end. Transparen-
cies reflect this penetrable quality with the object not being viewed as solid and
bounded, but rather as something insubstantial or pregnable. Rierdan, Lang and
Eddy (1978) argue that this sign, in and of itself, is enough to alert the clinician to
the possibility of suicidal potential.
In contrast, Hansell, Lerner, Milden and Ludolph (1988) found that a trans-
parency or cross sectional response was unrelated to current suicidal risk, but was
related to a history of suicide attempts. They speculate that the presence of this
sign and/or the color shading response may reflect a more permanent cognitive
style, rather than suggest an imminent suicide attempt. These signs may be indica-
tive of a “suicidal personality” characterized by numerous suicidal gestures and
self-destructive behavior, rather than a current suicidal danger

Color and Shading Shock

Rabin (1946) hypothesized that the joint appearance of shading shock and
color shock in a Rorschach protocol is indicative of suicidal potential. Card re-
jection, blocking, delayed reaction time, and poor form quality are all examples
of “shock” to either the color or shaded qualities of the blot. Crasilneck (1954),
Hertz (1948) and Pratt (1951) have all reported greater shading and color shock in
suicidal patients.

Built Up W on Card X

W responses on Card X are unlikely, and if the details are overelaborated

the person may be overinvested in interpreting the stimulus field. This sign is
frequently found among the depressed, due to their desire to make sense out of
what seems to be a chaotic sequence of events. They tend to look “beyond the
givens” of a situation and exhibit a tendency to incorporate everything, rather than
getting lost in insignificant details. For these same reasons, we must also suspect
suicidal rumination and depression among those individuals that provide a greater
than average number of W responses.
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Global Signs

Locus of Control

Persons with an external locus of control were found to be at a higher risk

for suicide than individuals with an internal locus of control (Henderson, 1972;
Lester, 1989; Sidrow and Lester, 1988). A person who believes that he/she is at the
mercy of his/her environment and powerless to change things is at a higher risk
for suicide than a person who is confident in his/her ability to effect changes in the
environment. On the Rorschach, a person’s belief in an internal locus of control is
perhaps best reflected by “active” movement, whereas an external locus of control
is represented by “passive” movement. There may be evidence of an external locus
of control in little “m” which usually reflects tension and anxiety, often resulting
from difficulties or dangerous situations with which one feels helpless to cope.
The individual feels like a helpless victim who is at the mercy of environmental
forces and may feel overwhelmed. This may result from the lack of personality
resources to deal effectively with these forces. This is reflected by Exner’s D score
(EA-es) which, if less than 0, indicates that the individual has limited resources
to deal with environmental demands and is vulnerable to disorganization, and
an inability to deal effectively with either internal or external demands. Diffuse
shading also reflects feelings of helplessness and loss of control, implying that the
more diffuse shading in a record the lower the person’s belief in an internal locus
of control.

Personality Style

Greenwald, Reznikoff and Plutchik (1994) explored the relationship between

personality style and suicidality. They found that two personality styles were
positively related to higher suicide risk: the borderline and schizoid personal-
ity. The relationship between the borderline style and suicide has been delineated
by Millon (1987) who found that, “the combination of self-damaging impulses
caused by fears of separation, coupled with the lowering of internal controls can
frequently lead to suicidal actions.” In the Rorschach record of a borderline patient,
one would expect to see regressive responses (representing a lowering of inter-
nal controls and/or a weakened ego), impulsive responding (represented by F re-
sponses), difficulty controlling anger (represented by C responses), and evidence of
orality.
With the schizoid individual we find a person who is socially isolated and
whose behavior is internally directed. Schizoid individuals were found to be at a
significantly higher risk for suicide (Greenwald, Reznikoff and Plutchik, 1994).
The record of a schizoid individual is likely to contain little, if any, emotional
expression, a limited range of content, and a lack of empathy (M).
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Regression and Introjection Defenses

These two defensive styles have been found to significantly discriminate sui-
cidal from non-suicidal patients (Apter, Plutchik, Sevy, Korn, Brown, and Van
Praag, 1989; Recklitis, Noam, and Borst, 1992). First, regression, according to
Apter et al. (1989) is considered to be the “basic component of many primitive
behaviors, one of which is suicide. Its mechanism is to encourage motoric expres-
sion of the aggressive impulse through the lowering of internal controls” (p. 1027).
Therefore, it would follow that regressive responses (i.e., high animal content) and
verbalizations in a Rorschach record would be indicative of a person who lacks
the internal control necessary to keep violent (suicidal) impulses in check. If such
responses are found in a record that also indicates high levels of aggression and
hostility, then the clinician should entertain the possibility that the patient may be
suicidal. The risk for suicide would be compounded if the aggression was directed
inwardly (Crasilneck, 1954).
Recklitis, Noam, and Borst (1992) investigated the relationship between ego
defense mechanisms and suicidality. They hypothesized that suicidal individu-
als would have higher levels of internalizing defenses (e.g., introjection), which
would direct the person’s aggression toward the self. They found that suicide at-
tempters/ideators would employ internalizing defenses compared with non-suicide
attempters/ideators who are more prone to use externalizing defenses such as pro-
jection and reaction formation. Introjection as a primary defense mechanism may
be represented in the Rorschach by an overelaboration of features (W+), in which
patients appear to draw more from their internal knowledge of the object rather
than from the structural properties of the blot.

SUMMARY

The assessment of suicide using the Rorschach has generated much research,
not all of which has supported the various hypotheses put forward. However,
that does not mean that the hypotheses are clinically useless. The assessment of
suicide has confounded both Rorschach researchers and clinicians alike. As of this
writing, there is no study that can definitively say that a single sign, or combination
of signs, is indicative of suicide potential. The present authors disagree, however,
with those who say that using the Rorschach to evaluate suicidal potential is a
useless endeavor. Although critiques in the literature are valid, they focus only on
whether a sign is found to be statistically significant and ignore the test’s clinical
utility.
The problem with many of the studies that have attempted to validate signs or
configurations is that they measure these signs alone, without taking into account
the examiner’s clinical expertise and ability to draw from many sources of data. For
example, Epstein and Lane (1996) in their study on the Bender Motor Gestalt Test
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302 Bishop, Martin, Costanza, and Lane

and depression suggest giving just as much weight to clinical behavior indicators
as to signs or configurations. It is not surprising to find conflictual results in the
literature. The clinician’s judgment is a highly subjective process and not readily
amenable to statistical analysis. This does not minimize the importance of statistical
analysis, but it does suggest that statistical analysis must augment, rather then
replace, our clinical judgment. The most statistically sound predictor of suicide
is meaningless without clinical expertise. Expertise includes one’s knowledge of
theory and its integration with one’s knowledge of the patient.
The act of suicide is multifaceted and cannot be predicted by one sign or
combination of signs alone. By taking the patient/examiner relationship out of the
equation, one has handicapped one’s position in evaluating the data. However, an
experienced clinician will know what signs to look for during the interview and
will use the Rorschach to either bolster his or her clinical judgment, or to provide
a focus around which the clinical interview can be built.
When the clinician faces a plethora of data on the patient, he or she must
determine how much weight any particular area should carry. This is where the
clinician’s judgment and professional expertise is invaluable, since it is inductive
reasoning based on facts (such as suicide risk factors and personality dynamics) and
not simply intuition that allows one to make judgments regarding a person’s suicidal
risk. Maltsberger (1992) states, “between the pinnacle of scientific certainty and the
slouch of intuitive guesswork lies the considerable territory of inductive clinical
reasoning. The principle work that takes place on the inductive plateau is the
integration of the information gathered into the context of what is known about
the character of the individual after which certain inferences that stop short of
certainty can be drawn” (p. 39).
The meaning of any determinant can only be interpreted in light of the total
situation. When assessing the patient for suicide risk the conscientious psychologist
must draw from many sources of data when making such decisions. One should
not look at individual signs, but rather combinations of features (configurations),
searching for the major conflicts and the ego’s way of handling problems.
The authors recommend the following strategy for the assessment of suicide
risk using the Rorschach:

1. Screen the patient’s speech and test record for indicators of clinical dynam-
ics associated with current suicidal risk (see Lane’s (1971) five points).
2. If suicidal risk is suggested, use those indicators and signs best supported
in the literature: Morbid content; Costello’s content signs; Hertz’ signs;
Exner’s suicide constellation; and color shading responses.

Some questions to be asked are: Does the patient tend to repress his emo-
tions? Is he explosive and prone to act impulsively rather than thinking through
a situation? Does the patient abuse substances? Is there a history of suicide at-
tempts? Only after taking all these factors into account, can the clinician make
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a fair assessment of the patient’s risk for committing suicide, and then intervene
appropriately.
While self-report measures may be a useful component in the assessment
process, if statistical validity replaces clinical acumen, the “person” is lost. Los-
ing his or her uniqueness as a person, the subject is summarily categorized and
placed within a group with other individuals who statistically represent their
most salient characteristics. Maltsberger (1992) points out that, “researchers
whose primary work is the construction and testing of suicide rating scales typ-
ically leave character variables in the background simply because they are dif-
ficult to quantify” (p. 40). He stresses the importance of interpreting the data
through the “lens of character,” rather than leaving such variables in the back-
ground.
Many contemporary psychologists treat the Rorschach as a relic of the past,
and thus do a great disservice to both the patient and the field of psychology.
These psychologists ignore psychodynamic theory and rely solely on statistical
approaches. Reasons for this attitude include the trend toward quicker more cost-
effective methods of assessment, and the increase in behaviorally-oriented psy-
chologies. Despite many of its shortcomings, however, the Rorschach remains a
valuable tool for the assessment of personality and suicide, and further research in
this area is warranted.

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