Rorschach perception and thinking domain and mentalization based treatment: an outcome study

Del-Ben, C., Vilela, J., Crippa, J., Hallak, J., Labate, C., & Zuardi, A. (2001). Confiabilidade teste-reteste da Entrevista Clínica Estruturada para o DSM-IV – versão clínica (SCID-CV) traduzida para o português. Revista Brasileira de Psiquiatria, 23, 156-159.


The objective was to identify perception and thinking changes in patients treated by psychoanalytical psychotherapy at a university public outpatient service. 68 patients participated, mainly women (80.9%), around 40 years old, and 11.5 years of education, who attended at least one session weekly for two years with a trainee therapist, psychiatrist or psychologist. The majority met the criteria for Major Depressive Disorder, (DSM-IV, Axis-I), and Cluster B and Cluster C on Personality Disorder (DSM IV, Axis-II). The Rorschach was administered upon admission and in annual follow ups. An adaptation from the Comprehensive System to the R-PAS was performed.  The results showed statistically significant differences were found on the Perception and Thinking variables, indicating structural changes were achieved.

 Social avoidance behavior, alexithymics more often stop their inpatient treatment in the early phase of therapy. At baseline, alexithymic patients show higher levels of psychopathological distress compared to nonalexithymics. The symptom reduction in alexithymics is lower and the psychopathological distress at the end of the intervention is still significantly higher than in nonalexithymics. There are no or only little changes in Toronto Alexithymia Scale scores in both groups over the course of the treatment.

The residency program in psychiatry and the specialization program in health psychology of a school of medicine, EPM, include training in psychodynamic psychotherapy. Besides attending a theoretical course, the trainees must treat at least two patients deemed suitable for long-term psychodynamically oriented psychotherapy, once a week. The trainees meet weekly with a supervisor in a group session to discuss the progress of the therapy until the end of the program, after two years. The supervisors are staff members of the Department of Psychiatry with a solid foundation in psychoanalysis.

The proposal of the study was to assess the effects of the psychotherapeutic treatment on the patients. The school hospital, including its outpatient services, is a free of charge institution.

In order to carry out this proposal the patients, upon admission, were submitted to the Structured Clinical Interview for DSM-IV (Axis-I, and Axis II) by trained psychiatrists, following these criteria (a) inclusion: at least 18 years of age, interest and availability to attend the psychotherapeutic sessions; and (b) exclusion: schizophrenic disorder, antisocial personality disorder, dementia disorder, mental retardation. The Rorschach method was the selected psychological instrument for assessing the possible changes in personality aspects, and was administered upon the admission of the patient, and after one and two years of psychotherapy.

The sample comprised 68 patients, mainly women (55 or 80.9%), with the mean of 39.7 years old, and with the mean of 11.5 years of education, who attended at least one weekly psychotherapy session for two years. As to the diagnosis, 46 (67.6%) patients met the criteria for Major Depressive Disorder (DSM-IV, Axis-I), and 44 (64.7%) met the criteria for Personality Disorder (DSM-IV, Axis-II) with the prevalence of cluster B (borderline, narcissistic histrionic or antisocial) in 27 (39.7%) patients, followed by cluster C (avoidant, dependent or obsessive-compulsive) in 17 (25.0%) of patients.

The Rorschach was administered according to the Comprehensive System (Exner & Erdberg, 2005) and an adaptation to the R-PAS (Meyer, Viglione, Mihura, Erard, Erdberg, 2011). A statistical comparison was performed between time 1, that is, upon admission (t1) and after two years of treatment, that is, time 3 (t3).

The variables of Perception and Thinking Domain are (1) Ego Impairment Index-3 ;(2) Thought and Perception Composition  (3) Weighted Sum of the six Cognitive Codes; (4) Severe Cognitive Codes; (5) Form Quality Percentages  ; (6) Popular [P].

Statistical significant differences were found on four out of the six variables of the Perception and Thinking Domain.

The changes toward improvement on perception and thinking are notable, meaning a cognitive improvement among the patients as to reality testing, more conventional perceptions, a decrease in the interference of severe disturbances on thinking and a mental process, which indicated severe pathology.

Therefore, there is a clear relationship between the mentalization based treatment or reflective function approach of the psychotherapists and the clear improvements on the perception and reasoning aspects of the patients. Fonagy, Gergely, Jurist & Target (2002) consider that um important aim of psychotherapy is the extension of mentalization.

The Rorschach proved to be an ideal instrument to capture the psychic changes caused by psychoanalytical psychotherapy. Psychic changes are those that occur inside the personality due to the development of the object relations, of the capacity to think and to symbolize. It is possible that for these patients with little ego integration and with damaged object relations, the psychotherapy was an experience of significant influence. Contemporary psychoanalysis places emphasis on the analytical relationship as a changing agent, not only in the sense of transference, but mainly as the analyst’s functions related to the holding, according to Winnicott (1956), to the condition of contention and to the facilitation of communication. The true patience of the analyst, his tact, his tolerance, his empathy, his absence of judgment, and his non-critical objectivity are non-interpretative aspects that represent conditions and components of the psychoanalytical process. Therefore, for these patients, the psychotherapist as a holding, nurtured object interested in the patient’s feelings, fantasies, life history and not just interested in symptoms and psychopathology can engender an impact capable of transforming the patient’s psyches and consequently his life.


Latife Yazigi, Norma Lottenberg Semer, Maria Luiza de Mattos Fiore, Roberta Katz Abela, Tatiana Gotlieb Lerman, Thaís Cristina Marques.

Department of Psychiatry, Escola Paulista de Medicina, Universidade Federal de São Paulo