The Rorschach

This has been a sad week.  Donald Trump was elected President and, on a much smaller scale, our faculty voted yesterday (9 to 1, with one abstention) to make a clinical psychology graduate course that I teach, the Rorschach, an elective rather than a required class.  Big deal, you may say, does every clinician need to know how to administer the Rorschach?  Isn’t that an old and outdated test?  And what difference does it make if students are taught one technique or another?  And, by the way, can’t they still take the class if they want to?  What’s your beef?

 You probably think of the Rorschach as an inkblot test.  That would make sense because Hermann Rorschach, when he published the test in 1921, stated that it was an inkblot test – and the 10 Rorschach cards look, at first blush, like inkblots.  Unfortunately, Hermann died of appendicitis before he could come clean (I reviewed biography of Rorschach published in 2017 here).  The stimuli in his test are actually his pen and ink drawings with a watercolor wash on some of them.  They have become archetypal symbols of psychology, and have even been plastered on dinnerware...

We didn’t know for sure that the inkblots were intentional drawings until the 1990s when John Exner visited Rorschach’s daughter and she allowed him to see Rorschach’s files.  In them, Exner discovered some old pen and ink drawings of Rorschach’s – he was a competent artist – as well as some inkblots – blotches of ink on paper that had been folded in half so that the resulting blot was symmetrical – and they resembled – but were clearly not the same as Rorschach’s stimuli.

Rorschach originally used inkblots to try to assess his patients.  But it is now apparent – and we have access to his data with the original inkblots – that his patients needed stimuli that were less vague – they needed stimuli that looked more like things.  They had trouble seeing things in the relatively amorphous blots.  So Rorschach created his masterpieces.   

Rorschach Blot Details

You can find Rorschach’s art on the internet – we tried to keep them as protected test materials, but ultimately failed to do that.  If you look at them closely, you will see that Rorschach drew things, but in strange and confusing ways.  You will find pink polar bears, and two people that clearly have both breasts and penises.  And these stimuli (our patients have always known they were drawings – they frequently ask us things like, “What was the artist trying to paint here?”), were crafted by Rorschach to help him observe the perceptual and conceptual challenges that his hospitalized patients faced in making sense of the world that they lived in.  For instance, it can be hard, when your thinking is strained, to screen out irrelevant stimuli – so you say, “This is a pink bear” rather than simply saying “This is a bear.”  Similarly, you are more likely to say, “This is a woman with a penis” rather than saying, “This is a man,” or “This is a woman.”

Rorschach also discovered that his test distinguished between various personality styles.  So, for instance, extroverts – people who are more tuned to others in their environment and who tend to be more emotionally spontaneous - tend to use the colors on the blots in the things that they reported seeing.  Introverts – people who are more likely to read a book than get together with others for coffee and who tend to be more focused on solving problems cognitively than emotionally, tend to report seeing people engaged in various activities more frequently.  And some people, whom Rorschach called ambitents, seem to be good at both styles of functioning.  

So what is the big deal about not requiring students to learn this particular means of assessing personality?  Aren’t there others way of doing that?  And there are.  We currently have, and will continue to have a required course on self- report personality assessment.  In this means of assessing personality, people take true/false or Likert scaled items and their responses are compared to norms to determine whether they are responding in ways that are similar to extroverts, ambitents, or introverts – or to people with symptoms of schizophrenia, depression, or bipolar disorder.  This way of assessing personality and psychopathology is much easier to administer, score and interpret.  These have been becoming the dominant means of assessing personality and psychopathology – along with interviews – over the past twenty or thirty years.  I am a big fan of these instruments.  I have taught this other course as well and use these instruments in my practice.  I find them critical and important sources of information.  I am also loathe to rely on them as a sole source of information.

The Rorschach, unlike self-report instruments, does not rely on the person who is being assessed to observe and rate their own behavior.  Instead, the clinician does this.  We present the person with a complex problem to solve – what does this abstract painting look like?  And we observe how they solve the problem and compare their solutions, after coding them, to the solutions of many other people.

The Rorschach is referred to as a projective test, meaning that people project their personal and interpersonal dilemmas onto the stimuli and we can make inferences about their dilemmas by decoding the projection.  This has been an important part of the interpretation of the Rorschach, but it is only a part – and a part with considerable controversy associated with it.  From my perspective, and that of other Rorschachers, the Rorschach is actually an objective measure of personality and psychopathology – because observers, using a standard set of stimuli, are observing and rating in a reliable and valid manner, the psychological functioning of another person.

In teaching The History of Psychology this semester, it has become apparent that the field of psychology is a shaky marriage between two very different traditions.  Academic psychologists, almost to a person, trace their lineage to Wilhelm Wundt, a German academician who, last in the 1800s, essentially invented the field of psychology by training people to closely observe and report their perceptions of the world.  He worked within the philosophical and scientific tradition of John Locke, a thinker who proposed that we are blank slates when we are born and that the best way to study ourselves and the world is through experimental techniques.  This is a bottom up process for creating a model of human functioning.  The behavioral tradition is a direct descendant of this tradition.   

Freud, the other father of psychology, also trained in the experimental tradition, but worked from a Leibnizian perspective – a perspective that supposes we are born with various structures that determine who we will become.  Though this is partly an issue of nurture (Wundt) vs. Nature (Freud), the essential difference that I would like to highlight is that Freud engaged with people as they presented to him in his consulting practice – as whole people who had difficulties they were asking for help with.  And he  responded by trying to do something that is next to impossible – he came up with a variety of models for how the mind, the most complex entity in the known universe, functions.  His models were, not surprisingly, incredibly complex.  And they were flawed.  And the century of fixes that very smart people added have made an already complicated system even more complex.

The Rorschach was originally used by Rorschach himself in the manner of Wundt/Locke.  Rorschach collected data on coded responses with the aim of distinguishing between normal and pathological response sets – and that help to articulate different personality styles.  After Rorschach’s premature death, a variety of individuals got hold of the instrument and developed it in different ways.  In the 1970s, John Exner began integrating these systems into his own “comprehensive” system.  When he died in 2006, a group that had worked with him published a report of the Rorschach variables that have strong research support and then used this to create a new system to evaluate Rorschach responses that is called R-PAS. 

In the United States currently, the two largest psychiatric hospitals are in prisons – one in Chicago and the other in Los Angeles.  When I went to a workshop to learn about this new scoring system for the Rorschach, there were a number of psychologists there from the California state penal system.  In the penal system, the mentally ill receive long term care – and it is when long term care is offered that it makes the most sense to really get to know a patient.  In most of the rest of the mental health care system in the US, the emphasis is on short term treatments that are focused on treating symptoms – sometimes as narrow as sleeplessness – and the assessments that are needed here are self report screening devices that quantify the intensity of a problem area or distinguish between similar sets of symptoms to better understand what configuration of symptoms is present – and to see if they are being caused by something more serious that is underlying the presentation. 

Unless our students end up working in prisons or a few other settings, it is less and less likely that they will be using the Rorschach as an instrument.  So, our faculty is voting to end its use based on the likelihood that it will not be part of their practice.  Why should they devote a semester class to learning an instrument they will not administer?  Good question.  I have puzzled over that question as this vote has been approaching. 

The best answer I have come up with comes from a completely different part of the curriculum.  Our students devote multiple courses to learning research methods and statistics and they write a dissertation.  The intent is manifold – to teach them how to do research, to read research articles, but more importantly to teach them how to think as a researcher.  Almost none of our students engage in research after they graduate, but my hope is that they all – to some extent – think like researchers when they are meeting with patients.  They should have hypotheses about what is causing the patient distress and they should evaluate how helpful the interventions that they are making are proving to be.

The Rorschach is a tool that we can use to teach our students to think like clinicians.  It teaches them to code their patient’s behaviors – to observe the behaviors and “score” them.  It teaches the characteristics of disturbed thinking and teaches them about how our emotions and thoughts interact.  The process of integrating these observations into a test report is one that teaches them how to articulate how this particular person is put together.  I think of my Rorschach course as being largely a writing class.  As one of my students recently put it, I am teaching the students to write an "imaginarrative".  I pointed out to the student that this neologism is codable in the Rorschach system, but also appreciated what he was stating.

The Rorschach teaches our students that the difficulties our patients face happen in a particular and weird context – the difficulties happen in the context of the person themselves who is having the difficulties.  In order to best treat the disorder, we need to know who the person is that has the disorder and  how the disorder is wrapped into and around the person who is experiencing it.  Using the Rorschach to create an “imaginarrative” is a top down approach to getting to know a person.  We are going to create distortions in the process of imagining them.  But it is the best tool I know to do this in an empirically supported way that occurs relatively quickly.  It also facilitates what I think is a central tenet of being a psychologist: we treat people, we don't treat illnesses.  

Mary Jo Peebles and Tony Bram recently published a book articulating how to use the Rorschach, self-report scales, and intelligence testing into what they call “Psychological Testing that Matters.”  They are teaching in that book the principles that I am referring to here.  And, in the year it was published, it was the American Psychological Association’s best selling book.  There continues to be interest on the part of psychologists in getting to know our patients and to telling others about them. 

Trump won this election by promising the American people a simpler world – one that he would create.  We have always craved that.  We want our burgers and fries to be the same whether we are pulling off the interstate in Walla Walla or Tucumcari; simple, predictable, the same.  People are, however, incredibly diverse.  Even within a homogeneous culture, once we look under the hood, we turn out to be unique.  Academic psychology has long been focused on what makes us alike.  Clinical psychology has focused more on the unique qualities of the individual.  My hope, in my career, was that I could be trained as both an academician and a clinician and that I could carry the clinical approach of Freud – and Rogers and other clinical heroes - into Wundt’s academy.  This week I feel like I got Trumped.

Postscript:  Since this post, a very nice biography of Hermann Rorscach has been published, which I have reviewed here.

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