Conklin Malone Fowler 2012 Mentalization and The Rorschach

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Mentalization and the Rorschach
Article in Rorschachiana Journal of the International Society for the Rorschach January 2012
DOI: 10.1027/1192-5604/a000035
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Rorschachiana 33, 189213 DOI: 10.1027/1192-5604/a000035
2012
A. C.Hogrefe
Mentalization
Conklin Publishing
et
andal.the Rorschach
Original Article

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This document is copyrighted by the American Psychological Association or one of its allied publishers.
Adam C. Conklin1, Johanna C. Malone2, and Jeb T. Fowler3

1
Cambridge Health Alliance/Harvard Medical School, Cambridge, MA, USA,
2
Massachusetts General Hospital/Harvard Medical School, Boston, MA, USA,
3
The Austen Riggs Center, Stockbridge, MA, USA
Abstract. The concept of mentalization the ability to think about mental

states (e.g., feelings, intentions, motivations) of self and others has become
increasingly inf luential in psychoanalysis (Bateman & Fonagy, 2004; Fischer-
Kern et al., 2010; Fonagy, 1991). Unfortunately, the clinical application and
further exploration of the construct has been limited by the time-consuming
and highly specialized methods used to assess it (Choi-Kain & Gunderson,
2008; Meehan, Levy, Reynoso, Hill, & Clarkin, 2009). In that mentalization
operates predominantly outside of conscious awareness and involves the as-
sessment of mental representations of self and other, projective measures such
as the Rorschach are possibly the most efficient to evaluate and further ex-
plore this construct. In this paper we present a conceptual framework for how
texture responses (T) as they relate to the ability to form attachments, and
human and human movement responses (M+/M, GHR:PHR) as they relate to
empathy, social understanding, and boundary formation, may be utilized in
the assessment of mentalization.
Keywords: Rorschach, mentalization, attachment, psychoanalysis, empathy
Introduction
The concept of mentalization, developed by Fonagy and colleagues over

the past 20 years, has assumed an increasingly inf luential role in the
psychoanalytic understanding of psychological development and its vi-
cissitudes, particularly in relation to borderline pathology and its treat-
ment (Bateman & Fonagy, 2004; Fonagy, 1991; Fonagy, Gergely, Jurist,
& Target, 2002; see Choi-Kain & Gunderson, 2008, for a recent review
of the literature). Mentalization is the capacity to accurately and f lexibly
ref lect on ones own and others mental states (e.g., feelings, intentions,
motivations, values, and beliefs) in making sense of interpersonal behav-
189
A. C. Conklin et al.
ior. The concept has its roots in research on theory of mind (Baron-Co-
hen, Leslie, & Frith, 1985), attachment theory (Main & Goldwyn, 1991;
Main, Kaplan, & Cassidy, 1985), and Wilfred Bions theories of thinking
(see Bateman & Fonagy, 2004; Bion, 1962). The ability to mentalize is an
achievement that develops out of a secure attachment relationship char-
acterized by affective attunement and accurate mirroring from caregiv-

ers (Bateman & Fonagy, 2004; Shai & Belsky, 2011). Successfully at-
tained, mentalization is hypothesized to support the development and
maintenance of a coherent sense of self, as well as the ability to form
stable and enduring relationships with others, and to regulate ones
emotions. When this developmental process is derailed most notably
through early abuse or neglect it is thought to result in characteristic
failures of mentalization that, in turn, disrupt the development of a
stable sense of self, relationships, and affect regulation.
Operationalized by Fonagy and colleagues as ref lective-self function
or (more recently) as ref lective function (Fonagy, Target, Steele, &
Steele, 1998), research has demonstrated a link between a parents abil-
ity to mentalize and the security of attachment of both the parent and
child findings suggesting that mentalization may mediate the intergen-
erational transmission of attachment patterns (Fonagy, Steele, Steele, &
Moran, 1991; Grienenberger, Kelly, & Slade 2005; Slade, Grienenberger,
Bernbach, Levy, & Locker, 2005). Consistent with a growing body of
research associating borderline personality disorder (BPD) with inse-
cure or unresolved attachment (Agrawal, Gunderson, Holmes, & Lyons-
Ruth, 2004), Fonagy and colleagues found that patients with BPD scored
significantly lower on ref lective-self function than patients with other
Axis II disorders, non-Axis II patients, or normal controls (Fonagy et al.,
1996). Further supporting an association between borderline pathology
and problems in mentalization, mentalization-based treatment (MBT)
has been shown in two randomized controlled trials to be an effective
approach to BPD (Bateman & Fonagy, 1999, 2009). Levy and colleagues
further illustrated the usefulness of mentalization in understanding bor-
derline pathology by showing that transference-focused psychotherapy,
another effective psychodynamic treatment for BPD (Clarkin, Levy, Len-
zenweger, & Kernberg, 2007), significantly increased ref lective function-
ing (and secure attachment status) in patients when compared to two
other types of treatment, leading them to conclude that changes in men-
talization and attachment representations may be an important mecha-
nism in the improvement of patients with BPD (Levy et al., 2006). Final-
ly, two recent studies demonstrated hypothesized relationships between
190
mentalization and psychoanalytically based measures of psychic struc-

ture (Fischer-Kern et al., 2010; Mller, Kauf hold, Overbeck, & Grab-
horn, 2006).
While these findings attest to the utility of the construct in research
and clinical applications, further work on mentalization has been limit-
ed by the time-consuming and specialized methods used to assess it

(Choi-Kain & Gunderson, 2008; Meehan et al., 2009). Most studies have
assessed mentalization through ratings based on the Adult Attachment
Interview (AAI; Main, 1991; Main & Goldwyn, 1991) or other lengthy
interview protocols (e.g., Slade, Grienenberger, Bernbach, Levy, & Lock-
er, 2005) that require considerable training to administer as well as time
to transcribe and score. Although other approaches are being devel-
oped, they also focus on the scoring of interview protocols or psycho-
therapy transcripts or depend on informants such as therapists who
have had considerable time to get to know the patient (Karlsson & Ker-
mott, 2006; Meehan et al., 2009).
The existing challenges in assessing an individuals capacity to mentalize
are formidable. While one can make a conscious or explicit effort to
mentalize, much of our mentalizing activity is implicit, i.e., occurring
outside of conscious awareness (Bateman & Fonagy, 2004). For this reason,
self-report measures are likely to provide limited (and perhaps f lawed) in-
formation. Ratings based on the observations of others (i.e., therapists) also
run the risk of being overly subjective and limited, or confounded by the
informants own ability to mentalize. The Rorschach may provide a way
around each of these difficulties, tapping into unconscious processes while
systematically generating data that can be scored objectively and reliably as
part of a more general assessment of personality functioning.
The Rorschach has been used to research and clinically assess a range
of psychological processes that support mentalization, and we contend
that, taken together, these may provide a basis on which to assess men-
talizing ability. In the section that follows we examine several variables
from the Comprehensive System (Exner, 2003) including texture (T) as
it relates to a persons capacity to attach to others1; human movement
responses (M and M) as they relate to empathic ability and empathic
accuracy; and the quality of human responses (GHR vs. PHR) and their
relation to the accuracy of perceptions of people. These variables are
also summarized in Table 1.
1 In this paper we define T as the sum of texture responses (T + TF + FT). In other

papers this is referred to as SumT (e.g., Exner, 2003).
191
Table 1. Proposed variables from Exner Comprehensive System with implications

for mentalization
Variable Interpretation
Texture (T) Attachment/interpersonal connectedness
T=0 Greater likelihood of avoidance or distancing
T=1 Comfort with closeness, higher likelihood of at-

tachment security
T>1 Preoccupied attachment behaviors, neediness
Human movement (M) Empathy, empathic accuracy, social perception
M = 0 Indicates likelihood of intact empathic abilities
and empathic accuracies (when M+ 3 and H
3).
M > 1 Distorted perceptions of interpersonal and intra-
personal processes; compromised empathic abili-
ties
M+ < 3 Lack of or limited engagement in processes relat-
ed to social perception
Good Human vs. Poor Human Responses Object representation quality: Accuracy, emotional va-
(GHR and PHR) lence, expectations for cooperation or aggression,
boundary disturbances
Human Responses H 3 and Positive or benign object representations
GHR PHR 1
Human Responses H 3 and Social ineptness, interpersonal conf lict, idiosyn-
GHR PHR < 1 cratic, illogical
Note. M+ refers to the sum of M+, Mo, and Mu responses (i.e., the sum of human
movement responses in a protocol that are not significantly distorted).
Rorschach Variables and Mentalization

Texture (T) and the Capacity to Form Attachments
As noted above, Fonagy and colleagues have hypothesized and re-

search thus far has largely supported the close relationship between
the capacity to form secure attachments and the ability to mentalize
(Fonagy et al., 1991; Grienenberger et al., 2005; Slade et al., 2005).
While the Adult Attachment Interview (AAI; Main, 1991; Main & Gold-
wyn, 1991) has been the gold standard for assessing attachment in
adults, recent research suggested that texture responses (T) on the Ror-
schach provide important insight into a persons attachment style (Be-
rant, Mikulincer, Shaver, & Segal, 2005; Cassella & Viglione, 2009; Iwasa
& Ogawa, 2010; Weber, Meloy, & Gacono, 1992).
Klopfer and colleagues (1938; Ainsworth & Klopfer, 1954) first iden-
tified texture as representing the individuals desires for interpersonal
closeness and contact. This relationship was posited to have its roots in
192
the early tactile bonds of relating. Exner (1974, 1978, 2003) included
texture in the Comprehensive System, making hypotheses about devel-
opmental history in interpreting the meaning of texture in a subjects
protocol. Specifically, the absence of texture was tied to early depriva-
tion and a later style that maintained separateness and avoided interper-
sonal connectedness. In contrast, more than one texture response re-

ferred to intense or excessive needs for closeness that likely had roots in
experiences of loss or relational disappointment that led the individual
to be constantly seeking to have dependency needs met. Exner and Leu-
ra (1975; Leura & Exner, 1976; see Exner 2003) supported this finding
in part by describing research in which foster-care children between the
ages of 712 years differed in their texture responses. Specifically, chil-
dren with multiple foster-care placements were less likely to have texture
responses than children who have lived with their biological parents
since birth, and children who have lost one or both parents and been
placed in the foster-care system within the past 2 months had a greater
number of texture responses. Interestingly, this research regarding expe-
riences of childhood caregiving and the availability of the parent corre-
sponds directly to the work of attachment theory.
Attachment theory posits that, based on early relationships, individ-
uals develop representations of self and others that shape their ability
for interpersonal connectedness, style of relating, and expectations of
how others will feel about them (Ainsworth, Blehar, Waters, & Wall,
1978; Bowlby, 1969, 1973; Main et al., 1985). These representations
serve as a mechanism for dealing with stress in the world, whether
through emotion, cognition, or behavior (Easterbrooks, Davidson, &
Chazan, 1993). Attachment security is demonstrated by mutual respon-
siveness and pleasure in relationships where closeness is valued while
maintaining an objective sense of self. Avoidant or dismissive attachment
is characterized by disinterested, devaluing, or neutral responses to at-
tachment relationships. A preoccupied attachment strategy is exhibited
through angry, fearful, or passive attempts to maintain closeness that
appear needy and dependent. In contrast to these previous attachment
styles, the concept of disorganized or unresolved attachment was identi-
fied as the lack of a consistent attachment strategy ref lecting lapses of
reasoning surrounding trauma and no coherent or reliable way of un-
derstanding the self and relationships (Hesse, 1999).
These classifications of attachment have been linked to the quantity of
texture responses on the Rorschach in both adult (Berant et al., 2005;
Cassella & Viglione, 2009; Iwasa & Ogawa, 2010) and adolescent sam-
193
ples (Weber et al., 1992). In studies of adults, a single texture response

in a protocol was consistently associated with secure attachment (Cassel-
la & Viglione, 2009; Iwasa & Ogawa, 2010). Individuals seem able to
express the desire for interpersonal closeness, but they do not seem to
be preoccupied with needing it in excess. In these same studies, more
than one texture response in a protocol was also linked to higher levels
of preoccupied attachment.
Interpretation of the absence of texture responses in its relationship
to attachment style has been more problematic. While it has largely been
hypothesized to relate to an avoidant style (Casella & Viglione, 2009),
results are inconsistent. In support, Berant and colleagues (2005) found
that the presence of texture responses was associated with less self-re-
ported avoidance. Using texture as a proxy for attachment, other studies
also found that disorders characterized by less empathy and ability to
internalize good objects (antisocial PD in adults and conduct disorder in
adolescents) are associated with fewer texture responses when compared
to other types of psychopathology (Gacono, Meloy, & Berg, 1992; Weber
et al., 1992). They suggest that the absence of texture in relation to fewer
human responses may be a particularly problematic combination with
regard to interpersonal relatedness. In contrast to these findings, Casel-
la and Viglione (2009) indicated the absence of texture was most related
to secure attachment (although low levels of security) rather than avoid-
ant attachment as they had hypothesized. In a Japanese sample, Iwasa
and Ogawa (2010) found that persons with no texture responses had
elevated levels of both preoccupied and avoidant attachment anxiety.
They suggest that this finding may be an anomaly due to cultural differ-
ences in the distribution of attachment classifications in Japan. There-
fore, the absence of texture in and of itself cannot be correlated with
confidence to insecure attachment or poor mentalization.
Other literature supporting the link between texture on the Ror-
schach and the ability to mentalize is found in personality pathology
research. As noted above, antisocial personality disorder was linked to a
lack of texture responses (Gacono et al., 1992; Weber et al., 1992). A
growing body of literature supports the assertion that antisocial behav-
iors and personality characteristics are linked to mentalization failures
or even to the absence of mentalization in specific moments (e.g., vio-
lence) (Bateman & Fonagy, 2008; Dolan & Fullam, 2004). Borderline
personality pathology, linked to unresolved attachment history often
characterized by trauma and loss (see e.g., Agrawal et al., 2004), is most
widely studied in relation to mentalization deficits (Fonagy, 2000;
194
Fonagy et al., 1996). In these cases attachment relationships are emo-

tionally charged, and the mentalization abilities may be underdeveloped
or unevenly developed (e.g., hypervigilant toward others but having no
understanding for their own mental states) (Fonagy, 2000). Exner (2003)
reported that patients with borderline personality pathology on average
had greater than two texture responses. In a sample of women with

borderline personality disorder, Fowler and colleagues (2005) found

that higher texture responses were significantly associated with lower
levels of isolation, suggesting the need for more interpersonal connect-
edness. However, evidence linking texture responses to borderline per-
sonality pathology has not been widely pursued, and some studies found
that borderline patients on average have a single texture response (Ga-
cono et al., 1992). This may indicate that the unresolved attachment
strategy, characterized by instability, may not consistently map onto a
specific number of texture responses since the attachment strategy itself
is inconsistent. Interestingly, histrionic personality disorder, another
Cluster B disorder, characterized by attention seeking, has been most
consistently linked in the empirical literature to elevated texture re-
sponses (Blais, Hilsenroth, Castlebury, Fowler, & Baity, 2001; Blais, Hil-
senroth, & Fowler, 1998). However, this disorder has yet to receive great-
er empirical study in the mentalization literature.
In the last decade there has been an effort to review the normative
reference data utilized for the Rorschach (Shaffer, Erdberg, & Meyer,
2007). There is significant variability when comparing norms interna-
tionally derived from those Exner developed in the United States. As
would be expected, there is also great variability across developmental
stages and clinical versus nonclinical samples (Meyer, Erdberg, & Shaf-
fer, 2007). For example, with regard to the sum of texture responses (T +
TF + FT), Exner (2007) reports a mean of 1.01 (SD = .69) in a nonclinical
sample, while the international reference data for texture, which are
based on 16 countries, are lower (mean = .65; SD = .91) (Meyer et al.,
2007). The cross-cultural variation is substantial, with Shaffer and col-
leagues (2007) reporting that the percentage of adults giving zero tex-
ture responses ranges at the low end, from 19% in the United States and
34% in Israel, to the upper end of 86% in Greece and 78% in Romania.
There is also developmental variation in the sum of texture responses,
with the mean for children in the international referenced norms being
.24 (SD = .57). Overall, the growing body of international norms suggest
that interpretations of texture responses, much like interpretations of
attachment classifications (see e.g., Van IJzendoorn & Kroonenberg,
195
1988), need to consider the cultural and developmental context. It ap-

pears that the contextual meaning of the absence of texture versus a
single texture response versus more than one response is an area that
continues to require ongoing inquiry.
Human Movement (M) and Empathic Understanding
In their paper on the ontogeny of the concept of mentalization, Choi-

Kain and Gunderson (2008) contend that
mentalization requires a panoply of intact cognitive skills that enable individuals
to imagine mental states with plausibility, f lexibility, and complexity, but optimal-
ly integrates this cognitive realm concerning reason and insight with emotion.
(p. 1128)
They also note a conceptual overlap between mentalization and em-

pathy (among other related concepts). Drawing on the work of Dece-
ty and Jackson (2004), they describe empathy as involving an affective
component in the sharing of another persons emotional state as
well as what they see as the more cognitive dimension of imagining
other peoples perspective and the ability to maintain a self-other
distinction (p. 1131). Each of these capacities is central to the ability
to mentalize as well.
As reviews of the literature by Stark (1966) and Urist (1976) attest,
there is a long history of Rorschach theorists and researchers associating
human movement responses (M) with the capacity for empathy. As Stark
notes:
In 1945 Bochner and Halpern identified human movement with ability to put
oneself in the place of another or to put oneself in different situations, also with
an individuals projection of himself into other people and situations. (Bochner
& Halpern, 1945, p. 39; see Stark, 1966, p. 243)
Schachtel (1950) expressed something similar, noting that, when one

sees human movement on the Rorschach,
he experiences it as if he knew, not merely from outside but from inside, how the
human figure seen in the inkblot moves or holds its posture. It is as if he were, for
a moment and to some extent, inside the figure seen. This is an experience similar
to that which one has in the act of kinesthetic empathy . . . (pp. 7172; see Stark,
1966, p. 244)
Both note that Klopfer (Ainsworth & Klopfer 1954) also maintained
there is a connection between M and empathy.
196
Despite many early Rorschach luminaries hypothesizing a relation-

ship between human movement (M) and empathy, it appears this has
been based more on theory than on empirical study (Urist, 1976). Re-
cent neuroscience research, however, suggests they may have been on
the right track. Giromini, Pineda, and colleagues posited a relation-
ship between M and empathy and mentalization, and completed two

studies suggesting that human movement (M) responses on the Ror-

schach may activate brain regions associated with social cognition, in-
cluding empathy (Giromini, Porcelli, Viglione, Parolin, & Pineda,
2010; Pineda, Giromini, Porcelli, Parolin, & Viglione, 2011). In both
studies they demonstrated that human movement (M) responses to the
Rorschach, as scored with the Comprehensive System (Exner, 2003),
were associated with mu suppression as assessed by EEG. Mu suppres-
sion, in turn, has been associated with the activation of the mirror
neuron system (MNS). They note that recent research suggests that
the MNS plays an important role in the ability both to understand
the others perspective . . . and share their feelings . . . (Pineda et al.,
2011, p. 223) factors essential both to empathy and mentalization.
They conclude that their findings suggest that M responses to the
Rorschach test may involve mirroring activity in the brain, thus sup-
porting its traditional interpretation as an index of empathy and so-
cial cognition (Pineda et al., 2011, p. 226).
Further support for a possible association between human move-
ment and empathy and mentalization comes from the research of Ho-
laday, Moak, and Shipley (2001). They found that boys diagnosed with
Aspergers disorder produced fewer human movement responses on
the Rorschach than boys with behavioral and emotional problems un-
related to pervasive developmental disorder. While they did not assess
empathy or other constructs related to mentalization (i.e., theory of
mind) directly, Aspergers disorder has been associated with deficits
in both areas (Lawson, Baron-Cohen, & Wheelwright, 2004).
While considerable theory and some research suggests that human
movement responses on the Rorschach are associated with the ability
to put oneself in the place of another, as Bochner and Halpern
(1945) characterized it, it remains unclear whether, as Urist (1976) not-
ed, this is with accuracy or investment in the other. Urist contended
that M does not provide an assessment of the degree to which the tie
to the other (p. 577) is narcissistic in nature. In this sense he believed
human movement responses may sometimes ref lect more of a self-ob-
ject (Kohut, 1970) form of relating than a deep understanding of the
197
subjective experience of another person. He noted as well that re-

sponses involving human details (Hd), rather than whole humans, may
suggest less investment in empathizing with the complete subjectivity
of the other. Similarly, human movement responses involving pairs (2)
may be more indicative of a capacity to empathize with the other. Pure
human responses (H) may better ref lect empathic understanding of

actual people in ones life than fictional human responses ((H)). As

the previous section on attachment and the Rorschach suggests, ex-
amining texture (T) in relation to human movement (M) may be a way
of assessing empathic accuracy in the context of empathic connection.
We return to this in a later section of the paper.
Several authors have suggested that the form quality of human
movement responses may relate to the accuracy of a subjects empath-
ic understanding of others (Urist, 1976). Exner and Erdberg (2005)
suggested good form M was a basic element of psychological mind-
edness, motivation and interpersonal skill (p. 250). This also agrees
with Weiners (1966, 2003) more general association of poor form M
responses (M) with interpersonal difficulties, ref lected in the char-
acterization of such responses in the Comprehensive System as an in-
dication of difficulties with social perception, and with the inclusion
of M > 1 as an item on the Perceptual-Thinking Index (PTI) (Exner,
2003; Smith, Baity, Knowles, & Hilsenroth, 2001). Weiner (2003) sug-
gested that the adjustment difficulties seen in individuals with M re-
sponses are often due to their difficulty understanding people and
social interactions.
To date there has been little empirical research on the relationship
between the form quality of human movement responses and psycho-
logical or social functioning. Nygren (2004) found that good form M
correlated with patients capacities to engage in psychodynamic ther-
apy. However, correlations between good form M and non-Rorschach
measures of positive ego functioning were not found. In their study
of the Perceptual-Thinking Index (PTI; Exner, 2003), Hilsenroth, Eu-
dell-Simmons, DeFife, and Charnas (2007) found that the number of
M responses correlated in predicted ways with nonpatient status (r =
.35, p < .005), psychotic disorder diagnosis (r = .25, p < .05), and a
measure of diagnostic severity (r = .36, p < .0001). Unfortunately, they
did not report whether there were significant differences in the num-
ber of M responses among the nonpatients, personality disordered
patients, or psychotic patients in their study. Blatt and Ritzler (1974)
compared several groups of patients categorized by degree of bound-
198
ary disturbance as measured with Rorschach Special Scores such as

Fabulized Combination and Contamination scores. Across these
groups, which varied in chronicity and severity of psychotic distur-
bance, they found that, although there was no significant difference
between the groups in inaccurately perceived human responses (M,
H, Hd), there were more instances of what they termed distorted

human representations (p. 376). These included blends of human

and inanimate percepts, and were associated with greater boundary
disturbance and measures of severity and chronicity such as disruptive
behavior and likelihood of their having been diagnosed with a psy-
chotic disorder. Although it is unclear whether measuring M respons-
es alone would have shown significantly different frequency across the
groups, this suggests that human movement responses may need to be
interpreted in relation to other Rorschach variables, especially those
that may measure boundary disturbance such as Fabulized Combina-
tion or Contamination scores, in assessing the accuracy of a persons
intuitions about the mental states of others.
Quality of Human Response (GHR:PHR) and Accuracy of

Ref lection on Mental States of Self and Other
While there is theory and some evidence to suggest that human move-
ment responses relate to the capacity to empathize with another, and
that poor form human movement responses (M) likely indicate difficul-
ties in this area, as Urist (1976) noted, good form quality M may not in
and of itself assure the resiliency within in the ego required to identify
with another without fusion or to differentiate ones own inner state
from that of the other individual (p. 576). Similar to Blatt and Ritzler
(1974), in developing the Mutuality of Autonomy scale Urist (1977)
moved beyond single variables, such as human movement, to assess
these capacities. Where Blatt and Ritzlers assessment of boundary dis-
turbance emphasized special scores (one of which is no longer in the
Comprehensive System), Urists scale focused more on content. Within
the Comprehensive System (Exner, 2003), the Special Scores ratio of
good human to poor human responses (GHR:PHR) seems to most di-
rectly address the accuracy of perception of self and others as well as
boundary disturbance as it relates to the capacity to mentalize. GHRs
and PHRs are dichotomous variables determined by combinations of
form quality, determinants, content, and other Special Scores. Viglione
199
and colleagues (2003) suggest that GHRs and PHRs are actually repre-
sentations of self and other; and Weiner (2003) has contended that they
are linked not only to current functioning, but also to the history the
individual has within relationships. A GHR is generally coded when a
human is perceived in the blot with adequate form quality (not minus),
an absence of aggressive movement or morbid quality, at times cooper-

ative or benign interaction, and lack of marked cognitive lapses. These

responses, characterized by positive and intact representations of self
and others, are described as being accurate, logical, and positive percep-
tions of humans and human interactions. In contrast, PHRs result from
human responses with poor form quality and/or cognitive lapses, and
are often characterized by negative and confused object representations
that are distorted, unrealistic, and damaged with aggressive and hostile
themes. When there are at least three human responses in a protocol
and the number of PHRs is equal or greater to the number of GHRs,
Exner (2003) indicates that individuals will have interpersonal difficul-
ties including social ineptness and conf lict.
The possible contributions of GHR and PHR responses to under-
standing mentalization capacities are suggested by a number of empiri-
cal studies of populations likely to have deficits in ref lective functioning.
First, Zodan, Charnas, and Hilsenroth (2009) used PHR as a partial
predictor of borderline personality disorder, asserting that it measures
the number of negative perceptions an individual has with regard to
interacting with others. They found a significant difference in the num-
ber of PHR scores for patients diagnosed with BPD compared to a group
of nonpersonality disordered patients with Axis I disorders. They linked
this variable to Westens (1990) contention that people with a BPD diag-
nosis tend to make highly idiosyncratic, illogical and inaccurate attribu-
tions of peoples intentions (p. 678).
Other research examining GHR and PHR responses has focused on
priests with and without histories of sex-offending (Gerard, Jobes, Cim-
bolic, Ritzler, & Montana, 2003). Given the evidence that individuals
who commit violent and otherwise exploitative acts may have dimin-
ished mentalization or even interspersed mentalization failures (Bate-
man and Fonagy, 2008; Dolan & Fullam, 2004), it could be hypothesized
that sex-offending priests have difficulty accurately representing the ex-
perience of their victims and are likely to draw upon hostile, damaged,
and distorted interpersonal schema. Gerard and colleagues (2003)
found that priests with a history of sex-offending gave significantly more
poor human responses than the priests with nonsexual psychiatric dis-
200
orders. Contrary to their prediction, however, the sex-offending priests

did not give significantly fewer good human representational responses.
It is noteworthy that a comparison of ratios of PHR to GHR rather than
the scores of each may not have detected a difference in this study in
which the mean difference was approximately one PHR.
Hilsenroth et al. (2007) examined both GHR and PHR in their study
exploring the reliability and validity of the Perceptual-Thinking Index.

They found that the number of GHR and PHR responses were correlat-
ed in predicted ways with nonpatient status (GHR r = .40, p < .0001; PHR
r = .36, p < .0001), psychotic disorder diagnosis (GHR r = 36, p < .0001;
PHR r = .23, p < .05), and a measure of diagnostic severity (GHR r = .44,
p < .0001; PHR r = .37, p < .0001). Unfortunately, they did not report
whether there were significant differences in the number of GHR or
PHR responses among the nonpatients, personality disordered patients,
or psychotic patients in their study.
The association of PHR with BPD, psychotic disorders, and priests who
sex offend suggests both a link between this variable and boundary diffi-
culties as well as impaired mentalization and empathy. While the specific
application of the GHR:PHR ratio is less clear, taken individually the num-
ber of GHR and PHR responses appear to have implications for the multi-
faceted way in which an individual views human relationships. These vari-
ables are promising in the assessment of mentalization in that they draw
upon multiple components of object representations within a single re-
sponse. However, further research is needed to replicate these findings and
make the connection to boundaries and empathic capacity explicit.
Integration of Comprehensive System Rorschach

Variables for Understanding Mentalization Capacity
As outlined above and presented in Table 1, a number of variables of

the Comprehensive System have the potential to assess mentalization
capacities when synthesized and interpreted clinically. Our goal was
first to identify these variables and next to highlight the meaning of
specific combinations that clinicians and researchers could draw up-
on in their work. We next outline three simplified scenarios or poten-
tial findings that are based on our synthesis of the empirical and the-
oretical literature.
201
Profile 1
Adequate mentalization capacities: T = 1, M+2 3, M 1, GHR PHR 1

with H 3. Adequate mentalization capacities are associated with an
ability to form secure attachments (T = 1), that support empathic invest-
ment and understanding of others (M+ > 3) as well as relatively accurate

and undistorted perceptions of self and others (M 1 and GHR

PHR 1 with H 3)3. Subjects with these Rorschach findings would be
predicted to exhibit an ability to understand and ref lect on their own
mental states and the states of others. Representations of self and others
would be balanced, with comfort with interpersonal closeness that is
reciprocal in nature, and expectations of others that are relatively posi-
tive and benign.
Profile 2
Mentalization failures: Distortion in the context of neediness and negative va-

lence: T > 1, M > 1 or M+ < 3, GHR PHR < 1 with H 3. Increased
neediness in the context of difficulties with attachment (T > 1) and ei-
ther deficient or distorted empathic understanding (M+ < 3 and/or
M > 1) as well as distorted or overly negative representations of self and
others (GHR PHR < 1 with H 3) is hypothesized to result in charac-
teristic failures in mentalization. These failures are expected to have
their roots in developmental instability creating interpersonal needi-
ness, anger, and the expectation that others are unreliable or unavail-
able. Past experiences and overwhelming needs and desires impair the
ref lective functioning abilities of such individuals. They may be inter-
personally driven to connect, yet experience consistent failures due to
2 M+ refers here to the sum of M+, Mo, and Mu responses (i.e., the sum of human
movement responses in a protocol that are not significantly distorted).
3 The values chosen for T, M, H, and GHR PHR are based on the literature
reviewed above. As noted in the discussion of T, norms for Rorschach variables
tend to vary across cultures and across developmental stages (Shaffer et al.,
2007). Although we selected these values based on the extant literature, which
incorporates the theoretical viewpoints and research of the authors noted above,
they are also consistent overall with the latest Exner (2007) U. S.-based adult
nonpatient sample. As we discuss further in the conclusion, empirical research
is needed to ascertain the best cut-off value for each of these variables.
202
their trouble maintaining interpersonal boundaries and maintaining

empathic attunement.
Both the Rorschach literature and research on attachment suggests
that Profile 2 likely maps on to borderline pathology. However, as noted
above, there have been inconsistent findings for texture in borderline
samples as well as more generally for the relationship between the ab-
sence of texture and security of attachment. It is possible that the high

levels of unresolved attachment styles in these patients may result in
f luctuations in texture responses that ref lect the chaotic oscillations
between avoidance and preoccupation with others often seen in patients
with BPD. Given this, the number of T response may be inconsistent
across samples when assessing borderline pathology, with high and low
levels of T washing out possible findings. There is a need to understand
how individuals with unresolved attachment utilize texture responses on
the Rorschach in future research. Therefore our expectation is that in-
dividuals with borderline personality pathology will have a higher num-
ber of M responses and PHR responses, but less predictable levels of T.
Profile 3
Mentalization failures: Disengagement and hypo-mentalizing activity: T = 0,

M > 1 or M+ < 3, H < 2 or GHR PHR < 1. In contrast to the previous
form of mentalization failure, this deficit is characterized more strongly
by disengagement and avoidance of understanding the mind of the oth-
er. While distortions may exist (M, PHR), the more dominant aspect of
this style is the absence of interest in understanding the human mind
more generally. These subjects are likely to display a limited interest in
people (H < 2) and decreased empathy (M+ < 3). A low number of tex-
ture responses would also be expected in such profiles as the desire for
interpersonal closeness will likely be limited and a more avoidant attach-
ment style may be observed.
When applying this profile to specific forms of psychopathology
known to have empathic deficits, variations are likely to occur, depend-
ing on whether the disengagement from mentalization is more rooted
in antisocial behavior and personality characteristics or in a develop-
mental disorder such as an autism spectrum disorder. Our expectation
based on the extant literature is that the number of M responses will be
lower in both groups (mean in U. S. nonpatient sample = 4.83; SD = 2.18;
Exner, 2007). As Holaday and colleagues (2001) suggested, individuals
203
with an autism spectrum disorder are likely to have overall fewer human
responses compared to those with youths with features of antisocial per-
sonality pathology. While the absence of engagement in mentalization
is likely to occur in both forms of pathology, the interpretation of find-
ings for individuals with such disorders will need to be considered more
broadly across the structural summary.

Conclusion and Future Directions
Mentalization has become an increasingly important construct in the

psychoanalytic understanding of psychological development and psy-
chopathology as well as in the treatment of borderline personality disor-
der (Bateman & Fonagy, 2004; Fischer-Kern et al., 2010). Its study and
assessment in clinical settings, however, have been limited by the cum-
bersome and more research-based methods typically used to evaluate it
(Choi-Kain & Gunderson, 2008; Meehan et al., 2009). The assessment of
mentalization is further complicated by its predominantly operating out-
side of conscious awareness, limiting what can be learned about it
through self-report or most forms of direct observation. In this paper we
have contended that the Rorschach provides a way around these diffi-
culties. Drawing on the available theoretical and empirical literature, we
defined a set of Comprehensive System (Exner, 2003) variables that are
hypothesized to assess aspects of psychological and interpersonal func-
tioning vital to mentalization. Taken together, these variables may pro-
vide a picture of a persons ability to mentalize including underlying
factors that contribute to the characteristic failures in mentalization that
Fonagy and colleagues have observed (Bateman & Fonagy, 2004, 2008).
Our hope is to provide a starting place from which clinicians and re-
searchers may begin to utilize the Rorschach and results from psycho-
logical testing to better understand the mentalization capacities of their
patients. Empirical study in both clinical and nonclinical settings is need-
ed to investigate how each of the Rorschach variables we propose make
independent contributions to the assessment of mentalization, and to
define the critical values for each variable as it relates to mentalization.
One possible approach would be to test the incremental validity of each
of these variables in accounting for the variances of already established
scales of ref lective functioning. It is likely that the variables will work
differently depending on the personality characteristics of the individ-
204
ual, the presence of a developmental disorder, and the underlying at-

tachment style. We proposed that the variables will likely be most mean-
ingful when placed within the constellations of other Rorschach vari-
ables (rather than in isolation). The profiles we propose could then be
converted to categorical subgroups and differentiated using scales of
external validity. Research may also reveal how Rorschach mentalization

variables relate to levels of affective attunement of parents in interac-

tions with their infants. This would provide insight into mechanisms of
intergenerational transmission of empathic capacities and, more broad-
ly, ref lective functioning.
In conclusion, we propose that the Rorschach offers the opportunity
to extend our current understanding of mentalization and is likely to be
both a useful and efficient tool for understanding this nuanced relation-
al process. While we find compelling theoretical and empirical evidence
to support this link, there is a need for direct empirical study of this
topic.
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Adam C. Conklin
Cambridge Health Alliance, Cahill-4
1493 Cambridge Street

Cambridge, MA 02139
USA
Tel. +1 617 665-1933
E-mail adam_conklin@hms.harvard.edu
Summary
The concept of mentalization the ability to think about mental states

(e.g., feelings, intentions, motivations) of self and others has become
increasingly inf luential in psychoanalysis (Fischer-Kern et al., 2010; Fo-
nagy, 1991). It is thought to operate predominantly outside of conscious
awareness and to develop in the context of a secure early attachment
relationships characterized by affective attunement and accurate mirror-
ing from caregivers. It is associated with the development of a coherent
sense of self, the capacity to form and maintain relationships, and the
ability to regulate ones affective experience (Bateman & Fonagy, 2004).
Although most research has focused on borderline personality patholo-
gy and its treatment, some studies have demonstrated the consequences
of impaired mentalization abilities for a range of clinical presentations
(Bateman & Fonagy, 2004, 2008; Fonagy, Bateman, & Bateman, 2011).
Unfortunately, the clinical application and further exploration of the
construct has been limited by the time-consuming and highly specialized
methods used to assess it (Choi-Kain & Gunderson, 2008; Meehan et al.,
2009). In this paper we propose that the Rorschach may provide an
efficient alternative for the assessment of mentalization, tapping into
the predominantly unconscious processes that support it while generat-
ing objective and reliably scored data as part of a more general assess-
ment of personality functioning. The Rorschach may also provide new
information regarding mentalization processes and development as they
occur in the context of a broader personality profile. We review the
theory and research of specific variables within the Exner (2003) Com-
prehensive System that are relevant to mentalization capacity. These
include texture responses (T) as they relate to the ability to form attach-
210
ments, and human and human movement responses (M+/M,

GHR:PHR) as they relate empathy, social understanding, and boundary
formation. We synthesize the results across these variables to create
three potential profiles of mentalization capacity and descriptions of
how these appear in clinical settings. The paper concludes by discussing
future directions for utilizing the Rorschach in the assessment of men-

talization.
Rsum
Le concept de mentalisation la capacit penser les tats psychiques

de soi-mme et dautrui (par exemple les motions, intentions ou moti-
vations) a de plus en plus dinf luence sur la psychanalyse (Fischer-Kern
& al., 2010; Fonagy, 1991). La mentalisation opre principalement en
dehors du champ de la conscience et se dveloppe dans un contexte
dattachement scurisant, ds le plus jeune ge. Le dveloppement dun
self cohrent, dune capacit maintenir des relations et de la capacit
rguler ses motions est inf luence par la mentalisation.
La recherche sest principalement intresse aux personnalits tats-
limites et leur traitement. Toutefois, certaines tudes ont dmontr la
pertinence de ce concept dans dautres pathologies (Bateman & Fonagy,
2004, 2008; Fonagy, Bateman & Bateman, 2011).
Malheureusement, la recherche dans ce domaine reste limite, car
complexe et laborieuse (Choi-Kain & Gunderson, 2008; Meehan, Levy,
Reynoso, Hill & Clarkin, 2009). Cet article propose de dmontrer que le
test du Rorschach peut tre un outil alternatif et efficace pour lvalu-
ation de la mentalisation car il permet une mesure fiable des processus
inconscients du sujet dans le cadre dune valuation gnrale de la per-
sonnalit.
Le Rorschach peut aussi fournir de nouvelles informations sur les pro-
cessus et le dveloppement de la mentalisation dans le contexte dune
valuation plus taye de la personnalit. Cet article prsente une revue
de la littrature thorique et de recherche spcifique aux variables du
systme intgr du Rorschach de Exner (2003) qui sont pertinentes pour
lvaluation de la mentalisation. Celles-ci sont les rponses Textures (T),
lies la capacit de former un attachement autrui, les kinesthsies et
reprsentations humaines (M+/M, GHR:PHR), lies, elles, la
prsence de lempathie, de la comprhension sociale et des limites. En
synthtisant les rsultats pour chaque variable, nous proposons un profil
211
des capacits mentaliser du sujet et comment le reprer dans la

clinique. Enfin, cet article prsente, en conclusion, quelques pistes pour
approfondir lutilisation du Rorschach dans lvaluation de la mentalisa-
tion.
Resumen
El concepto de mentalizacin: la capacidad para pensar sobre estados

mentales (afectos, intenciones, motivaciones) de uno mismo o de otros,
ha ido incrementando su importancia en el Psicoanlisis (Fischer-Kern
et al., 2010; Fonagy, 1991). Se cree que opera predominantemente fuera
del pensamiento consciente y que se desarrolla en el contexto de una
vinculacin temprana segura y caracterizada por la sintona afectiva y
por una respuesta especular ajustada por parte de los cuidadores; se
asocia al desarrollo de un sentido coherente de s mismo (self), a la
capacidad para crear y mantener relaciones y a la habilidad para modu-
lar las propias experiencias afectivas. (Bateman & Fonagy, 2004). Aun-
que la mayora de las investigaciones se han focalizado en la patologa
de la personalidad borderline y su tratamiento, los estudios han
mostrado tambin las consecuencias de una mentalizacin deficitaria en
un amplio rango de presentaciones clnicas (Bateman & Fonagy, 2004,
2008; Fonagy, Bateman, & Bateman, 2011). Desgraciadamente, las apli-
caciones clnicas y la exploracin ms avanzada de este constructo han
tenido como obstculo la necesidad de utilizar mtodos de evaluacin
que requieren mucho tiempo y una elevada especializacin (Choi-Kain
& Gunderson, 2008; Meehan, Levy, Reynoso, Hill, & Clarkin, 2009). En
este artculo se propone que el Rorschach puede ofrecer una alternativa
eficiente para la evaluacin del nivel de mentalizacin, apuntando a los
procesos predominantemente inconscientes en los que ste se apoya, a
la vez que genera datos codificables de manera objetiva y fiable como
parte de una evaluacin ms general del funcionamiento de la person-
alidad. El Rorschach tambin aporta nueva informacin sobre los
procesos de mentalizacin y sobre su desarrollo en el contexto de un
perfil ms amplio de personalidad. Se revisa la teora y la investigacin
sobre variables especficas dentro del Sistema Comprehensivo de Exner
(2003) que son relevantes en la capacidad de mentalizacin. Ello incluye
las respuestas de Textura (T) por su conexin con las habilidades re-
lacionales y las respuestas Humana y de Movimiento Humano (M+/M,
GHR:PHR) ya que se asocian con la capacidad de empata, de compren-
212
sin social y de formacin de los lmites. Se sintetizan los resultados a

travs de estas variables para crear tres perfiles potenciales en la capaci-
dad de mentalizacin y se describen sus formas de presentacin en el
contexto clnico. El artculo concluye con una discusin sobre futuras
tendencias en la utilizacin del Rorschach para la evaluacin de la men-
talizacin.
213
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Mentalization and the Rorschach

Prototype diagnosis View project

Mentalization and the Rorschach

Adam C. Conklin1, Johanna C. Malone2, and Jeb T. Fowler3

Abstract. The concept of mentalization the ability to think about mental

Keywords: Rorschach, mentalization, attachment, psychoanalysis, empathy

The concept of mentalization, developed by Fonagy and colleagues over

acterized by affective attunement and accurate mirroring from caregiv-

mentalization and psychoanalytically based measures of psychic struc-

ed by the time-consuming and specialized methods used to assess it

1 In this paper we define T as the sum of texture responses (T + TF + FT). In other

Table 1. Proposed variables from Exner Comprehensive System with implications

T=1 Comfort with closeness, higher likelihood of at-

Rorschach Variables and Mentalization

As noted above, Fonagy and colleagues have hypothesized and re-

sonal connectedness. In contrast, more than one texture response re-

ples (Weber et al., 1992). In studies of adults, a single texture response

Fonagy et al., 1996). In these cases attachment relationships are emo-

had greater than two texture responses. In a sample of women with

borderline personality disorder, Fowler and colleagues (2005) found

1988), need to consider the cultural and developmental context. It ap-

Human Movement (M) and Empathic Understanding

In their paper on the ontogeny of the concept of mentalization, Choi-

They also note a conceptual overlap between mentalization and em-

Schachtel (1950) expressed something similar, noting that, when one

Despite many early Rorschach luminaries hypothesizing a relation-

ship between M and empathy and mentalization, and completed two

studies suggesting that human movement (M) responses on the Ror-

subjective experience of another person. He noted as well that re-

human responses (H) may better ref lect empathic understanding of

actual people in ones life than fictional human responses ((H)). As

ary disturbance as measured with Rorschach Special Scores such as

H, Hd), there were more instances of what they termed distorted

human representations (p. 376). These included blends of human

Quality of Human Response (GHR:PHR) and Accuracy of

an absence of aggressive movement or morbid quality, at times cooper-

ative or benign interaction, and lack of marked cognitive lapses. These

orders. Contrary to their prediction, however, the sex-offending priests

exploring the reliability and validity of the Perceptual-Thinking Index.

Integration of Comprehensive System Rorschach

As outlined above and presented in Table 1, a number of variables of

Adequate mentalization capacities: T = 1, M+2 3, M 1, GHR PHR 1

ment and understanding of others (M+ > 3) as well as relatively accurate

and undistorted perceptions of self and others (M 1 and GHR

Mentalization failures: Distortion in the context of neediness and negative va-

their trouble maintaining interpersonal boundaries and maintaining

sence of texture and security of attachment. It is possible that the high

Mentalization failures: Disengagement and hypo-mentalizing activity: T = 0,

broadly across the structural summary.

Conclusion and Future Directions

Mentalization has become an increasingly important construct in the

ual, the presence of a developmental disorder, and the underlying at-

external validity. Research may also reveal how Rorschach mentalization

variables relate to levels of affective attunement of parents in interac-

talization-based treatment versus structured clinical management for borderline

Exner, J. E. (2007). A new U. S. adult nonpatient sample. Journal of Personality Assess-

. . . Fonagy, P. (2010). The relationship between personality organization, ref lec-

between mental states and observed caregiving behavior in the intergenerational

Rorschach Perceptual and Thought Index (PTI): An examination of reliability,

validity, and diagnostic efficiency. International Journal of Testing, 7, 269291.

Rapid Communication of Neuroscience Research, 22, 223226.

testing, affect and object representation of borderline pathology: A comparison