The Rorschach in Planning Treatment of Alcohol ... - Hogrefe eContent

Rorschachiana 31, 192–222 © 2010 Hogrefein Publishing N. Kostogianni Rorschach Alcohol Treatment

DOI: 10.1027/1192-5604/a000011

Special Section: Rorschach and Health Psychology

The Rorschach in Planning Treatment of Alcohol Addiction Patients Two Clinical Case Studies with the Comprehensive System Nikoleta Kostogianni1,2 1

Center of Addiction Treatment, Hospital Emile Roux, Limeil-Brévannes, France, 2 Department of Psychology, University of Paris 10, France

Abstract. The present study demonstrates the utility of information derived from the Rorschach Comprehensive System (CS) in treatment planning for alcohol-dependent patients through two clinical cases. These case studies were selected because they clearly demonstrate the complex relationship between alcohol addiction, clinical syndromes, and personality. Both patients were women. The assessment took place on the third week of an inpatient alcohol rehabilitation program. The referral questions included (1) the magnitude of the emotional distress, (2) the motivation to change, and (3) the adequacy of their interpersonal style with our outpatient group treatment lasting 12 weeks. Each patient was assessed on the MINI, the SCID-II, the MMPI-2, and the Rorschach CS. Rorschach findings completed the information obtained by the clinical interview, the structured interviews, and the self-report inventory by generating hypotheses about clinical diagnoses, the role of alcohol, motivation for change, treatment targets, patients’ strengths and interpersonal style, as well as the potential obstacles for treatment and therapeutic relationship. Specific treatment plans and pertinent techniques for therapy were ascertained for each patient. Keywords: Rorschach, alcohol addiction, treatment planning

When alcohol addiction is the reason behind referral to addiction treatment centers, the patient’s pattern and severity of alcohol abuse are usually the aspects of clinical presentation that are already well described. However, the diagnosis of alcohol addiction tells us, in itself, very little about the person. What is the individual’s personality like? The other types of psychological problems that may have predated, or 192

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surfaced during, alcohol addiction remain essentially unknown, even though they usually contribute to the aggravation or maintenance of alcohol abuse behaviors. Alcohol addiction frequently occurs within a broader cluster of psychiatric problems. High rates of comorbid disorders are found in clinical samples (Driessen, Veltrup, Wetterling, John, & Dilling, 1998; Sallmen, Nilsson, & Berglund, 1997) as well as in epidemiological surveys (Kessler et al., 1997; Regier et al., 1990). The most common comorbid disorders found in such studies are mood, anxiety disorders, and personality disorders. Further, alcohol addiction obeys the same psychological principles that govern behavioral problems in general, and treatment methods with a documented efficacy for alcohol addiction are primarily psychological ones. Many of the effective treatments for alcohol addiction do not focus exclusively or even primarily on alcohol use but address the complex array of adjustment problems related to risk of relapse (Miller & Brown, 1997). The wide heterogeneity of psychological problems associated with alcohol dependence requires clinical f lexibility and sophistication to accommodate individual differences. In that sense, psychological assessment can be of substantial importance for case conceptualization and treatment planning. Knowledge of the personality traits of patients with alcohol addiction may add to our understanding of the motives of the addictive behavior for that individual. Research has demonstrated the role of personality traits in the etiology and the course of substance use disorders (Cloninger, Sigvardsson, & Bohman, 1988; Krueger, Caspi, Moffitt, Silva, & McGee, 1996). Furthermore, studying the role of the personality as well may contribute to an understanding of the clinical heterogeneity among individuals suffering from alcohol addiction and thereby help to identify patients who might be more difficult to treat with the standard addiction counseling (Ball, 2005). For patients suffering from personality disorders, the routine addiction treatment may not be useful since the maladaptive personality traits form major vulnerabilities toward relapse (Griggs & Tyrer, 1981; Thomas, Melchert, & Banken, 1999). Disentangling personality from addiction may also facilitate the matching of different therapeutic modalities to different patients. Evidence suggests that the practice of matching specific treatments to specific patients may enhance treatment effectiveness (Kadden, Cooney, Getter, & Litt, 1989; Lindström, 1992). Direct therapeutic attention to maladaptive personality traits may increase coping skills, which in turn may reduce the risk for relapse to alcohol abuse and motivate patients to participate in aftercare programs (Verheul, Ball, & Van den Brink, 1997). In addition, an 193

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assessment of the patient’s interpersonal style and motivation for change might help the clinician to better tailor standard interventions to the individual and to improve the working alliance and prevent premature dropout. In alcohol abuse, interpersonal interaction between the patient and the therapist is one of the strongest predictors of a person’s strength of motivation for change (retention, adherence, behavior change). Recent research on alcoholism treatment suggests that the interactions between the therapist behaviors and the patient’s attributes may be even more important for treatment effectiveness than any differences between the discrete treatment approaches. Mismatches between the patient’s personal attributes (such as depressive symptoms, trait anger and interpersonal reactance) and the therapist’s behaviors (such as focusing on emotional material, using confrontation and therapy structure) are associated with a higher frequency of posttreatment alcohol use compared to patients without such mismatches (Karno & Longabaugh, 2007). Premature dropout is one of the most challenging problems in alcohol addiction treatment, typically averaging about 50% within 4 weeks of the commencement of treatment. Patients who drop out prematurely tend to have essentially the same clinical outcomes as untreated patients and also represent a significant factor of frustration and discouragement for the clinical staff as well as a major recurring expense for treatment organizations (Stark, 1992). There is considerable literature on the assessment of patients suffering from alcohol addiction using structured interviews and self-report inventories, but very little has been written on the use of the Rorschach for this kind of assessment. Although structured interviews and self-report inventories may save the professionals time and effort, exclusive reliance on these instruments is not recommended. Structured interviews and self-report inventories cannot differentiate alcohol-related lifestyle behaviors (such as lying, suspicion, social avoidance, passivity, identity confusion, cognitive, affective or perceptual disturbances) from the underlying personality of the individual (Ball, 2005). The use of the Rorschach as a technique for personality assessment has generated considerable controversy. On the one hand, it is suggested that the Rorschach has many advantages because it can supply significant information about a personality construct, regardless of whether individuals have accurately conceptualized that construct, have weighed how the construct describes them, are self-aware, and are willing to openly communicate about that construct (Ganellen, 2007). This is of 194


particular interest when assessing alcohol abusers, as these individuals habitually tend to manipulate and deceive, and this may reduce the validity of self-report data (Skinstad, Troland, & Mortensen, 1999; Vanem, Krog, & Hartmann, 2008). One study showed that Rorschach protocols of pilots having completed a treatment program for alcohol or substance abuse revealed emotional distress, self-critical ideation, and interpersonal difficulties – problems that were not reported on the MMPI (Ganellen, 1994). On the other hand, it is unclear how the Rorschach could be used in routine practice and whether its use is consistent with the manner in which it is used in research (Hunsley & Bailey, 1999). More importantly, there is no replicated evidence indicating that Rorschach-informed pretreatment assessment actually leads to better treatment outcomes or lowered attrition rates (Hunsley & Bailey, 2001). This argument, however, is equally true for all psychological tests. Recent studies showed that the Rorschach yields an important information concerning long-term outcome and relapse in children (Stokes et al., 2003), as well as concerning future improvement across a range of interventions in adults (Meyer, 2000; Perry & Viglione, 1991) not attainable through simpler, less time-consuming methods. One study that used the Rorschach Comprehensive System (CS, Exner, 1993, 2000, 2001) to identify the personality characteristics of women with alcohol addiction found that these Rorschach profiles were characterized by aberrations in self-concept, self-esteem, identity, interpersonal perception, and thought processes (Bergman, Haver, Bergman, Dahlgren, & Nielsen, 1998). Moreover, it found that these women tended to handle information in a somewhat careless way and perceived objects and people in a different, more subjective, and unconventional way than other people generally do. Another study compared two groups of male alcoholics using the Rorschach: one diagnosed with borderline personality disorder and the other with mixed personality disorder (Skinstad et al., 1999). The findings revealed that alcoholics diagnosed with borderline personality disorder showed more interest in other people than did alcoholics diagnosed with mixed personality disorder. However, their interest in other people was marked by ambivalence, feelings of aggression, and withdrawal from social interaction. The borderline group also showed a significantly greater tendency toward pathological thinking and confusion. The Rorschach employed with the CS can provide information about emotional, cognitive, and social functioning; each may cause or maintain alcohol addiction or have implications for treatment planning. Ac195

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cordingly to Weiner (2004), the Rorschach helps to identify a prospective patient’s levels of personality integration and subjectively felt distress. It also distinguishes among various styles of personality that make patients differentially responsive to particular kinds of treatment approaches. In addition, it contributes to delineating the kinds of personality change that may be beneficial for a patient as well as personality traits that may interfere with treatment. In our practice, we use the Rorschach according to the CS (Exner, 1993, 2000, 2001; Weiner, 2003, 2004) in order to better understand individual differences among patients with alcohol addiction and to design treatment interventions that address their individual needs. The present report illustrates the utility of the information derived from the Rorschach CS in planning treatment for alcohol-dependent patients by presenting two clinical cases. These case studies were selected since they demonstrate the complex relationship between alcohol addiction, clinical syndromes, and personality. Both patients presented psychological distress and symptoms of depression typical for assessment referral in our practice. The analysis of these case studies points out the challenge to assessing affective states when they are also associated to alcohol dependence as well as to the individual’s ability of motivational enhancement: Motivation is commonly recognized as a key issue in treating alcohol addiction. Finally, the adequacy of interpersonal style with a group therapy such as the one that is usually provided in addiction recovery programs.

Method Participants Both patients were women. They were referred to an addiction treatment center by their primary-care physician because of alcohol dependency. They were first seen for a pretreatment standard evaluation by a consultant psychiatrist. According to this evaluation, both patients fit the ICD-10 (World Health Organization, 1993) diagnostic criteria for alcohol dependence and for major depression disorder. The patients confirmed their motivation to stop drinking and were willing to enter the inpatient alcohol rehabilitation program of 3 weeks minimum followed by 12-week outpatient group treatment. They were both admitted 196


to the inpatient alcohol rehabilitation program. During the first week of hospitalization, they both complained of depressed mood, fatigue, feelings of worthlessness, and inability to cope. Staff members said that both women were reluctant to join the group activities at the center. In this context, the staff psychiatrist recommended a psychological evaluation. The referral questions included (1) the magnitude of the emotional distress, (2) the motivation to change, and (3) the adequacy of their interpersonal style with our outpatient group treatment lasting for 12 weeks. The 12-week outpatient group treatment (see Appendix) integrates motivational enhancement and cognitive-behavioral therapy (CBT) in the form of coping skills training for relapse prevention (Monti, Kadden, Rohsenow, Cooney, & Abrams, 2002).

Measures The assessment took place on the third week of the inpatient alcohol rehabilitation program. The author conducted all tests. Each patient was assessed on the MINI, the SCID-II, the MMPI-2, and the Rorschach.

MINI The MINI (Mini International Neuropsychiatry Interview for ICD-10) is a short structured interview that screens for all psychiatric disorders except for personality disorders (Lecrubier et al., 1997).

SCID-II The SCID-II (Structured Clinical Interview for DSM-IV Axis II Personality Disorders) is a semistructured interview designed to evaluate the presence or absence of personality disorders (First, Spitzer, Gibbon, Williams, & Benjamin, 1997). Both women were administered the French version of SCID-II Patient Questionnaire and were interviewed using the SCID-II questions for all confirmed items (Bouvard et al., 1999). 197

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MMPI-2 The MMPI-2 (Minnesota Multiphasic Personality Inventory) is a self-report inventory containing 567 descriptive statements. Respondents indicate whether each statement is true or false for them. MMPI-2 scales suggest various features of psychopathology and personality functioning (Butcher, Dahlstrom, Graham, Tellegen, & Kaemmer, 2001)

Rorschach The Rorschach is a performance-based method to personality assessment. Responses to the Rorschach make up the end product of a complex, cognitive-perceptual problem-solving process. Administration and scoring of the Rorschach protocols were done according to Exner’s CS procedures and guidelines (1993, 2001). Protocols were reviewed by two clinical psychologists with proper training in the CS (including the author) to ensure coding accuracy. Disagreements were resolved through discussions. The interpretative strategy is based on key variables, as recommended by Exner (2000).

Results The two patients, the assessment results, and the implications for treatment planning in relation to the referral questions are presented one after the other. Follow-up data after 1 year are also presented.

Case 1: Elisa Elisa is a 37-year-old woman presenting with a 6-year history of regular alcohol abuse. During the clinical interview, Elisa described a 6-month history of depressed mood, hopelessness, insomnia, reduced appetite, poor memory, impaired concentration, decreased energy, and lack of motivation. She complained about being lonely and feeling worthless, but denied any thoughts of suicide. Elisa has experienced a number of negative life events in the past 6 months, including family conf lict – her partner of the last 10 years had 198


left her because of her heavy drinking, following a couple of years of disputes as well as work-related and financial problems. Her job as an insurance agent was in jeopardy because of her tardiness and poor performance. She has no children. She reported having only two close friends who play an important role in her life. They talk on the telephone nearly every day, and she said that she feels lost without them. Her father was also alcohol-dependent but was alcohol abstinent at the time of assessment. Elisa started drinking at the age of 17. By the age of 30, she drank large amounts of alcohol a few times a week and when she was 30 she started drinking alone on a daily basis between 7 and 10 standard drinks of wine per day. She reported that alcohol gave her confidence, relaxed her, and helped her sleep at night. She has tried to quit on several occasions but has been unable to do so. Elisa reported no previous contact with either mental health or substance abuse services. Before presenting for treatment, she was prescribed antidepressants by her general practitioner but did not complete a full course. Assessment Results MINI According to the MINI, Elisa meets the criteria for major depressive disorder, dysthymic disorder, and alcohol dependence. SCID-II According to the SCID-II, Elisa meets the criteria for depressive personality disorder. MMPI-2 On the MMPI-2, Elisa has 1-2-3 highpoints profile, “the neurotic triad,” suggesting a wide variety of complaints, including physical discomfort, depression, sleep disturbance, somatic complaints, irritability, hostility, despondency, and feelings of hopelessness and pessimism. She uses somatization to explain difficulties as due essentially to physical problems rather than to anything psychological. She seeks affection, attention, and sympathy from others to reassure herself that others care about her. She may not be comfortable with her dependency needs and may experience conf lict because of it. Persons with this code type are usually diagnosed as having a somatoform disorder, anxiety disorder, or depressive disorder. 199

N. Kostogianni Table 1. Structural summary data for case 1: ELISA

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Rorschach CS The structural summary for Elisa is shown in Table 1. Rorschach data indicate a major affective disturbance (DEPI = 6). This finding is often associated with a diagnosable mood disorder or a chronic disposition to recurrent depressive episodes. At present, she experiences emotional distress and confusion (SumShading > FM + m; Col-Shd Blends > 0), pessimism (MOR > 2), negative self-attitudes (3r + (2)/R = .22), relational withdrawal (COP < 2, Isolate/R > .24) and low energy (Blends < 4). This emotional distress seems to be particularly disturbing for Elisa because she relies heavily on her feelings to guide her thinking and behavior, yet she is uncomfortable about emotions and tries to avoid them (EB = 2:5.5; L = 1; Afr = .50). Her tendency to avoid emotional situations may be the result of some recognition of her difficulty to modulate her affects (Afr = .50; L = 1). In fact, Elisa experiences and expresses feelings in an overly intense and dramatic fashion and is highly changeable in her moods (FC:CF + C = 0:5; C = 1). She views the world and herself with a very narrow lens (L = 1), and she can be very rigid in her ways of thinking (a:p = 4:0). Elisa tries to avoid complexity and tends to respond to situations in the simplest possible terms. She often acts quickly so as not to feel needy, by engaging in self-gratifying behaviors without sufficient delay or restraint (FM = 1). The self-image is marked by negative characteristics (MOR = 3) and low self-esteem (3r + (2)/R = .22). The thematic imagery of this protocol lacks sufficient richness to reveal very much about her inner life. However, the presence of these MOR responses on card VII “a mincing knife, the rounded handle and the cutting blade for chopping the meat, it is dangerous, it scares me, it can hurt somebody, it can even kill somebody” and on card VIII “a person who has been disemboweled, we can see the lungs, the muscles,” identifies Elisa’s negative attitudes toward herself and her body. It seems that she is feeling intensely vulnerable and concerned about the integrity of her body. Elisa has a rather naïve perception of herself (FD = 0, V = 0, H = 1) and of interpersonal relations [H:(H)Hd(Hd) = 1:4]. She is capable of efficient interactions with people (GHR:PHR = 4:2), and she seems to manifest many dependency behaviors. She would be expected to request extensive help and guidance from others, have difficulty making independent decisions, and be naïve in her expectations of others (Fd = 1). At present, there are very few people in whom she could confide (Iso201

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late = .28). There is probably an intrapsychic dilemma concerning dependency and avoidance (Fd = 1 and Isolate = .28). Elisa seems to be a cognitively well functioning person. She organizes information efficiently (Zd = –0.5), perceives events realistically (XA% = .78, WDA% = .81), and is capable of thinking about her experiences in a consistently logical and coherent manner (WSum6 = 4).

Implications for Treatment Planning The first issue raised in the referral was the need to assess the magnitude of the emotional distress. The assessment data suggest significant depressive features. Elisa currently experiences significant depression superimposed on a chronic, longstanding depression deeply ingrained in her character. Affective disturbance seems to be a chronic problem for Elisa, an enduring form of depression like dysthymia. Alcohol seems to serve as an avoidance strategy to cope with problems and a response to her emotional distress (self-medication hypothesis). Clinically significant mood symptoms in patients with substance use disorders are viewed as either the manifestation of an underlying comorbid mood disorder, the product of substance abuse, or possibly a combination of the two. High rates of depressive symptoms usually resolve with prolonged abstinence. However, for a significant minority of individuals, depression persists after weeks of abstinence (Driessen et al., 2001; Nunes & Levin, 2004). Given the significant impact that coexisting depression and alcohol abuse can have on the individual, these conditions should be addressed simultaneously. Two goals need to be set for Elisa: abstinence from alcohol and stabilization of depressive symptoms. Elisa should explore for herself the relationship between alcohol addiction and depressive symptoms, and examine the links to current distress and impairment from both perspectives. CBT seems indicated because it assists the patient in gaining insight into the function of alcohol in her life. It may also address the behavioral, cognitive, and affective features of depression and alcohol addiction (Brown, Evans, Miller, Burgess, & Mueller, 1997; Carroll, 2004). Strategies aimed at restructuring the global negative beliefs about the self and the world, and at managing painful affects that are common relapse precipitants, contribute to emotional amelioration and relapse prevention. The objective is to help Elisa replace alcohol consumption by new healthier coping skills. Cognitive 202


therapy will be facilitated by her clear thinking, adequate reality testing, and reasoning capacities. A second issue raised in the referral considered her motivation to change. Emotional distress could motivate Elisa for change at least until she feels some relief. Otherwise, Elisa possesses some negative therapyinterfering characteristics. She is able to tolerate a high level of discomfort. She handles psychological conf lict through repression and by attending to real, exaggerated, or imagined physical difficulties. Therefore, she experiences little need to change. Elisa avoids introspection and is not psychologically sophisticated. Therefore, she is not easily amenable to examining aspects of experience that are typically overlooked. It definitely seems that Elisa would not be a good candidate for longterm insight-oriented therapy. Instead, a short-term cognitive-behavioral intervention for depression and alcohol addiction seems to be more indicated. Because of her difficulties modulating her affects, Elisa would benefit from treatments that focus on learning to understand her emotions and connect them to her thoughts and behaviors. Once this has occurred, it is likely that any somatic complaints that exist due to inability to properly modulate affect will dissipate as well. By taking her entrenched pattern of thinking into account, Elisa may greatly resist attempts at change. The use of confrontational techniques is likely to be unsuccessful with Elisa. She strongly needs to be liked and approved by others. A motivational treatment approach that emphasizes the attainment of personal benefit including acceptance by others is more likely to be productive. At the same time, Elisa is inclined to rely on others for direction and support, and tends to be rather naïve in her expectations concerning interpersonal relations. CBT would also respond to her implicit invitation for action with clear proposals for behavioral changes in a supporting, nonconfrontational environment, a strategy consistent with the therapeutic principles of motivational interviewing. Finally, another issue raised in the referral concerns the adequacy of her interpersonal style with a group treatment lasting 12 weeks. Elisa has a positive perception of human relationships, and she is likely to have collaborative relationships with members of the group. Despite her capacity for empathy and potential for bonding, Elisa lacks social support and could benefit from group therapy to establish connections with other people and thereby reduce her social isolation. Group support and cognitive techniques may reinforce positive self-esteem based on accomplishments such as abstinence from alcohol and renewed respect for the intrinsic value of self. 203

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Some evidence suggests that motivational interviewing can improve treatment engagement, and that CBT is associated with moderate but durable effects on depressive symptoms and alcohol use (Carroll, 2004). We can reasonably hope that Elisa would make progress concerning her mood disorder and alcohol addiction by participating in a short-term CBT outpatient group like the one currently being offered in our addiction treatment center.

One-Year Follow-Up Elisa completed the relapse prevention group therapy. She participated actively in this group, and for the most part she completed the homework assignments. According to the group therapists, she was motivated to change her alcohol consumption, and she was sincerely devoted to abstinence. One year after the psychological assessment, Elisa continues to see her addiction counselor once a month. Elisa consumed alcohol on a couple of occasions but was able to demonstrate effective lapse management and thus prevent relapse. She is presently abstinent from alcohol. Most of the depressive symptoms disappeared progressively. Her social functioning has greatly improved; she is dating someone and she is again performing in her job.

Case 2: Nathalie Nathalie is a 24-year-old single woman with no children who presents a 5-year history of alcohol addiction. She began drinking at the age of 15 and became a heavy drinker at the age of 19. For the past 2 years, Nathalie had been drinking between 6 and 14 units a day (mostly beer and wine) for several days in a row. After a number of days she would collapse for 2 days, too sick to drink, after which she would resume drinking. Nathalie stopped working several months ago, and the frequency and the quantity of her drinking has increased. During the past month, Nathalie has been drinking on a daily basis. Although she acknowledges alcohol dependence, she minimizes the consequences of drinking on her social and professional functioning. Nathalie complains also about feeling depressed, not being able to structure her day, having difficulty sleeping and eating. She had never consulted a psychiatrist before the pretreatment evaluation. She complains that her parents and sister do 204


not support her financially and emotionally, which has led her to this pathetic state. When she gets drunk, she calls and insults them. She uses suicidal threats in order to “punish” them and to attract their attention. She explains that she has no intention of hurting herself. She has never manifested any self-mutilation behavior. Her father was chronically depressed. He was physically abusive toward her mother, although he never laid a hand on Nathalie. Her mother openly favored her sister. Nathalie has constantly been compared to her “perfect” younger sister and grew up feeling “left out.” Because of her family, she explains that she became fundamentally distrustful toward other people. She had worked as a part-time secretary but was fired several months ago because of relational problems with her colleagues. She feels that she has been treated unfairly because she always tried to do her job carefully but felt unappreciated by her superiors. Nathalie says that she has some friends. She has recently been arguing with her neighbors. She has been involved in some short-lived and tumultuous relationships. Nathalie feels that her family, her neighbors, and her friends are against her. She thinks that they all see her as a profoundly disturbed person. When asked why she refuses to join the other patients during activities, she explains that she doesn’t want to be bothered by them and she is convinced that she has many more difficulties besides alcoholism, and that other patients couldn’t understand her. Her family is particularly insistent on Nathalie getting help in order to stop drinking. Nathalie explains that she has the intention to use therapy as a means for bringing about major changes in her life.

Assessment Results MINI According to the MINI, Nathalie meets the criteria for major depressive disorder and alcohol dependence. SCID-II According to the SCID-II, Nathalie meets the criteria for avoidant, depressive obsessive-compulsive, and borderline personality disorder. MMPI-2 She shows a 6-4-2 code type. Individuals with such a code feel trapped, defeated, angry, and bitter. Their depression is manifested in negativism 205

N. Kostogianni Table 2. Structural summary data for case 2: NATHALIE

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and in suicidal threats. Nevertheless, it is the personality features rather than the depressive mood which dominate the psychological picture. Nathalie probably thinks her current depression is due to other people and unreasonable situations. She tends to be demanding of others in subtle, guilt-inducing ways, which provokes anger in others. At the same time, she is resentful of even the mildest demands made on her by others. She focuses on how she has been hurt, neglected, mistreated, or ignored by others, particularly by family members. To avoid rejection and maintain a certain level of security, she has become adept at manipulating others. Much of her discomfort apparently stems from fears of becoming vulnerable, overly dependent, and therefore controlled by others. Consequently, she tends to avoid deep involvement. Possible diagnoses are a dysthymic disorder, passive-aggressive, or borderline personality. Rorschach CS The structural summary for Nathalie is shown in Table 2. In everyday life, her inclination is to plan before taking action (EB = 8:4). However, the presence of ideational rigidity (a:p = 7:3) and pessimism (MOR = 4) limits the effectiveness of her thinking. Further, Nathalie uses intellectualization to deny unpleasant feelings (2AB + Art + Ay = 10). For intellectualization to work, the clarity and quality of her thinking have become quite important. Unfortunately, her thinking tends to be disorganized, inconsistent, and marked by faulty judgment (WSum6 = 42, M– = 4). Four out of the seven critical special scores are coded as FABCOM2, signifying that, at times, she makes some irrational and bizarre associations. Her peculiar thinking seems to be related to themes of rapprochement which reveal separationindividualization or separation-abandonment conf licts. She perceives others in dichotomous “all-good” or “all-bad” terms. Hence, her perception of relationships alternates between extremes of idealization and devaluation. For example, on card I “a winged character is trying to help this person. Two hands stretch toward the person to hold him, save him. The four white areas in the center are his interior light. His light protects him from darkness.” On card III “two sisters are looking at each other. A broken heart or rather two hearts that are separated represent the rupture between the two women. This part looks like a vagina. This evokes the idea of a common birth, something that goes way back to childhood. The hearts are not completely broken; a bond still remains a joint. This implies that reconciliation is always possible. It could be that in the future these two beings would 207

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reconcile.” On card IX “it is beautiful, the colors are pretty. We can see a light that invades these two beings. There are two intelligent beings that have been reconciled, and each one has delimited his territory. The light goes down from the top, it looks like f lames. It invades the head of these two beings. The territory of each one, the line is used for delimiting the territory of the immaterial f lames that are not made to burn.” This response is immediately followed by this one: “Two hens very angry screaming at each other. They want to trace the limits of their territories. They are so angry that they spit f lames of anger.” Her conceptualizations seem to be strongly inf luenced by preoccupations and delusions that ignore social reality (M– = 4). She tends to misperceive events and form mistaken impressions of people and what their actions signify (XA% = .73, WDA% = .73). Although her thinking is sometimes particularly disturbed and her reality testing moderately impaired, it would be unrealistic to think of her as having a schizophreniform problem. Her speech and behavior are not disorganized, and there is no evidence from which to suspect hallucinatory experience. Cipolli and Galliani (1988) concluded that M– in Rorschach protocols of opiate users indicated a borderline personality structure with some prepsychotic traits preexistent to heroin use, rather than a mental deterioration. Skinstad et al. (1999) found that alcoholics with borderline personality disorder showed significant pathological thinking and confusion. There is probably a pattern of overcontrol followed by acting out, then overcontrol (AdjD = 3, D = 3; FC:CF + C = 1:4; pure C = 1). Nathalie shows a substantial capacity for the volitional control of her behaviors (AdjD = 3, D = 3). She has an abundance of resources in reserve on which to call when she needs them (EA = 13). Thus, when problems arise, she may initially be able to remain unf lustered. She can use intellectualization excessively and minimize the implications of events that should capture her attention and cause her concern. By doing so, she fails to notice more subtle signals of impending problems or interpersonal strain, and lacks sufficient sensitivity to deal with people and situations effectively. As she becomes frustrated and overwhelmed with emotion, she may display temper outbursts that can destabilize and even destroy close relationships (FC:CF + C = 1:4; pure C = 1; Blends:R = 6:15, two out of the six blends contain three determinants). Rorschach findings were not suggestive of depressive difficulties (DEPI = 3; CDI = 0). However, her proclivity to attach both pleasant and unpleasant connotations to experiences signifies the presence of significant anhedonia (Col-Shd Bld = 2). Her self-image is characterized by great self-involvement and self-den208


igrating preoccupation that produce considerable discomfort (3r + (2)/R = .47, Fr + rF = 0). There is a perception of self as deeply injured (MOR = 4). Her responses on card IV “a clamping plate crushed by a car” and on card VI “an animal which we did not respect and we killed it” probably involves concerns about being damaged or victimized. In addition, there is an Hx response in the record that also includes a critical special score (FABCOM2). This suggests that she may be prone to dealing with issues of self-image in an overly intellectualized manner that tends to bend or ignore reality. On a more positive note, there is a capacity for insight despite the self-focus (FD = 2). However, her occasionally faulty reality testing and illogical reasoning will probably inf luence what she concludes about herself when she introspects. She gives evidence of feeling uncomfortable in social situations and having difficulty dealing with people. She is interested in others, but she does not understand them well [H:(H)Hd(Hd) = 3:4]. She misperceives the implications of interpersonal relationships (M– = 4), which is typically associated with impaired empathic capacity. Her expectations of relationships are highly ambivalent. She anticipates both high cooperation and aggressiveness in an alternating sequence (COP = 2, AG = 2). She is often rejected by others because of her interpersonal behaviors (GHR:PHR = 2:7). Therefore, she is disinclined to form close attachments to others (T = 0).

Implications for Treatment Planning Both the MMPI-2 and Rorschach findings revealed serious and chronic type of psychopathology such as difficulties in affect regulation, cognitive impairments, interpersonal difficulties, and poor self-image. Overall, diagnostic considerations indicated the presence of a serious coexisting personality disorder with borderline traits. On the SCID-II, Nathalie met the criteria of multiple personality disorder. The high level of co-occurrence found among personality disorders is a regular concern with the diagnosis of personality disorder. Many borderline patients have clinically significant traits or meet full criteria for other personality disorders. It is worth mentioning that Nathalie’s lack of impulsivity in the areas of self-mutilation and suicidal efforts are good prognostic signs. Considering Nathalie’s difficulties in logic and judgment, a referral for a psychiatric evaluation to determine whether initiation of psychotropic medication is needed seems necessary. 209

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The referral asked to evaluate the magnitude of the emotional distress. On the MINI, Nathalie met the criteria of major depression. Nathalie’s score on scale 2 (T = 72) of the MMPI-2 indicates discomfort, dissatisfaction with life situations, and lack of involvement. Rorschach findings seem to reveal more a feeling of chronic dissatisfaction, emptiness, and poor self-esteem than an acute depressive episode probably because depressive symptoms in borderline personality disorder undergo great f luctuation and variability. They change dramatically over a short period. Another explanation is that her complaints of depression can be a manipulative demand for attention, sympathy, and control. The referral asks for estimates regarding her motivation to change. Nathalie’s personality makes substance abuse behavior particularly difficult to treat. Alcohol addiction seems to constitute a central part of an overall rigid defense system and a primary means of coping. Nathalie uses alcohol as a self-destructive attempt to cope with interpersonal conf licts, to regulate affect, avoid discomfort, or alter sense of self. Her long-standing patterns of self-defeating behavior would be resistant to change. Besides, Nathalie is an ideationally oriented person whose attitudes and values are relatively well fixed. This reduces the likelihood that challenges to her way of thinking would be effective. With respect to her maladaptive personality traits, there are many treatment objectives, though none seems easily achievable in a 12-week group program. A realistic treatment plan would require considerably more time and effort. Optimally, psychological intervention needs to focus on Nathalie’s severe limitations in her capacity to establish meaningful and satisfactory relations. Developing her skills to negotiate healthy reciprocal relationships and enhancing her interpersonal social network should be long-term goals for Nathalie. Her tendencies to overintellectualize, to misinterpret social reality, and to express her feelings in ways that are not well controlled could also be considered potential targets for intervention. The referral also asks for an evaluation of her interpersonal style in order to join relapse prevention group therapy in our center. Nathalie does not seem to be a good candidate for this kind of treatment. Her inefficient interpersonal behaviors would make it difficult for her to develop trusting relationships. She exhibits limited empathic capacity, and she perceives aggressiveness as a natural mode of exchange. She is likely to act out her chronic, maladaptive interpersonal patterns with particular intensity in the group. She would probably place many demands and strains on the group. She could easily misinterpret the benign statements of others members as personal criticism. She could 210


become argumentative and hostile when her demands are not met. Group treatment might serve as supplement treatment after a period of individual psychotherapy. It should not be undertaken, however, until she has identified more resources with which to enhance her interpersonal and affective functioning. That is why we think that she may derive more profit from individual psychotherapy. We advocate a simultaneous focus on both alcohol addiction and personality disorder by a sufficiently trained therapist. The treatment relationship should be used to enhance her functioning in the wider world. Forming an alliance will be rather difficult because of her troubled and greatly f luctuating interpersonal attitudes and behaviors that will probably infuse Nathalie’s engagement with the therapist. Attention should be paid to the patient’s dysfunctional views of self and others in order to increase trust and strengthen the therapeutic alliance (Beck, Wright, Newman, & Liese, 1993), which will also facilitate treatment for the substance abuse. Supportive empathic but directive communications will help Nathalie feel heard and understood. Her potentially high resistance to change might need to be discussed with her early in the treatment to promote a more treatment-expectant attitude. Her ability to gain insight into her problems and to control her behavior should assist Nathalie in benefiting from psychological intervention. Nathalie was referred to a therapist trained in schema therapy for personality disorders (Young, Klosko, & Weishaar, 2003) and in coping skills training for alcohol relapse prevention (Monti et al., 2002). In this kind of integrated approach, during the early sessions, emphasis is placed on the establishment and maintenance of abstinence, but with a secondary focus on identification of and psychoeducation about maladaptive schemas. Once abstinence has been maintained for several months, personality problems can be addressed more directly in ways that call on the increased capacity of the patient to tolerate and work for change. This treatment model assumes that a broad range of patients’ difficulties (e.g., substance abuse, interpersonal dysfunction) can be subsumed by maladaptive schemas that organize these behaviors (Ball, 1998). Nathalie could also have been referred for psychodynamic psychotherapy if this kind of treatment were accessible in this center. Chronically impaired individuals with a tendency to use intellectual defenses may benefit from insight therapy despite long-term psychological disorganization (Beutler & Harwood, 2000)

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One-Year Follow-Up Intensive individual therapy permitted establishing a working alliance. Nathalie initially had 5 months of continued alcohol abstinence, though she now alternates between times of abstinence and alcohol consumption usually in a context of interpersonal conf lict or boredom. According to her therapist, her deeply entrenched dysfunctional belief systems and external attributions are major obstacles to therapy. During this year, Nathalie attended Alcoholics Anonymous meetings. This kind of group creates a culture in which belonging is highly prized, and where the members themselves are validated. Initially, she idealized the Alcoholics Anonymous group, but a couple of months later she became particularly aggressive toward other members. She was convinced that some of the members were laughing at her. She continues to have troublesome relationships with her family. She worked for 6 months but she did not get along with some of her colleagues.

Discussion These two cases are examples of use of the Rorschach in response to typical referral questions in alcohol treatment. We illustrated the way that psychological assessment in general, and the Rorschach in particular, can be employed to better understand the psychological functioning and personality characteristics in patients with alcohol addiction and to design treatment interventions. As to the psychiatric diagnosis – although the Rorschach should be not used primarily as a diagnostic test – it did produce valuable information. The evaluation of emotional distress in patients with alcohol addiction is a frequent referral question, although it poses a challenge for the clinician since acute intoxication, active disease, withdrawal, detoxication, and recovery can produce the same subjective symptoms and objective signs as the ones included in the diagnosis of a major depression. A standard clinical interview with a diagnosis of major depression disorder and alcohol dependence and a structured interview (MINI) confirmed these diagnoses in both patients. The Rorschach (performancebased method) as well as the MMPI-2 (self-report inventory) provided further information that was consistent with major depression and dysthymia disorder for Elisa, whereas the Rorschach findings indicated a 212


picture combining feelings of anhedonia, pessimism, labile mood, poor self-esteem and interpersonal problems than acute depression for Nathalie. Psychological assessment allowed us to formulate an alternative interpretation of Nathalie’s complaints of depression as a manipulative demand for attention. A standard clinical interview was poor at reporting personality disorders for both patients. A structured interview for personality disorders (SCID-II) provided multiple diagnoses of personality disorders for Nathalie. In fact, there is some evidence that the SCID-II tends to show a significant overlap between criteria for distinct personality disorder and may result in an overestimation of the overall rate of Axis II (Bottlender, Preuss, & Soyka, 2006). Overlapping personality disorders may also be explained by the presence of the coexisting alcohol dependence. For instance, social avoidance can be a sign of avoidant personality as well as an alcohol-related lifestyle behavior. For Nathalie, the combination of data from different sources (self-report inventory, structured interview, and performance-based method) allowed us to establish the diagnosis of borderline personality disorder. The description of personality characteristics with the Rorschach generated hypotheses about the role of alcohol for these patients. This kind of information can be particularly valuable when patients are considering stopping drinking. Motivation for change is a permanent issue in alcohol treatment. For Elisa, it seemed that the main motive was relief from emotional distress, while for Nathalie it was focused on the reduction of interpersonal problems. Rorschach findings complemented the information obtained by the clinical interview, the structured interviews, and the self-report inventory by identifying maladaptive personality traits or problem areas such as entrenched or pathological patterns of thinking, closed mind to change, difficulties in affect regulation, negative beliefs about the self, social isolation, interpersonal conf licts, difficulties in developing a trusting relationship, dysfunctional coping, or rigid defense mechanisms. Moreover, content themes in Nathalie’s protocol revealed information about her way of experiencing relations as either totally good or totally bad. All these issues served as targets for treatment. At the same time, they were potential obstacles for treatment efforts and the therapeutic relationship. Knowledge of these potential obstacles permitted us to make hypotheses about the conditions under which these two patients were most likely to engage with a therapist and stay in treatment. Additionally, the Rorschach identified the patient’s strengths such as reasoning capacities and relationship competencies for Elisa or self-control and insight 213

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capacities for Nathalie. Identifying a patient’s strengths can be equally helpful in designing treatment plan and increasing the motivation for treatment and the confidence in the change process. By looking at the idiosyncratic components of each patient’s experiences, we ascertained specific treatment plans and pertinent techniques for therapy. Hence, we recommended different kinds of treatment format, duration, and techniques for these two alcohol-dependent women. Brief group therapy based on motivational enhancement and cognitive behavioral therapy for relapse prevention seemed to be indicated for Elisa. In contrast, standard addiction treatment seemed unlikely to resolve many of Nathalie’s problems such as poor interpersonal relationships, pathological thinking, difficulties in affect regulation and self-devaluation. Intensive long-term individual schema therapy focused on interpersonal relationships would be likely to help Nathalie reach a more mature level of cognitive, affective, behavioral, and interpersonal functioning, and to maintain abstinence from alcohol. In conclusion, these two cases illustrate the utility of the Rorschach in clinical practice with alcohol-addicted patients. Because alcohol addiction rarely occurs as a completely independent condition, it is important to identify personality traits or functions underlying this condition. The Rorschach, although somewhat time-consuming, can describe strengths as well as vulnerabilities that the patient may be unaware of and that are unavailable through other sources. Therefore, it can be a particular helpful and ultimately cost-effective way of deciding on a treatment plan. Unfortunately, Rorschach studies of alcohol addiction have been developing slowly compared to other clinical groups. It is necessary to further establish the usefulness of the Rorschach in planning alcohol addiction treatment by empirical studies investigating the accuracy of prognostic assessment for therapy outcome which would complement clinical case reports.

References Ball, S. A. (1998). Manualized treatment for substance abusers with personality disorders: Dual focus schema therapy. Addictive Behaviors, 23, 883–891. Ball, S. A. (2005). Personality traits, problems, and disorders: Clinical applications to substance use disorders. Journal of Research In Personality, 39, 84–102. Beck, A. T., Wright, F. D., Newman, C. F., & Liese, B. S. (1993). Cognitive therapy of substance abuse. New York: Guilford.

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Rorschach in Alcohol Treatment Bergman, I., Haver, B., Bergman, H., Dahlgren, L., & Nielsen, G. H. (1998). Personality characteristics of women with alcohol addiction: A Rorschach study of women in an early treatment program. Scandinavian Journal of Psychology, 39(1), 47–54. Beutler, L. E., & Harwood, T. M. (2000). Prescriptive psychotherapy: A practical guide to systematic treatment selection. New York: Oxford University Press. Bottlender, M., Preuss, U. W., & Soyka, M. (2006). Association of personality disorders with Type A and Type B alcoholics. European Archives of Psychiatry and Clinical Neuroscience, 256(1), 55–61. Bouvard, M., Fontaine-Buffe, M., Cungi, C., Adeleine, P., Chapoutier, C., Durafour, E., ... Cottraux, J. (1999). Etude préliminaire d’un entretien structuré des troubles de la personnalité: Le SCID II [Preliminary study of the structured diagnostic interview for personality disorder: The SCID II]. L’Encéphale, 25, 416–421. Brown, R. A., Evans, D. M., Miller, I. W., Burgess, E. S., & Mueller, T. I. (1997). Cognitive-behavioral treatment for depression in alcoholism. Journal of Consulting and Clinical Psychology, 65, 715–726. Butcher, J. N., Dahlstrom, W. G., Graham, J. R., Tellegen, A. M., & Kaemmer, B. (2001). MMPI-2: Manual for administration and scoring (rev. ed.). Minneapolis, MN: University of Minnesota Press. Carroll, K. (2004). Behavioral therapies for co-occurring substance use and mood disorders. Biological Psychiatry, 56, 778–884. Cipolli, C., & Galliani, I. (1988). Negative movement responses in Rorschachs of heroin users. Perceptual and Motor Skills, 67, 114. Cloninger, C. R., Sigvardsson, S., & Bohman, M. (1988). Childhood personality predicts alcohol abuse in young adults. Alcoholism: Clinical and Experimental Research, 12, 494–505. Driessen, M., Meier, S., Hill, A., Wetterling, T., Lange, W., & Junghanns, K. (2001). The course of anxiety, depression and drinking behaviors after completed detoxification in alcoholics with and without comorbid anxiety and depressive disorders. Alcohol and Alcoholism, 36, 249–255. Driessen, M., Veltrup, C., Wetterling, T., John, U., & Dilling, H. (1998). Axis I and axis II comorbidity in alcohol dependence and the two types of alcoholism. Alcoholism: Clinical and Experimental Research, 22(1), 77–86. Exner, J. E. (1993). The Rorschach: A comprehensive system, Vol. 1: Basic foundations (3rd ed.). Oxford, UK: Wiley. Exner, J. E. (2000). A primer for Rorschach interpretation. Asheville, NC: Rorschach Workshops. Exner, J. E. (2001). Rorschach workbook for the Comprehensive System. Asheville, NC: Rorschach Workshops. First, M. B., Spitzer, R. L., Gibbon, M., Williams, J. B. W., & Benjamin, L. S. (1997). Structured clinical interview for DSM-IV personality disorders (SCID-II). Washington, DC: American Psychiatric Press. Ganellen, R. J. (1994). Attempting to conceal psychological disturbance: MMPI defensive response sets and the Rorschach. Journal of Personality Assessment, 63, 423–437.

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N. Kostogianni Ganellen, R. J. (2007). Assessing normal and abnormal personality functioning: Strengths and weaknesses of self-report, observer, and performance-based methods. Journal of Personality Assessment, 89(1), 30–40. Griggs, S. M., & Tyrer, P. J. (1981). Personality disorder, social adjustment and treatment outcome in alcoholics. Journal of Studies on Alcohol, 42, 802–805. Hunsley, J., & Bailey, J. M. (1999). The clinical utility of the Rorschach: Unfulfilled promises and an uncertain future. Psychological Assessment, 11, 266–277. Hunsley, J., & Bailey, J. M. (2001). Whither the Rorschach? An analysis of the evidence. Psychological Assessment, 13, 472–485. Ingersoll, K. S., Wagner, C. C., & Gharib, S. (2002). Motivational groups for community substance abuse programs. Richmond, VA: Mid-Atlantic Addiction Technology Transfer Center. Kadden, R. M., Cooney, N. L., Getter, H., & Litt, M. D. (1989). Matching alcoholics to coping skills or interactional therapies: Posttreatment results. Journal of Consulting and Clinical Psychology, 57, 698–704. Karno, M. P., & Longabaugh, R. (2007). Does matching matter? Examining matches and mismatches between patient attributes and therapy techniques in alcoholism treatment. Addiction, 102, 587–596. Kessler, R. C., Crum, R. M., Warner, L. A., Nelson, C. B., Schulenberg, J., & Anthony, J. C. (1997). Lifetime co-occurrence of DSM-III-R alcohol abuse and dependence with other psychiatric disorders in the National Comorbidity Survey. Archives of General Psychiatry, 54, 313–321. Krueger, R. F., Caspi, A., Moffitt, T. E., Silva, P. A., & McGee, R. (1996). Personality traits are differentially linked to mental disorders: A multitrait-multidiagnosis study of an adolescent birth cohort. Journal of Abnormal Psychology, 105, 299–312. Lecrubier, Y., Sheehan, D. V., Weiller, E., Amorim, P., Bonora, I., Sheehan, K. H., ... Dunbar, G. C. (1997). The Mini International Neuropsychiatric Interview (MINI): A short diagnostic structured interview: Reliability and validity according to the CIDI. European Psychiatry, 12, 224–231. Lindström, L. (1992). Managing alcoholism: Matching clients to treatments. Oxford: Oxford University Press. Meyer, G. J. (2000). Incremental validity of the Rorschach Prognostic Rating scale over the MMPI Ego Strength Scale and IQ. Journal of Personality Assessment, 74, 356–370. Miller, W. R., & Brown, S. A. (1997). Why psychologists should treat alcohol and drug problems. American Psychologist, 52, 1269–1279. Monti, P., Kadden, R., Rohsenow, D., Cooney, N., & Abrams, D. (2002). Treating alcohol dependence: A coping skills therapy guide. New York: Guilford. Nunes, E. V., & Levin, F. R. (2004). Treatment of depression in patients with alcohol or other drug dependence: A meta-analysis. Journal of the American Medical Association, 291, 1887–1896. Perry, W., & Viglione, D. J. (1991). The Ego Impairment Index as a predictor of outcome in melancholic depressed patients treated with tricyclic antidepressants. Journal of Personality Assessment, 56, 487–501.

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Rorschach in Alcohol Treatment Regier, D. A., Farmer, M. E., Rae, D. S., Locke, B. Z., Keith, S. J., Judd, L. L., & Goodwin, F. K. (1990). Comorbidity of mental disorders with alcohol and other drug abuse. Results from the Epidemiologic Catchment Area (ECA) Study. The Journal Of the American Medical Association, 264, 2511–2518. Sallmen, B., Nilsson, L., & Berglund, M. (1997). Psychiatric comorbidity in alcoholics treated in an institution with both coerced and voluntary admission. European Psychiatry, 12, 329–334. Skinstad, A. H., Troland, K., & Mortensen, J. K. (1999). Rorschach responses in borderline personality disorder with alcohol dependence. European Journal of Psychological Assessment, 15, 133–142. Stark, M. J. (1992). Dropping out of substance abuse treatment: A clinically oriented review. Clinical Psychology Review, 12, 93–116. Stokes, J. M., Pogge, D. L., Powell-Lunder, J., Ward, A. W., Bilginer, L., & DeLuca, V. A. (2003). The Rorschach Ego Impairment Index: Prediction of treatment outcome in a child psychiatric population. Journal of Personality Assessment, 81(1), 11–19. Thomas, V. H., Melchert, T. P., & Banken, J. A. (1999). Substance dependence and personality disorders: Comorbidity and treatment outcome in an inpatient treatment population. Journal of Studies on Alcohol, 60, 271–277. Vanem, P. C., Krog, D., & Hartmann, E. (2008). Assessment of substance abusers on the MCMI-III and the Rorschach. Scandinavian Journal of Psychology, 49(1), 83–91. Verheul, R., Ball, S., & Van den Brink, W. (1997). Substance abuse and personality disorders. In H. R. Kranzler & B. J. Rounsaville (Eds.), Dual diagnosis and treatment: Substance abuse and comorbid medical and psychiatric disorders (pp. 317–363). New York: Marcel Dekker. Weiner, I. B. (2003). Rorschach Inkblot Method. In M. Maruish (Ed.), The use of psychological testing in treatment planning and outcome evaluation (3rd ed.). Mahwah, NJ: Erlbaum. Weiner, I. B. (2004). Principles of Rorschach Interpretation. Mahwah, NJ: Erlbaum. World Health Organization. (1993). The ICD-10 classification of mental and behavioral disorders. Geneva: WHO. Young, J. E., Klosko, J., & Weishaar, M. E. (2003). Schema therapy: A practitioner’s guide. New York: Guilford.

Nikoleta Kostogianni Department of Psychology University of Paris 10 200 avenue de la République F-92001 Nanterre France E-mail [email protected]

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Appendix Outpatient group treatment for alcohol dependent patients 12 weekly sessions of 2 h Session 1:

Introduction to Group and Exploration of Lifestyles

Session 2:

Looking Forward and Exploring Values

Session 3:

Decisional Balance: Pros and Cons of Changing and Staying the Same

Session 4:

Introduction to Coping Skills Training

Session 5:

Drink Refusal Skills

Session 6:

Managing Thoughts about Alcohol and Drinking

Session 7:

Coping with Cravings and Urges to Drink

Session 8:

Managing Negative Moods

Session 9:

Receiving Criticism

Session 10:

Seemingly Irrelevant Situations and Problem Solving

Session 11:

Planning for Emergencies and Coping with a Lapse

Session 12:

Termination

Sources: Adapted from Ingersoll, Wagner & Gharib, 2002 and Monti, Kadden, Rohsenow, Cooney & Abrams, 2002

Summary Alcohol addiction rarely occurs as a completely independent condition. Therefore, it is important to identify personality traits that might call for a more complex treatment program. The present study aims to demonstrate the utility of the information derived from the Rorschach Comprehensive System (CS) in treatment planning for alcohol-dependent patients by presenting two clinical cases that demonstrate the complex relationships between alcohol addiction, clinical syndromes, and personality. Both patients were women. They were referred to an addiction treat218


ment center by their primary-care physician because of alcohol dependency. The patients confirmed their motivation to stop drinking and were willing to enter the 3-week inpatient alcohol rehabilitation program followed by a 12-week outpatient group treatment format. In this context, the staff psychiatrist recommended a psychological evaluation. The referral questions included (1) the magnitude of the emotional distress, (2) the motivation to change, and (3) the adequacy of their interpersonal style with the 12-week outpatient group treatment. Assessment took place during the third week of the inpatient alcohol rehabilitation program. Each patient was assessed with the MINI, the SCID-II, the MMPI-2, and the Rorschach CS. Rorschach findings complemented the information obtained by the clinical interview, the structured interviews, and the self-report inventory by generating hypotheses about clinical diagnoses, the role of alcohol, motivation for change, treatment targets, patients’ strengths and interpersonal style, as well as the potential obstacles for treatment and therapeutic relationship. Specific treatment plans and pertinent techniques for therapy were also suggested for each patient on the basis of Rorschach data.

Résumé Le Rorschach dans la planification du traitement des patients dépendants à l’alcool: deux études de cas avec le Rorschach en Système Intégré. La dépendance à l’alcool existe rarement comme une situation clinique isolée. Pour cela, il est important d’identifier les traits de personnalité qui nécessiteraient une prise en charge plus complexe. La présente étude vise à démontrer l’utilité des données recueillies au Rorschach en Système Intégré dans la planification du traitement des patients dépendants à l’alcool en présentant deux cas cliniques. Ces études de cas ont été choisies puisqu’elles démontrent bien la relation complexe entre la dépendance à l’alcool, les syndromes cliniques et les traits de personnalité. Il s’agit de deux femmes. Elles ont été adressées à un centre de traitement des addictions par leur médecin traitant pour un trouble de dépendance à l’alcool. Les deux patientes ont affirmé qu’elles étaient motivées pour arrêter de boire et elles étaient prêtes à suivre une hospitalisation de trois semaines pour sevrage et par une prise en charge en groupe 219

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pendant 12 semaines en hôpital de jour. Dans ce contexte, le psychiatre du centre nous a adressé les patientes pour un examen psychologique. Les objectifs de l’examen psychologique étaient d’évaluer (1) l’importance de la détresse émotionnelle ressentie (2) la motivation au changement et (3) l’adéquation de leur style relationnel avec une prise en charge de groupe pendant 12 semaines. L’examen a eu lieu durant la troisième semaine de l’hospitalisation. Chaque patient a été évalué avec le MINI, le SCID-II, le MMPI-2 et le Rorschach en Système Intégré. Les données recueillies au Rorschach ont complété les informations obtenues à l’entretien clinique, les entretiens structurés et l’auto-questionnaire en générant des hypothèses concernant les diagnostics, le rôle de l’alcool, la motivation au changement, les objectifs du traitement, les ressources et le style relationnel ainsi que les obstacles potentiels pour le traitement et la relation thérapeutique. Des plans de traitement spécifiques et des techniques thérapeutiques pertinentes ont été dégagés pour chaque patiente.

Resumen Es infrecuente que la adicción al alcohol se presente como una característica completamente aislada. Por tanto, resulta esencial identificar otros rasgos de personalidad que puedan requerir un programa de intervención terapéutica más complejo. El presente trabajo intenta demostrar la utilidad de la información derivada del Rorschach (Sistema Comprehensivo) para la planificación del tratamiento en pacientes con dependencia alcohólica, a través de la presentación de dos casos clínicos que muestran las complejas relaciones existentes entre la adicción al alcohol, los síndromes clínicos y la personalidad. Ambas pacientes son mujeres que acudieron a un centro de tratamiento para adicciones a través de su médico de atención primaria, debido a su dependencia alcohólica. Ambas confirmaron su motivación para dejar de beber y se mostraron dispuestas a incorporarse a un programa de rehabilitación de tres semanas de ingreso, seguido de la asistencia a un tratamiento de grupo de 12 semanas como pacientes externas. En este contexto, el psiquiatra solicitó una evaluación psicológica, con preguntas concretas sobre estas pacientes: 1) magnitud del malestar afectivo, 2) motivación para el cambio, y 3) adecuación de su estilo de relaciones interpersonales al programa grupal ambulatorio de 12 semanas. La evaluación se llevó a cabo durante la tercera semana de in220


greso en el programa de rehabilitación. Se les administró a cada una de ellas los tests MINI, SCID-II, MMPI-2 y Rorschach (Sistema Comprehensivo). Los datos de Rorschach se complementan con la información obtenida en la entrevista clínica, las entrevistas estructuradas y el inventario de autoinforme, generándose hipótesis sobre diagnóstico clínico, papel del alcohol, motivación para el cambio, objetivos del tratamiento y estilo intepersonal, así como sobre obstáculos potenciales para el tratamiento y la relación terapéutica. También se sugieren las posibilidades y técnicas más adecuadas para la psicoterapia de cada una de las dos pacientes, teniendo como base los datos del Rorschach.

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