A Rorschach Case Study

Roy Schafer (1954) began his classic work Psychoanalytic Interpretation in Rorschach Testing with the following statement:

Since Schafer spoke these words, the importance of integrating psychological theories of development and psychopathology into test interpretation has been recognized as a well-established axiom of diagnostic testing. However, we are often faced with the question of which guiding theory to use. Do we select the one that inherently appeals to us, that makes most sense and has the greatest explanatory power; or, like Fred Pine (1990), do we seek to evolve a unifying perspective among various models of the mind?

At the 2013 Convention of the Society for Personality Assessment (Kleiger et al., 2013) and again at the 2014 International Congress of Rorschach and Projective Methods (Kleiger et al., 2014), distinguished panels of senior psychologists furthered this debate by presenting their interpretations of a single Rorschach protocol from multiple psychoanalytic theoretical lenses.

The panelists not only demonstrated how they thought and how they used theory to make data come alive, but like the proverbial blind men describing different parts of the elephant, the contributors represented different theoretical perspectives or schools of thought, anchoring their inferences and formulating treatment implications within the parameters of the particular clinical psychoanalytic model they represented.

Each contributor was given the Rorschach and Structural Summary from a patient referred to as Ms. B. and asked to interpret the data from one particular psychoanalytic model of personality. Contributors were asked to organize their presentations around the following questions:

1. 1.
   How does your model aid in a diagnostic understanding of Ms. B.’s internal experience and personality functioning? What unique aspects of her functioning does your model address?
2. 2.
   What features of her Rorschach (formal scores, indices, thematic content, behavior) lend themselves particularly well to your model? In other words, what Rorschach data help you form links with key constructs in your model?
3. 3.
   How does your model guide you in addressing the referral questions and in making inferences about treatment issues based on Ms. B.’s Rorschach (e.g., type of treatment, intensity, potential transference–countertransference themes, need for supportive interventions)?

The panelists, now authors, and their psychoanalytic models included:

1. 1.
   Irving Weiner, PhD, psychoanalytic ego psychology;
2. 2.
   Bruce L. Smith, PhD, object relations theory;
3. 3.
   Marshall Silverstein, PhD, self psychology;
4. 4.
   F. Barton Evans, PhD, Sullivanian interpersonal theory; and
5. 5.
   Ety Berant, PhD, attachment theory.

Dr. Jed Yalof served as discussant for each paper. His integrated discussion is included in this series of papers.

The Case of Ms. B

Ms. B was an 18-year-old Caucasian woman referred for a psychodiagnostic consultation by her psychotherapist, Dr. X. Early in the spring, Ms. B. ingested a potentially lethal dosage of medication (Ambien and Oxycodone) in an attempt to take her life. Her suicide attempt occurred in the context of close communication with Dr. X., who had spoken to her not long before her overdose. Ms. B. and her therapist had been talking about her depression, but Ms. B. had reportedly reassured Dr. X. that she was safe; she denied plans and intentions to hurt herself. Additionally, she agreed that she would not act on any suicidal feelings without first talking to her therapist or someone else.

After her overdose, Ms. B. was discovered by a roommate, who called 911. When Dr. X. eventually spoke with Ms. B. at the hospital, she was reportedly enraged that people were taking away her right to decide if she lived or died. Ms. B. was clear that she had attempted to kill herself. Although she initially refused a voluntary hospitalization, she reluctantly agreed to inpatient treatment after involuntary admission was presented as the only other option. Soon after she was admitted, Ms. B. was said to have calmed considerably. She was no longer voicing any suicidal thoughts or feelings. She was eager to return to classes and her dorm and carry on as if nothing significant had happened.

Officials at her college were cautious about having Ms. B. return to school following a suicide attempt without psychiatric clearance. The question about whether she should be allowed to return to school added weight to Dr. X.’s questions about Ms. B.’s mental status, level of suicidality, diagnosis, and treatment recommendations. Thus, Dr. X. formulated the following questions for this psychodiagnostic consultation:

1. 1.
   To what degree does Ms. B. still present a risk for suicide or self-harm? Should she be allowed to return to her dormitory?
2. 2.
   Is there evidence of an emerging bipolar disorder, and to what degree does posttraumatic stress contribute to the diagnostic picture. Finally, is there evidence of a vulnerability to dissociation or psychotic symptoms?
3. 3.
   What are the implications for treatment? What would be the appropriate setting and level of intensity to help Ms. B. address her problems?

Ms. B.’s Rorschach responses (Appendix A), coding and sequence of scores (Appendix B), and Structural Summary (Appendix C), based on the Comprehensive System (Exner, 2005), are presented.

Summary

Six experienced clinicians interpreted the Rorschach of Ms. B., an 18-year-old patient who had been referred for psychological testing following a severe suicide attempt. The clinicians each conducted a blind interpretation of Ms. B.’s Rorschach from six different psychoanalytic schools of thought, which included ego psychology, object relations, self psychology, interpersonal theory, the French psychoanalytic school, and attachment theory. In their interpretations of Ms. B.’s Rorschach, the clinicians organized their formulations according to the following set of questions: (1) How does your model aid in a diagnostic understanding of Ms. B.’s internal experience and personality functioning? What unique aspects of her functioning does your model address?; (2) What features of her Rorschach (formal scores, indices, thematic content, behavior) lend themselves particularly well to your psychoanalytic model?; and (3) How does your model guide you in addressing the referral questions and in making inferences about treatment issues based on Ms. B.’s Rorschach (e.g., type of treatment, intensity, potential transference–countertransference themes, need for supportive interventions). A discussant integrates the interpretations of Ms. B.’s Rorschach from multiple psychoanalytic perspectives.

Résumé

Six cliniciens expérimentés ont interprété le Rorschach de Mme B., une patiente de 18 ans qui avait été renvoyée pour un test psychologique suite à une tentative de suicide. Les cliniciens ont chacun effectué une interprétation aveugle du Rorschach de Mme B. venant de six écoles différentes de pensée psychanalytiques, notamment la psychologie de l’ego, les relations d’objet, la psychologie du soi, la théorie interpersonnelle, l’école psychanalytique française et la théorie de l’attachement. Dans leurs interprétations du Rorschach de Mme B., les cliniciens ont organisé leurs formulations en fonction des questions suivantes: (1) Comment votre modèle aide-t-il à une compréhension diagnostique de l’expérience interne de Mme B et du fonctionnement de sa personnalité? Quels aspects uniques de son fonctionnement correspondent à votre modèle? (2) Quelles caractéristiques du Rorschach (scores formels, indices, contenu thématique, comportement) se prêtent particulièrement bien à votre modèle psychanalytique? Et (3) Comment votre modèle vous pousse à aborder les questions de recommandation et à faire des inférences sur les problèmes de traitement en fonction du Rorschach de Mme B (par exemple, le type de traitement, l’intensité, les thèmes possibles de transfert et contre-transfert, le besoin d’interventions de soutien). Un intervenant intègre les interprétations du Rorschach de Mme B. à partir des multiples perspectives psychanalytiques.

Resumen

Seis clínicos experimentados interpretaron el Rorschach de la Sra. B., una paciente de 18 años remitida para una administración de tests después de un grave intento de suicidio. Cada clínico realizó una interpretación a ciegas del Rorschach de B. según seis escuelas de pensamiento psicoanalíticas diferentes, que incluían la psicología del yo, la teoría de las relaciones objetales, la psicología del self, la teoría interpersonal, la escuela psicoanalítica francesa y la teoría del apego. En sus interpretaciones del Rorschach de B., los clínicos organizaron sus comentarios de acuerdo con las siguientes preguntas: (1) ¿Cómo ayuda su modelo a la comprensión diagnóstica de la experiencia interna y el funcionamiento de la personalidad de la Sra. B? ¿Qué aspectos singulares de su funcionamiento aborda su modelo? (2) ¿Qué características de su Rorschach (codificación, índices, contenido temático, comportamiento) se adaptan particularmente bien a su modelo psicoanalítico? (3) ¿Cómo le guía su modelo al abordar las preguntas sobre el motivo de consulta y al hacer inferencias sobre cuestiones relacionadas con el tratamiento, basadas ​​en el Rorschach de la Sra. B (por ejemplo, tipo de tratamiento, frecuencia, cuestiones sobre transferencia-contratransferencia, necesidad de intervenciones de apoyo)? Un comentarista integra las interpretaciones del Rorschach de B. desde múltiples perspectivas psicoanalíticas.

要 約

６人の経験のある臨床家が、重篤な自殺企図により心理検査に紹介されてきた１８歳の女性であるMs.Bのロールシャッハ法の解釈を行った。臨床家たちは６つの異なった精神分析の学派からMs.Bのロールシャッハ法のブラインドアナリシスをそれぞれ行った。６つの学派には、自我心理学、対象関係論、自己心理学、対人関係論、フランス精神分析学派、愛着理論が含まれる。Ms.Bのロールシャッハ解釈において、臨床家たちは以下の疑問に答えるように彼らの解釈をまとめた。（１）あなたのモデルはMs.Bの内的経験やパーソナリティ機能を診断的に理解するのにどのように助けているか？彼女の機能のどのようにユニークな側面にあなたのモデルは対応するのであろうか？（２）彼女のロールシャッハのどの特徴（形態のスコア、指標、主題内容、行動）があなたの精神分析モデルに特に役立っているのか、（３）あなたのモデルはMs.Bの紹介されてきた疑問にどのように対応し、Ms.Bのロールシャッハに基づく治療上の問題ついてどのような推論をするか（すなわち、治療のタイプは、可能性のある転移—逆転移のテーマは、支持的な介入の必要性）。討論者は多様な精神分析の観点からのロールシャッハ解釈を統合している。