Measures

All Rorschach systems use the same set of 10 inkblot stimuli originally created by Rorschach (43), in which examinees are invited to look at each inkblot and say what it looks like or what it might be, giving one or more responses per inkblot. The Rorschach Comprehensive System [CS; (44)] we used in our study includes the CS suicide constellation “S-Con” (23), on which we focused our study, is an index composed by the number of variables exceeding (or being comprised within) specific threshold values, among a set of 12 variables (Sum VF + FD > 2; C-S Bl >0; Ego > 0.31>0,44; MOR > 3; Zd> ± 3,5; es>EA; CF + C > FC; X+% < 70; S < 3; P < 3 >8; Pure H < 2; R < 17); a value equal or > 8 in S-Con is considered as a cut-off sensitive in detecting people with significant suicidal ideations on the basis of empirical findings. Hence, it is suggested that the protocol of any person reaching the S-Con cut-off must be taken very seriously [for further details see (45–47)]. Namely, according to Mihura et al.' recent seminal review, the interpretation of each S-con variable can be synthetized as follows: high Vista and Dimension responses (Sum V + FD), which stand for depth perceived by gradations of dark and light or by shape, reflect negative self-perception, feelings of discomfort, jointly with personal introspection; high color over form responses (FC < CF+C) reflect self-control failure by an external or internal stimulation, placed by an exaggerated emotional reaction; High color shading blends (C-S Bl), which stands for color and its shading as seen simultaneously, reflects simultaneous experiencing joy and pain; Low Conventional Ordinary Form Quality (low X+%), which stands for low number of conventional perceptions of blot areas, reflects abnormal ability to perceive the world as others do, and maybe impaired reality testing; very high or very low Ego Index, which is a composite measure based on the number of reflections and pairs of objects, may be associated with an impaired ego organization and a capacity to meet internal and external demands and stressors: the Ego index can be either narcissistic or distress related (when high) or related to a negative self-image (when low); high white responses (S), provided when white background space is used in the response, reflects oppositional tendencies, and feelings of anger and aggression; High responses with damaged, dysphoric or morbid content (MOR) reflect morbid imagery and are associated with depressive and/or destructive thoughts or feelings; low or high Popular responses (P; i.e., the 13 most statistically common objects reported by at least one third of the normative sample) reflect, when low, unusual and, when high, stereotyped perceptions of reality; high or low scores in the processing efficiency (Zd), reflects, respectively excessive or impaired information processing or accounting; a low number of Images of whole, realistic human figures (Pure H), reflects an impaired perception of Self and others viewed as whole; Experienced Stimulation greater than Experience Actual (es > EA) reflects the current level of coping abilities in terms of experiencing more stress than what can be handled; finally a low number of total responses given to the whole protocol (R) reflects a limited ability to provide ideas, or solutions to a given issue.

Further four variables were considered in our analysis: the number of Human Movements (M), which reflect, respectively mental abilities (i.e., planning, empathic behaviors); moreover, since impaired reality testing and illogical combination of ideas can occur in loss and dysphoria, we grouped indices reflecting more serious forms of cognitive disarray (i.e., incongruous combination, INCOM level 2 + Fabulized combination, FABCOM level 2 + Contamination, CONTAM); finally, we considered poor Human Representation (poor H), i.e., Human or quasi-human images that are illogical, aggressive, damaged, or poorly formed, as they reflect disturbed and maladaptive understanding of others.

The BDI (36) is one of the most widely used self-report inventory for measuring the severity of depression. It consists of 21 item on a 4-points Likert scale in which a score of 0 corresponds to “I don't have any thoughts of killing myself,” 1 corresponds to “I have thoughts of killing myself, but I would not carry them out,” 2 corresponds to “ I would like to kill myself” and 3 corresponds to “I would kill myself if I had the chance.”