Degree of Unitary Self-Representation on the Rorschach (SRI): Diagnostic and Psychotherapeutic Value in Psychosis Clinics

Abstract

The aim of this article is to present a new marker of the degree of self-representation unity, developed from the Rorschach test, to assess the strength or fragility of psychotic patients’ narcissistic foundations. The marker exhibited discriminative value when comparing a group of paranoid subjects (n = 25) to two other groups of schizophrenic (n = 26) and paranoid schizophrenic subjects (n = 30). This indicator also appears useful for assessing the positive effects on the narcissistic Ego in psychotherapy.

1. Introduction

Claude De Tychey taught the Rorschach test with great enthusiasm for many years at the University of Nancy. In order to facilitate the use of the Rorschach method for students as well as apply the latter to his research in psychiatry, De Tychey created two distinct scaling systems, an object relations grid and a self-representation grid, inspired entirely from the scaling system developed by Nina Rausch of Traubenberg and Sanglade [1]. From this grid, an indicator was subsequently created which facilitates the diagnosis and evaluation of the long-term therapeutic effects on the psyche of our patients. This marker is called the degree of whole unitary self-representation (Self-Representation Indicator—the SRI).

The objective of the present study is to show the relevance of this new indicator constructed from the contents projected on the Rorschach test as well as from the extensive experience of Claude De Tychey who conscientiously improved the Rorschach approach over time. This grid was transmitted from Nina Rausch to De Tychey and subsequently to the current author, giving this indicator a strong symbolic ancillary character.

The interest of this tool is explained by the fact that level of self-representation cannot, in essence, be assessed by current scale, because it underlies an unconscious psychic construction to which the subject does not have access. This is why the Rorschach assessment is the only conceivable and objectifiable method, beyond traditional clinical observation.

The SRI is initially based on the self-representation scale [1] from which a revised version was published by De Tychey in 2014 [2], which ultimately inspired the development of the current approach described herein (the degree of unitary self-representation on the Rorschach), yielding a more accurate assessment of the strength or fragility of the subject’s narcissistic foundations.

To test the discriminative capacity of this new indicator in projective diagnosis, we compared the distributions of three subgroups of psychotic subjects presenting the three most collapsed levels of narcissism, based on the structural psychoanalytical approach of Bergeret [3,4] in increasing order of dissociation: paranoid, paranoid-schizophrenic and schizophrenic functioning.

The usefulness of the SRI was then tested on its ability to assess remote changes during therapeutic management of a psychotic patient aimed at strengthening the subject’s narcissistic foundations. For this purpose, the evolution of a clinical case of paranoia, which was the subject of a test-retest comparison study at two years’ interval, is presented linking the evolution of the clinical presentation with that of the SRI generated from the Rorschach test.

1.1. Assessing Narcissism According to Catherine Chabert

Chabert [5,6] associated narcissism to a dualling mechanism against which the subject fights by trying to refocus the content of his or her response to the test expressed by specular relationships translated either directly (representations of mirroring relationships or surfeit of reflect responses) or indirectly (by the absence of interaction between representations or cathexis of symmetry). Chabert also emphasizes the negation of instinctual drive movements in narcissistic functioning in representations of relationships. Narcissistic functioning is also purported by the author to be expressed by the tendency of the subject to verbalize responses centered on subjective experiences. Chabert also reviewed other aspects of narcissistic functioning, emphasizing the cathexis (of the limits of the Self) characterized by the increase in Skin responses and contents determined solely by the percentage of pure form responses (F%) while also pointing out the difficulty of the subject in recognizing the source of the internal drive (manifested on the Rorschach by a devitalization of the human responses). However, a complex issue remains unresolved: the difficulty in differentiating normal narcissistic functioning from pathological narcissistic functioning.

1.2. The Contributions of Claude de Tychey According to His Theoretical Referent

De Tychey [2] reflected on the usefulness of comparing, in the Rorschach test, the balance between defensive movements projecting a dequalification of self-representation associated with a devaluation mechanism and those which, on the contrary, express a restoration of self-representation through idealization. Kernberg’s theory [7] and Ego psychology [8] has noticeably influenced De Tychey’s work. This is illustrated by a duality of responses to card V of the test (see Appendix A), classically regarded as the quintessential card in assessing self-representation, where subjects arriving at a unitary representation of themselves typically see a bat or a butterfly. The projection of “an ugly and sad butterfly with fraying wings” would express, through a channel associating projection and depreciation, the severity of the narcissistic pathology leading to a degraded and depressive self-representation. The restoration of narcissism would be expressed in this setting by a second image borne by the defense mechanism of idealization and resulting in the perception of a golden eagle. Bergeret’s nosography [3,4], which is De Tychey’s theoretical referent, defines narcissism as a structure which ensures the cohesion and unity of self-representation when it is not damaged. This cohesion can be found in all forms of personality organizations depending on the existential avatars that each personality structure can encounter, including the most deep-rooted forms corresponding to neurotic Oedipal conflicts. However, for Bergeret [3,4], narcissism is generally much more undermined in borderline pre-oedipal character structures all of which present more or less a narcissistic disease, a major factor of instability and of the fight against depression. Narcissistic collapse is even more severe in the three large psychotic organizations of Bergeret’s model, where according to the latter [3], one can observe a gradient of increasing dissociation of self-representation which is fragmented during the transition from manic-depressive structures to paranoid structures, ultimately reaching the level of extreme dissociation with schizophrenic structures (paranoid-schizophrenic structures occupying an intermediate position between the two aforementioned structures). In light of the above, we hypothesized that the SRI would be lessened in all psychotic subjects in our study sample (n = 81), albeit more pronounced in the schizophrenia group (n = 26) than in the paranoid schizophrenia group (n = 26) and even higher in the latter than in the paranoid group (n = 25).

2. Methodology

2.1. Sample Selection

This study was approved by an ethics and personal protection committee within a Regional Hospital Center located in the East of France (Jury Les Metz, Head of Department: Dr. Decker). The patients included in this study were tested as part of routine rehabilitation care. Other tools were used for the assessment of patients, which allowed us to establish a link between our point of view and that of neuropsychology. Which gave rise to an oral communication [9] in Ljubljana. During this communication we argued in favor of the interest of neuropsychoanalysis in the evaluation of patients suffering from psychosis.

All (N = 81 subjects) were informed and gave their informed consent for the use of their data in this research. They were evaluated either in the center where they were hospitalized or on an outpatient basis in Psychological Health Centers (Medical Psychological Center) after their discharge from the hospital. These are 81 subjects aged 19 to 69 years (M = 41.19; SD = 12.17) for whom a diagnosis of psychosis has been made by a psychiatrist. This study was part of a major rehabilitation campaign (2014–2018) for chronic patients in Jury Hospital, so this collect of data does not interfere with treatment and was conducted by a multidisciplinary team (doctor in medicine and clinical psychologist, neuropsychologist).

Subjects with diagnosis of paranoia were mostly encountered in medical and social centers, These individuals are more rarely hospitalised (n = 4/25) and their symptoms (delusional ideas on the theme of persecution) are more discret but really present. Subjects with diagnosis of schizophrenia, on the contrary, were almost all hospitalised with severe disorders. However, all individuals with schizophrenia are under neuroleptic treatment: mainly Risperidone or (and) Clozapine contrary to subjects with paranoia where only 60% of them take neuroleptic treatment (mainly Abilify). If there is a significant intergroup difference in terms of treatments (X² Cor = 25. 714, p < 0.01), this however has no impact on the results of the Rorschach test, according to Biagiarelli et al. [10].

The 81 selected subjects were divided into three subgroups: 25 subjects diagnosed with paranoia, 26 diagnosed with paranoid schizophrenia, and 30 diagnosed with schizophrenia. The initial diagnosis was made by the departmental psychiatrist based on ICD10 criteria and subsequently assessed by the clinician responsible for the projective assessment. Other inclusion criteria were:

• Men or women volunteers, hospitalized or not;
• “Normal” or corrected vision;
• Subjects were aged between 22 and 76 years (inclusively), with an average age of 41 years (standard deviation 14). There were 18 women and 63 men.

Exclusion criteria were as follows:

• Subjects who had never consulted in psychiatry;
• Prior history likely to affect brain anatomy or linked to an anomaly;
• Legally protected adults;
• No mastery of the French language or foreign country nationality (cultural norms are too influential on the test);
• Disabling sensory disorders, particularly visual (color blindness, etc.).

2.2. Operationalization of the SRI

The grid developed by De Tychey’s [2] and used herein allows codifying each content projected with the Rorschach test in a dichotomous manner into whole unitary content or non-unitary content. To be codified as whole unitary (signifying narcissistic cohesion and unity), the content fantasized by the subject must combine the following characteristics: be perceived as a whole, have good formal quality and not be degraded by one of the numerous qualitative aspects of verbalization corresponding to French codifications: criticism of the object, self-criticism, devitalization, confabulation, contamination, defect, or telescoping between realms.

A summary of the grid illustrating the coding used herein is shown in

Table 1. Structural summary of the grid depicting the Rorschach coding methodology.

Nature of the Contents	Whole (Unitary)	Piecemeal	Fragmentary
Nota Bene.: a content of poor quality or content comprising telescoping between realms will incur a deterioration of the content, which is no longer whole unitary; Defect; Devit.; Self-crit.; Crit obj.; Contam. Confab. Non unitary: Human child Animal child Frag (H) (death, dead) whole (A) (death, dead) whole	H whole unitary gendered H whole unitary H whole non-unitary A whole unitary gendered A whole unitary A whole Botanic whole unitary Botanic whole H surreal or imaginary whole gendered H surreal or imaginary whole H surreal or imaginary A surreal or imaginary whole gendered A surreal or imaginary whole unitary A surreal or imaginary whole Obj. whole unitary gendered Obj. whole unitary Obj. whole	Hd Ad Fetus Fragments of objects or of any other content	Ultrasound or anatomical X-rays Sex Anatomies (skeletons or visceral)

Devit: devitalization; Self-crit: self-criticism; Crit obj: critical view of the object; Contam: contamination; Confab.: confabulation; Frag.: fragmentary; H: human; A: animal; Hd: a part of human; Ad: a part of animal.

. A unitary content that is not of good formal quality at the outset or, if it includes one of the aforementioned qualitative degradations, is codified as non-unitary. The contents of the third and fourth columns of the grid (piecemeal and fragmentary) are by definition non-unitary given that they are not whole. Each response of the subject to the test is therefore rated as unitary or non-unitary, which ultimately results in the calculation of a percentage of unitary response relative to the total number of responses to the test, which corresponds to the degree of unitary self-representation reflecting the relative extent of the subject’s narcissistic foundations. This coding is easily achieved with an inter-rater reliability of 0.90.

For exemple with card V, the “bat” response will be rated as a whole unitary response. On the other hand, it will receive the opposite codification if the subject adds elements of dequalification to his or her representation such as “it is ugly” (critical view of the object) or “I am useless at giving you answers that everyone gives” (self-criticism aspect). Other qualitative deteriorations can occur such as conveying a representation of the bat as “dead” or “crushed” (defect rating associated with a deterioration of the formal quality of the response), “stuffed” (devitalization rating) or seeing “a rabbit with wings” or a “bat-rabbit” (contamination rating) or even a football (bad shape rating). Instead of an entire content, the subject can also immediately give a disjointed (e.g., “a head of a rabbit”) or fragmentary (e.g., “lungs”) representation, which will necessarily be non-unitary.

In definitive, to obtain the SRI just have to add all the whole and unitary responses together and then to divide them by the number of total responses on the test. Score range is 0% to 100%, and the cut off score to detect a level of psychosis disorders is <40%. Future studies should investigate SRI in another functioning mode as well as individuals who have never consulted in psychiatry and compare the results with this one. Meanwhile to obtain this data, it seems coherent to think that a SRI score’s of 60% is linked with a narcissistic identity satisfactorily well constructed. Advantages to use this indicator is that it is inexpensive in terms of time and accessible to neophytes who do not have a lot of experience with the test. Just have to rate each answer obtained in accord to the grid (Table 1). It is important to use a Manual of codification to assess the formal quality of the content, because a bad formal quality deteriorates the unit content, regardless of the underlying theory orientation (R-PAS or French school).

2.3. Statistical Analysis of the Comparative Data from the Three Groups

Statistical analysis for this indicator was carried out using the non-parametric Wilcoxon test, which is specifically adapted to compare subgroups whose variables are not normally distributed. It is well suited for small sample. A p value < 0.05 was considered statistically significant. Analyses were carried out using the R Studio 7.4 software package.

3. Analysis of the Results

Several noteworthy observations emerged when comparing the mean scores obtained by the three subgroups (These results are summarized in

Table 2. Table presenting the mean percentages of whole unitary self-representations in the three groups.

Percentage of whole unitary self-representation to the Rorschach	Comparison paranoia versus schizophrenia	Comparison paranoid-schizophrenia versus paranoia	Comparison schizophrenia versus paranoid-schizophrenia
	Mean (SD) 27.40% (11.65) W = 450.5, p-value = 0.0184 *	Mean (SD) 17.17% (9.67) W = 550.5, p-value = 0.003079 **	Mean (SD) 18.94% (14.02) W = 379.5, p-value = 0.8695 N.S.

* p < 0.02; ** p < 0.004; N.S.: not significant.

):

In keeping with the initial hypothesis, the mean percentage of whole unitary self-representations among the subjects in the study sample was collapsed in all three groups, with 27.4% for paranoid subjects compared to 17.17% for paranoid schizophrenic subjects and 18.94% for schizophrenic subjects. As expected, the dissociation of self-representation was significantly less pronounced in paranoid individuals when compared statistically to schizophrenics (W = 450.5. p < 0.01) and paranoid schizophrenics (W = 550.5, p < 0.003).

On the other hand, the mean score of the schizophrenia group did not statistically differ from that of the paranoid schizophrenia group (W = 379.5 p < 0.87 NS), which was unexpected and warrants further discussion. Currently in DSM-5, there is no more difference between schizophrenia and paranoid schizophrenia and these results tend to confirm A.P.A. point of view. According to many authors, paranoid traits are a means of preserving narcissism and are favorable pronostic indicators in schizophrenia [11].

A proposed interpretive hypothesis may relate to the nature of the final composition of the schizophrenia group. Clinical experience shows us on a daily basis that not all patients become schizophrenic in the same manner. While the most well-known path to schizophrenia is precocious, at the end of adolescence or the beginning of adult life, there are also other later pathways, linked in particular to severe decompensations organizations long considered “borderline” in light of the medico-psychological reports which accompany these organizations and which ultimately end in a state of chronic treatment failure by deconstructing into a psychotic mode. The detailed analysis of the schizophrenia group shows that 9 of the 30 subjects indeed followed this course. Their Rorschach test is a particularly sensitive indicator of their evolution since it contains remnants of their previous organization, with consequently slightly more unitary representations and by the same token the trademarks of the breakdown of their current self-representation, i.e., much more dissociated.

The above observations depict the possible evolution of self-representation on both the psychopathological level and psychological functioning perspective. The following section illustrates this evolution with a clinical vignette comprised of a test-re-test follow-up at two years’ interval allowing highlighting the clinical value of the proposed SRI, namely the degree of unitary self-representation to the Rorschach test as an indicator of the nature of the subject’s narcissistic foundations and their possible evolution during therapy.

4. Clinical Illustration: Degree of Unitary Self-Representation to the Rorschach Test and Therapy: The Case of Manual

4.1. Presentation of the Clinical Case

At the time of his first Rorschach test, Manuel was hospitalized in a closed psychiatric department for one month at the request of a third party (his father). This hospitalization was due to a paranoid psychotic decompensation with ideation of persecution and hetero-aggressive threats towards his parents (following yet another argument with his parents, albeit more violent this time around. He allegedly pushed his mother into the stairs). Manuel refused any treatment and categorically contested his hospitalization. This was a first hospitalization. He was 32 years old and a computer scientist, his fatheran engineer and his mother also a computer scientist. Manuel asserts having been burglarized in his apartment two years prior to (“despite an armored door”) but only realizing it two months later when he noticed items were missing from his apartment, stored in boxes, including vinyls and CD-ROMs (speeches from the Second World War, etc.) of which he is a fervent collector. The memory of a rape then appears to him. He repeatedly sees, in the middle of the night and on a regular basis, a man with his face covered by a white mask who rapes him; in the aftermath of these “flashbacks”, he feels sensations such as “the tongue sticking out” and “a body stiffness”. Manuel relates these facts with confidence and firm conviction. He also believes that the burglar used “gas” to blur his memories. He indicates that he suffered even more from this episode because his co-workers apparently realized that he had been raped and had said to him one morning “but you’re a fag”. He then took a one-year sabbatical to compose music, his passion, and left his apartment to live with his parents. However, cohabitation with his parents in the large family home turned into a nightmare, with constant arguments. He also explains that he has edged knives of all types since the burglary (even including a machete) which he collects and hides under his pillow to protect himself.

In terms of hospitalization, as the days went by, Manuel felt more and more persecuted by the psychiatric system, his defenses becoming increasingly rigid and his aggressiveness escalating. The patient, however, accepted a contract conditioning his discharge from the hospital by which he agreed to a follow-up in a medical psychological center (MPC) including bifocal therapy provided on the one hand by the psychiatrist who also prescribed Manuel’s chemotherapy (neuroleptic treatment with Xeplion in monthly injections) and by a psychoanalytical-oriented psychotherapist. A lasting transference link was founded, allowing the emergence of a relationship of trust. Manuel appreciated the space left to him during these sessions, gradually allowing him to put into words his anxieties and his analysis of the world now less distorted by his initial paranoid projective mechanisms.

At the end of these two years, Manuel was able to obtain housing and the lifting of the protective measures. Social assistance was able to help him find accommodation in which he seemed peaceful for almost a year, although his parents now want to purchase an accommodation for him to settle in. No new hospitalizations have occurred and the clinical picture has clearly stabilized. Manuel no longer exhibits episodes of acting out aggressively and his perception of the world has ceased to be continually distorted by paranoid projective mechanisms.

4.2. Analysis of the Rorschach Test at T1 (at the Beginning of the First Hospitalization) and at T2 (After Two Years’ Follow-Up)

Upon analyzing the evolution of the SRI between T1 and T2, together with those of several other important indicators of the Rorschach test in conjunction with the evolution of the clinical picture observed between T1 and T2, the first revealing observation is the narcissistic restoration achieved between T1 and T2 two years later. In effect, the percentage of response reflecting the degree of unitary self-representation, which was very low at T1 and corresponding to Manuel’s hospitalization phase, was only 28.5% (4 responses out of a total protocol of 14 referring to a whole unitary self-representation), while rising to 50% (including 9 responses out of a total of 18 referring to whole unitary self-representation) at T2. The comparison of the two multi-card test protocols is particularly edifying, illustrated herewith by a few examples. On card I, at T1, Manuel first projected “a dog’s” or “cat’s head with four eyes”, i.e., a rather delusional piecemeal response, followed by a projection of “a crushed insect” relative to a detail on the card, reflecting a self-representation in terms of fear of bodily disintegration, and ultimately ending with an attempt to resort to reality and intellectualization of questionable formal quality (rating F+−) expressing the vagueness of the representation (“An ink stain folded in two; moreover it’s like I’ve seen before in films”). None of these responses reflect a whole unitary self-representation. In T2, his first answer certainly remains piecemeal close to that given in T1 “a dog’s face” but ceases to be delusional (there is no longer a reference to “four eyes”). It is followed by a very elegant intellectualization reflecting a capacity for successful identification with humans expressing a whole unitary self-representation and an objectal cathexis in terms of positive mutual interaction: “two Russians dancing the troika”. On card III (see Appendix A) whose bilateral content calls for projecting representations of object relations, Manuel first perceives in T1 “two people who appear face to face”, but the latent aggressive driveness reactivated by the red color of certain details of the card immediately leads him to a freezing of this drive leading to devitalization: the depicted individuals become “African icons like deformed African statuettes”, which translates both the narcissistic infringement (also reflected by the last criticism of the object) and the failure of objectal cathexis as a result of the devitalization. This response is followed by a subsequent response reflecting a telescoping of species of poor formal quality: “An upside-down beetle, an insect and a fly”, confirming the absence of unitary self-representation. At T2, Manuel’s dynamic response is the opposite. It begins with a perception close to T1: upside down, looks like a beetle, certainly of equally poor formal quality and therefore non-unitary but without a telescoping of species”. On the other hand, he succeeds in the ensuing response in developing aggressive drivenness in a particularly adaptive manner owing to a reaction formation defense mechanism to counter aggressivity which allows him to identify with a whole gendered human representation and to establish an object relationship invested on cooperation. He indeed sees: “In the reverse view it looks like two waiters who are bringing a bucket to someone”. The comparison of card V at both test and retest also shows that Manuel manages to provide a whole unitary representation of himself at T2, while the representation at T1 was weakened by the telescoping of species accompanying the production of the mundane response given: “A type of bat butterfly”. At T2, Manuel does indeed see “a bat, yeah, yes a bat”.

Lastly, the present comparative analysis culminates with card X (see Appendix A) whose fragmented configuration notably tests the degree of unitary self-representation of all the subjects.

The self-representation offered by Manuel in T1 first translates the fragmentation of the bodily envelope in a transparent manner since he sees “an anatomical form”, a response followed by a piecemeal content also indicating his inability to convey a whole unitary representation of himself to this card: “the shape of a face, the two eyes, the mustaches”. In T2, he demonstrates a rather remarkable restoration of unitary self-representation, through the three successive answers that he gives stemming from three responses relating to details on the card, associated with whole contents of good formal quality, successively an “Eiffel Tower”, then “a brassiere”, and finally with the trite answer “two crabs”.

It is noteworthy that the significant changes observed at T2 in the dimension of the SRI following bifocal therapy attest to the at least partial restoration of his narcissistic foundations. The variable favored herein correlates with both the behavioral changes observed clinically and other parameters of the Rorschach test indicating Manuel’s adaptation to reality as well as to his social adaptation. Indeed, the control of reality index measured in the Rorschach test by the percentage of responses of good formal quality (F+%) and reflecting the subject’s sense of reality, while remaining weakened (42%) as typically observed in a large number of psychotic states of mind, is clearly improved at T2, comparatively to only 18% initially, i.e., completely collapsed at T1. The evolution of anxiety also followed the same path. The latter is assessed with the Rorschach using an indicator called AI%: an anxiety index calculated as the percentage of fragmented responses to human parts (Hd) + anatomical parts (Anat) + responses referring to sex and blood. This percentage reflecting unmetabolized anxiety by the Self, which was very pathological and much higher than the norm at T1 (21% of the total responses to the test), drops to 0% at T2! The indicators of social adaptation measured by the Rorschach test also improved at T2: the number of popular responses that did not deteriorate increased from 2 to 4 at T2, remaining nonetheless below the norm (between 5 and 7).

5. Limitations

In definitive, major default of this study is the absence of control group. The comparison with a none psychiatric population will have to be conduce in the future to establish more exhaustive standards. Added to this, assessment of therapeutic efficacy on self-representation in only one clinical case does not seem sufficient and we also have to further investigations.

Concerning the non significative difference between schizophrenia and schizophrenia paranoid group, we believe such finding poses the central predicament inherent to any comparative research when dealing with quantitative clinic options due to a certain number of variables that are impossible to control completely and linked to inevitable intra-group heterogeneity, even if each subject in the group shares the same major independent variable, in this instance psychopathological status. When assessing the psychological characteristics of a group of subjects, they are indubitably not identical even if they share the same diagnostic status. The data collected will differ according to whether the assessment was performed at the peak of decompensation or after an initial period of re-stabilization, or depending on the variable impact of medication which generally accompanies any psychosis therapy. These data can also vary depending on the defensive mechanisms implemented during the existential crises that accompany decompensation and the links that the subject manages or fails to weave during treatment. The standard deviation values associated with the mean percentage of unitary representation to the Rorschach constitute, in our opinion, a trustful indicator of this intra-sample heterogeneity. These SD values were higher in the schizophrenia group recalling that, in a manner not consistent with our model, this group had a very slightly higher mean unitary score than the paranoid schizophrenia group, even if the difference was not statistically significant.

6. Conclusions

Thurin & Thurin [12] in their studies on the evaluation of psychotherapies emphasize (p.55) that “research on processes focuses on the factors internal to psychotherapy which contribute to change. It is hence distinguished from research on results which focus on its manifestations [la recherche sur les processus se concentre sur les facteurs internes à la psychothérapie qui contribuent au changement. Elle se distingue donc de la recherche sur les résultats qui se concentre sur ses manifestations]”. Our own research on Manuel’s follow-up endeavored to combine these two aspects by simultaneously approaching Manuel’s changes at the internal level (strengthening of narcissistic foundations at T2 measured by the improvement in the degree of unitary self-representation on the Rorschach test) and the improvement in adaptation to reality as well as socio-environment adaptation, by linking the elements of clinical observation (reduction in behavioral disturbances at T2) and the other markers of the Rorschach test that can account for this improvement. To ensure that these changes are sustainable, it remains essential to be able to follow Manuel’s evolution over a longer time span.

Multiple avenues of research would benefit from further studies based on the research presented herein. The first would be to confirm the validity and discriminative power of this new indicator for measuring the described degree of unitary self-representation from a comparative quantitative clinical perspective. It would allow ascertaining the percentages of the degree of unity of psychotic subjects compared to their counterparts with borderline or neurotic personality structures, while also being cognizant of the hazards of such an undertaking due to the extreme difficulty in controlling the intra-individual homogeneity of subjects from the same group presenting varying profiles depending on (i) whether their organization is stable, unstable or decompensated, (ii) whether the implemented chemotherapy is effective or not, and (iii) whether a stable transference link can be developed or not within the framework of therapeutic monitoring. In any event, the present approach fully subscribes to the point of view recently developed by Brun-Camps-Verdon & Vuillod [13] who underscored the value of projective tools for measuring change in psychoanalytically-oriented psychotherapies. Another avenue of research could be to refine the discriminative sensitivity of our newly-constructed indicator in a simple dichotomous mode (whole unitary content versus non-unitary content, either whole degraded, or piecemeal or fragmentary) in a first instance. In effect, the non-unitary column currently groups together three types of content, all certainly corresponding to degrees of alteration of unity, but which do not have the same degree of severity. A weighting of the scores at the rating level according to the degree of severity of the alteration would likely enable further improving the discriminative power of the indicator, although would require upstream confirmation of inter-rater reliability which may be more difficult to achieve.

The author of the article would like to thank her thesis director Claude De Tychey for the many constructive and fruitful discussions in developing the indicator of the degree of unitary self-representation as well as for his kindness and generosity.