Blatt 1975
Blatt 1975
To cite this article: Sidney J. Blatt (1975) The Validity of Projective Techniques and Their Research
and Clinical Contribution, Journal of Personality Assessment, 39:4, 327-343, DOI: 10.1207/
s15327752jpa3904_1
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Journal of Personality Assessment, 1975,39, 4
did not relate significantly to any of the based on the assumption that nosological
conventional Rorschach categories such categories have a consistent conceptual
as M, ZC, m, F+%, W%, etc. Only one base which can lead to reliable differenti-
significant correlation (.24, p < .05) was ations. Most studies, however, never indi-
found and that was between problem- cate how the nosological distinctions
solving efficiency and Animal percent. If were made, or even how the concepts
the Rorschach had been used in a general were defined. One rarely knows in re-
way to explore dimensions related to search reports, for example, how schizo-
cognitive efficiency, the results with the phrenia was defined and whether it was
traditional Rorschach scoring categories differentiated from other psychotic
(either individually or in a configurational states. This issue becomes all the more
analysis) would have indicated that the critical when one considers the frequent
Rorschach contributes little to the under- disagreements about nosological distinc-
standing of cognitive efficiency. Yet a tions even within a single clinical setting.
highly significant correlation was ob- Even if there were agreement about the
tained (.46, p < .001) between problem- definition of the various nosological
solving efficiency and the capacity to groups, these criteria can be applied with
integrate drive-laden and nonlogical varying degrees of precision. It is unusual
thinking into more realistic and under- for a research report to specify the degree
standable responses. The psychological of reliability of the nosological distinc-
implications of this finding are discussed tions and whether the diagnostic classifi-
elsewhere (Blatt, Allison, & Feirstein, cation was a tentative admitting diagnosis
1969), and the results are presented here made by a first year trainee or resident
to illustrate that the Rorschach can be a after a brief interview, an administrative
valuable research instrument if it is not diagnosis made to keep a particular
used in a mechanical fashion, but rather is patient from being discharged, or a con-
used to evaluate psychological processes sidered opinion of a diagnostic council
with the differentiations, qualifications, after weeks of intensive observation and
and integrations that are made in the study. The number of studies which
clinical application of the Rorschach. In attempt to compare schfzoghmnics, neu-
evaluating research with the Rorschach rotics, character disorders, organics, hos-
one must consider whether it was used pital staff, and college sophamores is by
with clinical sophistication or whether it now legion. These studies persist despite
was used in a limited manner based on the fact that usudly no attention is given
only gross scoring categories. to the reliability of the criteria. Even
In addition to the manner in which the further, there is increasing awareness thsit
Rorschach is utilized in research, another current diagnostic concepts are only gross
SIDNEY J. BLATT
categories and that patients usually factors. Though we may have gained
function on several levels of psychological extensive understanding of psychological
organization which transcend any single organization and functioning from the
category. There is little wonder that Rorschach, we still may not be able to
research based on such inconsistently predict complex social behavior.
defined concepts, applied with such vary- If prediction of complex social be-
ing degrees of precision, lead to ambigu- havior is an inappropxiate criterion for
ous and contradictory findings (Blatt & validating inferences drawn from psycho-
Allison, 1968). logical tests, then what are the alterna-
A second type of criterion frequently tives? Kaplan (1964), like some other
used in research with projective tech- philosophers of science, has argued that a
niques is the prediction of behavior in a reconstructive or postdictive model can
complex social matrix. These issues were be an appropriate research methodology
discussed, in part, in a paper by Engel and for clinical research. This type of research
Blatt (Note 2). The prediction of com- model is seen frequently in longitudinal
plex social behavior such as recidivism of studies where prior observations are
a parolee or a schizophrenic, success in examined for consistent patterns which
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entiated from predictions that are made cedures. Primary reliance on the predic-
from one level of discourse to another. It tion of complex social behavior as the
would be useful to evaluate studies on the means for validating inferences about
basis of the range of levels covered in the psychological processes is generally an
design. Within level predictions, such as inappropriate criterion. The time span of
the study of the relationship between the the prediction is usudly long, the predic-
two psychological constructs of fantasies tion can extend over several levels (from
and defenses, would test the inferential the deepest fantasy to the most complex
process and theory. Predictions between behavioral level), and the direction of the
levels, such as the relationship between prediction is to a situation in which there
fantasy and overt behavior, tests whether is relatively little control over many of
within level inferences can be applied to the variables. In evaluating research on
other levels of functioning. Failure to projective techniques it is imp~rtantto
predict between levels would not have the ask whether research methodology has
same implications for the validation of been appropriate for validating inferences
clinical inferences as would failure to about psychological processes. Have the
predict within levels. projective techniques been used in ways
Prediction in research can occur from which reasonably approximate the dis-
more closed systems to more open ones tinction an experienced clinician would
or vice versa. One can, for example, try to make in evaluating the phenomepon? Are
predict complex social behavior from test the validating criteria carefay defined,
data or one can study individuals who reasonably reliable, and under sufficient
have demonstrated a particular behavior control so that extraneous and unknown
and compare their test protocols with variables have minimal influence?
appropriate control groups. The research Though projective procedures have
strategy which proceeds from open to limitations in the investigation of psycho-
more closed (or controlled) systems logical processes, they do not result in a
offers more possibility for precision Since meaningless series of random responses.
the prediction is to an experimental or They provide a reasonably consistent
test situation in which environmental sample of an individpal's perceptual and
factors can be kept relatively constant. cognitive functioning. Tho interpretation
(This is not to imply that the test or of the individual's perceptions, associ-
experimental situation is not a complex ations, integrations, and daborations to
social irlteraction, but it is much less open these relatively standard, albeit ambigu-
to extraneous factors than a normal social ous, stimuli is a complex task. But re-
context.) Generally, the type of research sponses to projective procedures may
which attempts to predict behavior in offer us the opportunity to study styles
SIDNEY J. BLATT 333
and contents of thinking and perception the interaction of various levels of drive,
which may not be readily accessible defense and adaptive functions with a
through many other observational pro-' specification of the principles which ac-
cedures. It is true that if one were simply count for these interactions. All too
to tally research findings on projective frequently psychological test reports are a
techniques, a large majority of the studies series of descriptive statements or, at
would indicate little, if any, support for best, a series of conditional statements. If
the validity of projective procedures. But testing is to make a meaningful contribu-
why has there been so much uncritical tion, we must work toward conjunctive
acceptance of the research findings? statements in our evaluations which inte-
Could it be that the same social-psycho- grate a number of observations across a
logical forces which affected the attitudes number of different inferential levels
of many psychologists toward diagnostic (Engel & Blatt, Note 2). It is insufficient,
,assessment may also be the reason for the for example, to state that a patient has
(eager and uncritical acceptance of nega- problems dealing with anger when pro-
tive research findings. Results are far voked; it becomes meaningful only when
from disheartening when they are based we can specify when, where, and in what
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(on studies in which clinically appropriate ways these difficulties are experienced.
(differentiations were related to carefully We have to try to specify, for example,
specified and well-controlled criteria. In the nature and degree of provocation that
Fact, a large proportion of these studies is needed and the likely form and inten-
offer considerable support for many of sity of the anger. We should also be able
the interpretive assumptions of projective to specify how the issues are defended
techniques. against and what happens to psychologi-
cal organization when the anger is con-
Projective Techniques tained or expressed. The purpose of this
and the Clinical Process type of assessment is to enrich and
Before discussing the possible contri- extend the understanding of a patient. It
butions of psychological testing to the should organize and integrate diverse
clinical process, it is essential to specify observations which may seem unrelated
what constitutes an adequate psychologi- or even contradictory.
cal evaluation. Diagnostic testing can be a Testing need not be done routinely
search for a diagnostic label but this, at but only when there are contradictions
best, is a limited goal. Rather, psychologi- and ambiguities or when critical decisions
cal testing should provide an assessment must be made and there is insufficient
of ego structures including an evaluation material in interviews or case material.
of the strengths and weaknesses of ego Most frequently testing is requested early
functions and an evaluation of the modes in the clinical process when the assess-
lhe individual uses to cope with intra- ment of the patient's psychological
psychic conflict and reality demands. An organization can aid in dispositional de-
adequate psychological evaluation must cisions (such as the need for therapy,
specify the nature, extent, and areas of type of thterapy or therapist, and the need
conflict and preoccupation; the hierarchi- for hospitalization in an open or closed
cal organization of defenses and their ward). Testing done early in the therapeu-
effectiveness; the adequacy of reality tic process can also offer a therapist a
testing and the modulation of affects; the formulation of the patient's assets and
capacity for and the quality of inter- pathology so that the therapist can pro-
personal relationships; and adaptive ceed with greater sensitivity and confi-
strengths and capacities. A psychological dence early in therapy. Testing can also
evaluation must be more than a simple be useful at critical moments in the
enumeration of a variety of pathological therapeutic process such as when the
processes, conflicts, symptoms, and de- patient Is being considered for discharge,
fects in ego control. It must be an transfer, termination, when the therapist
integrated and synthesized evaluation of wants to evaluate progress, or when the
TJze Validity of Projective Techniques
therapist feels confused or when therapy from subject and fear from wish in the
has reached an impasse and is no longer content of the responses. Haley, Draguns,
proceeding in a positive direction. and Phillips (1967), in their extensive
Psychological testing always occurs in review of the content dimension of the
a transactional context and the contri- Rorschach, state that there is a need to
bution of psychological assessment is begin to "search for the mediating vari-
always contingent upon the skills and ables that facilitate or inhibit the nature
talents of the various members of the and the extent of covariation between
clinical staff, upon the patient with real-life behavior and Rorschach indices.
whom they are working, and upon the Situational and contextual characteristics,
philosophy, values and attitudes of the all too often overlooked even in the
specific clinical facility. In order to better studies reviewed, will no doubt
specify some of the limitations imposed emerge as one of the constraints that
on the utilization of psychological test- affect the links between behavior and
e g , each dimension in the patient- content." Draguns, Haley, and Phillips
dagnostician-therapist-institution trans- (1968) stress the need to incorporate a
action must be considered. consideration of structural features (e.g.,
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Though there is little data available defenses and style) in the study of the
about the relative contribution of psycho- relationships between motivational states
logical evaluations with different types of as expressed in Rorschach content and
patients, it seems likely that this is an behavior. They suggest that content is
important factor. Patients actively en- always interwoven with style and struc-
gaged in a treatment process or patients ture and that these dimensions must be
who have the potential for movement are considered simultaneously in research as
likely to be those with whom psycho- they are considered in clinical practice.
logical testing can make its greatest con- Thus, another important dimension in the
tribution. Patients relatively inaccessible response process in the Rorschach is the
to treatment procedures, as they are structural or formal aspects, the stable
currently conceptualized, are likely to and persistent cognitive, perceptual styles
present clinical situations in which (e.g., Gardner, Holzman, Klein, Linton, &
psychological assessment can make only Spence, 1959; Gardner, Jackson, &
minimal contribution. Messick, 1960; Shapiro, 1965; Witkin,
A second factor in the proper utiliza- Dyk, Faterson, Goodenough, & Karp,
tion of diagnostic testing is the skill and 1962) whch express the levels and types
the level of training of the diagnostician. of personality organization. Another
The contribution of diagnostic pro- dimension of the response process is a
cedures is explicitly contingent upon the patient's reactions to his responses. The
training and sensitivity of the clinician. fear or joy of taking tests or of giving a
Interpretation of clinical procedures is particular percept is a valuable observa-
dependent on the clinician's capacity for tion which must be integrated with the
careful and thoughtful observations of a content and structure of the responses.
variety of dimensions of psychological Another, somewhat neglected source of
testing, The quality and character of the data in diagnostic testing, is the subjective
clinical transaction during diagnostic test- reactions of the clinician. The integration
ing can provide invaluable observations, of the clinician's empathy and intro-
but there are other important sources of spection with the more objective aspects
data, such as the content and the struc- of testing is essential for the multi-
ture of the patient's responses to the faceted, comprehensive and systematic
range of psychological test stimuli. The understanding of psychological processes.
content of a response, the overt as well as These five sources of data (the nature of
covert themes are a frequently used the clinical transaction, the content,
aspect of projective techiques. Content, structure and affect of the response
however, c m vary from day to day and it process, and the clinician's subjective
is often difficult to differentiate object empathic response) are all essential for a
!SIDNEY J. BLATT
comprehensive psychological evaluation. gain further understanding and insight.
13mphasis on only one or on only a few of The institutional structure - the
these sources of data ignores a host of values and attitudes of the clinical facility
vitally important observations. Finally, - also play a significant role in defining
these diverse observations must be inte- the clinical contributions of psychological
grated into a conceptualization which assessment. In some clinical settings a
specifies the principles through which brief report is the sole communication
these various dimensions are integrated in between diagnostician and therapist.
a functional organization. In part, this Therapists may only read a short sum-
integration is contingent upon having a mary paragraph at the end of a report
theory which facilitates multi-level, multi- which, on occasion, might be supple-
dimension a1 formulations (Schafer, mented by a passing remark in the hall or
11954). a casual query over coffee. Frequently,
Another factor affecting the potential the attitude that prevails in these clinical
contribution of psychological testing is settings is best expressed in the philos-
the skill and training of the person who is ophy that if test formulations agree with
going to utilize the information obtained "clinical impressions" they are accept-
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from testing. One can ask, "What is the able, but if they do not agree, ignore
contribution of psychological testing to them. Tolerance for ambiguity, however,
the clinical process?", or "How much can might permit a more differentiated con-
the clinical process or the behavior of a sideration of the patient and contradic-
particular therapist vary in light of im- tions in formulations might be reconciled
portant knowledge gained from any by considering hierarchical organization
source?" A series of interviews conducted in which the patient communicates differ-
with a group of third-year residents indi- ent qualities and issues depending on the
cated that many of the residents were level of observation. In other clinical
making minimal use of psychological test- facilities there is an equally distorted
ing and they stressed its use primarily as attitude which is expressed in the un-
am evaluation of organicity or mental critical acceptance of the scientific or
retardation. A very interesting trend, magical test findings against whilch mere
however, emerged in these interviews interviews or case history are considered
which supports the contention that the q~lite inadequate. In these settings
utilization of testing is dependent upon psychologists may foster the myth of the
the skills of the therapist. Those thwd- scientific precision of testing by stressing
year residents considered independently the quantitative dimensions of test data
by their senior faculty to be the better and by minimizing the nature of the
residents were those who reported greater inferential process.
utilization of psychological testing.' It More accurately, psychological assess-
seems reasonable to expect that more ment involves essentizlly the same proces-
experienced or talented therapists would ses of inference that s therapist utilizes in
h~ave a greater range of responses in Brriving at his formulations. The differ-
therapy and therefore be able to alter ences, however, are in the methods and
their therapeutic approach in light of procedures which permit observation at a
important knowledge gained from any variety of levels. In adldition to appreciat-
source. A request for testing can reflect a ing the quantitative and clinical aspects of
therapist's insecurity and there can be diagnostic psychological testing it is
considerable conflict and ambivalence important that psychological assessments
about seeking consultation, especially be a collaborative effort. A referral for
firom a member of another discipline. But testing should serve as a springboard for
a request for consultation can also be extensive discussions between diagnos-
based on an appreciation of the complex- tician and therapist before and following
i t y of a particular patient and a desire to testing and even much later in the thera-
l'These observations were gathered in collabora- peutic process to evaluate change and
tion w t h Dr. Carl N. Zimet. progress. In this way, the diagnostician
The Validity of Projective Techniques
may function as a consultant or super- capacity to understand and facilitate a
visor and psychological testing is no patient's capacity for communication.
longer a luxury in terms of staff time nor Clinical psychologists with the skills,
a process which can be relegated to junior knowledge, sensitivity, and interests in
staff or trainees. When one considers the helping patients, however, often make a
complexity of the transaction of psycho- sharp cleavage between their roles as
logical assessment in the clinical process diagnostician and therapist. But is diag-
(the institutional setting, the type of nosis so distinct from treatment? Certain-
patient, and the level of training and the ly the patient's relationship with the
quality of the professional relationship diagnostician is short-term and transitory
among members of the clinical staff), the as compared to the long-term and endur-
question is no longer simply whether tests ing therapeutic relationship. But in both
make a contribution or not. Rather, situations the patient comes to a mental
attempts must be made to specify the health specialist and reveals significant
parameters which affect the utilization of dimensions of himself in the hope of
knowledge in the clinical process. alleviating his suffering and of learning
If diagnostic testing is well done it not
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seated at the child's table in the waiting ance would be highly unreliable, one
room, loudly singing a repetitive, primi- could say with assurance that this child
tive chant. He was banging the tune on was not ment,ally retarded. Also, his
the table, tapping it out with his feet, and manual dexterity was good, his percep-
it seemed as if his entire body were tual motor skills were intact, as was his
involved in this rhythmic activity. His memory, and th~arewere no indications of
singing seemeld to serve as a very primitive central nervous system damage. Rather,
form of speech by which he communi- he seemed to be a seriously disturbed
cated his apprehension. When he felt autistic child who had never made the
most threatened, the chanting would in- decision that contact with people and
crease in intensity and in tempo. He did with the world was worthwhile and desir-
not speak at all and any attempts to able. He found more safety, security, and
communicate with him were ignored or satisfaction in his rhythmic singing and
met by increased singing. He was an banging.
intensely frightened, apprehensive child During the six diagnostic testing
who had or wanted little, if any, contact sessions the chdd began to relate more
with his environment. His entire organi- readily to the examiner. When taken to
zation seemed focused around the reduc- the candy closet after each hour he would
tion of his fears and apprehension, and carefully select a piece of candy for
his primitive and rhythmic singing seemed himself and then select one for the
to soothe and pacify him. If he were to diagnostician. In the last testing session
interact at all, it would be on his terms he hummed "Happy Birthday" and the
and at a pace he could tolerate. diagnostician sang the words along with
In the first two testing sessions the him. Shortly thereafter, this supposedly
diagnostician sat quietly and unobtru- inarticulate child sang the first two lines
sively on the side of the room playing of the song, words and all. Aside from its
with some material from the Merrill- rich symbolic ]meaning, the song com-
Palmer Scale. Slowly the child began to municated the very important message
move out froim his incessant chanting and that, in fact, this child could speak. As he
his scrawling with a crayon. He walked began to experience feelings of trust and
around the room, touched objects, came security, the child emerged from his
over to the diagnostician, and while look- autistic chanting and rocking to explore
ing directly into his face, touched and and experience a very limited segment of
pinched his arm and then quickly re- his environment.
turned to his drawings and humming of In the process of understanding how
nonsense syllables. Any attempts to ap- and why this chid behaves the way he
proach him directly were met by an does, the diagnostician and the patient
The Validity of Projective Techniques
shared poignant moments and one might degree of their relevance, the posture
say, that in the sharing of these poignant taken by tlhe diagnostician toward this
moments., psychotherapy had begun. The material can influence the patient's
initial contacts in the diagnostic relation- expectations of what might be encount-
ship devoted to an appraisal of the ered in other aspects of the clinical
problem have blended into therapy and context. If the diagnostician is distant,
the diagnostician could either continue seemingly disinterested in the material, or
with the child, or gradually make the only interested in recording and observ-
transition to another person who would ing, the patient may see this reaction as
function as the therapist. The gains made typical of ]many clinical interactions. If
early in the diagnostic relationship, how- the diagnostician attempts to minimize,
ever, would serve as a major impetus for avoid, or reassure the patient about dis-
the psychotherapeutic process, if the turbing material, he suggests a model
transition were skillfully handled. which encourages the avoidance or sup-
In reviewing the diagnostic evaluation pression of painful and disruptive
process with this child, it seems that thoughts and affects rather than actively
diagnostic testing could facilitate treat- encouraging the patient to recognize, to
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ment not only by presenting the therapist understand, and to cope with this ma-
with the analysis of test responses, but terial. If the diagnostician, on the other
also by having a direct and highly signifi- hand, communicates explicitly and
cant effect of facilitating communication implicitly to the patient an interest in the
with the patient. One can argue that this patient's thoughts and feelings because
is a dramatic case or that there is less they are direct and significant communi-
differentiation between therapy and cations, the patient may expect similar
diagnosis with children than with adults, reactions from other members of the
but the diagnostician and the patient, in clinical staff. The patient can begin to
any diagpostic situation, share poignant share the clinician's attempts to recognize
and sensitive material and the diagnos- and understand the patient's thoughts
tician can either notice but not respond and feeling!;.
to these poignant moments or can begin
to integrate his therapeutic and diagnostic There need not be a sharp juxta-
skills and attempt to facilitate more position between the patient's experi-
directly the treatment process. ences in diagnostic evaluation and in
Tf one makes the assumption that in psychotherapy but the therapist and the
diagnostic testing unconscious and pre- diagnostician can strive toward the sense
conscious material is provoked and of continuity. A therapeutic tone could
elicited which has direct relevance for a be establislhed in the diagnostic relation-
patient's particular conflicts, then the ship, by considering testing as an exten-
patient must be aware to some degree of sion of therapy and the patient and the
this emerging material. This awareness diagnostician may have the option of
may take the vague form of a patient respondang to the emerging material in a
being uncomfortable about a particular variety of ways. A patient may spontane-
response or it may take a more direct ously elaborate the relevance of a particu-
form of a patient being aware that a lar response, or the diagnostician, as part
particular TAT story is explicitly auto- of general inquiry at the end of a particu-
biographic. Some Rorschach responses lar procedure, may want to inquire into
are accompanied by strong affective re- the patient's general reactions to testing
actions and on occasion patients will also or to the observation that he seemed
have the feeling that a Rorschach re- concerned about a particular response. If
sponse reminds them of a particular event the diagnostician and the therapist have
or object that they have experienced in tentatively agreed on a particular treat-
their life. If some of the responses given ment plan for a patient (if, for example,
in diagnostic testing relate to conflictual they agreed that the patient seems to
issues, and if the patient is aware to some have the resources to cope with difficult
SIDNEY J. BLATT
material), a diagnostician might comment patient, for example, is to receive pri-
to a patient that he seemed upset by a marily supportive, rather than interpre-
particular card and ask what the patient tive psychotherapy, the diagnostician's
thought about this. By enlisting the response to emerging conflictual material
patient's aid in understanding what he is should be consistent with that decision.
experiencing and thnking, the patient is The diagnostician's orientation to emerg-
offered the option of avoiding this tenta- ing material and issues should be one of
tive confrontation or he has the oppor- support and consolidation. When the
tunity, as he will have in therapy, to patient seems distressed and concerned
explore his feelings and thoughts around about the material elicited, the diagpos-
this event. Thus the patient's responses tician can offer reassurance or support
add an important dimension to the diag- the patient's defenses. If the treatment
nostic appraisal - the assessment of the plan is undecided, the diagnostician may
patient's initial capacity for candor and want to assume a more neutral role,
introspection. In offering the patient the possibly altering his reactions to the
opportunity for exploration, one directly patient as a function of his increasing
assesses the patient's capacity and willing- knowledge of the patient through the test
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ness to begin to establish a therapeutic data and as there is more general agree-
alliance. The maneuvers a patient uses in ment in the clinical setting about the
dealing with this opportunity for explora- therapeutic plan for the particular
tion can offer valuable insight into the patient. As the material evolves over
major assets or obstacles a therapist may several diagnostic sessions, the clinician,
encounter in working with the patient. using traditional structural and content
This proposal raises the possibility that dimensions of test protocols, may be able
the therapist might also conduct the to form impressions about the relative
diagnostic evaluation. Most often, how- strengths and capacities of the patient
ever, it seems appropriate that the diag- and what may be the major areas of
nostic and the therapeutic functions be conflict. If the therapeutic plan, on the
assumed by different members of the other hand, is one of uncovering and
clinical staff. It is valuable with difficult working intensively with the patient, then
and ambiguous patients to have an inde- the diagnostician may take a similar
pendent opinion; even more important, it orientation toward the patient. He can
is often helpful for some patients to have permit the patient to focus on and
the possibility of maintaining a separation elaborate sources of conflict and diffi-
between "evaluation" and therapy. culty that emerge during testing, possibly
articulating dimensions which might not
Leventhal, Slepian, Gluck and Rosen- have been available until later in the
biatt (1962) and Boreham (Note 3) have psychotherapeutic process. As distressing,
discussed a more active transaction be- significant, and revealing material is elici-
tween patient and diagnostician and how ted, the diagnostician may comment on
these may influence the patient's subse- the patient's seeming, distress and offer
quent behavior in clinical settings and the patient the opportunity to explolre
permit a fuller assessment of the patient's and elaborate this material. As the patient
accessibility for thesapy. Equally impor- discusses this material and begins to
tant, however, is the fact that in this type consider its relevance and importance, the
of diagnostic transaction, there is a conti- diagnostician can encourage the patient
nuity between diagnostic assessment and to bring this material into his therapy
psychotherapy. If the therapist and diag- sessions. This approach to diagnostic test-
nostician have discussed fully the tenta- ing is based on the ass;umption, that the
tive treatment orientation and plan for a material elicited by the Rorscbwh and
particular patient, the diagnostician can TAT is particularly central to a patient's
respond t o material that emerges in diag- problems and that it may not bw t ex-
nostic testing in a fashion similar to the pressed for some time in treatment. If the
way the therapist might respond. If the diagnostician's response to sagmants of
The Validity of Projective Techniques
the material enables the patient to recog- with these difficulties.
nize emerging material, to elaborate its Another case, illustrative of this ap-
relevance and importance, and to deal proach in diagnostic testing, was a
with t h s material more intensively in the 23-year-old single female patient who had
enduring relationship with his psycho- been hospitalized on numerous occasions
therapist, diagnostic testing can be an during the prior eight years with a diag-
important facilitation of the therapeutic nosis of schizophrenia, and her most
process. In this approach to diagnostic recent hospitalization followed a suicide
testing, the diagnostician serves as a attempt. Testing was requested by the
bridge between therapist and patient, therapist to confjrm his tentative formu-
enabling the patient to articulate relevant lations that the patient had little capacity
and possibly crucial dimensions and en- for intensive psychotherapy. The initial
couraging the patient to deal with these plans were to work toward establishing a
issues in more detail with his therapist. reasonable level of integration and con-
An example of this approach in diag- trol, leading to eventual discharge from
nostic testing is illustrated in the testing the hospital. If this was not readily
of a 45-year-old man who had had a attainable, the patient was to be trans-
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sing the material with her therapist. The structure and where exploration should
structure and content of the test proto- be encouraged.
cols, along with the patient's capacity for There are, of course, inherent limita-
candor and introspection, clearly indica- tions in this approach to diagnostic test-
ted her accessibility for psychotherapy. ing. The diagnostician must be aware of
The woman's capacity for entering inten- the influence he has on subsequent diag-
sive psychotherapy was discussed with nostic material. Although most inquiry
her therapist as was the emergence of and explorations of a patient's responses
both her desire and fear of discussing the would be conducted after the completion
h~omosexualmaterial. Diagnostic testing of the particular test, responses in subse-
in this case not only served to clarify the quent diagnostic sessions may still be
inaccurate initial assessment of her influenced. It is also possible for the
capacity to benefit from psychotherapy, diagnostician to lose perspective of the
but as reported subsequently by the fact that he is an extension of therapy
tlherapist, it facilitated treatment by and is not the therapist himself. The
making specific conflictual material avail- diagnostician's attempts to facilitate the
able in therapy for the first time. therapeutic process must be closely
Occasionally in diagnostic testing with coordinated with the therapist's orienta-
borderline psychotics, patients can be- tion and goals. A therapist may want to
come acutely agitated and increasingly proceed on a supportive level with short-
disorganized, particularly while taking the term patients; or a particular patient,
Rorschach. The demands of coping with though pgrchologically capable of enter-
ambiguity and diffusion in the Rorschach ing into intensive treatment, may be
can precipitate acute disorganization. In financially unable to continue treatment.
my experience I have seen one psychotic The diagnostician should not create
break in a borderline patient which expectations in the patient about treat-
seemed precipitated by the experience of ment, which for practical considerations,
taking the Rorschach. Federn (1952) cannot be met. If the diagnostician's
bsiefly comments on the relatively rare relationship with the therapist is not well
precipitation of a psychotic break in established, the therapist can perceive the
secriously disturbed patients after taking diagnostician as intruding into the thera-
the Rorschach. An important therapeutic peutic relationship. The patient can be-
response in diagnostic testing, particularly come the stage for the: acting out of the
with borderline patients, may be the competitive strivings of both ~e diagnos-
postponement or discontinuing of testing tician and therapist. If, however, the
if there are indications of the patient's diagnostician and theleapist have estab-
move toward serious decompensation. lished a cadlaborative relationship based
The Validity of Projective Techniques
on mutual trust and respect, the diagnos- in becoming more fully aware of critical
tician can support current defenses as the material that emerges during diagnostic
patient attempts to cope with the feelings testing. If the patient begins to elaborate
provoked by diagnostic testing or he can these possibly critical dimensions in the
offer the patient the opportunity to diagnostic setting and is able to bring
explore his feeliqgs and his preconscious them back into the ongoing therapeutic
recognition of conflict-laden material. rela ti onship, the psychotherapeutic
The sensitive and subtle reactions to process may be markedly facilitated.
segments of the diagnostic material create Projective techniques can provide the
a continuity between diagnosis and ther- clinical psychologist, as well as the
apy, while permitting each of these roles patient, with diffusion, ambiguity and a
to maintain their relative contribution to relative lack of structure. As with our
the clinical process. The diagnostician can patients, much of what we do with this
still make a unique contribution to the potential ambiguity and lack of structure
therapeutic process through an insightful depends on our creative capacities to
analysis of test protocols, but he can also differentiate and synthesize. Projective
contribute through his responses to the techniques have important contributions
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patient's struggles with material elicited to make to some research endeavors and
by the diagnostic procedures. to the clinical process if we are able to
On occasion, the relationship estab- recognize and articulate the limitations as
lished in diagnostic testing can become well as the exciting potentials inherent in
intense. Exploring critical and sensitive these procedures.
material in the brief and temporary diag-
nostic relationship does not give a patient References
much opportunity to resolve the feelings Allison, J., & Blatt, S. J. The relationship of
that may be evoked in the relationship Rorschach Whole responses to intelligence.
with the diagnostician. Patients may re- Journal of Projective Techniques & Person-
quest retesting prior to terminating treat- ality Assessment, 1964,28, 255-260.
ment, ostensibly for reassurance that they Blatt, S. J., & Allison, J. Methodological con-
siderations in Rorschach research: The W
are now ready for termination or dis- response as an expression of abstractive and
charge. It seems, however, that they may integrative strivings. Journal of Projective
also be attempting to resolve a relation- Techniques & Personality Assessment, 1963,
ship established earlier when they were 27, 269-278.
initially seen for testing. Blatt, S. J., & Allison, J. The intelligence test in
personality assessment. In A. Rabin (Ed.),
The active transaction between patient Projective techniques in personality assess-
and diagnostician adds several dimensions ment. New York: Springer, 1968.
to diagnostic testing. First, it can influ- Blatt, S. J., Allison, J., & Feirstein, A. The ca-
ence the attitude and orientation with pacity to cope with cognitive complexity.
Journal of Personality, 1969, 37, 269-288.
which a patient approaches subsequent
Draguns, J. G., Haley, E. M., & Phillips, L.
clinical contacts. If the patient perceives Studies of Rorschach content: A review of
the diagnostician as actively interested in research literature. Part 111: Theoretical
his thoughts and feelings, the patient can formulations. Journal of Projective Tech-
expect similar reactions from other mem- niques and Personality Assessment, 1968,
32, 16-32.
bers of the clinical staff. Also, this ap-
Fedem, P. Ego psychology and the psychoses.
proach permits a fdler assessment of the New York: Basic Books, 1952.
patient's capacity to enter into a thera- Friedman, H. Perceptual regression in schizo-
peutic dliqnce. Observation of a patient's phrenia. An hypothesis suggested by the use
modes pf response to offers of support or of the Rorschach test. Journal of Projective
exploration can provide valuable addi- Techniques, 1953,17, 171-186.
tional insight into the major assets or Gardner, R., Holzman, P. S., Klein, G. S.,
obst~clrtsthat a patient may present in Linton, H., & Spence, D. P. Cognitive
control - a study of individual consistencies
therapy. Even more important, however, in cognitive behavior. Psychological Issues,
is the fact that in the patient-diagnos- #4. New York: International Universities
tician transaction the patient can be aided Press, 1959.
!SIDNEY J. BLATT
Gardner, R. W., Jackson, D. N., & Messick, S. J. Schafer, R. Psychoanalytic interpretation in
Personality organization in cognitive con- Rorschach testing. New York: Grune &
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jective Techniques and Personality Assess-
ment, 1967, 31, 5-38. Reference Notes
I-Iolt, R. R. manual for the scoring of primary 1. Mayman, M. Form level scoring manual
process manifestations in Rorschach respon- Unpublished manuscript, Menninger Foun-
ses. (8th ed.) New York: Research Center dation, Topeka, Kansas, 1962.
for Mental Health, 1962.
2. Engel, M., & Blatt, S. J. Clinical inference in.
Holt, R. R., & Havel, J. A method for assessing psychological diagnosis. Paper presented at
primary and secondary process in the Ror- the meeting of the American Psychological
schach. In M. A. Rickers-Ovsiankina (Ed.), Association, Philadelphia, August, 1963.
Rorschach psychology. New York: Wiley,
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climate. Paper presented at the VII Inter-
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Kaplan, A. The conduct of inquiry. San Fran- national Congress of Rorschach and Other
cisco: Chandler, 1964. Projective Techniques, London, August,
Leventhal, T., Slepian, H. J., Gluck, M. R., & 1968.
Rosenblatt, B. P. The utilization of the
psychologist-patient relationship in diagnos-
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Sidney J. Blatt, PhD
Rapaport, D., Gill, M., & Schafer, R. Diagnostic Department of Psychiatry
psychological testing. Chicago: Year Book, Yale University
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Smason, E. K. The discriminatory value of the New Haven, Connecticut 06510
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lished PhD Thesis, Clark University, 1950. Revised: June 3,1974