Introduction
The United States maintains the world’s largest population of prisoners [1]. According to Carson, “U.S. state and federal correctional facilities held an estimated 1,574,700 prisoners on December 31, 2013, an increase of 4,300 prisoners from yearend 2012” [2]. Recidivism rates in the United States are also among the highest. Results of a 2002 study showed that among the 275,000 prisoners released in 1994, 67.5% were rearrested within 3 years, 51.8% of whom were serving prison terms [3]. Additionally, minority groups account for a major portion of the prison population in the United States. In 2009, African Americans represented 39.4% of the prison and jail population while Hispanics represented 20.6% [4]. Taken together, these statistics encompass the continued need for research geared toward the development of assessment measures to improve rehabilitation and psychological treatment programs for the prison population in the United States.
One important component of rehabilitation may involve the cognitive functioning of prisoners. Studies have demonstrated a significant number of prisoners within secure forensic settings exhibit cognitive difficulties related to problematic thinking styles. Lindsay, Hastings, Griffiths, and Hayes, for instance, found a significant number of offenders in their study had an intellectual disability (IQ < 70) or were within the borderline range (IQ between 70 and 79) of intellectual functioning [5]. Similarly, Sinclair, Blencowe, McCaig, and Misch found prisoners tend to have significantly lower mean scores on the Full Scale Intelligence Quotient (FSIQ) and Verbal Comprehension Index (VCI) on the Wechsler Adult Intelligence Scale-Fourth Edition (WAIS-IV) than the general population [6,7]. Prisoners in that study also demonstrated greater neuropsychological deficits in behavioral inhibition, cognitive flexibility, and problem-solving [6]. Such difficulties are likely to underlie problem behaviors or cognitive distortions that result in criminal activity or other issues that affect social functioning. Understanding the relationship between cognitive deficits and criminal behavior thus has important implications for the conceptualization and rehabilitation of offenders.
have significantly lower mean scores on the Full Scale Intelligence Quotient (FSIQ) and Verbal Comprehension Index (VCI) on the Wechsler Adult Intelligence Scale-Fourth Edition (WAIS-IV) than the general population [6,7]. Prisoners in that study also demonstrated greater neuropsychological deficits in behavioral inhibition, cognitive flexibility, and problem-solving [6]. Such difficulties are likely to underlie problem behaviors or cognitive distortions that result in criminal activity or other issues that affect social functioning. Understanding the relationship between cognitive deficits and criminal behavior thus has important implications for the conceptualization and rehabilitation of offenders.
While the association between low intellectual functioning and criminal activity has long been demonstrated, standard neuropsychological measures have limitations in specifically assessing the prison population. Intellectual measures like the WAIS-IV are often insensitive to demographic variables such as ethnicity and educational attainment [11,12]. Lower scores may be representative of factors such as low socioeconomic status and poor quality of educational experience rather than true cognitive deficits. This is likely to result in the misclassification of many prisoners based on their perceived level of intellectual ability. Important aspects of cognitive functioning that pertain to treatment may also be overshadowed by the low base rates of the prison population. For this reason, additional measures and techniques, such as performance-based measures, may be necessary to supplement the assessment of prisoners to ensure greater accuracy.
Perceptual reasoning is one important aspect of cognition that plays a critical role in problem-solving. Perceptual reasoning is generally considered to be less affected by educational experience when compared to verbal comprehension tasks [13]. Measures that assess components of perceptual ability (i.e., accuracy and complexity) may therefore offer critical information about the cognitive ability of disadvantaged populations, such as offenders. The Rorschach is a behavioral problem-solving task in which respondents must use reasoning and problem-solving skills to make sense of the perceptual regularities and irregularities found in inkblots. In creating a response to the ambiguous and complex stimuli, respondents must utilize their internal cognitions and underlying schema. According to Perry, Viglione, and Braff, this makes the Rorschach a good technique for assessing thought disorder, psychological complexity when problem-solving, and interpersonal understanding of human representations [14].
The Rorschach includes several scales that incorporate cognitive functional abilities. The complexity scale from the Rorschach Performance Assessment System (R-PAS), for instance, provides information regarding a person’s cognitive capacity for problem-solving and organizing his or her environment. Responses that integrate different locations and have multiple descriptive variables result in higher complexity scores. The form quality scale represents adaptive functioning in how the individual interprets or organizes external stimuli from the environment. In a sense, this scale allows researchers to examine how an individual organizes ambiguous information into some type of order. Creating some type of order when information is random and disparate is important for successful problem-solving. According to Frank, form quality may also reflect an individual’s “capacity for better functioning in the world” [15]. Together, these scales may provide a key interpretation of the functioning of a person in his or her environment, as well as the ability to approach a situation that is unfamiliar, organize it, and respond cohesively. In this manner, performance-based measures, such as the Rorschach, tap into crucial components of cognitive style, or rather the preferred way in which an individual processes information.
Statement of the Problem
Current cognitive assessment of the prison population is hindered by a variety of factors, including test bias of intellectual measures, subcultural components of the prison environment that influence performance, and the underrepresentation of prisoner normative data on the standard measures used. The Rorschach, however, may offer a unique opportunity to enhance the assessment of intellectual and cognitive ability specific to the prison population. Contemporary intelligence tests appear to be better indicators of socioeconomic status and education, thus giving clinicians information on the limitations or relative cognitive strengths of their patients. These measures, however, do not provide a window into how a subject processes stimulus. The Rorschach demonstrates where the perceptual processing problems are located and indicates how faulty processing may lead to problematic thinking and judgment. In other words, intelligence tests indicate the result of cognitive processes whereas the Rorschach demonstrates the underlying cognitive processes that (in combination with other factors such as education and socioeconomic status) result in the IQ test scores a person ultimately obtains. Thus, the Rorschach may potentially give unique information to provide better intervention strategies and treatment that will address patients’ specific needs, because focus can be brought to specific cognitive processes that need to be modified if people are to make better intellectual analyses and decisions. However, limited empirical support, especially in relation to the prison population, exists to support this claim. While perceptual accuracy appears to play an important role in the development and maintenance of cognitive distortions, it remains unclear as to how perceptual problems specifically relate to social functioning and criminal behavior.
While the prison population and recidivism rates remain high, it is necessary to understand how problems with social and cognitive functioning may result in criminal behavior for some individuals. The present study was designed to address two specific goals. The first was to uncover how intellectual ability relates to performance within the cognitive domains of the Rorschach (i.e., perceptual accuracy, thought complexity, and thought disturbance). The second goal was to investigate how perceptual inaccuracy relates to problems with social functioning or criminal behavior. The current study was guided by a quantitative design in which the researcher examined archival data from two assessment sites. In doing so, the researcher compared the intellectual functioning, perceptual accuracy, thought complexity, and thought disturbance of adult male prisoners from a California prison for men to those of an adult male sample from an outpatient clinic. Each participant previously had been administered a neuropsychological battery that included the WAIS-IV, Rorschach (using the R-PAS scoring method), and the Personality Assessment Inventory (PAI) or the Minnesota Multiphasic Personality Inventory-2 (MMPI-2). These measures were used separately to determine overall intellectual abilities (WAIS-IV FSIQ, VCI, PRI, WMI, PSI), perceptual reasoning (WAIS-IV PRI), perceptual accuracy (R-PAS FQo%, FQu%, FQ-%, WD-%), perceptual complexity (R-PAS Complexity and F%), and thought disturbance (R-PAS WSumCog, TP-Comp, EII-3).
This study offers several important implications for clinical practice. Determining whether the Rorschach cognitive variables correlated with other neuropsychological measures was designed to support its utility to enhance the understanding of a patient’s cognitive style. As measures such as the WAIS-IV may be limited in terms of assessing certain populations, the Rorschach may help to correctly classify individuals with poor intellectual functioning specific to problems with perceptual accuracy or complexity. Furthermore, by uncovering the relationship between perceptual accuracy and problems with social functioning, clinicians in correctional settings can better address the specific needs of their patients.
The present study
While it appears that perceptual accuracy may relate to adaptive functioning, it is unclear whether severe deficits lead to more problem behaviors, including criminal activity. The present study was designed to address two specific goals. The first was to uncover how the Rorschach variables of form quality, complexity, and thought disturbance underlie the cognitive processes that influence IQ score as measured by the WAIS-IV. The second goal was to investigate how perceptual accuracy, thought complexity, and thought disturbance scores relate to problems with social functioning or criminal behavior. The current quantitative study involved an examination of archival data from two assessment sites to observe differences between the intellectual functioning, perceptual accuracy, and thought complexity of adult male prisoners compared to a normal sample. Data from adult male inmates from the men’s prison and adult male clients from the outpatient clinic were used. Each participant previously had been administered a psychodiagnostic battery that included the WAIS-IV, Rorschach (using the R-PAS scoring method), and the PAI or MMPI- 2. The study involved exploring the relationship between Rorschach cognitive variables (perceptual accuracy, thought complexity, and thought disturbance) and intellectual/perceptual ability as measured by the WAIS-IV. In addition, it involved an examination of differences between the two samples on R-PAS performance, as well as differences that existed within the incarcerated sample by designated level of care.
Null hypotheses
Five hypotheses (stated in null form) were determined based on the findings from the literature:
A. Hypothesis 1: There will be no significant difference between participants’ performance on Rorschach cognitive variables (form quality, thought complexity, and thought disturbance scores) based on intellectual ability.
B. Hypothesis 2: There will be no significant difference between participants’ performance on Rorschach cognitive variables (form quality, thought complexity, and thought disturbance scores) based on perceptual ability (PRI).
C. Hypothesis 3: There will be no significant difference in R-PAS variables (form quality, thought complexity, and thought disturbance) between offenders and outpatient subjects.
D. Hypothesis 4: There will be no significant difference in R-PAS variables (form quality, thought complexity, and thought disturbance) between varying degrees of institutional care level for offenders (GOB, CCCSM, MHCB).
E. Hypothesis 5: There will be no significant interaction effect between incarceration status and level of cognitive functioning on R-PAS variables.
Considering that the Rorschach variables of form quality, thought complexity, and thought disturbance have demonstrated some relation to intellectual ability, it was expected that participants with lower FSIQ and PRI scores would show greater impairment levels on these Rorschach variables. Furthermore, as problems with perceptual accuracy, thought complexity, and thought disturbance have been demonstrated to be related to psychopathology, learning disabilities, and poor social functioning, it was expected that offenders would demonstrate greater problems on these variables when compared to an outpatient sample.
Methods
Participants
A purposeful and convenient sample was collected using archival data from the men’s prison in California, and from the outpatient clinic in California. The archival data from the prison consisted of previously collected test batteries that were administered by psychodiagnostic practicum students with adult male offenders who were referred for psychodiagnostic assessment. Archival data from the outpatient clinic consisted of previously obtained test batteries also administered by psychodiagnostic practicum students with adult males (>18 years) who were referred for psychodiagnostic or neuroeducational assessment. All testing completed from both sites was supervised by a licensed psychologist. Only complete batteries were considered for the current study. A complete battery consisted of a WAIS-IV, PAI or MMPI-2, and a Rorschach using the R-PAS scoring system. Data from participants were excluded if the presence of a previously diagnosed brain injury, psychotic disorder, or dementia was indicated in their case file. Data collected from the outpatient clinic were also excluded for those participants with a reported history of arrest. Test validity of the remaining participants was then screened using the validity scales of either the PAI or MMPI-2. Only those participants with valid profiles were used for this study, resulting in 36 participants from the CIM and 43 from AUTAPS for a total of 79 participants.
The mean subject age of the inmate sample (n = 36) was 44.33 (SD = 14.48) years. The mean subject age of the outpatient sample (n = 43) was 28.51 (SD = 9.95) years. Education for the entire sample (N = 79) ranged from 6-22 years. The mean education level for the inmate sample was 11.64 (SD = 2.53) years, while the mean education level for the outpatient sample was 14.16 (SD = 2.71) years. Ethnic background for the sample demonstrated a diverse pool with 54.5% identifying as White, 15% as Latino, 4% as African American, 4% as Asian, 2% as Native American, 5% as multiracial, and 1% as another ethnic background.
Measures
Wechsler adult intelligence scale-IV: The Wechsler Adult Intelligence Scale-IV (WAIS-IV [7]) was used to provide a measure of general intellectual functioning and perceptual reasoning ability. The WAIS is a well-established scale with high consistency. According to the test manual, over a 2-12-week time period, test– retest reliabilities ranged from 0.70 (seven subscales) to 0.90 (two subscales). Inter-rater coefficients were high, all being above 0.90. The WAIS-IV is also correlated highly with the Stanford-Binet IV test (0.88).
Rorschach inkblot technique: The Rorschach was used to assess perceptual accuracy, complexity of thought processes, and thought disturbance using the R-PAS scoring system [16]. The R-PAS scoring system was normalized using an international reference sample of 640 individuals. About one fifth came from the United States and about two thirds from nine European countries. Validity was established by correlating the scales with other known measures. For instance, Weiner found an effect size “almost identical” to the MMPI [17]. Viglione and Taylor demonstrated a strong inter-rater reliability between 85% and 99% [18]. Exner (as cited in Groth-Marnat) reported test–retest reliabilities from 26-92 over a 1-year interval considering 41 variables [19].
Several specific R-PAS variables were used in this study to investigate perception and thinking domains. Form quality (FQ) is designed to measure the accuracy of the forms involved in a response; in other words, how well a response fits the blot contours at the location on the card. As such, form quality percentages (FQ-%, WD-%, FQo%, and FQu%) generally measure the conventionality of perception and reality testing. FQ-% is a measure of distortion or misinterpretation, often leading to poor judgments or unconventional behavior. WD-% more specifically indicates whether distortion or misinterpretation occurs even in perceptual situations that are more commonly selected. FQo% is a measure of conventional judgment, while FQu% measures unconventional and individualistic ways of interpreting the world. Additional cognitive variables were used that are generally associated with thought complexity and thought disturbance. Complexity is a variable that measures differentiation, integration, and productivity at the response level. It is derived from the sophistication of location, space, and object qualities within one’s response. The Form % variable relates to the proportion of pure form responses in a record and is generally considered to be the opposite of the Complexity variable (i.e., simplicity). The Ego Impairment Index-3 (EII-3) is a broad measure of thinking disturbance with the components of reality testing, thought disturbance, crude and disturbing thought content, and measures of interpersonal misunderstanding and disturbance. The Thought & Perception Composite (TP-Comp) assesses reality testing and thought disorganization. Finally, the Weighted Sum of the Six Cognitive Codes (WSumCog) is a measure of disturbed and disordered thought. Procedures.
Archival data collected from CIM involved the testing of offenders who had been referred for psychodiagnostic evaluation. At the time of testing, subjects were provided an informed consent that explained their rights to confidentiality along with the process of neuropsychological evaluation. Subjects were then administered a battery that minimally included the WAIS-IV, the Rorschach (using the R-PAS scoring system), and the PAI or MMPI-2. The batteries were administered by psychodiagnostic practicum students who were supervised by a licensed psychologist. Once the testing had been completed, subjects were provided with a feedback session to discuss the findings of the evaluation.
Archival data collected from the AUTAPS clinic involved the testing of adult males who had been referred for psychodiagnostic or neuroeducational evaluation. At the time of testing, subjects were also provided with an informed consent that explained their rights to confidentiality and the process of neuropsychological evaluation. Subjects were then administered a battery that also minimally included the WAIS-IV, the Rorschach (using the R-PAS scoring system), and the PAI or MMPI-2. Once the testing had been completed, subjects were provided with a feedback session to discuss the findings of the evaluation.
For the purpose of this study, the researcher reviewed all available psychological assessments completed by psychodiagnostic practicum students from both the CIM and AUTAPS locations that met the inclusion criteria. All psychological test data and reports were kept confidential in a locked file cabinet in the corresponding office of each assessment program’s supervisor. Archival data and specific test score data were put into a spreadsheet with an ID number, so all assessment data were de-identified and aggregated. All the information was stored on a password-protected computer to which only the researcher and his supervisor had access. Demographic information such as age, race, and education level were accumulated into a spreadsheet format along with the prevalence and incidence rates of all other relevant variables. Any information that could identify the subjects was excluded from the data collection, including name, inmate number, date of birth, place of origin/crime, and any unique developmental/life characteristics or experiences.
Case information from the prison was then grouped according to level of care: general prison population (GOP), clinical care case management system (CCCMS), and mental health crisis bed (MHCB). Data from the outpatient clinic participants were grouped as the outpatient sample. From the WAIS-IV, the FSIQ, VCI, PRI, WMI, and PSI were recorded to account for the individual’s intellectual and perceptual ability. Scores were then grouped into seven categories according to the classification descriptions of the WAISIV: Extremely Low, Borderline, Low Average, Average, High Average, Superior, and Very Superior. From the R-PAS, variables that account for perceptual accuracy (FQ-%, WD-%, FQo%, and FQu%), thought complexity (Complexity, F%), and thought disturbance (WSumCog, TP-Comp, and EII-3) were recorded. Adjusted R-PAS scores using the R-Optimized administration were recorded and assessed for the purpose of this study.
Results
Statistical analysis was conducted using the SPSS software package. Descriptive statistics were computed for all demographic variables. Comparisons between age, education, and the two IQ score measures (Full Scale IQ Score and Perceptual Reasoning Index) based on incarceration status were examined using independent samples t tests. The results are reported below, and the means and standard deviations are presented in Table 1. Relationships between subjects’ R-PAS performance on perceptual accuracy (FQ-%, WD- %, FQo%, and FQu%), thought complexity (Complexity, F%), and thought disturbance (WSumCog, TP-Comp, and EII-3) and variables of level of care, incarceration status, cognitive functioning, and perceptual reasoning were analyzed using multivariate analyses of variance (MANOVAs). Follow-up analyses using age and education as covariates were also conducted.
Independent samples T tests
An independent-samples T test was conducted to compare age differences between the samples of outpatient and inmate subjects. The incarcerated sample was found to be significantly older than the outpatient sample; t (60.253) = -5.549, p = .000. The means and standard deviations are reported in Table 1.
An independent-samples T test was conducted to compare differences in level of education between the samples of outpatient and inmate subjects. The outpatient sample was found to have a significantly higher level of education compared to the inmate sample; t (77) = -4.250, p = .000. The means and standard deviations are reported in Table 1.
An independent-samples T test was conducted to compare differences in FSIQ scores between the sample of outpatient and inmate subjects. The outpatient sample was found to have significantly higher FSIQ scores compared to the inmate sample; t (77) = 3.293, p = .001. The means and standard deviations are reported in Table 1.
An independent-samples T test was conducted to compare differences in PRI scores between the sample of outpatient and inmate subjects. The outpatient sample was found to have significantly higher PRI scores compared to the inmate sample; t (77) = 2.726, p = .008. The means and standard deviations are reported in Table 1.
An independent-samples T test was conducted to compare differences in VCI scores between the sample of outpatient and inmate subjects. The outpatient sample was found to have significantly higher VCI scores compared to the inmate sample; t (77) = 4.201, p < .001. The means and standard deviations are reported in Table 1.
An independent-samples T test was conducted to compare differences in WMI scores between the sample of outpatient and inmate subjects. The outpatient sample was found to have significantly higher WMI scores compared to the inmate sample; t (77) = 3.531, p = .001. The means and standard deviations are reported in Table 1.
An independent-samples t test was conducted to compare differences in PSI scores between the sample of outpatient and inmate subjects. No significant difference was observed. The means and standard deviations are reported in Table 1.
Multivariate analysis of variance of effects of FSIQ on R-PAS variables
A MANOVA was used to examine form quality (FQ-%, WD-%, FQo%, and FQu%), thought complexity (Complexity, F%), and thought disturbance (WSumCog, TP-Comp, and EII-3) as dependent variables (DVs), and FSIQ score (Extremely Low, Borderline, Low Average, Average, High Average, Superior, and Very Superior) as the independent variable (IV). The multivariate analysis showed a multivariate effect for intellectual functioning, Wilk’s Lambda = .212, F (54,330.931) = 2.179, p < .001, indicating a difference in form quality and thought complexity among the different levels of intellectual functioning. Thus, Hypothesis 1, which was that there would be no significant difference in the R-PAS variables based on intellectual ability (FSIQ), was rejected.
Because the overall MANOVA was significant, univariate ANOVAs were conducted to determine which specific dependent variables showed differences among the different levels of intellectual functioning using FSIQ. The univariate F tests showed there were significant differences among the levels of intellectual functioning on Complexity scores, F = 6.674, df = (6,72), p < .001; F% scores, F = 3.699, df = (6,72), p = .003; and WSumCog scores, F=3.698, df =(6,72), p = .003. FQ-% scores approached conventional levels of statistical significance, F = 1.484, df = (6,72), p = .196, while the remaining variables were found to be not significant. A follow-up analysis using age and education as covariates resulted in similar findings.
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