Psychoanalytic Perspectives on the Rorschach

Paul M. Lerner

• Publisher: Routledge
• Year: 2013
• Print ISBN: 9780881632347
• eBook ISBN: 9781135828998
• Topic: Psychology
• Subtopic: Applied Psychology
• Index: Psychology

Few books illuminate a domain of clinical inquiry as superbly as Psychoanalytic Perspectives on the Rorschach. Paul Lerner has written a comprehensive text that offers a richly detailed, multidimensional vision of the Rorschach as the ideal medium for operationalizing, testing, and in some instances transforming contemporary clinical theory.

For psychoanalytic therapists, the book provides a fascinating overview of how the coevolution of psychoanalytic theory and Rorschach technique has created new possibilities for conceptual integration. Lerner explores recent advances in our ability to operationalize such clinical concepts as splitting, dissociation, and false-self organization. He then reviews how these advances have been applied to research into psychic organization across different diagnostic categories, including anorexia and bulimia, aggressive and psychopathic personality, and schizotypal disorders. Finally, Lerner shows how the resulting data offer a unique vantage point from which to clarify such critical topics as developmental object relations and the structure of primitive experience.

Rorschach scholars will appreciate Lerner's informed discussions of theorists as diverse as Rapaport and Schachtel, Exner and Mayman, Schafer and Leichtman. Rorschach students, for their part, will find the book an unusually lucid introduction to test administration, scoring, interpretation, and report writing. Even here, however, Lerner's breadth and originality are apparent, for his exposition of these testing fundamentals incorporates fresh discussions of the nature of the Rorschach test, the impact of the patient-examiner relationship, and the value of the test in treatment planning. Timely, definitive, and uniquely integrative, Psychoanalytic Perspectives on the Rorschach will be valued by students, clinicians, and researchers well into the next century.

1

AN EXPERIENTIAL PSYCHOANALYTIC APPROACH

As noted in the introduction, psychoanalytic approaches to the Rorschach test are based on the pioneering work of David Rapaport. Yet, recent and significant shifts in psychoanalytic theory are leading Rorschach theorists (P. Lerner, 1992) away from Rapaport’s virtually exclusive structural approach and toward an interest in experiential factors. In this chapter, I explain and discuss what is meant by an experiential psychoanalytic approach to the Rorschach. Although the emphasis here is experiential, this is not intended as a replacement of Rapaport’s earlier structural focus. Rather, it should be regarded as an extension.

I begin by comparing psychoanalytic approaches to the Rorschach with empirical ones. Such a comparison is meant to serve two purposes. First, it is a way of introducing the reader to a way of thinking about and using the Rorschach that is based in psychoanalysis. Second, it will assist the reader in beginning to place an experiential approach within the broader scheme of Rorschach approaches in general. To locate an experiential psychoanalytic approach more finely, I then discuss the nature of psychoanalytic theory and the relationship between the theory and the Rorschach. Finally, I trace the roots of and outline a psychoanalytically based experiential Rorschach approach.

♦ ♦ ♦ Two Approaches to the Rorschach

The past two decades have witnessed an unparalleled interest in the Rorschach as a means of studying and understanding people. Two streams have contributed to this renewal of interest: an empirical one exemplified by the work of Exner (1974, 1993) and his Comprehensive System, and a conceptual one exemplified in attempts to apply psychoanalytic concepts and formulations to Rorschach theory (Leichtman, 1996) and interpretation (P. Lerner, 1991a).

Despite creative and relatively successful attempts to integrate these streams (Erdberg, 1993; Weiner, 1994; Kleiger, in press), the approaches are markedly different. Basic ways in which they differ include the following: (1) primary emphasis, including the role and value accorded the person of the examiner; (2) accepted sources of Rorschach data; (3) the importance of a testing rationale; (4) the issue of a test battery; and (5) the role accorded a theory of personality that is independent of the test itself.

Clinical Versus Psychometric Emphasis

Implicit in an empirical approach to the Rorschach is a primary psychometric orientation. It is the test that occupies center stage, issues of test reliability and validity are of paramount concern, the process is conceived of as one of measuring, and the examiner’s essential task is to administer the test in the most unobtrusive and standardized way possible.

In contrast to a psychometric orientation, a psychoanalytic approach has a clinical orientation. Here, one is assessing, not measuring; the patient, rather than the test, is regarded as the centerpiece; and the assessment is conducted in a manner and style consistent with clinical purposes.

From a clinical perspective, the ultimate purpose of an assessment is not the achieving of a diagnosis and the assigning of a diagnostic label. Instead, one attempts to understand the testee in his or her totality, complexity, and uniqueness, and then use that understanding as a basis for making decisions and suggesting interventions that will be beneficial to that individual.

A clinical emphasis is especially reflected in the requisite capacities expected of the examiner and the expanded role and weighty responsibilities assigned to him or her. As with every clinical encounter with a patient, Rorschach testing requires that the examiner be sensitive, accepting, and nonjudgmental, and empathically attuned to the emotional nuances of the relationship. If, for example, a patient’s heightened anxiety is creating undo distress and is interfering with his or her capacity to engage in the testing, then it is incumbent upon the examiner to deal with the distress and not insensitively push forward with the testing.

The clinical examiner, too, values standardized test administration; however, such adherence is balanced with tact, a sense of appropriateness, clinical judgment, and one’s meaning-seeking orientation. For example, there are occasions when the examiner will depart from standardized test procedures. Slightly revising the precise wording of instructions, determining the patient’s attitude toward an unusual response, or pursuing the meaning of an especially jarring response are three such instances. When the examiner does depart from standard procedures, the reason prompting the departure and its effect on subsequent responses need to be understood and taken into account.

The questions the examiner puts to himself or herself are, in Mayman’s (1964a) terms, “person centered,” not “test centered,” and reflect his or her meaning-seeking stance. For example, rather than asking “Is this a schizophrenic sign?” or “How many texture responses are there?” one asks instead, “What use did the patient make of me in our testing encounter?” and “Is he or she likely to engage a therapist in a similar way?”

In clinical testing, then, the examiner is seen as vitally intrinsic to the process, and the role accorded is far broader and less prescribed. Underlying these differences in role and way of functioning, are contrasting attitudes toward the examiner. In psychometric testing, the examiner, like the research investigator, is seen as a potential source of bias and error. Efforts are made to minimize, if not altogether, eliminate his or her influence. Then too, little attention is paid to the transactions that occur between examiner and patient. In clinical testing, by contrast, the examiner is valued and trusted. He or she is regarded as a reliable and unique source of information. The variety of interactional reactions that inevitably and necessarily arise in the patient-examiner relationship are not avoided or disregarded. To the contrary, such reactions are observed, recorded, and then used as indispensable aids in bringing greater clarity and meaning to the patient’s behavior and attitudes.

Sources of Information

A second difference between the two approaches involves sources of information. In general, those who approach the Rorschach from an empirical perspective tend to rely on one source—the scores and their interrelationships. For instance, even though Exner’s Comprehensive system admits to three sources—the structural summary, the sequence of scores, and the patient’s verbalizations—in reviewing illustrative case material, it is clear that the structural summary is the heart and soul of the system and that the other sources serve to refine and extend inferences derived from the summary.

The psychoanalytically oriented examiner recognizes that test scores and quantitative summaries are important, but that certain facets of the individual’s experience are expressed on the Rorschach in ways not reflected by the scores. The psychoanalytic perspective, then, provides a number of sources of information about the patient that can serve as a springboard for developing clinical inferences. These include (1) the formal aspects of test responses, including test scores and their interrelations; (2) the content of the testee’s specific responses, including his or her attitude toward the response; (3) the sequence of responses; (4) the patient’s behavior in the assessment, including more spontaneous and offhand comments; and (5) the nature and vicissitudes of the patient-examiner relationship.

With respect to these various sources, the psychoanalytic examiner’s task is to attend to each of these sources and to integrate the data of one with that of another. Each source must be given its due and be seen as having its own consistency with the other types of information. The art of psychological testing, as Schlesinger (1973) noted, consists of sensitively shifting attention from one to another of these sources, while developing and checking inferences throughout the assessment.

With respect to the empirical and psychoanalytic approaches to sources of information, there are two provisions to be added. First, with the movement toward integration has come a greater appreciation of the other approach’s contribution. For example, those with an empirical bent (Exner, 1996) have begun to consider more seriously the inferential value of Rorschach content. At the same time, psychoanalytic examiners are coming to realize that more can be gleaned from a careful appraisal of the formal scores than they had allowed.

Second, beginning with Rorschach himself, a distinction has been drawn between the formal and structural features of a record and the substantative or content aspects. Some (Aronow, Reznikoff, and Moreland, 1995) have tended to associate the psychoanalytic approach with a primary if not exclusive concern with content. As I have indicated above, both historically and presently, this is not the case. Although several psychoanalytic theorists (P. Lerner, 1991b; Mayman, 1977) have suggested approaches to content that are thoughtful and systematic, this has not been to the exclusion or devaluation of structural features. Rapaport and those following in his tradition have insisted on complete and accurate scoring, together with a careful consideration of quantitative summaries.

Testing Rationale

The legitimacy of the Rorschach as a clinical diagnostic technique rests upon building bridges between test responses on the one hand, and personality, behavior, and the dynamic underpinnings of personality on the other hand.

Such connecting bridges, depending upon one’s Rorschach orientation, have been based upon empirical findings, theory, or a combination of both. Empirically based approaches, as to be expected and in keeping with their psychometric focus, have established such links primarily on the basis of empirical findings. Assumed relationships between particular scores or combinations of scores and specific character traits have been subjected to more rigorous scientific investigation. As a result, what at one time was considered Rorschach lore is now a sound body of knowledge, which furnishes a sturdy basis for Rorschach interpretation.

Psychoanalytic theorists have taken a different route, a more the oretical or conceptual one, in which emphasis is placed on identifying mediating processes that connect test responses with personality structure and functioning. Representative of this approach is the work of Rapaport (Rapaport, Gill, and Schafer, 1945-1946). For Rapaport, the construct “thought processes” served this mediating function. It was from the organization of thought, including such subprocesses as concept formation, anticipation, memory, judgment, attention, and concentration, that he derived inferences related to other aspects of personality functioning.

This conceptualization of thinking as a conduit to personality structure and functioning, and of the inferential power of assessing thought processes, is especially well stated by Schafer (1954):

A person’s distinctive style of thinking is indicative of ingrained features of his character make up. Character is here understood as the person’s enduring modes of bringing into harmony internal demands and the press of external events; in other words, it refers to relatively constant adjustment efforts in the face of problem situations. The modes of achieving this harmony are understood to consist essentially of reliance on particular mechanisms of defense and related responsiveness to stimulation associated with these defenses [p. 17].

Rapaport did something else too. In addition to explaining how and why personality structure is reflected in Rorschach responses, he also established a rationale as to why psychological testing should be included in psychiatric examinations. Although offered almost 50 years ago (Rapaport, 1950), his argument is still as relevant and cogent today.

Rapaport (1950) began by noting that psychiatry, like other clinical disciplines, requires objectivity. That is, it requires procedures to complement its methods, which tend to be subjective and judgmental. For sources of information, psychiatrists rely on case histories and psychiatric examinations. Material gained from each, however, is manifold and requires selectivity. In taking a case history, the clinician must not only organize the data, but must also subjectively select those aspects thought to be most relevant. In providing a case history the patient, the informant, or both also introduce selective factors: an unconscious one, rooted in the organization of their memories; an involuntary one, rooted in the limitations of their knowledge; and a deliberate one, rooted partly in judgments based on their attitudes and partly in intentions to conceal. As a consequence, different case histories are likely to contain different categories of data. This means that no point-to-point comparison is possible between case histories. Furthermore, because one cannot quantify the data, organizing the material into a meaningful whole, so as to yield a diagnosis and treatment plan, also involves subjective judgment and selection.

By comparison with information elicited in a case history, psychological test responses are limited segments of behavior. Such behavior segments can be recorded relatively completely. In this regard, they are more objective.

The same categories of behavior of reaction are obtained from all individuals. Therefore, a second advantage of testing involves being able to make comparisons between recorded data. Comparisons are made interindividually and intraindividually—one compares both differences in performance between individuals and different aspects of a single individual’s performance.

A core assumption to psychological testing is that every behavior segment bears the imprint of the organization of the behaving personality and, if properly chosen, permits a reconstruction of that personality. To be revealing of personality, the behavior segment must meet certain criteria: its meaning is unknown to, and not consciously manipulatable by, the subject, and the stimulus is unstructured enough so as to allow expression of the internal structuring principles of the individual. A relative lack of structure or multiple possibilities for structuring permit and encourage an expression of intrapsychic choices.

For Rapaport, then, psychiatric investigation constructs personality structure from observed or reported behavior, while psychological testing does so from the organization of thought as expressed in and inferred from psychological tests. The use of thought processes in this inferential way is predicated on the formulation that the development of thought organization is an integral part of and reflects the development of personality organization.

The Test Battery

The question of whether the Rorschach should be used as the sole assessment method or should rather be included as part of a test battery has interested both psychoanalytic and empirical writers. Exner (1993), from an empirical perspective, suggests an open-minded, flexible position. He argues that such a decision should be based on the nature of the referral question and practical considerations such as time and expense. His review of the literature yields mixed findings and different opinions. Those who challenge the use of a battery (Sarbin, 1943; Kelly and Fiske, 1950; Gage, 1953; Kostlan, 1954; Giedt, 1955) report that testers often do not use all the data, assign different weight to different pieces of data, and tend to reach a ceiling of predictive accuracy quickly. Others have found that a test battery does work well in the clinical situation (Vernon, 1950; MacKinnon, 1951; Luborsky and Holt, 1957; Holt, 1958). These authors report that validity is increased as data is added. Exner also argues against the use of a standard battery, suggesting instead that different referral questions may be best addressed with a different composite of tests. Approaching the issue from a very different vantage point, psychoanalytic examiners insist upon using a test battery, usually a standard one, as opposed to relying exclusively on one test. The importance they assign to a test battery comes directly from Rapaport’s formulations regarding the concepts of projection and levels of structure.

Historically, there has been a tendency to distinguish between projective and nonprojective tests. Accordingly, with nonprojective tests the questions asked (i.e., “At what temperature does water boil?”) have a single, verifiable answer, and the tasks required, such as copying a design with blocks, have a confirmable solution. In projective tests, by contrast, there is no single, verifiable correct response. Instead, the individual’s response is based on intrapsychic determinants and not on an external criterion of validity. Rapaport (1950) points out, however, that such a sharp distinction does not exist. Projective tests, he notes, also elicit responses that approach objective verifiability (i.e., popular responses on the Rorschach), and nonprojective tests do permit expressions of projective material. Indeed, Rapaport (1950) himself writes, “all the nonpro...

Table of contents

• Cover
• Halftitle
• Title
• Copyright
• Dedication
• Contents
• Introduction
• Part 1 Clinical Applications
• Part 2 Research Applications
• References
• Index