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Journal of Personality Assessment

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The Validity of Projective Techniques and

Their Research and Clinical Contribution
Sidney J. Blatt
Published online: 10 Jun 2010.

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

The Validity of Projective Techniques and Their

Research and Clinical Contribution
SIDNEY J. BLATT
Yale University School of Medicine
Summary: Numerous surveys have alternately demonstrated either a decline or continued
vitality of diagnostic assessment and projective techniques in clinical psychology. This paper
examines some of the factors which have contributed to the ambivalent attitudes about
projective procedures. The first part of the paper considers questions about the limitations
and potential contributions of projective techniques in research The second portion of the
paper examines some of the issues which limit the contributions of diagnostic assessment
and projective techniques in clinical practice. A proposal is made for conceptualizing
diagnostic assessment as a more integral part of the therapeutic process.

There is a marked discrepancy be- assessment in clinical practice and pro-

tween the rieliance placed on projective poses a way oj- conceptualizing and con-
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techniques, particularly the Rorschach, in ducting diagnostic evaluation which stres-

many clinical settings and the frequently
negative attitudes expressed about these
procedures by many research oriented
psychologists and psychiatrists. Attitudes
range from the belief that no evaluation
or assessmeint is complete without a
Rorschach to the conviction that the
interpretation of the Rorschach and other
projective procedures is no better than
reading tea leaves. In some clinical set-
tings, psychological test assessment plays
an important, if not critical, role in case
formulations. Case conferences may use
the psychological test report as a primary
validating criterion, often presented late
in the conference so that it does not bias
"more clinical" impressions. This reliance
on inferences from projective techniques
in some clinical settings stands in sharp
contrast to the current tendency or deci-
sion to discontinue teaching projective
techniques because of the myth that there
is little evidence to support the validity of
inferences derived from them or that they
make little contribution to the clinical pro-
cess. This paper examines several major
issues which have contributed to ambiva-
lent attitudes about projective techniques.
The first part of the paper attempts to
clarify some issues about the role of diag-
nostic assessment in research, and the
second part examines the role of diagnostic
Portions of this paper were presented at the
7th International Congress of Projective Tech-
niques, London (1968) in a paper entitled "An
Evaluation of Some Methodological Issues in
Research with Projective Techniques."
ses the potential therapeutic effects of
diagnostic assessment.
Many issues have entered into the am-
bivalent attitudes about projective tech-
niques. After World War 11, clinical assess-
ment was a major vehicle for psychologists
to gain entree to the clinical world. Ther-
apy and clinical administration were pri-
marily the responsibility of psychiatrists;
clinical psychologists were allowed to see
patients only for assessment. Clinical psy-
chologists with their primary role in assess-
ment were removed from day-to-day con-
tact with and responsibility for patient care.
The reluctance, hesitation, and unwilling-
ness of psychiatrists in the late 1940s and in
the 1950s to allow psychologists to func-
tion as therapists made psychologists feel
that testing was an ancillary function. It
was only in rare clinical settings that psycho-
logical assessment was held in high regard,
equivalent to that of a consultant or
supervisor. Usually in those settings,
psychologists also functioned as thera-
pists, so when psychologists took part in
clinical assessment, it was because they
wanted to and lbecause they felt it made
important contributions. The present
ambivalences about diagnostic functions
cannot be considered independent of a
prior attempt to repudiate a depreciated
role. Psychologists attempted to un-
shackle themselves from second-class
citizenship and to enter what they per-
ceived as the mainstream of clinical re-
sponsibility. As soon as they could, they

relinquished the responsibility for
psychological test assessment to junior
staff and to trainees. This struggle has
also occurred in the community mental
health movement, where prestige resides
with rapid treatment and with large scale
interventions through community organi-
zations. While community interventions
can make important contributions to the
well-being and mental health of members
of a society, there are always individuals
within any segment of society who need
direct and personal help. The relative lack
of current emphasis and reward for sus-
tained work with individuals has not only
diminished the prestige of doing individ-
ual treatment, but it has also made
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comprehensive psychological assessment
seem like an unnecessary luxury. This
decline in emphasis on psychological
assessment is paradoxical because careful
assessment is all the more important if
patients are to be seen briefly and by
staff with less training.
In addition to interdisciplinary strug-
gles and changes in mental health delivery
systems, clinical psychologists have had
to deal with the relative balance between
being a scientist and a practitioner. Re-
wards and recognition within psychology
are based primarily upon contributions to
empirical research. There is little space
available in major psychological journals
for clinically oriented comm~ications,
and academic departments, for the most
part, depreciate clinical publications.
Pressure on clinical psychologists is to
move toward experimental investigations.
Usually little recognition is given to the
fact that there is a need for solid clinical
experience and knowledge for the mean-
ingful investigation of clinical phenom-
ena. Most clinical psy~hologists either
move quickly into research or, if they
remain in clinical settings, become in-
volved in psychotherapy, community
consultation, or assume administrative
responsibilities. Few psychologists see the
potential of projective procedures as a
source for the systematic observation and
evaluation of clinical phenomena which
can serve to integrate clinical and research
interests. Testing remains, by and large, a
second-class clinical activity rather than a
fie Validity of Projective Techniques
highly valued way of studying cognition,
perception, affect, and the representation
of interpersonal relationships that can
contribute to both the clinical process
and to the systematic investigation of
clinical phenomena. The frequent separa-
tion between the clinical and research
uses of projective techniques is vividly
illustrated by the under-utilization of
enormous numbers of psychological test
records filed in precious space in most
clinical settings.
While various social-psychologicalpres-
sures in clinical and academic settings
have created ambivalent attitudes toward
psychological assessment, another major
source of concern has been the serious
questions raised about the validity of
inferences gained from projective pro-
cedures. In an evaluation of the research
on the validity of projective techniques
there are a number of methodological
issues which must be considered. Though
t h s section of the paper discusses metho-
dological issues in research primarily with
the Rorschach, it should be apparent that
the issues are also applicable to other
projective procedures such as the WAIS
and TAT, and to clinical research gener-
ally.
Projective Techniques and Research
Methodological problems in clinical
research can occur at two primary points
in the research design: in the use and
application of the observational or mea-
swing technique itself, and in the selec-
tion of appropriate validating criteria.
In considering the use of projective
procedures in research it seems that all too
frequently the Rorschach is used in either
of two extreme ways. It is often used
either to obtain global clinical judgments
or to study simple, gross, and undiffer-
entiated scoring categories. Findings
based on global clinical judgments con-
tribute little more to knowledge than the
fact that several judges, under certain
conditions, could, or could not, make
certain distinctions. In these studies there
is usually no way of evaluating why or
how the judges succeeded or failed in
their ratings. These studies tell us little
about the psychological processes in-
 SIDNEY J. BLATT
volved in the phenomenon or about the
inferential processes of the judges. This
type of research is too far removed from
the data to make meaningful contribu-
tions unless the judges specify the dimen-
sions utilized in their ratings.
Much research with the Rorschach has
been conducted at the other end of the
continuum where too little distance has
been maintained from the data. The focus
in these studies is usually on a limited
type of response or scoring category,
without considering the broader dimen-
sions of the protocol and the context in
which the particular type of response
occurs. The subtle, yet vital, differenti-
ations, distinctions, and qualifications
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made by an experienced clinician are
usually ignored. This type of methodolog-
ical error in research with the Rorschach
is illustrated, for example, by research on
the Rorschach Whole (W) response. It is
generally agreed in the Rorschach litera-
ture that the capacity to integrate the
diverse elements of the ink-blot into a
perceptual-associative response which in-
tegrates the entire stimulus can indicate a
capacity for abstract and integrative
functioning. This is probably the simplest
and most obvious hypothesis about the
Rorschach. Ibsearch attempts to test this
assumed relationship between W re-
sponses and abstract and integrative
capacities hawe been based generally on
correlating the number and/or percent of
W responses in a record with standard
measures of intelligence. Correlations be-
tween W responses and intelligence, how-
ever, are usually low and nonsignificant.
In addition, it has been observed fre-
quently (e.g., Sarason, 1950) that mental
defectives often give a large number of W
responses. On the surface one could
conclude easily that this most simple and
obvious hypothesis about the relationship
between W responses and abstracting and
integrating capacities has not been sup-
ported by research. However, it is impres-
sive that only rarely have studies con-
sidered that there are differences in the
quality of the W response. No systematic
attempts had been made to differentiate
global, vague, inaccurately perceived W
responses from those which are complex
and accurately perceived. Using a scoring
system developed by Friedman (1 953)
which makes these distinctions (as do
Rapaport, Gill, Schafer, 1946; & May-
man, Note 1)) highly significant cor-
relations were found between complex
and well-perceived W responses and cogni-
tive functioning (IQ and problem solving
efficiency) (Blatt & Allison, 1963; Allison
& Blatt, 1964). These specific findings are
not particularly important since the basic
point is apparent to most clinicians, but
they illustrate how many studies have
failed to find support for some of the
most fundamental Rorschach assump-
tions because researchers used test scores
in an undifferentiated way without
understanding the basic assumptions and
interpretive rationales of the procedure.
Many studies have simply failed to inte-
grate into their research methodology the
finer distinctions made by experienced
clinicians in interpreting a Rorschach.
Effective utilization of the Rorschach in
research requires that judgments reflect
the distinctions made in clinical practice
(Blatt & Allison, 1963).
The Rorschach as a psychological test
procedure does not exist independent of
the skills of the person administering and
interpreting the data. Some research
studies may require verbatim recordings
of the Rorschach response, supplemented
by the personal observations of the clini-
cian. As in most scientific endeavors, the
quality of the data depends on the
precision and sophistication of the obser-
vational techniques, therefore, in some
research designs the administration of the
Rorschach may have to be done by an
experienced clinician rather than by a
research technician.
Research by Holt and his colleagues
(Holt, 1960; Holt & Havel, 1962) is an
excellent illustration of the systematic
use of the Rorschach in research based on
extensive clinical experience and theory.
Holt developed a scoring system for
measuring the amount and type of pri-
mary process thinking on the Rorschach
and also the effectiveness of the attempts
to integrate t h s primary process material
into appr-opriate and realistic responses.
This scoring procedure has been widely

used in recent research with impressive
success. It has been used, for example, to
investigate whether the capacity to deal
with cognitive complexity in a logical,
abstract problem-solving situation relates
to a more general capacity to tolerate and
deal effectively with complexity (Blatt,
Allison, & Feirstein, 1969). It was
assumed that there is a continuity be-
tween the capacity to deal with cognitive
complexity in a highly logical task and
the capacity to modulate and integrate
representations of drive and affect and
segments of illogical thought into appro-
priate and realistic responses. Problem-
solving efficiency in 50 male graduate
students from a variety of departments
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did not relate significantly to any of the
conventional Rorschach categories such
as M, ZC, m, F+%, W%, etc. Only one
significant correlation (.24, p < .05) was
found and that was between problem-
solving efficiency and Animal percent. If
the Rorschach had been used in a general
way to explore dimensions related to
cognitive efficiency, the results with the
traditional Rorschach scoring categories
(either individually or in a configurational
analysis) would have indicated that the
Rorschach contributes little to the under-
standing of cognitive efficiency. Yet a
highly significant correlation was ob-
tained (.46, p < .001) between problem-
solving efficiency and the capacity to
integrate drive-laden and nonlogical
thinking into more realistic and under-
standable responses. The psychological
implications of this finding are discussed
elsewhere (Blatt, Allison, & Feirstein,
1969), and the results are presented here
to illustrate that the Rorschach can be a
valuable research instrument if it is not
used in a mechanical fashion, but rather is
used to evaluate psychological processes
with the differentiations, qualifications,
and integrations that are made in the
clinical application of the Rorschach. In
evaluating research with the Rorschach
one must consider whether it was used
with clinical sophistication or whether it
was used in a limited manner based on
only gross scoring categories.
In addition to the manner in which the
Rorschach is utilized in research, another
The Validity of Projective Techniques
potential source of methodological diffi-
culty in research with projective tech-
niques has been the selection of appropri-
ate validating criteria. One must consider
whether the Rorschach variables were
compared to a criterion which was estab-
lished through a thoughtful understand-
ing and assessment of the psychological
processes being investigated. Much re-
search with projective techniques has
been based on two types of criteria:
attempts to differentiate nosological
groups or attempts to predict overt be-
havior in a complex social matrix. Both
of these types of studies have serious
limitations.
The comparison of diagnostic groups is
based on the assumption that nosological
categories have a consistent conceptual
base which can lead to reliable differenti-
ations. Most studies, however, never indi-
cate how the nosological distinctions
were made, or even how the concepts
were defined. One rarely knows in re-
search reports, for example, how schizo-
phrenia was defined and whether it was
differentiated from other psychotic
states. This issue becomes all the more
critical when one considers the frequent
disagreements about nosological distinc-
tions even within a single clinical setting.
Even if there were agreement about the
definition of the various nosological
groups, these criteria can be applied with
varying degrees of precision. It is unusual
for a research report to specify the degree
of reliability of the nosological distinc-
tions and whether the diagnostic classifi-
cation was a tentative admitting diagnosis
made by a first year trainee or resident
after a brief interview, an administrative
diagnosis made to keep a particular
patient from being discharged, or a con-
sidered opinion of a diagnostic council
after weeks of intensive observation and
study. The number of studies which
attempt to compare schfzoghmnics, neu-
rotics, character disorders, organics, hos-
pital staff, and college sophamores is by
now legion. These studies persist despite
the fact that usudly no attention is given
to the reliability of the criteria. Even
further, there is increasing awareness thsit
current diagnostic concepts are only gross
 SIDNEY J. BLATT
categories and that patients usually
function on several levels of psychological
organization which transcend any single
category. There is little wonder that
research based on such inconsistently
defined concepts, applied with such vary-
ing degrees of precision, lead to ambigu-
ous and contradictory findings (Blatt &
Allison, 1968).
A second type of criterion frequently
used in research with projective tech-
niques is the prediction of behavior in a
complex social matrix. These issues were
discussed, in part, in a paper by Engel and
Blatt (Note 2). The prediction of com-
plex social behavior such as recidivism of
a parolee or a schizophrenic, success in
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college or in psychotherapy, or of aggres-
sive or suicidal behavior is an inappropri-
ate criterion for validating clinical infer-
ences. Why should we expect to be able
to predict such complex social behavior
from an understanding of psychological
processes alone when the behavior, at
least to some degree, is also determined
by the social context? It seems that
clinical psychologists have ignored one of
the basic dicta (Kurt Lewin) in social
psychology that behavior is a function of
the person as well as the environment.
Whether a previously psychotic patient
will be successful subsequent to discharge
from a clinjcal facility will depend as
much on the type of environment he
enters as it will upon his level of psycho-
logical integration. Supportive family
structures, an understanding and tolerant
employer, the lack of unexpected and
acute life crises will obviously contribute
to a patient's success. Understanding of
psychological organization alone, regard-
less of the source of that understanding,
can account for only one segment of the
variance. Equally important are the
dimensions of the social context which
can also affect outcome. In fact there
may be an inverse relationship between
an individual's psychological well-being
and our capacity to predict. More seri-
ously disturbed patients may repeat prior
patterns with less awareness of, and re-
sponse to, the environment. More integra-
ted individuals may alter their behavior as
a function of significant environmental
factors. Though we may have gained
extensive understanding of psychological
organization and functioning from the
Rorschach, we still may not be able to
predict complex social behavior.
If prediction of complex social be-
havior is an inappropxiate criterion for
validating inferences drawn from psycho-
logical tests, then what are the alterna-
tives? Kaplan (1964), like some other
philosophers of science, has argued that a
reconstructive or postdictive model can
be an appropriate research methodology
for clinical research. This type of research
model is seen frequently in longitudinal
studies where prior observations are
examined for consistent patterns which
relate to current functioning. In clinical
research, independent data, such as exten-
sive case material or information gained
in therapy, cam provide data to test
hypotheses about personality develop-
ment and current psychological function-
ing. Such research is complex, time con-
suming and presents many methoclologi-
cal problems, but it may provide a way of
testing the validity of some assumptions
in clinical theory and practice which are
not readily testable in other research
methodologies.
This postdictive methodology may leave
unsatisfied those who are concerned
about the prediiction and control of be-
havior; but prediction and control of
behavior shoulld be considered indepen-
dent of the validation of inferences about
psychological processes. How psycho-
logical processes interact with social fac-
tors in determining behavior and what
interventions aire most effective for alter-
ing behavior are obviously very important
questions. But it may be helpful to
consider these issues apart from our
attempts to test and validate inferential
p r o c e s s e s about psychological
phenomena.
In addition to the distinction between
prediction and postdiction other issues
such as the time span and the level of the
prediction need to be considered. There
may be important methodological differ-
ences and implications for short-term as
compared to long-term prediction. Long-
term prediction is probably more difficult
 332
since it leaves more opportunity for
unexpected environmental factors to have
an effect.
There is also a need to differentiate
levels of prediction. Inferences gained
from projective techniques are primarily
about psychological constructs. Predic-
tion from one clinical instrument to
another (e.g., from WAIS to TAT to
Rorschach) or from one segment of the
psychotherapeutic process to another are
probably considering phenomena on a
similar psychological level. A prediction
about the type of defense likely to be
associated with particular fantasies is
dealing with psychological constructs and
this type of prediction should be differ-
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entiated from predictions that are made
from one level of discourse to another. It
would be useful to evaluate studies on the
basis of the range of levels covered in the
design. Within level predictions, such as
the study of the relationship between the
two psychological constructs of fantasies
and defenses, would test the inferential
process and theory. Predictions between
levels, such as the relationship between
fantasy and overt behavior, tests whether
within level inferences can be applied to
other levels of functioning. Failure to
predict between levels would not have the
same implications for the validation of
clinical inferences as would failure to
predict within levels.
Prediction in research can occur from
more closed systems to more open ones
or vice versa. One can, for example, try to
predict complex social behavior from test
data or one can study individuals who
have demonstrated a particular behavior
and compare their test protocols with
appropriate control groups. The research
strategy which proceeds from open to
more closed (or controlled) systems
offers more possibility for precision Since
the prediction is to an experimental or
test situation in which environmental
factors can be kept relatively constant.
(This is not to imply that the test or
experimental situation is not a complex
social irlteraction, but it is much less open
to extraneous factors than a normal social
context.) Generally, the type of research
which attempts to predict behavior in
The Validity of Projective Techniques
more carefully controlled experimental or
test situations seems to reduce the prab-
lem of predicting into a highly variable
context in which differences may be
determined only in part by the psycho-
logical differences of the individual.
Though prediction may be one of the
hallmarks of scientific methodology,
types, levels, and direction of prediction
must be considered carefully. Issues such
as the distinction between prediction and
postdiction, the time span, and the level
and direction of the prediction are all
important in evaluating research findings.
Some types of predictions are more
appropriate than others for the validation
of inferences derived from projective pro-
cedures. Primary reliance on the predic-
tion of complex social behavior as the
means for validating inferences about
psychological processes is generally an
inappropriate criterion. The time span of
the prediction is usudly long, the predic-
tion can extend over several levels (from
the deepest fantasy to the most complex
behavioral level), and the direction of the
prediction is to a situation in which there
is relatively little control over many of
the variables. In evaluating research on
projective techniques it is imp~rtantto
ask whether research methodology has
been appropriate for validating inferences
about psychological processes. Have the
projective techniques been used in ways
which reasonably approximate the dis-
tinction an experienced clinician would
make in evaluating the phenomepon? Are
the validating criteria carefay defined,
reasonably reliable, and under sufficient
control so that extraneous and unknown
variables have minimal influence?
Though projective procedures have
limitations in the investigation of psycho-
logical processes, they do not result in a
meaningless series of random responses.
They provide a reasonably consistent
sample of an individpal's perceptual and
cognitive functioning. Tho interpretation
of the individual's perceptions, associ-
ations, integrations, and daborations to
these relatively standard, albeit ambigu-
ous, stimuli is a complex task. But re-
sponses to projective procedures may
offer us the opportunity to study styles
 SIDNEY J. BLATT
and contents of thinking and perception
which may not be readily accessible
through many other observational pro-'
cedures. It is true that if one were simply
to tally research findings on projective
techniques, a large majority of the studies
would indicate little, if any, support for
the validity of projective procedures. But
why has there been so much uncritical
acceptance of the research findings?
Could it be that the same social-psycho-
logical forces which affected the attitudes
of many psychologists toward diagnostic
,assessment may also be the reason for the
(eager and uncritical acceptance of nega-
tive research findings. Results are far
from disheartening when they are based
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(on studies in which clinically appropriate
(differentiations were related to carefully
specified and well-controlled criteria. In
Fact, a large proportion of these studies
offer considerable support for many of
the interpretive assumptions of projective
techniques.
Projective Techniques
and the Clinical Process
Before discussing the possible contri-
butions of psychological testing to the
clinical process, it is essential to specify
what constitutes an adequate psychologi-
cal evaluation. Diagnostic testing can be a
search for a diagnostic label but this, at
best, is a limited goal. Rather, psychologi-
cal testing should provide an assessment
of ego structures including an evaluation
of the strengths and weaknesses of ego
functions and an evaluation of the modes
lhe individual uses to cope with intra-
psychic conflict and reality demands. An
adequate psychological evaluation must
specify the nature, extent, and areas of
conflict and preoccupation; the hierarchi-
cal organization of defenses and their
effectiveness; the adequacy of reality
testing and the modulation of affects; the
capacity for and the quality of inter-
personal relationships; and adaptive
strengths and capacities. A psychological
evaluation must be more than a simple
enumeration of a variety of pathological
processes, conflicts, symptoms, and de-
fects in ego control. It must be an
integrated and synthesized evaluation of
333
the interaction of various levels of drive,
defense and adaptive functions with a
specification of the principles which ac-
count for these interactions. All too
frequently psychological test reports are a
series of descriptive statements or, at
best, a series of conditional statements. If
testing is to make a meaningful contribu-
tion, we must work toward conjunctive
statements in our evaluations which inte-
grate a number of observations across a
number of different inferential levels
(Engel & Blatt, Note 2). It is insufficient,
for example, to state that a patient has
problems dealing with anger when pro-
voked; it becomes meaningful only when
we can specify when, where, and in what
ways these difficulties are experienced.
We have to try to specify, for example,
the nature and degree of provocation that
is needed and the likely form and inten-
sity of the anger. We should also be able
to specify how the issues are defended
against and what happens to psychologi-
cal organization when the anger is con-
tained or expressed. The purpose of this
type of assessment is to enrich and
extend the understanding of a patient. It
should organize and integrate diverse
observations which may seem unrelated
or even contradictory.
Testing need not be done routinely
but only when there are contradictions
and ambiguities or when critical decisions
must be made and there is insufficient
material in interviews or case material.
Most frequently testing is requested early
in the clinical process when the assess-
ment of the patient's psychological
organization can aid in dispositional de-
cisions (such as the need for therapy,
type of thterapy or therapist, and the need
for hospitalization in an open or closed
ward). Testing done early in the therapeu-
tic process can also offer a therapist a
formulation of the patient's assets and
pathology so that the therapist can pro-
ceed with greater sensitivity and confi-
dence early in therapy. Testing can also
be useful at critical moments in the
therapeutic process such as when the
patient Is being considered for discharge,
transfer, termination, when the therapist
wants to evaluate progress, or when the

therapist feels confused or when therapy
has reached an impasse and is no longer
proceeding in a positive direction.
Psychological testing always occurs in
a transactional context and the contri-
bution of psychological assessment is
always contingent upon the skills and
talents of the various members of the
clinical staff, upon the patient with
whom they are working, and upon the
philosophy, values and attitudes of the
specific clinical facility. In order to
specify some of the limitations imposed
on the utilization of psychological test-
e g , each dimension in the patient-
dagnostician-therapist-institution trans-
action must be considered.
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Though there is little data available
about the relative contribution of psycho-
logical evaluations with different types of
patients, it seems likely that this is an
important factor. Patients actively en-
gaged in a treatment process or patients
who have the potential for movement are
likely to be those with whom psycho-
logical testing can make its greatest con-
tribution. Patients relatively inaccessible
to treatment procedures, as they are
currently conceptualized, are likely to
present clinical situations in which
psychological assessment can make only
minimal contribution.
A second factor in the proper utiliza-
tion of diagnostic testing is the skill and
the level of training of the diagnostician.
The contribution of diagnostic pro-
cedures is explicitly contingent upon the
training and sensitivity of the clinician.
Interpretation of clinical procedures is
dependent on the clinician's capacity for
careful and thoughtful observations of a
variety of dimensions of psychological
testing, The quality and character of the
clinical transaction during diagnostic test-
ing can provide invaluable observations,
but there are other important sources of
data, such as the content and the struc-
ture of the patient's responses to the
range of psychological test stimuli. The
content of a response, the overt as well as
covert themes are a frequently used
aspect of projective techiques. Content,
however, c m vary from day to day and it
is often difficult to differentiate object
TJze Validity of Projective Techniques
from subject and fear from wish in the
content of the responses. Haley, Draguns,
and Phillips (1967), in their extensive
review of the content dimension of the
Rorschach, state that there is a need to
begin to "search for the mediating vari-
ables that facilitate or inhibit the nature
and the extent of covariation between
real-life behavior and Rorschach indices.
Situational and contextual characteristics,
all too often overlooked even in the
better studies reviewed, will no doubt
emerge as one of the constraints that
affect the links between behavior and
content." Draguns, Haley, and Phillips
(1968) stress the need to incorporate a
consideration of structural features (e.g.,
defenses and style) in the study of the
relationships between motivational states
as expressed in Rorschach content and
behavior. They suggest that content is
always interwoven with style and struc-
ture and that these dimensions must be
considered simultaneously in research as
they are considered in clinical practice.
Thus, another important dimension in the
response process in the Rorschach is the
structural or formal aspects, the stable
and persistent cognitive, perceptual styles
(e.g., Gardner, Holzman, Klein, Linton, &
Spence, 1959; Gardner, Jackson, &
Messick, 1960; Shapiro, 1965; Witkin,
Dyk, Faterson, Goodenough, & Karp,
1962) whch express the levels and types
of personality organization. Another
dimension of the response process is a
patient's reactions to his responses. The
fear or joy of taking tests or of giving a
particular percept is a valuable observa-
tion which must be integrated with the
content and structure of the responses.
Another, somewhat neglected source of
data in diagnostic testing, is the subjective
reactions of the clinician. The integration
of the clinician's empathy and intro-
spection with the more objective aspects
of testing is essential for the multi-
faceted, comprehensive and systematic
understanding of psychological processes.
These five sources of data (the nature of
the clinical transaction, the content,
structure and affect of the response
process, and the clinician's subjective
empathic response) are all essential for a
 !SIDNEY J. BLATT
comprehensive psychological evaluation.
13mphasis on only one or on only a few of
these sources of data ignores a host of
vitally important observations. Finally,
these diverse observations must be inte-
grated into a conceptualization which
specifies the principles through which
these various dimensions are integrated in
a functional organization. In part, this
integration is contingent upon having a
theory which facilitates multi-level, multi-
dimension a1 formulations (Schafer,
11954).
Another factor affecting the potential
contribution of psychological testing is
the skill and training of the person who is
going to utilize the information obtained
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from testing. One can ask, "What is the
contribution of psychological testing to
the clinical process?", or "How much can
the clinical process or the behavior of a
particular therapist vary in light of im-
portant knowledge gained from any
source?" A series of interviews conducted
with a group of third-year residents indi-
cated that many of the residents were
making minimal use of psychological test-
ing and they stressed its use primarily as
am evaluation of organicity or mental
retardation. A very interesting trend,
however, emerged in these interviews
which supports the contention that the
utilization of testing is dependent upon
the skills of the therapist. Those thwd-
year residents considered independently
by their senior faculty to be the better
residents were those who reported greater
utilization of psychological testing.' It
seems reasonable to expect that more
experienced or talented therapists would
h~ave a greater range of responses in
therapy and therefore be able to alter
their therapeutic approach in light of
important knowledge gained from any
source. A request for testing can reflect a
therapist's insecurity and there can be
considerable conflict and ambivalence
about seeking consultation, especially
firom a member of another discipline. But
a request for consultation can also be
based on an appreciation of the complex-
i t y of a particular patient and a desire to
l'These observations were gathered in collabora- peutic process to evaluate change and
tion w t h Dr. Carl N. Zimet.
gain further understanding and insight.
The institutional structure - the
values and attitudes of the clinical facility
- also play a significant role in defining
the clinical contributions of psychological
assessment. In some clinical settings a
brief report is the sole communication
between diagnostician and therapist.
Therapists may only read a short sum-
mary paragraph at the end of a report
which, on occasion, might be supple-
mented by a passing remark in the hall or
a casual query over coffee. Frequently,
the attitude that prevails in these clinical
settings is best expressed in the philos-
ophy that if test formulations agree with
"clinical impressions" they are accept-
able, but if they do not agree, ignore
them. Tolerance for ambiguity, however,
might permit a more differentiated con-
sideration of the patient and contradic-
tions in formulations might be reconciled
by considering hierarchical organization
in which the patient communicates differ-
ent qualities and issues depending on the
level of observation. In other clinical
facilities there is an equally distorted
attitude which is expressed in the un-
critical acceptance of the scientific or
magical test findings against whilch mere
interviews or case history are considered
q~lite inadequate. In these settings
psychologists may foster the myth of the
scientific precision of testing by stressing
the quantitative dimensions of test data
and by minimizing the nature of the
inferential process.
More accurately, psychological assess-
ment involves essentizlly the same proces-
ses of inference that s therapist utilizes in
Brriving at his formulations. The differ-
ences, however, are in the methods and
procedures which permit observation at a
variety of levels. In adldition to appreciat-
ing the quantitative and clinical aspects of
diagnostic psychological testing it is
important that psychological assessments
be a collaborative effort. A referral for
testing should serve as a springboard for
extensive discussions between diagnos-
tician and therapist before and following
testing and even much later in the thera-
progress. In this way, the diagnostician

may function as a consultant or super-
visor and psychological testing is no
longer a luxury in terms of staff time nor
a process which can be relegated to junior
staff or trainees. When one considers the
complexity of the transaction of psycho-
logical assessment in the clinical process
(the institutional setting, the type of
patient, and the level of training and the
quality of the professional relationship
among members of the clinical staff), the
question is no longer simply whether tests
make a contribution or not. Rather,
attempts must be made to specify the
parameters which affect the utilization of
knowledge in the clinical process.
If diagnostic testing is well done it not
Downloaded by [Central Michigan University] at 05:42 05 December 2014
only can make important contributions
to the clinical process, but it can also be a
very valuable procedure in clinical train-
ing. In therapy supervision one depends a
great deal upon the sensitivity of the
student-therapists' observations. Also,
therapy presents the necessity for dealing
with a host of important reality consider-
ations. Verbatim protocols in diagnostic
testing, on the other hand, can allow
supervisor and student to study the
patient's productions, thinking, percep-
tions, and reactions in a more systematic
fashion. In diagnostic supervision the
student can be encouraged to listen to the
patient's multi-level communications, to
understand the organization of drives,
defenses and ego functions. It is this
increased sensitivity to the subtleties and
nuances of communication and to the
depth and range of psychological proces-
ses that is essential for good clinical
practice in both diagnostic testing and in
therapy.
h o t h e r major source of ambivalence
about diagnostic testing has been the
expegence that testing does not make a
direct contribution to the treatment pro-
cess, that testing is ancillary to direct
therapeutic involvement with the patient.
Part of these persistent feelings of dis-
satisfaction about the limited role of
diagostic testing in clinical settings stems
from the clinical psychologist's curious
separation of diagnosis and treatment.
Diamostic assessment and psychotherapy
require the same sensitive and empathic
The Validity of Projective Techniques
capacity to understand and facilitate a
patient's capacity for communication.
Clinical psychologists with the skills,
knowledge, sensitivity, and interests in
helping patients, however, often make a
sharp cleavage between their roles as
diagnostician and therapist. But is diag-
nosis so distinct from treatment? Certain-
ly the patient's relationship with the
diagnostician is short-term and transitory
as compared to the long-term and endur-
ing therapeutic relationship. But in both
situations the patient comes to a mental
health specialist and reveals significant
dimensions of himself in the hope of
alleviating his suffering and of learning
more effective modes of adaptation. The
candor, trust, and warmth in therapy
should also exist in the diagnostic rela-
tionship. The working toward an under-
standing of a patient's problems, a grasp
of the factors which make him function
as he does, and the understanding of the
ways he experiences his life are all impor-
tant issues in treatment and in diagnostic
assessment.
The understanding and evaluation of a
patient's responses to psychological tests,
that is, his modes of cognition and
perception, along with a sensitive and
thoughtful analysis of the interaction
during testing, have traditionally been of
value in many treatment settings. But
why has testing been limited to a consul-
tative role, even when the person doing
the diagnostic assessment may also be a
highly skilled therapist? Could the diag-
nostic relationship, under certain condi-
tions, be used as part of the therapeutic
process by offering the patient the oppor-
tunity to explore some of his perceptions
and associations? m e reactions to this
opportunity could provide further evalu-
ation of the patient's attitudes toward
psychotherapy, and it could serve, from
the initial contact, to establish a general
orientation toward the clinical ~ r o c e s s . ~
2These considerations of a more expanded role
in diagnostic testing began a number of years
ago and I am indebted to Drs. Sara K. Polka,
Mary Engel, and Roy Schafer for the oppor-
tunity to discuss some o f these issues with
them. Portions of this section o f the paper were
originally presented at the 1963 meetings o f the
American Psychological Association, Philadel-
phia, Pennsylvania, in a paper entitled "The
Therapeutic Effects of Diagnostic Testing."
 SIDNEY J. EILATT
This close interweaving between diag-
nosis and treatment is well illustrated by
the clinical transaction with a seven-and-
a-half year old boy who had been seen
over several years by many specialists. He
had only spoken, on rare occasion, three
or four words, and at various times had
been diagnosed as hard of hearing, men-
tally retarded, brain damaged, and
autistic. Psychological testing was reques-
ted to aid in clarifying the problem and
to assist in the development of a treat-
ment plan. The boy was healthy and
physically ralbust, but he was deeply
engrossed in the repetitive and highly
personalized rhythmic chant of nonsense
syllables. Seen for the first time, he was
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seated at the child's table in the waiting
room, loudly singing a repetitive, primi-
tive chant. He was banging the tune on
the table, tapping it out with his feet, and
it seemed as if his entire body were
involved in this rhythmic activity. His
singing seemeld to serve as a very primitive
form of speech by which he communi-
cated his apprehension. When he felt
most threatened, the chanting would in-
crease in intensity and in tempo. He did
not speak at all and any attempts to
communicate with him were ignored or
met by increased singing. He was an
intensely frightened, apprehensive child
who had or wanted little, if any, contact
with his environment. His entire organi-
zation seemed focused around the reduc-
tion of his fears and apprehension, and
his primitive and rhythmic singing seemed
to soothe and pacify him. If he were to
interact at all, it would be on his terms
and at a pace he could tolerate.
In the first two testing sessions the
diagnostician sat quietly and unobtru-
sively on the side of the room playing
with some material from the Merrill-
Palmer Scale. Slowly the child began to
move out froim his incessant chanting and
his scrawling with a crayon. He walked
around the room, touched objects, came
over to the diagnostician, and while look-
ing directly into his face, touched and
pinched his arm and then quickly re-
turned to his drawings and humming of
nonsense syllables. Any attempts to ap-
proach him directly were met by an
increase in chanting.
In the third testing session the child
came over and watched the diagnostician
place objects in the form board and at
one point directed the diagnostician's
hand to the proper slot on the form
board, indicating where blocks should be
placed. Later, he cautiously accepted
pieces and placed them himself. All this
proceeded with a minimum of verbal
contact, and c:ommunication was pri-
marily through gestures or by the increase
or decrease of his chanting.
On those sulbtests he participated in,
he was able to function at the highest
level of the lvlerrillBalmer Scale. Al-
though any IQ estimate of this perform-
ance would be highly unreliable, one
could say with assurance that this child
was not ment,ally retarded. Also, his
manual dexterity was good, his percep-
tual motor skills were intact, as was his
memory, and th~arewere no indications of
central nervous system damage. Rather,
he seemed to be a seriously disturbed
autistic child who had never made the
decision that contact with people and
with the world was worthwhile and desir-
able. He found more safety, security, and
satisfaction in his rhythmic singing and
banging.
During the six diagnostic testing
sessions the chdd began to relate more
readily to the examiner. When taken to
the candy closet after each hour he would
carefully select a piece of candy for
himself and then select one for the
diagnostician. In the last testing session
he hummed "Happy Birthday" and the
diagnostician sang the words along with
him. Shortly thereafter, this supposedly
inarticulate child sang the first two lines
of the song, words and all. Aside from its
rich symbolic ]meaning, the song com-
municated the very important message
that, in fact, this child could speak. As he
began to experience feelings of trust and
security, the child emerged from his
autistic chanting and rocking to explore
and experience a very limited segment of
his environment.
In the process of understanding how
and why this chid behaves the way he
does, the diagnostician and the patient

shared poignant moments and one might
say, that in the sharing of these poignant
moments., psychotherapy had begun. The
initial contacts in the diagnostic relation-
ship devoted to an appraisal of the
problem have blended into therapy and
the diagnostician could either continue
with the child, or gradually make the
transition to another person who would
function as the therapist. The gains made
early in the diagnostic relationship, how-
ever, would serve as a major impetus for
the psychotherapeutic process, if the
transition were skillfully handled.
In reviewing the diagnostic evaluation
process with this child, it seems that
diagnostic testing could facilitate treat-
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ment not only by presenting the therapist
with the analysis of test responses, but
also by having a direct and highly signifi-
cant effect of facilitating communication
with the patient. One can argue that this
is a dramatic case or that there is less
differentiation between therapy and
diagnosis with children than with adults,
but the diagnostician and the patient, in
any diagpostic situation, share poignant
and sensitive material and the diagnos-
tician can either notice but not respond
to these poignant moments or can begin
to integrate his therapeutic and diagnostic
skills and attempt to facilitate more
directly the treatment process.
Tf one makes the assumption that in
diagnostic testing unconscious and pre-
conscious material is provoked and
elicited which has direct relevance for a
patient's particular conflicts, then the
patient must be aware to some degree of
this emerging material. This awareness
may take the vague form of a patient
being uncomfortable about a particular
response or it may take a more direct
form of a patient being aware that a
particular TAT story is explicitly auto-
biographic. Some Rorschach responses
are accompanied by strong affective re-
actions and on occasion patients will also
have the feeling that a Rorschach re-
sponse reminds them of a particular event
or object that they have experienced in
their life. If some of the responses given
in diagnostic testing relate to conflictual
issues, and if the patient is aware to some
The Validity of Projective Techniques
degree of their relevance, the posture
taken by tlhe diagnostician toward this
material can influence the patient's
expectations of what might be encount-
ered in other aspects of the clinical
context. If the diagnostician is distant,
seemingly disinterested in the material, or
only interested in recording and observ-
ing, the patient may see this reaction as
typical of ]many clinical interactions. If
the diagnostician attempts to minimize,
avoid, or reassure the patient about dis-
turbing material, he suggests a model
which encourages the avoidance or sup-
pression of painful and disruptive
thoughts and affects rather than actively
encouraging the patient to recognize, to
understand, and to cope with this ma-
terial. If the diagnostician, on the other
hand, communicates explicitly and
implicitly to the patient an interest in the
patient's thoughts and feelings because
they are direct and significant communi-
cations, the patient may expect similar
reactions from other members of the
clinical staff. The patient can begin to
share the clinician's attempts to recognize
and understand the patient's thoughts
and feeling!;.
There need not be a sharp juxta-
position between the patient's experi-
ences in diagnostic evaluation and in
psychotherapy but the therapist and the
diagnostician can strive toward the sense
of continuity. A therapeutic tone could
be establislhed in the diagnostic relation-
ship, by considering testing as an exten-
sion of therapy and the patient and the
diagnostician may have the option of
respondang to the emerging material in a
variety of ways. A patient may spontane-
ously elaborate the relevance of a particu-
lar response, or the diagnostician, as part
of general inquiry at the end of a particu-
lar procedure, may want to inquire into
the patient's general reactions to testing
or to the observation that he seemed
concerned about a particular response. If
the diagnostician and the therapist have
tentatively agreed on a particular treat-
ment plan for a patient (if, for example,
they agreed that the patient seems to
have the resources to cope with difficult
 SIDNEY J. BLATT
material), a diagnostician might comment
to a patient that he seemed upset by a
particular card and ask what the patient
thought about this. By enlisting the
patient's aid in understanding what he is
experiencing and thnking, the patient is
offered the option of avoiding this tenta-
tive confrontation or he has the oppor-
tunity, as he will have in therapy, to
explore his feelings and thoughts around
this event. Thus the patient's responses
add an important dimension to the diag-
nostic appraisal - the assessment of the
patient's initial capacity for candor and
introspection. In offering the patient the
opportunity for exploration, one directly
assesses the patient's capacity and willing-
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ness to begin to establish a therapeutic
alliance. The maneuvers a patient uses in
dealing with this opportunity for explora-
tion can offer valuable insight into the
major assets or obstacles a therapist may
encounter in working with the patient.
This proposal raises the possibility that
the therapist might also conduct the
diagnostic evaluation. Most often, how-
ever, it seems appropriate that the diag-
nostic and the therapeutic functions be
assumed by different members of the
clinical staff. It is valuable with difficult
and ambiguous patients to have an inde-
pendent opinion; even more important, it
is often helpful for some patients to have
the possibility of maintaining a separation
between "evaluation" and therapy.
Leventhal, Slepian, Gluck and Rosen-
biatt (1962) and Boreham (Note 3) have
discussed a more active transaction be-
tween patient and diagnostician and how
these may influence the patient's subse-
quent behavior in clinical settings and
permit a fuller assessment of the patient's
accessibility for thesapy. Equally impor-
tant, however, is the fact that in this type
of diagnostic transaction, there is a conti-
nuity between diagnostic assessment and
psychotherapy. If the therapist and diag-
nostician have discussed fully the tenta-
tive treatment orientation and plan for a
particular patient, the diagnostician can
respond t o material that emerges in diag-
nostic testing in a fashion similar to the
way the therapist might respond. If the
patient, for example, is to receive pri-
marily supportive, rather than interpre-
tive psychotherapy, the diagnostician's
response to emerging conflictual material
should be consistent with that decision.
The diagnostician's orientation to emerg-
ing material and issues should be one of
support and consolidation. When the
patient seems distressed and concerned
about the material elicited, the diagpos-
tician can offer reassurance or support
the patient's defenses. If the treatment
plan is undecided, the diagnostician may
want to assume a more neutral role,
possibly altering his reactions to the
patient as a function of his increasing
knowledge of the patient through the test
data and as there is more general agree-
ment in the clinical setting about the
therapeutic plan for the particular
patient. As the material evolves over
several diagnostic sessions, the clinician,
using traditional structural and content
dimensions of test protocols, may be able
to form impressions about the relative
strengths and capacities of the patient
and what may be the major areas of
conflict. If the therapeutic plan, on the
other hand, is one of uncovering and
working intensively with the patient, then
the diagnostician may take a similar
orientation toward the patient. He can
permit the patient to focus on and
elaborate sources of conflict and diffi-
culty that emerge during testing, possibly
articulating dimensions which might not
have been available until later in the
psychotherapeutic process. As distressing,
significant, and revealing material is elici-
ted, the diagnostician may comment on
the patient's seeming, distress and offer
the patient the opportunity to explolre
and elaborate this material. As the patient
discusses this material and begins to
consider its relevance and importance, the
diagnostician can encourage the patient
to bring this material into his therapy
sessions. This approach to diagnostic test-
ing is based on the ass;umption, that the
material elicited by the Rorscbwh and
TAT is particularly central to a patient's
problems and that it may not bw t ex-
pressed for some time in treatment. If the
diagnostician's response to sagmants of

the material enables the patient to recog-
nize emerging material, to elaborate its
relevance and importance, and to deal
with t h s material more intensively in the
enduring relationship with his psycho-
therapist, diagnostic testing can be an
important facilitation of the therapeutic
process. In this approach to diagnostic
testing, the diagnostician serves as a
bridge between therapist and patient,
enabling the patient to articulate relevant
and possibly crucial dimensions and en-
couraging the patient to deal with these
issues in more detail with his therapist.
An example of this approach in diag-
nostic testing is illustrated in the testing
of a 45-year-old man who had had a
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cerebrovascular accident. There was a
marked loss in functioning and diagnostic
testing was requested to assess the degree
of impairment. During the Wechsler the
patient became very upset and, in intense
despair, expressed his concerns about the
drastic changes that had recently taken
place. Just a few weeks earlier he had
been a successful businessman, bright and
intact, and now he was faced with severe
memory impairment, physical disability
and a marked aphasia. A diagnostician, in
an attempt to aid the patient and himself
avoid the painful confrontation of the
severe loss in functions, could offer
support and reassurance by indicating the
possibility of spontaneous recovery or the
effectiveness of current physical
therapies. The painful confrontation
could be avoided by supporting the ten-
dency to utilize denial, a defense not
atypical in patients with acute central
nervous system damage. But one could
also realistically acknowledge that indeed
the patient had suffered a marked loss in
function and that testing was an attempt
to assess the degree of loss so that the
patient and his doctor could make plans
for coping with these problems. By
acknowledging the loss in functioning,
the diagnostician could encourage the
patient to face his problems realistically
and encourage him to cope with them
and could communicate the feeling that
the patient's problems were not hopeless
or insurmountable and that the clinical
staff were willing to try to help hi cope
The Validity of Projective Techniques
with these difficulties.
Another case, illustrative of this ap-
proach in diagnostic testing, was a
23-year-old single female patient who had
been hospitalized on numerous occasions
during the prior eight years with a diag-
nosis of schizophrenia, and her most
recent hospitalization followed a suicide
attempt. Testing was requested by the
therapist to confjrm his tentative formu-
lations that the patient had little capacity
for intensive psychotherapy. The initial
plans were to work toward establishing a
reasonable level of integration and con-
trol, leading to eventual discharge from
the hospital. If this was not readily
attainable, the patient was to be trans-
ferred to a state hospital for long-term
commitment. During the testing, the diag-
nostician was impressed with the relative
intactness of the woman's thought pro-
cesses. Although there were extensive
indications of primitive content, there
were relatively few indications of thought
disorder. Her Wwhsler scatter was intact
and her Rorschach contained accurate
perceptions which were only on occasion
disrupted by fabulized thinking. There
were no indications of contaminatory or
confabulatory thinking, autistic logic, or
associative fluidity. The initial diagnostic
relationship was characterized by her
attempts to avoid testing and to reduce
her apprehension about testing by being
playful and flirtatious and by attempting
to depreciate tho diagnostician. As testing
proceeded through five diagnostic ses-
sions, however, the tone of the relation-
ship began to shift toward a more serious
and thoughtful interaction. At the end of
the Rorschach the patient inquired about
her responses and in the subsequent
discussion she indicated that her primary
concern was about the homosexual impli-
cations of her response to Card VII. On
this card she saw "two cherubs probably
sticking their tongues out at each other.
They were fairy-like, like in a pose of two
male homosexuals." She asked if this
meant that she was a homosexual. The
examiner replied that he did not know
for certain but it seemed that she was
concerned about homosexuality.
Cautiously the patient began to discuss
 !SIDNEY J. BLATT
her fears of her homosexual thoughts and
her feelings of disgust about earlier homo-
sexual relationships. She indicated that
she had~wantedin the past to talk about
this with several of her therapists but was
always frightened of approaching the
issue. Apparently, the recognition that
she had already revealed her homosexual
preoccupations in her test responses gave
her the freedom to explore this issue
more fully. Also, the relationship with
the diagnostician was limited and transi-
tory and may have seemed a somewhat
safer situation for testing the reactions of
the clinical staff. The diagnostician, in
offering the opportunity for exploration,
enabled the patient to prepare for discus-
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sing the material with her therapist. The
structure and content of the test proto-
cols, along with the patient's capacity for
candor and introspection, clearly indica-
ted her accessibility for psychotherapy.
The woman's capacity for entering inten-
sive psychotherapy was discussed with
her therapist as was the emergence of
both her desire and fear of discussing the
h~omosexualmaterial. Diagnostic testing
in this case not only served to clarify the
inaccurate initial assessment of her
capacity to benefit from psychotherapy,
but as reported subsequently by the
tlherapist, it facilitated treatment by
making specific conflictual material avail-
able in therapy for the first time.
Occasionally in diagnostic testing with
borderline psychotics, patients can be-
come acutely agitated and increasingly
disorganized, particularly while taking the
Rorschach. The demands of coping with
ambiguity and diffusion in the Rorschach
can precipitate acute disorganization. In
my experience I have seen one psychotic
break in a borderline patient which
seemed precipitated by the experience of
taking the Rorschach. Federn (1952)
bsiefly comments on the relatively rare
precipitation of a psychotic break in
secriously disturbed patients after taking
the Rorschach. An important therapeutic
response in diagnostic testing, particularly
with borderline patients, may be the
postponement or discontinuing of testing
if there are indications of the patient's
move toward serious decompensation.
The consideration of alternative modes
of response in the diagnostic transaction
requires that the clinician have extensive
experience both in diagnostic testing and
in therapy. The utilization of the diagnos-
tic situation to facilitate the psychothera-
peutic process is contingent upon the
clinician's skills as a therapist and his
capacity to understand the various dimen-
sions of test protocols and the clinical
transaction. It is only when the extensive
experience with the formation of clinical
inferences on projective techniques is
integrated with clinical sensitivity and
experience in psychotherapy that the
diagnostician can decide when and where
during tesling a patient needs support and
structure and where exploration should
be encouraged.
There are, of course, inherent limita-
tions in this approach to diagnostic test-
ing. The diagnostician must be aware of
the influence he has on subsequent diag-
nostic material. Although most inquiry
and explorations of a patient's responses
would be conducted after the completion
of the particular test, responses in subse-
quent diagnostic sessions may still be
influenced. It is also possible for the
diagnostician to lose perspective of the
fact that he is an extension of therapy
and is not the therapist himself. The
diagnostician's attempts to facilitate the
therapeutic process must be closely
coordinated with the therapist's orienta-
tion and goals. A therapist may want to
proceed on a supportive level with short-
term patients; or a particular patient,
though pgrchologically capable of enter-
ing into intensive treatment, may be
financially unable to continue treatment.
The diagnostician should not create
expectations in the patient about treat-
ment, which for practical considerations,
cannot be met. If the diagnostician's
relationship with the therapist is not well
established, the therapist can perceive the
diagnostician as intruding into the thera-
peutic relationship. The patient can be-
come the stage for the: acting out of the
competitive strivings of both ~e diagnos-
tician and therapist. If, however, the
diagnostician and theleapist have estab-
lished a cadlaborative relationship based

on mutual trust and respect, the diagnos-
tician can support current defenses as the
patient attempts to cope with the feelings
provoked by diagnostic testing or he can
offer the patient the opportunity to
explore his feeliqgs and his preconscious
recognition of conflict-laden material.
The sensitive and subtle reactions to
segments of the diagnostic material create
a continuity between diagnosis and ther-
apy, while permitting each of these roles
to maintain their relative contribution to
the clinical process. The diagnostician can
still make a unique contribution to the
therapeutic process through an insightful
analysis of test protocols, but he can also
contribute through his responses to the
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patient's struggles with material elicited
by the diagnostic procedures.
On occasion, the relationship estab-
lished in diagnostic testing can become
intense. Exploring critical and sensitive
material in the brief and temporary diag-
nostic relationship does not give a patient
much opportunity to resolve the feelings
that may be evoked in the relationship
with the diagnostician. Patients may re-
quest retesting prior to terminating treat-
ment, ostensibly for reassurance that they
are now ready for termination or dis-
charge. It seems, however, that they may
also be attempting to resolve a relation-
ship established earlier when they were
initially seen for testing.
The active transaction between patient
and diagnostician adds several dimensions
to diagnostic testing. First, it can influ-
ence the attitude and orientation with
which a patient approaches subsequent
clinical contacts. If the patient perceives
the diagnostician as actively interested in
his thoughts and feelings, the patient can
expect similar reactions from other mem-
bers of the clinical staff. Also, this ap-
proach permits a fdler assessment of the
patient's capacity to enter into a thera-
peutic dliqnce. Observation of a patient's
modes pf response to offers of support or
exploration can provide valuable addi-
tional insight into the major assets or
obst~clrtsthat a patient may present in
therapy. Even more important, however,
is the fact that in the patient-diagnos-
tician transaction the patient can be aided
The Validity of Projective Techniques
in becoming more fully aware of critical
material that emerges during diagnostic
testing. If the patient begins to elaborate
these possibly critical dimensions in the
diagnostic setting and is able to bring
them back into the ongoing therapeutic
rela ti onship, the psychotherapeutic
process may be markedly facilitated.
Projective techniques can provide the
clinical psychologist, as well as the
patient, with diffusion, ambiguity and a
relative lack of structure. As with our
patients, much of what we do with this
potential ambiguity and lack of structure
depends on our creative capacities to
differentiate and synthesize. Projective
techniques have important contributions
to make to some research endeavors and
to the clinical process if we are able to
recognize and articulate the limitations as
well as the exciting potentials inherent in
these procedures.
References
Allison, J., & Blatt, S. J. The relationship of
Rorschach Whole responses to intelligence.
Journal of Projective Techniques & Person-
ality Assessment, 1964,28, 255-260.
Blatt, S. J., & Allison, J. Methodological con-
siderations in Rorschach research: The W
response as an expression of abstractive and
integrative strivings. Journal of Projective
Techniques & Personality Assessment, 1963,
27, 269-278.
Blatt, S. J., & Allison, J. The intelligence test in
personality assessment. In A. Rabin (Ed.),
Projective techniques in personality assess-
ment. New York: Springer, 1968.
Blatt, S. J., Allison, J., & Feirstein, A. The ca-
pacity to cope with cognitive complexity.
Journal of Personality, 1969, 37, 269-288.
Draguns, J. G., Haley, E. M., & Phillips, L.
Studies of Rorschach content: A review of
research literature. Part 111: Theoretical
formulations. Journal of Projective Tech-
niques and Personality Assessment, 1968,
32, 16-32.
Fedem, P. Ego psychology and the psychoses.
New York: Basic Books, 1952.
Friedman, H. Perceptual regression in schizo-
phrenia. An hypothesis suggested by the use
of the Rorschach test. Journal of Projective
Techniques, 1953,17, 171-186.
Gardner, R., Holzman, P. S., Klein, G. S.,
Linton, H., & Spence, D. P. Cognitive
control - a study of individual consistencies
in cognitive behavior. Psychological Issues,
#4. New York: International Universities
Press, 1959.
 !SIDNEY J. BLATT
Gardner, R. W., Jackson, D. N., & Messick, S. J.
Personality organization in cognitive con-
trols and intellectual ability. Psychological
Issues, #8. New York: International Univers-
ities Press, 1960.
IHaley, E. M., Draguns, J. G., & Phillips, L.
Studies of Rorschach content: A review of
research literature. Part 11: Non-traditional
uses of content indicators. Journal o f Pro-
jective Techniques and Personality Assess-
ment, 1967, 31, 5-38.
I-Iolt, R. R. manual for the scoring of primary
process manifestations in Rorschach respon-
ses. (8th ed.) New York: Research Center
for Mental Health, 1962.
Holt, R. R., & Havel, J. A method for assessing
primary and secondary process in the Ror-
schach. In M. A. Rickers-Ovsiankina (Ed.),
Rorschach psychology. New York: Wiley,
1960, 263-315.
Downloaded by [Central Michigan University] at 05:42 05 December 2014
Kaplan, A. The conduct of inquiry. San Fran-
cisco: Chandler, 1964.
Leventhal, T., Slepian, H. J., Gluck, M. R., &
Rosenblatt, B. P. The utilization of the
psychologist-patient relationship in diagnos-
tic testing. Journal of Projective Techniques,
1962,26, 66-79.
Rapaport, D., Gill, M., & Schafer, R. Diagnostic
psychological testing. Chicago: Year Book,
1946.
Smason, E. K. The discriminatory value of the
Rorschach test between two etiologically
different, mentally defective groups. Unpub-
lished PhD Thesis, Clark University, 1950.
Schafer, R. Psychoanalytic interpretation in
Rorschach testing. New York: Grune &
Stratton, 1954.
Shapiro, D. Neurotic styles. New York: Basic
Books, 1965.
Witkin, H. A., Dyk, R. B., Faterson, H. F.,
Goodenough, D. R., & Karp, S. A. Psycho-
logical differentiation. New York: Wiley,
1962.
Reference Notes
1. Mayman, M. Form level scoring manual
Unpublished manuscript, Menninger Foun-
dation, Topeka, Kansas, 1962.
2. Engel, M., & Blatt, S. J. Clinical inference in.
psychological diagnosis. Paper presented at
the meeting of the American Psychological
Association, Philadelphia, August, 1963.
3. Boreham, C. Projective testing in a changing
climate. Paper presented at the VII Inter-
national Congress of Rorschach and Other
Projective Techniques, London, August,
1968.
Sidney J. Blatt, PhD
Department of Psychiatry
Yale University
333 Cedar Street
New Haven, Connecticut 06510
Received: January 31,1974
Revised: June 3,1974