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The Thematic Apperception Test, The Children's Apperception Test, and The Senior Apperception Technique in Clinical Use SIXTH EDITION LEOPOLD BELLAK, M.D. Emeritus Professor of Psychiatry, Albert Einstein College of Medicine/Montefiore Medical Center Clinical Professor of Psychology, Postdoctoral Program in Psychotherapy, New York University

DAVID M. ABRAMS, Ph.D. Clinical Associate Professor in Clinical Psychology Doctoral Program in Clinical Psychology, City University of New York Doctoral Program in School Psychology, Ferkauf Graduate School of Yeshiva University Boston

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Nihil est in intellectu quid non antea fuerit in sensibus. Hume Esse est percipi. Berkeley Allyn & Bacon A Viacom Company Needham Heights, MA 02194 Internet: www.abacon.com America Online: keyword: College Online Copyright © 1997, 1993, 1986, 1975, 1971, 1954 by C.RS., Inc. All rights reserved. No part of the material protected by this copyright notice may be reproduced or utilized in any form or by may means, electronic or mechanical, including photocopying, recording, or by any information storage and retrieval system, without written permission from the copyright owner. Library of Congress Catag-in-Publication Data Bellak, Leopold The Thematic Apperception Test, the Children's Apperception Test, and the Senior Apperception Technique in clinical use / Leopold Bellak and David M. Abrams. --6th ed. Includes bibliographical references and index. ISBN 0-205-18999-7 1. Thematic Apperception Test. 2. Children's Apperception Test. 3. Senior Apperception Technique. I. Abrams, David M. II. Title. RC473.T48B45 1996 96-29032 155.2'844-dc20 CIP

THE PRO Printed in the United States of America 10 9 8 7 6 5 4 00 99

CONTENTS Preface About the Authors CHAPTER 1 INTRODUCTION The Projective Hypothesis Description of the T.A.T. History of the T.A.T., C.A.T., and S.A.T. Six Decades of T.A.T. Research Bellak and Exner A Basic Set of T.A.T. Cards for Males and Females 1 1 6 7 11 13 15 CHAPTER 2 THEORETICAL FOUNDATIONS FOR PROJECTIVE TESTING The Psychology of Projective Techniques in General and the T.A.T. in Particular Apperceptive Distortion: A Theory Concerning Content of Responses as Seen Particularly in the T.A.T. The Basic Assumptions for Diagnostic Inferences from the T.A.T. and Similar Methods Toward a General Psychology of Thematic Apperception Tests 16 17 31 41 46 CHAPTER 3 CLINICAL USE OF THE T.A.T. The T.A.T. and Related Methods Indications for Use of the T.A.T. Standard istrative Procedure for the T.A.T. Psychological Problems of Test istration 48 48 51 54 57

vi CONTENTS CHAPTER 4 THE T.A.T. PICTURES AS STIMULI Standard Sequence of 10 T.A.T. Cards Typical Themes Elicited by the Standard T.A.T. Sequence Typical Themes Elicited by the Other T.A.T. Cards Sequential Analysis of the Standard T.A.T. Sequence CHAPTER 5 REVIEW OF SCORING APPROACHES FOR THE T.A.T. CHAPTER 6 THE BELLAK SCORING SYSTEM Observation-Near and Observation-Distant Diagnosis The Bellak T.A.T. Analysis Blank How to Use the T.A.T. Analysis Blank Scoring Categories (10 Variables) The Summary and Final Report The Short Form of the Bellak T.A.T. and C.A.T. Blank Case Illustrations CHAPTER 7 SOME CLINICAL AND OTHER SPECIAL PROBLEMS OF THE T.A.T. On Diagnostic Groups The Influence of Contemporary Events on the T.A.T. Stories CHAPTER 8 USE OF THE T.A.T. IN PSYCHOTHERAPY Special Therapeutic Uses of the T.A.T. The Systematic Use of the T.A.T. in Relation to the Basic Steps of Psychotherapy Use of the T.A.T. in Group Psychotherapy Programs Diagnostic Aspects in Relation to Therapy Some Contraindications to the Use of Psychological Tests CHAPTER 9 REVIEW OF LITERATURE RELEVANT TO INTERPRETATION OF THE T.A.T. Stimulus Value of the T.A.T. Sample Variables Aggression and Hostility Motivation and Apperception Study of Character and Defenses in the T.A.T. 59 60 61 66 72 76 89 90 92 92 94 103 104 106 152 152 164 172 172 176 180 181 182 184 184 185 188 191 195

CONTENTS vii CHAPTER 10 THEMATIC ANALYSIS IN THE STUDY OF NARRATIVE AND LIFE HISTORY Somerset Maugham: Analysis of the Stories Summary Final Report Discussion CHAPTER 11 OBJECT RELATIONS ASSESSMENT WITH THE T.A.T., C.A.T., AND S.A.T. Perspectives on Object Relations Theory An Object Relations Approach to T.A.T. Analysis T.A.T. Protocol of a Neurotic Adolescent Boy T.A.T. Protocol of an Actively Psychotic Man CHAPTER 12 BORDERLINE AND NARCISSISTIC DISORDERS IN THE T.A.T., C.A.T., AND S.A.T. Brief Overview of the Diagnostic Concept of Borderline and Narcissistic Disorders Salient Indicators of Pre-Oedipal- and Oedipal-Level Functioning C.A.T. Protocols Illustrating Pre-Oedipal- and Oedipal-Level Functioning Specific Indicators of Borderline Pathology T.A.T. Protocol Illustrating Borderline Disorders with Some Psychotic-Like Features Specific Indicators of Narcissistic Pathology C.A.T. Protocol Illustrating Narcissistic Pathology CHAPTER 13 THE T.A.T., C.A.T., AND S.A.T. IN NEUROPSYCHOLOGICAL ASSESSMENT Some General Remarks on Neuropsychological Assessment Identifying Features of Neuropsychological Deficit in the T.A.T. and C.A.T. Responses C.A.T. Protocol Illustrating Attention Deficit Disorder T.A.T. Protocol Illustrating Attention Deficit Disorder CHAPTER 14 THE C.A.T. Nature and Purpose of the Test History of the C.A.T. and the C.A.T.-H Theory of the C.A.T. Some Differences between C.A.T. and T.A.T. Responses 205 207 213 214 215 216 216 218 219 226 234 234 235 239 242 243 248 249 255 255 257 262 267 272 272 276 278 284

viii CONTENTS istration of the C.A.T. Description of and Typical Responses to Pictures Influence of the Perceptual Aspects of the Stimulus on Responses CHAPTER 15 THE C.A.T.-H Development of the C.A.T.-H Review of Studies Comparing Animal versus Human Pictures Modification of the Pictures for Use in the C.A.T.-H Studies with the C.A.T.-H CHAPTER 16 INTERPRETATION OF THE C.A.T. Ten Variables Use of the Short Form T.A.T. and C.A.T. Blank Case Illustrations Further Examples Special Clinical Problems Illustration of Longitudinal Clinical Data CHAPTER 17 A SUPPLEMENT TO THE C.A.T. Purpose of the C.A.T.-S. istration Inquiry Description of and Typical Responses to Pictures Interpretation Norms Case Illustrations 285 286 289 291 291 291 292 292 301 302 3o7 307 348 352 355 359 359 360 361 362 364 364 368 CHAPTER 18 REVIEW OF LITERATURE RELEVANT TO INTERPRETATION OF THE C.A.T. 371 Use of the C.A.T. in Developmental Assessments of Normal Children 371 Sample Variables and Sociocultural Studies 372 Diagnostic Studies 373 Bases for Interpretations 376 Interpretive Outlines 377 CHAPTER 19 THE S.A.T. Nature and Purpose of the Technique Construction of the Senior Apperception Technique Four Pilot Studies Based on the S.A.T. 379 380 382 385

CONTENTS ix istration Description of and Typical Responses to Pictures Interpretation Case Example Future Use of the Senior Apperception Technique CHAPTER 20 GENDER AND MULTICULTURAL ASSESSMENT WITH THEMATIC TESTS Domains of CrossCultural Inquiry A Standard Battery with Adequate Test Norms Development of Culture-Specific T.A.T. Cards The Question of Gender, Cultural, and Power Bias Conclusion CHAPTER 21 THE PSYCHODIAGNOSTIC TEST REPORT BLANK References Name Index Subject Index 388 396 403 403 406 410 410 412 413 422 426 432 440 479 485

PREFACE It is now over six decades since the first publication on the Thematic Apperception Test by Morgan and Murray (1935) and over four decades since Leopold Bellak published the first edition of this book in 1954. Leopold Bellak and Sonya Sorel Bellak developed the Children's Apperception Test (C.A.T.), the Children's Apperception Test-Human Figures (C.A.T.-H.), the Children's Apperception Test- Supplement (C.A.T.-S.) for children, and the Senior Apperception Technique (S.A.T.) for elderly individuals. Thematic tests are now mainstays in the standard battery of psychological tests employed by nearly every psychologist who conducts a psychological evaluation. The many new advances in the research and clinical use of thematic tests have contributed to major revisions in this book over the last six editions. In the past, many psychologists have been unsure as to the value of the T.A.T. in diagnostic assessment, since past practices have been characterized by inadequate methods of istration that elicit only sparse descriptions of T.A.T. cards, choosing different cards for different test takers based on which cards "pull" for material that resembles the test taker's personality, and interpreting the stories based only on "an impressionistic summary of themes." This sixth edition presents a clear and scientifically consistent approach to the T.A.T. with a standard method of istration, a standard T.A.T. sequence of 10 cards (which can be supplemented by cards that "pull" for specific material), and a standard method of scoring. This is the same concept that Bellak utilizes with the C.A.T. and C.A.T.-H., which can be supplemented by other cards from the C.A.T.-S., and the S.A.T., which can be supplemented by other cards after the standard sequence is istered. Another development in thematic testing is a multidimensional assessment approach, which is part of the Bellak Scoring System. Originally, thematic tests were considered only personality tests; today, the contemporary psychologist utilizes an entire group of tests in the psychological test battery to evaluate all the different dimensions of cognitive-intellectual functioning, neuropsychological or learning disability assessment, creative thinking, and social-emotional functioning. Intelligence tests are no longer considered only cognitiveintellectual measures. The Bender Gestalt test is no longer considered only a neuropsychological screening instrument, and the T.A.T. and the Rorschach are no longer employed only as personality, projective tests. Psychologists use intelligence tests to evaluate intellectual functioning; however, test behavior and other aspects of the intelligence test also reveal many aspects of the test taker's personality. The Bender Gestalt is primarily employed for screening perceptual-motor neuropsychological functioning; however, specific evaluation XI

xii PREFACE of line pressure, spacing of designs, and size of designs also reveal a lot about personality characteristics. Thematic tests are primarily windows into the inner feelings, conflicts, defense and coping mechanisms, interpersonal relations, and other personality" factors of the test taker. Psychologists also utilize them to obtain a sample of language usage, evaluate the level of logical thinking in the organization of story elements into a coherent whole, and evaluate other aspects of cognitive, intellectual, and neuropsychological functioning of the test taker. (See the updated Chapter 13 on neuropsychological assessment with thematic tests and the two case examples of individuals with attention deficit disorder). Murray's (1943a) Thematic Apperception Test Manual, which is published with the test pictures, is no longer employed in clinical use of the T.A.T. Leopold Bellak worked with Murray during the development of the T.A.T. and developed an interpretative system that includes part of Murray's scoring approach within a more comprehensive and practical scoring system. Thus, this book has become the primary manual for istering and interpreting the T.A.T., and, of course, the C.A.T. and the S.ASI: The last six decades of extensive research and clinical use of these tests have set in motion a process of continuous revision and updating of the text in order to provide for a comprehensive and current coverage of the main uses of these tests in contemporary practice. What was once the relatively slim volume of the first edition of this book has now grown into a substantial book in order to provide an overall review of the clinical use and research with the T.A.T. and related methods and to show the clinician how to ister thematic tests in a standardized manner and how best to score the T.A.T. protocol from a clinical standpoint. The primary purpose of this book is to improve the psychologist's ability to utilize the T.A.T., C.A.T., and S.A.T. in making clinical diagnoses and facilitating the psychotherapeutic process. Since the senior author is a long-standing exponent of Freud's ego psychology and its related object relations and self-psychology approaches, this book also includes an introduction to the history and theory of the psychoanalytic, or psychodynamic, approach to projective testing in Chapter 2. This chapter, entitled "Theoretical Foundations for Projective Testing," shows how pivotal this perspective is in the history of projective tests and why Murray and others employ the term apperception in the names of most of the thematic tests. The book also provides as comprehensive a review of research with thematic tests as possible in order to assist students and researchers undertaking their own research. However, our main aim is for this book to serve as a practical handbook for the working clinician to consult on aspects of testing different age groups, individuals of different gender and cultures, and different clinical disorders. The chief goals in this book are the following: 1. To provide an explanation of the theoretical bases for thematic tests in particular and projective tests in general 2. To provide a comprehensive, up-to-date introduction to thematic tests in clinical use 3. To provide a comprehensive review of the clinical and research literature on thematic tests 4. To present the background on the varieties of istration of the T.A.T. in the field and the rationale for following a standard "set" T.A.T. istration

PREFACE xiii 5. To provide a clear introduction to the Bellak Diagnostic Scoring System for thematic tests 6. To provide an understanding of how the Bellak Interpretive System facilitates assessment of different pyschiatric disorders 7. To provide an introduction as to how thematic tests may be utilized in the treatment process 8. To provide a review of the important gender and cultural issues in utilizing thematic tests in research and psychological evaluation. For the sixth edition, we have added two pivotally important and related new chapters: Chapter 1, which gives an introduction to the projective hypothesis and the main sections and issues in the clinical use of thematic tests, and Chapter 20, which reviews the many attempts to develop gender-specific and culture-specific thematic tests. The majority of this past literature has been limited to adapting Murray's original T.A.T. pictures primarily by making pictures that portray people, background settings, and situations familiar to the particular culture. In today's multicultural society, we emphasize that the contemporary clinical use of thematic tests also needs to take into consideration the test taker's primary language and cultural belief framework, the existence of test norms for the thematic test being employed for the test taker's particular culture, and the gender and cultural context of the testing situation (i.e., whether the tester is male, the test taker female, the tester of mainstream culture, the test taker of a minority culture, etc.). The ends of Chapters 1 and 20 come back to our beginning issue of the projective hypothesis as to what makes for the most meaningful and revealing projective test - pictures that are clearly similar to the individual being tested, pictures that are slightly ambiguous or that portray individuals slightly different from the test taker, culturally familiar everyday situations, or situations that portray universally powerful human situations? In this continuing debate on the importance of gender and cultural sensitivity in psychological testing, we emphasize that the value of culturally specific T.A.T. cards should not overshadow the equally important value of a standardized T.A.T. istration, comprehensive categories of interpretation, norms for different ages and different psychiatric disorders, and more quantitative test analyses in order to bring the T.A.T. to the level of Exner's (1994) more quantitative approach for scoring the Rorschach. This book emphasizes that the last six decades of research and clinical use of thematic tests have brought professionals much closer to a more standardized and scientific approach to the use of these tests in clinical practice. The establishment of age, gender, and cultural norms for individuals with different clinical disorders make it possible for the psychologist to ister a standard T.A.T. card sequence with individuals of widely different cultures and to supplement the standard T.A.T. sequence with gender- specific and culture-specific cards, if these are available. Other highlights of this new edition are major revisions of the extension of the Bellak Scoring System to the lively interdisciplinary field of the study of narrative and life history (Chapter 10), guidelines have been added for the assessment of adolescents with the T.A.T. (Chapter 7), and substantial updating of the chapter on the S.A.T., which now includes new test pictures (Chapter 19). Chapter 19 describes the critical role of thematic tests in the important, developing field of social

xiv PREFACE gerontology or geriatic psychology, and it provides a clinical case example utilizing the 1996 revised S.A.T. pictures. The entire book has been completely revised and updated to include references that (1) are more comprehensive, to include the most significant publications from the entire span of six decades of thematic test research; and (2) cover the important and exciting new research in the last decade. Several individuals have contributed significantly to this book over the y-ears. Drs. Leonard Small and M. Brewster Smith read the first edition of the book and made many helpful suggestions. Lynn Lustbader helped with literature review and Ann Noll helped with editorial suggestions with the second edition. Caroline Birenbaum helped edit the third edition. Dr. Susan Berger helped with the fourth edition, and Lorin Perits, Mylan Jaixen, Deborah Reinke, and Lynda Griffiths assisted with the fifth edition. For the sixth edition, Jane Slater contributed many insights, translated the manuscript among several different word-processing formats, handled the considerable international correspondences, kept track of new citations, and provided editing and proofreading. Her monumental efforts to help bring the text into the computer age were indispensable. A wonderful highlight of this new edition is the revised 1996 S.A.T. pictures that were redrawn by artist Violet La Mont, to whom we are very grateful for her fine and careful work. Marina Livshits of the clinical psychology department of Yeshiva University in New York City assisted in istering the new, revised S.A.T. pictures and assisted with the literature review. Michael Hiam helped prepare the bibliography to meet A.P.A. style and contributed important clinical and editorial suggestions. Special thanks also to Emilito Osorno, Yvonne Prempeh, Helen Marsh, Madeleine Seifter Abrams, and Jonathan and Rebecca Abrams for their assistance. At Allyn and Bacon, we are indebted to our main editor, Mylan Jaixen, for his editorial direction and many creative ideas; his assistant, Susan Hutchinson; and Lynda Griffiths of TKM Productions for valuable copyediting. We would also like to thank the three reviewers who contributed many useful suggestions for this revision: Scott D. Churchill, University of Dallas; Steven Kubacki, University of Wyoming; and Sharon Shindelman, Board of Cooperative Educational Services in Yorktown Heights, New York. Finally, Marlene Kolbert, as Leo Bellak's istrative assistant, has had a major role in this book, as she has had in the previous editions. She has also contributed in many invaluable ways over the last decades as the manager of C.ES., Inc., which publishes the C.A.T., C.A.T.-H., C.A.T.-S., S.A.T., the Bellak Short Form for scoring thematic tests, Ego Function Scoring Blanks, handbooks, and other books, (Written by David M. Abrams). A list of these tests and publications may be obtained by writing C.ES., Inc., Box 83, Larchmont, NY 10538, or by calling or faxing a request to (914) 833-1633.

ABOUT THE AUTHORS Leopold Bellak, M.A., M.D. Most psychologists know Leopold Bellak as the inventor of the C.A.T., C.A.T.-H, and S,.T., who worked with Henry Murray at Harvard University from 1940 to 1942 prior to the publication of the T.A.T. (Murray, 1943) and who published one of the first and best experimental research studies on Freud's concept of projection using the T.A.T. (Bellak, 1944), a paper successfully replicated nearly 50 years later by Cramer (1991b). Other inventions in the field of assessment are the scoring tem- plate that is placed over the Coding and Digit Symbol subtests in the Wechsler intelligence tests and the dysphorimeteg, a simple sound-clicking device useful in research on depression, anxiety, pain, and other dysphoric states (Bellak et al., 1989). Born in Vienna, Austria, on June 92, 1916, Bellak attended medical school at the University of Vienna and studied psychoanalysis in Sigmund Freud's last years in Vienna from 1935 to 1938. When Hitler's forces marched into Vienna on March 13, 1938, he was arrested and imprisoned by the Nazi Secret Service. American psychoanalyst, Dorothy Tiffany Burlingham, arranged for Bellak's release, and he was able to emigrate to the United States, where he completed an M.A. in psychology at Boston University in 1939 and an M.A. in psychology at Harvard University in 1942. He completed all requirements for the Ph.D. in psychology, except the dissertation, prior to completing his M.D. at New York Medical College in 1944 and his internship and residency in psychiatry at St. Elizabeth's Hospital in Washington, D.C. He completed psychoanalytic training after an additional four years at the New York Psychoanalytic Institute in 1950. Therefore, Bellak has the highest level of training in the fields of clinical psychology, psychiatry, and psychoanalysis. He is a licensed psychologist in the state of New York and a Diplomate in Clinical Psychology from the American Board of Examiners in Professional Psychology. He is similarly licensed in medicine and psychiatry and certified in psychoanalysis from the American Psychoanalytic Association. Bellak has held many teaching appointments in psychology at City College of New York, the New School for Social Research, Columbia University, and New York University, and in psychiatry at New York Medical College, George Washington University, and Albert Einstein College of Medicine. Bellak published his first book, Dementia Praecox, in 1948, which brought a systems orientation to the diagnosis of schizophrenia and opened it up to be viewed

xvi ABOUT THE AUTHORS not as a single entity but as including several subtypes. He later (1952, 1958, 1969, 1973, 1979) published five additional books on this systems approach to schizophrenia, affective, and related disorders. Along the same lines, he (1979) contributed one of the first books on the diagnosis of attention deficit disorder in adults, continuing to bring a systems perspective to this disorder (1983, 1984, 1986) and a subtype analysis with his identification of "ADD psychosis" (1994). Since Bellak studied psychoanalysis during Freud's last years in Vienna, he brought to Harvard University in the early 1940s the latest thinking in psychoanalysis based on Freud's (1920, 1923) more sophisticated theory of ego psychology. Most U.S. mental health practitioners and academic psychologists at that time knew Freud primarily from his book, The Interpretation of Dreams (1900), and primarily applied Freud's first libido theory, which views the libido, or sexual drive, as the main motivator of human experience. Murray's approach to the T.A.T. was primarily influenced by Freud's libido or drive theory and that of other early psychoanalysts, such as Alfred Adler's emphasis on the aggressive drive and the power motive, Otto Rank's emphasis on the creative drive, and Carl Jung's emphasis on self-realization and other motivators. Murray broadened the early psychoanalytic drive notions to a hierarchy of internal "needs" and environmental "presses." Bellak, on the other hand, chose as his doctoral dissertation the aforementioned experimental study of the ego defense of projection on the T.A.T. (1944), wrote the first paper on how ego defense mechanisms are seen on thematic tests (1950), and developed an ego psychology scoring system for the T.A.T. (1947 and this text). Bellak is equally well known in the fields of psychoanalysis and psychiatric diagnosis for his identification and clarification of 12 ego functions, which has become a major component of diagnostic evaluation by all mental health practitioners, particularly psychiatrists, when they conduct a psychiatric evaluation to evaluate a patient for ission to an inpatient hospital, as part of treatment planning for psychotherapy, and prior to prescribing medication. He (1973) published a major research study on schizophrenics, neurotics, and normals, which established his ego function assessment as an invaluable tool in clinical assessment that has been used by many other researchers and clinicians (Bellak & Goldsmith, 1984) and that Bellak (1989) further clarified in his popular Handbook of Ego Function Assessment. Bellak's ego function assessment is as important in the fields of social work and psychiatric evaluation as the current book on the T.A.T. is in psychology. Bellak's 12 ego functions are an established part of what is known in mental health as the Mental Status. There is not a psychiatrist today who would make a diagnosis of a patient without utilizing Bellak's ego functions, such as reality testing, judgement, sense of reality, object relations, defensive functioning, stimulus barrier, synthetic function, or the level of the individual's adaptive functioning. Bellak is especially appreciated for this ability to translate contemporary mental health concepts into methods of assessment that are clear, direct, and practical. He has developed simple scoring forms that facilitate scoring a T.A.T. (Bellak, 1947, and this text), writing up the overall psychological report (The Psychodiagnostic Test Report Blank, 1965), and conducting a Mental Status evaluation in psychiatry and other fields (Bellak, 1989). Undoubtedly, his training in clinical and research psychology, psychiatry, and psychoanalysis helped him apply an interdisciplinary, systems approach to several

ABOUT THE AUTHORS xvii different fields simultaneously. Hence, the editor of an early collection of Bellak's papers entitled the book The Broad Scope of Psychoanalysis (Spence, 1967), which Bellak (1993) further demonstrates in his presentation of experimental research on psychoanalytic concepts and of the psychoanalytic treatment process in Psycho-analysis as a Science. When he was Chief of Psychiatry at Ehnhurst Hospital in New York City, Bellak established the first 24-hour emergency psychiatry service. His continued contributions in emergency psychiatry, crisis intervention, and community mental health include 11 full-length books (Bellak, 1964, 1965, 1969, 1972, 1974, 1975, 1978, 1980, 1984, 1987, 1992). Another field in which he is one of the major pioneers is social gerontology, geropsychology, or geriatric psychiatry, to which he (1975) contributed the first handbook for the general public and one of the first handbooks in geriatric psychiatry (Bellak & Karasu, 1976). Both lend increased authority to his development of the Senior Apperception Technique (S.A.T.). Bellak is the author of over 37 popular, technical, and research books; over 200 published papers and other unpublished psychological tests, inventions, unpublished papers; and an unpublished play about the inventor of dynamite, Alfred Nobel. The autobiography of his youth, Confrontation in Vienna (Bellak, 1993), "a compelling of the worst sides of Viennese prejudice and barbarity" (Roazen, 1996), provides a dramatic contrast to the many later decades of open- minded and endlessly creative contributions to clinical psychology, psychiatry, and psychoanalysis. His unusual practice and high level of leadership of three active professions caused the psychologist-psychoanalyst Erich Fromm to say, when he first met him, "Oh, I know the other Bellak." Among his many honors are the Annual Merit Award from the New York Society of Clinical Psychologists in 1964, the Frieda Fromm Reichmann Award by the American Academy of Psychoanalysis for outstanding contributions toward a better understanding schizophrenia in 1981; the Bruno Klopfer Award from the Society for Projective Assessment in 1990; the Award for Distinguished Professional Contributions to Knowledge from the American Psychological Association in 1993, and an honorary doctorate in psychology, the Honoris Causa, from the University of Paris in 1996. David M. Abrams, Ph.D. (Written by Leopold Bellak) David M. Abrams has collaborated with Bellak since 1980-1983, when Bellak was his supervisor in the Postdoctoral Training Program in Psychoanalysis and Psychotherapy of New York University's Department of Clinical Psychology. Abrams (1977) had earlier applied an ego psychology and folklore analysis to children's narrative fantasies in his doctoral dissertation at Columbia University under Professor Brian Sutton-Smith, an expert in the developmental psychology of children's expressive behavior (such as storytelling, symbolic play, games, and humor), and Professor Rosalea Schonbar, an expert in clinical psychology research on dream narratives.

xviii ABOUT THE AUTHORS Abrams coauthored with Sutton-Smith (1981) and others, The Folkstories of Children, a book that helped establish the growing, new interdisciplinary field of narrative studies in children and adults. For the 1986 fourth edition of this book, Abrams coauthored three chapters with Bellak on a new way to score object relations on thematic tests, the use of thematic tests in the assessment of borderline and narcissistic disorders, and neuropsychological indicators on thematic tests. The latter chapter presented the first thematic test protocols of the then-not-well-accepted diagnosis of attention deficit disorder (ADD) in children and adults, which has now become the "diagnosis of the 90's." Abrams also coauthored with Bellak and Ruby Ackermann-Engel a book in 1992 entitled Handbook of Intensive Brief and Emergency Psychotherapy. Among his own pioneering papers is one on the intensive treatment of a profoundly deaf girl (Abrams, 1991), dream interpretation (Abrams, 1992) and the first case presentations of thematic test protocols of children and adolescents with a primary diagnosis of the not-yet-well-accepted diagnosis for children of narcissistic disorder (Abrams, 1993, 1995, in press). Abrams has broad experience in the field from personality assessment to neuropsychology, crisis and early intervention, and a long-standing commitment to community mental health with profoundly deaf and poverty populations. He is qualified in both adult psychoanalysis and child psychoanalysis and is a member of the Association for Child Psychoanalysis. Over the last several years, he has been researching and writing a book on Herbert Graf (1903-1972), the inventive opera stage director who was the subject of Freud's (1909) famous case known as "Little Hans" (a 4-year-old boy who was afraid of horses), and working on a handbook on treatment planning. From his doctoral dissertation and 13 years as Chief Psychologist at the Center for Preventive Psychiatry, White Plains, New York, to later work as Clinic Director, East New York Diagnostic and Treatment Center; Lexington Center for Mental Health Services; Associate Clinical Professor in the Doctoral Program in Clinical Psychology at City University; the Doctoral Program in School Psychology of Yeshiva University; and the Institute of Child, Adolescent, and Families Studies in New York City, he has perhaps istered and supervised more thematic tests than many psychologists of his generation. Abrams approaches clinical work as a creative collaboration with patients to help them discover their own cure, which brings unique insight and prescience to his psychological test evaluation and psychotherapy with children, adolescents, and adults.

CHAPTER 1

INTRODUCTION The Projective Hypothesis In the field of psychological testing, intelligence tests such as the Wechsler I.Q. tests and achievement tests such as the Wide Range Achievement Test are often referred to as cognitive tests. Personality assessment instruments such as the House-Tree-Person Drawing Test (H-T-P), Kinetic-Family-Drawing Test (K-F-D), Rorschach, and Thematic Apperception Test (T.A.T.) are often referred to as pro-jective tests. The term projective test goes back to Sigmund Freud's (1900) conception of pro-jection, defined as a psychological mechanism by which an individual "projects" inner feelings onto the external world, then imagines these feelings are being expressed by the outside world toward oneself. For example, a 4-year-old boy is angry at a babysitter who left for another job. He projects this anger onto the babysitter and now believes that the babysitter took another job because "she hates me!" Similarly, when an individual has a dream, draws a picture, or makes up a story, this form of imaginary self-expression may be considered a "projection" onto the dream, drawing, or story of the individual's own inner thoughts, feelings, and conflicts. Cognitive tests generally ask for only one response and are more specific; they are a fact-based way of eliciting what an individual knows about the world and how he or she thinks and solves intellectual, logical problems. Projective tests do not have any correct answers; they are considered to be less structured, more open ended, and more creative, and the individual is freer to express inner feelings and reveal his or her basic personality orientation. A tradition in projective tests is that the more unstructured and more ambiguous the stimulus, the more an individual may express her or his deepest inner wishes, anxieties, and conflicts. If the psychologist asks an individual to "draw a person," the individual may express a deeper feeling about the self-image than if the request is to "draw yourself." Similarly, the Rorschach set of inkblot pictures has the vagueness of looking at clouds that allows everyone to see many different things in them. Some argue that intelligence tests also can be interpreted as projective tests in the sense that the Vocabulary and Comprehension subtests of the Wechsler I.Q. tests can be seen as word association tests; that is, the individual's particular choice of words may contain projections of inner feelings and conflicts as well as the attempt to find the best answer to the questions. Similarly, the Rorschach also presents a perceptual and logical problem for the individual to solve by structuring the inkblot into a logically organized Whole (W) response. When Henry Murray (1943a) and his associates developed the Thematic

2 CHAPTER 1 Apperception Test (T.A.T.), they predominantly had pictures of white, middle-class individuals in different situations, a couple of pictures of working-class and poor people, a dragon near a mountain, an imaginary-looking man in a graveyard, and a pastoral scene of a small lake. They also had different card sequences recommended for women, girls, men, and boys. Murray's idea was that, depending on the individual's age and sex, he or she should be given the sequence that primarily depicted individuals of the same age and gender in order for the individual to feel most comfortable in revealing her or his deepest feelings. Some of the individuals were drawn in order to make the particular gender of the individual ambiguous, so that individuals of both genders could utilize the same pictures. This gave birth to numerous adaptations of the original T.A.T. cards for different ethnic groups, cultures, and countries. Such adaptations were based on the same hypothesis that an individual will feel freest to express inner feelings if he or she is asked to make up stories to pictures that show individuals as the central figures who most resemble the storyteller's age, gender, ethnicity, socioeconomic status, and culture. Since the T.A.T. elicits a group of fantasy narratives, it is probably the projective test most similar to a dream, which Sigmund Freud (1900) believed was the "royal road to the unconscious." For that reason, perhaps, Freud's famous biographer, Ernest Jones, wrote to Murray to tell him that he believed that the T.A.T. provided the best bridge between Freud's psychoanalysis and academic psychology (Robinson, 1992, p. 413). Freud believed that all dreams have disguised meanings beneath the most obvious surface meaning of the story of the dream. The figure that most resembles the dreamer in a dream may be said to be what is closest to the individual's "conscious awareness," whereas the figures least resembling the dreamer may express deeper, more "unconscious" feelings about the self (Abrams, 1992). An exciting, developing area in T.A.T. research in the last two decades, called interpersonal object relations, has as one of its basic assumptions that every figure in a dream or T.A.T. story is an aspect of the self on some level. This approach then looks at the level of interpersonal object relations in a T.A.T. as a way of assessing how an individual being tested conceptualizes his or her relations with others. Bellak (1947, 1950a, 1950b, 1950c, 1950d, 1954a) has frequently pointed out that one of the T.A.T.'s major strengths is that it provides a way to assess a person's relationship with others by examining the relationships among the figures in the T.A.T. stories; "relations to others" has always been one of Bellak's main scoring categories. For the Fourth edition of this book, Abrams and Bellak (1986) published a more specific approach to scoring this dimension of interpersonal object relations, which is the currently updated Chapter 11. Other object relations scoring approaches were published by Thomas and Dudeck (1985) and Westen (1991b). Certain psychiatric disorders - such as schizophrenia and borderline and narcissistic personality disorders - have as one of their major symptoms an impairment in the ability to relate well with other people. Hence, it is important for the clinician to make a very careful and thorough evaluation of this interpersonal relations dimension in a psychological assessment. For that reason, we provide a case example of an actively psychotic man's T.A.T.

INTRODUCTION 3 :lass poor and . the feel iuals , SO dif- the e or fig- staDjec- the :gra- pro- dogy tings ure the the ams, died in a then sing hers. that rela- :A.T. cate- red a ions, ; and :hizo- their ople. :nt. in Chapter 11. We have also updated Chapter 12 to reflect the exciting new developments from the fields of ego psychology, object relations theory, and selfpsychology on the use of thematic tests with individuals who have borderline and narcissistic disorders. Freud's projective hypothesis was also the basis of Bellak and Bellak's (1949) Children's Apperception Test (C.A.T.), which does not consist of pictures of children but of little animals in different situations. The C.A.T. has become the most popular thematic apperception test for children from 3 to about 11 or 12 years of age. This follows the assumption that an individual may feel more comfortable to project feelings about his or her self-image onto a figure drawing if the individual is first asked to "draw a person" rather than "draw yourself." Therefore, one argument is that T.A.T. pictures that are not obviously similar to the individual being tested may help the individual to feel "freer" to express deeper feelings about the individual's internal identity. Blum (1950) also developed a thematic apperception test for children featuring a litde dog named "Blacky"; hence, this test is known as The Blacky Pictures. The C.A.T. has been published in 11 different countries and has become the main thematic test used by school psychologists, by clinicial psychologists, and in a plethora of important research studies. Bellak and Bellak (1965) developed a human version of the C.A.T. called the C.A.T.-H., which is useful for children from 11 or 12 years to 14 or 15 years, if the children are still preadolescent before the age when the T.A.T. would be preferable. Chapters 14 through 18 present the C.A.T. and C.A.T.-H. and their clinical and research tradition. A fascinating quesdon related to the projective hypothesis is: Why do preschool and elementary school-aged children prefer making up stories to the animal pictures of the C.A.T. to making up stories to pictures of children in the same situations on the T.A.T. or C.A.T.-H.? This topic will be discussed in Chapters 14 and 15. Another area of exciting, developing T.A.T. research during the past two decades is the literature on gender and multicultural assessment that appears to dis- agree with presenting individuals being tested with pictures that are ambiguous or somewhat dissimilar to the individual's gender, ethnicity, socioeconomic status, and culture (Abel, 1973, Dana, 1993). Just as it is obviously culturally biased to evaluate an individual's level of intelligence based on I.Q. tests developed and normed for white, middle-class individuals, this research tradition argues that personality assessment also should not be conducted with culturally biased test materials. This assumption has spawned many adaptations of the T.A.T. and C.A.T. for different cultures, which have a huge literature dating from the 1940s to the present. Early research on the Thompson (1949) modification of the T.A.T. for African Americans found that African Americans were as comfortable and told as revealing stories to the Thompson T.A.T. as they did to Murray's T.A.T. The main aim of the majority of cultural adaptations of the T.A.T., the C.A.T., and C.A.T.-H. is to have people and backgrounds that are culturally specific for different cultures. Some of the better cultural adaptations, such as the TEMAS (Costantino, Malgady, & Vazquez, 1981) of the C.A.T.-H. for elementary school- aged urban poor and working class Hispanic American children, attempt to have culturally specific people and backgrounds as well as the depiction of culturally specific situations.

4 CHAPTER 1 The C.A.T.'s depiction of young animals has made this test a universally appealing projective test stimuli for children of widely different cultures, which may make the C.A.T. a more useful clinical and research instrument than the TEMAS with children of the Hispanic American urban culture, since the C.A.T. is basically independent of culture specificity. A drawback of many of these T.A.T. adaptations is that the pictures of people, backgrounds, and situations are not always as revealing and powerful as those of Murray's original cards. Murray and his colleagues worked for over nine years, trying out hundreds of different pictures, redrawing pictures to have a coherence of style, and trying out different sizes to pictures, from the first paper by Morgan and Murray (1935) to the current version of the T.A.T. (Murray, 1943a). It is also interesting that Murray had two versions - the first series of everyday situations and the second series of more dramatic situations--and different pictures for males, females, young boys, and young girls. However, over the years, clinicians have found a combination of pictures that they use with both males and females that are primarily from the first everyday series. Another important point regarding the question of gender and cultural adaptation of the T.A.T. and C.A.T. is that there has now been over six decades of research on the T.A.T. and over four decades of research on the C.A.T. Thus, there is a background of age norms and norms for individuals with different personality orientations and psychiatric conditions. In attempting to meet questions of gender and cultural bias regarding these instruments, it is important to consider carefully the down side of discarding this long history of research and clinical experience in favor of more contemporary and more culturally specific pictures of the moment. A solution proposed in Chapter 4 of this book is to ister a basic set of 10 T.A.T. cards in the same order, independent of the gender and culture of the individual tested, so that there is a standardized stimulus for all individuals given the test. After that, other T.A.T. cards in Murray's series or culturally specific cards developed by others could be employed by the researcher or clinician. In this way, the T.A.T. will continue to build on a standardized research tradition, which will pave the way for the level of quantitative, computer program scoring of the Rorschach scoring system of Exner (1994). When Abrams and Bellak (1986) wrote Chapter 13 on "Neuropsychological Assessment with Thematic Tests," attention deficit disorder (ADD) was only beginning to be used as a diagnosis by mental health professionals. Earlier, when it was called "minimal brain dysfunction," Bellak (1979) was one of the pioneers in leading the way for ADD to be recognized as a viable diagnosis in adults at the time. Bellak contributed several papers on ADD in adults. In fact, his (1994) paper for the lifetime award from the American Psychological Association presented his identification of ADD psychosis as a particular subtype of schizophrenia that calls for specific psychiatric medication and psychotherapeutic intervention. Chapter 13 has been updated to incorporate these important developments on neuropsychological indicators on thematic tests, as well as these new developments on ADD psychosis and attention deficit disorder, which is currently recognized as one of the major psychiatric diagoses in children and adults. A new feature of this sixth edition is the publication of revised pictures for the

INTRODUCTION 5 Senior Apperception Technique (S.A.T.) for elderly individuals. The normal life span for people throughout the world has been steadily increasing. The world's population of those over 65 years of age is rapidly becoming so large that psychologists are increasingly being asked to evaluate elderly individuals in a number of different contexts. The increasing population of elderly individuals has given rise to new fields, such as gerontological psychiatry, for which Bellak was one of the pioneers. Bellak (1975) wrote one of the first general handbooks on aging for the lay public and one of the first handbooks in the new field of geriatric psychiatry (Bellak & Karasu, 1976). Thematic tests also were the foundation for the classic research in the new field of social gerontology (Neugarten & Guttlnann, 1968; Maddox, 1994). While the S.A.T. pictures of Bellak and Bellak (1973) have been the mainstay of many researchers and clinicians working with the elderly, the pictures were redrawn by Violet Lamont in 1996, the same artist who drew the pictures for the C.A.T. Research and clinical experience with these new S.A.T. pictures find that the increased detail and artistic style similar to the C.A.T. and T.A.T. make the revised S.A.T. a much more successful projective test with an elderly population. Chapter 19 has been totally rewritten to reflect the important developments of gerontological psychology - or geropsychology - and the exciting use of the S.A.T. and revised SA.T. of 1996. The reader is invited to consider the following important questions about what makes for the most revealing and useful thematic apperception tests in research and clinical use: 1, Should Murray's (1943a) pictures be redrawn to be more up to date, showing people and backgrounds more in tune with contemporary fashion, rather than continuing to ister Murray's pictures from the 1930s and 1940s? 2, Should the people and backgrounds in Murray's pictures be redrawn to be culturally specific for testing individuals from other than white, middle-class U.S. culture and society? 3. Should totally different pictures than Murray's be developed that depict individuals of the same age, gender, and culture as the person being tested? 4. Should clinicians continue to use a small group of different T.A.T. cards for specific clinical problems (such as cards 1, 3BM, and 13MF for possibly depressed individuals)? Or should a standard set of the same 10 T.A.T. cards be istered in the same order for all individuals, independent of their possible clinical disorder? 5, Should a projective instrument provide the person being tested with a little psychological distance and ambiguity? Or should it be an immediately recognizable picture of a person in an everyday situation that looks very similar to the person being tested? 6. Is Murray's second series of "more dramatic situations" as revealing or more revealing than his first series of "everyday situations"? 7. Which are more revealing psychologically projective tests: (a)T.A.T. cards that depict a central character of the same general age, gender, and culture as the individual being tested, (b) T.A.T. cards that depict people from a past era of society, (c) T.A.T. cards that depict people of a slightly different culture and

6 CHAPTER 1 background or even gender as the individual being tested, or (d) C.A.T. cards that depict animals? 8. Is the T.A.T. an appropriate instrument for young children? What are its main drawbacks as an instrument used with this age group? 9. Is the S.A.T. a more appropriate instrument with elderly individuals than the T.A.T.? 10. If the T.A.T., C.A.T., and S.A.T. are too open to gender and cultural bias, should the contemporary psychologist avoid using them altogether in favor of more ambiguous, more cultureqndependent stimuli, such as the Rorschach? 11, Are thematic apperception tests the best projective tests for evaluating interpersonal object relations? 12. What do thematic apperception tests offer that other projective tests do not? Description of the T.A.T. The Thematic Apperception Test (T.A.T.) of Murray (1943a) consists of 31 pictures of people in different solitary and social situations. There is a specific sequence of cards for girls, women, boys, and men that have, as the central figure, an individual of the same sex and general age group as the individual who is being tested. There are some common cards used for all ages and sexes and one blank card. The individual is asked simply to "make up a story" to each picture. The first half of the stories are considered to be pictures of everyday events; the second group is considered to be more dramatic, more similar to the deeper world of the dreamlife. In Murray's need-press method of scoring the stories, the psychologist makes an inventory of the numerous "needs" of the hero of each story and an inventory of contrasting requirements or forces from the environment that "press" on the hero. An example is the hero loves a woman, but she hates him. Hence, there is a "need for love or affiliation" met by a "press of hate or rejection." Murray (1938) developed a theory of personality called personology that consists of a large variety of these need-press dichotomies. His system lists needs for abasement, achievement, aggression, acquisition, autonomy, creation, deference, destruction, dominance, intraggression, nurturance, ivity, and succorance. His list of presses include affiliation, aggression, dominance, nurturance, lack, loss, and physical injury. In Murray's (1943a) method of scoring the T.A.T., each story is analyzed according to all these needs and presses, each of which receive a weighted score. A hierarchy of the relationship of the needs to each other is also obtained with such concepts of Murray's as need-conflict, need-subsidiation, and need-fusion. For example, if a hero wants to buy a restaurant with the notion of giving people better and more healthful food and at the same time enriching himself by means of this public service, we would speak of a fusion of the hero's need for nurturance and acquisition. On the other hand, the hero may want to buy the restaurant because he expects it to be a good source of income that he needs to take care of his family. In this case, we would say that his need for acquisition (of money) is subsidiary to his need for nurturance; namely, he wants to acquire money in order to [ chid ran] Mtt of t'. ing and[ Leo pos met. the t cate: terp fun( ther Cori the 7 [19 the l fun( worlI secLI func

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INTRODUCTION 7 1) C.A.T. its main than the tral bias, favor of rschach? ng interNe tests ts of 31 ecific se- gure, an is being e blank I'he first second td of the ologist [d an in- Iress" on ie, there lat con- eeds for erence, ace. His ass, and ry is an- 'eighted ,btained t need- ,f giving nself by OF nur- restau- ke care )ney) is n order to be able to take care of his family. By means of these two concepts, whole hierarchies of motivation can be recognized in the T.A.T. Nearly a dozen such schemes of categories provide a quantitative need-press rank ordering along with a page for recording more general clinical impressions. Although Murray's (1943a) Thematic Apperception Test Manual is sold with every copy of the T.A.T. plates, his method of scoring never became a popular method of scoring the T.A.T., since learning to score these need-press dichotomies is very difficult and each T.A.T. scoring takes nearly four hours to complete. A more comprehensive and practical method of scoring the T.A.T. is that of Leopold Bellak, who came to work with Murray at Harvard University after Bellak emigrated from studying psychoanalysis in Vienna, Austria, in 1938. Bellak proposed an early method of scoring the T.A.T. in 1941 (with Murray's encouragement) that included a shorter inventory of the hero's needs with key categories of the later "ego psychology" approach of Sigmund Freud (1920, 1923). For example, categories included conception of the world, relationship to others (now called interpersonal object relations), aggression, main conflicts, defense mechanisms, ego functions, and superego functioning (Bellak & Murray, 1941). Bellak (1947) further developed his system of analysis, which was published by the Psychological Corporation as the Bellak TAT Blank, Analysis Sheets, and Guide to the Interpretation of the TAT. (The interested reader will find this early scoring scheme in Abt and Bellak [1980, p. 196]). Bellak (1954b) later expanded on his method of T.A.T. analysis in the first major textbook on the T.A.T., which was the first edition of this book. Bellak's system consists of 10 categories of analysis: (1) main theme; (2) self- functioning of the hero; (3) main needs and drives of hero; (4) conception of the world; (5) interpersonal object relations; (6) main conflicts; (7) nature of fears, insecurities and anxieties; (8) main defense and coping mechanisms; (9) superego functioning; and (10) general ego functions. Each story is scored quickly for each category on a fold-out form called the Bellak (1947) T.A.T. Short Form. This is a clinical way of thinking about the T.A.T. of an individual, rather than a quantitative scoring method. However, different dimensions can be scored in a quantitative manner, as was demonstrated for general ego functions in Bellak, Hurvich, and Gediman (1973) and Bellak and Goldsmith (1984). The clinician quickly jots down notes about each of the 10 categories for each story on the Short Form and then works across all stories for each category to make some general comments about the individual tested on each category. For example, the clinician will look at his or her notes for the defense mechanisms seen in all the stories in order to make a general listing or commentary about the individual's main defenses at the end of this category. Finally, the clinician works downward over all 10 categories in order to come to a general commentary on the personality organization as expressed on the overall T.A.T. protocol.

History of the T.A.T., C.A.T., and S.A.T. When he developed the T.A.T., Murray was a professor of psychology at Harvard University at a time when the psychoanalysis of Sigmund Freud was being

8 CHAPTER 1 translated into English and being brought to the United States by students of Freud's, such as Murray's young graduate student, Leopold Bellak. The most famous work of Sigmund Freud (1900) is his Interpretation of Dreams in which Freud shows that dreams have two layers of meaning: the manifest content that consists of the "surface" everyday meaning of the dream's story and the latent content that consists of the often disguised, underlying unconscious meaning of the dream. For Freud, the primary motivation of most dreams was a disguised, unconscious, sexual or "libidinal" wish. An example is a woman who dreams of going to a musical concert and sitting next to a man, who asks her in the dream for the directions to go to a restaurant after the concert. In the dream, she answers that she does not know any good restaurants in the entire city. The manifest content is the basic facts of the dream, as a story of being asked a question that the dreamer cannot answer, which could mean that the woman has an anxiety about what she knows about the world. The latent content might be that she is attracted to the man and wants him to ask her to go to a restaurant with him after the concert and perhaps later to make love. The first theory of Freud's psychoanalysis was called the libido theory, because he first believed that the primary motivation of all of human behavior was related to the sexual or libidinal drive. A drive is defined as a motivating force within the personality similar to a primary need, such as the need for hunger and sleep. In 1900, Freud thought that the sexual drive was the primary motivating force within the personality. Toward the end of his life, Freud (1920, 1923) changed his theory to what he called ego psychology, which broadened his view of human motivation to include a loving libidinal drive as well as an aggressive drive, called the Id, an internal conscience as to what is right and wrong, called the Superego; and an internal organizing force that attempts to maintain a balance within the personality, called the ego. The ego itself includes the functions of perception, memory, symbolic thinking, and the defense and coping mechanisms with which the individual attempts to manage the sexual and aggressive impulses from the id and the conflicting internalized moral imperatives of the superego. An ego psychology view of the previously mentioned dream example is that the woman has an underlying id wish of going out with the man, which is the unconscious libidinal meaning of the man asking her for directions to go to a restaurant after the concert they are attending. Her answer that she does not know any good restaurants in the entire city is her moral sense from her internal conscience superego that she should not allow her loving impulses to be expressed so freely as to agree to go to a restaurant and perhaps later make love to a man she has just met. The ego comes in to defend against these "unconscious" desires and conflicts by distancing their meaning from her conscious awareness in the form of a dream that does not state anything about wanting to go out with this man, let alone make love to him. The defense mechanism is repression or denial to push this underlying id impulse or wish into the unconscious, and the defense mechanism of projection, which takes the unconscious wish and projects it into a disguised story in the form of a dream. Freud (1900) proposed that the unconscious meaning of a dream can be discovered by Je associating to each element in the dream. One can ask oneself what comes the mind about this man in the dream? What did he look like? What about the r know or hi on d Freu, way free of hi on tl tire 1 effec Ul'lCG ods what (MoJ ilar t lend Drea syste begi level tive the : (i.e. he 1 ceec ceed state oriel lOWS othe idea pret mai cho] thei rive this se atty. nin

INTRODUCTION 9 the man's question about restaurants and the woman's answer that she did not know any good restaurants and so on. A therapist can help a patient understand her or his unconscious anxieties, wishes, conflicts, and feelings by working in this way on dreams that the patient reports during psychotherapy. On the other hand, Freud showed in his Interpretation of Dreams (1900) that anyone can work his or her way toward understanding deeper, unconscious meanings of personal dreams by free association to parts of the dream by oneself, as Freud did with many examples of his own dreams. When Murray and his colleague, Christiana Morgan, published the first paper on the T.A.T., they argued that the T.A.T. was a kind of brief, inexpensive alternative to psychoanalytic therapy, especially for young people. They stated that it is "an effective means of disclosing a subject's regnant preoccupations and some of the unconscious trends that underlie them"(1935). Among the many different methods Murray had developed at the Harvard Psychological Clinic, the T.A.T. yielded what they felt was "the best understanding of the deeper layers of personality" (Morgan & Murray, 1935, pp. 8-12). Since a T.A.T. story is a personal narrative similar to a dream that might be reported by a patient to a psychotherapist, the T.A.T. lends itself very nicely to similar methods of analysis as in Freud's Interpretation of Dreams. As we will present later in the book, one of the first scoring steps in Bellak's system is to do an analysis of the main theme of each story in which the clinician begins with a descriptive level and moves to an interpretative level, to a diagnostic level, and then to an elaborative level. One way of looking at this is that the descriptive level is the "manifest content" of the story, or a short digest of what is stated on the surface of the basic plot. It is what could also be called experience-near analysis (i.e., what the person who is istering the test actually experiences as she or he hears the words spoken by the individual being tested). Then the clinician proceeds to an interpretative level of underlying psychological meaning, which is proceeding to the latent content of the story. Next, one moves to a diagnostic level statement according to one's understanding of the storyteller's possible personality orientation, psychiatric symptoms, or clinical disorder. Finally, the elaborative level allow for some free association to let oneself go and see if one associates to some other type of meaning to the story (Abrams, 1993a, 1995). An important biography of Murray, entitled Love's Story Told: A Life of Henry A. Murray by Forrest Robinson (1992), shows how Murray's background made him an ideal individual to develop a major personality test that could lend itself to a comprehensive personality diagnostic assessment for working clinicians based on the main dimensions of research on the psychology of personality in academic psychology. Often, interdisciplinary thinkers have training in a different field from their chosen profession, and innovative theorists occasionally bring a new perspective to their chosen field by not having been trained in the established tradition of this field. Sigmund Freud was a physician with extensive experience in medical research and neurology, but he had little, if any, direct training in the field of psychiatry. Jean Piaget worked with Alfred Binet on pioneering research on the beginnings of intelligence testing, but his formal degree was in biology - not psychology. Henry Murray was a physician who did a fellowship in biochemistry and who qualified in surgery.

10 CHAPTER 1 He became a literary authority on Herman Melville, became attracted to the psychoanalytic theories of Freud and Carl Jung, and co-founded the Harvard Psychological Clinic. His background and reading was always eclectic, broad, and interdisciplinary. At the Harvard Psychological Clinic, Murray experimented with a number of different methods with which to study human imagination and human personality organization. One of his students and colleagues, Cecilia Roberts (who married historian Crane Brinton), is said to have returned home one night to find that her son had created stories to different pictures in a magazine. When she reported this to Murray, he and Christiana Morgan, one of his assistants who had considerable artistic ability, set out to collect a number of different pictures of paintings in museums, ments in magazines, pictures for movies, and other sources. Morgan and Samuel Thal then redrew these items in order to have a consistent style of presentation (Douglas, 1993). One of the most interesting sources for the T.A.T. pictures is the picture of the child prodigy violin virtuoso, Yehudi Menuhin, sitting at a desk in front of his violin, which became the picture for card 1. The current set of 31 pictures is the third version of this test, following a suggestion by psychologist Frederick Wyatt to double the size of the pictures to increase the power of the pictures to elicit personal psychological identifications. Wesley Morgan (1995) has an interesting paper that details the history of each of the current T.A.T. cards. To Murray's broad, humanistic mind, Freud's theory of unconscious sexual and aggressive drives oversimplified the multifaceted complexity of human motivation. He found Freud's "contribution to man's conceptualized knowledge of himself" as "the greatest since the works of Aristode"(Murray, 1959, p. 37), but at the same time, he felt that Freud's view of human nature was too one-sided. Murray stated that Freud's early libido theory was much too circumscribed and limited, as if the "libido has digested all the needs contributing to selfpreservation, self- regard, and self-advancement, together with a host of others, and rebaptized them in the name of Sex; and that sex itself is never given either its profound evolutionary status or its interpersonally creative status" (Murray, 1959, p. 37). For that reason, Murray emphasized in the T.A. TManual that his need-press approach provides a way of scoring the T.A.T., so "a psychologist can use these variables without sub- scribing to any particular theory of drives" (Murray, 1943a, p. 9). On the other hand, Murray had a period of supervision under psychoanalyst Harms Sachs, whose understanding of patients Murray found to be outstanding. "Time and time again," Murray noted, Sachs "could predict my patients' trends several days or even weeks before they were exhibited. A theory that can do this is valuable" (Murray, 1940, p. 156). Perhaps largely because of his profound respect for the clinical utility of psychodynamic theory and his broad albeit ambivalent feelings about psychoanalysis, Bellak feels that Murray never seemed to view what Bellak brought to T.A.T. as a threat to what Murray had contributed. Therefore, Bellak and Murray (1941) collaborated on Bellak's first attempt to outline a T.A.T. scoring approach based on the Freud's later ego psychology. Murray and Bellak remained friends until Murray's death in 1988 at the age of 95 years. In 1948, art historian-psychoanalyst Ernst Kris suggested to Bellak that children might feel freer to identify with pictures of young animals in different situations than pictures of actual children. Freud's (1909) most famous child case, the ce O side hi first id asayc like M tures o be mo drawn popuk h set of 1 was th S.A.T.'! of prin ent thz tures " C.A.T. Violet publish more p lized w ,

Six Dq TI great d, cob of studies search , McClell and Vet R, in the 1 ory. Th, 1957b); (Mandl. 1964; C 1977; su and get Dudek, 1973; %, In has dew (1) the: oped wi

INTRODUCTION 11 at- the itic, • of ais- on to case of Little Hans, revolved around a 4-year-old boy who was afraid to travel outside his house for fear a horse would bite him. Freud showed how the little boy had first identified his parents with horses and later in the treatment identified himself as a young horse. Therefore, Bellak and his wife, artist Sonya Sorel, set out much like Murray and Christiana Morgan before them - to create a series of different pictures of animals in different situations in order to determine which pictures would be most evocative in clinical use with children. The final set of 10 cards was then drawn by the gifted artist, Violet Lamont. This test has since enjoyed international popularity, being published in 11 countries. In 1973, Bellak and Sonya Sorel Bellak worked in the same way to develop a set of pictures appropriate for clinical use with an elderly population. The S.A.T. was then published, which has been used successfully for over two decades. The ST.'s situations have been found to be clinically powerful stimuli to elicit issues of primary concern to elderly individuals. However, it increasingly became apparent that the test would be even more successful as an assessment device if the pictures were redrawn in a style as richly detailed and evocative as that used in the CA.T. and T.A.T. pictures. Therefore, the S.A.T. pictures have been redrawn by Violet Lamont, artist of the pictures for the C.A.T. These revised pictures are newly published in the current edition of this book and have been found to be much more profound stimuli than the original S.A.T. pictures. They are already being utilized with interesting results in cross-cultural studies in the United States, Brazil, , and Spain.

Six Decades of T.A.T. Research The beginnings of T.A.T. research in the 1940s and 1950s tended to focus a great deal of attention on the study of sexual and aggressive drives in T.A.T. protocols of different groups of people influenced by Freud's first libido theory and on studies of selected parts of Murray's need-press approach. These consisted of the research direction of McClelland and colleagues (1953), McClelland (1955), and ldcClelland and Steele (1973) on the need for achievement; and of Atkinson, Hyns, and Veroff (1954) and Shipley and Veroff (1952) on the need for affiliation. Research on aspects of the Bellak scoring system developed most prominently in the late 1950s, 1960s, and 1970s, influenced by Freud's later ego psychology the- 0ry. There was work on Bellak's scoring dimension of the main hero (Friedman, 1957b); significant conflicts (Abrams, 1977; Epstein, 1962); nature of anxieties (Mandler, Lindzey, & Crouch, 1957; Stamps & Teevan, 1974); main defenses (Blum, 1964; Crarner & Carter, 1978; Dias, 1976; Haworth, 1963; Heath, 1958; Heilbrun, 1977; superego and moral judgment (Kohlberg, 1969; Shore, Massimo, & Mack, 1964); and general ego functions (Bachrach & Peterson, 1976; Born, 1975; Dies, 1968; Dudek, 1975;Johnson & Kilmann, 1975; Morval, 1977; Pine & Holt, 1960; Stolorow, 1973; Weissman, 1964; Wyatt, 1958). In the decades of the 1980s and 1990s, contemporary psychodynamic theory has developed in three primary areas with parallel developments in Q,A.T, research: (1) the analysis of internal conflict expressed in drive-defense constellations developed within mainstream psychoanalysis; (2) the British so-called object relations

12 CHAPTER 1 school developed Freud's ego function of "interpersonal object relations" into a primary approach to treatment, and (3) Kohut (1971, 1977) developed Freud's early work on narcissism and the ego function of the capacity for self and object representation. Consequently, this book and Bellak's Comprehensive Scoring System have further emphasized these three important developments. Most notably, the work within mainstream ego psychology on defense and ego analysis by Joseph Sandler, Charles Brenner, and Paul Gray can be seen in the valuable scoring system for defense mechanisms on the T.A.T. by Cramer (1991a). The development of the British Object Relations School of psychoanalysis is best represented in T.A.T. research in the object relations scoring systems of McAdams (1980), Thomas and Dudeck (1985), and the promising work of Westen and colleagues (Berends et al., 1990; Leigh, 1992; Westen et al., 1990a, 1990b, 1991b). The Kohut direction of selfpsychology or the study of normal and pathological narcissism has not resulted in any development in T.A.T. scoring. However, pioneering adult T.A.T. case presentations of narcissistic patients have been published by Franqoise Brelet-Foulard, who has also published under the name of Franqoise Brelet (1981, 1983, 1986) in , Shulman and Ferguson (1988) and Shulman, McGarthy, and Ferguson, (1988) in the United States, and narcissistic child and adolescent C.A.T. and T.A.T. case presentations by Abrams (1993a, 1995, in press). Related to the area of interpersonal object relations is the major therapy field of family therapy, which has contributed T.A.T. family studies by Ferreira and Winter (1965), Ferreira, Winter, and Poindexter (1966), Minuchin and associates (1967), Richardson and Partridge (1982), Werner, Stabenau, and Pollin (1970), and Winter and Ferreira (1969, 1970). Perhaps the most important application of the family systems perspective to T.A.T. research is the communication deviance scoring approach first published by Jones (1977), which has continued to be developed in a host of valuable research publications (Doane et al., 1989; Doane & Mintz, 1987; Goldstein, 1985; Karon & Widener, 1994; Miklowitz et al., 1986, 1991; Rund, 1989; Sharav, 1991, Velligan et al., 1990). Given the fact that the three pivotal approaches to psychotherapy are psychoanalytic therapy, family therapy, and behavior therapy, we have long awaited a contribution to T.A.T. research and clinical diagnosis from the field of behavior therapy. Finally, there has appeared the well-conducted research papers on the personal problem-solving T.A.T. scoring approach of George Ronan and colleagues (Ronan, Colavito, & Hammontree, 1993; Ronan, Date, & Weisbrod, 1995), which is an important new development in the field. Other developments in the last two decades of T.A.T. research have been the extension of T.A.T. into diagnostic studies of borderline disorders (Rogoff, 1985; Rosoff, 1988; Westen et al., 1990a, 1990b), the aforementioned work on narcissistic disorders (Abrams, 1993, 1995; Brelet, 1981, 1983, 1986; BreletFoulard, 1994, 1995; Harder, 1979; Shulman & Ferguson, 1988), attention deficit disorder (Abrams & Bellak, 1986, Costantino, Malgady, & Vazquez, 1988), mental retarda- tion (Hurley & Sovner, 1985), substance abuse (Cabal Bravo et al., 1990, Fassino et al., 1992), and trauma (Henderson, 1990; Hoffman & Kuperman, 1990; Ornduffet al., 1994; Ornduff & Kelsey, 1996; Stovall & Craig, 1990).

INTRODUCTION 13

Bellak and Exner As the T.A.T., C.A.T., and S.A.T. move into the twenty-first century, the Bellak scoring approach will further strengthen its quantitative, empirical foundation in the manner of Exner's (1994) Comprehensive System for the Rorschach. Bellak's system resembles that of Exner's, since both scoring systems are based on the major clinical and research dimensions of their respective tests in contemporary clinical practice and academic research psychology. Moreover, after more than six decades of research on the T.A.T. (since the first publication on the T.A.T. in 1935 by Morgan and Murray), there is now a strong foundation for understanding the major personality dimensions expressed on the TA.T. necessary for diagnostic evaluation. There is solid research literature on how individuals with different psychiatric disorders behave on this test and there is an ever-increasing literature on how individuals of different ages, gender, and culture express themselves on thematic tests. From 11 research studies in 1941, the current textbook has close to 800 T.A.T. research studies in its bibliography, with increasing numbers being reported each year throughout the world. Several important large-scale studies have attempted to develop empirical scoring approaches to the T.A.T. (Avila Espada, 1990; Neman, Neman, & Sells, 1974; Zubin, Evon, & Schumer, 1965) in which a large number of quantitative scoring variables with good inter-rater reliability are scored on a large normative sample. However, these approaches did not also test the same quantitative scoring variables with different clinical groups in order to compare what is typical for "normal" individuals of the same age with what is typical for individuals with different psychiatric disorders. Exner, on the other hand, has established statistical age norms and norms for different psychiatric disorders on the Rorschach with hundreds of empirical studies using the same set of quantitative scoring variables. Another valuable aspect of his approach is his computer program, which a psychologist may use to input the individual's scores. The scores can then be compared against the normative data from Exner's age group and clinical subgroup studies and a set of clinical hypotheses of "subjective probability" outlined by Exner from his own expert clinical experience and that of other Rorschach specialists. The end product is a printout of a narrative assessment of the individual's main personality characteristics and probable psychiatric disorder(s). Bellak's Comprehensive System by contrast, is a more clinical approach. The different dimensions of his system are not quantitative, as in Exner's approach. They constitute a way of addressing the important dimensions of personality organization, such as identifying the individual's anxieties and different ways the individual attempts to defend against these anxieties with different defense mechanisms. llellak's scoring dimensions are a way of reminding oneself which are the important dimensions of the personality, so that the psychologist does not forget to address mine of the significant areas. For example, when a clinician works with a patient in psychotherapy who reports a dream, the clinician may choose to discuss one or two dimensions of the dream that appear to communicate a pressing, current issue in the treatment. If a recently divorced woman is struggling with her relationship with her ex-husband and dreams of the ex-husband having a car accident, the therapist and patient may choose to focus on the dremn's expression of the woman's anger at the ex-husband for leaving her (perhaps symbolized in the dream by traveling in a car).

14 CHAPTER 1 Bellak's system helps the psychologist consider the main theme, such as the ex-husband leaving and having a car accident; a main need, such as the woman expressing anger at the husband for leaving; and other dimensions, such as the superego aspect of the ex-husband perhaps being punished severely for leaving the woman by having the car accident. Some of Bellak's scoring categories have quasi-quantitative scoring dimensions, such as number of figures and number of objects introduced in a story. Also, the is able to rate the adequacy of superego functioning in a story according to three levels if the superego is appropriate or innappropriate, or three levels of ego integration in a story if the plot is complete, incomplete, or inappropriate. Bellak's system helps the psychologist run quickly through these 10 basic dimensions of personality dimension for each story in order to come to an overall summary as to how the individual's personality is organized. If only one dimension is known for example, that most of the stories deal with the main theme of a woman being angry with a man for leaving - nothing else is yet known about how the woman attempts to defend against these feelings (defense mechanisms); if she has any other main needs and other anxieties other than fear of someone leaving her; her overall view of the world (conception of the world); the level of her interpersonal object relations; what her main conflicts are; how adaptive her coping mechanisms are and other ego functions; and how her superego functions to help monitor her desire to express antisocial feelings (such as wishing her ex- husband would have a car accident). If the psychologist identifies from repeated themes on the T.A.T. that a woman seems to have a need to express angry feelings toward her ex-husband, yet she is unaware of those feelings, her psychotherapy will be benefited. However, an overall view of how her personality is organized is of considerably more benefit from a clinical standpoint. For example, if the psychologist also knows that the woman has good ego functioning to control her antisocial wish for her ex-husband to have a car accident and adequate superego control that would not permit her to act on such antisocial feelings, the psychologist will have a better understanding of the woman's likelihood to act or not to act out these feelings. Similarly, in the case of identifying suicidal ideation in T.A.T. stories, the psychologist needs to address the evidence of suicidal feelings on several T.A.T. stories, how the individual attempts to defend against these feelings being expressed in reality, and the level of superego functioning as to whether the individual appears to feel she or he should be punished severely for these feelings or past actions. If a man draws a head cut off from the rest of a body or without the hands attached to the arms at the wrist on the Draw-a-Person Test, it may suggest suicidal feelings. A next step is for the psychologist to look for evidence of lack of ego control or impulsivity indicators, such as uneven dots, overlapping designs, or very largely drawn figures on the Bender Gestalt Test. The Bellak system helps the psychologist consider how these different personality dimensions are expressed and related together on the T.A.T., which can later be checked and corroborated with similar indicators on other tests in the psychological test battery.

AI psy the rid tes tir (a al bu pr: mi T. ch m th St U B( ol T. ir h,

INTRODUCTION 15

A Basic Set of T.A.T. Cards for Males and Females In previous editions of this book, we have criticized the sloppy practice of a psychologist only using a few cards chosen primarily for which cards seem to "pull" the most for personality aspects the clinician senses may be at issue with an individual being tested. Typically, if the individual appears depressed in slow-moving test behavior and lack of motivation on previous tests, the psychologist, becoming tired at this point in the test battery, may decide only to ister for the T.A.T. card 1 (a boy sitting at a desk looking ively at a violin on the desk), card 3BM (a man or woman sitting on the floor resting his or her head against a couch with a revolver on the floor), and card 13MF (a man standing with downcast head buried in his arm, behind him a woman is lying in bed as if asleep or dead). This practice has undoubtedly developed because Murray's original instruction to ad- minister 10 cards the first day and then another 10 the following day made the T.A.T. istration too time consuming. Therefore, we advocate the use of the same basic set of ten T.A.T. cards for males and females to be istered in the same order: Cards 1, 2, 3BM, 4, 6BM, 7GF,, 8BM, 9GF, 10, and 13ME. If clinicians want to ister other "favorite" cards that are not included in this basic set, they can do so after first istering the basic set. The recommendation of the basic set is based on numerous polls of which cards are most frequently istered by psychologists, by our own clinical experience, and the importance of a balance between male-designed and female-designed cards. Standardized istration of this gender-balanced T.A.T. basic set facilitates the kind of sequence analysis possible on the Rorschach and helps to move the clinical use of the T.A.T. closer to the standard for Rorschach istration set by Exner. By utilizing a basic set of 10 T.A.T. cards istered in the same order, which can be supplemented by other T.A.T. cards, it is also possible to bring the 10 Bellak scoring categories to a more quantitative level. Moreover, since the majority of quantitative research on the T.A.T. has studied variables that fit under Bellak's 10 major categories, it may soon be possible to follow the example of Exner's quantitative scoring of the Rorschach to be able to input quantitative scoring data for the T.A.T. In this way, the clinician's scoring of the T.A.T. will be improved and a research corroboration will be provided for the clinical analysis of the stories according to the major personality dimensions of contemporary psychology and mental health practice.

CHAPTER 2

THEORETICAL FOUNDATIONS FOR PROJECTIVE TESTING theJ Bell sior ing] istk ten po ten We see ma the During World War II, the personnel needs of the Armed Forces constituted a tremendous task and challenge. Young men with little training had to become clinical psychology experts in weeks, and older ones with experience and training in the laboratory and in academic settings also had to become clinical specialists. This pressure of circumstances produced many new projective techniques and led to their acceptance as gospel, even when the "oldest" were almost entirely invalidated and poorly understood. The Thematic Apperception Test was developed during this fertile period during World War II and shortly thereafter by Professor Henry Murray with the assistance of Christiana Morgan and other colleagues at the Harvard Psychological Clinic. The fascinating historical story of Murray's work with Christiana Morgan and others during this formative period of the T.A.T. is profiled in the biography by Robinson (1992), Love's Story Told: A Life of Henry A. Murray. While Murray developed what he called a need-press approach to scoring the T.A.T., his student, Leopold Bellak, worked with him to develop a scoring approach based on the ego psychology of Sigmund Freud (1920, 1923). This state of affairs paralleled the development of intelligence testing during World War I. After the periods of pressure that both wars produced to develop intellectual and personality assessment instruments, this heightened phase of pioneering innovation was followed by more careful scrutiny and empirical investigations of the tools themselves. Consider the large number of Rorschach research papers after World War II on the nature of the Color and Achromatic Color response (Lazarus, 1949; Meyer, 1951; Rockwell et al., 1948; Siipola, 1950), the statistical normative studies on adults by Hertz (1970), developmental norms from childhood to adulthood on the Rorshach by Louise Bates Ames and colleagues at the Yale Child Center (Ames, 1961; Ames et al., 1961), and a wealth of other empirical studies that paved the way for the major breakthrough in a systematic structural scoring for the Rorschach by Exner (1974, 1986, 1994). This book shows that the T.A.T. has a similar history. On the one hand, there have been many empirical investigations of individual dimensions of the T.A.T., such as word length, word frequency tables, and aspects of test behavior, which we refer to in this book as "research studies of thematic tests." On the other hand, 16 the el er wil ps sc tr ce te pl fi o n P tl rl

THEORETICAL FOUNDATIONS FOR PROJECTIVE TESTING 17 there have been many different scoring systems similar to those of Murray and Bellak that provide the clinician with a way to address the key personality dimensions of the individual tested. Following the discovery of the T.A.T., we have seen these two areas increasingly converge. The majority of empirical research studies of individual characteristics of thematic tests have essentially researched different needs in Murray's system - such as need for achievement, the need for affiliation, and the need for powermand different aspects of the original ten scoring categories of Bellak's system, such as Cramer's (1991a) important work on defense mechanisms and Westen's (1991a, 1991b) work on interpersonal object relations. As the reader we see, the Bellak scoring system provides a comprehensive diagnostic scoring for thematic tests, since it includes the major personality components that have also been the predominant areas of empirical research.

The Psychology of Projective Techniques in General and the TA.T. in Particular The requirements for validity and usefulness in projective techniques can be seen as twofold: Projective methods are expected to perform as tools of both nomothetic and idiographic sciences. Formulated by Windleband (1904) and notably elaborated by Allport and Vernon (1937), nomothetic science is concerned with general lawfulness (e.g., in physics, chemistry, etc.) and idiogvaphic science is concerned with understanding one particular event (e.g., of a historical nature, such as what led to the unique event of the storming of the Bastille). The main efforts in U.S. psychology are directed toward making projective methods the tools of nomothetic science; the basic Rorschach scores (Exner, 1994; Judson, 1963), the development of signs (Hertz, 1970; Piotrowski, 1950), and the work with group Rorschachs (Harrower, 1950; Munroe, 1951) bear testimony to that trend. The purpose - extremely valuable and, in part, carried over from brass-instrument laboratory concepts of the "average" person and from statistical psychometrics-- is to arrive at criteria that are applicable to groups of people or to syndromes. When these signs are encountered, they are helpful in asg a given person to a given group. For instance, Mr. Jones perceives in such a way that he must be considered a schizophrenic, a criminal, or an engineer. Idiographically speaking, one would be satisfied to describe Mr. Jones as a unique person who perceives configurations in a certain way and tends to control his impulses under given circumstances, generally constituting a uniqueness of functioning that will not be exactly duplicated by any other individual. Some projective methods undoubtedly lend themselves more readily to the nornothetic approach than others. Perhaps the generalization can be made that the expressive methods and those scoring schemes primarily predicated on formal characteristics lend themselves better to valid generalizations than those concerned primarily with content. Surely the Rorschach is relatively easier to harness lawfully than the T.A.T. (which has remained one of the most idiographic of all instruments). From a clinical standpoint, in fact, one might choose testing procedures according to whether one wants nomothetic or idiographic information.

18 CHAPTER 2 The nomothetic approach, to be sure, is extremely valuable and necessary. The failures and limitations of projective methods as nomothetic instruments are the main impetus for further research and attempts at better conceptualization. The problem is often discussed as the difficulty of making inferences from test data to behavior. Naturally, if a psychiatrist wants to know if someone is suicidal or of criminal inclination, the psychologist is expected to be able to report whether the signs and dynamics of suicide or criminality in the person's projective data imply whether the person is likely to act on her or his destructive impulses. Similarly, the personnel executive will want to know from the psychologist if an individual will make a good of- ricer in reality, not in fantasy! It is quite possible, however, for a technique to fail idiographically. When psychological testing is done prior to an extensive psychotherapy, psychotherapists occasionally discover that while the major components of personality functioning were addressed by the psychologist who conducted the testing, the psychotherapy process may later uncover other areas not covered in the psychological test report. Thus, while nomothetic performance can best be checked statistically, idiographic performance can probably best be investigated by a study of records against data from an intensive course of treatment, which may be said to be the most idiographic of all studies. The failures and limitations of projective techniques have often been related to a lack of consistent conceptualization (Bellak, 1993a; Cattell, 1951; Exner, 1994; Rapaport, 1947). When Frank (1939) coined the term projective methods (or projective tests), it was certainly the most appropriate at that time, but it has proved to be a misleading term. Projection, taken from Freud, was generally formulated in U.S. psychology (Bellak & Chassan, 1964) as a defense mechanism in the service of the ego, designed to avoid awareness of unacceptable wishes, thoughts, and impulses, accomplishing its task by ascribing such undesirable subjective phenomena to the objective world. For example, a 5-year-old girl has a dream of a monster angrily attacking her after she was angry with an adult the day before the dream. Here, she is projecting her own anger at the adult into the figure of a scary monster being angry at her. Projection has this type of boomerang effect of displacing one's inner thoughts and feelings onto someone else, who one then imagines is having these thoughts and feelings. This meaning of projection was primarily taken from Freud's discussion of paranoia in the case of Schreber (Freud, 1943), who projected his own thoughts and feelings onto other people as well as onto inanimate objects. The T.A.T., Rorschach, House-Tree-Person Drawing Test, Kinetic-Family- Drawing Test, and the Sentence Completion Test are considered projective tests in the sense that the individual is thought to project his or her main conflicts, thoughts, and feelings into these tests. The story told to a T.A.T. card, such as the little girl's dream of a scary monster, is thought to be a projection of the individual's own thoughts and feelings. Only belatedly did some workers in the field (Bell, 1948; Bellak, 1944) become aware that Freud (1938) saw projection in a much broader sense as a general perceptual process, whereby all contemporary meaningful perception is predicated on and organized by the memory traces of all previous perceptions. This broader concept, formulated by Bellak (Bellak & Brower, 1951) as apperceptive distortion, might possibly serve as a more useful frame of reference for some of the so-called projective methods.

THEORETICAL FOUNDATIONS FOR PROJECTIVE TESTING 19 This is the meaning of the term apperception in the Thematic Apperception Test. The basic assumption of an individual's T.A.T. protocol is that the individual tends to distort some of what she or he perceives in each picture, because of her or his own personality dynamics. An attempt at a breakdown of the processes involved in all the tests currently considered "projective" led to five categories of study (Bellak & Brower, 1951): (1) content, (2) expressive data, (3) Gestalt formation, (4) body image, and (5) a study of choices. (See "Toward a General Psychology of Thematic Apperception Tests" in this chapter for further elaboration.) 1, Methods based upon the study of content. Here, we are concerned with what the patient says. The T.A.T. and the Make A Picture Story (M.A.ES.) Test are the best examples. To a certain extent, the Rorschach inquiry and finger-painting method also belong here. 2. Study of expressive, structural aspects. The main inquiry is directed toward how the subject says or does something. Here, we refer to techniques like the Mira, Mosaic, Rorschach, and graphology, which belong to the subsemantic levels of myoneural functioning insofar as these are valid procedures for the understanding of personality factors and structure. 3. Gestalt functions. These are exemplified in the Bender Gestalt, the Mosaic, and again in the Rorschach. In the T.A.T., this function enters only rarely, to any extent when the subject is unable to apperceive the picture as a whole or when he or she leaves the stimulus altogether. 4, Body image or self-image, The Figure Drawing Test is primarily predicated on this approach. It also enters into the Rorschach when, for example, the subject identifies with puppets, and in the T.A.T. when the subject sees the hero as crippled (picture 3BM), or sees the violin as broken and/or "dead" (picture 1), or identifies with an athlete (picture 17BM). 5. Methods of preference. The Szondi, as a test of an individual's unconscious identifications, is based on a system of selective choices as personality indicators. Color choice in finger painting, selection of figures in doll play (as well as in the M.A.ES.), and so on, also come under this category. It is apparent that all five organismic aspects enter into every one of the projective methods in varying degrees. The problem is to find a consistent body of theory under which five such divergent aspects of psychologic functioning can be subsumed. All these variables-- fantasy content as in the T.A.T.; perceptual organization as in the Rorschach; ability to see Gestalten as in the Bender; self-perception and motor expression as in the Figure Drawing Test, the Mira test, or graphology; and recognition and the making of choices as in the Szondi---are functions of the ego and resultants of its interaction with inner drives, which are internal impulses, thoughts, and feelings that motivate or drive the individual in certain directions. The answerwa broad enough roof to cover the house of projective testing lies in contemporary psychodynamic personality theory.

20 CHAPTER 2 Projective techniques, similar to early psychoanalysis, have primarily been steeped in Freud's (1900) first theory called the libido therapy, which was primarily concerned with the libidinal or sexual impulses or drives and their expression. In this view, the majority of dreams were thought of as projections of the dreamer's own unconscious sexual wishes. Psychoanalysis made its major step forward when it turned from being solely a psychology of the unconscious drives to a study of the interaction of these drives with the ego, superego, and the outside world (Anna Freud, 1936). Murray's need-press theory of personality was an attempt to broaden the conception of drives to a large variety of basic needs, which are thought to motivate and drive the individual (such as a need for achievement), and forces that press on the individual from the outside world. Contemporary personality theories--such as interpersonal object relations, selfpsychology, and family systems theory - provide further understanding for a comprehensive theory of personality functioning. Since the foundation of contemporary personality theory is ego psychology, we will discuss how its basic assumptions relate specifically to the T.A.T. The Role of the Ego in Imaginative Production In order to study the participation of the ego in imaginative productions, we need first to review briefly the psychoanalytic concept of the nature and functions of the ego, most succinctly formulated by Hartmann (1950) and discussed by Bellak (1993a), particularly from the standpoint of ego strength. The ego is that aspect of personality that: 1. Organizes and controls motility and perception. 2. Serves as a protective barrier against excessive and internal stimuli (see number 6). 3. Tests reality and engages in trial action (Freud's concept of thinking) and sends out danger signals (anxiety). 4. Has organizing and self-regulating functions that include mediating between ego and superego and id on the one side, and reality and all the variables on the other. This includes frustration tolerance, capacity for detour behavior, and all that is comprised under defenses. 5. Has some autonomous functions that include abilities, intelligence, and an unspecified number of inherited characteristics, possibly including ego strength. 6. Has the capacity for self-exclusion. Not only must the well-functioning ego be able to repress (i.e., exclude) disturbing id (and superego) impulses for the sake of good organismic functioning (e.g., a driver must not be unduly distracted by a pretty girl or feel unreasonably compelled to avoid a mud hole) but it must also be able to exclude some or nearly all of its own functions. Hartmann (1951) and Kris (1950), who described the ego's capacity for self-exclusion and regression in the service of the ego (one of the last discovered and most important functions), have pointed out that it is necessary that cognitive ego functions be excluded in order to be able to fall asleep.

les, sim- ]rst the- tinal or dreams wishes. y a psy- 'es with d-press a large 1 (such mtside ations, fOra mtem- sump1S, we :tions ;ellak lure-

and leen s on Nor, [ an ego , be the dis- ,le) rls. elf- 'ed THEORETICAL FOUNDATIONS FOR PROJECTIVE TESTING 21 For instance, a person who is driven by undue anxiety of nocuous stimuli to maintain his or her cognitive functions will keep his muscles tense, hear the clock ticking, see the light flashing, feel the blanket pressing, and so on. Under certain circumstances, the withdrawal of the cognitive functions can be subjective experiences (hypnagogue phenomena, especially Silberer's [1951] functional phenomenon). Our projective tests, their strength and limitations, now need exploration in the light of these ego functions. The amount of ego participation in various productions, and the type of ego function involved, differ from method to method and from case to case. The ego participates in varying degrees in imaginative productions in a way that suggests a continuum from minimal to maximal participation, in the following sequence: dream, hypnagogue phenomena, preconscious fantasy, daydream, free association, artistic productions, test behavior on proecfve techniques, and problem solving. The Dream One could consider Freud's description of "dreamwork" (condensation, symbolization, displacement, and secondary elaboration) as defensive efforts of the ego. (The theory of the ego had not yet been developed when The Interpretation of Dreams was written.) Some patients may recount a number of dreams experienced in one night, or four or five different parts of one dream, manifestly connected or not. Dream analysis demonstrates that all dreams or dream parts have the same content; sometimes the first one may be the most undisguised statement, and the subsequent ones may be more and more covered up. At other times, sequence analysis will reveal the opposite--a decrease of defensive distortion of underlying latent content - and other times, there may be a fluctuation back and forth. This greatly resembles phenomena observed in T.A.T. productions (Bellak, 1952e; Cramer, 1991a). Patients' particular constellations of defense mechanisms are often expressed in their dreams. However, for the most part, the dream is predominantly a primary process and shows less ego participation than any other mental phenomenon, except possibly psychotic productions. This is related to the problem of the diagnostic value of dreams, in of identification of nosological syndromes from dreams. Most mental health professionals hold that one cannot diagnose a psychosis from the manifest dream content (i.e., the dreams of psychotics are not manifestly differentiable from those of nonpsychotics). Piotrowski (1952) pointed out that there are typical dreams of psychotics. This involves the assumption that there may be more or less pure "primary processes" in dreams and thus, by implication, better or less wellfunctioning defenses in the dream. In advanced or chronic psychotics, there may be such a decided lack of any dreamwork as to be manifestly different. Mental health professionals, in part, agree with this position when they differentiate children's dreams from those of adults as being manifestly more primitive and more directly wish fulfilling. Similarly, if, in a clinical situation, a patient should recount an openly incestuous dream before the analytic process had loosened the defenses, a psychoanalyst would at least carefully consider this lack of defensive dreamwork a a possible indication of psychosis.

22 CHAPTER 2 Hypnagogue Phenomena Hypnagogue phenomena2 are associated with the process of falling asleep Described particularly by Silberer (1951) as autosymbolic phenomena and Isakower (1938), these phenomena are predicated on partially existing ego functions: a subjective awareness of the process of falling asleep, of the withdrawal of the cognitive functions, and of external cathexis. The most frequent type of experience is having a door shut or a window screen closed, sudden darkness indicating the closing of the eyes or the narrowing of the visual perception. Actually, such phenomena occur primarily when the process of falling asleep is disturbed, together in a situation where one should stay awake and thus struggles against falling asleep, or where anxiety disturbs the smooth self-exclusion of the ego. An even] more widespread phenomenon of this type, which may also be considered a hypnagogue phenomenon, is that of having fallen asleep and waking with a start upon the sensation of falling. This phenomenon is due to a disturbance in the! smooth self-exclusion of the ego functions concerned with muscular control and awareness, Preconscious Fantasy Preconscious fantasies are processes that are not conscious at the time but can easily be made conscious on effort. They were most extensively described by Varendonck (1931) and occur particularly while some monotonous or semiautomatic task is being performed. Frequently, upon some additional stimulus, one may "snap out of it" and suddenly become aware of the fantasies that have lived a nearly autonomous life. Such fantasies may have started as regular daydreams, or may have developed in tangential relation to some internal or environmental stimulus that The distinction between hypnagogue phenomena, preconscious fantasies, and daydreaming is not an entirely clear one, nor is there agreement on the definition. Silberer (1951) stated that the autosymbolic phenomena comes about in a transitional state between waking and sleeping, in the presence of a struggle between the two states (he did not conceptualize in of the ego.) He gives the following example: He was trying to think through some philosophical problem, part of which began to elude him, while he was nearly falling asleep. Suddenly, he had some dreamlike experience in which he requested some information from a secretary who morosely disregards him. He had symbolized and concretized his quest for enlightenment as met by his sleepiness. In response to an internal stimulus, a preconscious : fantasy developed antonomously that could be made conscious and brought in relation to a conscious process. On the other hand, much of what Varendonck (1931) reported as preconscious fantasy also took place in the process of falling asleep. Rapaport (1951) believes that Verendonck spoke of preconscious fantasies when he really meant daydreams. At any rate, we wish to differentiate preconscious fantasies by their quality of being ego alien, similar to mild obsessive phenomena, as compared with such fantasy as ego syntonic, and for which I prefer the term daydream. It is, however, entirely possible for a person at one time to run the entire continuum from hypnagogue thinking to preconsious thinking, daydreaming, and problem solving, all possibly related to the same problem. Kris (1950), in a discussion of preconscious mental processess, has discussed this continuum and its relation to the creative process and its metapsychologic implications.

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THEORETICAL FOUNDATIONS FOR PROJECTIVE TESTING 23 may be recognized as related by subjects who have learned to introspect. People in psychotherapy, people who are deeply preoccupied, and prepsychotics may experience an abundance of such fantasies that are, to a certain extent an ego function (inasmuch as they are in some relationship to environmental or originally conscious stimuli) and can be made conscious upon effort. To a considerable extent, daydreams are under the control of the ego. Many people will reach for ready-made daydreams that they think of routinely in frustrating situations. Others will keep their daydreams within some limits of reality. Indeed, controlled daydreams may be the forerunners and concomitants of problem-solving behavior (e.g., a person who daydreams of success and in this process hits on a workable formula). The patient who is asked to free associate in the clinical situation is asked to perform a complex task: to let his mind run freely (i.e., to decrease the controlling function of his ego), and at the same time, or in brief succession, to increase the cognitive function of the ego concerned with self-awareness. It is the nature of this complex task, of an oscillating function or ability of the ego to change from self-exclusion to control, that makes free association so difficult for some patients. Notably, obsessive-compulsives find it difficult to "let go" and thus report a dearth of ideas. In these cases, rigidity is in direct contrast to the flexibility of ego functions necessary for free associating. Frequently, their ability really to free associate coincides with the time of their cure. Some other patients, possibly hysterics more than others, may find it difficult to keep enough distance to do a good job with the observing function (The tasks for the ego become even more complex when a third function becomes necessary; aside from "letting go" and observing, insight presupposes the ability to see new configurations.) (Bellak, 1961, 1993a; Bellak & Goldsmith, 1984). The process of free association can be explained in a more lucid way by re- formulating the concept of self-exclusion of the ego or, better, of adaptive regression in the service of the ego (Bellak, 1961). As it involves free association, it involves a relative reduction of certain adaptive functions, one of which is a reduction of secondary process qualities of thinking and an emergence of primary process thinking and unconscious content. The first phase of the process is succeeded or overlapped by an increase in adaptive and synthetic ego functioning. In this way, insight emerges, partly due to oscillation from regression of specific ego functions to an increase in others. The regressive phase consists of two aspects: the temporal regression of ego functions to levels characteristic of earlier ages and the topological regression from mainly conscious functioning to functioning at the preconscious and unconscious levels. The topological regression of certain ego functions, frequently simultaneously, involves a temporal regression of these ego functions and often a regression in the libidinal zones and modes. In the process of free association, metapsychological problems other than the topological are involved; these are the structural, dynamic, genetic, and energetic (Bellak, 1993a).

24 CHAPTER 2 Artistic Creation This process, similar to free association, also necessitates both the ability of self-exclusion of the ego and the rapid change to cognitive critical awareness. Ernst Kris has pointed out that only in the presence of intact ego functions (regression in the service of the ego) can one speak of art (an accentuated form of communication of experiences in distinction to the productions of advanced psychotics). In the case of many borderline or ambulatory psychotics who are artists, there is still enough ego function left so that one can consider their productions as truly artistic. Projective Techniques In a procedure such as the T.A.T., the person is again asked to perform a complex task. We ask the individual to let his or her mind run freely - that is, to induce some self-exclusion of the ego. Then we continue our instructions to the effect that he or she is to tell a story about the picture, tell us about what is going on, what led up to the situation, and what the outcome will be. We ask the subject to adhere to the stimulus and to maintain a set consistent with our formula. As in free association and artistic production, performance on the T.A.T. and other projective techniques presupposes an oscillating function of the ego. The overly rigid patient will not be able to decrease the control and will give only descriptive data and meager data altogether; the patient with insufficient ego control will leave the stimulus and leave the task. The "letting go" gives us the drive content thus far primarily studied in projective methods. By observing the oscillating functions and the defenses against the underlying impulse or drive material, we may infer ego strength and may often observe drive content that does not appear prima facie. The following stories may illustrate the point. 9BM: Group of four men who are running away from something -something the fellow on the left is looking for. Probably they've broken out of confinement. The position - the way they're lying doesn't seem to indicate they're under any great stress or tension. They could just as well be four hunters. The fellow on the left could be watching for whatever they're hunting, duck or game of any sort. Little siesta after working on any kind of on- location job. This response of an adolescent boy really consists of at least three stories: They are running away from something, possibly escaping confinement; then (a much more innocuous story than the first) they are merely hunting; and (even more innocuous), finally, the aggressive connotation of hunting is given up and the picture becomes one of utmost peace and ivity - siesta. Thus, we see one way of meeting, with obsessive elaboration, the threat of (one's own) aggression. It is by such study that fine features of defense and character may be discovered. From the ellipse or the omission, or from the sequence of defenses, we may learn the content. A study of the equilibrium of impulse and defense or drive and control is the most useful method of investigation. Similarly, in the Rorschach, one studies the ego's ability to perceive, to organize, to perform cornt sion, tor e tent capa, tern choi tivity the e Proj as cr First, creat in o1 emel mare SUlTI when cycli, Mate culty that tots, ence same higff the c dard The i from cial situa: ther PTvbi than volved Cases ently flexibJ

THEORETICAL FOUNDATIONS FOR PROJECTIVE TESTING 25 ctural, iility of i. Ernst ion in ication he case mough | a COID-- i induce iect that qhat led lhere to : associa- ire tech- )ent will meager tflus and [ in pro- hinst the Often ob- is may il-

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char- uence of and de- in perform complex tasks (see later discussion of color shock), and to control anxiety, aggression, and sexual impulses. In the Figure Drawing Test, graphology, and the Mira test, one studies the motor executive functions of the ego. In the Bender Gestalt Test, and to a certain extent in the other tests, the ability to perceive figure and ground properly and the capacity to interpret well are studied (see discussion of signs). In the Szondi, a system of selective choices is the basis for personality indicators. The nature of the choices involved is a matter of disagreement, but there can be no doubt that the activity of choosing between alternatives is always, to a certain extent, influenced by the ego; this holds true cognitively and conatively? Projeaive Responses as Products and Indicators of Creativity There are four central factors in making inferences from projective responses as creative products that are different from those operant in other creative acts. First, the unconscious and preconscious conditions needed in artistic and scientific creativity often require a (conscious) mental set to create that may not be available in objective settings. Second, whereas the creative process generally attains the emergent level only in its own course, in projective testing, the commands the subject to create. Similarly, in interpreting projective protocols, it is assumed that creativity is composed of continually operant variables of personality whenever it is present. This is not valid for all creative people; creativity may by cyclic. (See item 4 under "Possible Means of Increasing Productivity of T.A.T. Material by an Ego Psychological Approach" later in this chapter.) The third difficulty in inferring general creative ability from projective tests is based on the fact that the creative product is the resultant of many factors, including situational facton, the nature of the stimulus, and so on. The fourth problem in making inferences about creativity is due to the fact that the personality syndromes are not the rome at different dines, and that the degree of variability over a period of time is a highly significant personality index. Consideration of these four problems leads to the conclusion that it may be impossible to ascertain creative potential with standard tests (Bellak, 1958). Latent and the Manifest The ability to relate to and from the latent to the manifest (behavioral) level-- from the projective test data to actual behavior--has often been considered the cru- problem of projective testing. This is not true for clinical practice, since, in this |ituation, the psychologist should not be called on to make blind diagnoses. A good therapist would never interpret a dream from the manifest content without knows solving as an imaginative production is the type of activity involving more ego participation ti , of the others. There, reality testing and adaptation, with all the resources of the ego, are in - even in this situation, a certain ability for selfexclusion of the ego may he helpful. in which a solution to a difficult problem comes to one just prior to falling asleep, or even appartats/during sleep, are not infrequent. The capacity for insight - to see new wholes - presupposes some of the perceived boundaries of existing wholes.

26 CHAPTER 2 ing the life situation, the day's residue, and the like. Similarly, a psychologist should only interpret unconscious data as a complement of behavioral data. One can learn the most from a combination of both levels: If a man's T.A.T. drips with blood and gore and he turns out to be a Casper Milquetoast behaviorally, one can make inferences as to the nature of his conflicts and tensions. There are, however, certain situations in which therapists are legitimately called on to make inferences from the latent to the manifest. Examples include theoretical, experimental purposes; clinical situations such as the prediction of criminal behavior and suicide; and problems such as personnel selection. The ego must be considered the intervening variable between the latent and the manifest level. A study of ego functions in relation to drive may permit one to see that aggressive impulses are or are not permitted to break through. This can be illustrated by the following story of an obsessive patient given in response to picture 17BM: The man shown here is a circus performer and has been one for many years. His ambition has always been to be a solo performer instead of part of a trapeze trio. Until now he has not had the opportunity. In tonight's performance he will save a fellow trouper from a serious accident and as a reward for his bravery will be given the chance to do his act alone. One may formulate the following: This person wants to be in the limelight and do away with the competitors; this thought is not permitted expression. Instead of the aggressive thought, the hero gives help in an accident - that is, the aggression is impersonalized, the helpfulness appears manifestly, and the original goal is given as a reward. In other words, the sequence of the story demonstrates this subject's use of reaction formation in avoiding expression of manifest aggression. Sometimes, a picture of the entire defensive nature of the character structure reveals itself clearly in the T.A.T. A relationship among drive and superego and ego may permit one to prognosticate suicide. Stories in which the punishment far exceeds the crime, and in which the punishment is immediate and severe (or cruel), are consistent in our experience with real suicidal danger. The adequacy of the hero in dealing with the task that the subject himself has constructed is an excellent criterion of ego strength. The more adequate the hero and the more appropriate, realistic, and happy the outcome, the safer the inference that one is dealing with a person who will bring other tasks to a good completion. One is not now considering specific aspects of ego strength needed for specific jobs; the ego strength required of a research scientist is concerned with ability for detour behavior and so on, as compared with the abilities required of a combat of- ricer (e.g., capacity for anxiety tolerance and the ability to libidinize anxiety). Further Problems an Ego Psychology of Projective Techniques May Answer Barren Records The problem of barren records has been mentioned before in connection with one of the ways in which a projective technique may fail. Murray (1951c) speaks of "chaff" needing to be separated from the "wheat" in T.A.T. stories. We are not in agreement with this formulation. n W S( le h 0 t p tl t ti b n g d il,, io h si g V(

THEORETICAL FOUNDATIONS FOR PROJECTIVE TESTING 27 To speak of chaff is reminiscent of the days when psychoanalysts still saw resistance as a nasty way in which patients behaved and something they had to overcome. With the analysis of the ego, the analyst has learned a great deal from the analysis of the resistance. The analyst learns, in fact, how the ego and the defenses are structured, which was not possible to learn without also understanding the resistances. Similarly, analysis of the chaff, of what is considered barren, will give much information about the defenses of the ego, as in the earlier examples. From the standpoint of determinism as an essential axiom of psychological science, every psychological performance--and thus every utterance - must be meaningfully related to the total structure of personality. It is true that, practically and clinically speaking, it will usually not be worthwhile or possible to investigate each detail. In patients whom we have treated for as long as three years, and whose T.A.T.s and other projective data we also have, we have had occasion to compare production in treatment and on the tests. For all practical purposes, the generalization can be made that the defenses used in the clinical situation and on the projective techniques were identical: Those who use avoidance, denial, and isolation, and who gave barren records, also tended to spend hours on the couch reporting apparently meaningless data that had to be interpreted and could become meaningful only by inferring the basic issue about which they were. Considerable experimental studies have ed the fact, long known in clinical practice, that avoidance of aggressive responses to aggressive stimuli is indicative of a great deal of aggression (Bellak, 1950a; Kaplan, 1967; Kornadt, 1982; Megargee, 1967; Megargee & Hokanson, 1970; Tachibana et al., 1984). Inconsistent Result In certain cases, failure to obtain test data that one could expect to find may be understandable in of ego psychology. For instance, in lobotomized or topectomized patients, various projective techniques and other tests may fail to show any deficit behavior. Lobotomies, in particular, and topectomies, to some extent, are still blind procedures neurologically and, particularly, psychologically speaking. The results and effects differ widely from case to case, sometimes strengthening and sometimes weakening the ego. When the surgical procedure somehow interferes with the "drive push" of the patient, the ego may be secondarily strengthened and none of its integrating functions impaired in such a way that a disturbance in the ego function would manifest itself in psychological test behavior. In other words, the failure of tests to reveal expected pathology incident to the surgical trauma is due to the fact that none of the ego functions involved in test behavior were involved in the trauma. Signs Organic signs are symptoms of ego defect in situations in which the organic lesion involves ego functions. The reliability and validity of organic signs will be greatly improved if they will be expected only in such lesions that are likely to involve the ego functions tested in a particular procedure. Other inconsistencies in test results may consist not only of not finding what "ought" to be there but also, not infrequently, of finding data that "ought not" to be there, in the sense of indicating much more pathology than can be ed for.

28 CHAPTER 2 For example, if more than 50 percent of the students of a city high school show schizophrenic signs on the Rorschach, there is obviously something wrong with the signs. Signs are a result of the pressure for nomothetic data in the search for the "average" person and the hunted deviant. Many of them are arrived at simply by the use of faulty generalizations by the factor-analysis hunters. Schizophrenia being the most fashionable diagnosis, faulty diagnosis of this syndrome probably constitutes the majority of all misdiagnosis. It is safe to say that the less experienced the psychiatrist or psychologist, the more often she or he will make the diagnosis of schizophrenia, notwithstanding the fact that she or he will sometimes miss it when it does exist. The main problem seems to be that the so-called signs of schizophrenia are almost all signals of disturbances of the ego, such as poor control, poor reality testing, and so on. Although ego weakness is a primary factor in schizophrenia and other disorders (Bellak, 1952b), it must be ed that it is not the sole criterion (cathexis also playing a role) and that other conditions of ego weakness may obtain the same ego indicators. Adolescents notably have weak egos, and many phenomena in adolescence would have to be interpreted as schizophrenia in other age groups (which makes the diagnosis of the real adolescent schizophrenic one of the most difficult). By the same token, an artist who has learned to exclude his or her ego functions in creative situations may "let go" in the testing situation to the point of giving signs of ego weakness that may be inappropriately interpreted as schizophrenic. Eron (1948) has shown that what was reported as schizophrenic in T.A.T.s by Rapaport (1946) could frequently be found in nonschizophrenics of all kinds, including people who are considered "normal." Another group that is frequently inappropriately diagnosed as schizophrenic on the basis of signs is the mentally deficient. These subjects also have a defect of the ego, which often manifests itself in poor control, poor perception of reality, and even paranoid interpretation of an environment that they have every reason to fear and suspect of "putting something over" on them. It is not useful to mistake their intellectual deficit state for a psychosis. Color Shock Color shock is one of the most interesting and most embattled signs of the Rorschach. Siipola (1950) has done important work on this phenomenon. She has contended that when color and form suggest divergent concepts, there may be three different ways of dealing with the situation. The normal individual may be able to achieve an integration nevertheless (an object first suggesting a bear by shape but being green in color may be quickly seen as a chameleon) ; the neurotic may be stymied and "shocked" into silence by the conceptual conflict; and the psychotic may have judgment impaired to the point where he or she cheerfully gives the response, "green grass bear." It is Siipola's contention that color shock occurs only where form and color clash, and that it constitutes a response to a more difficult task. We would go further and say that this is best stated in of ego psychologymnamely, that the normal ego is strong enough to achieve a difficult integration, the neurotic's ego is too weak to accomplish this, and the judgment “ought not" to be ed a school show with the signs.

THEORETICAL FOUNDATIONS FOR PROJECTIVE TESTING 29 ch for the "av- simply by the ;nia being the ly constitutes ,.nced the psyinosis of schiz- aiss it when it schizophrenia t, poor reality ophrenia and ot the sole cri- weakness may and many phe- .ia in other age .nic one of the [ude his or her 0n to the point :eted as schizorenic in T.A.T.s ics of all kinds, S schizophrenic have a defect of n of reality, and y reason to fear to mistake their Jed signs of the inenon. She has , there may be ividual may be ;sting a bear by n); the neurotic ict; and the psycheerfully gives or shock occurs .' to a more diffi-erms of ego psy- e a difficult inte- d the judgment functions of the psychotic ego are so impaired that he or she easily combines form and color inappropriately. In line with what was said about caution in the interpretation of signs, it must be pointed out that a nonrepresentational artist, accustomed to decreasing ego functions without being psychotic, might well not hesitate to say "green grass bear," and that a psychoanalyzed subject may equate the testing situation with the analytic situation and induce a similar egoexcluding "set" that might permit the same "green grass bear" response. Conscious Control and Faking Superseding questionnaires and rating scales, projective psychologists like to think of themselves as real scientists and of their instruments as practically fool- proof. All the more disturbing to them, therefore, are reports of successful conscious control and faking on the Rorschach, the T.A.T., and other tests (Holmes, 1974; Lindzey, 1952; Orpen, 1978). Such faking can be understood and restricted to its limitations by understanding the productions from an ego point of view. To the extent to which conscious attitudes and conscious ego control can be introduced, the subject may alter the record to a relatively small degree in one direction or another, concerning such variables as overall "wholesomeness." Particularly with regard to Weisskopf and Dieppa's (1951) work with the T.A.T., it must be ed that only a few pictures were used, and the most difficult task for the subject would be to fake consistently over the whole series of pictures. Furthermore, an analysis of the defenses would probably reveal the basic structure of the character, no matter how much faking the subject endeavored to engage in. Naturally, such characteristics, which, though under the control of the ego, are not under its conscious control and not on the semantic level, are unlikely to be affected at all. Possible Means of Increasing Productivity of T.A.T. Material by an Ego Psychological Approach If relative "barrenness" of records is the chief complaint of psychologists, we may be able to suggest a number of ways to increase productivity: 1. An analysis of the defenses as they appear in the T.A.T. record has already been discussed at some length as a means of increasing the yield, which has been reviewed in detail in books on the thematic apperception tests and defenses by Brody and Siegel (1992), Cramer (1991a), and Dias (1976). If barrenness is the result of overly increased ego control, for example, a number of measures capable of decreasing ego control must then increase the productivity. This could be accomplished by: 2. Providing stronger stimuli. If the stimuli have more affective pull, the ego will find it more difficult to control the affect. In the T.A.T., this coincides with the need for better pictures - primarily a wider range of stimuli to facilitate study of apperceptive distortions of situations not currently provided for in the existing set. A recent example is the Senior Apperception Test (S.A.T.), which now has new, improved drawings that are able to elicit richer fantasy responses (Bellak & Bellak, 1996).

30 CHAPTER 2 3. Any other form of increase of pressure might also increase productivity. Stein's (1949) use of tachistoscope exposure is one way in which this might be done, the shorter exposure time causing more tensions and increasing the ambiguity (see item 4). Both this approach and the one of stronger stimuli might prove a double-edged sword: Although this might decrease the ego control in some subjects, others might freeze up even more. It is helpful to utilize the standard approach first, and only if this has failed and if there are no other contraindications (such as excessive anxiety) will it be economical to increase the pressure. 4. Increasing ambiguity has been attempted by Weisskopf (1950a) and Weisskopf and Lynn (1953) with the T.A.T. and the Children's Apperception Test (C.A.T.). Presenting tracings of the usual pictures and interrupting the outlines to make less good Gestalten may - up to a point - increase productivity to some extent. Murray's (1951c) modification in presenting the pictures for only 30 seconds and then removing them also increases ambiguity and prevents excessive descriptive clinging to the stimulus. Other studies indicate that cards that are medium ambiguous are best for projection (Epstein, 1966, Kaplan, 1969, 1970). Murstein (1965d) suggested that pictures most useful for thematic production are those that are clearly structured as to who is in the picture but relatively ambiguous as to what is going on. Such cards are medium ambiguous. Many studies have indicated that highly ambiguous cards are least useful for personality assessment (Kaplan, 1967; Kenny, 1961). Lazarus (1953) and Kaplan (1970) have noted that, because of high ambiguity of stimuli in projective tests, the lack of expression of certain needs (i.e., aggression) could be due either to lack of arousal value of the stimulus or to ego defenses against the related impulses. 5. Physiological means of weakening the ego, such as barbiturates or alcohol, have worked well at times. 6. A stress inquiry in the form of a request for controlled associations to any of the stories, and particularly to any specific concrete references in them (after all the stories have been told), may be a useful means of increasing the data of otherwise barren records. 7. Finally, if a certain test fails to give the necessary data, use another test. Some psychologists utilize a variable series of different tests, rather than a standard battery of a core of the same tests for all individuals of the same age group. This is reminiscent of the shotgun prescriptions of prescientific medicine. The doctor puts dozens of ingredients into every prescription in the hope that, if one would not help, another might. Clearly, a psychological test should be fitted to the needs. If one needs content of the psychodynamics, one should use the apperceptive tests; if one wants an assay of ego strength and generally quantitative indicators, one should use the formal expressive tests. But if, for example, aggression is not meaningfully expressed in the T.A.T., it may be very useful to study figure drawings. The verbal expression of aggression may be successfully controlled when its muscular expression is clearly seen in heavy line pressure of the human figure or other drawings. Often enough, the problem can be stated in a generalization--namely, that when one fails to obtain data on the semantic level, tests probing the subsemantic area may produce information.

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THEORETICAL FOUNDATIONS FOR PROJECTIVE TESTING 31 There is good reason, on the other hand, not to leave out the semantic tests routinely, since they can elicit much more detailed, more subtle information than can safely be inferred from the organizational subsemantic methods of personality appraisal.

Apperceptive Distortion: A Theory Concerning Content of Responses as Seen Particularly in the T.A.T. The preceding section discussed the general framework of ego psychological theory of projective techniques and the various dimensions of tests subsumed under that term. Since we wish to describe the T.A.T. particularly, and the T.A.T. is characterized as primarily a test of content, we will now address, more specifically, psychological theory concerning what the patient says. Certain theories concerning adaptive and expressive formal test behavior are necessary. It will require special parts of a general ego psychological theory of personality (to be postulated and verified) to determine why outgoing movements on Mira's test should be associated with outgoing, aggressive personalities, or why extensor movements in the Rorschach should be associated with healthy, active striving. Why a preference for Dd in the Rorschach should be related to obsessive- compulsive tendencies might well be satisfactorily explained by psychoanalytic hypothesis. Why color should play a special role may need psychological hypotheses additional to those of Exner (1994), Siipola (1950), and others. However, projection in its original sense - namely, as referring to content of perception - is our special concern. The term projection was first introduced by Freud (1940a) as early as 1894 in his paper, 'The Anxiety Neurosis," in which he said: "The psyche develops the neurosis of anxiety when it feels itself unequal to the task of mastering [sexual] excitation arising endogenously. That is to say, it acts as if it had projected this excitation into the outer world." In 1896, in a paper, "On the Defense Neuropsychoses" (Freud, 1940d), elaborating further on projection, Freud stated more explicitly that projection is a process of ascribing one's own drives, feelings, and sentiments to other people or to the outside world as a defensive process that permits one to be unaware of these undesirable" phenomena in oneself. Still further elaboration of the concept occurs in his paper on the case of Schreber (Freud, 1943) in connection with paranoia. In brief, the paranoiac has certain homosexual tendencies that he transforms under the pressure of his superego from "I love him" to "I hate him," a reaction formation. He then projects this hatred onto or ascribes to the former love object, who has become the persecutor. The ascription of hatred presumably takes place because emergence into consciousness and realization of the hatred is prohibited by the superego, and because an externalized danger is more readily dealt with than an internal one. The superego inhibits expression of the hatred because it morally disapproves of it. Although projection thus originated in connection with psychosis and neuroses, it was later applied by Freud to other forms of behavior for example, as the main mechanism in the formation of religious belief as set forth in The Future of an Illusion (1940) and in Totem and Taboo (1938).

32 CHAPTER 2 Even in this cultural context, projection was still seen as a defensive process against anxiety. Freud originally considered repression the only defense mechanism; at present, at least 10 mechanisms are mentioned in the psychoanalytic literature. Although projection is firmly established as one of the most important defensive processes, relatively little work has been done on it. Sears (1943) stated: "Probably the most inadequately defined term in all psychoanalytic theory is projection." There is a long list of papers on projection, however, particularly clinical psychoanalytic and some academic ones. The definition of projection as a defense mechanism was more than adequate until a crucial point arose in connection with attempts at the experimental investigation of the phenomena in one of the earliest studies on the T.A.T. (Bellak, 1944), which was later successfully replicated by Cramer (1991b). The first experiment consisted of provoking a number of subjects and giving them pictures of the T.A.T. under controlled conditions. In the second experiment, the subjects were given the posthypnotic order to feel aggression (without being directly aware of it) while telling stories about the pictures. In both instances, the subjects behaved according to the hypothesis of projection and produced a significant increase of aggression, as compared with their responses of the pictures when they had not been made to feel aggressive first. Similarly, when the subjects were under posthypnotic orders and were told that they were extremely depressed and unhappy, it was found that they projected these sentiments into their stories. Up to this point, there was no need to change the concept of projection as the ascription to the outside world of sentiments that are unacceptable to the ego. When the experiment was varied, however, and the posthypnotic order was given to the subjects that they should feel very elated, it was found that elation, too, was projected into the stories given to the T.A.T. pictures. At this point, it occurred to us that this could not possibly be subsumed under the concept of projection as a defense mechanism, since there was obviously no particular need for the ego to guard against the "disruptive" effects of joy. Such a case can be hypothesized, for example, when joy is inappropriate, as in the death of a person toward whom ambivalence is felt. Such was not the case, however, in the experiment. Therefore, it was necessary to examine further the concept of projective phenomena and to suggest a reexamination of underlying processes. As so often happens, it was found on careful rereading of Freud (following a reference by Ernst Kris) that Freud had anticipated our present trend of thought. He said in Totem and Taboo:

But projection is not specially created for the purpose of defense, it also comes into being where there are no conflicts. The projection of inner perceptions to the outside is a primitive mechanism which, for instance, also influences our sense-perceptions, so that it normally has the greatest share, in shaping our outer world. Under conditions that have not yet been sufficiently determined, even inner perceptions of ideational and emotional processes are projected outwardly, like sense perceptions, and are used to shape the outer world, whereas they ought to remain in the inner world .... (1938, p. 857) The thing which we, just like primitive man, project in outer reality, can hardly be any thing else but the recognition of a state in which a given thing is present to the senses and to consciousness, next to which another state exists in which the thing is latent, but can reappear, that is to say, the coexistence of perception and memory, or, to generalize it, the existence of unconscious psychic processes next to conscious ones. (p. 879) thin1 but

the

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THEORETICAL FOUNDATIONS FOR PROJECTIVE TESTING 33 This thought of Freud's, not further elaborated on nor systematically expressed anywhere and stated without any of the sophistication of modern semantics, contains everything necessary for a consistent theory of projection and general perception. Freud's main assumption is that memories of percepts influence perception of contemporary stimuli.4 The interpretation of the T.A.T. is, indeed, based on such an assumption. A subject's past perception of her own father influences her perception of father figures in T.A.T. pictures, and this constitutes a valid and reliable sample of her usual perception of father figures. Clinical experience, as well as experimental investigation, has borne out this point. Our own experiments have shown that the behavior of the experimenter can bring out sentiments that originally were probably related to the father figure. While these sentiments had a demonstrable but temporary overall influence on the perception of stimuli--individual differences were maintained according to the genetically determined structure of the personality. It seems, then, that percept memories influence the perception of contemporary stimuli - and not only for the narrowly defined purpose of defense, as stated in the original definition of projection. One is compelled to assume that all present perception is influenced by past perception, and that, indeed, the nature of the perceptions and their interaction with each other constitutes the field of the psychology of personality? It is necessary to describe the nature of these perceptual processes and later to attempt to formulate a psychoanalytic or more general psychology of personality based on these conceptions. Projection as a variant of perception has indeed become an integral part of the psychology of personality (see below). Apperception and Apperceptive Distortion To use the term projection for general perceptual processes does not seem useful in view of the history of the concept and its present clinical applications. On the other hand, perception has been so definitely linked with a system of psychology that has not been concerned with the whole personality that we hesitate to use it any further in the context of dynamic psychology. Although terminology is certainly not a matter of primary importance here, the term apperception should be used hence4 Herbart antedates Freud on this idea (see p. 16 of Runes, 1955). This theory, in its broadest implications--name, that perception is subjective and is the primary datum of all psychology - is, of course, not original with Freud. Hume's "Nihil est in intellectu quid non anteafuerit in sensibus" is virtually a perceptual theory of personality, though not meant that way. Similarly, philosophical idealism, such as Schopenhauer's Die Welt als Will and Vorstellung and Kant's transcendental state, represent a similar position.

34 CHAPTER 2 forth. We speak of apperception as an organism's (dynamically) meaningfully interpretation of a perception, following the definition by C. E Herbart in his Psychologic als Wissenschaft (Part 111, Section 1, Chapter 5, p. 15) as quoted in Dagobert D. Runes, editor of the Dictionary of Philosophy: "Apperception (latin, ad plus percipere to perceive) in psychology: The process by which new experience is assimi- lated to and transformed by the residuum of past experience of any individual to form a new whole. The residuum of past experience is called apperceptive mass." This definition and the use of the term apperception permit us to suggest, purely for the purpose of a working hypothesis, that there can be a hypothetical process of noninterpreted perception, and that every subjective interpretation constitutes a dynamically meaningful apperceptive distortion? Conversely, we can also establish, operationally, a condition of nearly pure cognitive "objective" perception in which a majority of subjects agree on the exact definition of a stimulus. For instance, the majority of subjects agree that picture 1 of the T.A.T. shows a boy sitting in front of a violin. Thus, this perception can be established as a norm. Anyone who, for instance, describes this picture as a boy at a lake (as one schizophrenic patient did) distorts the stimulus situation apperceptively. If we let any of our subjects go on to further description of the stimulus, however, we find that each one of them interprets the stimulus differently, such as a happy boy, a sad boy, an ambitious boy, or a boy urged on by his parents. Therefore, we must state that purely cognitive perception remains a hypothesis, and that every person distorts apperceptively, the distortions differing only in degree. In the clinical use of the T.A.T., it becomes quite clear that one deals with apperceptive distortions of varying degrees. The subject is frequently unaware of any subjective significance in the story he or she tells. In clinical practice, it has been found that simply asking the subject to read over his or her typed-out story may often give the individual sufficient distance from the situation to perceive that the gross aspects of it refer to himself or herself. Only after considerable psychotherapy, however, is the subject able to see his or her more latent drives, and he or she may never be able to "see" the least acceptable of the subjective distortions, on the presence of which any number of independent observers might agree. It may be permissible, then, to introduce a number of for apperceptive distortion of varying degree for purposes of identification and communication.7 Forms of Apperceptive Distortion Inverted Projection It is suggested that the term projection be reserved for the greatest degree of apperceptive distortion, such as paranoid delusions. Its opposite pole would be, hypothetically, a completely objective perception. 6 We might add that, as long as the formation of a new configuration results in a commonly agreed upon "appreception," we may call it just that (e.g., the apperception of a certain wooden structure as a "table"). If there is any disagreement on the nature of an apperception, somebody must be engaged in apperceptive distortion. 7 It must be understood that these various forms of apperceptive distortion do not necessarily exist in pure form and frequently patently coexist with each other. pothedcally, in clinical neurodc case of true sentiments ceptable to addition, niques. This essentiall "He hates m ably involvin unacceptable also unaccept hates me." That projection ation of an{ that, in the mosexually) is father as a and replaces first with the tion that a simple proj The mec] it is a frequenl joke: Joe Smith' thinks of how he the last time I fant,, by replies in over, arrives at Jim's h, for you?" and Broken down, previous rei may not be with him, and hates me." In greate See Murray's

THEORETICAL FOUNDATIONS FOR PROJECTIVE TESTING 35 Projection was originally described in clinical psychoanalys is as pertaining to psychoses, in particular, and to certain neurotic defenses, generally, and to some "normal" maturational processes. In the case of true projection, one is dealing not only with an ascription of feelings and sentiments that remain unconscious, in the service of defense, but that are unacceptable to the ego and are therefore ascribed to objects of the outside world. In addition, they cannot be made conscious except by special prolonged therapeutic techniques. This concept covers the phenomenon observed in a paranoid that can be essentially stated as the change from the unconscious "I love him" to the conscious "He hates me." True projection in this case is actually a very complex process, probably involving the following four steps: (1) "I love him" (a homosexual object)--an unacceptable id drive; (2) reaction formation--"I hate him"; (3) the aggression is also unacceptable and is repressed; and (4) finally, the percept is changed to "He hates me." Only the last step usually reaches consciousness. That process might well be called inverted projection, as contrasted with simple projection (discussed next). The first step in the process usually involves the operation of another defense mechanism: reaction formation. It is sufficient to say here that, in the case of the paranoid, "I hate him" is approved, whereas "I love him" (homosexually) is socially disapproved and was learned early by him in relation to his father as a dangerous impulse. Therefore, in this case, "I hate him" extinguishes and replaces the loving sentiment. Thus, in inverted projection, one really deals first with the process of reaction formation and then with an apperceptive distortion that results in the ascription of the subjective sentiment to the outside world as a simple projection. (See Murray's (1938) concepts, p. 38) The mechanism of simple projection is not necessarily of clinical significance; it is a frequent everyday occurrence and has been well described in the following joke: Joe Smith wants to borrow Jim Jones's lawn mower. As he walks across his own lawn, he thinks of how he will ask Jones for the lawn mower. But then he thinks: 'Jones will say that the last time I borrowed something from him I gave it back dirty." Then Joe answers him in fantasy by replying that it was in the same condition in which he had received it. Then Jones replies in fantasy by saying that Joe will probably damage Jones's fence as he lifts the mower over. Whereupon Joe replies.., and so the fantasy argument continues. When Joe finally arrives at Jim's house, Jim stands on the porch and says cheerily, "Hello, Joe, what can I do for you?" and Joe responds angrily, "You can keep your damn lawn mower!" Broken down, this story means the following: Joe wants something but recalls a previous rebuff. He has learned (from parents, siblings, etc.) that the request may not be granted. This makes him angry. He then perceives Jim as angry with him, and his response to the imagined aggression is: "I hate Jim because Jim hates me." In greater detail, this process can be seen as follows: Joe wants something from Jim. .

36 CHAPTER 2 This brings up the image of asking something from another contemporary-his brother, for example - who is seen as jealous and would angrily refuse in such a situation. Thus, the process might simply be: The image of Jim is apperceptively distorted by the percept memory of the brother, a case of inappropriate transfer of learning. We will attempt to explain later why Joe does not relearn if reality proves his original conception wrong. The empirical fact is established that such neurotic behavior does not usually change except under psychotherapy. Joe differs from the paranoid not only by the lesser rigidity with which he adheres to his projections but also by less frequency and less exclusiveness as well as the smaller degree of lack of awareness, or inability to become aware of how patently subjective and "absurd" is the distortion. The following process is certainly not infrequent: Ann arrives late for work on Monday morning and believes, incorrectly, that her supervisor looks angrily at her later in the day. This is spoken of as "a guilty conscience"--that is, Ann behaves as though the supervisor knew that she had come late, when, in reality, the supervisor may not know it at all. This means that Ann sees in the supervisor the anger that she has come to expect in such a situation. This behavior can then be understood again as a simple (associative) distortion through transfer of learning, or in more complex situations, the influence of previous images on present ones. Sensitization If the preceding case of a subject's coming late to work is modified so that there is a situation in which the supervisor feels a very slight degree of anger at the latecomer, a new phenomenon may be observed. Some subjects may not observe the anger at all and thus not react to it, whereas others may observe it and react to it. In the latter case, one will find that these subjects are the ones who tend to perceive anger even at times when it does not objectively exist. This is a well-known clinical fact and has been spoken of as the "sensitivity" of neurotics. Instead of the creation of an objectively nonexistent percept, one is now dealing with a more sensitive perception of existing stimuli? The hypothesis of sensitization merely means that an object that fits a preformed pattern is more easily perceived than one that does not fit the preformed pattern. This is a widely accepted fact, for example, in the perceptual problems of reading, wherein previously learned words are much more easily perceived by their pattern than by their spelling. Sensitization is also the process that took place in an early experiment by Levine, Chein, and Murphy (1943). When these experimenters first starved a number of subjects and then fleetingly showed them pictures in which, among other things, were depicted objects of food, they found two processes: (1) When starved, the subjects saw food in the fleeting pictures, even if there was none, and (2) the subjects correctly perceived actual pictures of food more frequently when starved. Apparently, in such a state of deprivation, there is an increased cognitive efficiency of the ego in recognizing objects that might obviate its deprivation, and also a simple compensatory fantasy of wish fulfillment that the authors call autistic perception.

THEORETICAL FOUNDATIONS FOR PROJECTIVE TESTING 37 Thus, the organism is equipped for both reality adjustment and substitutive gratification where real gratification does not exist. This is really an increase in the efficiency of the ego's function in response to an emergency--a more accurate perception of food in the state of starvation. This process can also be subsumed under our concept of sensitization, since food images are recalled by the starvation and real food stimuli are more easily perceived. An experiment by Bruner and Postman (1954) may possibly also follow the same principle. The authors had their subjects adjust a variable circular patch of light to match in size a circular disk held in the palm. The perceptual judgments were made under the influence of varying degrees of shock and during a recovery period. Results during shock did not vary markedly. During the postshock period, however, the deviations of perceived size from actual size became very marked. The authors tentatively proposed a theory of selective vigilance. In of this theory, the organism makes its most accurate discriminations under conditions of stress. When tensions are released, expansiveness prevails and more errors are likely to occur. We may make the additional hypothesis that the tension results immediately, in a greater awareness of the image in memory, and more acute judgments of equality of size between the percept memory of the disk and the light patch are made. The concept of the mote-beam mechanism of Ichheiser (1947) may also be subsumed under the concept of sensitization. Ichheiser proposed to speak of the mote- beam mechanism in cases of distortion of social perception when one is exaggeratedly aware of the presence of an undesirable trait in a minority group, although one is unaware of the same trait within oneself. In other words, that there is a sensitization of awareness (coexistent with unawareness of the process itself and of the existence of the trait within oneself, as inherent in any defensive mechanism) owing to one's own unconsciously operating selectivity and apperceptive distortion. Autistic Perception Whether the perception of desired food objects in the state of starvation among stimuli that do not objectively represent food objects constitutes a form of simple projection or is a process that should be described as distinct from it depends on rather fine points. Both Sanford (1936) and Levine and colleagues (1943) have demonstrated the process experimentally. One may see that the increased need for food leads to a recall of food objects, and that these percept memories distort apperceptively any contemporary percept. The only argument that can be advanced for a difference from simple projection is that one deals here with simple basic drives that lead to simple gratifying distortions rather than to the more complex situations possible in simple projection. Externalization Inverted projection, simple projection, and sensitization are processes of which the subject is ordinarily unaware, and decreasingly so in the order mentioned. It is correspondingly difficult to make anyone aware of the processes in himself or herself. On the other hand, every clinician has had the experience of a sub ject relating a story about one of the T.A.T. pictures similar to this: "This is a mother looking into the room to see if Johnny has finished his homework, and she scolds him for being tardy."

38 CHAPTER 2 On looking over the stories in the inquiry, the subject may spontaneously say: "I guess that really was the way it was with my mother and myself, though I did not realize it when I told you the story." In psychoanalytic language, one may say that the process of storytelling was preconscious; it was not conscious while it was going on but could easily have been made so. This implies a slightly repressed pattern of images that had an organizing effect that could be easily recalled. The term externalization is suggested for such a phenomenon purely for the facilitation of the clinical description of a frequently occurring process (Cramer, 1991a; Sandier, 1985). Murray (1951b) has formulated a number of hypotheses concerning projection that need mention here. In the first place, he chose to differentiate between cognitive projection (actual misbeliefs of what he calls the Freudian type) and imaginative projection, which he believes is what therapists deal with in projective techniques. Murray feels that when therapists ask patients to imagine something, the process involved deserves differentiation from the clinical concept of projection. This seems a good idea to keep in mind for distinguishing the severity of disturbance as it appears in the protocol, but probably does not merit a theoretical differentiation. There are many patients who, when shown the T.A.T., believe that they are functioning cognitively and that their response corresponds to the actual content of the pictures. At best, one might say that the degree of ego participation or voluntary exclusion of its reality testing functions varies in the case of response to projective techniques. However, Murray very usefully differentiated between supplementary projection and complementary projection. He reserved the first term for projection of self-constituents--that is, for the distortion of external objects by one's own needs, drives, wishes, and fears. He would speak of complementary projection as the projection of what he called figure-constituents, which he defined as "the tendencies and qualities that characterize the figures (imaged objects) that people the subject's stream of thought and with which he interacts in fantasy. For the most part these are images of significant objects (father, mother, siblings, friends, enemies) with whom the subject has been intimately related .... In short, subjects are apt to ascribe self-constituents to one character (say, the hero) of the story, and figure- constituents to other characters." In other words, Murray's concern centered primarily on the definition of subtypes of projection predicated on the specific content of the projection, whereas our discussion so far has been primarily concerned with the degree of severity or complexity or relative unconsciousness of distortion. It may be profitable to combine the two points of view. The problem of degree of distortion was also investigated by Weisskopf. Weisskopf wondered how well the T.A.T. pictures lend themselves to projection (by eliciting more than purely cognitive perception). Weisskopf developed a "transcendence index" as a quantitative measure of this factor. Subjects were instructed to describe each of the T.A.T. pictures rather than to tell a story about it. In order to obtain the transcendence index of a picture, the number of comments about the picture that went beyond pure description were counted. The transcendence index of the picture is the mean number of such comments per subject.

nother scolds

'.ct may myself, [ng was te been anizing such a quently projec- )etween d imagi- ve tech- ing, the jection. .f distur- tical dif- :hat they :ual con- ation or ponse to '.n supple- ,r projec- ne's own ection as "the ten- .ople the most part enemies) is are apt id figure- tered pri- fic content ned with it tnay be 'eisskopf. ,.ction (by a "tran- astructed In order bout the ce index THEORETICAL FOUNDATIONS FOR PROJECTIVE TESTING 39 Pictures with high transcendence indices make impersonal observation difficult and lure the subject away from the prescribed objective path of the instructions, forcing him or her to project. Weisskopf found that the pictures that had high transcendence indices were those lending themselves to interpretation in of parent/ child relationships or in of heterosexual relationships between contemporaries. Purely Cognitive Perception and Other Aspects of the Stimulus Response Relationship Pure perception is the hypothetical process against which one measures apperceptive distortion of a subjective type, or it is the subjective, operationally defined agreement on the meaning of a stimulus with which other interpretations are compared. It supplies the end point of a continuum upon which all responses vary. Inasmuch as behavior is considered by general consent to be rational and appropriate to a given situation, one may speak of adaptive behavior to the "objective" stimulus, as discussed next. In Bellak's earlier experiments, it was found that aggression could be induced in subjects and that this aggression was "projected" into their stories in accordance with the projection hypothesis. It was further found that certain pictures are more often responded to with stories of aggression, even under normal circumstances, if the experimenter does nothing beyond simply requesting a story about the pictures. Also, those pictures that, by their very nature, suggested aggression lent themselves much more readily to projection of aggression than others not suggesting aggression by their content. It seems that the first fact (e.g., that a picture showing a huddled figure and a pistol leads to more stories of aggression than a picture of a peaceful country scene) is nothing more than what common sense would lead one to expect. In psychological language, this simply means that the response is, in part, a function of the stimulus. In of apperceptive psychology, it means that a majority of subjects agree on some basic apperception of a stimulus and that this agreement represents the operational definition of the "objective" nature of the stimulus. Behavior consistent with these "objective" reality aspects of the stimulus has been called adaptive behavior by Allport and Vernon (1942). In card 1 of the T.A.T., for example, the subjects adapt themselves to the fact that the picture shows a violin. Several hypotheses may be formulated: 1. The degree of adaptive behavior varies conversely with the degree of exactness of the definition of the stimulus. T.A.T. pictures and the Rorschach test inkblots are purposely relatively unstructured in order to produce as many apperceptively distorted responses as possible. On the other hand, if one of the pictures of the Stanford-Binet Test (the one depicting a fight between a white man and Native Americans) is presented, the situation is well enough defined to elicit the same response from the majority of children between the ages of 10 and 12.

40 CHAPTER 2. The exact degree of adaptation is determined also by the Aufgabe, or set. If the subject is asked to describe the picture, there is more adaptive behavior than if he or she is asked to tell a story about it. In the latter case, the subject tends to disregard many objective aspects of the stimulus. If an air-raid siren is sounded, the subject's behavior is likely to differ greatly if he or she knows about air raids, expects to hear sirens, and knows what to do in such a situation. He or she will differ from the individual who does not know the significance of the sound, and who may interpret the noise as anything from the trumpet of the Day of Judgment to the announcement of a stoppage of work, and behave accordingly: 3. The nature of the perceiving organism also determines the ratio of adaptive versus projective behavior, as previously discussed. The experiment of Levine, Chein, and Murphy (1943) demonstrated sensitization, and we have found that people distort apperceptively in varying degrees. Even the same person may react altogether differently to a stimulus when awakened from sleep than when wide awake. Other aspects of the subject's production for example, that given in response to T.A.T. pictures--have been more simply discussed in an earlier paper (Bellak, 1944), which refers to what Allport has termed expressive behavior. By expressive aspects of behavior, we mean, for example, that is a variety of artists are exposed to the same conditions, one would not expect the same creative productions. There would be individual differences expressed in the way the artists made their strokes with their brushes or with their chisels; there would be differences in the colors they preferred and differences in arrangement and distribution of space. In other words, certain predominandy myoneural characteristics, as Mira (1940) calls them, would determine some features of their product. Expressive behavior is of a different nature from both adaptation and apperceptive distortion. Given a fixed ratio of adaptation and apperceptive distortion in a subject's response to either Stanford-Binet picture, individuals may still vary in their styles and in their organization. One may use long sentences with many adjectives; another may use short sentences with pregnant phrases of strictly logical sequence. If individuals write their responses, they may vary as to upper and lower length in spacing. If they speak, they may differ in speed, pitch, and volume. All these are personal characteristics of a rather stable nature for every person. Similarly, the artist may chisel in small detail with precision or choose a less exacting form. He or she may arrange things either symmetrically or off center. And again, in response to the air-raid signal, a person may run, crouch, jump, walk, talk and do each of these things in his or her own typical way. If, then, adaptation and apperceptive distortion determine what one does and expression determines how one does it, it is needless to emphasize that one may always ask how one does what one does. Adaptive, apperceptive, and expressive behavior are always coexistent. In the case of artistic production, for example, the ratio of adaptive to apperceptive material and to the expressive characteristics may vary, of course, from artist to artist and, to a certain extent, from one product to the other of the same artist. In a similar way, expressive behavior influences the T.A.T. productions, ac- counting for individual differences in style, sentence structure, verb-noun ratio

40 CHAPTER 2 2. The exact degree of adaptation is determined also by the Aufgabe, or set. If the subject is asked to describe the picture, there is more adaptive behavior than if he or she is asked to tell a story about it. In the latter case, the subject tends to disregard many objective aspects of the stimulus. If an air-raid siren is sounded, the subject's behavior is likely to differ greatly if he or she knows about air raids, expects to hear sirens, and knows what to do in such a situation. He or she will differ from the individual who does not know the significance of the sound, and who may interpret the noise as anything from the trumpet of the Day of Judgment to the announcement of a stoppage of work, and behave accordingly. 3. The nature of the perceiving organism also determines the ratio of adaptive versus projective behavior, as previously discussed. The experiment of Levine, Chein, and Murphy (1943) demonstrated sensitization, and we have found that people distort apperceptively in varying degrees. Even the same person may react altogether differently to a stimulus when awakened from sleep than when wide awake. Other aspects of the subject's production - for example, that given in response to T.A.T. pictures - have been more simply discussed in an earlier paper (Bellak, 1944), which refers to what Allport has termed expressive behavior. By expressive aspects of behavior, we mean, for example, that if a variety of artists are exposed to the same conditions, one would not expect the same creative productions. There would be individual differences expressed in the way the artists made their strokes with their brushes or with their chisels; there would be differences in the colors they preferred and differences in arrangement and distribution of space. In other words, certain predominantly myoneural characteristics, as Mira (1940) calls them, would determine some features of their product. Expressive behavior is of a different nature from both adaptation and apperceptive distortion. Given a fixed ratio of adaptation and apperceptive distortion in a subject's response to either Stanford-Binet picture, individuals may still vary in their styles and in their organization. One may use long sentences with many adjectives; another may use short sentences with pregnant phrases of strictly logical sequence. If individuals write their responses, they may vary as to upper and lower length in spacing. If they speak, they may differ in speed, pitch, and volume. All these are personal characteristics of a rather stable nature for every person. Similarly, the artist may chisel in small detail with precision or choose a less exacting form. He or she may arrange things either symmetrically or off center. And again, in response to the air-raid signal, a person may run, crouch, jump, walk, talk and do each of these things in his or her own typical way. If, then, adaptation and apperceptive distortion determine what one does and expression determines how one does it, it is needless to emphasize that one may always ask how one does what one does. Adaptive, apperceptive, and expressive behavior are always coexistent. In the case of artistic production, for example, the ratio of adaptive to apperceptive material and to the expressive characteristics may vary, of course, from artist to artist and, to a certain extent, from one product to the other of the same artist. In a similar way; expressive behavior influences the T.A.T. productions, ac- counting for individual differences in style, sentence structure, verbnoun ratio (Balken & Masserman, 1940; McGrew & Teglasi, 1990; Sells, Cox, & Chatman, 1967), and other linguistic and formal characteristics. (Bali 196 then what Th¢ and Basi tion non for spe ada1 agn and thel dea rati, any test Sire bo $or ch the anl

de in the ma eit" otl of.

THEORETICAL FOUNDATIONS FOR PROJECTIVE TESTING 41 Expressive features reveal, then, how one does something; adaptation and apperceptive distortion concern what one does. The Basic Assumptions for Diagnostic Inferences from the T.A.T. and Similar Methods Basic Principles A diagnosis is an heuristic hypothesis concerning (1) a variety of causal relationships (e.g., between the present and the past, between several discrete phenomena and a common base); (2) psychodynamics; and (3) structure (e.g., in the form of ego functions and general adaptiveness). In its broadest sense, analytically speaking, the concept of diagnosis involves a metapsychological formulation of the adaptive, genetic, dynamic, structural, economic, and topographical factors. A diagnostic hypothesis thus involves propositions concerning the etiology, treatment, and prognosis of the disease under consideration. A temporal statement should, therefore, depart from all diagnostic propositions to the extent that, when one is dealing with dynamic constellations, one is dealing only with quasistable configurations. If one accepts an organismic view--that any part is a function of the whole-- any aspect of human behavior can be used for "testing." A "test" can be considered a sample situation that permits inferences concerning the total personality. In principle, asking a subject to stand on his or her head could be used as a testing situation, and inferences could be drawn concerning his or her personality. Similarly, in organic medicine, since the fingernails are undoubtedly a part of the bodily organism, a diagnosis could be made by inspection of the fingernails, as someone is said to have done. Presumably, with enough experience and detailed analysis, many conditions could be recognized by their reflection in the metabolic changes in fingernails. Nevertheless, diagnosis in organic medicine is not made by inspection of the fingernails but by physical examination of the whole body and by such tests that tend to be most valid and economical as indicated for specific problems. A final diagnosis cannot be obtained without carefully integrating the various X-ray and laboratory findings with the clinical picture; diagnoses on laboratory evidence alone are often misleading. Similarly, in psychological diagnosis, test findings can never stand alone; they must be integrated with the total picture, whether the clinician is a psychiatrist, a psychologist, or a social worker. There is no slot-machine diagnosis possible-one cannot put in a coin and get out a diagnosis-- either in medicine, in psychiatry, or in psychology. Integration of test results with other facets of the personality is an essential principle. Thus, it is preferable that test results be reported as follows: The results are consistent with a diagnosis of.. Psychological determinism is another basic assumption that is absolutely essential to the interpretation of T.A.T. productions.

42 CHAPTER 2 The hypothesis of psychological determinism is regarded as a special case of the law of causality, (10) namely, that everything said or written as a response to some stimulus situation, like all other psychological productions, has a dynamic cause and meaning. The principle of overdetermination must be taken into in this context since it insists that each part of the projected material may have more than one meaning, corresponding to different levels of personality organization. It is useful to recall, by way of example, that a story may be consciously taken from a movie recently seen and yet may be reported only because it reflects an important conflict of the subject on a preconscious level and also because it may, at the same time, have significant symbolic meaning on an unconscious level. Similarly, a given act may have several different unconscious meanings, each of them valid in relation to the whole personality. Startling as this principle may appear at first to behaviorists, it must be pointed out that it holds in the physical sciences also. In physics, for instance, the flight of an object through the atmosphere is the result of a number of factors, such as its size, weight, and shape and the wind velocity. In present language, its final path is overdetermined. In a quite similar manner, a psychological act is the result of a number of different psychological processes. Saying that a psychological event may have several meanings simply indicates that it may be viewed as causally related to a number of different factors. Another basic assumption is that of the continuity of at least the basic personality of one person. To use an analogy: If a river is sampled at various relatively close intervals, the chemical analysis of the content will be highly similar. Any pailful will be representative of the total content. Now, if a new tributary s the river (as compared to a new situational or developmental factor in psychological sampling), it may, of course, add factors about which the assayer has to know in order to ac- count for changes in content. A primarily genetic theory of personality, like psychoanalysis, maintains that the main contents of the stream will remain the primary matrix which, beyond a certain point, tributaries can only modify to a greater or lesser degree. Some Common Assumptions There are certain assumptions basic to the interpretation of the T.A.T. that are commonly held by most practitioners of this method. According to Lindzey (1952) these assumptions are the following: In completing or structuring an incomplete or unstructured situation, the individual may reveal his own strivings, dispositions, and conflicts. Lindzey (1952) then lists five assumptions involved in determining revealing portions of stories: 1. In creating a story, the storyteller ordinarily identifies with one person in the drama, and the wishes, strivings, and conflicts of this imaginary person may reflect those of the storyteller. 2. The storyteller's dispositions, strivings, and conflicts are sometimes represented indirectly or symbolically. 10 In the sense of a high probability, causality remains a useful concept despite the apparent exceptions in quantum mechanics.

eter- hing gical ation pro- t Icy- story only 1 and n un- neantst be e, the , such final mlt of event elated erson- }, close ul will cer (as piing), 7to ac- ke psy- ¢imary ater or hat are (1952) , the in- (1952) ries: n in the on may s repreexceptions

THEORETICAL FOUNDATIONS FOR PROJECTIVE TESTING 43 3. All the stories are not of equal importance as diagnostic of the storyteller's impulses and conflicts. Certain crucial stories may provide a very large amount of valid diagnostic material, whereas others may supply little or none. 4. Themes that appear to have arisen directly out of the stimulus material are less apt to be significant than those that do not appear to have been directly determined by the stimulus material. 5. Recurrent themes are particularly apt to mirror the impulses and conflicts of the storyteller. Lindzey (1952) then lists four assumptions involved in deriving inferences about other aspects of behavior from these revealing portions of fantasy material: 1. The stories may reflect not only the enduring dispositions and conflicts of the subject but also the conflicts and impulses that are momentarily aroused by some force in the immediate present (e.g., the test istration). (See Chapter 7, under the heading "The Influence of Contemporary Events on T.A.T. Stories.") 2. The stories may reflect events from the past that the subject has not personally experienced but has witnessed or observed (e.g., street scene, motion picture, story). It is assumed further that, although the subject has not experienced these events and is telling them as he or she observed them, the fact that he or she selects these events rather than others is in itself indicative of the subject's own impulses and conflicts. 3. The stories may reflect group hip or sociocultural determinants in addition to individual or personal determinants. 4. The dispositions and conflicts that may be inferred from the storyteller's creations are not always reflected directly in overt behavior or consciousness. All of these points are discussed in various chapters of this book. One major qualification to assumptions such as the preceding that needs to be recognized is that the cognitive style of the subject often determines whether and how his or her needs and conflicts will be expressed in thematic content. Klein (1954) has noted that cognitive controls function as delay mechanisms and need to be considered in the evaluation of behavior (e.g., projective test responses). This cognitive control approach is consonant with the current psychoanalytic trend of regarding ego processes as determinants of perception, rather than simple need states. In line with this thesis are Holzman and Klein's (1969) comments concerning the importance of cognitive controls in perception, specifically in relation to the perceptual dysfunction in schizophrenia. Literature is accumulating on both cognitive styles and proprioceptive disorders in the schizophrenic syndrome. Holzman has stated that the act of perception, defined as the transferring of physical stimulation into psychological information, can be broken down into its component phases of reception, registration, processing, and . The perceiver, due to his or her particular personality organization, has a unique influence on the organizing and reorganizing of the percept at each of these successive stages as well as in the function. Each individual's personality organization is based on

44 CHAPTER 2 his or her unique set of cognitive controls that are manifested in any disease process (i.e., through the level of perceptual functioning), including states of disorganization. These controls determine the nature of the individual's psychopathological organization. Bases for Diagnostic Validity of the T.A.T. and Related Tests Normative, Statistical Factors (Interindividual Factors) Projective techniques have been a matter of much concern to academic psychologists because they cannot easily be made to conform to the usual methods of establishing reliability and validity. The collection of norms of intelligence or achievement tests can follow a clear-cut pattern: A representative sample population is tested and the norms are established on a distribution curve. Any individual subsequently tested can then be compared to the sample population, and a specific point on the distribution curve may be assigned to him or her. This type of procedure is difficult to follow with projective techniques. For one thing, it is almost impossible to find a sample representative of a large enough segment of the population. Athough this may not be quite so difficult for the Rorschach, it is extremely difficult for a test such as the T.A.T.; the content of psychodynamics is infinitely more affected by the many cultural substructures in the United States than, for example, an intelligence test. New Yorkers of second- generation Irish, Italian, or Jewish background will differ markedly from each other, not to mention midwesterners or southerners, even if they are all matched for age, sex, intelligence, and economic level. Further, even if such a normative approach were possible--or to the extent that it is possible--it is hardly very useful. As Rosenzweig and Fleming (1949) have pointed out, in projective techniques we are not only interested in the definitive value of the subject's standing with regard to group modes of behavior (what they call interindividual comparisons) but also, and primarily, in those aspects of the responses characteristic of this one individual. A statistical approach to projective techniques is of necessity to an atomistic approach, whereas the value of projective techniques lies in their molar approach to personality. Thus a breakdown of the responses robs the test results of much of their meaningfulness. Sharkey and Ritzler (1985) review the general status of studies of the diagnostic validity of the T.A.T. They cite Renaud as having found few differences and Davison as being unable to find consistent differences between neurotics and schizophrenics. On the other hand, they cite Dana (1955, 1956a, 1956b, 1959a, 1959b) who found consistent differences between normals, neurotics and psychotics on measures of story organization. They are critical of the studies of Eron and associates (1950; Garfield & Eron, 1948; Ritter & Eron, 1952) for using measures of emotional tone, story outcome, and activity level to differentiate normals, neurotics and psychotics. They feel that the story content in response to T.A.T. stimuli is excessively determined by the stimulus characteristics. This is a critique difficult to understand, since many therapists have, for decades, found great individual differences in response to these stimuli (Lundy, 1985). da lec re] In da m ist tai se st n m, W fe th h t p W W al o a

a re ve

THEORETICAL FOUNDATIONS FOR PROJECTIVE TESTING 45 Lundy's comment regarding studies of reliability of the T.A.T. is that the standard psychometric test, coefficient alpha, is not an appropriate means of determining the reliability of the T.A.T., despite its wide usage. T.A.T. pictures are selected from a domain that is highly heterogeneous, and coefficient alpha is most reliable when determining the reliability of a test whose concern is homogeneous. In addition, the T.A.T. test-retest conclusions may be adversely affected by the standard instructions to write a "creative" story. To a certain extent, any accumulation of statistical data concerning the T.A.T. may be helpful as a frame of reference, particularly in respect to formal characteristics. For example, it may be useful to accumulate thousands of samples to ascertain what percentage of males sees the figure in 3BM as male or what percentage sees the woman on the right in picture 2 as pregnant. If we were to discover, for instance, that only 10 percent of a large population tested sees the woman as pregnant, we would then hesitate to infer that not seeing her as pregnant signifies a meaningful scotoma; if 50 percent or more men see the figure in 3BM as a female, we would hesitate to consider such a response as even the merest suggestion of a feminine identification. Nevertheless, even knowing this, we might have to decide that it may mean feminine identification in some and not in others, depending on how much empathy with specifically feminine traits is revealed in making a woman the hero of the story. Even if 90 percent of all males do not mention the woman in picture 2 as pregnant, if someone describes her as slim and well proportioned, we would still have to interpret this as a denial of pregnancy. In other words, although we recommend accumulation of such data, the final interpretation must be from an idiographic approach. Each response must be evaluated in relation to all the other responses in the test. Content Analysis Content analysis is a method of counting the occurrence of certain words within a given context. One could, for instance, count all the words pertaining to aggression and love on a page of Dickens and a page of Hemingway. One might find that words connoting aggression occur much more often on the Hemingway page. One can apply the same technique counting the frequency of various words in transcripts of psychotherapeutic sessions utilizing apperceptive methods. Within certain limits of usefulness, relative frequency of certain words will tell one something about the narrator, if compared to frequency of the same words in other peoples' responses to the same stimuli. The technique therefore lends itself to a quantitative analysis of responses to apperceptive techniques. Intratest Patterns In essence, the T.A.T. deals with a series of social situations to which subjects are asked to respond. In interpreting the results, therapists are primarily interested in any repetitive patterns of behavior in dealing with these various situations. A response gains its meaningfulness in part from its relationship to the rest of the responses and in part from its relationship to similar responses to other situations.

46 CHAPTER 2 For instance, if all stories end on a hopeless note, or if all females are seen as benign and nurturant, or if all males are seen as protective, a therapist feels entitled to make the inference that the repetitiveness of the apperceptions are related to a definite variable in the subject's personality. Thus, the repetitiveness itself, and any patterning within the test responses, becomes a criterion of reliability (and by implication, of validity) of the responses for the given individual, irrespective of any relationship to population scores. By this token (and the facts mentioned below), the responses of one individual to a stimulus may be considered interpretable as psychologically significant. We suggest calling this basis of validity the intratest validity. (Rosenzweig speaks of this as the intraindividual comparison, but we prefer to reserve this term for the following variable.) Intraindividual Comparisons: Behavior Variables and "Fanstasy" Test Variables In addition to the two comparisons mentioned by Rosenzweig and Fleming, it should be pointed out that a comparison between manifest behavior and fantasy behavior in the test responses is a valuable basis for inferences. For instance, if we learn that, behaviorally, someone is a Casper Milquetoast and all his stories are filled with blood and thunder, we may feel entitled to infer that there is a good deal of repressed aggression in the subject. Or if we deal with a manifestly" boisterous and aggressive male and find a predominance of themes of ivity, we may make the inference that manifest behavior is in a defensive relationship to the latent variables. This factor again emphasizes the importance of a global approach to personality; in clinical practice, there is no place for experimentation. The psychologist should be informed of behavioral data, or final evaluation of test data should only be made by a clinician who has access to both the behavioral and test data. Toward a General Psychology of Thematic Appercepion Tests The predominant theoretical orientation to clinical diagnosis in psychology, psychiatry, social work, and the other allied mental health professions is that of psychoanalytic ego psychology. This is the reason why the psychoanalytic ego psychology point of view is emphasized in this book. However, the best illustration of the prominence of this perspective in mental diagnostic clinical practice is in the gradual addition of new axes to the American Psychiatric Association's Diagnostic and Statistical Manual, as it develops through its several different versions. The first axis is that of the primary, presenting disorder of the individual. The second axis is the predominant personality orientation, the third is the possible physical disorder, the fourth is the individual's level of environmental stressors, and the fifth is a global rating of adaptational functioning. The addition of other axes have been regularly proposed and discussed, such as the level of adaptational and defense mechanisms developed by Vaillant (1971, 1977). As the reader will readily recognize from the preceding discussion in the chapter, the gradual addition of several axes of diagnosis represented in the Diagnostic and Statistical Manual follows Freud's (1915) recommendations to evaluate clinical data from "multiple points of view."

THEORETICAL FOUNDATIONS FOR PROJECTIVE TESTING 47 as beto a an by im- of any :elow), as test va- tO , it if we are ,od deal rous make latent to psy- test data and test The clinician not only considers a list of presenting symptoms but also evaluates these symptoms in relation to current and past stressors, the level of adaptation and defense mechanisms, degree of the superego, and other factors. It is this multiple perspective that is the basis of the Bellak Long and Short Form approach to thematic apperception test diagnosis, which we will present in this book. We will discuss alternative methods of T.A.T. analysis that are built on other theoretical orientations to personality diagnosis, most notably that of interpersonal object relations (which some argue is a subfield of psychoanalytic ego psychology), family systems therapy, and cognitive-behavioral therapy. However, it is our belief that the majority of individual dimensions in these alternative thematic test-scoring schemes are already included within the multiple perspective of the Bellak system of 10 categories. Therefore, it would appear that clinical diagnosis and personality research are gradually developing from an individual "trait" analysis to an ego psychology and currently toward an increasingly more comprehensive general psychology of personality. of psy- )sychol- of the the grad- and first axis is the the a global regularly hanisms in the .*d in the to evalu-

CHAPTER 3

CLINICAL USE OF THE T.A.T. The T.A.T. and Related Methods The Thematic Apperception Test is a technique for the investigation of the dynamics of personality as it manifests itself in interpersonal relations and in the apperception or meaningful interpretation of the environment. In its present form, it consists of a series of 31 pictures. Testees are asked to tell stories about some of the pictures, thereby presumably revealing their personal, individual apperceptions of purposely ambiguous stimuli. Although the T.A.T. was originally described by Morgan and Murray in 1935, Tomkins and Tomkins (1947) show that there were earlier attempts by psychologists and psychiatrists to elicit meaningful responses of individuals to pictures. These include Brittain, who published such an attempt in 1907; Libby, who used a procedure like that of Brittain with children in 1908; and Schwartz, who developed his Social Situation Test in 1932. None of these forerunners, however, attained the popularity of the T.A.T., which currently ranks second only to the Rorschach in projective tests. In fact, most surveys of psychological test usage show that the T.A.T. is among the top six tests used in the standard battery of psychological tests, consisting of a Wechsler intelligence test, the Wide Range Achievement Test, the Bender Gestalt Test, the Rorschach, and the Minnesota Multiphasic Personality Inventory (MMPI) (Archer et al., 1991; Craig & Horowitz, 1990; Goh, Teslow, & Fuller, 1981; Lubin & Larsen, 1984; McCully, 1965; Piotrowski & Keller, 1984; Thelan, Varble, & Johnson, 1968). In the 1950s and 1960s, the T.A.T. and the Rorschach led all other tests in frequency of usage. The August 1953 Newsletter of the Division of Clinical and Abnormal Psychology stated that the Rorschach and the T.A.T. were the two most widely used tests. An A.RA. report on the use of tests (Report on Survey of Current Psychological Practice, Supplement to Newsletteg, Division of Clinical and Abnormal Psychology, A.EA., Vol. 4, No. 5) indicated that the Rorschach and the T.A.T. were used to about the same extent, with the Rorschach being used somewhat more. The report stated: "In general the TAT runs the Rorschach test a close second . . . but is not as frequently considered 'very important' (62% for T.A.T. versus 85% for Rorschach) ." In the 1970s and early 1980s, Polyson, Norris, and Ott (1985) found a slight decline in T.A.T. research. However, surveys of test usage for the purposes of psychological evaluation conducted at the same time showed that the T.A.T. continued to rank in the top six or seven tests (Goh, Teslow, & Fuller, 1981; Lubin & Larsen, 1984; Piotrowski & Keller, 1984; Piotrowski, Sherry, & Keller, 1985). 48

CLINICAL USE OF THE T.A.T. 49 the ap- n, it the s of )35, gists . in- oce- i his )op- jec- F. is lsist- der tory 981; e, & t fre- and llOSt rmal were The but for light !psy- jued For example, Piotrowski and colleagues (1985) investigated test usage and practices of the hip of the Society for Personality Assessment (SPA). A questionnaire was sent to 400 potential respondents in 1984; 206 returned it. The results for SPA with regard to the frequency of usage of various psychodiagnostic tests showed that of 35 techniques, the Wechsler scales were the most frequently used, followed by the Rorschach, the MMPI, and then the T.A.T. The C.A.T. was in ninth place, following the Bender Gestalt, Draw-a-Person, Sentence Completion (all kinds), and House-Tree-Person. If, however, one looks only for a test for children exclusively, then the C.A.T. ranks first, as the preceding tests are equally used with adults as with children. The present T.A.T. pictures (Murray, 1943a) are the third set to be used since 1935. Aside from additions and omissions made since the first series was issued, the cards in the second and third series are distinguished by being twice the original size--a fact that probably facilitates the testee's rapport with the pictures. Aside from the present wide use of the T.A.T., similar verbal and picture tests have been devised to meet the special problems presented by different cultures and particular age groups. These include the M.A.RS. (Make A Picture Story Test) developed by Edwin S. Shneidman in 1947. It varies the T.A.T. material principally by separating the figures and the background, allowing the test taker to select and place his or her figures on depopulated backgrounds before telling his or her story. Thus, the test taker responds to a stimulus situation that he or she has partly created and he or she has the opportunity for using motor expressive acts in accomplishing the test task. The materials for the M.A.ES. Test consist of 22 background pictures, which comprise both structured and unstructured (ambiguous) situations, and 67 figures--adults, children, minority group figures, silhouettes, and figures--with blank faces. The Thompson (1949) Modification of the T.A.T. for African Americans is based on the assumption that it is easier for racial/ethnic groups to identify with figures of their own group than figures of white individuals. Accordingly, several of the original pictures have been adapted by substituting African American figures for the original white ones. Six of the original pictures have been used unchanged, and one has been omitted. The new drawings were made by V. A. Winslow, director of the Art Department of Dillard University, New Orleans, Louisiana. In 1942, the U.S. Office of Indian Affairs and the Committee on Human Development of the University of Chicago inaugurated the Research on Indian Education. About 1,000 children from 6 to 18 years in 11 Papago, Zuni, Hopi, Navaho, and Sioux communities were studied. The T.A.T. used was a series of 12 pictures drawn by a Native American artist and representing people and social situations presumed to be within the everyday experience of all Native American children--a picture of two boys facing a man; two adults, one leading a horse; an adult woman with a baby in arms and with two other children seated before her; a group of children and adults around a grinding stone; several young men in dance regalia; and a landscape scene of fields, fences, dried animal bones, and the like. All the people in the pictures are Native Americans.

50 CHAPTER 3 A modification of the T.A.T. was designed by Uma Chowdhury (1960a) of the Department of Anthropology, Indian Museum of Calcutta. The pictures were made from live models and imaginary pictures to suit Indian cultural patterns. Another cultural modification of the T.A.T. was developed by Boris Iflund of the University of California for use on the University Expedition to South Africa. The same principle was employed--translating the dramatis personnae and the setting to South Africa. Another set of pictures was devised for the South Pacific Micronesian culture (Lessa & Spiegelmann, 1954). Several pictures from these different culture-specific T.A.T. adaptations can be found in Edgerton's (1971) book, The Individual and Cultural Adaptation. Chapter 20 of this book discusses research with these thematic tests and related clinical issues in gender and multicultural assessment. There have been attempts to develop alternatives to Murray's T.A.T. for use in mainstream Western culture, such as the Apperception Picture Test (APT), which utilizes a Likert-type scale approach to measure aspects of the test taker's perceptions about each figure in each picture, such as rating whether a figure is very unfriendly, .... unfriendly, .... neutral," "friendly," or "very friendly" (Holmstrom et al., 1992, 1994). A very interesting variation of the T.A.T. is the Object Relations Technique of Phillipson (1955), consisting of photographs of people in different situations, using various degrees of ambiguity and clarity. The Iowa Picture Interpretation Test is a multiple-choice variation of Murray's T.A.T. (Hurley, 1955; Johnston, 1957). Another intriguing variation of the T.A.T. is Stone's (1953) Auditory Apperception Test (AAT), which asks people to make up stories to the presentation of different sounds. The basic conception of a projective method for diagnosing group properties was developed at the Research Center for Group Dynamics by Horwitz and Cartwright (1951). The technique, involving a projective picture test with slightly modified T.A.T. instructions, was first employed at the National Training Laboratory for Group Development, at Bethel, Maine, in 1947. The way the interacting group phrases a relatively unstructured stimulus configuration, the kind of relationships it sees, and the feelings it deems relevant may provide important insights into the group's structure and internal processes. A set of five pictures was developed by Henry and Guetzkow (1951) to show up different aspects of group processes. They consist of: (1) a conference group--seven men assembled around a conference table; (2) a man standing in the doorway of a house; (3) two men facing each other; (4) an older woman and a younger man; and (5) an informal scene of four men in what looks somewhat like a club room. It had long been felt that the T.A.T. was not particularly suitable for young children, so in 1949, Leopold Bellak and Sonya Sorel Bellak developed the Children's Apperception Test (C.A.T.) consisting of pictures of animals in different situations for use with children between the ages of 3 and 10.5 Blum (1950) similarly developed The Blacky Pictures of a little dog in different family situations to be used with young children. Costantino, Malgady, and Vazquez (1981) developed the TEMAS, which features pictures in color of urban African American and Hispanic children. See Chapter 13 on the C.A.T.

CLINICAL USE OF THE T.A.T. 51 ,ung the rent fimi- ts to )ed Since Thompson and Bachrach (1951) and Semeonoff (1976) found that using chromatic T.A.T. pictures appeared to increase the level of emotional reactions, as established for the Color and ColorForm Rorschach cards, Costantino and associates (1981) developed a picture story test for urban minority children using colored paintings, which is a good projective test alternative for African American and Hispanic urban elementary school-aged children. Another variation of the C.A.T. is the School Apperception Test (SAM), consisting of pictures of children in school settings (Solomon & Starr, 1968). A similar group of thematic test pictures of school situations was developed in (Nathan, 1966). These pictures are useful in obtaining information as to a child's different school-related conflicts and overall level of socialization. Symonds's (1948, 1949) Picture Story Test was designed for the study of adolescent boys and girls. It consists of 20 pictures divided into set A and set B, both of which may be used on successive days, or set B may be used alone. These pictures are designed to facilitate the projection of problems typical of the adolescent, such as leaving home, coming home late at night, social-sexual rivalry around dating, concern about the future (in a picture showing a young boy and girl consulting a fortune teller), a girl looking at her new self in the mirror, a boy apparently suffering from Weltschmerz (sorrows of the world), pictures concerned with delinquency and jail, and other situations. A further variation on the T.A.T. theme (though developed earlier and independently) is the Four-Picture Test designed by D. J. van Lennep and Houwink (1948). The task here is not to tell four separate stories but to tell a single story in which all four pictures appear. The first picture shows two people together, the second shows one person alone, the third represents being socially alone (a figure leaning against a lamppost in a dark street), and the fourth signifies being together with others in a group (the scene is of two tennis players with others watching). Lennerlof (1967) developed a variation of the T.A.T. showing people in industrial work situations, which he calls the Industrial Thematic Apperception Test. Independently at the same time, two thematic tests were developed for elderly individuals depicting elderly individuals in different situations - the Gerontological Apperception Test of Wolk and Wolk (1971) and the Senior Apperception Technique of Bellak and Bellak (1973, 1996), which is presented in Chapter 19. Indications for Use of the T.A.T. The T.A.T. is a complex test which, even in the hands of the most experienced practitioner and when used in an abbreviated form, takes considerable time and effort in istration and interpretation. Even though the test can be group- or self-istered, any systematic interpretation will still take at least half an hour per record, and often longer. Aside from the economic aspects, it is in the nature of the T.A.T. to deal with the subtle, dynamic factors of the personality that will be the subject of investigation only under specific circumstances. Perhaps a comparison of the psychological

52 CHAPTER 3 examination and the physical examination is in order. There are routine physical examinations by inspection, auscultation, and percussion, possibly by taking the blood pressure. A more complex examination may include urine examination, fluoroscopy, and a blood count. Chest X-rays have become routine, but X-rays of other parts of the body, tests of body chemistry, basal metabolism, and the like, are requested only when there are stringent differential diagnostic reasons, or a particularly careful evaluation is necessary for especially stressful tasks or prior to under- going major surgery. Similarly, for ordinary purposes, paper and pencil tests of ability, intelligence, and achievement may suffice for routine examinations of students, employees, and so on. However, if one is called on to do a special selection for highly demanding tasks--such as those of pilots, special government personnel, or chief executives-- if differential diagnosis is indicated, or if the patient is about to undergo a major form of psychotherapy, then more complex procedures such as a T.A.T. are indicated, and deserve the time and effort investigated. The question, of course, remains as to which of the major tests should be used when a complex psychodiagnostic task is to be performed. One popular answer to that problem is to use batteries of projective tests. This approach undeniably has some merit. For reasons that are only partly understood, one test may show problems that the other tests do not, even though, in principle, it should illustrate the same problem. However, the principle of "the more, the better" should not apply. The unnecessary use of whole batteries has bogged down personality testing more than necessary. One principle in assorting batteries should certainly be that the tests included tap the personality structure and dynamics by different means (e.g., a verbal test such as the T.A.T. should be combined with an expressive test such as the Figure Drawing Test). The indications for using the T.A.T. can be stated even more specifically: The T.A.T. is a content test. More than any other test in use at present, it shows the actual dynamics of interpersonal relationships. There is the Kinetic-FamilyDrawing Test, which asks the subject to "draw your family doing something." The various spatial elevations, the sizes of the figures, and the differences in line pressure provide insight into how the drawer views the role relationships and power structure of the family--who is more important in the family, who is more important to the drawer, and so on. Degrees of closeness among family may be glimpsed by examining which family are drawn closer to which other family , and other issues, such as rivalry, may be visually communicated by the drawer showing two siblings playing a competitive game or other similar activity. The T.A.T. is a much richer vehicle for examining the test taker's interpersonal dynamics within the family and in relations with others. It provides a way to corroborate hypotheses about family dynamics suggested by the Kinetic-Family-Drawing Test and it provides an indepth view of the test taker's level of interpersonal object relations, which is one of the most important dimensions to assess from the standpoint of psychotherapy (see Chapter 11). The T.A.T. is also the best vehicle for revealing an individual's basic fears, anxieties, and insecurities and defense and coping mechanisms employed to deal with these fears, anxieties, and insecurities. Schafer's (1954) book, Psychoanalytic Interpretation of Rorschach Testing, is a classic treatise on how to diagnose affect/defense constellations on the Rorschach. offe port nee are an only dard thes WOU ent custo "psyc parei and and

CLINICAL USE OF THE T.A.T. 53 ysical g the 1, flu- other re re- rticu- nder;ence, s, and nding ives-- major . indie used wer to ly has prob- tte the apply. more tat the s (e.g., ;uch as ly: The the ac- .rawing us spa- rovide .' of the drawer, exam- '.rs, and howing .T. is a ; within ,otheses Irovides hich is of psytrs, anx- eal with oanalytic However, Exner's (1994) Comprehensive System does not adequately include the same level of diagnostic assessment of these very important dimensions. It is most important to know the test taker's main anxieties and concerns and how the test taker attempts to defend against or to cope with these issues. Test behavior provides a glimpse of defenses by the way the test taker sits, sits back away from an "unpleasant" card, and answers too quickly or pauses rather too long. But T.A.T. stories with adequate action sequences provide excellent vehicles for analyzing how the test taker may approach an area of conflict or concern, such as interpersonal intimacy presented in card 10, and how the test taker attempts to deal with it. The juxtaposition of actions in narrative that is unique to the T.A.T. is what facilitates the assessment of the relationship of psychological problem areas, anxieties, and conflicts and defense and coping mechanisms. The important work of Cramer (1991a) in this area is described in Chapter 9. The Rorschach test is invaluable as a formal, percept-analytic technique, since it reveals better than any other test available the formal, expressive nature of thought processes and those of emotional organization. By this token, it reveals patterns that are more or less typical for certain psychiatric syndromes or disease processes, particularly those of severe psychopathology. The content analysis of the Rorschach test, although it has its natural limitations, has not been utilized to the extent it deserves in the majority of present methods of interpretation. By the very nature of the pictures, the T.A.T. also gives basic data on the test taker's relationship to male or female authority figures, to contemporaries of both sexes, and frequently suggests the gender in certain family relationships, which is basically only hinted at on the Rorschach. For example, the Rorschach card 4 shows a large, looming figure, which may provide some hints as to how the test taker may view certain aspects of her or his own father. But the T.A.T. actually shows pictures of different family relationships, which provide a vehicle for corroborating these hypotheses from the Rorschach. The T.A.T. may not so clearly indicate the intensity of fears as does the Rorschach, but it tells the nature of them - fear of lack of or fear of attack by males in specific situations--and it shows the hierarchy of needs and the structure of the compromises among id, ego, and superego. The T.A.T. and the Rorschach corroborate aspects of clinical assessment. They are not competitive or mutually exclusive techniques. It is very misleading to make an assessment of an aspect of someone's personality from only one indicator on only one test. The customary practice in psychological testing is to employ a standard battery of several different tests and to examine "patterns of response" across these different tests. If a child in the middle of a custody battle between the parents drew herself or himself closer to one parent than to the other, the psychologist would not want to state in the report that the child therefore feels closer to this parent and should remain with this parent after the divorce is finalized. Forensic child custody evaluations in the past used to attempt to assess which parent is the primary "psychological parent," as if any child only has a psychological need for only one parent. Contemporary practice considers one indicator on one test a "hypothesis," and looks for corroborating evidence of this hypothesis elsewhere on the same test and across the entire standard test battery.

54 CHAPTER 3 Standard istrative Procedure for the T.A.T. As in every testing situation, the test taker should be put at ease and a proper noncommittal rapport established. The test taker is seated in a chair. Usually, it is desirable to have the test seated behind and to the side of the test taker so that he or she cannot see the examiner but so that the examiner may have full view of the patient's facial expressions. This position may have to be modified with suspicious and otherwise disturbed patients and with children. The instructions for istration of the T.A.T., as suggested by Murray, are as follows: Form A (suitable for adolescents and adults of average intelligence and sophistication): "This is a test of imagination, one form of intelligence. I am going to show you some pictures, one at a time; and your task will be to make up as dramatic a story as you can for each. Tell what has led up to the event shown in the picture, describe what is happening at the moment, what the characters are feeling and thinking, and then give the outcome. Speak your thoughts as they come to your mind. Do you understand? Since you have 50 minutes for 10 pictures, you can de- vote about five minutes to each story. Here is the first picture." Form B (suitable for children, adults of little education, and psychotics): "This is a storytelling test. I have some pictures here that I am going to show you, and for each picture I want you to make up a story. Tell what has happened before and what is happening now. Say what the people are feeling and thinking and how it will come out. You can make up any kind of story you please. Do you understand? Well, then, here's the first picture. You have five minutes to make up a story. See how well you can do." The exact wording of these instructions may be altered to suit the age, intelligence, personality, and circumstances of the test taker. It may be better not to say at the start, "This is an opportunity for free imagination," as an instruction of this sort sometimes evokes the suspicion in the test taker that the examiner intends to interpret the content of his free associations (as in psychoanalysis). Such a suspicion may severely check the spontaneity of one's thought. The instructions recommended in this book are, in essence, identical, except we omit "This is a test of imagination, one form of intelligence" since it seems inappropriate in the clinical setting; also, we often add: "Let yourself go freely." Then one may have to answer, in a nondirective way, any questions the test taker may ask. It is permissible and even helpful to make some encouraging remark at the end of the first story. Otherwise, it is better for the examiner to say nothing for the rest of the time, unless the test taker has become too involved in a long, rambling story. At such times, one may remind the test taker that what is wanted is a story about what goes on, what leads up to it, and what the outcome will be. If the test taker remains entirely on the descriptive level, or tells only very brief stories, it is useful to remind him or her that what is needed is a story of what is going on, what people are feeling and thinking, what happened before, and what the outcome may be. Self-istration The standard procedure is for the test taker to tell each story orally and for the examiner to record the responses by hand or by means of a recording device. It is ten { a tin help per , the t 45 SUC COE tak ant sati stat dm mo Ad $0I thi: je Cr

CLINICAL USE OF THE T.A.T. 55 It is economical in many cases to give the selected cards to the test taker with written or oral instructions, emphasizing that each picture should be looked at one at a time, and then to write the stories on plain paper in the office or at home. It is helpful to let the test taker know that she or he is expected to write about 300 words per story as spontaneously as possible. The following instructions may be typed on the front inside cover of the set that is given to the test taker for self-istration: Instructions for Self-istration 1. Please write a story about each picture in this folder. 2. Do not look at the pictures before you are ready to write. 3. Look at one picture at a time only, in the order given, and write as dramatic a story as you can about each. Tell what has led up to the event shown in the picture, describe what is happening at the moment, what the characters are thinking and feeling, and then give the outcome. Write your thoughts as they come to your mind. 4. It should not be necessary to spend more than about seven minutes per story, although you may spend more time if you wish. 5. Write about 300 words per story, or about one typing-paper page if you write in longhand. If at all possible, please type the longhand story later, without changes, in duplicate, double-spaced, one story per page. 6. Please number the stories as you go along, and then put your name on the front sheet. The obvious advantage of this time-saving procedure is somewhat offset by such disadvantages as a possible loss of spontaneity by the test taker, the inability to control the length of the stories, and the lack of opportunity to intervene if the test taker begins to show lack of co-operation in responding. Nevertheless, in psychiatric and psychological office practice, the self-istration method has proven quite satisfactory. Again, for practical reasons, it has increasingly become the custom to use a standardized sequence of 10 pictures (see Chapter 4). After istering the standard sequence, the clinician may then select other cards that seem most indicated, most likely to illuminate the details of presumably existent problems of the patient. A discussion of the special usefulness of each picture and the special features of personality it is likely to elicit is presented in Chapter 4. This is particularly true when the T.A.T. is used as part of a clinical practice, where one is likely to know a few things about the test taker prior to testing and the practitioner can permit oneself as much flexibility as one wishes in obtaining material for one's own use. Group istration Group istration of the T.A.T. continues to be a popular method of obtaining T.A.T. stories for the purposes of research. Typically, the pictures are projected on a screen and the research participants are given the same instructions as for individual istration, but are asked to write their stories down. Many of Cramer's (1991a) well-done studies of defense mechanisms in T.A.T. studies were

56 CHAPTER 3 obtained through this group istration approach - an approach first reported by Clark (1944). Clark (1944) collected 852 stories from a wide group of individuals ranging in age from 16 to 64, and basic themes for each picture were selected. Then, 50 college students were shown T.A.T. pictures projected on a screen, given a list of the basic themes for each card, and asked to check the story that most nearly represented their idea of the picture portrayed. The same students were also given a modified form of the usual T.A.T. in which they were asked to write original stories. Clark found a substantial relationship between results obtained by both methods, but the relationships were higher when the clinical form was istered first. She concluded that the group projection test merits further study as a possible screening device when the usual istration is not feasible. Other group istration T.A.T. studies are those of Lindzey and Silverman (1959) and Murstein (1972), whose T.A.T. norms for college students provide norms for written stories to a group-istered T.A.T. This is obviously different from the T.A.T. obtained by a psychologist in the usual testing situation in which the individual relates a story for each card and the psychologist writes down the responses. Comparative studies of different methods of T.A.T. istration are those of Baty and Dreger (1975), Eron and Ritter (1951a), and Garfield, Blek, and Melker (1952). Eron and Ritter (1951a) investigated possible differences between T.A.T.s istered orally-individually and those obtained in a group where every- body wrote his or her own stories. Using two groups of 30 students each, they found that oral stories were longer, but that the quality and amount of thematic content were identical. The written stories had a somewhat happier tone and seemed to evoke more flippancy. However, the authors felt that because of the similarity of thematic content, the written stories elicited much the same material. Inquiry Contrary to statements by other authors, such as Rapaport (1946), it is most important that the inquiry be conducted only after all the stories have been told - not following each story. Otherwise, the clinician's inquiry questions may influence subsequent T.A.T. responses and preconscious material may become conscious and interfere with the rest of the test responses. The inquiry may actually become a free association process and part of a psychotherapeutic situation (see Chapter 8). Clearly, the T.A.T. inquiry becomes more useful, as the psychologist gains increasing experience in interpretation and knows what to ask for. As a routine, one inquires for free associations or thoughts concerning all places, dates, proper names of persons, and any other specific or unusual information given by the test taker (Becache, 1987). Bruno Bettelheim (1947), the celebrated psychologist, contributed a creative discussion of the conduct of the inquiry after obtaining T.A.T. stories in which he suggests the value of asking test takers to provide their own ideas and impressions about the possible psychological meaning of their stories. Luborsky (1953) also illustrates the value of self-interpretation with the T.A.T. One way of doing a self-interpretation of the T.A.T. is to have a session with the test taker after all the tests have been istered, but before the test report is written up and the final results are provided. In this session, the psychologist provides preliminary results of the cognitive and achievement tests and then goes over the raw data of the projective tests, asking the test taker what thoughts and feelings could be communicated by each test. ch( in wh dre tio witl an t asp vid, [ab or i ad( to! the moi yen trill tee

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CLINICAL USE OF THE T.A.T. 57 For example, when each T.A.T. picture is shown and the examiner reads back the responses, the test taker attempts to interpret what each stow may communicate about underlying psychological issues conflicts, the test taker's overall personality, and personal interests. This clinical approach resembles working with a patient's dream in psychotherapy. Toward the beginning of treatment, the therapist may be more active in asking patients to free associate to different aspects in the dream, to think about what events during the previous day could have influenced the themes in the dream (what Freud called the "day residue"), and to ask them about how the situation in the dream may relate to aspects in the their current lives and relationships with friends, family, and possibly with the therapist. As treatment becomes more of an active collaboration, patients increasingly take more initiative in choosing which aspects of the dream to explore through free association, and eventually they provide their own interpretations (Abrams, 1999). Psychological testing is much more therapeutic when there is an active collaboration between the psychologist and the patient (in the case of testing an adult) or between the psychologist, the child, and the parents (when testing children and adolescents). When testing an adult or a child, the preliminary report could be sent to the parties most involved to read and think about prior to coming to meet with the psychologist for the final session. This provides the test taker with more opportunity to react to the preliminary results, provide more of his or her own interpretations of the projective tests, and have more input into which interventions may be most helpful. Psychological Problems of Test istration The istration of the T.A.T. is simple in manifest procedure, but it is intrinsically fairly complex. Undoubtedly, the relation between the tester and the testee is very important for the richness of the responses. Beginning students almost invariably complain that the stories they get are too short. Brevity need not be a serious drawback (Murray states in his manual that he considers 300 words as average per story); as the course continues, the protocols the students obtain become miraculously longer. The tester/testee relationship has a certain resemblance in its problems to those of the transference situation in psychotherapy. The test taker comes for help; he or she may be frightened and not know what to expect. Rapport is a magic word-- in this instance, it means the tester must appear interested but not overeager or the test taker may feel the enterprise is chiefly for the interest of the psychologist. The clinician should be friendly but not over friendly, which may elicit heterosexual or homosexual panic in the patient. The best atmosphere is one in which the test taker feels that the two of them are working together seriously on something very important that will be of help and that will not be something threatening. Having had the opportunity to get to know patients well over a long stretch of time in intensive psychotherapy makes it possible to learn a good deal about what

58 CHAPTER 3 test istration means to patients. One patient with an anxiety disorder with hysterical features provided unexpectedly poor stories when tested on the T.A.T. About two weeks later, she had a dream in which the therapist was sitting at a front desk of an advertising agency, as a clerk, and she was sitting as she had sat during the test istration with the same therapist. Her associations to the dream revealed that she felt that since the therapist worked in a clinic, the therapist could not be any good (just a clerk) and that she was there primarily as a guinea pig, and that the therapist would tell () all about her to medical students. Naturally, such a mental set, whether conscious or unconscious, does not permit good responses. Another patient had an even more markedly negative dream concerning the test istration: She dreamed that the therapist was peeking into her bathroom while she was defecating. Her T.A.T. stories were very constricted. Generally, people do not respond with the first thought or story or impulse to any projective technique. When they do not tell the first thing that comes to mind and the response is given aloud, the defense operations become clearly apparent. However, it is very encouraging that the preferred substitute is nearly as informative as the suppressed response, and it reveals defenses in addition? These processes hold true for all the projective techniques, not just the T.A.T. For instance, Dr. Molly Harrower asked one patient to draw whatever was most unpleasant to him (as part of her Most Unpleasant Concept Test), and he drew a crab. While free associating in the treatment situation with Bellak, the patient stated that actually his first idea had been "vagina." He associated by seeing the crab as a dangerous, cutting, castrating animal. In other words, instead of the object of the drive aim, the patient responded with a concept expressing his idea of punishment for the wish. Thus, the response may be seen as the result of the original impulse plus--or rather, substituted by--the superego representation. However, when the patient associated during the testing situation, the fuzziness of the crab's tentacles reminded him of pubic hair, thus constituting more of a breakthrough of the original idea. If some individuals relate very short, meager stories, one may simply suggest that they could tell a longer story, or suggest that they try to let themselves go more, adding some reassuring words to this statement. Some individuals may tell poor stories regardless of how the test istration is carried out, and this is as diagnostic as any other form of behavior. In our clinical experience, hysterical individuals typically take more to the T.A.T. and obsessive-compulsive individuals to the Rorschach. This may also hold true for the choice of method by psychologists (i.e., more obsessive psychologists may prefer to work with the Rorschach). A number of artificial steps can be taken in an attempt to enrich the responses, such as Murray's4 suggestion to show the test taker each card for only 10 seconds, after which the story is told, thus obviating description. to male first stran in worl( it ver prac! choo choo i ings, iting the 10,1 a cli tests one to an lem card 2 In the treatment situation, test takers will often report what their first real response was that they had not given to the tester. 3 Personal communication to Bellak. 4As reported in The T.A.T. Newslett 1952, 6, 152, p. 2.

1985

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CHAPTER 4

THE T.A.T. PICTURES AS STIMULI Murray's (1943a) original plan for the T.A.T. istration was for 20 cards to be given to each subject, with a slightly different set given to females than to males. The first 10 are to be given one day, the second 10 on a subsequent day. The first 10 are more everyday-type scenes, whereas the second 10 are more bizarre, strange, and extraordinary. Going from the first to the second grouping is like going from the more mundane world of one's daydreams to the deeper, unconscious world of one's dreams and nightmares. The richness of such complete 20-card T.A.T. protocols can be seen in Schafer (1948). The large number of tests in contemporary psychological test batteries makes it very time consuming to ister all 20 cards. This has led to a rather informal practice of some psychologists employing a smaller number of cards, which they choose based on an attempt to match their clinical impressions of the test taker's personality with T.A.T. cards that seem to feature themes and issues more typical of these particular types of personality. The term most often used for this practice is choosing cards for particular individuals that "pull" for their particular issues (i.e., "card pull"). For example, if the test taker appears depressed, the psychologist may ister cards 1, 3BM, or 13MF, since these cards are thought to "pull" for feelings of depression. If it appears to be a reactive depression to the death of a closely related person, card 15 or 12M may be given. Card 12M is also very valuable in eliciting a patient's attitudes toward therapy and therapist, thus providing clues as to the prognosis of psychotherapy. If an individual seems to have intimacy fears, 9BM, 10, 17BM, and 18BM may also be included. One problem with istering a limited number of cards to "corroborate" a clinical impression from the test taker's test behavior and responses on previous tests is that one may not tend to gain any new information. Another problem is that one is not able to do a "sequential analysis," as one can do with the House-Tree- Person Drawing Test or the Rorschach. Sequential analysis is often very revealing as to an individual's areas of conflict and difficulty and ability to deal with these problem areas. As in the Rorschach when one deals with a card that stimulates a conflict response, such as regressing by giving a lower level of response on a "color shock" card, it is possible to assess the individual's capacity to "recover" from such a regression by organizing a higher-level, more adaptive response on a subsequent, less conflictual card. A few researchers have utilized the full 20-card sequence (Avila Espada, 1983, 1985; Eron, 1950). However, it is more common for researchers to employ only a 59

60 CHAPTER 4 handful of T.A.T. cards, as in the example of McClelland and colleagues' (1953) studies of need for achievement, Cramer's (1991a) research program on defense mechanisms, or Ronan's (Ronan, Colavito, & Hammontree, 1993; Ronan, Date, & Weisbrod, 1995) cognitive-behavioral studies of problem solving. While many research studies have used similar cards, others have recognized the value of establishing a standard T.A.T. sequence of 8 to 10 cards, as in the 9 cards of the Bender Gestalt Test, 10 cards for the Rorschach, or 10 cards for the C.A.T. Hartman (1970) surveyed 90 psychologists, asking them to rank order their most frequently employed T.A.T. cards. The rank order from the most frequent to less frequent was: 13ME 1, 6BM, 4, 7BM, 2, 3BM, 10, 12M, and 8BM. A drawback of Hartman's basic set is that the cards are all cards for males. Chusmir (1983) pointed out that a T.A.T. sequence that is gender balanced is preferable to a gender-specific sequence, because it provides the test taker with an opportunity for "psychological distance" with those cards featuring the opposite gender. Other studies of the most popular core group of T.A.T. cards show a parallel grouping to that of Hartman (Cooper, 1981; Irvin & Woude, 1971; Newmark & Flouranzano, 1973). Psychologists have increasingly adopted the practice of employing a basic set of 10 cards istered in the same order to males and females, which are chosen based on these surveys of what is considered the essential core T.A.T. cards, the recommendations in tests such as the current one, and including the most popular cards developed by Murray for both males and females (cards 1, 2, 4, 10, and 13MF). Standard Sequence of 10 T.A.T. Cards This has led to a gradual consensus on the following gender-balanced T.A.3: sequence recommended to be istered to both males and females in the same exact order: 1, 2, 3BM, 4, 6BM, 7GF, 8BM, 9GE 10, and 13MF If the clinician has other "favorite" cards not on this list or wants to give certain cards that "pull for" or elucidate specific problems, such as marital conflict or suicide, then these cards may be given after first istering the standard sequence of 10 cards. These 10 pictures appear to illuminate powerful emotions and basic human relationships, as well as make it possible to compute statistics for the 10 scoring categories and 12 ego functions of the Bellak T.A.T. Blank and Analysis Sheet. The number of the total 10 cards that show the defense of denial, for example, can be reported similar to reporting the number of shape rotation errors on the Bender Gestalt Test (Koppitz, 1963) or of Whole responses on the Rorschach (Exner, 1994; Klopfer & Kelly, 1942; Schafer, 1948). Cognitive scoring of narrative form and thematic content scoring may then be derived for the T.A.T. similar to Rorschach structure and content systems of analysis, and sequential and other response patterns may then be mathematically computed in the manner of the Rorschach ratios. For those clinicians who wish to ister a gender-specific T.A.T. sequence,

THE T.A.T. PICTURES AS STIMULI 61 the most common practice has been to ister the following sequence for females: 1, 2, 3BM, 4, 6GF, 7GF, 9GF, 10, 11, and 13ME For a male-specific T.A.T. sequence, the following is recommended: 1, 2, 3BM, 4, 6BM, 7BM, 8BM, 10, 12M, and 13ME However, the gender-balanced T.A.T. sequence recommended above is preferable for the reasons stated earlier, as well as consistency with the gender-balanced sequence of the C.A.T. and S.A.T. No doubt there are many areas of life not as fully suggested by the T.A.T. pictures as one might wish. For this reason, modifications for other age groups--such as Symonds's M.A.ES. and Bellak's C.A.T., C.A.T.-H., and S.A.T. - were designed. Murstein (1965a, 1965b, 1965c, 1965d) discusses the general area of thematic modifications, some of which can also be added after the standard set of 10 cards are istered. A major weakness of the T.A.T. is that there are not sufficient experimentally derived performance standards for "normals" and for various diagnostic groups, although much work has been carried out to provide evidence of modal performance for of various groups. It is hoped, therefore, that with the increasing use of this standard set of 10 cards, it will become possible to computer- ize the scoring categories of the Bellak Long and Short Form in a manner similar to Exner's (1994) comprehensive system for Rorschach analysis. The T.A.T. may then find its proper place on a more rigorous and scientific empirical foundation.

Typical Themes Elicited by the Standard T.A.T. Sequence Picture 1 A young boy is contemplating a violin that rests on a table in front of him. This is the single most valuable picture in the T.A.T., insofar as such a statement can be made. If permitted only one picture, this would be the best choice for an attempt to make statements about the total personality. One great value of this picture lies in the fact that it is a good start to the testing situation. It is nonthreatening and induces a feeling of reverie in adults and adolescents. As to themes, this picture usually leads to an easy identification of the test taker with the boy and brings out the relationship toward the parental figures. That is, it usually becomes quite apparent whether the parents were perceived as aggressive, domineering, helpful, understanding, or protective. Aside from learning about the test taker's relationship to her or his parents, one may also gain insight into the type of relationship with each parent. Frequently, we obtain themes on the conflict between autonomy and compliance with authority in all its wide variations and different patterns. For example, the boy may try to escape the parental commands to practice the violin by playing in the street, but then he finally feels that he ought to go in and play the violin, or he may run away from home. Or the hero may be described as not obeying his parents and doing what he wants. Later on, he experiences failure because he did not obey them. Thus, one may display guilt feelings about one's autonomy, while in other cases, all may go well after one has broken away. Hence, this card is especially successfully employed with adolescents. Another need this card frequently brings out is that of achievement. It is particularly important to see how the success is achieved, whether just on a fantasy level or on a reality level. Finally, many subjects give symbolic sexual responses to this card.

62 CHAPTER 4 The play on the strings of the violin, the play with the fiddle, frequently become symbolic stories of repetitive selfsoothing behavior, such as masturbation; and castration fears in boys and men often emerge when one relates in a story that the strings have been broken. The relationship between bow and violin may also be seen as that of a male and a female. Mastery of the violin frequently constitutes a fusion of sexual and achievement drives - to be able to fiddle as well or better than the father. Aggression may also be expressed, with and without sexual connotations, in breaking the violin or bow. Superego anxiety may express itself in stories in which the boy is said to be blind, which could be, from a psychodynamic view, an expression of castration fears related to voyeuristic wishes. The body image or, in a wider sense, the self-image is frequently significantly illuminated in this picture. Most often, the violin, and sometimes the bow, serve in this capacity; although the image of the boy may do so, too. There may be references to the violin's having a crack, or being dead inside and mute, revealing a sense of not functioning well, of being muted. Reference to "deadness" usually indicates feelings of very severe emotional impoverishment to an extent that compels one to consider schizophrenia in the differential diagnosis. The figure of the boy is sometimes seen as crippled, also suggesting a literally warped body image. Obsessive preoccupations may become apparent when the test taker is much concerned with the notepaper, or the mussiness of the hair, or a black speck present in most of the reproductions of the pictures. In these instances, it is referred to as dirt. Frequently, the violin, as lying beneath, is identified as a female and the bow as a male, and the whole story about playing the violin may then be seen as sexual activity. Neuropsychologically, picture 1 is particularly useful. For years, it has been an amazing experience to find that there are a good number of subjects with adequate eyesight, of average intelligence, and who are nonpsychotic, who do not recognize the violin, to judge by their spontaneous stories. Inquiry will often lead them to recognize it correctly. It is not entirely clear why this occurs. In none of the cases in our experience has there been valid reason to suspect that cultural factors might have been involved. Some individuals who have difficulty with attention, such as those with attention deficit disorder, may tend not to recognize the violin. Picture 2 Country scene: In the foreground is a young woman with books in her hand; in the background, a man is working in the fields and an older woman is looking on. This picture usually offers excellent indications of the subject's family relations. Even males usually identify with the central figure of a young girl, because it is so definitely the figure in the foreground. Again, varying themes of autonomy from the family versus compliance with the conservative, backward existence are extremely frequent. These themes show the type of divergence between the test taker and the family. Oedipal themes and sibling rivalry also appear in full bloom.

THE T.A.T. PICTURES AS STIMULI 63 Most useful for our purposes is the test taker's handling of the woman leaning against the tree, who is often seen as pregnant. A great deal of information can be obtained from the manner in which the subject handles apperception of pregnancy. It may be completely ignored or it may lead to highly informative notions about it in all ages. The figure of the man may illuminate heterosexual and homosexual attitudes: Men may overly ire his musculature, for example. In this picture, which contains a relatively large number of objects, obsessive-compulsive subjects may comment on small details such as the lake in the background and the tiny figure in the background among others, in a way that virtually permits the diagnosis of compulsive tendencies. Sometimes, most of the remarks concern the horse, possibly a regressive and avoidance phenomenon. Similarly defensive may be obsessive preoccupation with the small details or complaints that the furrows are not straight. Again, stories to this picture are frequently removed in time and place, as a form of removal from one's own conflicts. The way in which the relationship of the two women to the man is discussed-- whether as a farmhand run by the woman, or as a father, husband, or brother - adds a good deal of information about the test taker's conception role of the sexes. Picture 3BM On the floor against a couch is the huddled form of a boy with his head bowed on his right arm. Beside him on the floor is a revolver. This also belongs to the group of most useful pictures. As already mentioned, this card may be used for females too-they identify with the figure readily enough, manifestly seeing a woman, or identifying latently. Normative data on the percentage of men seeing it as a man may be most useful for future research. Empirically speaking, most men see the huddled figure as a man; if it is seen by men as a female figure, this may be considered a point to keep in mind--not to make the diagnosis but to keep in mind factors of possible latent homosexuality, which may be confirmed if more suggestive evidence appears in other pictures. How the object on the left is perceived often gives a great deal of information about problems concerning aggression. Officially, this object is described as a gun. Some individuals may recognize it as a gun; it is interesting to observe the manner of handling the aggression - whether it is used as extraaggression (e.g., somebody else is being shot by the hero) or whether it is used as intra-aggression (the hero is being shot or he commits suicide). If it leads to extra-aggression, it will be interesting to see what happens to the hero. Whether he is punished severely or whether he escapes is a kind of protocol that indicates the strength of the superego of the subject. On the other hand, some clue is desired as to what leads to the depressive pattern that finally results in suicide. It is obvious that this picture is especially useful with depressed patients. The pistol may be turned into a toy pistol and thus rendered harmless. This may indicate denial, but it is important to find out by checking the consistency with other stories whether it is a superficial escape from reality entering into the story or whether this corresponds to the fact that one is simply dealing

64 CHAPTER 4 with a healthy person who has neither excessive intra- nor extra-aggression. Again, a person who has to repress latent aggressiveness may completely deny the presence of the gun by omitting reference to it, seeing it as a hole in the floor, as a cigarette case, or not seeing it at all. Sometimes, a great conflict around aggression, particularly when it has led to a compulsive pattern, will manifest itself by the test taker's hemming and hawing for a considerable time over what the object may be. Here, again, the body image may become illuminated: The figure may be seen as crippled, extremely ill, and the like. The mere fact that a story concerns suicide has, in itself, no prognostic significance. Only if such a story coincides with a great deal of latent intra-aggression, a severe superego, and a great deal of aggression should suicide be considered as a serious possibility. Picture 4 A woman is clutching the shoulders of a man whose face and body are averted as if he were trying to pull away from her. This picture elicits a great variety of needs and sentiments in regard to male - female relationships. Themes of infidelity are often found, and the male attitude toward the role of women may appear. She may be a protector who tries to keep him from rushing into something poorly thought out or one who tries to hold onto him by being overly possessive, dependent, or clinging. Similarly, a woman's attitude toward men as persons who may have been aggressive toward her becomes apparent. Another object of interest is the picture of the semi-nude in the background, which is perceived by more than two-thirds of the test takers. If it is not perceived or discussed at all, it may be a clue to the fact that there is a sexual problem. On the other hand, it may be seen as a poster or as an actual figure in the background, prompting themes of triangular jealousy. Whether the difference in depth perception involved in seeing it as a poster or as a living person may be considered a differential criterion of value is not clear at this point. There is a possibility that there is a defensive element in seeing it as a poster. Picture 6BM A short elderly woman stands with her back turned to a tall young man. The latter is looking downward with a perplexed expression. This is an indispensable picture for males, reflecting all the problems of motherson relationships and all their derivatives in relation to wives and other women. Oedipal themes are frequent. The stories given to this picture run such a complete range of this fundamental problem that only a monograph could do it justice. The downward-cast heads of the two figures often elicit feelings of loss, such as the son bringing the news to the mother than the father has died.

THE T.A.T. PICTURES AS STIMULI 65 Picture 7GF An older woman is sitting on a sofa close beside a girl, speaking or reading to her. The girl, who holds a doll on her lap, is looking away. This picture will bring out the relationship between mother and child in females. It may encourage negative attitudes toward the mother, because of the fact that the girl is looking off into the distance rather than at the mother. The doll, in turn, may reflect the test taker's attitude toward expectancy of children. Often, the theme concerns the mother telling a fairy tale, and very instructive data may be in this theme within a theme. Picture 8BM An adolescent boy faces the front of the picture. The barrel of a rifle is visible at one side, and in the background is the dim scene of a surgical operation, like a reverie image. This is a very useful picture. Male test takers usually identify with the boy in the foreground. The aggression-essential themes that may be developed center on either someone being shot and now being operated on (in the background) or on stories of ambition--the boy dreaming of becoming a doctor, for example. The operation scene may elicit a fear of being mutilated while ive. Whether the rifle at the left is recognized or not, and what is made of it, are problems similar to those of the pistol in 3BM. The way in which the figures are described--for example, the attitude toward the doctor as an older person or toward the person being operated on--if seen as a paternal figure, frequently gives clues as to the oedipal relationship. This picture may be fairly difficult to cope with for some people, since it taxes the synthetic integrative capacity. Most often, it is made into a dream or a daydream of success as a surgeon or of the perpetrator of a shooting. One way of distancing oneself is to ascribe the scene to something that happened long ago. Also, the event may be described as an accident of someone else's. In those people, who tend to deny aggression, the gun may be simply ignored. The clinical inference that avoidance of mentioning the weapon in this or other T.A.T. pictures may mean particularly severe latent hostility has frequently been attacked as "damned if you do and damned if you don't" by academic psychologists. However, this fact has been verified experimentally by Eriksen (1951). Picture 9GF A young woman with a magazine and a purse in her hand looks from behind a tree at another young woman in a party dress running along a beach. This is an invaluable picture in getting a notion of the woman-to-woman feeling, particularly for bringing out sister rivalry or daughter/mother hostility. It is very important in cases in which one suspects depression and suicidal tendencies, since frequently in such circumstances the girl below is made into someone who, in a panic, runs into the sea.

66 CHAPTER 4 Again, suspiciousness, at the least, may be brought out by the fact that stories sometimes raise discussions as to why this one person is watching the other maliciously. This factor may, at times, be strong enough to warrant the consideration of paranoia. Men are frequently introduced in stories to this picture, often in romantic or aggressive connotations. A male is frequently introduced into the story as a sexual attacker from whom one woman flees, while the other comes to her rescue. On the other hand, one often obtains stories of one woman or the other or both running to greet a long-lost lover arriving by ship. One may be jealous of the other's relative success in love relations. Picture 10 One person's head is against another person's shoulder. The gender of the two individuals is rather ambiguous, as in card 3BM. For those who see the figures as a man and a woman, it may bring out the level of intimacy the test taker may experience in relationship with one of the opposite gender. If it is interpreted as an embrace between two males by a male test taker or an embrace between two women by a woman test taker, it may suggest latent homosexuality or actual homosexual activity. If it is described as a man and a woman by either males or females, it will be interesting to observe whether it is made a story of arrival or departure, reflecting in the departure theme latent hostile needs. Picture 13MF A young man is standing with his downcast head buried in his arm. Behind him is the figure of a woman lying in bed. This is an excellent picture for disclosing sexual conflicts in both men and women. In very inhibited subjects, this may virtually lead to "sex shock," which will find expression in the stories. In females, it may elicit fears of being raped, attacked, or otherwise abused by men. In males, it will often bring out guilt feelings about sexual activity and will easily show the disgust of homosexuals. Feeling between husband and wife may be projected. Not unusual are stories of economic deprivation in response to this picture, and oral tendencies will frequently appear in discussion of the breasts. Again, since this is one of the pictures containing a relatively great amount of detail, obsessive-compulsives will easily be recognized by their concern with details. Typical Themes Elicited by the Other T.A.T. Cards Picture 3GF A young woman is standing with downcast head, her face covered with her right hand. Her left arm is stretched forward against a wooden door.

THE T.A.T. PICTURES AS STIMULI 67 This is a picture that may also bring out depressive feelings. Frequently, however, it has been found more useful with females to use 3BM, with which they easily identify, as stated earlier. Picture 5 A middle-aged woman is standing on the threshold of a half-opened door looking into a room. This is often interpreted as the mother who may be watching different activities. At times, this becomes a symbolic story of fear of observed masturbation, or the mother appears as benevolently interested in how the child is, or she may be seen as reprimanding the subject for being up late. Voyeuristic material is quite frequent and may actually lead to disguised stories of the primal scene. Again, fear of attack, particularly in female subjects, is often reflected in a story of burglary, whereas in males it may lead to rescue fantasies, in the psychoanalytic sense. Picture 6GF A young woman sitting on the edge of a sofa looks back over her shoulder at an older man with a pipe in his mouth who seems to be addressing her. This is really meant to be a counterpart of 6BM to reflect the relationship of females to the father probably because of the apparently relatively slight age difference. However, the man is usually, at least manifestly, not seen as the father image but rather as a contemporary, who may thereupon be invested with any number of qual-fies, from those of an aggressor, a seducer, or a proposer of marriage. Frequently, this man is made into an uncle, who probably represents the picture of an idealized father, as is so often done in folklore, as in the instance of Uncle Sam or Uncle Czar. All in all, the picture is not a particularly useful one. Picture 7BM A gray-haired man is looking at a younger man who is sullenly staring into space. This picture of an old man and a young man is helpful in bringing out the father-son relationship and all its derivatives (in males) in the form of attitudes to male authority. Picture 8GF A young woman sits with her chin in her hand looking off into space. Almost any theme may be produced to this picture, usually of a shallow, contemplative nature. The card is not particularly useful.

68 CHAPTER 4 Picture 9BM Four men in overalls are lying on the grass taking it easy. This is another important picture for disclosing contemporary, man-to-man relationships. It may, for one thing, offer a general indication of social relationships namely, with which of the figures the test taker is identified. In extremes, the test taker may identify with someone outside the group, who looks askance at the group or he may be part of it or even the center. Again, homosexual feelings or fears may become apparent in stories to this picture. Social prejudices may be brought to light here, as in stories of homeless individuals. Picture 11 A road skirting a deep chasm between high cliffs. On the road in the distance are obscure figures. Protruding from the rocky wall on one side are the tong head and neck of a dragon. Picture 11 is particularly useful because it operates on a more disguised plane and puts many people off guard; although it may frighten others. Here, many infantile or primitive fears emerge, since the animals permit projection of such emotions. If a person has fears of attack, this is a most useful picture, since it may expose the fine features of the fears of being attacked, as for example, by the phallic symbol of the dragon. Stories of oral aggression are also frequent. This picture offers good clues to the mood of the test taker, whether or not one escapes and, if so, how. Anxiety, in common with other psychopathologic symptoms, is often expressed in content changing with cultural factors. For example, in the Middle Ages, hallucinations were primarily thought of as the undue influence of the devil and other supernatural forces. In the early twentieth century, electricity and, later, radio waves entered into hallucinatory and delusional content, as in a paranoid indivi ual who felt that radar was being used on him. Similarly, fear of destruction is frequently elicited by this picture in stories about an atomic holocaust leaving everything desolate in its wake. When such stories refer to everything being dead, it may indicate an intrapsychic state consistent with very severe emotional impoverishment. Picture 12M A young man is lying on a couch with his eyes closed. Leaning over him is the gaunt form of an elderly man, his hand stretched out above the face of the reclining figure. This is a most important picture for indicating the qualities of the relationship of a younger man to an older man, particularly regarding ive homosexual fears and fears of being under the domination of superior figures. Stories to this picture may reveal whether ivity is ego syntonic or greatly feared; sometimes, the man in the upright position is seen as helpful, istering aid, giving comfort, and no anxiety is expressed. At other times, he is seen as exerting an evil influence (e.g., by hypnosis) or as attacking or having attacked a helpless victim. Rapaport (1946) has stated that this picture may prognosticate therapeutic success.

THE T.A.T. PICTURES AS STIMULI 69 Insofar as complete, unthreatening ivity may make therapy much more difficult, this may be correct. As to the stories revealing positive or negative feelings toward the therapist, it must be ed that the mere fact of an initial positive or negative transference is not of therapeutic significance. Stories to this picture may indeed nicely reflect the relationship to the therapist, inasmuch as the couch and supine position may be unconsciously related to the psychoanalytic treatment situation or the generally dependent attitude of the patient. Such stories lend themselves particularly well to direct use in therapy, as vehicles for insight and interpretation. The following example illustrates this point: This can't have too many stories. He's either dead or being hypnotized. If dead, the person with his hand raised over him is doing a rather uncommon thing. Trying to practice some kind of witchcraft. The other man has his knee raised, so he doesn't look too dead. Reclining on a small bed of some sort. Not too dead. Probably just waiting for some kind of black magic from the other fellow. If he's sick, they're trying to remove whatever his sickness is. If he's dead, this fellow is trying to perform whatever they do to dead men, so that he will be acceptable to wherever he's going, if he's going anywhere. This picture seems more abnormal than any of the others. It's so terribly abnormal that I don't see how anybody could tell anything but a terribly abnormal story - not even a story but to keep on going and not necessarily ever to have to finish. I'm struck by this and shocked. The hypnotizing, or black magic. Picture 12F A portrait of a young woman. A weird old woman with a shawl over her head is grimacing in the background. This may bring out conceptions of mother figures, but, in all, it is not a picture that is particularly useful. Frequently, the evil mother figure is made the hero of a story in the guise of a mother-in-law. To appreciate this tendency, it must be understood that mothers-in-law are often the recipients of the negative emotions felt toward one's own mother. One may be aware only of positive feelings toward one's mother and readily project all the negative feelings onto the less holy figure of the mother- in-law. This is responsible for the position of the mother-in-law in so many cartoons and jokes. Picture 12BG A rowboat is drawn up on the bank of a woodland stream. There are no human figures in the picture. This picture is meant, as the initials indicate, for boys and girl, but it has not proven very useful. The fact that none of the T.A.T. pictures was useful often enough with children below the age of 10 prompted Bellak's development of the Children's Apperception Test. This picture has not been found too helpful in any specific case, except in suicidal or very depressed subjects. It may, then, elicit stories of someone having jumped or fallen out of the boat.

70 CHAPTER 4 Picture 13B A little boy is sitting on the doorstep of a log cabin. To a lesser degree, this is not unlike the boy with a violin picture of Card 1 in prompting stories of childhood and may be of some use with young boys, although not markedly. It may induce reverie in adults in much the same way as the violin picture. Picture 13G A little girl is climbing a winding flight of stairs. This picture has not been found to be especially useful thus far in our experience. Picture 14 The silhouette of a man (or woman) against a bright window. The rest of the picture is totally black. This silhouette may be a most useful figure. For one thing, it is interesting to note the gender identification of the figure. It often brings out childhood fears in relation to darkness. Again, this card may be very useful, when one suspects suicidal tendencies, which may be expressed in a story of jumping out of the window. Frequently, it may induce themes of simple contemplation and reveal much of the philosophical rationalization of the subject. Occasionally, it may reveal esthetic interests, and wish fulfillment stories may be offered. It may result in burglary stories, if someone is seen as coming into the window. Picture 15

A gaunt man with clenched hands is standing among gravestones. This picture of a figure in a graveyard is especially important if the test taker has had a death in the immediate family and the clinician wants to discover the test taker's sentiments regarding that death. It is also very useful in that it may disclose notions and fears of death in most people who are presented with this picture. Depressive tendencies manifest themselves clearly. What is clinically interesting and important, and may appear in response to this picture, is the fact that there are many different conceptions of death. Psychopathology may differ according to whether the idea of death is one of being violently hurt (castrated or anally hurt) or devoured; or whether the idea is concerned with being dead, as an acceptable or unacceptable fantasy of ivity of an oral nature, as Lewin (1950) in particular has pointed out. The most specific and unusual fear of death Bellak encountered e isted in an agoraphobic patient where the exhibitionistic fantasy of lying stark naked on the undertaker's slab was particularly fear arousing. The aggressive and ive fantasies of death are probably represented in the religious dichotomy of heaven and hell. All these considerations are particularly important in those pictures concerned with suicidal possibilities.

THE T.A.T. PICTURES AS STIMULI 71 Picture 16 This blank card is of extreme value with verbally gifted subjects, who may really let loose and project freely. If the test taker has given previous indications of difficulty in expressing fantasy material, however, the blank card is often of not of any real value. The instructions here are first to imagine a picture and then tell a story about it, producing something like superprojection (Wakefield, 1986). Picture 17BM A naked man is clinging to a rope. He is in the act of climbing up or down. There are many useful aspects to this picture. There may be revelations of fears in the stories of escape from physical trauma, such as fire, or fleeing from someone. The latter often leads to disclosures concerning oedipalfears, particularly in young, socially immature adolescents, where this picture may actually be seen as someone fleeing from the king or the prince. Again, homosexual feelings are easily brought out, even by descriptive details. Not unusual are stories of a competitive nature, making this an athletic meet or the like. In males, there will often be an indication of their body image - whether or not they feel themselves to be muscular, for example. It has been suggested that outgoing, active people tell stories of people climbing up, in distinction to others. This makes sense in of Mira's (1940) observations and those of other expressive studies. taker e test close Eture. d ira- many |ether or de- Dr un- ar has ed ex- i stark le and Picture 17GF A bridge over water. A female figure leans over the railing. In the background are tall buildings and small figures of men. Here is another useful card when one suspects suicidal tendencies in women, since it opens the way for stories about jumping from a bridge. Otherwise, a great variety of stories may be told to 17GF, which is not one of the more useful cards, except for the one purpose just stated. Picture 18BM A man is clutched from behind by three hands. The figures of his antagonists are in- visible. This is another of the more important pictures for learning about, or ing, any anxiety, particularly in males. Fears of attack, particularly of a homosexual nature, become most apparent. If a test taker has any anxiety at all, it is bound to come out in response to this picture.

72 CHAPTER 4 On the other hand, it can be made into something innocuous, such as a story of , for example, of a man in an intoxicated condition being brought home by his friends. How the problem of supernumerary hands is handled is frequently of great interest insofar as the thought processes of the person are concerned. Sometimes, the story is made innocuous in somewhat the following way: "A man was out at a stag dinner and now, inebriated, is being helped home by his companions, who have ducked behind him to push him up the stairs. Viribus unitis.' Hard-luck stories are often related to this picture, and, of course, one wants to know what a particular person thinks of or fears as hard luck. Picture 18GF A woman has her hands squeezed around the throat of another woman, whom she appears to be pushing backwards across the banister of a stairway. This picture gives an excellent indication of how aggression is handled by women. It may be completely evaded by the denial that any aggressive act is taking place. Sometimes, stories of how one woman is helping another up the stairs or up from the floor are told in attempts to evade aggressive implications. Mother/daughter conflicts may also be highlighted. and onl quence ginning to deeper sec tions quent c: the reasons process

ilarly Howeve red, whi aggressi rienced defense ciations Picture 19 A weird picture of cloud formations overhanging a snow-covered cabin in the country. A picture sometimes useful with young adolescents, but otherwise not notable. Picture 20 A dimly illuminated figure of a man (or woman) in the dead of night leaning against a lamppost. The figure may be seen either as a man or as a woman. We do not have any definite indication of the differential implications of such gender identification. Women may present stories of fear of men or of the dark. Otherwise, fears may be brought out by either gender in making it a gangster story. Again, it may be made an entirely innocuous theme by a story of an evening's date. Sequential Analysis of the Standard T.A.T. Sequence The recommended sequence of 10 T.A.T. cards include 9 cards from the first series of so-called everyday situations (1, 2, 3BM, 4, 6BM, 7GF, 8BM, 9GF, and 10) and only one from the second series of more dramatic situations (13MF).

THE T.A.T. PICTURES AS STIMULI 73 This sequence is similar to that of the Rorschach, since it provides for a relatively easy beginning of a boy thinking about practicing the violin (1) and a young girl going off to school holding her books (2), but moves back-and-forth to more "dramatic" deeper conflict situations and more familiar "everyday situations." This facilitates a sequence analysis of the test taker's level of defensive reactions to different situations and capacity to "recover" and organize a higher level of response to subsequent cards. The level of defensive reaction is often a measure of the level of intensity of a conflict. For one source of insight into an individual's conflicts and to the intensity of these conflicts is often through evaluating the defenses organized to attempt to manage these conflicts (Freud, Anna, 1936). This is one of the main reasons that sequential analysis on the Rorschach and T.A.T. is so valuable in the process of psychological evaluation. The first two Rorschach cards are black-and-white achromatic cards that similarly provide for a relatively easy association to butterflies, moths, and so forth. However, the second and third Rorschach cards add the new element of the color red, which many associate with blood or aggression. For those with conflicts around aggression or physical illness related to internal bleeding, the second card is experienced as providing "color shock." This conflictual situation is likely to bring about defense reactions of denying or blocking the red by not including it in one's associations to the cards or a regression in providing a fragmented or other lower-level response. The next four Rorschach cards return to the achromatic black-and-white situation, which provides the psychologist with an opportunity to evaluate if the individual has coping mechanisms with which to "recover" from the earlier conflictual "color shock" situation in order to be able to provide higher-level or integrated responses. The last three Rorschach cards, then, reintroduce color, but this time the amount of color progressively increases to the full panoply of card 10. Another dimension of Rorschach sequence analysis is the type of common figures seen in the different cards. For example, some cards are associated with females, such as cards 3 and 7, and other cards are associated with males, such as cards 4 and 6. If one has considerable conflict around females, the associations may be more fragmented, lower-level responses. Or if one experiences males as aggressive and sadistic, the associations to the "male" cards may be to more primitive, sadistic animals or people, rather than to more benign and friendly figures. As with the color dimension, one may evaluate this individual's ability to "recover" from a conflict area on one card, when one approaches the task of associating to subsequent cards. Further dimensions for sequence analysis on the Rorschach are the ratios and other dimensions (Exner, 1994; Schafer, 1954). After the first two family situations around achievement of a child in T.A.T. cards 1 and 2, the test taker is presented with card 3BM of the dejected person sitting on the floor with head against a couch and a revolver next to the figure prior to the more dramatic situation of a figure sitting on a floor with head on a couch and a revolver next to the figure. For an adult, the first two pictures help to take the individual back to a common situation of childhood regarding studying, practicing a skill, and going to school with common issues surrounding the child's relationship with the parents around schoolwork, achievement, growing up, and independence.

74 CHAPTER 4 These first two situations are also fraught with conflict, more for some than for others, but the conflict around achievement is a common issue for most all individuals in the world (McClelland et al., 1953). The next card, 3BM, the individual with downcast head sitting on the floor next to a revolver, brings the test taker to the more primitive situation of an individual possibly contemplating a violent end to one's life. This is very similar to the "color shock" situation of cards 2 and 3 on the Rorschach, since it brings in a similar possible association to aggression to which the test taker may defend by not mentioning the revolver. The next card, 4, a woman holding onto the shoulder of a man, who is looking in another direction, provides for some relief from the primitive situation of card 3BM. This situation is a more familiar one of a couple perhaps having a disagreement over the man feeling a need to go do something elsewhere and the woman attempting to hold him back. Cards 6BM, of a man with head down next to a woman looking out a window, and 7GF, of a girl listening to a woman read her a story, are similarly more familiar everyday situations. Hence, the test taker may provide longer and more organized narratives to these three cards than may have been provided to card 3BM (which is parallel to the dimension of form level and level of integration of details into an organized Whole response on the Rorschach). Card 8BM, a boy looking at the front with the two men appearing to operate on a man on a table with a rifle to the side, brings the test taker back to a deeper, more conflictual and more primitive situation of someone, possibly the boy's father, having been shot and being operated on in a primitive, perhaps military, setting. This may bring out primitive oedipal wishes of the boy for the death of the father or a bereavement issue of the test taker over the loss of a family member, who may have died from an illness. Card 9GF tends to bring the test taker back to the "surface" of more everyday reality of two peers, perhaps one jealous of the other, who may be more successful in a love relationship than the other, since it features two women, one watching the other walking along a beach. Card 10 may bring some relief from Card 9GF, since it shows two individuals very close to each other, perhaps in an intimate, love situation. The closeness of Card 10 is then followed by Card 13MF, which shows a man with his arm against his forehead standing in front of a woman, who is supine with her breast somewhat exposed, as if he is feeling guilty over having slept with her or sad over her death. This last card is similar to the emotionality of the many-colored card 10 on the Rorschach and, as such, it is a fitting finale to the T.A.T. Therefore, it is clear that Murray's first series that include cards 3BM and 8BM are not exclusively "everyday situations." Moreover, the moving back-and-forth from pictures featuring children, young adults, and older adults on the T.A.T. sequence encourages the test taker to bring out earlier conflicts in one's life, to confront deeper, more primitive types of conflicts, and then to move back up to the surface of more adult current reality. As mentioned earlier, the psychologist may wish to add two or three favorite cards not in this sequence or two or three cards that "pull" for specific conflict areas that appear germane to the main questions of the psychological evaluation or based on clinical impressions of the test taker gained from test behavior or previous tests. This standard T.A.T. sequence provides consistency with the standard sequence for the Bender Gestalt Test, House-Tree-Person Drawing Test, Rorschach, as well as for the Wechsler intelligence and other cognitive and achievement tests in the standard test battery.

THE T.A.T. PICTURES AS STIMULI 75 The standard T.A.T. sequence is also possible to ister, along with time for an inquiry, in about 30 to 45 minutes.

CHAPTER 5

REVIEW OF SCORING APPROACHES FOR THE T.A.T. If one accepts the hypothesis of determinism of psychological behavior, it follows that deductions concerning the personality of an individual can be based on any kind of performance. Similarly, nearly any test can be analyzed for a great many different aspects and, since each dimension is by necessity a function of the test taker's personality, one is bound to have results. The crux of the matter is for tests to combine maximum applicability with maximum validity, reliability, and economy. By the same token, analytical variables or scoring categories that offer the most information with the least effort are needed. Scoring categories are like fishnets. Large, coarse mesh nets will catch only a few very large fish, losing many medium-sized ones. Exceedingly fine-meshed nets will catch so many tiny organisms as to make it almost impossible to pull in the net and haul in a useful catch. Therefore, one must select the sort of net best adapted to the task at hand and the desired goal. For research purposes, a very finely meshed set of categories may be desirable. Having very few variables, or none at all, may leave one almost empty-handed. The ideal set of variables will be one that obtains enough information for clinical purposes without making the task over-whelming. Before discussing different methods that have been applied to interpretation of the T.A.T., it is helpful to review the main working assumptions held by psychologists concerning the nature of psychological tests. Interpretations of T.A.T. responses, and the diagnostic inferences based on them, are most useful when the interpreter views such responses in the light of the broader framework provided by the following assumptions: Psychological tests represent a way of securing behavior samples of the individual. The individual's test responses are the end results of thought processes stimulated by test items. These end products are causally linked to the person's typical ego-organizing principles that is, to the means used in selecting and organizing internal and external stimuli. Test responses should be differentiated from scores. Scores are "designed to facilitate intra- and inter-individual comparisons and, as such, are extremely useful in clinical testing," but "to real behavior, it fol- can be based on for a great many ction of the test matter is for tests ty, and economy. 76

ffer the most in- will catch only a fine-meshed nets to pull in the net net best adapted ies, a very finely es, or none at all, [1 be one that ob- g the task overito interpretation ;held by psychol- ons of T.A.T. re- ;eful when the in- york provided by aples of the indit processes stim- :1 to the person's [ in selecting and uld be differenti- d inter-individual ting," but "to reaREVIEW OF SCORING APPROACHES FOR THE T.A.T. 77 son only in of the score, or even score patterns, is to do violence to the nature of the raw material" (Schafer, 1948). Interpretation needs to take of the context in which the test responses are made. For example, the meanings of similar formal test patterns may be different in different contexts. A battery of tests is needed in order to obtain a good picture of the many dimensions of ego functioning. No one test is able to reach all the different levels of psychic functioning. As we outlined in Chapter 1, Murray's (1943a) scoring system for the T.A.T. was based on the interest within academic psychology of the 1930s and 1940s in Freud's (1900) first theory of psychoanalysis called the libido theory, which conceptualizes human motivation as based on the sexual or libidinal drive. Freud (1920) added the aggressive drive in his book, Beyond the Pleasure Principle, and other of the group of early Freudians, such as Alfred Adler, Carl Jung, and Otto Rank, added other drives, such as the power motive (Adler), self-realization (Jung), and the creative drive (Rank). Murray (1938) renamed these drives as needs and expanded the small list of needs from the early Freudians into a large group of needs from within the person and a corresponding list of presses acting on the individual from the environment. The group of needs becomes organized into a hierarchy of needs and the relationship of each person's hierarchy of needs and the contrasting presses from the environment are what define the person's behavior. Murray called this the personology theory of human personality. This is applied to the T.A.T. in the following manner: The hero of a story loves a woman, but she hates him: need (for) love met by (press) hate. Every story is analyzed according to all needs and presses, and each need and press receives a weighted score. A rank-order system of the needs and presses is then tabulated. At the same time, the hierarchical relationship of the needs to each other is investigated, with such concepts of Murray's as need-conflict, need-subsidiation, and need-fusion. Nearly a dozen possible schemes of categories were developed by Murray and Bellak in 1941 at the Harvard Psychological Clinic. A test manual and a guide to the interpretation were designed based on an earlier one by White and Sanford (1941). Aside from a page for the recording of the quantitative need-press data, there is also a page for the recording of more molar qualitative data, not unlike some of the categories described in the recommendations for interpretation that indicated below. The need-press scheme of interpretation still has many advantages for use in experiments in which detail is most important and time is no object. The method has not become at all popular clinically, however, since it is not easy to master the need concept, and it takes four to five hours to interpret 20 stories with this system. Therefore, a great number of attempts to interpret the T.A.T. have been developed. The majority of scoring systems have been either extensions of Murray's need-press approach, such as McClelland and colleagues' (1953) scoring system for need for achievement and Winter's (1973) scoring system for the power motive or extensions and variations on the scoring system of Bellak (1947 and this text). Some of the more interesting of these scoring systems are presented below.

78 CHAPTER 5 Rotter (1947) suggests interpretating the T.A.T. in three steps: 1. The first step encomes autobiographical quality; coherence; predominant mood; handling of sex; endings and their relationships to stories; repetition of themes; unusual wording; attitude toward the world; characteristics of central figure; typical methods of solving problems; and characters that can be identified with mother, father, daughter, son, and so on. 2. In the second step, five principles of interpretation are proposed: frequency of occurrence of an idea; unusualness (regarding plot, language, misrecognition); determination of identification; determination of clichés; and selecting alternate interpretations (decision between two possible interpretations). 3. The third step contains qualitative suggestions for the analysis of personality trends as the final step of interpretation. In a later paper, Rotter and essor (1951) proceed in five steps: 1. The entire protocol is read for suggestive leads (mood, unusual plots, unique verbalizations, methods of solving problems, and frequency of specific themes) and for the formulation of tentative interpretations and questions to be investigated further. 2. Each story is analyzed for basic ideas and structural characteristics and is compared with plot norms. 3. Each story is considered as a unit in order to identify the characters, the conflicts, and the relationship; to decide whether the material is wishful, autobiographical, or superficial; and to select hypotheses on the basis of consistency. 4. All the stories are considered as one organized combined unit. . The interpretive hypotheses are integrated into a final summary evaluation, under five categories: familial attitudes; social and sexual attitudes; general (educational, vocational, etc.) attitudes; personality characteristics; and etiological implications. Rapaport's (1947) interpretation is predicated on an examination of the clich6 quality of the responses, and the subject's deviation from clichds serves as a baseline for orientation. In his "points of view" for scoring, Rapaport suggests two major classes: 1. Formal characteristics of story structure, of which there are three aspects: a. Compliance with instruction (omissions and distortions; misplacing of emphasis; dwelling on picture rather than on situation; introduction of figures and objects not pictured), b. Consistency within the test taker's production (inter-individual consistency, as shown by deviation in expressive and aggressive qualities, deviation from the usual significance of a particular picture, and deviation concerning language and narrative form; intraindividual consistency), c. Characteristics of verbalization 2. Formal characteristics of story content: a. Tone of narrative, b. Figures of story identifications and memory representations, c. Strivings and attitudes, d. Obstacles REVIEW OF SCORING APPROACHES FOR THE T.A.T. 79 Henry (1947), in one of the most extensive and detailed scheme for analysis next to Murray's, distinguishes (1) form characteristics from (2) content characteristics. 1. Form characteristics are divided into six major categories, each of which has several subclasses: a. Amount and kind of maginal production (length of story, amount and kind of introduced content; vividness, originality; rhythm and smoothness; variation in the consistency of all these factors) b. Organizational qualities (presence or absence of antecedents of story and of outcome; level of organization; coherence and logic; manner of approach to central concept; contribution of elaborations and of details; variation in the consistency of all these) c. Acuity of concepts, observations, and their integration d. Language structure (movement, action, qualifying, descriptive words, etc.) e. Intraception-extraception f. Relation of story told to total thought content (condensed, suppressed) 2. Content characteristics: a. General tone (positive and negative tone of language; ivity or aggressiveness of language; expressed or implied conflict; expressed or implied interpersonal harmonies or affiliative action and thought) b. Positive content (characters described in the story; interpersonal relations; action core of story) c. Negative content (what subject failed to say; what subject might have been expected to say) d. Dynamic structure of content (symbols, associations) In the relation of the form and content characteristics, eight areas are considered: mental approach, creativity and imagination, behavioral approach, family dynamics, inner adjustment, emotional reactivity, sexual adjustment, and descriptive and interpretive summary. Tomkins and Tomkins (1947), in a systematic attempt at a logically consistent analysis of fantasy, distinguished four major categories: 1. Vectors, comprising needs, or the quality of strivings "for," "against," under," "by," "away," from," and "of" 2. Levels, such as those of wishes and daydreams 3. Conditions that may be either external forces (Murray's press) or inner states, such as anxiety or depression (conditions do not refer to the goals of strivings but to given states the individual finds outside or inside himself or herself) 4. Qualities, such as intensity, contingency (certainty), and temporal considera-ions The principle underlying this system of analysis is that each class can be related to any other class. One vector can be the object of any other vector (e.g., the wish to act).

80 CHAPTER 5 The Tomkins method, which is primarily for training and research, comprises both scoring and interpretation. Each story is scored according to the previously mentioned four main categories: 10 vectors, 17 levels, 12 conditions, and 6 qualifiers. The interpretation utilizes three main approaches: canons of inference, such as Mill's methods (of agreement, difference, of concomitant variation, etc.) and additional methods (for the study of cause and effect involving two or more factors); level analysis (degree of variance, relative frequency, cause-effect relationships, and sequence analysis of levels) to study the relationship between overt and covert needs, the degree to which the subject is aware of his own wishes and behavior, and the nature of the conflict between repressed wish and repressing force; and diagnosis of personality, which includes relative importance of the family, love and sex, social relationships, and work. Korchin's (1951) use of the Tomkins method is a variant of the previously mentioned approach. It is less formalized and therefore better adapted to clinical use. It examines the characteristics of the heroes, the more generalized meanings of the main themes, the outcomes, and the levels. It also analyzes the areas of family, social relationships, work, and so on. Wyatt (1947) uses 15 variables for the analysis of the T.A.T.: (1) story description, (2) stimulus perception, (3) deviations from typical responses, (4) deviation from self, (5) time trend, (6) level of interpretation, (7) tone of story, (8) quality of telling, (9) focal figure, (10) other figures, (11) personal relationships, (12) striving, avoidances, (13) press, (14) outcome, and (15) thema. Arnold's (1951) method of interpreting the T.A.T. emphasizes the content of the stories. Situations involving interpersonal relations--such as parent/child, heterosexual, and so on--are examined for the feelings and actions described. Thus, information is obtained about the subject's attitudes, conflicts, and dominant problems. The stories are also subjected to a brief "sequential" analysis in order to see whether there is a consistent development of the central theme. The five steps in this procedure are synopsis, situational analysis, analysis of attitudes (from the situational analysis), sequential analysis, and final integration. Aron (1951) works on the level of manifest story content, deliberately leaving aside, for the most part, formal aspects of the performance. She uses the Murray- Sanford scheme of variables - need and press--with numerous changes intended to bring the scheme into close harmony with clinical approaches and psychoanalytic theory. Each need or press is recorded together with the characters who are the subject and object of the behavior, so that a given variable can be examined in relation to the context in which it is expressed. Also recorded are surface defenses, such as conflict, denial, rejection of behavior, fantasy, uncertainty, and so on; intensity of variables, which is expressed numerically; and outcomes. The results are analyzed in of the main features in variable scoring and in variable sequences. Eron (1951b) uses a normative, statistical approach. Norms are based on all 20 T.A.T. cards for adult males istered in the original prescribed order. Stories are rated for emotional tone (from very sad to very happy) and for outcome (from complete failure to great success). Themes are noted according to a checklist of more than 100 themes classified as interpersonal, intrapersonal, and impersonal; disequilibrium (tension) and equilibrium. Any deviations from the task of making

tg and research, comprises :cording to the previously 2 conditions, and 6 quali- canons of inference, such ant variation, etc.) and ad- ring two or more factors); e-effect relationships, and 3etween overt and covert wishes and behavior, and epressing force; and diag- )f the family, love and sex, variant of the previously better adapted to clinical ore generalized meanings analyzes the areas of fame T.A.T.: (1) story descrip- 1 responses, (4) deviation ,one of story, (8) quality of L1 relationships, (12) strivemphasizes the content of such as parent/child, het- actions described. Thus, flicts, and dominant prob- tl" analysis in order to see t theme. The five steps in f attitudes (from the situ- ntent, deliberately leaving ce. She uses the Murrayerous changes intended roaches and psychoana- the characters who are iable can be examined in • ded are surface defenses, ncertainty, and so on; in- )utcomes. The results are ring and in variable seIorms are based on all 20 prescribed order. Stories ) and for outcome (from cording to a checklist of iersonal, and impersonal; from the task of making REVIEW OF SCORING APPROACHES FOR THE T.A.T. 81 up a narrative and any distortions of the physical properties of the pictures, as well as certain other formal characteristics, are noted. The ratings are then compared with the norms. The basic data for this system are the frequency and unusualness of specific fantasy content. Interpretation of personality structure and content depends on the theoretical orientation of the interpreter and on the behavioral data from other sources. Fine's (1951) method stresses primarily feelings and interpersonal relationships. It makes use of a checklist for scoring the presence or absence in each story of feelings (affection, anxiety, pain, etc.): interpersonal relations (moving toward, moving against, etc.) between specific types of persons (mother to child, man to woman, etc.); and the outcomes (favorable, unfavorable, or indeterminate). The interpretation is a sort of qualitative summary of the results. Hartman (1951) uses a psychometric approach originally designed for research and aims at establishing quantitative norms as a basis for interpretation. It consists of the following steps: 1. Each story is rated on a five-point scale for 65 response categories covering thematic elements, feeling qualities, topics of reference, and formal response characteristics. 2. Numerical ratings on each category are totaled for all stories, and consistency and trend of ratings are noted. 3. From a list of over 40 personality variables, which previous research proved significantly correlated with certain response items, those personality variables are selected which are associated with each response category found important in the protocol. 4. Data thus obtained are integrated with other findings, to obtain a clinically meaningful personality picture. The method used by Holt (1951) is a clinical approach in which the interpreter reads over the stories,jots down tentative hypotheses as she or he goes along, and integrates these notes into a final personality summary. There is not any formal scoring system, and the method may be described as intuitive. The theoretical bases are those of psychoanalytic theory and Murray's need-press formulations. The system devised by Joel and Shapiro (1951) deals primarily with the functioning of the ego. First, interpersonal warmth and hostility and flight from such interpersonal feelings are translated into scoring symbols. Then the sequence of these interactions is analyzed, and finally the interpretation provides a picture of the process of coping with the social environment. In Klebanoff's (1951) method, intended primarily for research, the content of the stories is tallied on a checklist according to overtly stated themes grouped under such categories as loss of life, aggression, internal stress, and positive themes. Profiles of absolute and percentage frequencies for each theme and each category are then analyzed. Interpretation is based on that analysis. Lasaga (1951) uses a clinical method intended to discover the psychodynamic causes of neurotic and psychotic disturbances and to be an aid in psychotherapy. It focuses attention on the patient's main conflicts and emphasizes the fact that conflicts may be disguised by a process of symbolic substitution. The actual procedure

82 CHAPTER 5 consists of the following: reading the record for general impressions; underlining phrases that express the main idea or important aspects of the main idea; summa- rizing each story in of the main idea; finding clues for discovering the key conflicts; studying anomalies among the ideas or among reaction times; taking into consideration "basic data" about the patient; and knitting all these impressions together into a summary evaluation. Sargent (1953) has devised two methods. The Sargent Insight Test Scoring Method was originally developed for scoring written responses to the author's Insight Test, but is also applicable to the T.A.T. Affects (A) are scored under 12 categories (pleasure, aggression, etc.) and three expressive modes (action, manifest, and latent feeling expression); defense activities (D) are scored under three categories (evaluations, elaborations, and qualifications). Maladjustment (M) scores, based on the use of the first person pronouns, irrelevant feeling expressions, and "subjectivism," are also obtained. The A/D ratio and the A-D-A/D pattern are evaluated and interpreted in of established norms, together with qualitative interpretation of the content. The Cox-Sargent T.A.T. Normative Scoring Method is designed as a research tool for analyzing the normative aspects of responses to individual T.A.T. pictures. It uses the following main categories: feelings (frustration, anxiety, etc.); heroes (man, girl, etc.); needs (security, conformity, etc.); threats (guilt, death, etc.); actions to meet need or evade threat (negative, evasive, etc.); and outcomes (success, failure, etc.). Symonds's (1951) method utilizes impressions derived from careful readings of the protocol as a whole, rather than from the separate stories. The data extracted from the stories are classified largely in of themes (aggression, love, punishment, anxiety, defenses, moral standards, conflicts, guilt, depression, forms of sublimation, etc.) and relationships (to parents, siblings, teachers, etc.). The final write-up attempts to synthesize the themes of primary importance and to indicate the dynamic relationships among them. White (1951) devised a 'alue analysis" method, wherein the manifest content is rewritten in of 50 value words that represent motivating forces. In addition, the notations indicate whose point of view is considered, so as to shed light on the storyteller's identification, and also indicate the in which the characters are described, in order to get at the storyteller's social perception. The data are treated quantitatively by tallying. A frustration/satisfaction ratio is obtained from the frequencies of the positive and negative values. The overall interpretation "depends on the clinical insight and disciplined imagination of the analyst." Piotrowski (1950) does not offer any systematized, formal method of approach to the T.A.T., but he lists nine rules of interpretation, as follows: 1. Proceed on the assumption that T.A.T. stories reflect with much greater freedom and with much less distortion the test taker's activities and attitudes than they reflect the actual individuals toward whom the test taker's activities are directed and toward whom the test taker assumes the attitudes are manifested in the T.A.T. 2. When interpreting T.A.T. stories, proceed on the assumption that every figure in the T.A.T. stories expresses some aspect of the test taker's personality.

ining Ilma- key into as toring hor's ' cat- ifest, cate- ores, , and eval- re inarch ures. !roes i; access, ings cted fish- sub- final cate tent ion, the , are ated fre- ;nds REVIEW OF SCORING APPROACHES FOR THE T.A.T. 83 3. The more acceptable an intended action (drive) is to the consciousness of the test taker, the greater the similarity between the test taker and the T.A.T. figure to whom the drive is attributed. 4. Bear in mind that the degree of generalization of your conclusions affects their validity. The more specific the conclusions, the more difficult it is to confirm and the more easy it is to invalidate them by facts. The more general and more restrained the conclusions, the more likely they are to be valid. 5. Take into consideration the possibility that the stories may not reflect genuine drives but superficial and stereotyped attitudes developed by the test taker in order to hide specific personality traits. 6. Proceed on the assumption that the stories frequently reflect what the test taker thinks and feels about persons represented by the T.A.T. figures (i.e., about the old and the young, the male and the female persons). Of course, the T.A.T. could disclose the test taker's ideas about those old, young, male, and female persons who play important roles in the test taker's life rather than the test taker's ideas about old, young, male, or female persons, as such. 7. The more varied and the more incompatible the drives in a person's stories, the greater the possibility of poor personality integration, of great inner tension, of fear that the unacceptable drives will undermine self-control and will prompt the test taker to act contrary to one's self-interest. The greater the di- versity of the T.A.T. drives, the greater the test taker's indecisiveness and anxiety. 8. The chances of a T.A.T. thema being manifested in the test taker's overt behavior are positively correlated with the frequency of the thema's appearance in the T.A.T., with the consistency of the total T.A.T. record (absence of incompatible themas), and with the emotional intensity accompanying the expression of the thema. 9. Employ all formal rules that have been proven valuable in the study of creative associative power. Theses rules are not specific to the T.A.T. and refer to a variety of formal aspects of the T.A.T. performance: uneven pace in the production of the stories, long and variable pauses, marked differences in the number and elaboration of ideas elicited by some pictures as compared with those prompted by other pictures, disregarding of picture details which usually produce comments, farfetched and bizarre notions, sudden or gradual increase or decrease of ideas, and so on. McClelland (McClelland et al., 1953), addressing himself to achievement motivation exclusively, has devised a measure of this motive as it is expressed in imaginative stories, particularly the T.A.T. First, the scorer must determine whether the story contains any reference to an achievement goal that would justify scoring the subcategories as achievement related. Stories are scored for such Achievement Imagery (A.I.) only when at least one of three criteria, all of which deal with manifestation by a story character of "competition with a standard of excellence," is met. The scoring subcategories are: 1. Stated need for achievement (N). Someone in the story states the desire to reach an achievement goal.

84 CHAPTER 5 2. Instrumental activity. (I+, I?, I-). Indicates whether the outcome of the instrumental activity is successful, doubtful, or unsuccessful. 3. Anticipatory goal states (Ga+, Ga-). Someone in the story anticipates goal attainment or frustration and failure. 4. Obstacles or blocks. Stories are scored for obstacles when the progress of goal- directed activity is blocked or hindered by a personal obstacle (Bp) or environmental obstacle (Bw). 5. Nurturant press (Nup). Forces in the story, personal in source, that aid the character who is involved in ongoing achievement-related activity, are scored as nurturant press. 6. Affective states (G+, G-). Affective states associated with goal attainment, active mastery, or frustration of the achievement-directed activity are scored G. 7. Achievement thema (Ach Th). Achievement thema is scored when the achievement imagery is elaborated so that it becomes the central plot of the story. The n achievement score for any individual is computed by combining in- dexes as follows: Unrelated imagery is scored - 1, doubtful achievement imagery is scored 0, and A.I. is scored +1. If a story is scored for A.I., the subcategories are scored. Each subcategory is scored only once per story and given a weight of +1. An achievement score for each story is obtained by summing algebraically the category scores for that story. The n achievement score for the subject is the total of scores obtained on all the stories. Pine (1960) devised a manual for rating drive content in T.A.T. stories. Dual significance is posited in the use of drive content in these themes; absence of such content implies a pervasive, rigid, and fragile system of ego defenses, whereas at the other extreme there are two possibilities: (1) a weakening of ego control over impulses, such that results are maladaptive, or (2) drive energies have been neutralized, so that they can be used in productive mental activity. The present manual provides a method for rating libidinal and aggressive drive material in the manifest content of stories, and also describes a procedure for rating the degree to which drive content is integrated into the theme (effectiveness of such integration is considered an index of ego control). Three ratings are obtained for integration of drive content, based on three types of drive content that are distinguished: thematic, incidental, and nonappropriate. Three ratings are also arrived at for three levels of directness of expression of drive content; these levels are direct (unsocial- ized, direct-socialized) and indirect (disguised or weak). Shentoub of the Universit6 Rene6 Descartes in Paris has developed a very detailed checklist scoring system for the T.A.T., which she has applied in numerous papers on the T.A.T. (Shentoub, 1972-1973, 1973, 1981; Shentoub & Debray, 1969) and two books (Shentoub, 1987; Shentoub et al., 1990). One of her students, Franqoise Brelet-Foulard (1986, 1987, 1990), also published a book utilizing Shentoub's scoring approach in a comparison of narcissistic, borderline, and depressed patients. Si Moussi (1990) also utilizes Shentoub's approach in his book on use of the T.A.T. in Algeria. Shentoub's checklist contains over 50 scoring items, such as "presence of unusual details," "precise numbers," "abrupt change of direction of a story," "introduction of figures not in the picture," "fabulation far from the picture," "theatrical quality, .... digressions," "hesitation on the sex of different figures," "1 towards quence, checkli various pear to thinkin list inve pare th siderin useful. book appro conce' solvin o

REVIEW OF SCORING APPROACHES FOR THE T.A.T. 85 Le of the instrucipates goal at"ogress of goal- e (Bp) or enviat aid the char- are scored as ,inment, active scored G. n the achieve- of the story. combining in- ent imagery is categories are right of+l. An y the category total of scores ries. Dual sig- ence of such vhereas at the atrol over ira- been neutral- esent manual the manifest ree to which ration is con- ltegration of guished: the- I at for three ;ct (unsocialed a very de- tumerous pa- ebray, 1969) ier students, ok utilizing he, and de- his book on ring items, ge of direc- ar from the ifferent figures," "tendency to refuse cards," "accent on the everyday, factual, actual, or the concrete," "accent on sensual qualities," "motoric agitation," "demanding behavior towards the examiner, .... confusion of objects," "disorganization of temporal sequence," 'vague, indeterminate discourse," or "short associations." Some of her checklist items are similar to Bellak's Short and Long Form, such as her listing of various defenses of "intellectualization" or "projection." But Shentoub does not appear to organize her checklist along the lines of contemporary psychoanalytic thinking in the manner of the Bellak scoring system. In her scoring approach, Shentoub and her colleagues move from this checklist inventory of items in the manifest level of the content of a T.A.T. story and compare these items to certain common underlying latent content themes, such as considering the T.A.T. card 2 as the "oedipal triangle." Although this lends a more speculative dimension to her method of analysis, many of her checklist items are useful. Moreover, her scoring manual (Shentoub et al., 1990) and particularly the book of Brelet (1986) are notable for the richness of their clinical examples. Ronan (Ronan et al., 1993, 1995) developed what he calls the PersonalProblem- Solving Scoring (PPSS) approach, which appears to be the first application of the approach of cognitive-behavioral therapy to the T.A.T. The T.A.T. cards are conceptualized as presenting the test taker with different social and personal problems. The stories obtained are scored according to four subscales of problem solving: 1. General orientation of the story. This includes how challenging the hero views the situation, the level of emotional distress that is conveyed, the level of problem- solving confidence, the degree of personal control, and whether the hero adopts an approach or avoidance style. This dimension is a measure of the test taker's general orientation to the area of personal problem solving. 2. Design of the story. This includes the components of story integration, levels of distorted thinking, and formulating a story with a past, present, and future. This dimension is a measure of the process of problem formulation. 3. Generation of story solutions. This includes assessing the number of problem- focused responses that reflect instrumental acts, emotion-focused responses that reflect alternatives designed to alter one's thinking about an event, and the number of alternative story solutions. This dimension measures the test taker's flexibility and creativity in being able to consider different possible solutions to a problem, which increase the possibility of finding an optimal solution, and the individual's cognitive capacity for causal means-end thinking. 4. Story resolution. This includes the degree to which positive aspects of the story resolution outweigh the negative, the likelihood of maximizing both short- and long-term goals, and the time and energy required to bring about problem resolution. This dimension is a measure of the individual's decision making and the stages of verification in the cognitive-behavioral model of problem solving (Dobson & Block, 1988; D'Zurilla & Goldfried, 1971; D'Zurilla & Nezu, 1990; Heppner, 1988; Nezu & Ronan, 1985, 1988; Spivack, Platt, & Shure, 1976). Ronan has done studies with the standard Murray (1943a) istration sim-

86 CHAPTER 5 ply to "make up a story" and a modification in which he informs the test taker: "This is a problem-solving task. I have some pictures I am going to show you. For each picture, identify the main character and describe what his or her problem might be. Write a story about the problem. Be sure to note how the problem developed, what is happening now, how the problem will be resolved, and what the outcome might be. Say what the main character and the other people in the story are thinking and feeling. The type of problem situation you develop is up to you." Ronan reports that this alternative instruction make the T.A.T. stories much easier to score according to his problem-solving system. The three major schools of psychotherapy are psychoanalytic, cognitive- behavioral, and family therapy. The school of psychoanalytic therapy has predomi- nated the field of projective test assessment with the rare exception of Exner's (1994) Rorschach scoring system and a few others. Sobel (1981) points out that the majority of research from the cognitive-behavioral perspective has utilized paper- and-pencil measures. Therefore, this cognitive-behavioral problem-solving T.A.T. system of Ronan is a very valuable contribution to the projective test literature. Family therapy has contributed a few interesting scoring systems. Most notably, there is the especially useful method for a modified, quantitative content analysis of T.A.T. stories of the entire families of schizophrenics, delinquents, and normals described by Stabenau and colleagues (1965), and a scoring manual developed by Werner, Stabenau, and Pollin (1970). Other schemes for scoring T.A.T.'s of different of a family are those of Ferreira and Winter (1965), Ferreira, Winter, and Poindexter (1966), Fisher and Fisher (1960), Mherson (1974), Minuchin et al. (1967), Richardson and Partridge (1982), Winget, Gleser, and Clements, (1969), Winter and Ferreira (1969, 1970), and Winter, Ferreira, and Olson (1965, 1966). A very important T.A.T. scoring approach from the standpoint of family systems therapy is that of Communication Deviance (CD) developed by Singer and Wynne (1966) and Jones (1977). This scoring approach derives from the pioneering work of Bateson and colleagues (1956), who suggest that a great deal of the pathological behavior in schizophrenia may be based on the parent transmitting conflicting, illogical, and unclear messages to the child, who then responds with the type of il- logic, misperception of reality, peculiar verbalizations, and disruptive behavior typical in schizophrenic disorders. In this view, many of the "thought disorder" difficulties in schizophrenia are considered to be fostered by a child-rearing environment in which the parents do not clearly initiate and maintain a shared focus of clear attention in their communication with the child. This is a psychogenic theory of the etiology of schizophrenic behavior, since it hypothesizes that much of the symptoms in the disorder derive from communication problems in the family, rather than being primarily based on biological factors. It could be argued that miscommunication styles between a parent and a child born with a biologically based schizophrenic disorder may develop miscommunication styles that are significantly influenced by the parent's frustrations in not being able to communicate logically and clearly with the child. This is not unlike the older theories of autism 'based on the concept that the parents were lacking in the capacity to make eye and to verbalize clearly with others. The pain and rejection experienced by parents of an autistic child may gradually engender a tenden tog cau and faro getl- a m, test part Con (19: the 199 du{ Me: witl (G{ ass SOI the ch diff din for velc $n dev

REVIEW OF SCORING APPROACHES FOR THE T.A.T. 87 ms the test taker: "This how you. For each pico er problem might be. )blem developed, what at the outcome might story are thinking and ,u." Ronan reports that ier to score according :hoanalytic, cognitive- : therapy has predomi- exception of Exner's 81) points out that the ive has utilized paper- ) roblem-solving T.A.T. :tive test literature. ing systems. Most no- , quantitative content nics, delinquents, and a scoring manual de- aes for scoring T.A.T.'s inter (1965), Ferreira, , Mherson (1974), , Winget, Gleser, and Winter, Ferreira, and aadpoint of family sys- [ by Singer and Wynne ! the pioneering work ;al of the pathological rnitting conflicting, il- !ds with the type of il- isruptive behavior typ- e "thought disorder" , a child-rearing envi- itain a shared focus of psychogenic theory of -nFiat much of the symp- the family, rather a a parent and a child evelop miscommuniustrations in not be- Fhis is not unlike the .s were lacking in the ers. The pain and re- aally engender a tendency to give up trying to get the child to look at them and communicate directly together. Whether or not one believes that miscommunication styles are the primary cause of schizophrenia, the theory provides a focus of clear attention for assessment and treatment of schizophrenic individuals, particularly from the perspective of family therapy. The family therapy approach is, then, to meet with the family together, help them identify patterns of miscommunication, and help them develop a more direct, less confused method of communicating with each other. Projective tests, such as the Rorschach and T.A.T. are useful in diagnosing characteristic patterns of miscommunication at the beginning phase of treatment. The Communication Deviance scoring system of Singer and Wynne (1966) and Jones (1977) is based on the following four areas: 1. Closure problems. Fragments of words or phrases, unintelligible ages in a story, parts of a story are left for the listener to provide the meaning, a story is left hanging, presence of contradictions, lack of integration of picture elements, "I don't know" uncertainty type of endings, and so on. 2. Disruptive behavior. Interruptions of the task, peculiar set toward the task, questions about the task instructions after the story is begun, associations about self that are not part of the story, tangential replies to examiner questions. 3. Peculiar perceptions and verbalizations. A card is misperceived, idiosyncratic meaning is assigned to details, presence of odd phrasing and word usage, slips of the tongue, peculiar reasoning of any kind, repetition of words or phrases, incorrect abstract word usage. 4. Additional formal characteristics. An average is taken of reaction time from presentation of the card to beginning each story and an index is taken of story length. This scoring system has generated many other interesting research studies on the relationship of communication deviance and schizophrenia (Karon & Widener, 1994), Miklowitz et al., 1986, 1991; Rund, 1989). Doane and associates (1989) conducted a cross-cultural study of communication deviance and schizophrenia in Mexican Americans and Anglo Americans. Longitudinal studies have been done with adolescents (Doane and Mintz, 1987) and in families over a 15-year period (Goldstein, 1985). This scoring system for the T.A.T. has also been employed in the assessment of adoptive parents (Sharav, 1991) and in a study of family problem- solving interaction (Velligan et al., 1990). The future of clinical and research use of the T.A.T. will undoubtedly bring about more integration among these three psychotherapy approaches of psychoanalytic, cognitive-behavioral, and family therapy. The Bellak approach to T.A.T. interpretation provides for an integration of different therapeutic perspectives, since its categories of analysis include the major dimensions of contemporary personality assessment. Because it includes a category for Murray's needs, the important quantitative refinement of the need for achievement developed by McClelland and associates (1953) and the need for power developed by Winter (1973) may be included within the Bellak system. As we will present in Chapter 11, the valuable scoring schemes for interpersonal object relations developed by McAdams (1980), Thomas and Dudeck (1985), and Westen (1991b)

88 CHAPTER 5 are included in Bellak's category #5 of "Relation to Others" and in the ego function subcategory of "interpersonal object relations" of category #10 of "Integration of the Ego." Similarly, aspects of Ronan's important cognitivebehavioral problem- solving scoring system are addressed in Bellak's scoring categories of "significant conflicts," "main defenses against conflicts and fears," and "integration of the ego manifested in story outcome and solution." Aspects of the Communication Deviance family therapy scoring approach are addressed under Bellak's scoring category "integration of the ego manifested in thought processes revealed in characteristics of the plot and in different subcategories of ego functions of reality-testing, judgment, sense of reality, thought processes, defensive functions, autonomous functions, and synthetic functions." The Bellak Scoring System, therefore, compares with that of Exner (1994) in providing for a comprehensive assessment of the major dimensions of psychological functioning and in being an approach that includes the other valuable research and clinical approaches of thematic apperception tests, rather than being an exclusive scoring approach that measures only one specific dimension from only one specific theoretical position. While based primarily on the perspective of contemporary psychoanalytic therapy, it is a broadbased, open system of assessment that addresses both the area of cognitive ego functioning and emotional personality functioning.

CHAPTER 6 ,o function egration of 1 problem- "significant of the ego munication scoring cat- t in charac- ality-testing, utonomous

er (1994) in i psychologi-

t ble research peing an ex-

is m

only one of contem- sment that personality

THE BELLAK SCORING SYSTEM T.A.T. responses have obviously been studied in many ways. The simplest procedure is the inspection technique. It is frequently helpful merely to read through the stories, treating them as meaningful psychological communications, and simply underlining anything that seems significant, specific, or unique. When an experienced examiner rereads the stories a second time, one can, almost without effort, find a repetitive pattern running through them, or one can find facets of different stories falling together into a meaningful whole. This method becomes easier the more experience one has with the T.A.T. and with the process of psychotherapy. In psychotherapy (see Chapter 8), it may be particularly helpful to have patients hold one carbon copy of the T.A.T. stories, while the psychotherapist has another, and then have the patients free associate generally to the stories and make their own attempts at interpretation. Since the strength of the T.A.T. lies in its ability to elicit the content and dynamics of interpersonal relationships and the psychodynamic patterns, the Bellak Scoring System is primarily concerned with these dimensions and only to a small extent with the formal characteristics. The main thing to in the interpretation of the T.A.T. is the following: The T.A.T. pictures are best seen psychologically as a series of social situations and in- ,terpersonal relations. Instead of responding to real people in real situations, the test flaker is responding to people in the pictures, which the test taker imagines as certain social situations. When under less constraint of conventionality of reality, one's responses are more likely to depict inner feelings. This means it is possible to get at the contemporary patterns of the test taker's social behavior and often infer the genesis of these patterns. Interpretation is the process of finding a common denominator in the contemporary and genetic behavior patterns of a person (Bellak, 1993a). Among other things, this definition of interpretation implies what cannot be too strongly emphasized, particularly for the beginner: A diagnostic statement should hardly ever be made that is based on data revealed in only one story. Impressions gleaned in one instance should only be considered to be a very tentative inference only, for which one must try to find corroboration in other stories or through some source of information external to the T.A.T. A repetitive pattern is the best assurance that one does not deal with an artifact. 89

90 CHAPTER 6 Observation-Near and Observation-Distant Diagnosis Psychoanalytic psychotherapy has, at times, suffered from the fact that one therapist may make one type of interpretation and another may make a divergent one. They may each be correct but be addressing themselves to different aspects of a patient's statement. It is, therefore, necessary to specify the level of abstraction one is addressing. "The patient is angry" would be an observation-near diagnosis. To say that some object representations are in conflict with some self- representations would be an observation-distant inference, involving structural concepts and internalization (e.g., of parental figures whose images interact conflict- ually with internalized images of oneself), which then produced anger. The chances for error and disagreements are much higher with such observation- distant conclusions. Similar problems occur in T.A.T. interpretations. It may hold true that the less experienced a clinician, the %41der" may be the interpretation. A major attempt to avoid wild interpretations is made by way of the T.A.T. Analysis Blank. This holds true especially for the breakdown of the theme into descriptive, interpretive, and diagnostic versions. The descriptive theme is the one nearest to observation, whereas the diagnostic and symbolic levels are quite observation-distant. Keeping these concepts in mind should further help avoid wild interpretations. The following story of a 15-year-old boy may serve as an example: Story 1 He doesn't obviously want to play the violin. He's a little mad, because his mom [told] him to play the violin, right? But he can't get that note. So he's a little mad and frustrated. So he wants to give up. But I think he's going to stick to it. What will the.outcome be? He'll stick to it. (Sings "stick to it" to himself). Descriptive Level. The boy does not want to play the violin because his mother told him to, but he feels frustrated that he cannot do it. He wants to give up, but also stick to it, and eventually sticks to it. Interpretive Level. If one is told to do something by a maternal figure, one gets angry and also frustrated that one cannot perform the task. Eventually, one sticks to it. Diagnostic Level. Reacts with anger to maternal figures. There is a conflict between disobeying and wishing.to be able to do it, and eventually the boy conforms and succeeds. This story reveals that the young man telling it has a conflict with maternal figures, but resolves the conflict by succeeding in his effort. The story tells one that this 15-year-old is rebellious against his mother, but that his own need for achievement makes him succeed in his tasks (broadly speaking, his growing up). kn ho lad SCI ot] in do int ob

THE BELLAK SCORING SYSTEM 91 ,ld] ;ed. tick Story 2 Three different things to this. Doesn't look too good. Three people probably don't know each other. This girl goes to school, and she's thinking of what she might have left at home. This guy's too busy to know about anything, because he's trying to hit this horse. The lady's off nowhere. She doesn't know that she's doing it, either. She's just looking out yon- der. So they all look like they're doing separate things. Descriptive Level. This card is usually considered to reflect family relations. The descriptive level is that three people do different things and do not even know each other. The girl might have left something at home. The guy uses business to stay uninvolved. He hits a horse. The female figure is "off" and does not know what she is doing, either. Interpretive Level. If a family of three is together, they remain utterly uninvolved with each other, though not without conflict. The girl thinks she might have left something at home. The guy uses overactivity for denial and directs his anger at the horse. The maternal figure is also off nowhere. Diagnostic Level. A family without any with each other, which the narrator regrets ("She might have left something at home"). The mother figure is described as "off nowhere." Her pregnancy is ignored. This is obviously a 15-year-old who feels a great deal of isolation within the family (which makes him angry) and wishes it were not so. He displaces his anger onto other things, as in hitting a horse. The example demonstrates the ease with which one may distill considerable information by a careful progression from observation-near data to more abstract observationdistant ones. Aside from this descriptive diagnosis, it is important to see that these two stories alone--and the rest of the stories not reported here and further insight--are a valuable guide to planning psychotherapy. The first picture of rebelliousness and poor performance in school becomes more hopeful therapeutically, as one sees the padent is frustrated and wants to do better and expresses perseverance. The second picture makes quite clear for anyone that he feels a lack of relationship in the family and that one will have to deal with the lack of warmth and relationship in the family, possibly with family therapy supplementing individual therapy. These simple stories demonstrate again that even a superficial study of the stories---the observation-near data--can be extremely useful for the therapist. This young man was seen in consultation because of learning difficulties. He is so restless that he has been dismissed from several schools and has been arrested several times for minor misdemeanors. He lives with his mother and her boyfriend in comfort but in emotional isolation. At the same time, he appears manifestly outgoing, friendly, and dynamic. He denies any anger, but is very difficult to live with. Subsequent responses to the T.A.T. and neuropsychological testing led to the diagnosis of attention-deficit disorder.

92 CHAPTER 6

The Bellak T.A.T. Analysis Blank Chapter 1 outlines how the history of the Bellak Scoring System began as a collaboration between Bellak and his professor, Murray, in 1941. Bellak added to Murray's category of "needs of the hero" and "environmental presses" several scoring categories from Freud's (1923) later theory of ego psychology, such as analyzing defense mechanisms, anxieties, conflicts, and superego functioning. Bellak's (1947) scoring system and his analysis blanks were published by Psychological Corporation, as the Bellak T.A.T. Blank and Analysis Sheet (Figure 6-1). 1 The system is simple enough to be most easily mastered, to serve as a guide and frame of reference, and to make it possible to glean the most important data of a complete 10- story T.A.T. in about half an hour.

How to Use the T.A.T. Analysis Blank The Bellak T.A.T. Blank consists of a six-page folder plus separate recording and analysis sheets, of which one page from the folder is duplicated. On the cover of the folder, one records the personal data of the client and, when the analysis is complete, one writes a Final Report. Assume that the examiner wishes to secure 10 stories from a client and that the examiner is going to write down these stories as the client tells them. The first story will be written on page 2 of the T.A.T. Blank; the second story will be written on the back of an analysis sheet. Story 3 is recorded on the back of another analysis sheet, and so on, until the 10 stories have been recorded. The examiner now has the 10 stories recorded, one on the inside cover of the blank and nine on the back of separate analysis sheets. If these are placed in order, printed side up, and laid on top of page 3 in the T.A.T. Blank, the examiner will note that when each sheet is turned over, there is an Analysis Sheet opposite the corresponding story. The Analysis Sheet for story 1 is on the front side of the paper on which story 2 is written, the Analysis Sheet for story 2 is on the front side of the sheet on which story 3 is written, and so forth. The analysis of story 10 (or the last story, if more or fewer stories are used) will be made on the Analysis Sheet that is printed as page 3 of the six-page Blank. After the stories have been analyzed in this fashion, the examiner can write a summary of each of the stories in the space provided on page 4. (If more than 10 stories are used, more summaries can be written on the back of page 4.) It is best to write these summaries after all the stories have been analyzed, because the summary is one of the stages of formally integrating the content of the analysis of each separate story. When the summary sheet has been completed on page 4, one is preWe are indebted to the Psychological Corporation of New York City for permitting the production here of material that they originally published as the Bellak T.A.T. Blank, Analysis Sheets, and Guide to the interpretation of the T.A.T. 2 Revised, 1973, and published by The Psychological Corporation, 55 Academic Court, San Antonio, Texas 78204.

THE BELLAK SCORING SYSTEM 93

egan as a added to veral scot- as analyz- g. Bellak's chological 'he system me of ref- nplete 10recording the cover analysis is t and that .. The first be written :her analy- .r now has the back nd laid on :h sheet is story. The y 2 is writ- ich story 3 e or fewer {e 3 of the :an write a re than 10 ) It is best e the sum- sis of each one is preiuction here ;uide to the an Antonio, Name 1. Main theme (descriptive, interpretive, diagnostic): Story No.__ (TAT Picture No.__ 2. Main hero: age__ sex.__ vocation interests____ traits_ abilities. adequacy (/, ,//, ,///)__ body image and/or self-image. 3. Main needs and drives of hero: a) behavioral needs of hero (as in story): dynamic inference:. b) figures, objects, or circumstances introduced: implying need for or to:__ c) figures, objects, or circumstances omitted:_ implying need for or to: 4. Conception of environment (world) as: 5. Parental figures (m__, f__) are seen as Contemp. figures (m__, f__) are seen as Junior figures (m__, f__) are seen as 6. Significant conflicts: and subject's reaction is__ and subject's reaction is_ and subject's reaction is__ 7. Nature of anxieties: (,/) of physical harm and/or punishment of illness or injury_ of disapproval of deprivation of lack or loss of love__ of being devoured. of being deserted of being overpowered and helpless other 8. Main defenses against conflicts and fears: (/) repression__ reaction-formation__ rationalization__ isolation____ regression__ introjection__ denial__ undoing__ splitting__ projective identification, other 9. Adequacy of superego as manifested by "punishment" for "crime" being: (/, ,//, V'/,/) appropriate inappropriate too severe (also indicated by immediacy of punishment) inconsistent too lenient_ also: delayed initial response or pauses__ stammer other manifestations of superego interference__ 10. Integration of the ego, manifesting itself in: (/, /,/, ,/#'/) (see also ego function rating scale on page 6 of Blank) adequacy of hero outcome: happy_ unhappy. realistic__ unrealistic__ solution: adequate__ inadequate thought processes as revealed by plot being: (/, /,/, /V'/) structured__ unstructured__ stereotyped_ original__ appropriate__ rational bizarre__ complete__ incomplete__ inappropriate__ Intelligence: (/) superior__ above average__ average__ below average__ defective__ Analysis Sheet for Use with the Bellak TAT Blank (Revised) Figure

Analysis Sheet for Use with the Bellak T.A.T. Blank

6-1

94 CHAPTER 6 pared to write the Final Report. It will be noted that by folding the Blank, the space for the final report and the summary page may be exposed side by side. When the task is done, the loose sheets may be stapled in the folder for safe- keeping, and the final report appears on the cover for convenient reference. As noted earlier, some psychologists prefer to have individuals write the stories themselves. Since individuals should not have access to the outline on the analysis sheet, they should write their stories on plain 81/z by 11 paper. If the stories are so short that there are several on a sheet, they can be cut up and either pasted or clipped to the back of the separate analysis sheets so that the final arrangement will be the same as if the examiner had written on the back of the analysis sheets. For some items on the analysis sheet, appropriate information from the story must be written in, using whatever short phrase or key word will most facilitate the analytic process. For others, indicated on the Blank by (,/), a system of checks is suggested. A single check (,/) may be used to indicate the mere presence of a given attitude, conflict, or the like. A double check (/) or triple check (]/]) may be used to indicate increasing levels of importance to be assigned to the given item in sum- marizing the story. It is hoped that this approach to quantification will further research studies of inter-examiner reliability of interpretation in addition to increasing the flexibility of the analysis form. Blank spaces are provided for adding categories or ideas not given in the outline. Despite the increasing use of the more popular Short Form of the Blank, the Long Form is still highly useful, especially for training and research.

Scoring Categories (10 Variables) The following suggestions for the use and interpretation of the individual scoring categories of the T.A.T. Blank may be helpful. I. The Main Theme The main theme is best understood as an attetnpt to restate the gist of the story. (It must be ed that one T.A.T. story may actually have more than one basic theme.) Since beginners in the use of the test tend to go off on a tangent most often in an interpretation of the main theme, a breakdown of the main theme into five levels is recommended.3 This breakdown of the main theme is an important teaching device. In essence, the student is guided to make sound inferences in the For the beginner, it is most helpful to force oneself to go through all five levels. However, it may not be necessary to put them all down in writing. The descriptive level, in particular, is a crutch; it may suffice just to state the theme at this level in one's mind. The interpretive level might be recorded on each analysis sheet, and the diagnostic, or higher, level may be the basis for the summary statement. These levels are primarily a learning device. Once one is experienced, the interpretive and diagnostic levels should be enough, just using the blanks for summaries.

THE BELLAK SCORING SYSTEM 95 space )r safe- he sto- on the stories pasted ;ement ,heets. e story rate the :s is sug- iven at- be used in sum- • ther reincreas- adding he more 5ally for dividual ist of the lore than a tangent fin theme an impor- ences in the ,r, it may not h; it may suf- rded on each .ment. These gnostic levels transition from primary data to diagnostic formulation. In that process, one automati- cally proceeds from observationnear inferences to the more ambitious, but also more risky, observation-distant conclusions. This procedure should protect one against wild interpretations. The five levels are: 1. The descriptive level: On this level the theme should be a plain restatement of the summarized meaning of the story, a finding of the common trend restated in an abbreviated form and simple words. 20 The interpretive level: State the general meaning of the story. 3. The diagnostic level: State possibly expressed psychological problems. 4. The symbolic level: State possible symbols with psychological meanings. 5. The elaborative level: State any free associations to story elements. The example of the following story may help (6BM): This is a young successful engineer. He is the only son in his family; his father is dead, and his mother is very close to him. He is in the oil business and he has been offered a contract to go everseas to the East Indies. He has signed the contract and is about to leave. He obtains her farewell and they part heartbroken. After a while she feels very lonesome and decides to follow her son to the East Indies. It is wartime and somehow she obtains age on a ship to the island on which her son is. An enemy submarine sinks her ship and she perishes. Her son had not heard about her intentions but had independently planned to visit her as a surprise. He decides to return home for a surprise. The ship on which he had obtained age is taking the same route his mother had taken. At the exact spot where his mother perishes, another enemy submarine attacks and he perishes also. The theme on a descriptive level could be briefly restated as: A son lives alone with his beloved mother and leaves her--when they both try to re each other, they die on the same spot. On an interpretive level, one may go a step further and put the meaning in a generalized form, assuming a meaning beyond the story. The patient believes that if one4 permits oneself (incestual) fantasies, such as living with the mother, then both parties die. On a diagnostic level, one transforms these impressions into a definitive statements: This man has incestuous problems and oedipal conflicts that cause him severe guilt feelings. On a symbolic level, one may choose to interpret symbols according to psychoanalytic hypotheses; extreme parsimony and caution must be strongly recommended since this level takes one relatively farthest away from hard facts. In our example one might, for instance, possibly want to interpret the torpedoes as paternal phallic symbols that endanger and destroy both mother and son for their illicit attempted gettogether. On an elaborative level, the psychologist provides elaborations and free associations to such specific data as: "East Indies," "engineer," to any proper names or dates, and any other associations he or she can give. The interpretive level can nearly always be stated as a generalized conditional clause introduced by "If orle ....

96 CHAPTER 6 2. The Main Hero The main hero of the story is the one who is most spoken of, whose feelings and subjective notions are most discussed, and, in general, the figure with whom the narrator seems to identify himself or herself. In case of doubt, the figure resembling the patient most closely in age, sex, and other characteristics should be considered the main hero. At times, a man may identify himself with a female "main hero"; if this occurs repeatedly, it might be considered a sign of latent homosexuality (depending on the total picture). While practically all young men identify in picture 2 with the young girl in the foreground, only some (there is disagreement regarding the percentage) consider the figure in picture 3BM a female. Vocation, interest, traits, abilities, and adequacy as well as body image of the main hero frequently depict qualities or desired qualities of the patient. By adequacy of the hero, we mean his ability to carry through tasks under external and internal difficulties in a socially, morally, intellectually, and emotionally acceptable manner. The adequacy of the hero frequently conforms to a pattern throughout the stories and is often in a direct relationship to the ego strength of the patient. It should also be mentioned here that, at times, there may be more than one hero in a story. The patient may use a second figure with whom to identify herself or himself, aside from the clearly recognizable hero. This happens rather rarely; usually it involves a figure introduced but not present in the picture itself, and concerns drives and sentiments that are even more objectionable to the person than the ones pertaining to the main hero. (Other devices for emphatically trying to dis- sociate oneself from a story are to place it far away geographically and/or tempo- rally (e.g., placing a story in Russia in the Middle Ages.) The body image concept was originally created by Schilder (1925), who stated: "The image of the human body means the picture of our own body which we form in our mind.., the way in which the body appears to ourselves." This concept reveals itself particularly clearly in the violin picture (picture 1), but also in 3BM and in the rope picture (17BM). In picture 1, one may learn about the subject's conception of his or her own body either in the discussion of the boy or often in the treatment of the violin. This instrument seems to become identified with the hero, and may be described as broken or empty, and dead and falling apart. Particularly in this latter case, the reference transcends the body image and really becomes a matter of self-image-including the emotional tone and the subject's conception of his role in the world. (Sometimes the violin is identified with the female body, the bow constituting the male.) Similarly, 3BM and 17BM lend themselves to the characterization of the conception of body and self and the social role. 5 Some of the following variables were used by Bellak in an earlier mimeographed scoring blank Bellak designed while at the Harvard Psychological Clinic in 1940-42. Thus, a great and not easily specified extent of information and stimulation concerning these variables was received from Dr. H. A. Murray, Dr. R. W. White, and indirectly from Dr. R. N. Sanford who, with Dr. White, had written a mimeographed guide to the T.A.T. which served as the major stimulus for systematic attempts of interpretation. We wish to express our gratitude to these and other of the staff of the Harvard Psychological Clinic.

3. M E hero's ment c Behavit data: It ber of remen person is an i need for agI mum, not or lidity c has su compl and r ures, t from or lat extrei (simp much ing th there name from autor avoid may t exar is a C while cient need /)yno toal secol sho

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n of, whose feelings be figure with whom loubt, the figure re- acteristics should be with a female "main latent homosexual- men identify in pic- is disagreement re- a female. Vocation, f the main hero freugh tasks under ex- lly, and emotionally aforms to a pattern the ego strength of y be more than one aa to identify herself ppens rather rarely; :ture itself, and con- to the person than atically trying to dis- zally and/or tempo(1925), who stated: body which we form is." This concept re- But also in 3BM and t the subject's con- boy or often in

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fied with the hero, apart. Particularly really becomes a ect's conception of

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e female body, the selves

to the char- le. led scoring blank Bellak d not easily specified exam Dr. H. A. Murray, Dr. ¢ritten a mimeographed interpretation. We wish t Psychological Clinic.

THE BELLAK SCORING SYSTEM 97 3. Main Needs and Drives of the Hero Experience in teaching the T.A.T. has shown that the inquiry concerning the hero's needs produces three types of data that are frequently confused to the detri- ment of the accuracy of the observations. Behavioral Needs. The behavioral needs of the hero constitute the rock-bottom data: If the hero is extremely aggressive in the story, attacking and hurting a number of people as the theme unfolds, it is worth recording. It is, of course, useful to that the behavioral needs of the hero may be the behavioral needs of the person, but prima facie they are only the fantasy needs of the person. The problem of the relationship of latent needs in the T.A.T. to overt behavior is an important one. The interpreter of T.A.T. stories often must decide whether a need expressed pertains strictly to the fantasy level or reality; for example, the need for aggression or for achievement. The psychologist should have available a maximum of clinical and biographical data about the patient. The clinical situation is not one concerned with testing the validity of the instrument. Problems of the validity of the T.A.T. are dealt with in experiments and must be decided there. If one has sufficient information about the patient, then the T.A.T. stories must be seen as complementary to the behavioral data obtained. For instance, if the subject is shy and retiring and the stories are full of aggression and guilt feelings about the figures, the implications are obvious. On the other hand, there are certain indications from intratest situations that permit one to make assumptions about the manifest or latent needs expressed in the T.A.T. For example, in stories of achievement, it is extremely important to notice whether they follow the deus ex machina mechanism (simple wish fulfillment) or are actually accomplished piece by piece and suggest much more that they correspond to a behavioral need for achievement. It was R. N. Sanford (1943) who pointed out some important rules concerning the relationship between fantasy needs and behavioral needs. He suggested that there are certain needs that are usually high in fantasy and low in behavior-- namely, those needs that are usually prohibited and inhibited by cultural pressure from overt manifestation. These are mainly the needs for acquisition, aggression, autonomy, and sexual activity, the wish to be taken care of, and the need for harm avoidance. However, some needs may find little manifest expression in fantasy but may find much expression "in manifest behavior because of reality demands--for example, the needs for order, for avoiding social blame, for learning. Again, there is a class of needs that,may be high both in fantasy and in behavior, indicating that, while these needs are permitted and encouraged socially, they may yet be sufficiently frustrated to require particular gratification on the fantasy level (especially needs for achievement, friendship, and dominance). Dynamic Inference. If a person (hero) is frequently very nurturant and ive to a number of other figures, one may have reason to suspect that these figures are secondary or tertiary identification figures for the person, and that the nurturance shown is indicative of a profoundly succorant, demanding attitude on the part of the hero, an attitude that he or she wards off in this way. Or one may have indications that the person who avoids all reference to aggression does so because of a

98 CHAPTER 6 great deal of aggression, which he or she has to keep under control by denying all of it (an inference permitted only if there is ive evidence). Figures, Objects, or Circumstances Introduced. A person who introduces weapons of one sort or another in a number of stories (even without using them in the context) or who has food as an integral part (even without eating it) may be tentatively judged on such evidence as having a need for aggression or oral gratification, respectively. Similarly, the introduction of such figures as punisher, pursuer, benefac- tor, and the like, or such circumstances as injustice, deprivation, and so on, may be interpreted with due regard to the rest of the record. Figures, Objects, or Circumstances Omitted. If a subject omits reference to the gun in 3BM and to the rifle in 8BM, or does not see the one woman in 18GF choking the other, one may infer a need to repress aggression--or a need to repress sexual stimuli if the semi-nude in the background of picture 4 is ignored, or if 13MF is seen as entirely devoid of sexual references. The inference can only be tentative until we have a large enough sample to achieve a statistical basis for what the expectations are when a certain object is introduced or omitted, so as to be reasonably accurate in judging when a person deviates from the norm. 4. The Conception of the Environment (World) This concept is a complex mixture of unconscious self-perception and apperceptive distortion of stimuli by memory images of the past. The more consistent a picture of the environment appears in the T.A.T. stories, the more reason we have to consider it an important constituent of the person's personality and a useful clue to his or her reactions in everyday life. Usually, descriptive will suffice, such as succorant, hostile, exploiting, friendly, dangerous, and so forth. 5. Figures Seen as... The T.A.T. is primarily an instrument that permits a study of the apperceptive distortions of the social relationships and the dynamic factors basic to them. Therefore, an exhaustive study of the hero's attitudes to parental, contemporary, and younger or inferior persons is an integral part of our scheme. This method permits recording these apperceptions and the person's reactions to his or her perception--that is, each picture allows the person to create a situation that can best be understood as a problem ("Tell me what is going on") which he or she then has to proceed to solve ("And tell me what the outcome will be"), thus baring his or her ability to come to compromise formations with personal needs; in other words, to show one's defenses. For instance, if a person chooses to perceive female figures in the T.A.T. as aggressive, then it is worthwhile for us to determine how he or she proceeds to react to these creatures of one's fancy, whether with withdrawal, counteraggression, intellectualization, or other forms of behavior.

THE BELLAK SCORING SYSTEM 99 :ontrol by denying all 7Ice). .troduces weapons of them in the context) t) may be tentatively oral gratification, re- aer, pursuer, benefac- n, and so on, may be ference to the gun in in 18GF choking the to repress sexual stim- [, or if 13Mr is seen as ' be tentative until we what the expectations re reasonably accurate perception and apper- l'he more consistent a more reason we have ality and a useful clue '.erms will suffice, such idy of the apperceptive tctors basic to them. irental, contemporary, me. This method per- ons to his or her per- situation that can best which he or she then be"), thus baring his onal needs; in other ,ses to perceive female s to determine how he ether with withdrawal, tvior. 6. Significant Conflicts When we study the significant conflicts of an individual, we not only want to know the nature of the conflict but also the defenses which the person uses against it. It is important, in designating which drive or force is in conflict with the superego, to specify in a word or two the resultant behavior: e.g., if the conflict is between superego and aggression, it may be that the person reacts with shyness. Here, one has an excellent opportunity for a study of the character structure and the prognosis of the person. Sometimes, the conflict may not be between the superego and such drives as aggression, acquisition, or sexual desires, but between two drives such as achievement and pleasure or autonomy and compliance. 7. Nature of Anxieties The importance of determining the main anxieties hardly needs emphasizing. Again, it will be valuable to note the defenses in this context, whether they take the form of ivity, flight, aggression, orality, or those mentioned next. 8. Main Defenses against Conflicts and Fears The T.A.T. should not be studied exclusively for need content, but should, in addition, be examined for the defenses against these needs. Such a study of de- fen-ses will often offer more information in that the needs may appear less clearly than the defenses against them; on the other hand, the defensive structure may be more closely related to manifest behavior. By studying drives and defenses, the T.A.T. often permits a clear-cut appraisal of the character structure of the person. It is also valuable to study the molar aspects of the stories. For instance, some people choose obsessive defenses against a disturbing picture content; they may produce four or five themes, each very short and descriptive, manifestly different but dynamically identical. Sometimes a succession of themes to one and the same picture shows the person's attempts to deal with a disturbing conflict; successive stories may become more and more innocuous, showing an increase in the defenses. On the other hand, each successive theme may permit more expression of the forbidden desire or need. 9. Adequacy of Superego as Manifested by "Punishment" for "Crime" The relationship of the nature of the punishment to the severity of the offense gives one an excellent insight into the severity of the superego; a psychopath's hero may consistently receive no punishment in stories of murder, with no more than a slight suggestion that he may have learned a lesson for later life; whereas a neurotic may have stories in which the hero is accidentally or intentionally killed or mangled or dies of illness following the slightest infraction or expression of aggression. On

100 CHAPTER 6 the other hand, a nonintegrated superego, sometimes too severe and sometimes too lenient, is also frequently met in neurotics. 10. Integration of the Ego This is, of course, an important variable to learn about; it reveals how well a person is to function. It tells to what extent he or she is able to compromise between needs and the demands of reality on the one hand, and the commands of superego on the other. The adequacy of the hero in dealing with the problems he or she is confronted with in the pictures, and his or her own apperception of it, reveals what the therapist wants to know in this respect. Here, one is interested in some formal charcteristics: Is the person able to tell appropriate stories that constitute a certain amount of cognizance of the adaptive aspects of the stimulus, or does he or she leave the stimulus completely and tell a story with no manifest relation to the picture because he or she is not well enough to perceive reality or too preoccupied with personal problems to keep them out, whether pertinent or not? Does she or he find rescue and salvation from the anxiety pertaining to the test by giving very stereotyped responses, or is the individual well enough and intelligent enough to be creative and give more or less original stories? Having produced a plot, can the person attain a solution of the conflicts in the story and within himself or herself which is adequate, complete and realistic, or do his or her thought processes become unstructured or even bizarre under the impact of the problem? These observations permit an appraisal of what really constitutes ego strength, often contributing a great deal to facilitating.possible classification of the patient in one of the nosological categories, in addition to the dynamic diagnosis which the content variables supply as the main contribution of the T.A.T0 Here, too, belong such considerations as the distance of the subject from his or her story; for instance, if the setting of the story is far away or long ago, or if the hero is merely an onlooker, or if it is reported as a scene from a movie, or if emotional situations are told in a sarcastic tone and embellished with sotto voce remarks, all these factors usually imply an attempt to isolate oneself from the emotional content of the story as a defense mechanism. On the other hand, if a person immediately involves himself or herself personally in the story and says, 'What is just what happened to me .... " it may mean a loss of distance and implies a very narcissistic preoccupation with the self. From a formal standpoint, it is useful to consider that telling stories about the pictures is a task which the person must perform. We may judge the person's adequacy, ego strength, and other variables from the standpoint of his or her ability and way of meeting the task. Clinical interest in ego functions has steadily increased. Therefore, a specific ego function assessment scale is provided on page 6 of the T.A.T. Blank. This scale is predicated on detailed definitions and extensive research reported elsewhere (Bellak, 1993a). When ego functions were studied by interview, psychological tests, and laboratory methods, it turned out somewhat surprisingly that ratings derived from the T.A.T. by several raters correlated more highly than those for the

THE BELLAK SCORING SYSTEM 101 severe and sometimes ut; it reveals how well a Lble to compromise be- , and the commands of g with the problems he a apperception of it, reis the person able to tell nizance of the adaptive Is completely and tell a she is not well enough .ems to keep them out, alvation from the anxi- ses, or is the individual note or less original sto- n of the conflicts in the lete and realistic, or do bizarre under the iraonstitutes ego strength, ication of the patient in aic diagnosis which the k.T. r the subject from his or her ng ago, or if the hero is vie, or if emotional sit- voce remarks, all these emotional content of oerson immediately in- Yhat is just what hap- plies a very narcissistic elling stories about the udge the person's ade- nt of his or her ability l. Therefore, a specific LA.T. Blank. This scale ch reported elsewhere iew, psychological tests, gly that ratings derived ly than those for the Rorschach, WAIS, Figure Drawings, and the Bender-Gestalt Test (Arnold, 1951, p. 331). Ego functions may be assessed from the T.A.T. stories themselves and entered on the rating scale. If desired, highest may be drawn to connect the ratings (see the figure below). One may also wish to assess ego functions from the test behavior. It is suggested that this be recorded and reported separately in the space beneath the scale on page 6. The 12 ego functions may be briefly defined as follows: Io Reality Testing The ability to differentiate between inner and outer stimuli involves continuous selective scanning and matching contemporary percepts against past percepts and ideas. Social contexts and norms will always be relevant in assessing reality testing. Inner-reality testing is included in this scale. It is reflected here in the degree to which the person is in touch with the inner self. Stated another way, this implies psychological-mindedness" or "reflective awareness" (e.g., of the implications of the T.A.T. stories). Ego Functions Levels of functioning: Characteristic: Highest: .................. Lowest:

102 CHAPTER 6 IL Judgment Ratings for judgment are based on data indicating comprehension and ap- praisais of hypothetical and real situations, and the person's evaluations of the consequences of action or other behavior related to these situations, as the person cre- ates them here. IH. Sense of Reality of the World and of the Self This scale assesses disturbances in the sense of one's self, as it relates to the outside world. It also assays the sense of reality or unreality of the world. For instance, some T.A.T. stories include talk about ghostly creatures and unreal half- worlds! IE. Regulation and Control of Drives, Affects, and Impulses This function refers to the extent to which delaying and controlling mechanisms allow drive derivatives to be expressed in a modulated and adaptive way, characterized, optimally, by neither under- nor overcontrol. V Object Relations Optimal relationships are relatively free of maladaptive elements suggesting patterns of interaction that were more appropriate to childhood situations than to the present ones. The most pathological extreme would be essentially an absence of relationships with any people; next would be present relations based on early fixations, unresolved conflicts, and very hostile sadomasochistic relationships. Optimal relations would be the most mature, relatively free of distortions, and gratifying to adult libidinai, aggressive, and ego needs. For picture 1 of the T.A.T., a story in which a violinist plays with pleasure before an empty Carnegie Hall, suggests a great deal of narcissism. VI. Thought Processes Disturbances in formal characteristics of logical thinking, as well as the interference of primary process material need to be rated. VII. ARISE Adaptive regression in the service of the ego (ARISE) refers to the ability of the ego to initiate a partial, temporary, and controlled lowering of its own functions (keep in mind here the component factors of the eleven ego functions) in the fur- therance of its interests (i.e., promoting adaptation). Such regressions result in a relatively free, but controlled, play of the primary process. This ego function can be particularly well observed from the way in which the person is able to deal with the T.A.T. as a creative task. VIII. Defensive Functioning Defenses protect preconscious and conscious organizations from the intru- sions of id derivatives, unconscious ego, and superego tendencies. They aid adaptation by controlling the emergence of anxietyarousing, or other dysphoric psychic content, such as ego-alien instinctual wishes and affects (including depression), gan opti and X. maj Fret and onci eas num

(3)

is stu tern Blank, tually '

THE BELLAK SCORING SYSTEM 103 which conflict with reality demands. Excessive defensiveness is of course also maladaptive. A notation--whether excessive or defective--is useful. 1X. Stimulus Barrier Both thresholds and responses to stimuli contribute to adaptation by the organism's potential for responding to high, average, or low sensory input, so that optimal homeostasis (as well as adaptation) is maintained. Stimulus barrier determines, in part, how resilient a person is or how he or she readapts after the stress and impingements are no longer present. A story of a mother who can't stand the yelling of her child and how it affects her would be very informative here. Autonomous Functioning Intrusion of conflict, ideation, affect, and/or impulse upon functioning is a major criterion for determining impairment of either the primary or the secondary autonomy. The basic apparatuses and functiuons of primary autonomy are: perception memory language intentionality hearing productivity concentration vision motor development attention speech and expression XI. Synthetic-Integrative Functioning This ego function fulfills one of the major tasks of the ego as defined by Freud, in of reconciling the often conflicting demands of the id, superego, and outside world, as well as the incongruities within the ego. We focus on the reconciling of areas that are in conflict and also on the extent of relating together areas that are not in conflict. X. Mustery-Competence Raters must score competence and sense of competence separately, since a number of different relationships between the two are possible: (1) they may be congruent, (2) actual performance may exceed the sense of competence, and (3) sense of competence may exceed mastery-competence.

The Summary and Final Report After all the stories have been analyzed, the main data obtained from each should be noted down in the appropriate space on page 4. When the summary page is studied after the analysis of all the stories has been completed, a repetitive pattern in the person's responses ordinarily becomes quite clear.6 6 Experienced T.A.T. workers, having become familiar with our method, may wish to use only the T.A.T. Blank, using the middle page for a guide to record relevant data on the summary sheet rather than actually filling in the details on 10 analysis sheets.

104 CHAPTER 6 The final report can be written in full view of the summary page. It is suggested that the form of the final report follow the sequence of the 10 categories on the analysis sheet. The main themes, the second and third variables, permit a description of the unconscious structure and needs of the person, while the fourth and fifth variables show us his or her conception of the world and of significant figures around him or her. Categories six, seven, eight, nine, and ten may actually be used as headings for statements concerning the respective dimensions of personality. The form of the final report will depend, of course, to a great extent on the person for whom it is intended. It is, however, strongly advised that empty phrases and erroneous inferences be avoided by the following procedure: The first half of the report may consist of general abstract statements concerning the person, following the outline above; a second part of the report should then consist of specific, concrete documentation by excerpts from stories or by specific references to stories from which the main abstract statements have been derived. This arrangement is particularly useful in instances in which the psychologist reports as part of a team to psychiatrists and to social workers who may not have the time or the experience to read the stories themselves, and for whom a purely abstract statement will not be sufficiently meaningful.7 If a diagnosis must be offered, or if one wishes to state one, we suggest that the following formula be used: "The data represented in the T.A.T. are consistent with the diagnosis of .... " This expresses our belief that the T.A.T. is not primarily a diagnostic test (diagnostic in the sense of labeling nosologically--of course it is diagnostic of dynamic and structural variables) and also that, preferably, no diagnosis should ever be made on the basis of a single test, or better, never on test evidence alone without additional information provided by a clinical interview. The Short Form of the Bellak T.A.T. and Cak.T. Blanks The short form of the original Blank has been published mainly for clinical convenience. While it uses practially the same variables as the earlier Blank, it consists only of a three-page form that folds into a single 8 x/2 by 11 sheet, with the summarized facts on the front. When the Blank is unfolded, each of the variables can be recorded in the appropriate boxes for all 10 stories and summarized consecu- tively under the same headings at the extreme right. The writing of the final report can be simplified by having the summary sheet opened out in frill view. It should be noted that the 10 major variables or categories are used primarily as a frame of reference; not all aspects will be relevant to every story and, occasionally, details not included in the Blank will occur and have to be recorded. The principal function of the Blank is to fiarther facilitate the transition from concrete primary data to the inferential summary and final diagnosis by having all three pages unfolded in front of one. Also the Short Form is easier to handle. In its 7 we are indebted to S. Sorel Bellak for suggestions and constructive criticism of the revision of this T.A.T. Blank and Manual. 8 Published by C.P.S. Inc., P. O. Box 83, Larchmont, New York. For examples of the use of the Short Form, see Case 3, the analysis of Somerset Maugham's short stories (Chapter 10), and Chapter 16.

THE BELLAK SCORING SYSTEM 105 !sug- $ on t de- and ,und eadthe ases If of ;fol- zific, ries :)gist . the 1 ab;that itent mar- !se it di- it evfical con- Rim- can ecu- port d be ! ref- not om g all n its f this new revised version, it shows a shift to more interest in ego psychology in that the revised form lists 12 ego functions. These are to be gauged--as many of them and a well as possible--as a further indication of adaptive capacity. A detailed of these ego functions can be found in Bellak and Loeb's The Schizophrenic Syndrome (1969), in Ego Functions in Schizophrenics, Neurotics, and Normals, and in a paper called "A Systematic Study of Ego Functions" (Bellak, Hurvich, & Gediman, 1973). Briefly, they can be described as follows:9 Reatity Testing. The major thctors are (a) the distinction between inner and outer stimuli; (b) accuracy of perception (includes orientation to time and place and interpretation of external events); (c) accuracy of inner reality testing (psychological mindedness and awareness of inner states). Judgment. (a) Awareness of likely consequences of intended behavior (anticipat- ing probable dangers, legal culpabilities, social censure, disapproval, or inappro- priateness); (b) extent to which manifest behavior reflects the awareness of these likely consequences. Sense of Reality of the World and of the Self. The component factors are (a) the extent to which external events are experienced as real and as being embedded in a familiar context (degree of derealization, d$jgt vu, trance-like states); (b) the extent to which the body (or parts of it) and its functioning and one's behavior are experienced as familiar, unobtrusive, and as belonging to (or emanating from) the individual; (c) the degree to which the person has developed individuality, uniqueness, and a sense of self and self-esteem; (d) the degree to which the person's self-representations are separated from his or her object representations. Regulation and Control of Drives, Affects, and Impulses. (a) The direcmess of impulse expression (ranging from primitive acting out through neurotic acting out to rela- lively indirect forms of behavioral expression); (b) the effectiveness of delay and control, the degree of frustration tolerance, and the extent to which drive deriva- lives are channeled through ideation, affective expression, and manifest behavior. Object (or Interpersonal) Relations. The components are (a) the degree and kind of relatedness to others and investment in them (taking of withdrawal trends, narcissistic self-concern, narcissistic object choice or mutuality); (b) the extent to which present relationships are adaptively or maladaptively influenced by or pat- terned on older ones and serve present, mature aims rather than past immature aims; (c) the degree to which the person perceives others as separate entities rather than as extensions of himself or herself; (d) the extent to which he or she can main° rain object constancy (i.e., sustain relationships over long periods of time and tolerate both the physical absence of the object and frustration, anxiety, and hostility related to the object). 9The material from here to Section G is reprinted from Bellak, Hurvich, and Gediman (1973) by per- minion.

106 CHAPTER 6 Thought Processes. The components are (a) the adequacy of processes that adaptively guide and sustain thought (attention, concentration, anticipation, concept formation, memory, language); (b) the relative primary-secondary process influences on thought (extent to which thinking is unrealistic, illogical, and/or loose). Adaptive Regression in the Service of the Ego. (a) First phase of an oscillating process: relaxation of preceptual and conceptual acuity (and other ego controls) with a concomitant increase in awareness of previously preconscious and unconscious contents; (b) second phase of the oscillating process: the induction of new configurations which increase adaptive potentials as a result of creative integrations. Defensive Functioning. (a) Degree to which defensive components adaptively or maladaptively affect ideation and behavior; (b) extent to which these defenses have succeeded or failed (degree of emergence of anxiety, depression, and/or other dysphoric affects, indicating weakness of defensive operations). Stimulus Barrier. The component factors are (a) threshold for, sensitivity to, or awareness of stimuli impinging upon various sensory modalities (primarily external, but including pain); (b) nature of response to various levels of sensory stimulation in of the extent of disorganization, avoidance, withdrawal, or active coping mechanisms employed to deal with them. Autonomous Functioning. The components are (a) degree of freedom from impairment of apparatuses of primary autonomy (functional disturbances of sight, hearing, intention, language, memory, learning, or motor function) ; (b) degree of or freedom from impairment of secondary autonomy (disturbances in habit patterns, learned complex skills, work routines, hobbies, and interests). Synthetic-Integrative Functioning. (a) Degree of reconciliation or integration of dis- crepant or potentially contradictory attitudes, values, affects, behavior, and self representations; (b) degree of active relating together and integrating of psychic and behavioral events, whether contradictory or not. Mastery-Competence. (a) Competence, the person's performance in relation to his existing capacity to interact with and master his environment; (b) sense of competence, the person's expectation of success, or the subjective side of actual performance (how well he believes he can do). Case Illustrations1° Following are some examples of analyzed T.A.T. records.11 An attempt has been made to present them as closely as possible to the actual use of the T.A.T. 10 In the first two cases, the Long Form is used; in the third case, the Short Form is used. 11 These records are by no means exhaustively analyzed, as anyone will recognize. To do so would not be practical here. Indeed, a whole monograph could be written about each T.A.T. record! Different styles of writing the final report are used to illustrate various possibilities.

THE BELLAK SCORING SYSTEM 107 im- ght, e of pat: dis- rep- and Blank Analysis Sheets. Since the format of this book is smaller than the actual size of the blank, these pages must of necessity be rather crowded. Another limitation is that the running commentary of a classroom is not easily approximated. The clinical notes are meant to take the place of classroom remarks---enlarging on one aspect or another which might easily appear arbitrary. For instance, in story 1 of John Doe, blindness is scored both as a defense (namely, a form of denial of the voyeurism which is also expressed in the story itself by the person's failure to recognize the violin) and again as a form of punishment. Psychological acts are overdetermined. Fear of blindness, especially in children, must be regarded clinically both as a wish not to have to see (for instance, primal scene events), and also as a fear of being punished for wanting to look. Seeing is sometimes experienced as something active, (i.e., the glaring stare of the hypnotist), or as something ive, by the person into whose eyes someone is staring forcefully. The eye may thus serve either as a male or a female sexual symbol. Frequently during psychoanalytic sessions related to the topic of masturbation, patients will rub their eyes and transitory symptoms of compulsive eye rubbing are not uncommon. This usually constitutes a masturbatory equivalent. The clinical notes accompanying each story are kept to a minimum and where possible printed on the same page as the story itself, as an editorial convenience. They are not an essential part of the clinical record, but are appended here for didactic purposes. Similarly, under clinical conditions, the descriptive theme need not be written out at all; the instructions are to write the interpretive theme under "Main Theme" on the Analysis Sheet, and to write the diagnostic level of the theme on the Summary Page. Howev for didactic reasons, we are reproducing here the descriptive, interpretive, and diagnostic theme below each story to show how the final diagnostic level is arrived at by easy stages from the actual story as given by the person. Then, just to keep the record straight, we also reproduce the interpretive theme on the Analysis Blank and the diagnostic theme level on the Summary Page, where they belong in the actual clinical record. Thus, the scheme as used here will often be repetitive in the interests of greater clarity. his mpe- irforhas I.A.T. r tot rent

Case 1 The first case we present is one of "blind" diagnosis--that is, the T.A.T. was ad- ministered by someone else in a neuropsychiatric hospital and sent to us as the protocol of ']ohn Doe," male, age 25, single.12 These stories are, on the whole, quite poor, thematically speaking, and as unsuitable for our type of analysis as could easily be found; we include them to show how much one can derive from the scheme even under poor story conditions. Although at the time of analyzing the material we knew nothing about this man except his age and sex, we are now including a condensed version of the summary evaluation of John Doe made by the mental hygiene psychotherapist: 1 Courtesy of Edwin S. Shneidman et al., Thematic Test Analysis, New York, Grune & Stratton, 1951. Since this T.A.T. interpretation was part of a research project, there was no objection to a blind diagnosis.

108 CHAPTER 6 The patient is a tall, slender young man of 25 who gives the impression of boyishness. He seems suspicious, indecisive, and unable to relax. There seem to be considerable effem- inate mannerisms in his behavior. He had never been able to make secure object relationships. He was very fearful and withdrawn from early childhood. Some of his guilt in relation to his sexual drives, masturbation, and probably also in relation to incestuous feelings toward a seductive mother. There seems to be considerable guilt in relation to his own hostility. He has established some defenses against this through obsessions, but his defenses are - c'Sng. The patient seemed obsessed with thoughts about death, homocide, and suicide. There were depersonalization, many ideas of reference, and a considerable amount of hostile fantasy. It is felt that this patient is a paranoid schizophrenic who is still able to maintain control over his hostile and destructive impulses, although his control is very tenuous. As long as he can live a withdrawn and sheltered life, perhaps he can continue to function outside a hospital; however, in the face of frustration he may become actively psychotic with homicidal and suicidal impulses. Following is a case reproduced as in the actual T.A.T. Blank, which means that the final report appears on what would be the first page of the blank, so that who- ever the report is intended for can read the essentials at one glance. The reader is advised first to go through the stories and then to turn back to the final report. Further on in this book, this case is analyzed in of object relations.

THE BELLAK SCORING SYSTEM 109 BELLAK T A T BLANK For Recordfug and Analyzing Thematic Apperception Test Stories Name JohnDoe Sex M Age 25 Date Education __ Occupation Referred by Analysis by

c vet an lital; !sui- hat ho- er is ort. FINAL REPORT This is an extremely disturbed man: he conceives of himself as ill, incapacitated, mutilated, feels depressed, fearful, and dead inside. He is exceedingly ambivalent toward both father and mother figures; his oedipal problems are entirely unresolved: he has a tremendous attachment to the mother, whom he sees as dangerous at the same time. He sees the father as cold, hostile, and inadequate. The patient has tremendous guilt feelings concerning both sexua and aggressive impulses (which appear fused). He frequently identifies with a female figure. He also has conflicts concerning exhibitionistic and voyeuristic tendencies, possibly related to urethral difficulties. His thought processes appear disturbed, tending toward the bizarre. There are data consistent with cosmic delusions and hallucinations. The total picture is consistent with a schizophrenic disorder, with potential paranoid and hebephrenic coloring. Suicidal risk is considerable. Homicidal risk should be considered. Sexual criminality, including overt homosexuality, is a possibility. Soecmc: Illness and mutilation appear in stories 1, 7BM; also in 12M, 14, and 16 (not reproduced here). Depression, fear, and guilt are apparent in every story, usually related to sex, such as prostitution in 7BM, adultery in 4, sex and murder in 6BM; sex and disgust also appear in 13MF, murder and stealing in 14 (the last two stories not reproduced here). Homosexuality is suggested by female identification. Blindiaess occurs in story 1, great notoriety in 3BM, stage acting in 6BM; not looking in 13MF and photography in 14 (the latter two are not reproduced here). These themes are consistent with voyeurism and exhibitionism. Water occurs in story 1, fire in 4, slightly suggestive of urethral problems. Conflict with parental figures appears in story 1, the female figure is seen as dangerous and seductive in 4, mother seen as dangerous in 6BM, father as cold in 7BM, as inadequate in 7BM (was also sick) and in 13B (not reproduced), and is fought symbolically in 14 (also not reproduced here). Thought processes appear most clearly to be disturbed and bizarre in stories 1, 6BM, and 16 (not reproduced here). U.S.A. Copyright 1947, © 1973. Leopold Bellak, M.A., M.D. All rights reserved as stated in the test manual and Catog. Published by THE PSYCHOLOGICAL CORPORATION. New York, New York 10017 73-262AS Note:The above represents one form of writing the final report, the general statements being separated from the specific concrete references they are based on. The reports for Case 2 and Case 3 show other pomibilides.

11o CHAPTER 6 1: This child is sick in bed. He has been given sheet music to study, but instead of the music he has come across a novel that interests him more than the music. It is probably an adventure story. He evidently does not fear the chance that his parents will find him thus occupied as he seems quite at ease. He seems to be quite a studious type and perhaps regrets missing school, but he seems quite occupied with the adventure in the story. Adventure has something to do with ocean or water. He is not too happy, though not too sad. His eyes are somewhat blank-coincidence of reading a book without any eyes or knowing what is in the book without reading it. He disregards the music and falls asleep reading the book. Descriptive theme A sick child is told to study music (ignores fiddle) and prefers adventure story to studying, feels not happy, not sad, unafraid of punishment, reads without eyes or knows what is in book without- reading, falls asleep. Interpretive theme (If one) is a sick child told to work (ignores fiddle), prefers pleasure reading (concerning water) to studying, without affect, unafraid of punishment, can see without eyes and is omniscient, falls asleep. Clinical notes Diagnostic level Feels a child, sick, poor body image. Feels coerced. Mech- anism of denial--re masturbation? Resists authority by withdrawal into fantasy; urethral interests, exhibitionism? Anhedonia? Deper- sonalization? (Fear of punishment), severe superego; denial. Bizarre ideas of magic; severe superego, castration, omnipotence. Withdrawal, ivity. The concept of the body image as sick, and merely a child, emerges here, supplemented by the idea of being blind later in the story, probably indicating poor concept patient has of himself, and at the same time probably indicating some intrapsychic awareness of (mental) iliness which one finds in patients who seem consciously unaware of being psychotic. Ignores fiddle altogether: rare in adults, usually signifying disturbance re violin playing as sexual symbol, particularly masturbatory. Instead of studying, prefers fantasy: resistant to parents; unable to study, or unwilling. Fantasy concerns water, ocean: since this is an entirely personal introduction by the subject, wonder if related to enuresis, urethral complex, and premature ejaculation as sexual disturbance, aside from actual urinary disturbances. Unafraid of punishment: negation probably means "I wish I were not afraid" (actually quite afraid), as pointed out by Freud (denial)). Not happy, not sad: anhedonia, underlying depression--mechanism of denial.

THE BELLAK SCORING SYSTEM 111 tt instead of the t is probably an nd him thus oc- perhaps regrets ', Adventure has ad. His eyes are g what is in the te book. ic level fild, sick, .y image. :ced. Mech- denial--re Ltion? thority by al into fantasy; interests, ,nism? fia? Deper- ion? punishment), ); denial. deas of were superego, i1, ience. wal, ivity. erges here, sup- indicating poor icating some in- i who seem conurbance re vioble to study, or al introduction premature ejac- .s. vere not afraid" -mechanism of Name__ Story No 1 (TAT Picture No. 1) 1. Main theme: () (If one is) a sick child, told to study music (ignores fiddle), prefers an adventure story concerning water, feels not happy, not sad, unafraid of punishment, possibly reading without eyes or knowing what is in book without reading it, falls asleep. ...... - not happy, not sad. 2. Main hero: age nIZE6 sex vocation___ intereststraitsabilities r in k with t s adequacy(,/,,/,/,,/,/,/) O ? body image and/or self-image ill in b" I n -n 3. Main needs of hero: a) behavioral needs of hero (as in story): . ds v n is d f st i m i ' dynamic inference:, h r, w I' r f, r .f n., rn,in __ b) figures, objects, or circumstances introduced: r nts w r h I r hr I implying need for or to: ill • r n wi h r in f n s .Pr i nwih n r fillne s. c) figures, objects, or circumstances omitted:v implying need for or to: i[ r m s urb i n 4. Conception of environment (world) as: 5. Parental figures (m_, f) are seen as coercive- and subject's reaction is into fantas,y Contemp. figures (m__, f__) are seen asand subject's reaction is__ Junior figures (m__, f__) are seen as___ and subject's reaction is____ 6, Significant conflicts' ancc-autonomE:achicvcmcnt- Icasurc' activit - ass[vit . 7. Nature of anxieties: (,/) of physical harm and/or punishment of disapproval of lack or loss of love__ of being deserted other of illness or injury. of deprivation of being devoured__ of being overpowered and helpless 8. Main defenses against conflicts and fears: (/) repression__ reaction-formation__ rationalization__ isolation__ regression introjection__ denial undoing__ splitting projective identification__other ' I ' ' __ 9. Severity of superego as manifested by : (,/) of voyeurism) sometimes also a form of castration. punishment for "crime"unishment immediate__ just. _ too severe__ delayed__ unjust_ too lenient __ inhibitions__ stammer__ delayed initial response or pauses__ 10. Integration of the ego, manifesting itself in: (/, v//, ,/,//) adequacy of hero 0 ? outcome: happy__ unhappy realistic__ unrealistic solution: adequate ____ inadequate____ thought processes as revealed by plot bering: (,/, /,/, ,///) structured__ unstructured / stereotyped__ original__ appropriate__ rational bizarre complete_ incomplete__ inappropriate__ Intelligence: (/) superior__ above average__ average below average__ defective__ Analysis Sheet for Use with the Bellak TAT Blank Copyright 1951, Leopold Bellak $1-119AS The Psychological Coporation Note: A slightly revised version of variables 9 and 10 of the above blank, to be published as before by The Psychological Corporation, is in process. The changes are identical with those appearing in the revised Short Form.

112 CHAPTER 6 Reading without eyes: bizarre statement; being blind is often punishment for voyeurism (related to exhibitionism) and often consistent with very great masturbatory guilt. Knows what is in book without reading it: bizarre statement; implies telepathic notions, superhuman power, possibly related to cosmic delusions. Falling asleep: resolves conflict situation (disobeying parents) by withdrawal. Story is far removed from stimulus, poorly structured, bizarre, consistent with severe thought disturbance; flat mood consistent with schizophrenia. 3BM: This is a gill in a cell and she has been jailed because she was found guilty of prostitution. She is in this position in the picture because she is very ashamed, not because of being arrested, because she is quite familiar with the police, but because of the fact that her picture and a newspaper write-up was being sensationally spread across the country. She knew that her sister, who was a nun, would suffer from it, and it made her feel very badly because she, at one time, had a chance and an opportunity to follow her elder sister's example but it was too late now. She grabs a concealed knife from under her blouse and stabs herself. Destive theme A girl is jailed for prostitution; is ashamed not for ar- rest (because she is quite familiar with police) but because of newspaper publicity which would hurt her sister, a nun. Once she could have followed her sister's example but it is too late now. Kills herself with knife. Interpretive theme (If a) girl is guilty of prostitution she is jailed; is ashamed of the publicity and the hurting of sister whom she should emulate in being a nun, Diagnostic level Great guilt over sex; feminine identification. Severe superego concerning also exhibitionism and ambivalence to sibling seen as pure. and kills herself. Intra-aggression. Clinical notes Subject apparently considers sex as dirty, in speaking of prostitution here. Apparently feels like an habitual criminal, since he says he is quite accustomed to jail. His fear of the introduced theme of publicity is quite consistent as the exhibitionistic counterpart of the voyeurism in story 1. Hero identifies with female in this story. This by itself is so frequent in this picture that it can only be considered a most tentative datum. However, this is such a vivid identification and sounds so convincing that it appears to portray something significant. 1. Main then publicity 2. Main intere 3. Main a) dynam b) implyir c) figures implyir 4. Concepti 5. Parental Junior 6. Significa of of of of beir other_ 8. 10. Intelli Copyright 1951, L

THE BELLAK SCORING SYSTEM 113 at for astur- athic :awal. t with

ailty of cause tct that xy. She tdly be- Kample herself. ]entifio ex- l am- bling ,n here. med to exhibithis pic- s such a mething Name_ Story No._ 2 (TAT Picture No. 3B__ 1. Main theme: (In) (If a) girl is guilty of prostitution she is jailed; is ashamed of the publicity andthe hurting of sister whom she should emulate in being a nun, and kills herself. 2. Main hero: age oug_ sex female vocation interests none noted traitsabilities adequacy (/, //, ,J J) 0 ? body image and/or self-image feminine identification? 3. Main needs of hero: outcast-criminal-sexually immoral. a) behavioral needs of hero (as in story): KI suff from h r actions. dynamic inference: de r ssion- uilt over sex-suicid I tend nies? res i n a inst mther b) figures, objects, or circumstances introduced: sist rubli it -s i ide implying need for or to: cxhi itionism and mbival ncct siblin r mo her se n as re __ c) figures, objects, or circumstances omitted: b'st I is mad int knife __ cle r-we kenin ressi n? implying need for or to:_ 4. Conception of environment (world) as: uni hin -oh rain -re rovin 5. Parental figures (m__, f__) are seen as and subject's reaction is_ Contemp. figures (m__, f) are seen as ur and subject's reaction is ambivalence Junior figures (m__, f__) are seen as____ and subject's reaction is_ 6. Significant conflicts:built conccrnin sex 7. Nature of anxieties: (,/) of physical harm and/or punishment____ of disapproval of lack or loss of love of being deserted_ other__ __ of illness or injury __ of deprivation__ __ of being devoured__ __ of being overpowered and helpless__ 8. Main defenses against conflicts and fears: (/) repression__ reaction-formation-- rationalization regression introjection__ denial_ undoing__ splitting__ projective identification__---- other ' i 'i ifi i n wi h r ss r.__ 9, Severity of superego as manifested by : (/) punishment for "crime"_ immediate just___ delayed unjust____ inhibitions_____ stammer__ delayed initial response or pauses 10. Integration of the ego, manifesting itself in: (,/, ,//, adequacy of hero_ O ? __ outcome: happy realistic solution: adequate thought processes as revealed by plot being: (/, /,/, ,///) structured __ rational Intelligence: (/) superior__ Copyright 1951. Leopold Belak tOO severe_ too lenient unhappy. unrealistic_ inadequate unstructured_ stereotyped_ original__ appropriate__ bizarre__ complete incomplete__ inappropriate above average__ average___ below average__ defective____ Analysis Sheet for Use with the Bellak TAT Blank $1-119AS The Psychological Corporation

114 CHAPTER 6 4: The girl in the picture is half-caste. She is in love with the man who is going to leave her and return to his wife. They have spent quite some time together in intimacy. She is pleading with him to stay with her or help figure some way to plan for the coming of the child she is going to bear. She is in poor circumstances financially, and he tells her she should make arrangements to conclude the birth and thus everything would iron out because he is definitely determined to leave as the affair in his mind is at an end. She is very broken up by it. She pleads for him to spend one more night, which he agrees to, and in the middle of the night she sets fire to the house, thus solving the problems of all concerned. Descriptive theme A half-caste girl has had a love affair with a man who has impregnated her and now plans to leave her to return to his wife. In their last night together she sets a fire and kills them both. Interpretive theme (If one) commits adultery, one is "half-caste" (inferior); will be rejected, poorly off, will kill oneself and lover by fire. Diagnostic level Sexual guilt; social prejudice; punishment is rejection, poverty. Has intra- and extra-aggressivity; urethral complex (identifies with girl again); but may also say: women are bad, do this sort of bad thing;endanger one (in secondary identification). Clinical notes The reference to the half-caste is intentionally reworded, "If one commits adultery, one is a half-caste," making a causal connection where there had been mere juxtaposition. This is consistent with psychoanalytic practice (e.g., in dream interpretation concerning unconscious modes of thought). The theme is a typical triangular oedipal one; the subject here again identifies with a female in an even more significant way, since here he could easily identify with a male figure. The introduction of fire again ties in with the urethral aspects of the use of water in the first story, aside from the fact that it connotes uncontrolled emotion. The occurrence of bizarre and unrealistic outcomes, in the presence of structured plots and thought processes, is probably a diagnostic sign of a latent psychotic who can still address himself to a task in an ordinary way even though the pathology underneath is extreme. 1. Main 2. Main 3. Main a) Juni 6. 9o

10. Intelli

THE BELLAK SCORING SYSTEM 115 is going to leave intimacy. She is ." coming of the s her she should ut because he is ry broken up by e middle of the Name Story No. 3 (TAT Picture No. 4 ) 1. Main theme: (l_nterpret.iv__e) (If one) commits adultery, one is "half-caste" (inferior); will be rejected, poorly off, will kill oneself and lover by fire. stic level social anish- :tion, td fivity; plex ith girl again) ; say: women his sort of bad get one (in .entification). ! one commits lere had been '.e.g., in dream ,me is a typical ale in an even :figure. s of the use of ailed emotion. e of structured psychotic who pathology un2. Main hero: age young dultsex F vocation none noted interests !one notct traits_half-cast& Door abilities @uilv adequacy (J, , J) 0 body mage and/or self-image ono 3. Main needs of hero: rejected-pregnant. a) behavioral needs of hero (as in sto): love and suppo dynamic inference: fear of abandonment and rejection b) figures, objects, or circumstances introduced: pregnancy-setting fire to house implying need for or to: intra- and extra-aggression very_ trong-possibility of uicidal and homicidal impulses: unconscious fear of impregnation, c) figures, objectS, or circumstances omitted: half-Iude female figure implying need for or to: sexual guilt-scotoma repression 4. Conception of environment (world) as: hostile and rejeoting 5. Parental figures (m__, f ) are seen as and subject's reaction is Contemp. figures (m_, f ) are seen as rejecting and subject's reaction is guilt; depression; ag- Junior figures (m__, f ) are seen as and subject's reaction is grcssion . Signilicanl conllicls: sexual guilt; intra- and extra-aggressivity; urethral complex 7. Nature of anxieties: (/) of physical harm and/or punishment of illness or injury_ of disapproval of deprivation ' of lack or loss of love of being devoured of being deserted of being overpowered and helpless. other 8. Main defenses against conflicts and fears: (,/) repression .___ reaction-formation regression introjection denial undoing projective identification other projection 9. Severity of superego as manifested by : (,/) punishment for "crime" immediate just__ delayed unjust inhibitions__ stammer delayed initial response or pauses 10. Integration of the ego, manifesting itself in: (,/. ,/,/, ,//,/) adequacy of hero O ? outcome: solution: thought processes as revealed by plot being: (/, structured v/ unstructured stereotyped rational __ bizarre complete_ Intelligence: (,/) superior above average __ rationalization__ isolation splitting__ too severe too lenient happy unhappy_ , realistic unrealistic adequate inadequate original__ appropriate v/ incomplete inappropriate average__ below average__ defective Copyright 1951, Leopold Bellak

Analysis Sheet for Use with the Bellak TAT Blank $1-119AS The Psychological Corporation

116 CHAPTER 6 6BM: This is a scene in a play. The two characters are on the stage; one is a famous elderly actress, who has a son about the age of the young man appearing opposite her. The dialogue in the play has suddenly taken on a new meaning for her. She sees now that the play, which was written by her son, has an entirely different meaning in this scene in the picture. The boy is telling the mother that he has just committed a murder. She understands now that this was her son's way of conveying to her the terrifying fact that that is actually what had happened. In the play, as her son had written it, the climax comes when the mother calls the police. But the famous actress decides to put her own climax into action after the play is over. She calls her son and says, "The climax of your play will have to be changed." She says, "I think the audience will prefer this one," so here she draws a revolver and shoots him. (What kind of murder was it?) Oh, a girl. Motive primarily to do with sexual. She had been unfaithful. Descriptive theme In a play written by her son an elderly actress suddenly understands that he has killed a girl for being unfaithful to him. Thereupon she kills him. Interpretive theme If a man kills a girl because she has been unfaithful to him and mother finds out in a play, symbolically the mother will kill him. Diagnostic level Aggression fused with sex. Exhibitionism and symbolism. Triangular oedipal situation feels rejected by girl. Mother seen as phalllic, aggressive, dangerous. Clinical notes The value of the theme construction is particularly obvious in this story, though cluttered with confusing descriptive detail. The aggressive sexual wishes of the subject toward the maternal figure and the fear of counteraggression by the mother figure become crystal clear. The "sudden understanding" is a typical experience in schizophrenics with paranoid tendencies, as so well described by Sullivan (1940). The patient is in a panic because of many different impulses and apperceptive distortions, finds a new configuration which gives him a measure of stability and a channeling of his fears and aggression--the paranoid constellation. The fact, too, that the information is conveyed symbolically is highly suggestive of a schizophrenic process. The actor is probably another identification figure for the subject, who attempts at first to keep some distance between himself and the mother in having someone else play opposite her.

THE BELLAK SCORING SYSTEM 117 famous el- er. The di- t the play, ae picture. Is now that tt had hap- alls the po- ,lay is over. " She says, hoots him. d been uned with aism and dipal sit- rejected s phalllic, ngerous. this story, L1 wishes of ,ion by the pical expe- by Sullivan and apper- re of stabil- [ation. The testive of a ct, who at- r in having Name Story No 4 (TAT Picture No. 6BM ) 1. Main theme: () (If a) man kills a girl because she was unfaithful to him, the mother will kill him. 2. Main hero: age sex vocation interests n2LL traits c abilities adequacy (/, //, ///) O ? body image and/or self-image 3. Main needs of hero: a) behavioral needs of hero (as in story): to unish k' irl wh w f i hf I him. __ dynamic inference: .r iv .r],, t,i.,,n ,f . b) figures, objects, or circumstances introduced: r' ill . implying need for or to: nishm n f r i I i[ f elin s' r s i n'n f r hi ' i ni m. c) figures, objects, or circumstances omitted: implying need for or to: 4. Conception of environment (world) as: f and rejecting_ 5, Parental figures (m__, f_) are seen,.L.:,as and subject's reaction isression Contemp. figures (m__, f_) are seen as and subject's reaction isression Junior figures (m__, f__) are seen as__ and subject's reaction is 6. Significant conflicts:_ 7. Nature of anxieties: (,/) of physical harm and/or punishment__ of illness or injury_ of disapproval of deprivation of lack or loss of love ,/ of being devoured of being deserted of being overpowered and helpless__ other. 8. Main defenses against conflicts and fears: (/) repression__ reaction-formation__ rationalization__ isolation__ regression__ introjection__ denial__ undoing__ splitting__ projective identification__ other YOJ 9, Severity of superego as manifested by : (/) punishment for "crime"__ immediate just__ too severe__ delayed unjust__ too lenient inhibitions__ stammer__ delayed initial response or pauses 10. Integration of the ego, manifesting itself in: (/, ,//, ,///) adequacy of hero O ? outcome: happy unhappy ,/,/,/ realistic unrealistic ,/,/,/ solution: adequate inadequate __ thought processes as revealed by plot being: (/, //, ///) structured unstructured__ stereotyped original__ appropriate__ rational__ bizarre_ /,/ complete incomplete__ inappropriate__ Intelligence: (,/) superior__ above average__ average__ below average__ defective__ Analysis Sheet for Use with the Bellak TAT Blank Cyrlght 1951, Leopold Bellak $1ol 19AS The Psychological Corporation

118 CHAPTER 6 7BM: This would be a man and his son. The son is very depressed over his health. The father is telling him that as a young man he too had the same illness, and that it can be cured if the son has the will to cure it. The father tells the young man that he himself alone can cure it. The son believes that there is no hope, but replies that he will go away for a little while and think it over. The father replies, "You are not doing a favor to me by saying that. I am thinking about your getting well for the simple reason that you have a wife and children to , and in the event of your being bedridden, the responsibility for your family will be put entirely upon your mother and me." The young man finally concludes that he will take his wife and family with him and try to make things go better in a healthier climate. (What kind of illness did he have?) T.B. (Did beget better?) No, I don't think he does. After a few years he dies and the children are old enough to mother or perhaps he left insur- ance. Never ed father again. No correspondence. After not having heard from each other for a long time, the old man dies and leaves the children a large estate. This is his way of having repented. Destive theme A young man suffers from T.B., and father tells him he used to have it too and that the son will have to cure himself so that his wife and children will not burden father. Son removes himself, angry at father, Both die, father leaving money to children. Interpretive theme If one is sick with T.B. and father had the same illness, father selfishly rejects one. Diagnostic level Feels sick. T.B. is castration. Father also seen as previously sick, castrated. Feels rejected by father. Father seen as cold, narcissistic. One is angry at father. One dies, and father dies too, repenting too late. Wants father to feels sorry about not having been nicer to him. Aggression toward father. Oral wishes toward father. Clinical notes In several years of clinical work with tuberculars, we find that the fantasies of having T.B. are most frequently either those of being invaded (phallically) by the T.B. germs, particularly in an impregnation fantasy, and having holes made in one (i.e., being castrated, particularly in connection with hemorrhages [Bellak, 1952c]). The fact that the father has also had the illness suggests that patient tended to think of the father also as castrated and weak. Since the father was an identification figure, this may have influenced the subject's emotional growth. T.B. may also mean venereal disease here.

over his health. The that it can be cured e himself alone can . go away for a little me by saying that. I a wife and children , for your family will ncludes that he will a healthier climate. he does. After a few erhaps he left insur- ng heard from each state. This is his way Diagnostic level eels sick, T.B. is stration. ather also seen as reviously sick, cas- 'ate& eels rejected by fa- er. Father seen as ld, narcissistic. ggression toward ther. Oral wishes )ward father. aat the fantasies of ,d (phallically) by having holes made norrhages [Bellak,

g gests that patient the father was an tiona! growth. T.B.

THE BELLAK SCORING SYSTEM 119 Name Story No 5 (TAT Picture No. 7BM ) 1. Maintheme: () (If one) is sick with T.B. and father had the same illness, father selfishly rejects one. One is angry at father. One dies and father dies too, repenting too late. Wants father to feel sorry about not having been nicer to one. 2. Main hero: age adult sex Mvocation interests traits abilities adequacy (,/, ,//, /,/,/) 0 ? body image and/or self-imageless 3. Main needs of hero: a) behavioral needs of hero (as in story): H J an s rt because f b in iJ) dynamic inference: feels we k hel I s d ilit te r I needs b) figures, objects, or circumstances introduced." wi e ot er chi dren il hess eath mon

implying need for or to: heterosex ain ed -w ntin ar from arents-f r fillne sand ath c) figures, objects, or circumstances omitted: implying need for or to: 4. Conception of environment (world) as: cold, hostile, unaring 5. Parental figures (m__, f v/ ) are seen as cold, spec- and subject's reaction is_Withdrawal, anger Contemp. figures (m__, f ) are seen as ulating and subject's reaction is Junior figures (m__, f ) are seen as and subject's reaction is 6. Significant conflicts: Bodily concern (T.B.-full of holes? or is it syphilis?) Strong dependency needs. Aggression toward father. " 7. Nature of anxieties: (,/) of physical harm and/or punishment of illness or injury. of disapproval of deprivation of lack or loss of love of being devoured__ of being deserted of being overpowered and helpless other Of death 8. Main defenses against conflicts and fears: (,/) repression reaction-formation regression introjection denial __ undoing projective identification other

prection, withdrawal g. Severity Of superego as manifested by : (v) punishment for "crime" immediate__ just delayed_ unjust__ inhibit, ions ....... sta.m.,rne.r , delayed initial response or pauses sees n rnselt.a.s, fatally hu posip ies eca.,use or ,anje,r a,t,ta,,ther. 10. Integration of the ego, manifesting itsel in: (,/, ,/V, adequacy of hero O ? outcome: happy realistic solution: adequate thought processes as revealed by plot being: (,/, /,/, ,/,//) structured _ unstructured stereotyped original__ rational bizarre _ complete incomplete Intelligence: (,/) superior__ above average__ average__ below average__ Analysis Sheet for Use with the Bellak TAT Blank Cht 1951, Leopold Sellak rationalization__ isolation splitting too severe too lenient unhappy_ unrealistic inadequate appropriate__ inappropriate defective S 1-119AS The Psychologica Corporation

120 CHAPTER 6 Record themes and summarize other significant data for each story. 1. Feels a child, sick, poor body image. Feels coerced by parents. Mechanism of denial--re: masturbation? Resists authority by withdrawal into fantasy; urethral interests, exhibitionism (?), anhedonia (?). Delusional omnipotence (knowing what is in book without reading it)-severe thought disturbance and flat mood consistent with schizophrenia. 2. Great guilt over sex; feminine identification. Severe superego concerning also exhibitionism and ambivalence to sibling (or mother) seen as pure. Intra-aggression. Self-image: outcast, criminal. 3. Sexual guilt; social prejudice; punishment is rejection, poverty. Intra- and extraaggressivity. Urethral complex. Identifies with girl again, but may also say: women are bad, do this sort of thing, endanger one (in secondary identification). Possibility of suicidal and homicidal impulses. Unconscious fear of impregnation. 4. Aggression fused with sex. Triangular oedipal situation feels rejected by girl. Mother seen as phallic, aggressive, dangerous. "Sudden understanding" consistent with paranoid schizophrenic process. 5. Feels ill and helpless with T.B. full of holes? or syphilis? Father also seen as previously sick (castrated). Feels rejected by father. Father seen as cold, narcissistic. Aggression toward father. Oral wishes toward father. Sees self as fatally ill, disturbed body image.

THE BELLAK SCORING SYSTEM 121 Mechanism of :o fantasy; ure- . omnipotence ht disturbance go concerning seen as pure. ,rty. Intra- and but may also econdary iden- tconscious fear els rejected by mderstanding" aer also seen as en as cold, nat- Sees self as faEgo function assessment from TAT data:

--I Ego Functions (From Bellak, Hurvich, & Gediman, Ego functions in schizophrenics, neurotics, and normals. Copyright © 1973, by C. E S., Inc. Reprinted by permissiotx of John Wiley & Sons, Inc.) Ego functions observed during test istration:

122 CHAPTER 6 Case 2 Following are stories given by a young man in his middle twenties.13 We have chosen a few for illustration. At the time of the istration of the T.A.T. he was in a prison hospital. He had gone AWOL from the armed forces because he found it impossible to urinate in the presence of others, and others were always present in the latrines. When he was picked up by M.P.s, he made an inadequate gesture at aggression and was thereupon shot in the abdomen. These few data may suffice to highlight the dynamic material revealed with regard to homosexual problems, problems of voyeurism and exhibitionism, and the handling of the problem of aggression; the subject was just aggressive enough to invite almost suicidal counteraggression on the part of the armed military police. He was intelligent and industrious and came from immigrant stock. The T.A.T. was not istered by the writer, and unfortunately, story 1, the boy with the violin, was not included. ' We are indebted to Dr. Blaise Pasquarelli for this material.

THE BELLAK SCORING SYSTEM 123

ge have he was found .sent in 'e at ag- ffice to )blems, of ag- .nterag- adustriy 1, the BELLAK T A T BLANK For Recording and Analyzing Thematic Apperception Test Stories Name Sex Male Age 26 Date Education __ Occupation Arm riv t __ leferred by. Ana]vsis by FINAL REPORT Choosing just a few of the stories of the subject, one sees his pervasive feeling of inadequacy of his fear of being overpowered running through nearly all the themes. He sees himself either as a woman (#2, 3BM) or as too small (14). When he has aggressive or sexual desires he thinks of himself as bad, inadequate (#13 MF and 18BM). His needs appear as a need for autonomy (2, 7BM, 14), achievement, and an oedipal type of competitiveness allied to the partial sexual components of voyeurism and exhibitionism. His conception of the world is one of deprivation (2, 3BM, 14, 18BM), of being overpowered and harmed (2, 7BM), actually representing an image of his parents whom he tries in vain to stand up to. His main conflicts center around autonomy versus compliance, activity- ivity, and achievement-inadequacy, and he shows a great deal of anxiety of being overpowered and injured. His main defenses are emotional isolation, projection, and attempts at sublimation by intellectualization. His superego is extremely severe, leading to intra-aggression particularly concerning incestuous sexual wishes. The integration of the ego is inadequate in that the hero hardly ever succeeds, is usually unhappy, and frequently suicidal. The subject appears to be of above average intelligence. Impulse control of aggressive and intra-aggressive drives seems so poor that one must consider him potentially suicidal and homicidal, particularly in homosexual panic. The record is consistent with that of a borderline schizophrenic with paranoid features. Printed in U.S.A. Copyright 1947, © 1973. Leopold Bellak, M.A., M.D. All rights reserved as stated in the test manual and Catalog. Published by THE PSYCHOLOGICAL CORPOIATION. New York, New York 10017 73-262AS Note: In this final report, abstract statements are interspersed with brief references to relevant stories. This procedure may be profitable enlarged, giving the condensed theme or part of the story as an illustration for the abstract statement.

124 CHAPTER 6 2: What the hell could have happened before in this picture? I don't know... (resistance) .... I would say that this here girl has just come from school and that she has something on her mind which she wants to ask her parents .... That's her father and mother in the background--her father on the plow, and her motber leaning up against the tree. She has been brought up very strictly, and her parents probably are of European stock but... they are immigrants. She is being held down and doesn't live the normal life that a normal girl should. She is very intelligent and a good student. She probably has just graduated and wants to ask her parents.., or rather wants to talk.., she wants to go to college and she doesn't feel that her parents will approve it. Whether or not, she probably has assumed that when she has finished high school that that is as far as a girl should have to go, and what she is thinking now is that she should get married and settle down on the farm the way they did .... Her father is a successful farmer who can afford to send her to college.., but will refuse to do so. This girl is very ionate.., emotional.., and unless she is alllowed to go to college she will probably develop some physical ailment (snicker) .... But that her father refuses in the end to send her to college whereas.., strike out whereas .... They find her a... suitor who they think will be suitable for her, and plan to have her married .... Is this too long? . . . The father is willing to bestow a portion of his land and the money and materials for a home which they can build on the land .... (Long pause.) She is very unhappy, or rather let's say that they become married and she is very unhappy. She refuses to have any children.., because she doesn't want to bring them up in this backward atmosphere, knowing that her parents will try to bring up her children as they brought her up. Her husband is similar to her father in his attitude towards education and how to bring up a child .... He insists that she bear him a child and in time attempts to use physical force te throw a fear into her so that she will do what he will ask of her. She becomes hysterical and ends it all by committing suicide .... That's all! Descriptive theme A very strictly brought- up girl wants to go to college, but is afraid that her parents will be against it and will marry her against her will, which makes her sick and unhappy. %then her husband, who resembles her father, uses physical force to impregnate her, she becomes hysterical and commits suicide. Interpretive theme (If one) is a young, strictly brought-up girl and wants to be autonomous, the parents are against it and force one into a submissive situation to which one responds by unhappiness, (mental)- illness. When threatened with male sexual aggression (by paternal figure), one comrnits suicide. Clinical notes Diagnostic level Feels strictly brought up; need for autonomy, achievement. Parents seen as restricting, coercive. Feels unhappy, mentally ill, fearful of sexual aggression. Fear of pregnancy, of male sexual aggression. Identifies men too much with father, Suicidal tendencies. Father and contemporary males (husband) are completely equated in this story, in which the subject identifies so vividly with the female figure. There is some awareness of mental disturbance.

THE BELLAK SCORING SYSTEM 125 Cnow... (resis- at she has some- r and mother in ast the tree. She ,n stock but... fe that a normal ;t graduated and college and she las assumed that go, and what she rm the way they lege.., but will ;he is alllowed to • But that her fa- s .... They find er married .... d the money and .) She is very un- )y. She refuses to backward atmos- ught her up. Her )w to bring up a physical force to Les hysterical and )iagnostic level ls strictly ught up; need autonomy, ievement. ents seen as re- :ting, coercive. ls unhappy, ntally ill, fearful lexual aggres- _. r of pregnancy, aaale sexual ag- Ssion. Identifies n too much father. tidal tendencies. equated in this There is some Name Story No 1 (TAT Picture No. 2 .) 1, Main theme: (Inter) If one is a young, strictly brought up girl and wants to be autonomous, the parents are against it and force one into a submissive situation to which one responds by unhappiness and (mental) illness. When threatened with male aggression one commits suicide. 2. Main hero: age young adultsex F vocation student interests education traitsautonomy abilities intelligent adequacy (/, //, ///) / body image and/or self-image feminine; helpless 3. Main needs of hero: a) behavioral needs of hero (as in story): Education; autonomy: to do better than parents dynamic inference: curiosity: feelina of heINessness toward parents: competition with parents. b) figures, objects, or circumstances introduced:' college: money: pegnency: suicide. ' implying need for or to: intellectual achievement: suicidal tendencies: fear of impregnation. c) figures, objects, or circumstances omitted: pregnancy of the older woman leaning against the tree i not mentioned in the story_. implying need for or to: fear of pregnancy 4. Conception of environment (world) as: coercive: depriving: aggressive. 5. Parental figures (m /, f / ) are seen as above and subject's reaction is attempt at autonomy; Contemp. figures (m__, f ) are seen as __ and subject's reaction is intra- Junior figures (m__, f ) are seen as and subject's reaction is aggression 6. Significant conflicts: ctwcen autonomy and compliance; cxtra-agrcssion and intraaggrcssion. 7. Nature of anxieties: (,/) of physical harm and/or punishment of disapproval of lack or loss of love of being deserted other strong homosexual fears 8. Main defenses against conflicts and fears: (/) repression reaction-formation regression introjection denial undoing projective identification other prection intellectualization g. Severity of superego as manifested by : (,/) punishment for "crime" immediate just delayed unjust__ inhibitions stammer__ delayed initial response or pauses of illness or injury. of deprivation of being devoured of being overpowered and helpless rationalization__ isolation splitting __ too severe too lenient 10. Integration of the ego, manifesting itself in: (,/, ,/,/, ,/,/,/) adequacy of hero outcome: happy. realistic solution: adequate thought processes as revealed by plot being: (/, //, /,/,/) structured v/ unstructured__ stereotyped__ rational __ bizarre complete ,/ Intelligence: (,/) superior above average , average__ Ceoydght 1951, Leopold Bellak

unhappy unrealistic inadequate original__ appropriate incomplete inappropriate__ below average_ defective Analysis Sheet for Use with the Bellak TAT Blank S1-119AS The Psychological Corporation

126 CHAPTER 6 3BM: Well, I would say that this was a young girl who . . . is in love with a young man .... And they had some disagreement, and in this picture she has committed suicide.., so she is dead (snicker). I would say that the man distrusted her, or believed that she was unfaithful to him .... Oh yeah.., you might add in there what happened to her fianc& That after she committed suicide, that he was so stricken with grief that he, in turn, committed suicide .... That is a pistol by her on the floor.... I would say that she shot herself through the head .... That's all .... The awkward position she is in would indicate that.., she would not just be sitting there, or laying there like that .... I would say her fiancfi committed suicide the same way. I can't think of anything else to say .... I would say it is a woman because it looks feminine.., a little wide through the hips.., the long hair.., the large bust.., large legs .... That's all. Descriptive theme Two people are in love with each other, have a disagreement because the man distrusts her faithfulness. She commits suicide, and then he commits suicide too. Interpretive theme (If one) has a love affair, one cannot trust the faithfulness of the loved one. This leads to disagreement and intra- and extra- aggression. Diagnostic level Sexual needs; distinct triangular oedipal theme; jealousy. Intra- and extra- aggression. Clinical notes Probably both are identification figures for the hero, since in the last few lines subject feels the need to give reasons for the feminine identification of the depicted figure.

THE BELLAK SCORING SYSTEM 127 th a young tmitted sui- elieved that ened to her he, in turn, tat she shot would indi- I would say • . I would • . the long ;tic level ',eds; dis- gular oedi- .; jealousy. 1 extra-

st few lines te depicted Name__ Story No. 2 (TAT Picture No. 1. Main theme: () (If one) has a love affair one cannot trust the faithfulness of the loved one. This leads to disagreement and intra- and extra-aggression. 2. Main hero: ageNex Fvocation none noted interests rLQEP traits non noted abilities adequacy (,/, ,/,/, ./,/,/)O body image and/or selfimage feminine 3. Main needs of hero: a) behavioral needs of hero (as in story): o b Iov • res i I'1 dynamic inference: nsion' edi I inv Ivement b) figures, objects, or circumstances introduced: om etitive real s implying need for or to: interests c) figures, objects, or circumstances omitted.'__ implying need for or to: 4. Conception of environment (world) as: • . untrustworth.y 5. Parental figures (m__, r --7 are seen asand sueject's reaction is Contemp. figures (m.., f._) are seen as,and subject's reaction isression and intra- Junior figures (m__, f__) are seen as__ and subject's reaction is a_gression 6. Significant conflicts: Between need for love and fear of a ression' feelin of inade uac __ 7. Nature of anxieties: (/) of physical harm and/or punishment__ of illness or injury of disapproval_ of deprivation of lack or loss of Iove of being devoured__ of being deserted_ of being overpowered and helpless____ other stron homoxu le ars 8. Main defenses against conflicts and fears: (,/) repression__ reaction-formation__ rationalization __ isolation regression__ introjection__ denial__ undoing__ splitting__ projective identification__ other 9. Severity of superego as manifested by : (,/) punishment for "crime"__ immediate just___ too severe delayed unjust__ too lenient inhibitions__ stammer__ delayed initial response or pauses__ 10. Integration of the ego, manifesting itself in: (v/, //, ///) adequacy of hero__ outcome: happy unhappy realistic__ unrealistic__ solution: adequate inadequate thought processes as revealed by plot being: (,/, /,/, //,/) structured___ unstructured__ stereotyped__ original__ appropriate___ rational bizarre__ complete incomplete__ inappropriate__ Intalligence: (/) superior__ above average__ average below average___ defective_ Analysis Sheet for Use with the Bellak TAT Blank Copyright 1951, Leopold Bellak $1-119AS The Psychological Corporation

128 CHAPTER 6 7BM: In this picture I would say that the younger person is a student who is . . . who is holding some political theories and he is fanatical about them .... That the older person is probably, I would say, his father, or professor, or teacher, or whatever you want to call him .... I would say that it is his father.... His father is telling him to give up his wild ideas about the government, but he refuses to give in .... The student is in favor of radical changes in society due to some ideals he is holding .... The son will probably.., well here • . . because of his political views will wind up in prison, or become killed . . . in some public forum somewheres where he is trying to arouse the masses more or less .... (Long pause.) But anyways, in the end he will learn that he should have listened to his father.... That's all .... I would say that he is just a reformer, that's all .... I would say he is against capital.., don't know, I think this is silly myself . . . (snicker). Descriptive theme A young student has radical ideas and will wind up in prison or be killed for them, repenting that he did not follow his father's advice to give up such ideas. It's all silly. Interpretive theme If one has aggressive ideas against authority, one is severely punished and repentant. Should comply with father figure. Tries to laugh it off. Diagnostic level Aggression against authority, particularly , male figures. Severe superego. Need for compliance with males. Rationalization, isolation. Clinical notes This story illustrates nicely that it is not merely psychoanalytic imagination which considers the government as a parental figure or, in this case, a paternal one, since the subject equates them easily, suggesting that the source of his political ideas also has a parental origin. Again, the snickering is probably used for defensive purposes to dispel the tension. Name 1. Main I punish 2. Main 3. Main a) b) c) 7. Nature of of of 8. Main 9. Severlty inhi 10.

THE BELLAK SCORING SYSTEM 129 ahois . . .who tt the older per- you want to call give up his wild t favor of radical bly.., well here • . in some pub- ess .... (Long his father.... say he is against :level [ainst au- ularly go. Need :e with alizadon, ic imagination paternal one, 0f his political d for defensive Name__ Story No 3 (TAT Picture No. 7BM 1. Main theme: () If one has aggressive ideas against authority one is severely punished and repentant. 2. Main hero: ageNex vocationitator interests rebellion __ traits wild abilitiested adequacy (,/, /,/, /,//) body image and/or self-image unsuccessfulradical 3. Main needs of hero: a) behavioral needs of hero (as in story): a ression'revolt a ainst f ther dynamic inference: u res b) figures, objects, or circumstances introduced: implying need for or to: concern with uthorit ' evere su ere o c) figures, objects, or circumstances omitted:_ implying need for or to:__ 4. Conception of environment (world) as: ' • ' .'. ' . . §. Parental f gures (m__, f) are seen as2OJY_,]; and subject's rea;lon isr Contemp. figures (m__, f__) are seen as and subject's reaction is__ Junior figures (m__, f__) are seen as and subject's reaction is 6. Significant conflicts: between autonom_v fused with a__gression and compliance 7. Nature of anxieties: (/) of physical harm and/or punishment of illness or injury. of disapproval of deprivation__ of lack or loss of love of being devoured. of being deserted of being overpowered and helpless other. 8. Main defenses against conflicts and fears: (,/) repression__ reaction-formation__ rationalization____ isolation regression__ introjection__ denial__, undoing__ splitting projective identification__ other with cnem_ 9. Severity of superego as manifested by : (,/) punishment for "crime"_ immediate just__ too severe delayed unjust__ too lenient ____ inhibitions__ stammer delayed initial response or pauses__ 10. Integration of the ego, manifesting itself in: (/, ,/,/, //,/) adequacy of hero outcome: happy unhappy_ realistic__ unrealistic____ solution: adequate__ inadequate thought processes as revealed by plot being: (,/, ,/,/, ,//,/) structured unstructured___ stereotyped__ original__ appropriate__ rational bizarre complete incomplete__ inappropriate__ Intelligence: (,/) superior__ above average average__ below average__ defective__ Copyright 1951, Leopold Bellak


130 CHAPTER 6 13Mr: This is a young man who is going to the local university.., a student .... He is very moralistic . . . that is, very virtuous . . . having a highly developed sense of what is right and what is wrong. He is also very religious .... He has been brought up very strictly and believes that one of the greatest sins that man can commit is to have sexual intercourse with a woman out of wedlock .... One evening, at a party, for some unknown reason, having taken too many drinks and feeling slightly lightheaded, he became very intimate with one of the girls present. He... his animal instincts came to the fore and he abandoned all his ideas of virtue, etc. He took this woman up to his room and went to bed with her. The next morning, after becoming sober and having regained his virtuous sense.., or whatever you want to call it... he looked over and saw this woman beside him in utter nakedness. He was filled with anger, and wild.., let's see (murmurs to himself).., and bitter ion at what he had done. A profound hatred swelled up in his chest for this woman that lay next to him. He ordered.., she by this time had become awake.., and he ordered her to leave his room .... She, not understanding what has brought this attitude of his about, believed that he was joking, and refused to leave in a jocular manner.... This man could think of nothing but to clear himself of this sin he had committed . . . cleanse himself of this sin .... And as this woman lay there laughing, and being overcome with his guilt, he seized her by the throat and strangled her.... Rising from the bed, and putting on his clothes, he became . . . he realized his predicament. He not only had committed a sin.., a moral sin.., but he had committed a greater sin by taking her life .... He gazed down as she lay there at her statuesque stillness and was filled with remorse. Remenbering a few days earlier.., that a few days earlier he had bought a bottle of iodine, and which was now in the cabinet of the washroom, he went there and gulped down its contents (laughs) and consequently died. That was the end of that .... I just said that he strangled her because she was laying in bed next to him, and that was the easiest thing he could have done, by reaching over and grasping her neck. Descriptive theme A virtuous, moralistic, religious, strictly brought up student, who considers sexual intercourse a great sin, takes too many drinks and is intimate with a girl. Later he is very angry at her, tells her to leave, and when she refuses, stran- gles her. Filled with remorse, he kills himself by swallowing poison. Interpretive theme If one is extremely moralistic, one considers sex a great sin which can only be committed under the influence of liquor. Thereafter one is angry at the woman, kills her and oneself, remorsefully in turn, by swallowing poison. Diagnostic level Feels extremely moralistic. Severe superego. Strong guilt feelings about sex. Need for liquor. Strong oral needs. Rationalizes. Projects (anger) on the woman. Impulse-ridden (it was the easiest thing he could have done). Strong intra- aggression. Oral needs. Main hero Main dynami b) figures, C) figures, 4o 5. Parental f Contemp. Junior fig, 6. 7. Nature of of phys of of of other_ 8. 9. Severity c punishr 10. Integrati adeque thou structul Intelligence: Clinical notes This story repeats both the orality and the fear of degeneration, as well as the strict superego. When tendencies recur several times in a story, such as oral needs in relation to drinking liquor, and again in the method of suicide, it can usually be considered an indication of the intensity of the problem. Copyright 1951,

THE BELLAK SCORING SYSTEM 131 , . He hat is a-ictly purse with ed all : The tever ]hess. lssion , next , leave lieved think )f this [lt, he )n his ted a gazed >ering :h was mghs) ler be- done, el re bout !quor. eds. ) on , (it thing

,tone). as the needs ally be

Name. Story No. 4 (TAT Picture No 13MF 1. Main theme: (Inter) If one is extremely moralistic, one considers sex a great sin which can only be committed under the influence of liquor. Thereafter one is angw at the woman, kills her and oneself, remorsefully in turn, by swallowing poison. 2. Mein hero: agetsex vocation studen interested__traits virtuous abilities none noted adequacy (,/, ,/,/, /,/,/)O body image and/or selfimage moralistic'_enerate 3. Main needs of hero: a) behavioral needsof hero (asin story): rinkin 'wm n' reion' intra-a ression. dynamic inference: oral needs' vr u ere o' stron a ression b) figures, objects, or circumstances introduced: iodine implying need for or to: oral needs c) figures, objects, or circumstances omitted:. implying need for or to: 4. Conception of environment (world) 5. Parental figures (m__, f__) are seen as__ and subject's reaction is__ Contemp. figures (m__, f) are seen as and subject's reaction iS2LC_ Junior figures (m__, f__) are seen as__ and subject's reaction is. 6. Significant conflicts: between need for sex and extra- and intra-a&grcssion 7. Nature of anxieties: (V') of physical harm and/or punishment__ of illness or injury of disapproval of deprivation, of lack or loss of love of being devoured of being deserted __ of being overpowered and helpless other [ n r I m [ n 8. Main defenses against conflicts and fears: (,/) repression__ reaction-formation__ rationalization isolation regression__ introjection denial_ undoing__ splitting __ projective identification__ other 9. Severity of superego as manifested by : (,/) punishment for "crime" immediate just__ too severe delayed unjust__ too lenient ____ inhibitions____ stammer__ delayed initial response or pauses_ 10. Integration of the ego, manifesting itself in: (/, ,/,/, ///) adequacy of hero outcome: happy unhappy_ realistic__ unrealistic__ solution: adequate inadequate thought processes as revealed by plot being: (/, ,//, ///) structured unstructured__ stereotyped__ original__ appropriate__ rational bizarre____ complete incomplete__ inappropriate__ Intelligence: (/) superior__ above average.__ average__ below average__ defective__ Copyright 1951. Leopold Bellak Analysis Sheet for Use with the Bellak TAT Blank $1-119AS The Psychological Corporation

132 CHAPTER 6 The most ominous feature of this story is the afterthought that he strangled her because "this was the easiest thing he could have done." Together with the realistic detail and the obsessiveness, it suggests that homicidal impulses are not far from the surface in this man. 14: Well, I'd say that this takes place in Paris,just for the heck of it .... That the papers have announced that there will be a... I would say that there will be . . . there will be meteors shooting across the sky on this date. This here person is a man . . . is watching.., shall we say astral displays .... The room he is in is his bedroom and he has put the light out to make it easier for him to see what is going on .... He watches for about 15 minutes, closes the window, puts the light on, and gets undressed and goes to bed .... And that's the end of that! . . . (resistance) .... The way the window opened up, I always imagined that windows like that were to be seen in Paris .... I would say that before he went to the windows he was laying on the bed, reading a book, until the time came around at which time the newspapers said that meteors would be seen shooting across the sky.... I would say that he is more or less of an amateur astronomer and that he has a great interest in the universe and.., let's say.., maybe we can make something out of this after all.., that he is working on some small job which has no future.., that he has always been interested in astronomy, but due to the fact that his parents did not have the resources with which to send him to school, that he could not further his education in that field . . . (resistance) .... He has some knowledge of the stars, and this display fascinates him and only makes him yearn for that education he might have had.., that's all! Descriptive theme A young man in a bedroom in Paris at night is watching meteors appearing according to schedule and feels small in comparison. This makes him yearn for education which the parents were too poor to give him. Interpretive theme If one watches big things at night appearing according to schedule, one feels small in comparison and feels that parents should have given one more (education). Diagnostic level Patient has witnessed primal scene frequently and has felt insignificant in relation to his father, and blames his parents for not having equipped him better genitally. Information and education are given phallic significance as a powerful tool. Clinical notes Paris probably means sex, as in the minds of so many. The meteors probably represent a big phallus. The reference to putting the light out to make it easier to see may well relate to the fact that patient would watch what was going on between parents when it got dark. The window is probably a reference to the female sexual organ and expresses the patient's notion that such (sexual) things would only go on in other dirty places, not in the parental home. He already knows what is going to happen from past experience (the newspaper) and feels himself but an amateur working in a small job (penis) and that it is his parents' fault that they did not equip him better. Name__ 1, Main t OrlC f( 2, Main I int ade 3. Main, a) be dyr to) figL C) figul mpl 4. Conce §. Parent Conte Junior 6. Signifi 7. Nature of pl of di of la of b othE 8. Main d repr regr pmi 9. Severi puni inhib 10. Integn adeq thou! struc ratim Intelligent

THE BELLAK SCORING SYSTEM 133 Name. Story No 5 (TAT Picture No. 14 1. Main theme: () If one watches big things at night appearing according to schedule, one feels small in comparison, and feels that parents should give one more (education). 2. Main hero: agesex Mvocation amateur astr nomer interestsastron m edu ation traitsabilities none noted adequacy (,/, /,/, ,/,/,/)_ body image and/or self-image small'not havin enou h 3. Main needs of hero: a) behavioral needs of hero (as in story): towatch't ac uire edu ation dynamic inference: vo urism' exhibitionism, sexual roblems' ur thral roblems" to be owerful b) figures, objects, or circumstances introduced. Paris'meteors' arents' nws a er implying need for or to: sex' r blem in relation to arents' vo eurism news a er • interest d c) figures, objects, or circumstances omitted: implying need for or to:__ 4. Conception of environment (world) as: ' ' ' ' ' ' ' 5. Parental figures (m, f,_) are seen as and subject's reaction is_ Contemp. figures (m__, f__) are seen as__ and subject's reaction is Junior figures (m__, f__) are seen as__ and subject's reaction is 6. Significant conflicts: between need for achievement and feelin 7. Nature of anxieties: (,/) of physical harm and/or punishment of illness or injury_ of disapproval_ of deprivation of lack or loss of love of being devoured of being deserted of being overpowered and helpless. other 8. Main defenses against conflicts and fears: (/) repression__ reaction-formation rationalizationS__ isolation____ regression__ introjection__ denial_ undoing__ splitting__ projective identification__ other 9. Severity of superego as manifested by : (/) not noted punishment for "crime" immediate__ just____ too severe delayed unjust__ too lenient inhibitions_____ stammer__ delayed initial response or pauses 10. Integration of the ego, manifesting itself in: (,/, //, adequacy of hero outcome: happy unhappy_ realistic unrealistic__ solution: adequate inadequate thought processes as revealed by plot being: (/, ,/,/, V'/,/) structured unstructured__ stereotyped __ original__ appropriate__ rational bizarre complete incomplete__ inappropriate__ Intelligence: (/) superior__ above average average__ below average__ defective__ Copyright 1951, Leopold Bellak


134 CHAPTER 6 18BM: This is a young man and he was formerly a successful lawyer. Then due to bad habits.., such as women and liquor.., he began to... let's see.., his gan to . . . degenerate. Uh... He is married and his wife is beginning to On this particular night he has.., he is in a barroom and has become quite intoxicated, l is time for the.., business to close and the bartender is helping him on with his coat. man is stupified and doesn't know what is happening. The bartender, not caring pens to him, escorts him to the door and leads him out to the street.., wher, enly walks, not knowing where is going, and finally winds up sprawled out on the where he is picked up by the police and spends the night in the city jail... (snickers). wife, knowing that he is in jail . . . that is, having been informed that he is in the jail, but refuses to pay his fine, or to aid him in any way whatever . . . (laughs). comes melancholy, and when he is finally let out of jail . . . knowing that he is.. are we? . . . let out of the jail? . . . knowing that he has been overcome by condition, he decides to depart.., to desert his wife and the city that he is in, and to go to another city to begin life anew .... That's the end of that! Descriptive theme A formerly successful young lawyer degenerates because of bad habits (women and liquor), and his wife turns against him. He is intoxicated in a bar, and an uncaring bartender sends him out and he is put in jail. His wife refuses to aid him, and he leaves the city to start life anew. Interpretive theme If one indulges in bad habits such as liquor and women, one degenerates, is rejected by one's wife and others, punished, becomes depressed, withdraws, but starts anew. Diagnostic level Feels himself a degenerate because interest in liquor and women. Feels rejected by male and female figures. Severe superego. Depression, withdrawal, counteraction. Oral needs. Clinical notes "Bad habits" refer most frequently to masturbation and resultant guilt. story shows at least a spark of health, in that the hero tries to begin life anew, though it is not told in any convincing detail.

THE BELIAK SCORING SYSTEM 135 Name__ Story No. (X/k3- Picture No. W) 1. Main theme: () if one indulges in bad habits such as liquor and women, one degenerates, is rejected by one's wife and others, is punished, becomes depressed, withdraws, but stars life anew. - with women Main hero: ageLJ_tsex M vocation interestsr traitsbilities adequacy (/, ,/,/, ,/,/,/) "/ body image and/or self-imagete Main needs of hero: a) behavioral needs of hero (as in story):ns with worn n' ounter-ac i n. __ dynamic inference: v nter-acti n assivit b) figures, objects, or circumstances introduced: wi" ther w m n'li uorail implying need for or to: oral n sand sever s ere o. c) figures, objects, or circumstances omitted: implying need for or to:__ 4. Conception of environment (world) as: ' ' ' ' ' ' 5. Parental figures (m__, f__) are seen as____ and subject's reaction is Junior figures (m__, f__) are seen as__ and subject's reaction is_ counter actnq 6. Significant conflicts: and counter-action. Sex and su e 7. Nature of anxieties: (,/) of physical harm and/or punishment of illness or injury of disapproval of deprivation__ of lack or loss of ove __ of being devoured__ of being deserted __ of being overpowered and helpless__ other 8. Main defenses against conflicts and fears: (,/) repression __ reaction-formation rationalization isolation____ regression_ introjection denial___ undoing__ splitting projective identification___-- other 9. Severity of superego as manifested by : (,/) not noted punishment for "crime"__ immediate__ just__ too severe_ delayed unjust__ too lenient inhibitions stammer delayed initial response or pauses__ 10. Integration of the ego, manifesting itself in: (,/, /,/, ,/,/,/) adequacy of hero_ / _ outcome: happy_ unhappy realistic _ / unrealistic ____ solution: adequate inadequate thought processes as revealed by plot being: (,/, //, ,//,/) structured unstructured stereotyped __ original__ appropriate rational__ bizarre complete____ incomplete__ inappropriate Intelligence: (,/) superior__ above average average__ below average__ defective___ Analysis Sheet for Use with the Bellak TAT Blank Copyright 1951. Leopold Sellak $1-119AS The Psychological Corporation

136 CHAPTER 6 Summary Record themes and summarize other significant data for each story. 1. Feels strictly brought up; need for autonomy, achievement. Feminine identification feels helpless. Fear of pregnancy. Suicidal tendencies. Strong homosexual fears. Extra- and intra-aggression. Parents seen as restrictive, coercive. Feels unhappy, physically ill. 2. Sexual needs; distinct triangular oedipal theme; jealousy. Intra- and extra- aggression. Homosexual interests. Severe superego. 3. Aggression against authority, particularly male figures. Severe superego. 4. Feels extremely moralistic. Severe superego. Strong guilt feelings about sex. Need for liquor. Strong oral needs. Rationalizes. Projects (anger) on the woman. Impulse-ridden (it was the easiest thing he could have done). Strong intra-aggression. Oral needs. 5. Patient has frequently witnessed primal scene and has felt insignificant in relation to his father, and blames his parents for not having equipped him better genitally. Information and education are given phallic significance as a powerful tool. Voyeurism. Conflict between need for achievement and feeling of inadequacy. 6. Feels himself a degenerate because of interest in liquor and women. Feels rejected by male and female figures. Severe superego. Depression, withdrawal, counteraction. Oral needs.

THE BELLAK SCORING SYSTEM 137 .ne identi- ;trong ho- tive, coermd extra;rego. bout sex. r) on the e). Strong :ant in re- t him bet- :ance as a :and feelFeels re- ithdrawal, Ego function assessment from TAT data: 10, 9 8 7 6 5 4 3 2 1 Ego Functions (From Bellak, Hurvich, & Gediman, Ego functions in sdizophrenics, neurotics, and normals. Copyright © 1973, by C. E S., Inc. Reprinted by permission of John Wiley & Sons, Inc.) Ego functions observed during test istration:

138 CHAPTER 6 Case 3 E.O. is a married man of 25 who came with marital difficulties as his chief complaint. He and his wife were of different religions, although this did not enter into the problems except for some difficulties with the in-laws on both sides. Both families, however, were several thousand miles away. The subject had suffered from depressive episodes of borderline nature and also from premature ejaculation. He had no specific complaints against his wife except that she was not a very good sexual partner, but he did have serious questions concerning his preference for another girl. It became clear dynamically that the other girl was probably a representation of a sister two years older than he and, in the long run, an image of his mother. Together with his ambivalence toward his wife went considerable jealousy (apparently unfounded) concerning her feelings toward other, usually older, men. At times the relationship to the wife was a clearly competitive one, with him equip- ping her in his fantasy with masculine features. She was in the entertainment field and he was a professional athlete. The patient responded favorably to a 6-months' course of psychotherapy. Final diagnosis: cyclothymic personality with some tendency towards a borderline manic-depressive syndrome and pronounced narcissistic features. For Case 3 we are using the Short Form (see also Chapter 16). The Short Form, as mentioned, is especially useful for the working clinicians. They are likely to make themselves brief notes in their personal shorthand, for which the space provided will usually suffice. In print, for public consumption, it is impossible to put all the necessary observations into the boxes. Therefore, the diagnostic theme also appears below each story, and only token references to it show in the boxes of the Blank. The same limitations of printing versus personal notes limit the utilization of the other spaces in the Blank. For the didactic purposes of this book, we are also reproducing the individual pages of the Long Form to allow the space necessary for printing some of the comments which might otherwise be personal abbreviations. Furthermore, also for didactic reasons, we chose some stories which by their richness allow more than an average of observations. For those whose personal style runs counter to the small space provided in the Short Form, the Long Form remains the ideal record. Note: All three final reports have been kept fairly brief in the interest of conciseness and because experience has shown that much longer reports are found objectionable by psychiatrists and others. Some T.A.T. workers may prefer a more rigid organization of the final report, under the specific headings referred to under "summaT," namely, unconscious structure and needs of subject, conception of world and of significant figures, significant conflicts, nature of anxieties, main defenses against conflicts and fears, severity (and integration) of superego, integration of ego, diagnostic impression (this record is consistent with . . .).

THE BELLAK SCORING SYSTEM 139 as his chief id not enter sides. Both ffered from :ulation. He :ry good sex- once for an- a represen- mage of his ble jealousy older, men. a him equip- inment field ychotherapy. a borderline i. The Short aey are likely ch the space ssible to put ic theme also boxes of the utilization of he individual e of the com- e, also for di- nore than an • ovided in the

SHORT FORM BELLAK T.A.T. and C.A.T. BLANK For Recording and Analyzing Thematic Apperception Test and Children's Apperception Test Name Education Referred by. High School Sex M Age 25 Date (circle one) --OccupationPr°fess i°nal Athlet,em. s. w. d. Analysis by After having obtained the stories analyze each story by using the variables on the left of Page 2. Not every story will furnish information regarding each variable: the variables are presented as a frame of reference to help avoid overlooking some dimension. When all ten stories have been analyzed it is easy to check each variable from left to right for all ten stories and record an integrated summary on page 4 under the appropriate headings. That way a final picture is obtained almost immediately. Then, keeping Page 4 folded out, the Final Report: Diagnostic Impressions and Recommendations can be written on Page 1 by reference to Page 4. Page 5 gives available space for any other notations. The stories then can be stapled inside the blank against page 5. FINAL REPORT: Diagnostic Impressions and Recommendations deprivation and aggression, as seen n stories 2, 13MF, and 18BM. He has a need to express his aggression, but there is a strong conflict in this regard and he frequently turns the aggression against himself (as in 18BM). His oral needs are very pronounced, manifesting themselves in a need for acquisition of money and fame (i, 2, 13MF). He sees the patena! figure as aggressive and depriving. Contemporary male figures are seen as competitive, and there is a strong homosexual interest in them. Maternal figures are seen with considerable ambivalence and guilt over his aggressive feelings toward them, and also with strong oral ,demands toward them. His main conflicts center around activity ivity, the expression of aggression, and the expression of his oral demands. He shows distinct fears of physical harm and and loss of love. His main defenses are reaction formation (stories 2, 6BM, 13MF, 17BM, and 18BM) and denial (i, 6BM, and 18BM). Me has an extremely severe superego. This man's extreme narcissism is highlighted in stories 1 and 17BH. His only real need for people seems to be in their capacity as an audience. His exhibitionistic needs thus seem considerably stronger than his heterosexual needs (this is particularly clear in story 17BM, where he states that his interest is not in the girls per se but merely in their acltiration of his prowess). Certainly his strong oedipal attachKtent impairs his heterosexual adjustment quite severely. Ego strength is of such a nagure as to enable him to tell structured, rational stories with, on the whole, perfectly adequate solutions. Me deals well enough with reality problems but employs many pathogenic defense mechanisms in order to achieve some equilibrium, especially denial. He appears to be of above average intelligence with a great deal of verbal facility (approaching the verbose), inspiration, and considerable superficial affect. The dynamic and ego psychological p£cture is consistent with an affective disorder without manifest psychosis. The combination of orality, low self esteem, and aggression against himself suggests some feelings of depersonalization, but they do not appear marked enough to constitute serious suicidal problems. Dynamic psychotherapy centering on the problems highlighted above should offer very good chances for considerable improvement and some structural changes.

md because expe-

nd others. Some icific headings re-

I

ception of world nst conflicts and n (this record is

Printsd in U.S.A. Copyright 1955 Published by Leopold Bellak, M.A., M.D. C.P.S. Inc. P.O. Box 83 Larchmont, N.Y. 10538

140 CHAPTER 6 1. Main Theme: (diagnostic level: if descriptive and interpretative levels are desired, use a scratch sheet or page 5) musical genius 2. Main hero: age 10-11 sexM vocation__ abilities interests__traits__ body image f.elin em adequacy (, /, JJ,/) and/or self-image 3. Main needs and drives of hero: a) behavioral needs of hero (as in story): t b nius implying: r m i ian bef mous b) figures, objects, or circumstances introduced: unseen ins r men s m n fame implying needier or to: f n s r

tificati n isti strivin nee f r fin n i I n th rs e s c) figures, objects, or circumstances omitted." eo le la in the instr m n s r v n n ien e implying need for or le: n rcissistic ratific tin 4. Conception of environment (world) as: m ' 5. a) Parental figures (m__, f__) are seen as and subject's reaction to a is b) Contemp. figures (m__, f__) are seen as. and subject's reaction to b is c) Junior figures (m__, f__) are seen as__ and subject's reaction to c is. Story No. 1 Story No. 2 Picture 2 Dissatisfied Wants to do with life. better than Fantasizes. family, Adequate on Female 19. manifest level. Student Feeling of failure, Need for autonomy. of emptiness. Oral needs. Money Success. Succorance. Reassurance. Pregnancy of older woman. Repression of sexual themes giving Restrictive 6. Significant conflicts: w r I' f Contradiction of eking out" and ff n f r hi i h' ' lentiful food 7. Nature of anxieties: (,/) of physical harm and/or punishment of disapproval of lack or loss of love__of illness or injury of being desered__of deprivation__ of being overpowered and helpless. of being devoured__othertiness Mentions "no people." Doesn't realize he is wealthy and famous. Thought processe- intact. Good intelligence 8. Main defenses against conflicts and fears: (,/) some secondary repression __ reaction-formation regressiondenial "ntrojection__ isolation_ undoing rationalization__other i f n projective identification__ splitting 9. Adequacy of superego as manifested by "punishment" for "crime" being: ( ) appropriate inappropriate__ too severe (also indicated by immediacy of punishment). inconsistent too lenient also: delayed initial response or pauses stammer__ other manifestations of superego interference__ 10. Integration of the ego, manifesting itself in: ( ,/,/, v/,//) Hero: adequate / - inadequate outcome: happy unhappy realistic__ un realistic drive control thought processes as revealed by plot being: (,, //, ///) stereotyped __ originalappropriate complete incomplete__ inappropriate syncretic__ cortcrete__contaminated Intelligence Maturation level 2 Reaction-formation. Denial, Adequacy Happy Realistic Thought processes appropriate and structured Superior intelligence

Story No. 2 Picture 2 Wants to do better than family. Female 19. Student Need for autonomy. Oral needs. Money Success, Succorance. Reassurance. Pregnancy of older woman. Repression of sexual themes Poor, but giving opportunity _ Restrictive Contradiction of ;king out" and lentiful food Reaction -formation. Denial, Story No. 3 6BM Attachment to mother coictng with matal adjustment. Young, indecisive male, To please mother and wfe. Dependence on female. Problems with wife. Fear of phallus. Demanding, __ Mother-nagglng, poor, omnipotent, aggressive Anger. Remorse. Pas__sivity. Between mothe Story No. 4 13MF Feels deprived orally. Male student, to help wife make money Implying: curiosity, nurturance. Acquisition. Poverty, Illness. Remorse shown.

THE BELLAK SCORING SYSTEM 141 Male athlete. Seen as skinny and funny. Competitiveness. Story No. 5 Story No. 6 Story No. 7 17BM 18BM Body narcissism, Need for verbal Exhibitionism. aggression. Young male. Labor leader. Second man. Girl. Audience

I Implying strict conscience.

r

beating. Masochism.

Story No. 8 Aggression to mother. Problem with male authority.

Cmpet

Parents seen as aggressive. Revolt. Reaction: aggressive-ive Aggression. Physical harm. Fantasies. Punishment. Guilt over anger Deprivation. toward mether. Being helpless Fear of disapproval and overpowered. Loss of love. Fear of lack or Fear of physical loss of love. harm and unishment and Denial. Rationalization. Projection. Projection. Denial. Adequacy Happy Realistic WW Thought processes appropriate and structured Superior intelligence Immediate. Too severe. Happy Unhappy Realistic Inadequate Thought processes Thought processe complete, structured and complete. Immediate. Too severe. Realistic Happy Unhappy W Realistic Inadequate W Adequate W Thought processe Thought processes structured and complete, structured and complete.

142 CHAPTER 6 Story No. 9 Story No. 10 SUMMARY 1-3. Unconscious structure and drives of subject (based on variables 1-3 A markedly oral, ive person of low self-esteem and high aspirations who reacts with a mixture of exhibitionism and mostly (secondary) narcissistic withdrawal, with similarly alternating depressive and elated moods. 4. Concel:)tion of world: As depriving, restrictive, aggressive. Wishes it to be his audience. 5. Relationship to others: Need for anaclitic, oral relationships. Wants to be ired and may experience some alienation. Often quite narcissistic. 6. Significant conflicts: Between ivity and activity. Desire to be taken care of and its denial. Between aggression and superego. 7. Nature of anxieties: Of emptiness, of inadequacy, of failure, of deprivation, and of his own (oral) ivity and homosexual concerns. 8. Main defenses used: Reaction-formation, Denial. Rationalization. Mood swings are result of relative weakness of defenses. 9. Superego structure: Consistently severe. 10. integration and strength of ego: Thought processes intact. Defenses rather weak but not enough so as to impair reality testing or judgment. Autonomous functions good. Impulse control good enough to avoid acting out Some creative ability. Little sense of competence, or self-esteem.

THE BELLAK SCORING SYSTEM 143 on variables 1--3 piatns wo narcissistic oods. /ishes it to be Wants to be ssistic. ;o be taken care deprivation,

Ego function assessment from TAT data: 13 12 11 10 9 8 7 6 5 4 3 2 1 Ego Functions j (From Bellak, Hurvich, & Gediman, Ego functions in schiz#phrenics, neurotics, and normals. Copyright © 1973, by C. E S., Inc. Reprinted by permission of John Wiley & Sons, Inc.) Ego functions observed during test istrations: |merit. acting out.

144 CHAPTER 6 Record themes and summa6ze other significant data for each story. 1. Feels like a 10 year old boy. Dissatisfied with his life. Feels own shallow affect (poor sexual performance? mild depersonalization?). Denies being temperamental. Switches from activity to grandiose fantasies of fame in a narcissistic way. Denies interest in money. Defenses; regression, denial. 2. Need for autonomy, self-improvement. Wants to do better than family. Family seen as restrictive, later proud of one's success. Need for success, including money. Wish-fnlfillment fantasies, rescue fantasies re mother. Need for nurturance, oral needs. Defense: reaction-formation. 3. Has attachment to mother, conflicting with marital adjustment. Projects own aggression toward mother on wife, rationalizing. Mother seen as nagging, poor. Identifies himself with child. Guilt over anger toward mother. Fearful fantasies of aggression (fellatio). Mother seen as omnipotent. Can feel peaceful only if conflict between attachment to mother and wife (and ambivalence toward both) is resolved. Defenses: reaction-formation, denial. 4. Feels deprived orally. Aggression against wife. Projection. Unconscious guilt feelings. Need for acquisition (money), for security. Guilt. Defenses: reaction formation, rationalization, projection. 5. Great body narcissism; exhibitionism. Little heterosexual interest. Homo- sexual competitiveness. Great stress on being thought entertaining. Feeling of inadequacy. Defense: reaction-formation. 6. Need for aggression denied. Sees female figure (mother?) as being against aggression, against authority. Authority is seen as depriving (inviting aggression- masochism). Severe guilt feelings. Socially acceptable aggression permissible (after self-punishment). Defense: reaction-formation. o to c( not

very sad in in th cons ev(ll 10.

THE BELIK SCORING SYSTEM 145 Story 1 1: This young lad of 10 or 11 years does not know that he is a genius of the music world to come--via his violin. He has been practicing a piece of music. This particular piece does not please him. He isn't temperamental--but he puts down his violin and stares at the music-it's emptiness--just a cute little melody--no feeling --no warmth--no excitement--just an empty melody. As he sits there--he starts--in his mind--to fix it up the way he feels it should have been written--and the melody is going through his head. The way he sees it, it's very sad, but beautifully so .... And as he goes further on . . . different instruments in--and very soon he has a whole orchestra in the background with the violin crying out its sad and beautiful melody--he isn't even conscious of the fact that there aren't any people playing-just the music and the instruments! As he grows older--he makes a name for hinself in the music field--and later on, he tires of playing and starts composing the music that is constantly in his head---he becmnes famous but this doesn't move him particularly--he doesn't even realize that he is wealthy--music is his life, and he is happy, because he is doing what he wants. Descriptive theme A lO-year-old boy is dissatisfied with his music piece, which feels empty, not warm. Stops it (though not temperamental). Fantasies writing a better one (sad and beautiful) ; instruments (not people) in. Becomes very famous, happy with music, uninterested in money. Interpretive theme If a boy is dissatisfied with his status because life is empty, cold, unex- citing, fantasies of resound- ing effect (without social participation). He achieves fame and money, without caring for the latter. Diagnostic level Feels like a lO-year- old boy. Dissatisfied with his life. Feels own shallow affect (poor sexual performance?) Denies being temperamental. Switches from activity to grandiose fantasies of fame in a narcissistic way. Denies interest in money and recognition. Clinical notes It is questionable whether one is justified in identifying the self-image with that of a boy in view of the fact that the picture actually shows a boy. However, people frequently tell stories of an adult thinking back to boyhood, thus clearly thinking of themselves as adults, and making the consideration of boyish self-imaging tentatively possible. The repeated reference to emptiness suggests this man's feeling of emptiness, probably involving some depersonalization. The different "instruments" might well refer to the proximity of people he needs to dispel this feeling, but at the same time the shallow, narcissistic relationship to them (they exist only as needfulfilling objects) is suggested by the fact that it turns out that only the instruments themselves, without people, are playing.

146 CHAPTER 6 Story 2 2: This girl, about 19 years old, would probably be named Olga, of Ukranian parentage and stock. For generations her family has farmed this piece of land.., just barely eking out an existence on this tired overused land. But food was plentiful, pure, and wholesome, and they were satisfied, all, until Olga grew up. She was the first in the family to get full schooling. At first the family thought it was useless to keep sending Olga to school, year after year--there was so much work to be done, and at 13 she was almost full grown-but Olga wanted to study and learn more. Finally they conceded, and four years later it was with pride that they watched their Olga graduate from the town school! It was indeed difficult to allow her to go to school all these years. Of course she helped after school hours, but that wasn't enough. And now, now Olga wanted to go to Normal School to become a teacher! This was ridiculous--but-finally, after Olga showed them how, in another two years, she would graduate and get a job earning a hundred dollars a month as a teacher, they gave in again. We see Olga coming from town---Normal School! It is almost sunset--and as she comes across the field, she sees her brother, stripped to the waist, tilling the land, and her mother, tired and with an aching back from seeding--resting for a moment--Olga sees this and turns away for a moment--she hates to see them slave, just to eat and sleep .... Soon, she thinks to herself, "I'll be earning money and we can buy a tractor--with automatic seeder.., and there are many kinds of farm equipment that could make work easy, and do it quickly; maybe we'll buy the ading piece of land and start making a living instead of an existence." She walks over to her mother, takes the seeds from her, and starts seeding .... Her mother, now holding Olga's books, looks at her young educated daughter, who is bent over covering the seeds with the earth, and a light shines in her eyes, as she thinks, "Good, she is not spoiled, my daughter with her books--soon she'll finish and all will be well"--and turns to go down to the house to prepare the evening meal! Descriptive theme A girl of simple Eu- ropean stock wants to study and improve herself. Food important. At first the family objects but then concedes and watches her succeed with pride. The girl sees the family toil, dreams of helping them, and actually relieves mother of work. Interpretive theme If a girl wants to do better than her family by studying (though having enough food?), the family first objects, then concedes, and is proud of her SUCCESS. One feels sorry for the family, fantasies of helping them, and actually helps mother. Mother is happy about her and prepares a meal. Clinical notes Diagnostic levd Need for autonomy, self-improvement. Wants to do better than family. Oral needs. Family seen as restrictive, later proud of one's success. Need for success, including money. Wish-fulfillment fantasies, rescue fantasies re mother. Need for nurturance. Oral needs. It is frequent for males to identify with the female figure in this picture, so that this by itself does not permit any particular inference. The need for success and money is re the (Bellak, 195 This is stricted, stance). Thi come from Story 6BM 6BM: only to have Then, when talking... wracking house." . . . mother.. new house ing his wife was still u and insistent well... ing scenes.. way he could, hemming am she sees how trivial.., an but obvious to do for you, with no " this pain bec for not being i angry with ] Well, ti kids.., enj eight.., the: About fish for ing.. hysterical.. child started bread box.. of stale bread grandmother' mad the child who was her feel... loom. o o !"

THE BELLAK SCORING SYSTEM 147 [kranian parent- . just barely ek- ure, and whole- he family to get a to school, year full grown--but later it was with deed difficult to hours, but that :ome a teacher[ r two years, she er, they gave in set--and as she e land, and her lent--Olga sees and sleep .... -with automatic ark easy, and do ng instead of an ts seeding .... tter, who is bent . thinks, "Good, 11 be well"--and ffnostic level r autonomy, )rovement. :o do better mily. Oral seen as re- , later proud g success. Dr success, in- i money. ,lfillment fan- 'escue fan- mother. )r nurturance. ieds.

I

lS picture, SO r success and

money is repeated here, this time without denial of the latter. But denial appears in the contradiction of "eking out" and plentiful food. The need for nurturance (Bellak, 1950a) may simply stand for need for succorance. This is a rather verbose, lively story of cheerful mood, probably typical of the somewhat hypomanic mood the patient was in (as compared with the meager, constricted, brief, often merely descriptive stories of obsessive-compulsives, for instance). This story is also to a certain extent autobiographical in that the patient did come from immigrant stock and helped his family. Story 6BM 6BM: This is an old folks' home, and the young man is visiting his old mother. She was only to have stayed for a short while. Till he had moved his family to the new house .... Then, when he thought of bringing his mother to the new home . . . his wife had started talking... "Grandma was spoilin the kids . . . She kept everyone awake with her nerve- wracking cough, and she was very untidy, and made so much extra cleaning work around the house." . . . At first, the young man was shocked to hear his wife speak that way of his mother.., he wouldn't think of letting her live in the old folks' home.., while he had a new house with plenty of rooms in it... but.., after a few weeks.., he got used to hearing his wife speaking in this manner . . . and he wasn't shocked to hear the words, but he was still upset about his mother living in the old folks' home .... His wife was stubborn and insistent . . . there wasn't anything he could say or do that would change her mind, well.., there wasn't much he could say now.., he was tired.., she kept yelling and making scenes .... So finally one day he went to see his mother.., to tell her.., the easiest way he could, that it was inconvenient for them.., for her to live with them... After much hemming and hawing . . . he finally blurted out his case .... The mother is very hurt, she sees how difficult it is for her son, and for his sake tries to make it all sound very trivial.., and actually she likes it at the home! . . . But the man can see through her kind but obvious front. And finally the mother starts talking.., about how you bring children into the world.., and no matter how much they love you.., and no matter what they try to do for you, you always feel that you are unwanted.., and yet.., what can an old woman with no income do? The man is feeling very bad.., his little old mother going through all this pain because his wife didn't want to clean an extra room! He is disgusted with himself for not being man enough to make his wife take his mother in... and at the same time he is angry with his mother for making it so difficult for him. Well, time wore on. The grandma would come to the house Sundays... play with the kids . . . enjoy their laughter and their tears. Stay for Sunday dinner, and around about eight.., the son would drive her to the home. About six months after the above incident.., on a Sunday... they were having fish for dinner.., when suddenly.., one of the children started coughing and splutter- ing.., everyone started pounding him on tle back.., the young mother started getting hysterical.., and the father kept yelling. "He's got a bone stuck in his throat." . . . The child started getting blue in the face. The grandma ran into the kitchen . . . went to the bread box.., took a piece of stale bread back to the choking child, put a goodsized piece of stale bread in his mouth.., told him to chew it a couple of times, and then swallow... no matter how difficult .... The child by this time was almost unconscious but, hearing its grandmother's calm voice it did as it was bid.., and the bread forced the bone down... and the child was all right, 'cept for fright .... The young mother looked at the man... who was her husband.., and said .... "If it weren't for your mother's old-fashioned reme- dies . . . we might have lost our son. I could feel what it was like. I know how she must feel . . . living away from you . . . us . . . now! I think I can manage to clean one more room... !" So, the grandma moved back.

148 CHAPTER 6 Descriptive theme There is a conflict between hero's mother and wife. Hero gives in to wife, and mother has to move to old folks' home. Mother feels son is ungrateful. He doesn't dare stand up to wife and is angry at mother. When mother saves life of grandchild when it has a bone stuck in its throat, wife and mother make peace. Interpretive theme If there is a conflict in one's loyalities to mother and wife, one reluctantly gives in to wife and rejects mother, who complains about it. If there is trouble with the child (who has object stuck in throat), mother helps. If mother and wife can be reconciled, all is well. Diagnostic level Has attachment to mother conflicting with marital adjustment. Projects aggression toward mother on wife, rationalizing. Mother seen as nagging, poor. Iden- tifies himself with child. Guilt over anger toward mother. Fearful fantasies of aggression (fellatio). Mother seen as omnipotent. Can feel peaceful only if conflict between attachment to mother and wife (and ambivalence toward both) is resolved. Clinical notes This story is most illuminating with regard to the subject's chief complaint of marital problems. Obviously, he is as ambivalent toward his wife as toward his mother and denies both. His relationship to the latter interferes with his relationship to the former. In his oedipal wishfulness, the father is out of the picture. Probably as a punishment both for his oedipal wishes and also because he conceives of the mother as a somewhat phallic woman, the phallus gets stuck in his throat. Making this happen to his own child removes the full impact from himself. The story of the bone is not unlike the apocryphal story of the origin of the Adam's apple--the forbidden (sexual) fruit getting stuck (Bellak, 1942). It implies a breast-phallus equation. The Kleinian school would speak of the "bad breast." The child is a secondary identification figure. The solution of the conflict between the two women by the bone incident, and the solution by the bread, are somewhat of the nature of a deus ex machina solution. not

Story 13MF 13MF: This scene takes place in a small room of a tenement house. Very poor people.., young--students. The betterment of the mind means so much to them. They have starved to go to the university.... Sometimes working at nights.., so... they can afford to go to school in the day. They have known each other since childhood, and as they grew older, married and, having much in common, lived happily though precariously, sometimes

THE BELLAK SCORING SYSTEM 149 ic level Ltachment to r conflicting aarital ad- nt. Projects sion toward r on wife, ra- izing. :r seen as nag- poor. Iden- fimself with Guilt over toward r. fl fantasies of sion (fellatio). r seen as om- mr. Can feel hl only if con- ,tween attach- :o mother and nd ambi- :e toward is resolved. ! complaint of as toward his h his relation- f the picture. . he conceives in his throat. imself. origin of the t2). It implies :l breast." The t between the . somewhat of 'ery poor peo- iem. They have ihey can afford Idas they grew asly, sometimes not having enough for food, most of the time dressed very poorly. This winter was very cold.., the girl's coat was very thin.., and somehow she must have caught a cold .... The boy, her young husband, finds her in bed shivering .... "What's the matter?" he asks. "Guess I caught a bit of a chill," she answers. He feels her brow and she is very hot! He becomes alarmed and says, 'Tll go get a doctor!" . . . "I'll be all right, don't bother." . . . He sits by her side, and talks to her, to keep her company.., besides, he has no money for a doctor! After a while he notices that she hasn't said anything for quite some time . . . he shakes her, but she is unconscious.., he becomes frantic, and runs out to find some doctor, but the doctor down the street is not in his office.., and he runs back to the room. The girl has pushed the covers partly off of her, in her fever, and her full round breasts are exposed . . . he leans down to talk to her . . . he sees . . . she is not breathing . . . ! So quickly life goes.., he doesn't know how long he has been sitting by the small bed.., he gets up... and calls the police... ! Heartbroken... he is determined... "To hell with education! Money is what counts! If we had had money.., she wouldn't have died!"... He leaves school.., goes into the world.., amasses a fortune after a time.., but, he has not peace of mind.., money can't buy that! Descriptive theme A poor starving girl dies because husband cannot afford a doctor. He calls police. Heartbroken, he makes much money without peace of mind. Interpretive theme If one is poor, one has to let one's wife die, calls the police, makes much money, is disturbed. Diagnostic level Feels deprived orally. Aggression against wife. Projection. Unconscious guilt feelings. Need for acquisition (money), for security. Guilt. Clinical notes Again, the acquisitive needs, denied in the first story, come out here strongly, very often feelings of material deprivation stand for a feeling of being deprived of love. In this story reference to starvation clearly refers to oral deprivation. The unconscious guilt feelings over unconscious aggression are demonstrated by his calling the police. Story 17BM 17BM: The boy or young man on the rope is a gymnast.., takes great pride in his muscles and ability.... Today some girls came in to see the men working out.., and this particular boy was doing everything to appear the hero and strong man in their eyes . . . not that he cared particularly to meet the girls.., it's just that he wanted them to see that he is the best around. While he is doing all this showing off.., a small, thin chap with glasses.., and a portfolio s the girls, and they all turn eyes on the muscular young man. He smiles to himself and he takes a running leap at the hanging rope and shinnies up like Tarzan, and starts doing all sorts of difficult feats, onearm planches, dislocations, and so on, for about five minutes, and then he looks at the group that were watching him, and sees that they (the girls) are laughing at the little fellow, who is trying to lift a huge weight.., and being very funny about it. The muscular one comes down the rope, watching as he descends. '3#3ay should they choose to look and laugh with the skinny, scholarly chap, when I was being so sensational!"

150 CHAPTER 6 Descriptive theme A young man with great pride in his muscles and ability shows off to girls to impress them as being best. At the same time a thin scholarly fellow makes them laugh, and the muscular one feels the other is stealing the show. Interpretive theme If one shows off with great pride in one's body, it is narcissistic more than het- rosexual. The girls may prefer a funny scholarly chap. Diagnostic level Great body narcissism; exhibitionism. Little heterosexual interest. Homosexual competitiveness. Great stress on being thought entertaining. Feeling of inadequacy. Clinical notes This story probably reflects a double identification, in that inquiry revealed that the subject thinks of himself both as muscular and, on the other hand, as too little. The other stories, too, show his need to be considered scholarly. His actual appearance was that of a small, inoffensive man, whereas he was a professional athlete. This theme is also related to competition with a brother three years older and has much to do with the patient's homosexual competitiveness with other men rather than genuine heterosexual interest. This man sees people primarily as an audience. His only object cathexis is an anaclitic one. The laughter which the second identification figure arouses was one of the patient's most important conscious needs (getting the laughs). Story 18BM 18BM: His wife always said . . . '`you can't step on peoples' toes.., and not expect to get hurt yourselfl" And he would answer, "If telling the truth.., if honesty is stepping on peoples' toes, then I damn well am going to step on plenty of toes!" This afternoon.., during the lunch hour in the factory.., he had a bunch of the workers gathered round him . . . and was explaining to them . . . the way the economic system worked. How they . . . the workers were browbeaten . . . how the people with money.., made more money by making them work like slaves.., for little more than slave money. That the worker had no chance for security in his old age.., working conditions weren't even good .... Look at the way they had accidents, because the power machines didn't have protection screens around them.., the bad lighting, etc .... etc .... One of the foremen overheard this and went to the boss'office.., and told what he had heard. That night, as he was walking down the dark street that led to his house . . . a car drove alongside, and some men jumped out.., something hit him on the head.., he was dazed by the blow.., then he was hustled into the car.., driven out to the country and beaten up. It was four o'clock in the morning by the time he got home.., sick and sore in his body.... He knew why he was beaten up .... The next day, although it was an effort for him to go to work.., he went.., his face all swollen . . . his body sore and wracked with pain .... His fellows started asking him questions . . . and he said . . . "You all know me. I have no enemies. I think I am well liked.., yet last night coming from work... I was set upon by some thugs.., thoroughly beaten . . . and apparently left for dead. It couldn't have been thieves . . . because they didn't try to take anything from me . . . and they kept shouting as they were kicking

Diagnostic level reat body narcis- sin; exhibitionism. ittle heterosexual terest. iomosexual com- titiveness. Great tess on being thought tertaining. Feeling inadequacy. that inquiry revealed he other hand, as too l scholarly. His actual as a professional ath- three years older and ness with other men le primarily as an au- Lter which the second important conscious !es... and not expect ! honesty is stepping on ihe had a bunch of the ilthe way economic the how the people with r little more than slave i.. working conditions te the power machines . . .etc .... One of what he had heard. ) his house . . . a car a the head.., he was mt to the country and • . . sick and sore in he went.., his face ws started asking him ies. I think I am well thugs.., thoroughly ,yes" . . because they i as they were kicking THE BELLAK SCORING SYSTEM 151 and punching ine 'This oughta teach you to keep your mouth shut . . . you lousy com- munist!' . . . You see, it was for what I have been speaking to you about that I was beat up! . . . I must of said some very true things for them to try and shut me up . . . !" The workers asked... "What are we going to do?".., and he answered... "What they have done to ME is not of great importance.., but WHY they have done it is! So, we must organize.., a union.., and force them to our demands!" The workers organized.., and started making small demands at first.., until they forced the bosses into making their shop . . . clean . . . safe . . . and better wages. This showed the way.., and very soon the other shops followed.., and at least now, the workers live like humans .... Descriptive theme A man tells workers they are being abused, even though wife says this might lead to harm to himself. Someone informs on him and he is severely beaten. Thereupon he leads the men to organize a union. Interpretive theme If one is verbally aggressive against authority against a female's advice one is severely harmed by agents of the authority. but then leads men to successful modified counteraggression. Diagnostic level Need for verbal aggression. Sees female figure (mother?) as being against aggression against authority. Authority is seen as depriving (inviting aggression-masochism). Severe guilt feelings. Socially acceptable aggression permissable (after self-punishment). Clinical notes The female figure is certainly unexpectedly introduced here. The exploiting authority is probably an image of the parents. The whole story shows this man's problem with aggression, his turning it against himself, and his ability to express it only in a modified form after he has been punished.

CHAFFER 7

SOME CLINICAL AND OTHER SPECIAL PROBLEMS OF THE T.A.T. On Diagnostic Groups The T.A.T. facilitates assessing the 10 different categories of personality functioning of Bellak's Scoring System, as well as contributing to the assessment of verbal language, neuropsychological, and other dimensions. Although it is clear that no single test is ever sufficient in making an overall psychological evaluation, there is a question whether it is possible to diagnose psychiatric disorders from the T.A.T. alone. Some individuals may reveal deep pathology, such as a suicidal level of depression, on most of the stories of the T.A.T., while their Rorschach, projective drawings, and other tests may appear fairly intact. Other individuals may not show any severe pathology on the majority of T.A.T. stories, but reveal deeper issues on only one or two stories. Our assumption is that the less structured and more ambiguous the test stimuli, such as the Rorschach inkblots, the more people are able to let go and reveal their deepest levels of psychopathology. If a patient is schizophrenic, the assumption is that the more structured stimulus of the T.A.T. will tend to show more ego structure, while the less structured Rorschach will reveal the patient's poor reality testing, poor level of self-object differentiation, and breakthrough of poorly controlled primary process sexual and aggressive impules. Generally, an individual's T.A.T. protocol will show a higher degree of ego control and ego integration than will the Rorshcach. If one has a very good, ego- enhancing day when the Rorschach is istered and a very upsetting experience when the T.A.T. is istered, we expect that the test given on the very bad day will show a lower level of ego functioning. Similarly, we expect an intellectually gifted schizophrenic woman to show a higher level of functioning on cognitive intelligence tests than she might reveal in a series of her dreams. In making a diagnostic evaluation, it is important to consider the level of structure of the different tests, the situational factors surrounding the times the tests were istered, and if there are a number of corroborating indicators of a particular dynamic or only a limited number. Pam and Rivera (1995) have presented a very thought-provoking and moving exception to these basic assumptions. After istering a psychological evaluation of a man who was hospitalized on a psychiatric ward, the psychologists recom152

CLINICAL AND OTHER PROBLEMS OF THE T.A.T. 153

LEMS of personality func- e assessment of ver- ugh it is clear that :al evaluation, there iers from the T.A.T. ;uicidal level of de- ,rschach, projective :luals may not show al deeper issues on red and more am- re people are able a patient is schizo- the T.A.T. will tend a will reveal the pa- :iation, and break- sive impules. iher degree of ego s a very good, ego- y upsetting experi- 'en on the very bad !ct an intellectually ng on cognitive in- In making a diag- ire of the different i istered, and ]dynamic or only a oking and moving chological evalua- zchologists recommended that he not be released in the near future, which led him to commit suicide. The patient's severe degree of dangerous aggressive imagery on the T.A.T. was the primary basis for their recommendation. The two authors have many years of experience in psychology internship training and their paper is an important teaching case on the issues of having sufficient data on psychological tests upon which to base one's diagnosis, the psychologist's responsibility to make difficult recommendations, when there are clear signs that the patient's and other individuals' safety is involved, and the importance of reexamining one's actions when there have been tragic outcomes in a patient's care. M1 too frequently, the opposite situation is the case. It is more typical for a psychologist to have istered a T.A.T. toward the beginning of a lengthy treatment process, where core problems and conflicts become very clear in the treatment process that may not have appeared with such clarity in the beginning T.A.T. protocol. For instance, the entire treatment of one male patient of 20 years old centered to an unusual degree around one focal sadomasochistic fantasy. That fantasy existed when the patient was 5 years old, with him in the ive role. He was healthy enough to switch to a more active, masculine role by the time he was age 12, but the fantasy was, in essence, the same (instead of being kidnapped, he became the kidnapper). In the course of nearly three years of intensive psychotherapy, the treatment process managed to identify the most detailed features of the fantasy and various pictorial aspects could be identified with specific places, dates, and occurrences of several years of his life. This fantasy has layers like the trunk of a tree. Nevertheless, only a glimmer of this fantasy occurred in the man's T.A.T. The intensive treatment, of course, did not merely consist of working on this one fantasy. On the contrary, the fantasy was pieced together only in the midst of all sorts of other more or less relevant material. And the T.A.T., of course, showed his anxieties, and that he used avoidance as a main defense mechanism; this very fact led to the suspicion, on first studying the T.A.T., that there must be more there than appeared in the stories. It may be that the mechanism of denial is particularly pernicious to securing projective data. This is, of course, the mechanism of choice in manics, and therefore many of our examples come primarily from that group, although not exclusively. (The previously mentioned patient had a character disorder, and most patients referred to here were seen in private practice, while they were carrying on gainful activities and were certainly not psychotic.) When the mechanism of avoidance is used, the T.A.T. material may be long and apparently very rich, yet it will defy analysis. This is, of course, the experience with any form of output of manics or hypomanics. Fortunately, at least one story usually turns out to contain the real core, while the others have such an overgrowth of defense that it requires very special pains and an awareness of the centrifugal nature of the material to be able to use it. With manics and other predominantly oral character disorders, a most useful story may be one told to picture 11. The theme of devouring, which this Boecklin picture suggests, contains precisely the stimulus to which this group respond. The defenses revealed by the T.A.T. are identical with those appearing in free associations and in dreams. Those patients who give the most frustrating T.A.T. stories may spend hours on seemingly irrelevant material

154 CHAPTER 7 and recount long, involved dreams more suitable for Hollywood scenarios than for analysis. However, the T.A.T. is very useful in revealing an individual's underlying psychodynamics. It shows the ambivalence, the exhibitionism, and the fear of aggression in agoraphobics, as well as the figures against whom the aggression is directed. A posteriori, one may identify all the component parts that belong to the diagnostic picture. An exception may be the quantitative aspects; as in dreams and fantasies, it is difficult to appraise the strength of the variables involved, and it is difficult to predict whether they are strong enough to turn up as manifest syndrome formation. The study of defenses, however, may be more possible. There have been a number of records, particularly of the C.A.T., where one may successfully predict anorexia as a clinical syndrome, although at times only a detailed consideration of the defenses permit us to differentiate between overeating and anorexia. These observations are entirely in agreement with the excellent theoretical formulations that Sargent (1953) presents in her pyramid of diagnostic inference (Figures 7-1 and 7-2). She states that after a consideration of the raw data of the tests comes a level of generalization; then a second inferential level of theoretical interpretation; and only then a third (abstract) inference as to the classificatory diagnosis. She demonstrates the overlapping of the two levels of inference for two (or more) diagnostic labels. It is clear that the identifying features of psychodynamics and character structure are revealed in the T.A.T. Within limits, one can often make statements about the diagnostic group to which a patient belongs from a T.A.T. protocol. Not infrequently, one will notice that obsessive-compulsives give their attention to small details in the pictures, and they will often respond with more than one story to a picture. We may also find that the storyteller stays distant and expresses sarcastic attitudes toward the hero, remaining emotionally isolated himself or herself (Finn, 1951). In hysterics and hypomanics, on the other hand, we find a great deal of affect and a lively identification with the hero. Manics will often indicate strong tendencies of oral incorporation; very many references to food and getting things may appear (although this is, of course, not pathognomonic at all). Again, in depressed patients, suicidal themes, a depressed overall mood, and self-depreciation, along with other signs of a very strong superego, may be apparent (Shneidman & Farberoxn, 1958; Valentine & Robin, 1950b). Following is the story of a manicdepressive girl in remission, illustrating the oral tendencies with three references to eating in a brief story. The picture (11) frequently elicits reference to food; stories of attack are often integrated with this theme: This picture takes place in Texas about 5,000 years from now. Civilization is extinct. An atom bomb has killed everyone, and the whole earth is beginning again. The remains of civilization are the Spanish arch in the right lower corner. On the top are a few birds looking for food. There's a mountain on the left side, and from a cave a sort of snake-bodied, duck- footed animal is wiggling out. He's going to strike the birds, eat them, and then go merrily on his way looking for more food. In the T.A.T. stories of psychopaths, one usually finds little punishment for any aggressive act engaged in by the hero in the story, evidence of a weakly integrated Levels1 IV Abstract Leve Classification or Diagnosis III Second Infer Theoretical Ir II First Inferenti Generalizing Personality fi I Base Line: Figure 7-1 P Source: H. Sargent, Level I. Test score associations, conte Level II. Identifyin Level III. Postulatc tion, introjection, Level IV. Categoric "poor" candidates 9Intrinsic validity { -External validiw, checked against c tional adjustment: superego (see noted similar 1943) and ofj 1956). There a ences--for ins ist--and we wi senior author released from excitement. Ix noncommittal again when h, and other tes the tests threv senior author

CLINICAL AND OTHER PROBLEMS OF THE T.A.T. 155 IV Levels1 Abstract Level: Classification or Diagnosis Second Inferential Level: Theoretical Interpretation2 First Inferential Level: Generalizing about Personality from Data2 I Base Line: Raw Data Abstractions Criteria3 Tests Observations Figure 7-1 Pyramid of Diagnostic Inference, Reasoning, and Abstraction Source: H. Sargent, The Insight Test (New York: Grune & Stratton, 1953). Reproduced by permission. Level I. Test scores, patterns, scatter, quantitative and qualitative signs (perceptual distortions, peculiar associations, content, over- or underresponse, etc.). Level II. Identifying characteristics: overalert, complaint, rigid, naive, anxious, disoriented, etc. Level III. Postulated mechanisms and processes such as projection, repression, regression, denial, isolation, introjection, etc. Level IV. Categories such as neurosis, psychosis, schizophrenia, hysteria, obsessive-compulsive; "good" or "poor" candidates for profession, employment, etc. 2Intrinsic validity established by convergence of independent judgments. External validity established by pre- or postdiction of events or conditions from tests and observations checked against criteria (C). Sample criteria: life history, course of illness, progress in therapy, vocational adjustment, experimental behavior, etc. superego (see stories of Streicher later in this chapter). Several other studies have noted similar T.A.T. characteristics of psychopathic defective criminals (Kutash, 1943) and of juvenile delinquents (Megargee, 1966a, 1966b; Purcell, 1956; Young, 1956). There are other cases where we would like to be able to make real inferences--for instance, if the potentiality (or actuality in the past) of antisocial acts exist-and we wish to help predict future behavior. One such case occurred when the senior author (Bellak) was asked to help determine whether a young boy should be released from an institution. He had killed a small child, apparently in some sexual excitement. Institutionalized, he was a model inmate on a behavioral level--bland, noncommittal, and inaccessible to psychotherapy. At the time of commitment and again when he came up for disposition at the end of a year, he was given the T.A.T. and other tests by the staff for help in understanding his problems. When none of the tests threw any light on the psychodynamics of the crime, he was referred to the senior author for the istration of a T.A.T. under the influence of intravenous

156 CHAPTER 7 IV Paranoid Hysterical Psychosis Psychosis Abstract Level: -- III Second Inferential Level: ,2 2 2. g /' \ Base Line: y ", Raw Data Test scores, patterns, scatter, etc. On ward, at activities, interviews, etc. Figure 7-2 Overlapping Diagnostic Pyramids Source: H. Sargent, The Insight Test (New York: Grune & Stratton, 1953). Reproduced by permission. Solid lines represent, for one case, the derivation of inference from raw data, interpretation from inference patterns, and abstraction from interpretations subsumed under the finally selected label. Dotted lines represent the same sequence for a second case. Note that a single first-level inference (e.g., anxiety) may be based on data fi'om several tests and/or observations and that a single test score may lead to more than one inference (e.g., test 3, perhaps the Rorschach). The interpretation that projective defenses are operating derives from not one but several inferred characteristics. Likewise, the diagnosis of paranoid schizophrenia or hysterical psychosis depends on a combination of theoretical interpretations or conceptualized processes. Amytal Sodium. After the intravenous istration of 71/ grams of Amytal Sodium and 1Vz grams of Nembutal orally, a marked psychomotor effect of the drugs was noted: general relaxation, drowsiness, slurring of speech, and occasionally such lack of motor control and sleepiness that the T.A.T. cards dropped out of the young boy's hands. Despite the action of the drugs, the boy gave 15 stories that, in no single instance, revealed any primary pathological evidence in the theme itself that would have permitted one to pick out his T.A.T. as belonging to a notice- ably disturbed person. However, although it was impossible from his T.A.T. stories to predict his actual behavior, small breakthroughs of original impulses came to light. For instance, he made one slip of the tongue in the following story to picture 8BM: These two boys have gone out hunting. They shot a lot of boys--I mean, animals, and decided to split up to get more pheasants. They agreed to meet at 8:30 at night to count the gane and to go home. This boy was standing in the bushes. Twenty feet from him he heard solnething move. He goes to look at what he caught and finds his friend and rushes him to the doctor. The doctor says the boy will be all right, and in the end the boy gets OK and for- gives him for what he did. The slip bet: sorbed in a perle boy's injury. An ir the time for light time that his rant: picture 1 by sayin: This boy doe He changes gave to picture H An undertak, out one night and he can undo his w( In this stor buried, revealing incongruent guil There are c who had previou lowing story to 31 Is this a girl? I think there's a g[ doing so had fallex bor perhaps that st reason you'd have She'll have chang Although, : ing actually occu to her behavior, propriate: a girl impulse is easil} strong reason fo dislike. The stor murderer: There's a p: eyes; seems to be morseful; seems t wasn't from natm Although in a "shock state previous story seems to be a cl Courtesy of Ms. B

CLINICAL AND OTHER PROBLEMS OF THE T.A.T. 157 ews, etc. tsion. 'ore in- ,el. .'st score that ewise, heoretikmytal of the asion- out of that, ne it- iotice- is ac- ance, and the aeard im to forThe slip betrays the apparently original aggressive impulse that becomes ab- sorbed in a perfectly acceptable hunting story, then breaks through again in the boy's injury. An inquiry into the small detail of 8:30 at night revealed that that was the time for lights out at the institution and strongly suggested that it was at this time that his fantasies were permitted to emerge. Similarly, he started his stoW to picture 1 by saying: This boy does not like to practice his trumpet--I mean he likes to play his violin. He changes a negative response immediately to a positive one. The stoW he gave to picture 15 is as follows: An undertaker; he is very sad because he is putting to rest all these people. He goes out one night and looks with remorse at all the work he has done. He tries to find out how he can undo his work. He can do nothing about it. In this story, the undertaker behaves as if he had killed all the people he buried, revealing the original aggressive impulse only by what would otherwise be incongruent guilt feelings. There are other T.A.T.s of murderers that present similar problems. A woman who had previously attempted to kill her x sleeping children by stabbing told the following stoW to 3BM:

Is this a girl? I think it's a girl; she seems to be crying; leaning against a bed. At her feet I think there's a gun. Well, it looks as though she had planned to use the gun and instead of doing so had fallen asleep. (?) Probably planned to shoot someone with it. (?) Well, a neighbor perhaps that she didn't like. (?) No one would know that but herself---can't imagine what reason you'd have for it except disliking them, maybe. I don't think anything will happen. She'll have changed her mind by the time she's more rested. Although, like all this woman's stories, the content is innocuous in that nothing actually occurs, and it would be impossible to make any concrete predictions as to her behavior, certain things do emerge. The effect in this story is grossly inappropriate: a girl who had planned to shoot someone falls asleep instead. An active impulse is easily replaced by a ive one. There appears to be not particularly strong reason for the planned shooting of the neighbor except a vaguely expressed dislike. The story she tells to 13Mr is in some ways reminiscent of those of the boy murderer: There's a picture of a young lady in bed and a man standing with his arms across his eyes; seems to be walking away from the bed. Seems to me the lady has died and he is remorseful; seems he is in a shock state of remorse over her death. (?) Nothing to indicate it wasn't from natural causes. (?) Husband; he'll have to go on alone. Although the woman in the picture died from natural causes, the husband is in a "shock state of remorse" over her death. (This resembles the undertaker in the previous story who is remorseful over the people he has buried.) In this story, there seems to be a clearer aggressive impulse and its denial. Courtesy of Ms. B. Guttman, of the Psychology Department, Queens General Hospital, N.Y.

158 CHAPTER 7 Psychiatric Differentiation Although attempts at psychiatric differentiation with use of the T.A.T. have been unsatisfactory in general, a good deal of recent work has ed our contention that various diagnostic groups differ clearly in certain of their ways of responding to thematic stimuli. In a study of psychoneurotics, Foulds (1953) found that hysterics started stories more quickly than depressives and told longer stories at a quicker pace. Depressives produced more illness themes to picture 3GF than hysterics, who produced more themes involving quarrels. Davison (1953) has described differences among certain diagnostic groups in the of the kinds of interaction described in their stories. He concluded that anxiety reactives produced a significantly greater number of themes of "man moving toward man, the depressive reactives of man moving toward woman, the hebephrenic schizophrenics of man moving against man, and the catatonic schizophrenics of no relationship between man and woman." There have been only a few studies of thematic test characteristics of individuals who are mentally retarded (Hurley & Sovner, 1985; Montague, Jensen, & Wepman, 1973; Upadhyaya & Sinha, 1974). They mostly focus on the tendency to use concrete description of the picture stimulus, inflexible stereotyped narratives, and a paucity of words. Chapter 12 discusses thematic test studies of borderline patients (Brelet, 1986), Rogoff (1985), and Western (1991a, 1991b) and of narcissistic patients (Abrams, 1993a, 1995; Brelet, 1981, 1983, 1986, 1994; Harder, 1979; Shulman & Ferguson, 1988; Shulman, McGarthy, & Ferguson, 1988). Chapter 13 discusses thematic test characteristics of children and adults with attention deficit disorder (Abrams & Bellak, 1986 edition of this text; Costantino et al., 1991). An important area of thematic test research is that of psychological trauma studies. From Haworth's (1964b) important study of the thematic test characteristics in children who suffered the death of a parent, the emphasis in later research has been primarily on thematic test characteristics of children and adolescents who have been the victims of child neglect, physical abuse, or sexual abuse (Henderson, 1990; Hoffman & Kuperman, 1990; Kalaita, 1980; Miller & Veltkamp, 1989; Ornduff et al., 1994; Ornduff & Kelsey, 1966; Stovall & Craig, 1990). The T.A.T. with Schizophrenics Theoretical stress on the role of power concerns underlying paranoid symp- tomatology led Wolowitz and Shorkey (1966) to study power themes in the T.A.T. stories of paranoid schizophrenics and other psychiatric patients. Paranoids' stories contained significantly more power imagery than those of the nonparanoids. Subdividing the nonparanoids into different diagnostic categories, it was found that paranoids were most highly differentiated, in of a greater number of power themes, from patients classified as anxiety neurotics, psychophysiological reactions, and nonparanoid schizophrenics. Karon's (1963) hypothesis, drawn from clinical experience--that mothers of schizophrenics are unable to meet the needs of their children and use the children to meet their own needs by manipulating their behavior--has been analyzed by means of the T.A. phrenic children dren on the tiation ed dominant and de specified needs pense of the depe of schizophrenic Contrary Eron's report (19 from the T.A.T. come to private ized schizophreni need a T.A.T. ambulatory schiz bance in the T.A. tent that did not to "reading withe tant symbolic awareness far T.A.T. stories, Certain signs for instance, ins and destruct trapsychic diagnosis of schi is the tendency family Piotrowski (19N treatment (Gok One may, artists who are examples of matic complain a happy and pr stories was tongue-in-cheel Kiss Me Any Papa, when you kiss m, brace a bush, it philosophy is n( tration, which so Papa takes th, father. Followin

,f the T.A.T. have pported our con- [ their ways of re- tlds (1953) found t longer stories at are 3GF than hys- a (1953) has de- of the kinds of in- zctives produced a an, the depressive )phrenics of man ttionship between :eristics of individ- tague, Jensen, & .n the tendency to ,.otyped narratives, ies of borderline pa- l and of narcissistic t4; Harder, 1979; 1988). Chapter 13 attention deficit dis- ., 1991). 1logical trauma stud- t characteristics in later research has 1 adolescents who tbuse (Henderson, rap, 1989; Ornduff ag paranoid symp- [emes in the T.A.T. i Paranoids' stories he nonparanoids. s, it was found that

i number of power l

ological reactions, :--that mothers of d use the children been analyzed by CLINICAL AND OTHER PROBLEMS OF THE T.A.T. 159 means of the T.A.T. Mitchell (1968) has demonstrated that mothers of schizophrenic children can be differentiated significantly from mothers of normal children on the basis of T.A.T. responses. The criteria used for the successful differentiation ed Karon's (1963) hypothesis; if there was an interaction between a dominant and dependent individual and the dominant individual did not meet the specified needs of the dependent individual or met his or her own needs at the expense of the dependent individual, the story was scored pathogenic. Most mothers of schizophrenic children received higher pathogenic scores than control mothers. Contrary to findings by Rapaport (1946), and in partial agreement with Eron's report (1948), schizophrenia does not appear to be easily diagnosed as such from the T.A.T. We are speaking here of the ambulatory schizophrenics one sees as they come to private offices. Rapaport's signs probably hold true primarily for hospitalized schizophrenics, where there is such manifest pathology that one would hardly need a T.A.T. to make the diagnosis. However, in a considerable percentage of even ambulatory schizophrenics, one may find ample indications of the severe disturbance in the T.A.T. stories. These indications may be either stories of bizarre content that did not appear in ordinary communication, such as John Doe's reference to "reading without eyes" in his story to picture 1 in Chapters 6 and 11, or very bla- tant symbolic expressions suggesting a closeness of the unconscious to conscious awareness far beyond the ordinary. Thought disturbances may become apparent in T.A.T. stories, when they are not discernible in conversation or in interviews. Certain signs may also be considered as suggestive, but not conclusive, indicators-- for instance, reference to deadness (e.g., with regard to the violin in story 1, and ru- ins and destruction in story 11). This type of response suggests a reflection of intrapsychic consciousness of lack of affect severe enough to be consistent with the diagnosis of schizophrenia. Other studies of T.A.T. characteristics of schizophrenics is the tendency to avoid the nuclear family (Alkire, Brunse, & Houlihan, 1974), the family research of Werner and colleagues (1970), the case presentation of Piotrowski (1950), and the study of changes in T.A.T. stories at different points in treaUnent (Goldman & Greenblatt, 1955). One may, however, find these signs or criteria in the records of adolescents or artists who are not schizophrenic insofar as one can determine. Following are good examples of stories given by a latent schizophrenic artist who was referred for somatic complaints. After fairly short-term psychotherapy, this man is now able to lead a happy and productive life. Since he is an artist, the grossly bizarre nature of his stories was influenced by his lack of conventionality and, possibly, a somewhat tongue-in-cheek attitude. Here is his story to picture 7BM, which he entitled, "Don't Kiss Me Any More": Papa, your moustache, with its horrid, dirty color, feels unpleasant against my cheek when you kiss me. In fact, I feel uncomfortable when you come too near. Why don't you embrace a bush, it has the same texture? And don't give rne your old philosopher's look, your philosophy is not objective enough, it's only based upon your own shortcomings and frustration, which all hark back to the fact that you were abnormally kind to your mother./Mad so Papa takes the son's advice and goes in the backyard to a bush, but finds that it is his own father. Following is his story to picture 11:

160 CHAPTER 7 Liberatus has just flown from the womb which hangs lazily on the castle ramparts, swinging in the breeze. He dashes over the bridge pursued by three horrible mammoth turkeys, with beaks lined with alligator teeth. The bridge expanse between them crumbles, dashing the turkeys against the rocks below. Temporarily safe, he looks back at the womb and it now appears as a tremendous tongue with four webbed feet. But his safety is temporary, for his supposed refuge ahead is the City, gleaming not from the sun but from heavy phospho- rus powder, which having been put layer on layer on the outside of the building, appears sponge-like, and when viewed closely is not glamorous but dusty and deadish. The heroic view of the city from this distance is indeed deceptive. The subject reported many dreams just like this story. His story to picture 12M follows: The son with his sensuous upper lip drawn up, his feet languidly held apart, and his hand close to his genitals, seems to be in the midst of a very pleasant dream. The old man motions and chants, believing he has induced this dream and sleepy state. As the old man turns, one sees that he has no facial features. He wants the young man to awaken now, so he can suck some of his youth from him, vampirish or something like that. The old man feels that then perhaps he will have a face again. But when the young man finally gets up, he kicks the old man down and walks away. An absence of facial features is another schizophrenic sign. Story 13MF: The young woman stands nude on the model stand. But she is without detail, no facial features, no teats, no fingernails. The artist first paints small circles on her breasts of a very beautiful color, a wonderful coral, like the color in some shells he brought from Acapulco. But as he paints in more details, she becomes less, rather than more, lifelike and finally falls down flat as if she were an uned mannequin. The artists feels very tired and sick in the stomach; all this work for nothing. He goes out into the streets and sees all his fellow mannequins mechanically moving about. An indication of emotional impoverishment consistent with schizophrenia may be seen in the "mechanically moving about." Story 17BM: Mike Jensen is climbing the thousand-foot rope that leads, though he does not know it, to Hell. He pauses on his ascent in the arena, as he notices a woman sitting in the second balcony, feet wide apart. Why is man always attracted to frustrating glimpses of women's thighs and hairy organs, when women happen to be a bit indecorous in the way they sit? Needless frustration, must train oneself not to be diverted by such things; the only worthwhile thing is the whole salami. So upward he goes again, but he slips when he unexpectedly comes to some thorns in- terwoven in the rope. Mad as he slips down the rope at a terrific speed, he is split in half, as he lands in the sawdust of the arena, he appears as two sides of a cow, newly delivered to the butcher, and waiting to be put in the icebox. But some people like warm meat; and just as spectators break from the bleachers to uproot the football goals, many people with grotesque ape-like faces rush to rip at the red- purple meat. The utter cruelty and bizarreness are again very suggestive and a strong indication of a schizophrenic process. An example of thought disturbances in the T.A.T. of another latent schizophrenic is the following story to 17BM:

CLINICAL AND OTHER PROBLEMS OF THE T.A.T. 161 e ramparts, : mammoth a crumbles, e womb and nporary, for ¢y phospho- ng, appears The heroic icture 12M ,art, and his he old man he old man I now, so he d man feels up, he kicks ail, no facial tsts of a very n Acapulco. finally falls and sick in tll his fellow izophrenia es not know the second of women's vay they sit? only worth- be thorns in-

Iv

it in half, as ered to the bleachers to

f

at the red-

l

trong indi- the T.A.T. The man is climbing up the rope. There is a crowd chasing him. He is viewing something. Might be looking out to sea. Looking for a boat to come in. He'd be one of the men to bring in the cargo. He's alongside of the building. People are chasing him because he is on the side of a building. He is in a hurry--he is in a funny position. People are mad at him--has no clothes on. Walking around the streets naked. He is some character in history. Brutus. He wouldn't be looking for a boat after all--just fleeing from the crowd. They are after him. He took their money--he wants to get rich all of a sudden and retire. He gets away-- does not look worried. Gets on top of the building. Gets on the road and gets away. He has no money with him--so he gets away somehow without the money. In this story one may see some incoherence, some non sequiturs: "People are chasing him because he is on the side of the building." Another example of a schizophrenic who, in the course of time, made a serious suicidal attmnpt, may be seen in the following stories: Story 1: • . . Broken violin . . . sick boy . . . unhappy boy . . . lonely boy . . . Outcome should be successful . . . could be competent violinist. May I ask, is there a time on this? (None) . . , (What led up tog) Well, he may have lost his mother--or his father.... Either of which may have been violinists .... Is that enough? . . . The alternate is suicide .... That's a problem which he will have to face himself. Story 3BM: (Long initial pause) It appears like--appears that this picture represents--a deformed person--possibly a hunchback . . . depressed and-contemplating what to do about his dilemma... As in the first picture, this problem is unresolved. I mean by that--it could be successful in that an adjustment can be made to his deformity , . . or . . . the alternate course of action. (Returns picture.) (Which would be?) Suicide. The "broken violin" and the "deformed hunchback" suggest extreme disturbances of self-image. The mention of suicide in a relatively inappropriate context forecasts the future development. Adolescents The T.A.T. stories of adolescents deal with stage-related developmental conflicts of separation versus individuation, dependency versus independence needs, loyalty to the peer group versus the desire to be unique, and the struggle with emerging feelings of sexuality (Bachtold, 1977; Brody & Siegel, 1992; Cooper, 1977; Dana, 1986; Henry & Farley, 1959a, 1959b; Megargee, 1966a, 1966b; Neman, Neman, & Sells, 1974; Oz, Tari, & Fine, 1992; Porter, 1990; Sheikh & Twerski, 1974; Teglasi, 1993). The full-length book clinical presentations of T.A.T.'s of adolescents in Brody and Siegel (1992) and Teglasi (1993) are especially recommended for the in-depth discussion of typical adolescent characteristics on the T.A.T. The one drawback of Teglasi's interesting book is that she confines her use of thematic tests to the T.A.T., even with young children, while Brody and Siegel's important developmental study more appropriately employs the C.A.T. with the same research participants when they were children and the T.A.T. during their adolescence, The majority of the adolescent T.A.T. studies stress the typical reemergence of the preschool conflict of separation/individuation and oedipal conflicts, as in the following story of a 13-year-old boy to picture 5:

162 CHAPTER 7 (Long pause) I am trying to figure the thing out. Well, she could be either calling a member of the family or investigating a noise she's heard in this room. The light's on. Looks to me like she's showing a little bit of the element of surprise. She's surprised. A little bit of fright mingled in with this. Surprise and fright mingled in. As if naybe she heard a burglar downstairs in the house. The way it's drawn she's tensed up in a way. As if ready for sudden action. Might be that there's a burglar in the house. She's calling somebody in the house. She could be calling one of the children or her husband. Or she heard this noise, came downstairs, found this burglar in the house. Doesn't quite know what to do. Been taken by surprise. Doesn't know whether the burglar will kill her or not--like most people who own their own homes, and burglars enter. Don't know whether the burglar will kill you or not. Most burglars carry guns or a blackjack to knock you out. Burglar overpowers her and takes valuables, or her husband comes down and overpowers the burglar. In saying, "She could be calling one of the children or her husband," he really asks whether he or the father would be the rescuer of the mother; also either the father or he could probably be the burglar. Judging by associations to the story in the last two lines, we have a choice of his being the burglar and taking the valuables or the father coming down and overpowering him. This story represents variations on the classical rescue fantasies. It also illustrates the most frequent dynamics behind burglar fears, and makes use of the classical symbolism of robbery of valuables from a woman as a representation of sexual drives. Similarly, story 11 of another adolescent boy of age 18 shows the paranoid-like fear of the father figure who has always "bested him": • . . Some surrealistic painter's idea of a fleeing individual chased by a number of goblin-like monsters led on by another person, possibly it's--a--sna--possible escape of this man being chased will be of no avail. He's just going on and on into everlasting nightmare .... By the appearance of the .... Man's touch has been around here . . . through the bridge, road. Must be a nightnare, then, of some human--because in the dream man's influence has shown itself in the bridge and the road. Possibly the dreamer is seeing himself chased into an eternity that there was no hope to escape from. Perhaps he was just fooling himself that getting away from these things for a while would make him safe. I suppose he hasn't given up life or thoughts of a better life because he hasn't given up running away from these evil things. Maybe the man behind these ghoul-like things is a person he fears or hates--some strong emotion between him and that man. Feels that he's been persecuted all his life by this man and has spent his whole life running away. Possibly this man driving the beasts has bested him in business deals or in the choice of a nate .... he's always had the upper hand. On the other hand, it may be his own reflection on himself that hemduring his life has persecuted some individual and--a--is repenting or seeing himself as a chased individual sees himself. The man whose mind is reflected in being the pursuer, he may because of his dastardly deeds be a washout or disintegrate because he feels sorry for the other man. And the other nan, after seeing himself in actual life being treated the same way he is, in his dreams, probably finally gave up trying to escape some relationship that will never end; just continue on till he dies; just gave up all hope. Another case of an adolescent girl (Bellak, Levinger, & Lipsky, 1950) permits us to demonstrate the value of the T.A.T. for studying small developmental changes in a personality. A 16 I/2-year-old girl was seen in a social agency and given a T.A.T., a Wechsler-Bellevue Intelligence Test, the Goodenough Drawing Test, and the Bender Gestalt Test. At that time, the girl was found to be an essentially normal adolescent with a compliant attitude toward a mother seen as benevolent, though somewhat domineering. si, tr: rf n s£ dl w n

told be either calling a a. The light's on. Looks surprised. A little bit of e she heard a burglar As if ready for sudden )mebody in the house. heard this noise, came tt to do. Been taken by most people who own lar will kill you or not. erpowers her and takes her husband," he re- : mother; also either 3ciations to the story and taking the valu- story represents vari- .ost frequent dynam- olisn of robbery of ws the paranoid-like based by a number of -sna--possible escape nd on into everlasting ,een around here . . . maan--because in the ?ossibly the dreamer is e from. Perhaps he was ould make him safe. I te hasn't given up run- -like things is a person eels that he's been per- tway. Possibly this man )f a mate .... he's al- ection on himself that !ting or seeing himself in being the pursuer, :ause he feels sorry for eing treated the same relationship that will ipsky, 1950) permits elopmental changes and given a T.A.T., ing Test, and the entially normal ado- enevolent, though CLINICAL AND OTHER PROBLEMS OF THE T.A.T. 163 Eight months later, the girl returned to the social agency because of a minor emotional problem. At that time, a psychiatric interview substantiated the impressions gained from the various tests. However, since the girl had suffered quite a traumatic experience since the istration of the test, a second T.A.T. was ad- ministered by a different examiner to ascertain whether there were any new dynamic developments. It was noted in the psychiatric interview that the girl now described the mother as somewhat more domineering--the description may have had some basis in fact, related to the mother's entering into the menopause. The first and second T.A.T.s were compared; they were then shown, independently, to two psychiatrists and to three classes on the T.A.T. that the senior attthor was conducting. These classes contained 110 students, most of whom had acquired a Ph.D. and many of whom were practicing clinical psychologists. In all cases, the two T.A.T. records were shown for blind comparison; the judges were told that these were T.A.T. records of the same person, given on two different occasions. They were not told which test was given when, nor what happened in between. The results were unanimous; the second record was identified as having been given later and was thought by the judges to have been istered after psychotherapy. They pointed out changes in the direction of maturation in the second record. It must be emphasized that the subject had not received any psychotherapy and that the changes noted by the judges confirmed our personal impression of this girl's spontaneous emotional growth over a critical eight-month period, as reflected in the difference in the two T.A.T. records. The slight emotional disturbance for which the girl returned to the agency seems to have been incidental to this developmental process and disappeared promptly. Following are four stories from each of the two T.A.T.'s istered, which are representative of the changes discussed. Picture 1, boy with violin: First record of T.A.T. See a boy at the fiddle; doesn't look very happy; seems to be sad. Don't think he wants to play fiddle, though mother must want him to. I think mother wants him to for his education; wants him some day to be a violinist, but he doesn't want to by looks of this. Second record of T.A.T. This is a boy looking at a violin. There is a sheet of music. He is thinking if he can play or not. I imagine he likes to play. He asked his mother for a violin and is thinking about it now. He played and became great. He looks very interested in it. In the first record, one sees the hero compliant to the mother, unwillingly and unhappily. In the second record, there is an independent striving, interest, the mother seen as giving. The tone is happier, though self-criticism has entered in it. Picture 14, silhouette at window: First record. Picture of fellow looking at stars or moon; must be thinking of someone he loves, or perhaps his mother; likes to be with her; seems lonesome; might be far away from home somewhere. That's all. Second record. This is a boy looking out of a window. It's dark out. He is looking at the stars and sky. He is thinking of his future; of opening up a business---or what he's going to do. He is thinking of his girl and home, and is peaceful. Maybe he got what he wanted, a happy life today, a happy home. The first record shows dependence on mother, longing and lonesomeness.

164 CHAPTER 7 The second record shows a very similar story, but the hero is peaceful, planning for the future, with independence and heterosexual gratification (even though the hero is still a male). Picture 17GF, a girl on bridge. First record. This picture looks as if by the river and men are working there. Girl leaning over bridge and she must be dreaming that someday her boyfriend, off to war, and someday he would come home. That's about all. (What sort of girl is she?) Looks to be nice, sits home and waits, wouldn't go out with other fellows; she must love him very much. Second record. This is a river scene, down South. I'd say a girl is on a bridge. It's a nice day and men are working. She's dreaming; looking out on water.2 Must have someone on seas-husband, or boyfriend and she's longing to have him near her and see him again, m have him safe. He comes home and she sees him once more and they're happy. Again, the two stories are extremely similar. But in the first record, it all stays on the fantasy level, and there is no resolution. In the second record, a happy solution of the same problem is permitted on the reality level. Picture 20, man by lamp post: First record. Man by a light; seems to be waiting for someone; seems to be impatient; seems to be waiting for fiancee and they can't see each other. Waiting for another man. The reason he may not be able to see his fiancee, for mother forbids it. (Why?) She may not like him and so they have to meet on corners. (Why doesn't the mother like him?) Bad disposition or different faith. (How does the girl feel about this?) Girl likes him very much and doesn't care what the mother says, but she doesn't want to hurt mother so sees him on the side. (What is the outcome?) In the end, she realized that he is bad for her and listens to her mother. Second record. He is waiting for his girl to come down. She is someone he loves. Her mother may not approve of him and they have to meet outside. They love each other deeply. They meet on street corners. In the end her mother realized that they love each other and grants their wish that they want to be married. Her mother disapproves of him because he might be of a different faith, might not have job, or be of a different class than she. In the first record, mother is seen as a barrier to the hero's psychosexual adjustment and the girl complies with her mother's wishes, which she identifies with her own advantage. In the second record, the mother is still seen as disapproving but her approval is no longer essential for the hero, who is more autonomous now, and, by implication, more attached to the heterosexual object than to the mother. Here, the mother subsequently grants her approval, and the person has thus achieved a synthesis.

The Influence of Contemporary Events on the T.A.T. Stories Bellak's (1944) doctoral dissertation study under Murray at Harvard dealt with the experimental situation of artificially introducing aggression in subjects by provoking them or giving them posthypnotic orders to feel aggressive. Therefore, when these subjects were asked to give stories to the T.A.T. pictures, it became ap2 Any reference to water or fire in T.A.T. (or C.A.T.) stories suggests a histo7" of enuresis. Empirically, this correlation has thus far been 100 percent in cases where inquiry was possible.

CLINICAL AND OTHER PROBLEMS OF THE T.A.T. 165 lanning for though the .'re. Girl lean- ,ar, and some- ) be nice, sits uch. lge. It's a nice '. someone on him again, to y. :d, it all stays , a happy sobe impatient; ther man. The e may not like . disposition or esn't care what (What is the out- r. ; he loves. Her h other deeply. each other and tim because he an she. chosexual ad- identifies with i disapproving )nomous now, to the mother. rson has thus arvard dealt in subjects by re. Therefore, . it became apparent that they would project some of the aggression into the stories. Split-half comparisons between five stories told under these circumstances and five stories told without induced aggression, however, showed that the main personality characteristics persisted despite he artificial situation that was introduced. To a large extent, the subjects would differ in their manner of handling the problem of aggression, expressing it either as extra-aggression or intra-aggression, or reacting with guilt feelings, and so on. This study was successfully replicated nearly a half century later by Cramer (1991b). On another occasion in a similar manner, Bellak (1944) studied depressive feelings and joyfulness induced by means of hypnosis. Again, the effect on the T.A.T. stories was such as to leave the essential personality structure intact. In an experiment by Coleman (1947), an attempt was made to gauge the effects of a pleasurable, optimistic movie on the T.A.T. stories of children. Of all the stories obtained from the 37 children tested both before and after the movie showing, only one story (out of a total of 370) seemed clearly to reflect the content of the film. A grim real-life situation provided us with another more reliable opportunity to study the effect of current experience on T.A.T. stories. Julius Streicher and Alfred Rosenberg were given T.A.T.s in Nuremberg prison at the time of their trials. The tests were given in German and then translated as carefully as possible.3 Both men were in prison at the time, after the failure of what to them was a life's work, awaiting a nearly certain death at the gallows. Since their T.A.T.s have no specific outstanding merit in and by themselves, for the sake of brevity only a few illustrative stories will be presented from each record. Streicher4 Julius Streicher probably deserved more than any other top-ranking Nazi the clinical diagnosis of psychopathy (in the sense of a person with an undeveloped superego). His newspaper, Der Stuerm was full of perverse, pornographic literature and pictures. He pulled out men's beards and engaged personally in whippings and other expressions of sadism and uninhibited impulses. His intelligence was the lowest of all the Nazis tested at Nuremberg. Below are presented four of his T.A.T. stories. 3BM: Kurt Heinz is the only son of the nanufacturer Grundher. Just as the proverb says, "one child is a misfortune," so it turned out to be in this case. All of Kurt Heinz's wishes mere fulfilled both by his father and his mother. There was nothing denied him. He was both Mama's and Papa's boy--but an unfortunate child. Although his father told him: "Kurt Heinz, never take the revolver I have in my night table," the spoiled child did what he had secretly decided to do. While the father and mother were going walking, he took the revolver uresis. Empirically, The tests were given by Dr. G. M. Gilbert (1947), in his official capacity as Army Prison Psychologist at Nuremberg; he reported on his experiences elsewhere. We are greatly indebted to Dr. Gilbert for making these T.A.T. records available. 4 Reprinted by permission of the Journal of Projective Techniques.

166 CHAPTER 7 out of the bedromn, and said to his friend Lothar: "Stand against the wall, I'll put an apple on your head and I'll play William Tell. Stand against the wall. You will see, nothing will happen. I'll shoot the apple off your head." Kurt Heinz suddenly realized the consequences of disobedience. Greatly disturbed and repentant, he waits for the return of his parents with the determination to tell his father: "Father, you were right when you warned me, I have learned enough from this moment to last me a lifetime. Fathm; I promise you, you will never have any more trouble with me." 4: He is an artist. His model is sitting half naked on the sofa. Suddenly, the door opens and his girlfriend surprises him in his studio, having just returned from a vacation and surprised him in this intimate episode in the studio. "Why do you do this to me?" she says to him. "Didn't you promise to think only of me, when I left you? Didn't you say, when you kissed me good-bye, that I am the only girl in your heart? Speak, why do you turn away? Can't you look me in the eye any more?" His eyes turned far away and he said: "I did not want to be unfaithful to you; I fought against it--but some demon in me caused me to forget for a moment--only for a moment. We'll talk about this later. Go now. Leave me alone with the girl. I'll talk to her and explain how this came about and why it had to be this way." After the model left, the young painter knocked on the door of the ading room and said: "Now we can talk." He looked at her with a penetrating look, as if to say, "We don't have to talk--you understood me when you left." She gave him both hands, and said to him, "My dear friend, I feel that I have not lost you. You are alive in me, and will always be in me. Your love excuses the moment you forgot me." (Now let loose and tell me what you realy think.) Of course, she is a mulatto; the artist is a fine type, with bright eyes and blond hair, is surprised by his mulatto lover at the moment that a blonde, blue-eyed Nordic girl came to pose for him. The mulatto makes accusations that he is two-timing her with the blonde. He is silent--if he were to talk, he would say, "I loved you only with lust. There is blood in you which prevents me from possessing your soul. Blood attracts blood. My true love belongs to the blonde girl, with whom I wanted to enjoy this hour." 5: The woman opens the door and says to her snoring husband: "Come on, the food is on the table." But the man says: "As long as I am eating, please stay in the kitchen, because when I see that face of yours I lose my appetite." 8BM: There was a duel. The two men had fought over a woman. Two doctors are busy trying to get the bullet out of the wounded one's body. The victor turns away fiom the operation and looks thoughtfully into the distance. He knows that he was the guilty one and his bullet had apparently killed an innocent man. He is thinking about it--self-accusations about the injustice of fate in this duel. He says with bitterness: "It's a terrible thing that I, the guilty one, am victorious, and the innocent one, who had a right to kill me, had to lose his life." Streicher's story to picture 3BM shows the hero engaged in a forbidden aggressive act--endangering his friend with a pistol. It is unclear from the story whether he actually wounds or kills his friend. If the latter, the story is certainly re- markably shallow with regard to punishment. Even if the implication is that he only used the forbidden pistol without causing physical harm, the repentance is shallow and without punishment (e.g., even a disciplinary measure by the father). In this, the theme differs markedly from similar stories of neurotics or well-adjusted people, who ma express various torms of retribution or remorse; the hero might be punished by the parents or by the police or court, or the hero might be considering suicide and might even think of a variety of ways of apologizing and attempting to console the victim. Story 8BM shows a similar theme. Against the background of an oedipal theme, the hero appears guilty and yet, in the duel, is permitted to kill the innocent mB:h @\ix%\S',Xk\'gatx\ 5'c <5eu:xce except some ver,/superficial verbalization that puni the , crim Stre by a con atti for reel war Je, his ea Ul b,"

, I'll put an apple nothing will hap- :consequences of is parents with the he. I have learned u will never have ly, the door opens t vacation and sur- o me?" she says to you say, when you u turn away? Can't "I did not want to me to forget for a me alone with the this way." After the and said: "Now we 't have to talk--you m, "My dear friend, e. Your love excuses ) Of course, she is a rised by his mulatto Jr him. The mulatto :--if he were to talk, events me from pos- .de girl, with whom I "Come on, the food the kitchen, because Two doctors are busy ns away from the op- the guilty one and his t it--self-accusations rrible thing that I, the ill me, had to lose his in a forbidden ag- lear from the story

i story is certainly re- l

ation is that he only pentance is shallow ' the father). In this, )r well-

adjusted peo- :; the hero might be might be consider- izing and attempting 'ound of an oedipal d to kill the innocent superficial verbalizaCLINICAL AND OTHER PROBLEMS OF THE T.A.T. 167 tion in the form of a monologue. We have found in past experience (Bellak, 1952e) that the relationship between a crime committed in the stories of the T.A.T. and the punishment meted out to the guilty one by the subject is an excellent measure of the strength of the superego. The more severe the punishment in relation to the crime, the more severe a superego we deal with, and vice versa. In the case of Streicher, we can certainly say that the punishment is much less than to be expected by any civilized mores and thus can conclude that he hardly suffered from a severely controlling superego. Similarly, in stories 4 and 5, we can observe the aggressive, unkind, primitive attitude toward women and the utter lack of feelings; he uses a glib rationalization for his unfaithfulness by ascribing it to some demon within him--a not infrequent mechanism in young children (particularly postencephalitic ones). His attitude toward women in story 4 leaves room for speculation about his possibly identifying Jews with them--seeing them as an inferior race--and its ultimate relationship to his feelings about his mother, but this is outside our present frame of reference. Rosenberg Mffed Rosenberg was the original theoretician, or rather, the mythologist, of the Nazi party, of Aryanism and racialism. He emphasized the cultural values of early Germanism, urged a return to the pre-Christian religious cults, and a love for unadulterated nature. In conflict with other Nazi leaders, he fell into disgrace years before the final debacle. Below are seven of his T.A.T. stories. 3BM: This is a woman who has had little happiness in her life and had no pleasure in her work. She has fallen in love with an adventurer, full of tantastic hopes. She clung to this last hope of her womanly existence and sacrificed all her savings to hin. When the lover began to notice that her money was becoming exhausted, he began to desert her until she finally realized one day that he had left her completely. When she realized this, her last hope was lost and she just collapsed. This moment is represented in the picture. It shows a woman who is not beautifully built, with ugly hands and fingernails, crying on the sofa. She is middle-aged and has no further hopes. 7BM: In a popular restaurant, a carefree young man gets acquainted with a man of the world. The old man sees a new victim in the young man. He introduces the young man into a circle of young adventurers and adventuresses. In the course of time, the young man drinks and gambles his fortune away so that he finally must tell the old man that he is no longer in a position to continue this wild life. At this moment, the friendship of the old man ceases and he considers whether to leave him for good or to advise him to get money by under- handed means. The picture shows the scheming old man and the disillusioned young man at this moment. 9BM: An adventurous youth gets tired of his home. The peaceful existence in his mother's home has become boring. He decides to go bumming and see life in the raw. On the way home, he runs into a vagabond party. A Negro who has run away from his boss and other similar characters are looking for jobs with little work and good pay. The young man s this trio; they do some work on farms along the way and the young man notices that each time they leave a place, they take something with them. But that was not what he left his home for. He finally decides that adventuring doesn't have to be combined with stealing and such things. On a hot afternoon, all four lie down on the grass for a rest .... The three tramps fall asleep and our young man now has time to look them over. He decides that they

168 CHAPTER 7 are rather brutal cmnpany with whom he could not live very long. He gets up slowly as they lie there snoring and decides to look for better company for his adventurous spirit. 10: A loving mother notices how her daughter has become gradually estranged from her. All her onitions to be careful in her selection of friends are laughingly rejected. The estrangement between mother and daughter becomes greater and greater. The daughter trusts herself entirely to her lover and ignores all warnings from her mother. One day, the daughter realized that her friend has left town without saying a word. She learns from her friend that he does not intend to return but has left for a foreign country. Betrayed in all her hopes, she returns to her mother. The latter receives her with understanding and love. This is the moment of the expression of motherly love, with an attempt to show that the daughter intends to be more careful in the furore. 12M: In a little town there lived an old man who had all kinds of mysterious magnetic and telepathic powers. It was said that he could often, though not always, produce cures by this means. One day he is asked for help by a worried mother. She tells him of her son who has recently become somewhat mentally disturbed. He suffered from attacks of mental depression. Little incidents appear to him like the persecution of bitter enemies and he has become quite sick and desperate. The old man follows the woman to her son. He sits at his bed, listens to the young man's stories, and then strokes him gently on the temples. At the same time, he explains all these incidents in a calm manner and in a short time the boy falls asleep. The next day, he wakes up refreshed and after some further visits the anxiety actually disap- pears and he can again associate freely with his friends. 17BM: The acrobat is pulling himself up for his trapeze act. At the other side of the circus he sees an old colleague doing a new stunt. He holds still for a while and watches this new stunt. His attitude is half wonder and half jealousy. He grasps his rope more tightly and says to himself, after watching a while, that he could never perform such a stunt with all his strength. Thus depressed, he climbs down again and refuses to perform any stunts that day. 19: A schoolboy had many friends who were artistically talented. One was musical; another had written sone stories. And so the boy was also inspired to take up some form of art. He tried painting. Since he could not succeed in spite of all efforts, he took lessons from a well-known painter, in order to be able to compete with friends. He pursued this study with great interest and, just as his friends indulged in fantasy on the piano, he wanted to make pictorial compositions. He painted clouds and waves. But when he finished a painting like that and showed it to his friends, he got only a storm of laughter. It was evident that, without talent, even painting was a book with seven seals. That was probably the story of the man who painted this picture. In story 3BM, Rosenberg identifies with a girl who has fallen in love with an adventurer who promptly deserts the girl and leaves her depressed. Story 10 is a repetition of this theme, with the one addition that the mother is left by a hapless girl who, however, returns to the understanding maternal care after having been left by the faithless man. Story 7BM is only a slight variation of the theme in that a young man comes under the spell of a ruthless adventurer who is about to desert the youngster as soon as he has been fully exploited. In story 9BM, the hero leaves what is specified as his mother's home, for bad company, with which he soon becomes disenchanted. In these stories it appears that Rosenberg identifies himself with a girl, or a young man, seduced and exploited and betrayed by a figure that one must strongly suspect of representing Hitler himself. Aside from the feminine-homosexual relationship of Rosenberg to Hitler, which these stories suggest, it becomes apparent that our subject had a strong mother fixation. A tone of depression and hopelessness can be noted throughout all responses. The bad company that the hero gets into in 9BM probably represents the Nazi party, for the plundering and brutality of which our subject expressed belated disdain. merit a ma] male 17BB to th learr of th ture time hires figur svei sam, agn{ have girl hop, wide facu T.A. fact thol of t ovel stor per the mo en{ T.A Fu sho pre the de 5S

CLINICAL AND OTHER PROBLEMS OF THE T.A.T. 169 Story 12M again shows the general tone of depression, with awareness of a mental disturbance in the hero, and a wishful ending. This is the only story in which a male figure is seen as benign; it must be pointed out, though, that even here the male is helpful only through the instrumentality and care of the mother. Story 17BM also shows hopelessness and depression in a competition that may well refer to the higher star of Joseph Goebbels. Story 19 speaks of a young man who tries to learn from a well-know painter in vain. It is most likely a repetition of the themes of the earlier stories, Hitler being the house painter and erstwhile illustrator of picture postcards who achieved quite some notoriety. The bitter criticism, at the same time, against the unsuccessful painter we may surmise to be directed against Hitler himself, in a not unusual condensation of the theme and the main identification figures. Streicher appeared in the T.A.T. as a man of great physical and verbal aggressiveness and with primitively lustful and despising attitude toward women. At the sane time, he showed an absence of superego functioning consistent with the diagnosis of psychopathy. Rosenberg appeared markedly depressed. He seems to have had a ive homosexual attachment to Hitler, identifying himself twice as a girl in this relationship. He also reveals a strong fixation on his mother. Both men were in jail, expecting to be hanged, with all their desires and hopes doomed. Even so, our brief and simple analysis of their T.A.T. records shows widely differing personalities despite the overwhelming contemporary situational factors to which both were equally exposed at the time of the istration of the T.A.T. The stories not published are consistent with this statement except for the fact that some depressive overtones also appear in some stories of Streicher, although mostly as superficial religious speculations. These T.A.T.s, then, we believe, throw some light on the much-discussed point of the possible invalidating influence of contemporary situational factors on the overall validity of the T.A.T. While the current mood of depression enters into the stories of both men, there is nevertheless evidence to show that clearly different personalities emerge; the essential character structure revealed is consistent with the historically known facts about these two men, and may be taken to represent the more stable, permanent, and significant features of their makeup. Thus, the influence of contemporary situational factors does not seem to affect the validity of the T.A.T. as a method of clearly demonstrating the essential dynamics of personality. Furthermore, these two T.A.T. records confirm previous work (Bellak, 1950c) which showed that such current experiences as experimentally provoked anger or depression (Bellak, 1944) did not disadvantageously affect the fhndamental validity of the personality structure revealed in the T.A.T. The Problem of Overt and Latent Needs in the T.A.T.5 The interpreter of T.A.T. stories is frequently presented with the necessity of deciding whether a need expressed pertains strictly to the fantasy level or might be 5 See Chapter 2.

170 CHAPTER 7 expressed in reality--for example, the need for aggression or for achievement. The psychologist should have available a maximum of clinical and biographical data about the patient. It must be kept in mind that the clinical situation is not one concerned with testing the validity of the instrument. Problems of the validity of the T.A.T. are dealt with in experiments and must be decided there. If one has sufficient information on the patient, then the T.A.T. stories must be seen as complementary to the behavioral data obtained. For example, if the subject is unduly shy and retiring and the stories are full of aggression and guilt feelings, the dynamic implications are obvious. On the other hand, there are certain indications from intra-test situations that permit us to make assumptions about the manifest or latent needs expressed in the T.A.T. For instance, in stories of achievement, it is extremely important to notice whether they follow the deus ex machina mechanism or are actually accomplished piece by piece, suggesting much more that they correspond to a behavioral need for achievement. It was R. N. Sanford who pointed out some important rules concerning the relationship between fantasy needs and behavioral needs. He suggested that there are certain needs that are usually high in fantasy and low in behavior--namely, those needs that are usually prohibited and inhibited by cultural pressure from overt manifestation. These are mainly the needs of acquisition, aggression, autonomy, and sexual activity; the wish to be taken care of; and the need for harm avoidance-- the last two suffering more cultural repression in men. On the other hand, some needs may find little manifest expression in fantasy but much expression in manifest behavior because of reality demands, such as the need for order, for avoiding social blame, for learning. Again, there is a class of needs that may be high both in fantasy and in behavior, indicating that, while these needs are permitted and encouraged socially, they may yet be sufficiently frustrated to need particular gratification of the fantasy level. To these belong especially the needs for achievement, for friendship, and for dominance. The study of the defenses as a means of linking the latent and the manifest is of signal importance (see Chapters 6 and 9). Again, it must be emphasized that the T.A.T. should be used to complement behavioral data; only in specific instances is it necessary or desirable to use the T.A.T. for the prediction of overt behavior. For these cases--personnel studies, appraisal of suicidal tendencies, or likelihood of overt extra-aggression--the internal evidence of drive versus defense must be weighted apart form manifest behavior. Psychosomatic Disorders and Thematic Tests There has been a considerable upsurge of the interest in the use of apperceptive techniques for exploring psychosomatic disorders (Cabras et al., 1983; Blumenthal et al., 1985; Hoffman & Kuperman, 1990; Silva, 1985; Viberg et al., 1987). This may be a time for cross-fertilization of all the fields concerned with psychodynamics and it may behoove physicians and pediatricians to acquaint themselves with treatments of the apperceptive techniques, certainly in simple ways more accessible than the Rorschach to anybody who can make any dynamic inference.

! re- !are

lose ,vert lmy, ome aani- cling th in [t eil- ratifi- it, for lest is t the ices is ir. For iod of st be CLINICAL AND OTHER PROBLEMS OF THE T.A.T. 171 Distorted notions of illness and medical procedures may be illuminated in simple projective techniques, and thus make the patient more accessible and cooperative. This plays a specific role in liaison psychiatry--where the task is to understand the patient in his or her illness very promptly and arrive at useful insights very promptly. In a study by Silva (1985), the Rorschach and the T.A.T. of two groups diagnosed with duodenal ulcer were compared. The initial aim of the paper was to ver- ify if the Rorschach and the T.A.T. could discriminate between the group whose ulcers healed after one month of treatment and the group whose ulcers did not heal or had reappeared. Factor analysis of the correspondent results suggested that the Rorschach tends to discriminate between them and the T.A.T. does not. In the same paper, a sample of responses characteristic of boys and girls to the C.A.T.-H were studied. The stories told to C.A.T.-H by 50 boys and 50 girls, from 6 to 10 years old, were analyzed in reference to apperceptive and thematic data. Significant differences of such data in boys and girls were found in each of the 10 cards, and occasionally consistent in more than 1 card. The assumption of sex- related patterns of response was discussed. Aaron (1967) was able to determine several personality differences between asthmatic, allergic, and normal children using T.A.T. responses. Some of the obtained differences were: Asthmatics showed significantly more hostility than nor- reals on a measure of hostility relating to card 3; asthmatics showed significantly more disturbance with the parent of the opposite sex than did normals, but none with the parent of the same sex; and asthmatics and allergics both indicated general feelings of loneliness and rejection by the parents significantly more than did normals. Other studies of thematic tests of individuals with somatic conditions include that of Cabras and associates (1983) of ulcerative colitis patients, Blumenthal, Lane, and Williams (1985) of cardiac patients, Greenbaum and colleagues (1953) of physically handicapped children, Holden (1947) of children with cerebral palsy, and Viberg, Blennow, and Polski (1987) of epileptic adolescents. Valuable research on T.A.T. characteristics of substance abs is Brelet (1988) on alcoholics, Cabal Bravo and colleagues (1990) on heroin addicts, and Fassino and associates (1992) on the inaage of the self and the environment in substance abs. A related study by Volhardt and associates (1986) finds signs of alexithymia in patients with rheumatoid arthritis, which is the tendency to blunt the expression of affect. i apper- 1983; et al., ith psy- t them- s more Fence.

CHAFEER 8

USE OF THE T.A.T. IN PSYCHOTHERAPY Special Therapeutic Uses of the T.A.T. Test responses are forms of behavior of the patient, like any other forms of behavior except that the responses are made to standard stimuli and thus permit controlled comparisons from one person to another. Furthermore, the content that appears in psychological tests may" demonstrate fantasies and psychodynamics, which even a skilled psychoanalyst will not anticipate or suspect after many months of psychoanalysis. Many years ago, a training analyst permitted the senior author to ad- minister the T.A.T. to a patient of his who volunteered to participate in the investigation. The analyst agreed that the T.A.T. pictures brought out important features that had not become clear during almost a year of psychoanalysis. Ethel Tumen Kardiner, in an unpublished study, was able to demonstrate experimentally with the cooperation of a number of psychoanalysts and their patients that the T.A.T. could successfully illustrate the psychodynamics that had become clear only after prolonged analysis. From the standpoint of planning treatment, it is useful to obtain as much advance information as possible. The T.A.T. is of particular value as a vehicle of the psychotherapeutic process itself, especially in cases where therapy must of necessity be short term, in emergency situations (self-endangering or extremely crippling depressions, or acute anxiety), or in social agency settings, clinics, and the like (Araoz, 1972; Bellak et al., 1992; Hoffman & Kuperman, 1990; Meyer, 1951). Bellak, Pasquarelli, and Braverman (1949), Meyer (1951), and Rosenzweig (1948) have suggested ways the T.A.T. may be employed with patients in regular individual psychotherapy. Araoz (1972) showed how it may be useful in marital therapy. Hoffman and Kuperman (1990) suggested how a discussion with patients in psychotherapy of repetitive themes in T.A.T. cards may be useful in pointing to a history of trauma, and Bellak, Abrams, and Ackermann-Engel (1992) outlined steps in utilizing thematic tests to obtain a quick view of psychodynamic issues in brief and emergency psychotherapy. The type of patient encountered in any of the preceding situations is frequently quite naive about psychotherapy and entirely unaccustomed to the thought processes involved in it. Patients may consider their complaints to be organic or ena The T.A.T. may be especially useful in Emergency Psychotherapy and Brief Psychotherapy (see additional references, Bellak & Small, 1965, and Bellak, Abrams, & Ackermann-Engel, 1992). 172

USE OF THE T.A.T. IN PSYCHOTHERAPY 173 aer forms of be- aus permit con- :ontent that ap- ynamics, which ' months of psy- ,r author to ad- e in the investi- ortant features . Ethel Tureen entally with the he T.A.T. could only after pro- ful to obtain as apeutic process term, in emer- sions, OF acute 1972; Bellak et asquarelli, and gested ways the !therapy. Araoz and Kuperman ly of repetitive na, and Bellak, iematic tests to 'psychotherapy. tuations is fre- to the thought ! organic or enitherapy (see addivironmentally caused, since they are quite unused to any degree of objective intro- spection. In such cases, one very important use of the T.A.T. is to help patients gain some "distance"from themselves and to establish the psychotherapeutic attitude. Adolescents, for instance, may come completely isolating all feeling, intellectualizing, and, in essence, saying that they are coming only because their parent wants them to. After creating T.A.T. stories, they can be asked what they think of them. They often reply that these are stories about the pictures and have nothing to do with them. The first step, then, is to tell them that we have heard very many stories about these pictures and that their responses differ from others we have heard before. To illustrate this to them, we can give them a number of themes, quite different from their own, to several pictures. This fact of being different often makes a strong impression; the entering wedge has been supplied. Part of their behavior has become ego alien instead of ego syntonic. We can now proceed to wonder why their stories are the way they are rather than the way some other people's stories are. Some very contrasting stories may be chosen to tell them. For instance, an emotionally isolating adolescent boy may have told stories that actually show a good deal of despair and anxiety. We may read someone else's less disturbed stories (if this seems necessary) and ask him what the difference is between his stories and the others. Now, insight may slowly emerge, and he may say that his stories show some unhappiness. We may then ask why that should be. If necessary, we may point out the specific circumstances of unhappiness in the stories--namely, loneliness, fear of failure and incompetence, and so on. A preferable approach is to hand the patient several of his own stories and ask him to play psychologist and tell the therapist what the two of them seem to have in common. This way, the patient may actually learn to look for common denominators in his behavior, and the process of working through may be started. By asking the patient to tell whatever else the stories bring to his mind introduces the patient to the concept of free association. Often, a central problem can be approached in this way, which may otherwise be almost unapproachable except in very long-term therapy. For instance, an ex- tuberculous patient was referred to the senior author in a social agency: He was well recovered but still retained considerable secondary gains from his past illness. It was extremely urgent that he help his family again. He had been in the theater, and many of his difficulties stemmed from the fact that he still wanted to pursue a theatrical career rather than a presumably steadier and more attainable means of livelihood. He was, to some degree, aware of the unreasonableness of his attitude, but felt unable to react differently--his heart was in the theater. Among a number of instructive T.A.T. stories, the one to 17BM proved most useful for the occupational problem. The patient's story was as follows (the italics in this and other stories are the authors'): A circus performer on a rope. There is a security on the rope that indicates that he has had much practice. He does not seem young though his physical appearance is that of a young man. There is a kind of satisfaction on his face, which makes me believe that his work is his greatest satisfaction. He knows he's good at this, if nothing else. He enjoys doinK this spec- tacular work, for at other times he is lonely and es unnoticed. To hear the audience marvel at his dexterity is compensation for his personal unhappiness.

174 CHAPTER 8 In associating to this story, the patient related that he had always liked to be ired. As a boy, he felt very much overshadowed by an older and very brilliant sister. Slowly, it emerged that he was a very good singer. His family came to marvel at his voice, and he was the center of the party when he sang. He finally felt less in the shadow. Then one day his voice started changing and his claim to iration and love vanished, which caused him to be most depressed. Not long thereafter, he had occasion to participate in a school theatrical production, and thus the transition was made to a theatrical ambition and new approbation. Now we could discuss things. Here, we had the dynamic core of this man's ob- session with a profession he could not afford to follow. We could discuss his feelings of loneliness and inferiority, which he felt were assuaged when he was in the limelight. Naturally, no miracles were achieved; the T.A.T. is not a magic wand. All the principles of psychotherapy must be observed. But this story served as a starting point for two or three sessions, which helped the man change enough to find gainful employment and maintain it. For the two succeeding years, he was a steady sup- porter of his family for the first time in his life. All test data may be useful when tied in to interpretations by the therapist. When one patient discussed the difficulties with which his wife threatened him, it facilitated matters greatly to show him his Figure Drawing Test, in which he had depicted the figure of the woman as a powerful Amazon while the male figure was much smaller and weaker. On seeing the pictures, he was struck by the fact that he tended to see women as stronger and himself as weak. In another case, a Rorschach response was useful after many months of psychotherapy, when the patient described her feelings of compliance: She had to do everything to please others, and she lacked a feeling of identity, always fitting herself into a role consonant with what the environment demanded of her. A "dress- maker's dummy," who will wear any clothes and comply inanimately, was the Rorschach response describing her feelings. In a patient who uses isolation as a main defense and who maintains an attitude of false unconcern, one may find it expedient to point out the recurrence of a hopeless, depressed tone and content in the stories. For instance, the 15-year-old boy whose stories 1 and 2 were mentioned in Chapter 6 also told the following stories. 3BM: Looks like a female in great despair. Just had a great tragedy befall her. Gadget at her knee seems to be a collapsed knife or keys or something like that. The tragedy could be anything. Dead parents, or husband--running away--or a horrible misfortune like that. She does seem to be a little deformed. (Author's note: Self-image--deformed, crippled, etc.) Can't put my finger on it but--could be a deformed person pondering and weeping over her misfortune. I see less in this picture than in most of the others. This is followed by a story to picture 13B: Some perspective there. Looks as though the picture were taken from the top of the door. Seems to be a rather recent picture, of the past 75 years. Modern dungarees. He wouldn't be a pionem: House is put together with nails; a kind of Tobacco Road. Boy is just staring at this photographer, who is a very unusual, a very new thing in his life. Seems to be looking at him with a little wonder, apprehension, tiny bit of fear. At first hand, I would have said he was a Kentucky mountaineer but the fact that the cabin seems to be in a dusty, sandy place--so---dust bowl, Oklahoma. The house is handmade, very old. The interior of the house seen obscure. Th come arol self. Work chance to i Doesn't Ic and his e seems to., In great de underpr ing any The sto come to In college, ably wit diate er ture 1, G George ter with his wonderi been t0 come a future, and to the tin mothe oboe, bed m was 1TI the lal the BI heard no so room maki lated one boy had Vie

USE OF THE T.A.T. IN PSYCHOTHERAPY 175 dways liked to be and very brilliant y came to marvel finally felt less in im to iration ng thereafter, he d thus the transiof this xnan's ob- iscuss his feelings was in the lime- gic wand. All the red as a starting ugh to find gain- was a steady sup- by the therapist. reatened him, it which he had de- 'male figure was i the fact that he }' months of psy- : She had to do !ways fitting her- f her. A "dress- ately, was the !aintains an atti- ie recurrence of the 15-year-old 011owing stories. er. Gadget at her 'edy could be any- ne like that. She pled, etc.) Can't ing over her misfrom the top of a dungarees. He Road. Boy is just life. Seems to be nd, I would have in a dusty, sandy interior of the house seems to be very dark and that would be the most revealing thing about him. And that's rather obscure. The family is very, very poor. He is jealous, envious of the big owners and bankers that come around to check up on the sharecroppers' lives. Probably sees very few people like himself. Works with his father--will hold the same position as his father without ever having a chance to have enjoyed himself. Multitude of brothers and sisters just like himself, though. Doesn't look like he's too happy a child in the picture. Seems to stem from his bewilderment and his environment, which isn't a very enjoyable picture. The lack of anything about him seems to show that he's very alone or very... (pause) . . . empty. In story 2, the hero feels isolated, alone, and angry. In 3BM, the hero is in great despair and deformed, and in 13B, the hero belongs to the suppressed and underprivileged. Yet, this boy presented a manifestly bland personal picture, denying any need for help and psychotherapy (for which his parents had referred him). The stories, however, offer a wealth of other material which, in due course, one may come to utilize as well (see Chapter 6). In the case of another patient who was referred for scholastic difficulties in college, the opening story immediately reveals how he compares himself unfavor- ably with his successful parents, on the one hand, and the conflict between immediate enjoyment and investment in work for the future on the other hand. To picture 1, the patient said: George's family is talented. His father and mother both have played before royalty. George is now eight years old and has been taking violin lessons for nearly a year. Today, after George has completed his practice session, he is reflecting on the months he has spent with his music while his friends have been enjoying themselves with less intellectual pursuits. He is wondering if he will benefit enough from the coming years of study to make it worthwhile. He has been told that he is very talented and, after all, his environment is ideal. Perhaps he will become a virtuoso comparable to his idols. His young mind unable to look any further into the future, George puts his violin in its case with reverence. He will now go out in the sunshine and tomorrow he will practice with renewed vigor. Another patient, a 52-year-old man, gave the following story to picture 1: The violin belongs to the boy's father. Now his father is dead. The boy is thinking of the times his father invited some other musicians in for a home concert as he often did. His mother played the piano and all the friends brought their instruments--a flute, a cello, an oboe, a French horn. They would play far into the night but the boy would listen from his bed and seek to catch the clear strains of the violin played by his father. One night the party was most gay--they played waltz tunes from Vienna and Hungarian dances. The boy heard the laughter and gay talk between pieces. Then they played the most beautiful waltz of all-- the Blue Danube. In the final beautiful movement as the waltz neared its climax, the boy heard the string on his father's violin break. Then all the playing stopped and the boy heard no sound--then a wail, low and prolonged, from his mother. He rushed down from his room. When the string broke, his father's heart had stopped. He was dead. This story probably reflects a biographical detail of listening to "the parents making music"---presumably overhearing an intercourse scene. The boy feels isolated and competitive. Intercourse is probably conceived of as dangerous on the one hand; on the other hand, the father's death represents a wish and leaves the boy the inheritor of the violin. The T.A.T. was given some time after psychotherapy had started and probably reflects some transference phenomena, since the Viennese music is probably a reference to the therapist (senior author).

176 CHAPTER 8 These examples may illustrate the direct use of one psychological test--the T.A.T.--as a vehicle for communication from patient to therapist as a basis for insight for both, and as providing a pattern for interpretation and working through, providing economy in all these processes in cases where economy is indicated, for external or internal reasons. Another therapeutic function of the T.A.T. has been noted by Holzberg (1963). He conceptualizes resistance to change in psychotherapy in of the patients' anxiety about adaptive regression. Holzberg's point is that projective techniques, such as the T.A.T., can play a significant role in overcoming such anxiety so that therapy can commence or continue. He regards the projective test experience as providing a chance to experience adaptive regression; thus, such test experience can overcome resistance to treatment by permitting the patient to practice regression under controlled conditions. Resistance in two patients noted by Holzberg was diminished in this way. A rather unique use of the T.A.T. cards was made by Seymour Hoffman and Nili Kuperman (1990). They tly treated a 13-year-old boy by using indirect therapeutic intervention that focused on the patient's responses to the T.A.T. cards. Rather than just exploring the content of the boy's story (which related directly to the traumatic event he had inadequately suppressed), they attempted to positively alter his perception of the story. To begin, the co-therapists each wrote their own stories to the same T.A.T. cards, each from a contrasting perspective. The psychologist, Hoffman, wrote of the central character's id and rigid superego aspects, which included his maladaptive coping mechanisms. The social worker, Kuperman, emphasized the positive and healthy aspects of the hero's ego in the story. Three consecutive sessions were held to discuss 8 of the 12 stories with the boy. The therapists first read the patient's story and then presented each of theirs in turn. The three then had an open dialogue to determine whose version of the story seemed the most accurate. During this discussion, a good amount of material was presented and the social worker's view mainly held up over the psychologist's. The Systematic Use of the T..T. in Relation to the Basic Steps of Psychotherapy In psychoanalytic therapy, one can speak schematically of four basic processes (which often overlap and coexist): communication, interpretation, insight, and working through. Communication The patient communicates with the therapist by means of verbal expressions.2 Through these, the therapist learns of the patient's behavior in a great many situations and finds a number of common denominators in the patient's behavioral patterns. The T.A.T. responses may serve as such communication. 2 This is not the only means of communication. The patient imparts information also by posture, facial expression, and so on.

:est--the is for in- :hrough, ated, for tolzberg the pa- ive tech- xiety so erience )erience regres- )erg was 1an and ect thef- T. cards. 7ectly to 0sitively eir own )sychol- aspects, erman, : Three e ther- rn. The eemed .sented ocesses It, and sions.') situa- • al pat'e, facial USE OF THE T.A.T. IN PSYCHOTHERAPY 177 Intepreaio When the therapist has become acquainted with a number of life situations of the patient, the therapist may perceive a certain common denominator in the behavioral patterns and point it out to the patient in such doses as seem to be suitable at various times. 1. Horizontal stud. The therapist may find a common denominator among the behavior patterns and interpersonal relationships of the patient's contemporary life situation. This process may be regarded as a horizontal study of patterns. 2. Vertical study. Sooner or later, it will be possible to trace, by free association or otherwise, the historical development of these patterns in the life history of the patient, leading to a more or less definitely defined early set. This part of the therapeutic investigation may be seen as the vertical study of life patterns. Frequently, it is necessary to point out both the vertical and the horizontal common denominators of the patient's current behavior in order to lead to a solution of the problems. 3. Relationship to the therapist. As a special case of current life situations of the horizontal pattern in its relation to the earlier historical ones, the relationship to the therapist may be discussed specifically in what is known in psychoanalysis as analysis of the transference situation. Interpretation, then, means that the therapist points out to the patient the common denominators in the behavioral patterns, horizontally, vertically, and in special relation to the therapist. In all three instances, the therapist finds that the patient suffers from apperceptive distortions of life situations. Interpretation really consists of pointing out the common denominators of the apperceptive distortions and, in certain cases, demonstrating the relationships of earlier life situations to percept memories in which these apperceptive distortions arose. The process involves the analysis of the present complex apperception into the parts that came to constitute the whole. A brief example may be helpful here. A young man may come in with the presenting problem of vague anxiety attacks. It may develop that these apparently puzzling attacks typically occur when the patient is in with a strict authority figure who produces hostility in him. After this horizontal pattern has appeared, at one time or another a vertical one may also be found: The patient had a more or less specific relationship to his father (as becomes clear in the T.A.T., for instance), who originally produced these feelings of hostility in him with resulting anxiety. Further study will reveal a whole history of relationships to similar authorities prior to the current situation, and a similar attitude vdll be expressed to the therapist. lns/gt Insight development is the next step in the therapeutic process. The term insight is abused almost as much as the term psychotherapy. Frequently, the term insight is used to mean simply that the patient is aware of being mentally ill. This is most often used in the discussion of psychotics, usually implying no more than just that.

178 CHAPTER 8 In the context of dynamic psychotherapy, insight must have this specific meaning-- the patient's ability to see the relationship between a given symptom and the previously unconscious apperceptive distortions underlying the symptom. More strictly speaking, we define insight as the patient's apperception (i.e., meaningful perception) of the common denominators of behavior as pointed out by the therapist. The problem is seen in a new light and handled differently from then on. This process may be analyzed into two parts: 1. Intellectual insight. Patients can see the interrelationship of their different horizontal and vertical patterns; they can see them as special cases of a general class or, in Gestalt language, they learn by insight and experience closure. The pieces of isolated happenings become a memory whole, and a repatterning and relearning takes place. 2. Emotional insight. The patient reproduces the affect pertaining to the intellectual insight--relief, anxiety, guilt, happiness, and the like. If the intellectual insight alone is produced, limited or no therapeutic result may be achieved, because emotional repatterning is an essential of the therapeutic process, be it conceived of as a regular libidinal-metapsychologic process or as a learning process in conventional academic psychological . The affect must be part of the Gestalt of a therapeutic experience. Working Through The next step in therapy consists of the working through of the new insight: 1. Intellectually. The patient now applies what has been learned to pertain to a few situations, as pointed out by the therapist, to a number of other situations to which the same general denominator applies. If it has been pointed out that a pattern of apperceptive distortion exists as applying to a woman's present employer, her teacher, her therapist, and her father, she may now situations involving an uncle, an elder brother, or others as having been reacted to similarly. 2. Therapeutically (emotionally). In the therapeutic situation, the patient must experience the preceding situations with real feelings, and also reproduce the feelings in relation to the therapist, and work them through. 3. Behaviorally. Outside the therapeutic session, the patient goes on meeting the situations discussed and new ones similar to the ones scrutinized. While in real situations, she is aware of the insight recently gained. Under the influence of her new "mental set," she reacts differently to a progressive extent to these situations in the corrective direction suggested by the analysis of the situation. New problems arising are reanalyzed and the problem is worked out by persistent adjustment and readjustment between mental set and reality. While the process of insight and the purely intellectual aspects of working through are best understood in of perceptual learning theory, the therapeutic and behavioral working through are actually best seen as a matter of condition- ing and reconditioning, as well as a problem in which trial and error and reward and punishment lead to the final best result. sub insi his pro gral SOIl do ita, offi nat con pisl giw tior pe( ati( OUl int in f the resi wail to t] and the star forl bri lem The stor free dis( or $ acc

USE OF THE T.A.T. IN PSYCHOTHERAPY 179 eaning-- iously un- g, we de- ) of the :oblem is ay be andifferent eral class pieces of learning :he inteltic result 'rapeutic or as a must be insight: .rtain to ttions to .at a pat- aaployer, tions in- tilarly. '.nt must the feelmeeting e in real e of her ttions in roblems ent and vorking !erapeu- ldition- reward The T.A.T. is an excellent, tailor-made way of studying both the horizontal and the genetic patterns that are revealed, particularly by the more psychologically naive subjects, who are often not aware of the implications of their stories. Valuable insight and cooperation are frequently gained when the patient discovers, to his surprise, that he has unwittingly reproduced some of his most important problems. Combs (1946) has demonstrated that there is an abundance of autobiographical material revealed in the T.A.T. that should enable the therapist to study some of the vertical patterns in the person's behavior. For the clinical use of the T.A.T. in therapeutic practice, one may either take down the stories oneself or use recording devices. In this situation, we have found it advantageous to have the patient write down the stories herself or himself either in the office or at home. It will quickly appear to any therapist at all conversant with dynamics that the T.A.T. practically always mirrors some or all of the basic problems, conflicts, and sentiments of the individual. Thus, it can be used not only by therapists for their own insights into their patients' psychodynamics but it can also be given to them for them to work on, in the same way as any of their other productions. 1. The T.A.T. can be used as a vehicle with any kind of psychotherapy. It is especially indicated in brief psychoanalytic psychotherapy because it reveals the situations that need discussing. One may select those pictures that are most apt to bring out the problems of a specific patient, where time is of the essence for external or internal reasons (Bellak et al., 1992). 2. The T.A.T. may be a useful vehicle when the patient has a special difficulty in free associating or in communicating generally because of lack of familiarity with the psychotherapeutic process, inhibitions, specific resistances (when protracted resistance is not analytically useful), and so on. When using the T.A.T. in the actual psychotherapeutic session, it is advised to wait for a time at the beginning of the session before presenting the story or stories to the patient. During that time, one may find out if there is anything more acute and specific the patient may have in mind that is more urgent than the material in the T.A.T. If there is nothing acute, and particularly if the patient has difficulty in starting or quickly runs out of material, it is a good time to take up the T.A.T. It is expedient to stop the interpretations of the T.A.T. material some time before the end of the session. This will allow the patient an opportunity either to bring up more distantly related material that was evoked or to discuss current problems that he or she did not before. The technique of analyzing and interpreting the stories for the patient varies. There should be two copies of each story. The method of choice in handling each story is to let patients read it and elaborate on it if they can, then to discuss it and free associate to it. After all associations have been made, the therapist steps in and discusses all the material again, with analysis and interpretations, as indicated. One or several stories may thus be taken up during each session, and therapy proceeds according to patterns revealed in the T.A.T. stories.

180 CHAPTER 8 Another method is to use the stories only when the patient has difficulty in free associating or when one or several of the stories contain the same pattern currently revealed by the patient's associations. Again, patients should be allowed to read a copy of their own productions. Often, they will see the pattern of their own accord and be able to interpret the story and their revelations, thus acquiring insight in the most desirable manner. If they fail to do this, the therapist can try to help them do so or analyze and interpret the material for them. In handling the T.A.T. stories, the therapist should consider the material as similar to a dream or fantasy and analyze it on that basis. The story and its analysis may be presented to patients as though it were their dream or fantasy, or it may be taken up as an almost direct statement of biographical material or emotional content connected to behavior patterns. The T.A.T. is helpful in facilitating the establishment of the "psychotherapeutic attidude," when patients find it hard to relate data of any value. In psychotherapy, we are, in essence, asking patients to stand off and observe themselves, to report to us what they observe, and to collaborate with us with a part of themselves. This is a difficult task, especially for the less sophisticated individuals. When we ask them to read over their own stories, they may say that they simply described the pictures. We can then tell them of other stories and interpretations that have been given to the same pictures. This usually has a marked effect on them: It may introduce them for the first time to a subjectivity of their thought processes, and they may now be more willing and able to stand off and observe themselves. This process may be facilitated if, on rereading their stories, they are spontaneously impressed by how much of the content refers to themselves, or if we have occasion to point out certain repetitive patterns to them. The use of the T.A. T does not obviate the fact that all the principles of careful psychotherapy must be observed: One should start with the more acceptable aspects, not upset the patient unduly, not interpret things that the patient is not ready for. No one inexperienced with psychotherapy should use the T.A.T. in therapy. Use of the T.A.T. in Group Psychotherapy Programs Brief mention should be made of observations that have indicated the usefulness of the T.A.T. in selection of group therapy candidates and in evaluating behavior in group therapy programs. Ullmann (1957) has noted that significant correlations were obtained in his investigation between T.A.T. scores of neuropsychiatric patients and group therapy scale predictions, as well as between T.A.T. scores and a hospital status criterion. The fact that T.A.T. cards are concerned with interpersonal relationships apparently affords the best explanation for their suit- ability as a potential method of selecting group therapy patients. Fairweather and colleagues (1960) have employed the T.A.T. to compare the relative effectiveness of psychotherapeutic programs. The test diagnosis interaction was significant; group therapy and control groups indicated more positive T.A.T. changes for nonpsychotics than for psychotics, and individual therapy was superior in of T.A.T. change when given to long-term psychotics. The abi thus received measure of ex able results ix search (Coch & GreenblattI Diagnostic Psychol ical patholog the psychott to be able tc well enough general mec should an e job to make be a substitu chotherapisI and for the situation. It with" such a masochistic Psyche simply attac If diagnosisI cance of th, If one they can be quan titativ( those whict is the main this divisio tions of int From gauge the: interpretat the pesona The c els, by stud] patterns 0 conscious Diagnostic siderations w

u- er- re- es.

USE OF THE T.A.T. IN PSYCHOTHERAPY 181 The ability of the T.A.T. to describe patients' behavior in psychotherapy has thus received some validation; the test can be used by the psychotherapist as one measure of evaluation of the patient's progress. Several authors have reported valuable results in the use of the T.A.T. an an outcome measure in psychotherapy research (Coche & Sillitti, 1983; Dymond, 1954; Frank & Gunderson, 1990; Goldman & Greenblatt, 1955). Diagnostic Aspects in Relation to Therapy3 Psychological tests have much the same relationship to psychotherapy as clinical pathological tests and X-rays have to general medicine. Like a medical doctor, the psychotherapist should have a basic knowledge of testing procedures in order to be able to request the appropiate one, and should understand the basic meaning well enough to be able to integrate the test results with the additional data. As in general medicine, the therapist should not blindly rely on the test results, nor should an exact diagnostic answer to every problem be expected. It is the clinician's job to make a careful clinical evaluation and to integrate all the factors. No test can be a substitute for clinical knowledge and acumen. It is inappropriate for the psychotherapist to expect an answer to all his or her problems from the psychologist, and for the psychologist to offer definitive statements without knowing the clinical situation. It is preferable to express test results in the form that they are "consistent with" such and such a disorder (i.e., 'This patient's record is consistent with a sadomasochistic character disorder"). Psychological tests may be helpful in diagnosis, if diagnosis does not imply simply attaching labels to a patient, but rather implies gauging liabilities and assets. If diagnosis involves therapeutic planning and prognostication, the great significance of the tests is obvious. If one restricts oneself to the projective personality tests, then it seems that they can be divided into two kinds: those concerned essentially with testing formal quantitative aspects (which appear to test primarily degrees of ego strength) and those which reveal content (psychodynamics). Of the first category, the Rorschach is the main representative; of the second, the T.A.T. It should be kept in mind that this division is somewhat arbitrary, in that the Rorschach may elicit some indications of interpersonal relations and the T.A.T. offers some ego strength indicators. From the standpoint of therapy, the quantitative indicators may permit one to gauge the amount of strain and stress to which a patient may be safely exposed by interpretations and transference tensions; the content tests supply the substance of the pesonality itself, like dreams and fantasies made to order. The quantitative indicators are predicated on the probing of subsemantic levels, by studying neuromuscular expressions (e.g., in a figure drawing) or perceptual patterns (e.g., in the Rorschach). Thus, they may reveal motivations that are unconscious in the sense of never having had any verbal representations. A break" Diagnostic aspects are discussed throughout the book. Here, we merely wish to emphasize a few considerations with regard to therapy.

182 CHAPTER 8 through of aggressive impulses due to a brain defect may often be covered up verbally, while it will manifest itself myoneurally (e.g., in a drawing). The content tests reveal particularly well matters that are unconscious in the psychoanalytic sense. More detailed principles of classification of what is usually subsumed under projective tests might be helpful for the clinical selection of proper tests for therapeutic purposes. These suggestions will indicate only the primary useful aspects of certain tests and will not ignore the fact that each test contributes on several levels. Available techniques may be grouped under five headings: 1. Methods based on the study of content: The T.A.T., C.A.T., and S.A.T 2. Study of expressive, perceptual, structural aspects: Mira, Mosaic, Rorschach, and projective drawings 3. Gestalt functions: Bender Gestalt, Mosaic, Rorschach 4. Body-image or self-image: Figure Drawing, T.A.T., Rorschach 5. Methods of preference: Szondi It is apparent that all five organismic aspects enter into every one of the projective methods, although in varying degrees. One may keep these categories in mind for the selection of techniques for each individual problem of diagnosis and therapy--either for the purpose of arranging a rounded battery or for selecting the one test for a specific clinical need. The five variables may be used for a systematic inquiry into the test results of any one technique. A more general classification scheme, relevant to the choice of tests for therapeutic purposes, derives from the levels hypothesis, which has generally been interpreted as meaning that the less the structure of the test, the deeper the level of personality being tapped. For example, Stone and Dellis (1960) found that the Wechsler-Bellevue, Forer Sentence Completion Test, T.A.T., Rorschach, and Draw° A-Person Test reached successively lower, or more primitive, impulse control systems in their subjects. In a similar vein, Theiner (1962) noted greater frequency of acceptable needs expressed in response to a relatively structured test (Rotter Incomplete Sentence Test), and greater frequency of unacceptable needs on the T.A.T. (less structured). Again, it is feasible that this "levels" principle can be used either toward the selection of a specific test in order to obtain specific kinds of information or toward the selection of several tests to secure a more global picture of the individual. Some Contraindications to the Use of Psychological Tests A brief statement is in order concerning contraindications for psychological tests, for whatever purpose they may be used. Meyer (1951 ) has published a paper on this topic. He showed particular concern with the effect of the prospect of testing on the patient (in of keeping or breaking appointments) and with how testing affects the continuation of therapy. By examining extensive clinical records, he found that testing does not generally have an adverse effect. However, he suggested seven contraindications to testing in order to avoid disturbing consequences:

USE OF THE T.A.T. IN PSYCHOTHERAPY 183 lp ver- it tests nse. under thera- ects of levels. and e pro- vies in lis and ng the .matic r ther- inter- vel of at the .Draw- bl sys- hcy of (otter n the 'd the )ward 1. Acute psychosis, incipient psychosis, or acute anxiety states 2. Extreme difficulty in establishing relationships (where adjustment to an additional person would be an undue burden) 3. Likelihood that the patient will interpret referral for testing as disinterest on the part of the therapist 4. Likelihood that referral will be interpreted as evidence of incompetence of the therapist 5. A specific fear of "test" situations in life and a tendency to run away from them 6. The possibility that testing material might stimulate more material than seems desirible at the time (incipient psychosis?) 7. Indication that the therapeutic situation at the time of referral seems to make testing inadvisable, whereas it might be advisable at a later, more suitable date These points seems to comprise the most careful consideration published thus far on the entire subject of the testing situation from the point of view of the patient/therapist relationship. We have frequently used the T.A.T. ourselves with patients in acute anxiety states and severe depressions without any untoward effects. Judgment must be used in all cases, and if extra precautions are taken to create a nontraumatic atmosphere, tests may still be very useful. In fact, in many acute conditions, when patients are otherwise unable to profit by communications, the T.A.T. and other tests may be easier for them to deal with and may help them focus on the very core of their problems. tests, this sting how :ords, sug- :onse-

REVIEW OF LITERATURE RELEVANT TO INTERPRETATION OF THE T.A.T. Stimulus Value of the T.A.T. It has long been recognized that, in order to properly interpret thematic responses, it is of primary importance to take into the influence of the stimulus itself in determining the response. There have been studies of stimulus factors in specific cards, such as the level of conflict and depression responses to Card 12BG (Boekholt, 1987), factors determining the gender of the figure in T.A.T. Card 3BM (Dungan & Holmes, 1982; Holmes & Dungan, 1981), and a long tradition of research on relative degrees of ambiguity in different cards (Epstein, 1966; Kaplan, 1967, 1969, 1970; Kenny & Bijou, 1953; Murstein, 1964, 1965b). Goldfried and Zax (1965) took the position that in evaluating T.A.T. themes, it is necessary to make interpretations only with regard to the stimulus value of the specific card. They obtained ratings of all the T.A.T. cards on 10 bipolar adjectival scales, such as happy/sad. The ratings indicated that the cards vary a good deal as to their ambiguity-that is, the number of scales that consistently describe the picture. It was also observed that the stimulus properties of some cards are such that it is likely they will "pull" negatively toned stories. Specifically, it was found that for certain cards (e.g., 2 and 5), the stimulus pull is weak enough to assume that the story reflects the inner state of the test taker; on the other hand, for pictures such as 4 and 13MF, the stimulus properties of the card are likely to be more responsible for the resultant story than are the test taker's inner needs. A few other studies have been reported that investigated the effect of stimulus properties on the expression of specific needs or personality variables. Lubin (1960) tested the effects of T.A.T. cards whose stimulus properties elicit the expression of either sex or aggression. The significant effect of the stimulus properties of cards of sexual and aggressive expression was interpreted as indicating that certain dimensions (Kagan, 1959) of the T.A.T. response are determined by stimulus configurations. Murstein (1962) studied the projection of hostility on the T.A.T. as a function of stimulus, background, and personality variables. The stimulus properties of the cards used ed for more than half of the total variance. Murstein 184

REVIEW OF LITERATURE RELEVANT TO THE T.A.T. 185 aaatic re- the stim- !s factors to Card k.T. Card dition of ; Kaplan, i and Zax make in- They ob- such as eir ambi- it was

also i they will rds (e.g.,

I

ts the in- 3MF, the resultant

of stimu- es. Lubin :it the ex- s proper- ating that by stimu- the T.A.T. alus prop- . Murstein concluded that the results provide evidence that the stimulus is definitely the most important determinant of the content of a T.A.T. response. Another possible way in which the stimulus properties may influence responses has been investigated in studies that have dealt with the effects of similarity between the test taker and certain characteristics of the T.A.T. figures. Weisskopf- Joelson and colleagues (1953) hypothesized that physical similarity between the test taker and the central T.A.T. figure would affect the amount of projection, but their findings indicated that increasing similarity did not yield statistically significant increases in either amount of projection or in the diagnostic value of the stimuli. Thompson (1949), using the African American T.A.T. that he devised, found that African Americans produced more when the T.A.T. used African Americans than they did with the traditional T.A.T. Other research, though, has questioned this result (Korchin et al., 1950; Riess et al., 1950). Weisskopf (1950b) has refuted Murray's (1943a) hypothesis that males project more when the central figure is male rather than female. Finally, Weisskopf and Dunlevy (1952) found no effect on amount of projection when pictures of physically normal, obese, and crippled figures were shown to the respective test-taker groups. Alter reviewing these findings, Weisskopf-Joelson and colleagues (1953) suggested that differences in the similarity dimension may cause qualitative changes in projection rather than quantitative, and specifically that decreasing similarity should lead to increased projection of ego alien materials. Hunt and Smith (1960) studied the constraining effects on responses to thematic projective material of structural elements involving shared cultural meanings. It was hypothesized that patterns such as those depicted in the T.A.T. are likely to include a variety of cultural and subcultural symbols that can act so as to evoke responses mediated by shared cultural meanings and given independently of any effects of individual personality. By comparing a modified T.A.T. card with the original, it was shown that variations in component features of the cards produced notable differences in sociocultural classifications that were likely to affect their use (e.g., differences in the test taker's perceptions). Sample Variables Illustrative examples of the possible influences of certain sample variables on thematic responses are contained in the following studies. Sex differences in fantasy patterns have been found by May (1966), who deduced from clinically oriented studies the types of sequences to be expected in men's and in women's fantasies. In women's fantasies, it was hypothesized that the following would be reflected the sequence in feminine masochism: suffering followed by joy, failure followed by success. Fantasies of men were expected to reflect the pattern of ascension followed by descension, the syndrome of the male's attempt at ascension and later fear of falling. These hypotheses were strongly ed by May's study with the T.A.T. in that, in of sequence of action and feeling, women's stories showed movement from more "negative" emotion and experience to more "positive" emotion and experience, whereas with men this direction of movement was reversed. Men tended to see any decline or fall as total and final, while the possibility of resurgence was

186 CHAPTER 9 implicit in the female pattern. A second finding was that stories written by women tended to include, more often thma those of men, phenomena such as dreams, fantasy, and prayer--elements that signify that women are more likely to tolerate, and make use of, shifts in level of psychic functioning Tooley (1967) examined the expressive styles of three age groups of women, adolescents, late adolescents (18 to 22 years), and adults, as reflected in T.A.T. themes, in order to obtain a description of the defensive and adaptive modes peculiar to late adolescence. Themes written for card 2, which has shown its relevance to late adolescent problems (Henry, 1956), and card 18GF, chosen to maximize affective arousal so that defensive techniques could be seen, were judged according to the criteria of "flamboyant," "impersonal," and "constricted." Late adolescents were judged to be flamboyant in writing style significantly less often than the other two age groups, and impersonal significantly more often. The expressive style of late adolescents was described as moderate in emotional tone and heavily characterized by intellectualizing defenses--a style that facilitates the handling of developmental tasks of late adolescence and that indicates a defensive structure specific to that developmental period. This kind of study points to the potential usefulness of the T.A.T. in studying developmental differences. Rubin (1964) compared the T.A.T. stories of two I.Q. groups: seventh- and eighth-grade girls of high I.Q. (M = 124), and seventh- and eighth-grade girls of low I.Q. (M = 78). With respect to data uncorrected for the effects of verbal productivity or socioeconomic status, there was a tendency for the high I.Q. group to use more achievement, dominance, and affiliation themes in their stories than the low I.Q. group; there was no difference between the two groups in number of rejection, seclusion, or dependency themes expressed; and the high I.Q. group used a greater total number of themes in their stories. In general, differences in the incidence of specific themes or total number of themes did exist between the two groups, but such differences were found to be associated with either verbal productivity, socioeconomic status, or both. When the effects of socioeconomic status were held constant, differences continued between the measures of achievement and dominance themes in the two groups, although differences on the measures of affiliation and total number of themes disappeared. One of the findings is contrary to past research done by Rosen (1958) and by Veroff and colleagues (1953), who found that incidence of achievement themes in T.A.T. stories is related to socioeconomic status. Present findings indicate that the incidence of achievement themes is more closely related to I.Q. than to socioeconomic status. Thematic expression has been found to vary along the dimensions of so many variables that it is not surprising to learn that thematic drive expression has been studied in relation to different occupational groups. Levine (1969) compared the T.A.T. performances of mathematicians, creative writers, and physicians by means of Pine's (1960) system for rating amount, integration, and directness of drive expression, and also in of expression of affect. Writers were most expressive, followed by mathematicians and then physicians. Mathematicians tended toward relatively high use of direct, socialized forms of drive content, whereas physicians were characterized by indirect, disguised forms more than the other groups. These em- phases appeared to serve defensive and integrative functions. Writers showed no

REVIEW OF LITERATURE RELEVANT TO THE T.A.T. 187 men , fan- , and men, 7.A.T. '.s pe- 'ance te af- :ding cents ther ,le of arac- [evel- ecific lness . and ,f low uctiv- ) use e low .'tion, eater :ce of ;, but held lomi- ation tst te- l that ;ocio- ment many been d the teans e ex- .', fol- rela- were . em- d no emphasis on either direct or indirect expression. Intergroup differences that were obtained indicated the existence of relationships between occupations and characteristic patterns of regulating drives and affects. The study also demonstrated the reliability of Pine's system, which evidently taps dimensions of personality not necessarily relevant to psychopathology but that reflect characterological differences significant in major life adaptations. The studies that have been concerned with possible race differences in thematic responses have led to somewhat less than definitive conclusions, mainly because of variations in the number and kind of related variables that have been experimentally controlled and in the type of differences being evaluated. Mussen (1953) compared the T.A.T. responses of African American and white lower-class boys and found that African Americans perceived the general environment as more hostile. Aggression expressed by African Americans was more verbal and less physical; African Americans expressed less need for achievement and fewer themes of accomplishment, and whites suffered more feelings of rejection in personal relationships, particularly in the case of the mother. Mussen concluded that many differences exist among the African American and white cultures not attributable to differences in class structure. Megaree's (1966a) conclusions about this problem area are somewhat different, although he is concerned more with personality differences than cultural ones, as manifested in the T.A.T. He compared the scores of lower-class white and African American male juvenile delinquents on the T.A.T. and two other projective tests and found no differences on T.A.T. scores. The two groups had been matched on I.Q. It was noted that these results were consistent with those of other studies previously reported in the literature that also matched African American and white samples on I.Q.; earlier studies that had not matched I.Q.s reported more projective test differences. For example, Veroff and colleagues (1953) did not match for I.Q. and found a high proportion of significant differences. Megaree's concluding opinion was that projective test differences should not be used to make inferences about basic racial personality structure unless careful matching on other variables has been achieved. The present study indicates that white norms are applicable to African American test takers of equivalent I.Q in cus- todial settings. Johnson and Sikes (1965) investigated subcultural differences in thematic responses. They compared the T.A.T. responses of African American, Mexican American, and Anglo male psychiatric patients, whose ages, educational backgrounds, and occupational levels were quite similar. Diagnostically, the subgroups were almost equal. Using themes of achievement on card 1 as the measure of achievement concern, a tendency was found for Mexican American and African American groups to show more achievement. These themes also included the subcategory of frustration, which appeared more often in African American and Mexican American stories than in Anglo stories. Large differences were found for the family unity dimension, as shown in card 2 themes. The Mexican American group had the most consistent view of the family as unified, whereas the African Americans were lowest in this category. Responses to the mother/son card (6BM) showed significant differences. For Mexican Americans, the scene was one of a son leaving his mother, both viewed as being sad, whereas African Americans tended to

188 CHAPTER 9 see the mother as rejecting and a situation of conflict. The father/son card elicited significant differences also, with African Americans and Anglos responding similarly, and Mexican Americans seeing a father giving his son advice and the son taking it. Johnson and Sikes concluded that it may be in the measurement of the relative strengths of interpersonal identifications that projective tests can be most useful in the formulation of culture and personality theories. These issues of cultural differences in thematic tests are discussed in greater detail in Chapter 20. was

diffe as we on a Aggression and Hostility Considerable research has focused on the dimensions of aggression and hostility as they are manifested in T.A.T. responses (Benton, 1983; Fiester & Siipola, 1972; Gluck, 1955; Kagan, 1956, 1958, 1959; Kornadt, 1982; Matranga, 1976; Megargee, 1967; Megargee & Cook, 1967; Megargee & Hokanson, 1970; Mormont, 1988; Pam & Rivera, 1995; Pollack & Gilligan, 1982; Tachibana et al., 1984). The study of Megargee and Cook (1967) was one of the first to demonstrate that aggressive fantasy on the T.A.T. is directly related to overt acting out of aggression. Mormont (1988) pointed out that 20 years of further research on this topic continue to Megargee and Cook's basic finding. James and Mosher (1967) emphasized the relevance of the stimulus situation. They related thematic aggression, which was elicited by thematic stimuli of high- and low-stimulus relevance, to the aggressive behavior of a group of Boy Scouts. Thematic aggression to high "pull" cards was related significantly to physically aggressive behavior, but thematic aggression to low "pull" cards was not. There was no relationship between self-reported hostility/guilt and fighting behavior; nor was any relationship obtained between hostility/guilt and thematic aggression elicited by cards of high stimulus relevance. Hostility/guilt was significantly negatively correlated with aggressive stories told to cards with little aggressive stimulus relevance. It was hypothesized that, when pictures are not suggestive of aggression, perhaps only people who are low in guilt over hostility are able to accept the responsibility for producing aggressive themes. The relationships obtained between thematic aggression and fighting behavior in adolescent boys Kagan's (1959) position. Kagan has stated that "unambiguous pictures are the best stimuli for yielding indicants of behavioral aggression." The results of the present study imply that to maximize prediction for thematic cards one must use stimuli that are quite similar to the relevant behavior. Megargee (1967) studied hostility on the T.A.T. as a function of defensive inhibition and the stimulus situation. He hypothesized that there would be significant differences in the aggressive imagery of inhibited and uninhibited test takers when T.A.T. cards or instructions strongly suggested an aggressive response, but not when experimental conditions did not suggest hostile themes. The following findings held true for women but not for male test takers: Less inhibited people had higher hostility scores than the more inhibited; instructions to give hostile stories resulted in higher hostility scores than did neutral instructions; the higher the aggressive pull of the cards, the higher were the obtained hostility scores; and finally, the major hypothesis, noted above, was confirmed, but for women only. Partial with ence to with (196 tent the cove the was scale for colle host resp gest that don', tem pres

REVIEW OF LITERATURE RELEVANT TO THE T.A.T. 189 elicited ag sini- son tak- :he rela- )e most of cul- - 20. nd hos- Siipola, ,, 1976; )rmont, 4). The that ag- cession. )ic con:uation. ff high- Scouts. :ally ag- was no lor was elicited ely cor- evance. erhaps sibility atic ag- sition. g indi- ;O max- ailar to sire in- fificant 's when t when ridings ,higher esulted ressive he ma- lpport was thus found for the hypothesis that variations in aggressive imagery in response to stimulus conditions that are likely to elicit aggression reflect differences in inhibition level. Since the present study used group istration, the obtained sex difference could be an artefact of sex differences in response to group T.A.T.'s, such as were found by Lindzey and Silverman (1959). Reznikoff and Dollin (1961) investigated the concept that persons rated high on a social desirability (SD) scale would avoid expression of aggression on the T.A.T., which the authors considered socially undesirable. Test takers were grouped according to their Edwards SD scale score and given T.A.T. cards that were later scored for overt, covert, and total hostility. SD groups could not be differentiated with regard to mean score on any hostility variables, although significant differences were obtained for all variables with regard to stimulus pull of the cards. Further analysis did indicate that high SD test takers were more likely than others to use covert hostility rather than overt. This is consistent with the idea that people with high SD are not likely to express aggressive feelings directly. It is Murstein's (1963b) opinion that personality sets such as the SD do not really affect the themes obtained with strongly structured cards such as those that compose the T.A.T. Hafner and Kaplan (1960) conducted a methodologically sound hostility content analysis of the Rorschach and T.A.T. and compared the hostility dimension on the two tests. The constructed scales were applied to the Rorschach and T.A.T. protocols of a group of psychiatric patients. For the Rorschach, correlations between overt and weighted scale scores, covert and weighted scale scores, and overt and covert scales were all positive and significant. The same results were obtained for the T.A.T. hostility scales except that the correlation between overt and covert scales was significantly negative. Correlations between the Rorschach and T.A.T. weighted scale scores, overt scale scores, and covert scale scores were all nonsignificant. Since for the T.A.T., overt and covert scale scores were highly related to weighted scores, but not to the same degree as for the Rorschach, and since T.A.T. overt and covert scale scores were negatively related as well, it was concluded that the T.A.T. was more sensitive to individual differences in regard to the overt/covert dimensions of hostility than was the Rorschach. An interesting study was conducted by Winter and colleagues (1966) using the Hafner-Kaplan scoring system (1960). T.A.T. stories were produced contly by three-member families: 50 families with normal children (Nor), 44 with emotionally maladjusted children (Mal), 16 with schizophrenic children (Scz), and 16 with delinquent children (Del). The Nor and Scz groups produced stories low both in weighted hostility and overt hostility, stories of Mal groups were high in both variables, and the Del families scored high in weighted hostility but close to the normals in overt hostility. The deviation of the Scz families' responses from the kind expected from clinical experience led the authors to suggest that their hostility is either so far removed from the level of explicit expression that it is conveyed in highly subtle ways or that the families avoid expression of emotional antagonism. No hypotheses were proposed in explanation of the unexpected responses from the Del groups. It was deduced, in general, that the basic value systems of the Mal, Del, and Scz groups are equally abnormal, but the mode of expression of hostility differs. In addition to the information about the expression of hostility contributed by this study, it should be noted that research such as this can

190 CHAPTER 9 result in effective use of the family T.A.T. as a diagnostic instrument as well as effective use of the T.A.T. in assessing family pathology. In a series of well-conducted studies of the relationship between simple T.A.T. aggression and overt aggression, Murstein (1963a, 1963b, 1965a, 1965b, 1968; Murstein et al., 1961) concluded that there is little correspondence between the two with typical samples of adults, adolescents, and children. On the other hand, he stated that for both adults and children, persons with histories of overt hostility are relatively easily differentiated by thematic aggression. The following studies are representative of those that have been conducted using the T.A.T. with test takers who have such histories of overt hostility. Stone (1956) studied army prisoners who had committed nonviolent crimes, or deserted, or murdered, or intended to kill someone. The assaultive group projected significantly more hostility than the combined nonassaultive groups in their T.A.T. responses. Purcell (1956) classified army trainees into three groups varying in antisocial behavior. Of the 15 comparisons made between any two of the three groups, 12 indicated highly significant differences. Antisocial men responded with more aggression themes than other groups, and their hostility expression was more direct. Punishment depicted was often of the external kind, while nonantisocial people manifested more frequent internal punishment than external. Mussen and Naylor (1954) were inspired in their research by Sanford and colleagues' (1943) finding that expression of high aggressive needs in the T.A.T. was correlated with low overt aggression, with a middle-class sample. Mussen and Naylor predicted that with lower-class test takers, high fantasy aggression would be overtly expressed, since in lower-class environments aggressive behavior is not punished. They tested preadolescent and adolescent delinquent lower-class boys with the T.A.T., and found that, among these boys, those who manifested high aggressive needs on the T.A.T. showed more aggressive behavior than those with low fantasy aggressive needs. A second result was that boys who showed much punishment press relative to aggressive needs in their stories showed less overt aggression than those who had low punishment press relative to aggressive needs. This relationship was less marked than the first was. Third, when high expression of aggressive needs was paired with a low ratio of anticipation of punishment to aggressive needs, a high amount of overt aggression was generally found, and vice versa. This study was offered as evidence of the validity of T.A.T. inferences concerning aggressive needs, although the conclusions were limited to the social class and age levels studied. A study that confirmed Mussen and Naylor's (1954) general finding but whose scope was somewhat broader was conducted by Weissman (1964). Four matched groups of adolescents participated. They were identified as (1) aggressive acting-out institutionalized test takers, (2) less aggressive acting-out institutionalized test takers, (3) nonacting-out high school boys, and (4) aggressive acting-out high school boys. T.A.T. stories were compared on several hypothesized dimensions deemed relevant to aggressive acting-out behavior. The following three dimensions manifested significant and consistent differences: (1) The number of aggressive stories was viewed as most likely to be useful as an indicator of aggressive overt behavior when groups being compared are distinctly different with respect to aggression. Weissman suggested that T.A.T. fantasies of aggressive adolescents, when compared to adults', are more closely related to characteristic behavioral patterns than to conflicts re ies. (2) cards dictor Shalit Japan. A sion findim and durin jective cholo wheth, alyze cal subje a wonl the re who treme a T.A5 OUS Ca vice h; ful fin out o such have ditio test tots 1992;

REVIEW OF LITERATURE RELEVANT TO THE T.A.T. 191 t as well as elsimple T.A.T. 1965b, 1968; e between the e other hand, overt hostility ng studies are 4th test takers prisoners who tended to kill than the com- lassified army comparisons ificant differ- 3ther groups, . was often of uent internal tford and col- he T.A.T. was n and Naylor dd be overtly ot punished. oys with the [h aggressive a low fantasy punishment ression than relationship "essive needs ,ive needs, a his study was .ssive needs, studied. finding but 1964). Four ) aggressive nstitutional- e acting-out ktimensions :limensions ressive sto- zert behav- aggression. compared aan to conJcts resulting from artificially induced drive states, such as reported by other studies. (2) Aggressive boys were more likely to tell aggressive stories to nonaggressive cards than were nonaggressive test takers. (3) Reaction time was the single best pre- dictor of aggressive overt behavior for all groups. Other studies include that of Shalit (1970) on the relationship between environmental hostility and hostility on thematic tests and Tachibana and associates (1984) aggression and catharthis in Japan. A major controversy in the field is whether the acting out of serious aggression can be predicted by mental health practitioners. Megargee and Cook's (1967) finding that aggressive fantasy on the T.A.T. is directly related to overt acting out of aggression is illustrated in a thought-provoking clinical case presentation by Pam and Rivera (1995). The case reported by Pam and Rivera is a man, who was tested during his psychiatric hospitalization. The T.A.T. specifically contained many projective indicators of serious aggressive, actingout tendencies, which led the two psychologist authors to recommend that the patient not be discharged. When the patient was informed of this decision, he committed suicide. Ten years after this tragic outcome, the authors took a second look at the T.A.T. protocol and considered whether their decision on the basis of this T.A.T. protocol was the correct clinical decision. The paper presents the full T.A.T. protocol, so that the reader can also analyze the test results and decide if the authors were, in fact, justified in their clinical recommendations. In view of Klein's (1987) controversial argument that projective tests are too subjective to be clinically useful, the courageous paper of Pam and Rivera (1995) is a wonderful teaching device for all clinicians employing the T.A.T., since it orients the reader to important ethical and clinical responsibilities facing psychologists who work in psychiatric hospital situations. Jo-Ann Rivera was a staff psychologist and A1 Pam was her supervisor at the time of the psychological testing. The authors provide a very valuable picture of some of the difficult emotional reactions such extreme indicators of dangerous aggression may elicit in a psychologist, who obtains a T.A.T. protocol of this nature, and the process of carefully examining such a serious case in supervision in of the overall quality of care, when a clinical service has an incident of suicide. This case is a very powerful example of the most useful finding on the relationship of aggressive fantasy to the possibility of overt acting out of aggression by Megargee (1970)--cards that have a high pull for aggression, such as Card 13MF, indicate poor inhibition of aggressive acting out, and cards that have a low pull, such as Cards 6BM and 7GF, indicate self-instigation of aggressive acting out.

Motivation and Apperception The effects of several needs on the content of thematic stories, and the conditions that appear to determine whether or not these needs will be manifested in test takers' responses, have become the focal point of interest for naany investigators (Atkinson, 1964; Byrne et al., 1963; Blumenthal et al., 1985; Campus, 1976; Chusmir, 1985; Heckausen, 1967; Maddi et al., 1965; McAdams, 1980; Spangler, 1992; Winter, 1973). The pre,ious review of literature that has dealt with aggression

192 CHAPTER 9 represents only one area within the more general field that will presently be surveyed. The achievement motive has been extensively studied by McClelland and colleagues (1953). They have determined that the occurrence of achievement in a thematic story is a t function of three variables: (1) cues in the everyday environment and in the relatively autonomous thought processes of the individual, (2) specific cues introduced through the experiment, and (3) controllable cues in the specific picture. According to McClelland, when achievement imagery is part of the thematic story, it can be concluded that the individual is motivated to achieve and not indicating wish-fulfilling fantasy. McArthur (1953) reexamined the effects of need achievement on the content of T.A.T. stories and hypothesized that self-projection s for all such effects. This hypothesis inherently questioned the list of eight effects of increasing the test taker's need achievement that had previously been proposed by McClelland, who had considered four possibilities as to the description of the relationship between the test takers and the traits of the characters in his story. These were self-projection, contrast projection, complementary projection, and instrumental projection. McArthur stated that four of McClelland's proposed effects (more mastery tales, hero states need for mastery, hero wishes for mastery, and more mastery images) should hold true, while the other four (failure by the hero, actions to overcome failure, press hostile to mastery, and anxiety about mastery) merely represent artifacts of McClelland's design. This hypothesis was tested against a group of academic overachievers, and the results suggested that the concept of selfprojection does explain most of the achievement content of T.A.T. stories. An interesting study was conducted by Orso (1969), in which he compared the effects of achievement and affiliation arousal on the need for achievement (nAch). As determined from T.A.T. responses, it was found that male nAch scores were not significantly affected by achievement or affiliation arousal, whereas female nAch scores increased significantly after affiliation arousal and decreased significantly after achievement arousal. These sex differences were discussed in of differences between the male and female roles in society insofar as there are dis- crepant meanings of achievement for men and for women. Several studies have sought to provide an index of the strength of the affiliation motive in T.A.T. stories (Atkinson et al., 1954; Byrne et al., 1963; Carrigan & Julian, 1966; Orso, 1969; Rosenfeld & Franklin, 1966; Shipley & Veroff, 1952). Shipley and Veroff (1952), for example, used "separation imagery" as the criterion for designating affiliation-related stories. The results did not differentiate between aroused and control conditions. The scoring procedures used by Atkinson and colleagues (1954) represent a more general definition of affiliation than those used in the earlier study, in which the definition of affiliation imagery was limited to separation anxiety. In the study by Atkinson and associates, affiliation imagery was scored when the story indicated concern in one or more of the characters over establishing, maintaining, or restoring a positive affective relationship with another person. Affiliation motive arousal in some test takers was achieved by istering a sociometric test to them before the T.A.T. The low motivation control condition was a college classroom. The success of the scoring system and of the method of motive arousal was indicated by the significant difference obtained between the two conditions for their median n affiliation scores.

REVIEW OF LITERATURE RELEVANT TO THE T.A.T. 193 be sur- nd and ent in a ay envi- ividual, cues in ;part of achieve :ontent effects. ing the lelland, lhip be- elf-pro- projec- xastery :eT im- :o over- present of aca- jection npared vement t scores female signifi- .rms of are disaffilia- gan & 1952). terion etween nd col- ased in o sepa- !ry was )ver es- nother stering dition aod of he two The relationships between the need for dependency and the T.A.T. and interview measures of dependent behavior were investigated by Kagan and Mussen (1956) and Fitzgerald (1958). Fitzgerald based his research on Rotter's formula (1960)--that need potential is a function of freedom of movement (FM) and need value (NV). Fitzgerald hypothesized that projective responses represent symbolic ways of obtaining gratification, and that frequency of response would be greatest when FM was low and NV high, thus creating a conflict situation. The finding was that projection of dependency on the T.A.T. was significantly related to conflict but not related to interview ratings of dependency. It was inferred that, at least for dependency, the T.A.T. is not a direct medium for the expression of need but is instead related to ego functions (e.g., conflict). Thematic sexual responses have been investigated in relation to experimentally induced drive and inhibition (Clark, 1952; Clark & Strivzer, 1961; Cuenca & Salvatierra, 1981; Davids & DeVault, 1960; Epstein & Smith, 1957; Martin, 1964; Pine, 1959, 1960; Ruth & Mosatche, 1985; Strivzer, 1961). Clark (1952) found that men shown pictures of nude women projected less sexual imagery than controls, whereas Strivzer (1961), in a comparable study demonstrating the influence of drive on apperception, found that arousal increased sexual imagery. The factor that seems to have determined these conflicting results is that Clark's upper-class test takers were probably more inhibited than the lower-class test takers who participated in Strivzer's study. Thematic responses to some degree depend on the individual's personal evaluation of the situation. The research conducted by Davids and DeVault (1960) explicitly investigated the relations between personality and perception that were implicitly suggested in the two previously described studies. The T.A.T. and Draw-A-Person Test (D.A.RT.) were included in a battery of psychological tests given to pregnant women. The sample was subdivided into a "normal" group and an "abnormal" group on the basis of hospital records of childbirth experiences. As predicted, a significantly greater proportion of women in the normal group perceived pregnant women in the T.A.T., particularly a pregnant woman in card 2, and drew female pictures on the D.A.RT. Davids and DeVault noted that the finding in regard to selective perception in response to T.A.T. stimuli is relevant to the area known as "personality and perception," in which concern is directed to the influences of motivational factors on selection in perceptual organization. In the present study, working with a real-life condition with specific physiological correlates, definite relations between motivation and perception were obtained. Compared to many women who have taken the T.A.T., the pregnant women in this study manifested a much greater likelihood of selectively perceiving pregnant women in the stimuli. Spangler (1992) and Dana (1968, 1972, 1985, 1993) reported that the majority of the research that has employed thematic techniques to assess human needs has focused specifically on the needs for achievement, affiliation, hostility, sex, and power. This large body of research suggests that the most relevant variables for clinical practice are card cue value, test-taker variables, examiner variables, and arousal conditions. These variables interact with each other and affect the expression of any need in thematic content.

194 CHAPTER 9 Cue Value Crude sortings of thematic stimuli for degrees of card pull for any one need have been frequent. While criteria for achievement cards of high and low cue value have been established, cue content for achievement should also be varied for similarity to work experience (Veroff et al., 1953), race (Cowen & Goldberg, 1967), and sex (Veroff et al., 1953). Low cue-value pictures (Veroff et al., 1953) and early use of low cue-value stimuli are valid need measures, where as high cue-value pictures may measure guilt, at least for sex and hostility (Epstein, 1962). Murstein (1963a) has suggested the use of medium or low cue-value cards following strong arousal by instructions. Such cards are clear in regard to identification of hero but ambiguous as to what is happening in the picture. Test-Taker Variables Dana (1968, 1972, 1985, 1993) identified these two major classes: (1) relatively permanent conditions that directly affect the intensity of need states (sex, race, religion, social class, education, intelligence, values, parental conditions, and family behaviors); and (2) transitory internal states that influence the expression of need states, generally by inhibition of scores (anxiety, conflict, defenses, guilt, and self-concept conditions). Not all the conditions of either class have the same effects across need states. The following data are relevant to the first class of variables. The sex of the test taker is more relevant to nAch than to nAff. Whenever there is a differential definition by sex of what constitutes any need state, the thematic stimuli and arousal conditions must be varied in accord. Normative data from a sample of both sexes for nAch, nAff, and nPower have shown the contributions of age, education, family income, occupation, and race (Veroff et al., 1953), although test- taker variables had only limited effects. Rosen (1961) showed the interactive effects on nAch of social class, family size, birth order, and age of mother. Nuttal (1964) determined that although race (African American) is relevant to nAch scores, the geographic region of childhood experience has as large an influence. It has also been demonstrated that religion influences nAch, with Jews, Catholics, and Protestants, respectively, obtaining decreasing scores in a national sample (Veroff et al., 1953). One finding relevant to the second class of test-taker conditions was that, for nAch, all measures showed that anxiety or conflict over fears of possible failure served to inhibit or distort achievement scores (Sampson, 1963). Examiner Variables Bernstein (1956) has shown that the sheer presence of an examiner and individual differences between examiners influence the expression of affect on the T.A.T. Broverman and colleagues (1960) have pointed out that there are definite differences, at least for nAch, between individual and group istration due to the more immediate influence of the examiner on individual istrations. Sexual imagery and nSex scores are also affected by examiners or social settings

REVIEW OF LITERATURE RELEVANT TO THE T.A.T. 195 ny one need low cue value .ried for simi- g, 1967), and and early use alue pictures tein (1963a) ng arousal by it ambiguous ses: (1) rela- t states (sex, aditions, and .xpression of es, guilt, and same effects ariables. The :here is a dif- naatic stimuli m a sample of of age, edu- lthough test- active effects [uttal (1964) h scores, the . It has also tholics, and nple (Veroff nditions was s of possible ). iiner and in- l'fect on the iare definite tion due to tinistrations.

l

cial settings

(Martin, 1964). In conclusion, Dana (1968, 1972, 1985, 1993) suggested that future research relevant to clinical assessment should include these issues: (1) simultane- ous measurement of needs, (2) assessment of anxiety and conflict relative to each need by independent indices and/or by intraindividual comparison of need scores from neutral and aroused conditions, (3) control of both classes of test-taker conditions, (4) recognition of examiner influences, and (5) consensus on methods for measuring needs. In the German language, two books dealing with the T.A.T. are in the form of slim volumes. Seifert (1984), in a paperback illuminatingly called Der Charakter und Seine Geschichten (The Character and Its Stories), developed a schema with four subgroups: Complaint, the Gelebte Methode, Style of Life, and Problems of Construction. These apparently refer to an attempt at systemization of the complaint and the actual behavior of the patient. The difficulties of translation reflect the difficulties of conceptualization. The four subdiagnoses resemble in part the subdiagnostic level of Bellak's T.A.T. Blank, where he speaks of a descriptive level of the stories, the interpretive, and the diagnostic level as an attempt to project the progression from primary data to observation-distant diagnoses. In other respects, Seifert proceeds along the lines of classical psychoanalysis in arriving at psychodiagnostic data. A book by Revers and Allesch (1985) called Handbuch zum Thematischen Gestaltungstest concerns itself primarily with the Thematic Gestaltungs Test, a series of 20 pictures designed to supplement the T.A.T. pictures. The volume addresses itself frankly to the clinical practitioner, with a few critical asides to academic psychologists. The interpretation, though following some schemata of the author's own, is basically a psychoanalytic one. Study of Character and Defenses in the T.A.T. A very important area of research has been the study of defense and coping mechanisms in thematic tests, which began in Bellak's earliest T.A.T. papers (1944, 1947, 1950). As Schafer (1954) demonstrated in his profound explication of defense mechanisms on the Rorschach, Bellak's early papers and the scoring category on defenses in his Short Form have been enriched by many later studies of defenses on thematic tests (Blum, 1964; Brody & Siegel, 1992; Bush et al., 1969; Cramer, 1991a, Dies, 1976; Haworth, 1963; Heath, 1958; Heilbrun, 1977; Kimura, 1983; Lazarus, 1961). A valuable effort in developing a scoring form for the C.A.T. for adaptational mechanisms is that of Haworth (1963), which is included in the Bellak's manual for scoring and interpreting the C.A.T. (see Chapter 15). The books by Dies (1976) and Cramer (1991a) on defenses in the T.A.T. are also important additions to this research tradition. A problem with the work of Dies is that the particular way of scoring individual defenses is not clearly spelled out in the book. Cramer's work, on the other hand, sets a high standard for clearly defin- ing the T.A.T. scoring for defense and submitting her scoring method to several reliability and validity studies (Cramer, 1979, 1983, 1991a, 1991b; Cramer & Blatt, 1990; Cramer & Carter, 1978; Ci-amer et al., 1988). The only drawback of her work

196 CHAPTER 9 is that, unfortunately, she has only studied the three defenses of denial, projection, and identification. Hibbard and colleagues (1994) compared 40 undergraduate college students with 29 successive issions to an acute psychiatric ward of a VA hospital on Cramer's Defense Mechanism Manual for the T.A.T. They found that the psychiatric patients used more primtive types of defense (more denial and projection) in their T.A.T. stories, whereas the college students used more of the higher-level defense of identification. This study provides further validation of Cramer's scoring approach for defense mechanisms. Defense mechanisms can be defined as methods employed by an individual in order to manage fears, anxieties, and insecurities. For example, if a child gets bitten by a dog, the child may decide to avoid going near dogs for a period of time. The defense, in this case, is termed withdrawal or avoidance. If the child continues to avoid dogs over a long period of time, the defensive avoidance of the fear of being bitten by a dog once again may harden into a habitual avoidance of dogs and later transfered to a generalized avoidance of all larger animals. As the habitual avoidance becomes more "second nature,"--that is, as it becomes more ingrained in one's daily behavior of avoiding larger animals and perhaps also assertive people-- the defensive avoidance may be said to have "hardened" into becoming part of the individual's character. In other words, the individual now has what may be called an avoidant personality disorder. The word characterin the English language can be roughly equated with moral traits: One speaks of a good character and a bad character, and of character wit- nesses (who testify to one's good moral character). The word character in German is not exactly identical with but roughly corresponds to the American usage of the term personality. However, in U.S. psychoanalysis, psychiatry, and psychology, the term character neurosis is generally accepted and does not clearly relate either to character or neurosis. A character neurosis is a disorder of which the afflicted is usually unaware, although it is apparent to persons in his or her environment. It consists of character traits that are ego syntonic for the person having them. They usually cause the person no complaint or concern, and are often the object of pride and affection on the part of their owner. However, by directly bringing him or her into conflict or unpleasant with environmental forces, the character traits may produce hardship and discomfort. Probably the most frequently mentioned subspecialty of this disorder is the obsessive/compulsive character neurosis in which a person iso- lates his or her emotions very well (too well), is apparently unaffected by what goes on around him or her or manages to appear well controlled and smooth, and is often thought of as machine-like in efficiency, orderliness, lack of spontaneity and real warmth, and so forth. The diagnostic counterpart of a character neurosis is the psychoneurosis, in which the person suffers from test symptoms that appear more or less ego alien. It has become axiomatic that there is scarcely a psychoneurosis without some character neurosis, and that there is hardly a character neurosis that does not show some psychoneurotic features under pressure or under some psychoanalytic scrutiny. Nevertheless, the distinction is a very useful one, although it may be only quantitative. Having neurotic"haracter traits can probably most easily be conceptualized

REVIEW OF LITERATURE RELEVANT TO THE T.A.T. 197 .al, projection, tndergraduate ward of a VA tey found that enial and pro- more of the validation of tdividual in or- dld gets bitten ] of time. The I continues to fear of being dogs and later mbitual avoid- ingrained in rtive people-- ing part of the y be called an ted with moral character wit- r in German is a usage of the term character racter or neu- ly unaware, al- ts of character cause the per- d affection on ato conflict or may produce ubspecialty of a a person iso- 5 by what goes toth, and is of- ontaneity and choneurosis, in Ss ego alien. It some charac- tot show some dytic scrutiny. only quantita- nceptualized as a syndrome of defenses functioning well enough to avoid direct and open drive conflict at the cost of impoverishment of other ego functions. The impoverished ego functions may be those of spontaneity (e.g., in the case of obsessive rigidity') or those of reality testing (as in the case of extensive rationalizations, such as are involved in systematic political, ethnic, or scientific bias) or in the inability to learn from past experiences (e.g., in the "success neurosis," which will be discussed later). The justification for this discussion of psychopathology lies in the fact that the T.A.T. may be an excellent means for the analysis of such character problems. Not infrequently, a single story may clearly set forth the central theme of a person's life--an often pernicious theme and one of which the one afflicted may be entirely unconscious. The following story told to picture 1 clearly illustrates such a pernicious theme: At the age of 9, Karl was intrigued by the wonderful tones of his father's violin. Whenever Karl's father played, Karl would watch and listen and dream. After one such performance, Karl's father asked him to put the violin back in its case. Karl was placing the violin on the table when he just sat back and stared at the instrument. It was at this moment that Karl realized that he must be a violinist like his father. Staring at the violin, Karl suddenly closed his eyes and dreamed, as most children do, of some years later, when he would stand on a pedestal in the Great Palace of Vienna. Itwas his premiere as a soloist with a great orchestra. He was shaking, nervous, and afraid, yet intent. Intent on fulfilling his ambition. The noise of the impatient andience, the shouting of the stage hands in the adjustment of props and lights, the tuning of the various instruments, all helped to create his nervousness. Then, without further delay, the curtain opened, the audience became dead silent, the con- ductor knocked his baton repeatedly on the stand, raised it a final time, and on the drop, Karl began to play. A sweet Viennese waltz, combined with the pleasures of his heart and soul, poured from his violin. The music ended, the audience rose to its feet and acclaimed Karl as a great interpreter of his country's music. The music of his fathm: Taking the customary bow in the recognition of his appreciation, Karl suddenly fell from the pedestal. He never awoke from his dream, you see, Karl was dead. The shock of visualizing such a success was too much for his ailing heart to bear. Thus, the music world lost a promising nusician because of a violin, an ambition, and a dream. Freud coined a term, Schicksalsneurose, which can only be poorly translated as "fate neurosis." It is sometimes spoken of as a success neurosis, with a more limited meaning. It could also be called the "Schlemiehl syndrome" to describe a person for whom everything seems to go wrong, through no apparent fault of his or her own--fate always seems to play the person a dirty trick. The term success neurosis is more properly reserved for those cases where the attainment of success produces anxiety, depression, and other symptoms. Both disorders have in common a deep masochistic disturbance. The story just quoted can probably be easily analyzed for its main features by anyone conversant with psychopathology: Karl tries to fiddle as well as his father. When he permits himself this attainment, even in a dream, he dies for it. This must be viewed as a theme of competition with the father (probably on an oedipal level) and the punishment commensurate with the crime of wanting to replace the father. The analysis of the story was corroborated by the man's therapist, who reported that he had suffered from repeated uncanny failures in his life. Hence, it is possible to guess that the main content of this person's character neurosis is almost entirely ed for in this story.

198 CHAPTER 9 Another individual told the following story to picture 11: Two men have come to kill the dragon. When the dragon appears, spouting flames that light up the area, one man flees in terror; while the other, equally afraid, hides from the terrifying animal by turning away from it but is unable to flee. This dragon has been the scourge of a country, devastating the land by scorching it with his breath whenever it walks abroad. Two strangers who visit this country are told of this danger to the community and volunteer to kill this menace. The man who has remained behind finds soon that the heat and light disappear and turning around comes face to face with the dragon, who no longer is terrifying. The dragon speaks of his loneliness because all run from him. He wants to be able to have with people but realizes they are frightened of him. He is very happy that this man has stayed and asks what it is that makes everyone run from him. The nan tells him of the destruction the dragon leaves behind him. The dragon then understands this but also knows that his breathing flame is a part of him that he does not know how to change. He promises that he will not in the future wander around as he has done but remain hidden in the rocks where he will not do injury, and the man returns to the village to tell the people what happened. The people run him out. They are divided between those who do not believe him and those who believe him but blame him for not having taken this opportunity to kill the dragon, since they are sure the dragon will not keep his promise. However, the dragon does, and as the community again is able in time to build up its wealth, the people make pilgrimages to the mountain to leave thank-you offerings to the dragon. It is most regrettable that Alfred Adler had to renounce all of psychoanalysis in order to feel that his contribution was secure; it is equally regrettable that psychoanalysis has not adopted some of his (e.g., "style of life"). Many character neuroses can most easily be described in of a defensive style of life, geared to neurotic goals, and blindly repetitive. For instance, in the case of the story just quoted, the patient clearly identified with the would-be monster who really wanted to be loved and appreciated. The patient felt monstrous inside because of his hostility. Orally deprived, the patient had often described himself as feeling like a puppy-inappropriately over friendly to strangers, yet at the same time holding himself aloof from any real emotional involvement. He often an- tagonized people deeply without being aware of it and left himself open to being hurt by his expectation of being loved by everyone. In the story, he is not only the monster but also the victian (who wants to be) befriended by the monster. Such a style of life finally led to enough realistic repercussions to bring him into treatment. A different problem is depicted in the stories of a brilliant young scientist, who suffered conflicts between his allegiance to the ways of his parents and new ideas (superimposed on earlier conflicts). This is his story to picture 1: A youngster has been called in from play by his mother to practice his violin lessons. He is annoyed and sulking over it. He is thinking of all the activities he would prefer to be carrying on. But he is a talented and sensitive child. Soon he will get over his annoyance and will take the instrument into his hands and practice. He will begin to enjoy his lessons. This story shows a conflict between autonomy and compliance, which is resolved in favor of comp.!iance. The most significant aspect of this story is that the compliance becomes ego syntonic: He will begin to enjoy his lessons. rosis study not pa leans again lot of ily th secti job, his b resol in hi

REVIEW OF LITERATURE RELEVANT TO THE T.A.T. 199 rs, spouting flames !raid, hides from the land by scorching it untry are told of this light disappear and rrifying. The dragon to have with s man has stayed and ,f the destruction the mows that his breath- raises that he will not e rocks where he will L happened. The peo- im and those who be- he dragon, since they toes, and as the com- [rimages to the moun:all of psychoanaly- ally regrettable that Df life"). Many char- fensive style of life, ., in the case of the [-be monster who re- }onstrous inside be- Oescribed himself as iers, yet at the same inaent. He often an- imself open to being iry, he is not only the a f .he monster. Such )ring him into treatliant young scientist, his parents and new ,icture 1: :rice his violin lessons. es he would prefer to will get over his annoy- will begin to enjoy his apliance, which is re- ef this stoW is that the lessons. The other stories show that this process of psychoneurosis into character neurosis was not quite successful. Following is his story to picture 3BM: The peasant boy has just been told by his father that he may not go to the big city to study sculpting and carving. He is needed to help on the farm. The family is poor and cannot pay for hired labor. The boy has gone into his own room and, unable to control himself, leans against his cot and weeps. His carving knife lies on the floor. But in time he will forget and accommodate himself to the limited ways and aspirations of the peasant. The weight of frustration will make him somewhat irritable, impatient, dulled, unaspiring,and uninspiring. To picture 9BM, he tells the following: Four hoboes relaxing. They have just finished their improvised lunch, prior to which they had relaxed, prior to which they had breakfasted, prior to which they relaxed. On completing their noon nap, they will be on their way, planning the evening meal so they may again relax. They have accepted tedium as their lot and made peace with it. Tedium is the lot of so many of us; we differ only in that we have not reconciled to it. Within us weighs heavily the hope and longing for end and purpose. And to picture 14: He has spent several pained and fruitless hours twisting and turning in his bed, dis- secting in his mind the two choices before him. Shall he hold onto the security of his present job, whose future is uncertain, or leap into the uncertainty of the present in the hope of achieving a greater certainty in the future? How difficult he finds it to renounce! He leaves his bed, goes to the window, and looks out among the pinpoints that dot, and the houses sil- houetted against, the gradually lightening sky--as though they would offer him some aid in resolving his dilemma. He will return to his bed, his choice unmade, and will find a solution in his dreams. These stories show the unresolved conflict, the intrapsychic awareness of the deadening process of repression and emotional isolation: tedium, dulled, uninspiring. Only irritability and impatience remain as a semblance of emotion, in what otherwise could best be characterized by Myerson's term, anhedonia. This anhedonia, this absence of any pleasurable sensation, is frequently the outcome of gross emotional impoverishment under the impact of obsessive/compulsive defenses, somewhat equivalent to a mild depression. The process depicted in the T.A.T. is incomplete. Had it gone on to its completion, the person would probably become somewhat peculiar, mild-mannered, gentle, and living up to one-tenth of his potential. This study of the character really involves a study of the defenses. The study of the defenses is so intimately connected with the problems of personality that this topic had to be discussed extensively in the elaboration of the ego psychology of projective techniques and again in discussing the relationship of the overt to the latent. If this test-taker matter is once more taken up here for its own sake, it is because a strictly clinical discussion should be presented in its own context: This aspect of apperception is relatively the newest, least is known about it, and it is probably the most important. According to Fenichel (1945), ego defenses may be divided into successful defenses, which bring about a cessation of that which is warded off, and unsuccessful defenses, which necessitate a repetition or perpetuation of the warding-off process to prevent the eruption of the warded-off impulses. Sublimation is a successful, not

200 CHAPTER 9 a pathogenic, defense. It is not characterized by a specific mechanism and is thus not very easily discernible in T.A.T. stories. Denial is an exceedingly common defense. The tendency to deny painful sen- sations and facts is as old as the feeling of pain itself. The ability to deny unpleasant parts of reality is frequent, both in children and in adults, and we find many instances of this defense mechanism in T.A.T. stories. One patient, in response to picture 2, described the woman ordinarily seen as pregnant as "slim, thin, and well proportioned." His mother's pregnancy with a younger sibling had played an important role, and pregnancy fantasies were at the root of his anxieties. Here, he simply denies the existence of pregnancy. Denial of one's own aggressive impulses is another very frequent defense. The following story was told to picture 18GF by a woman who had attempted to kill her children: Looks like a mother holding a child at the foot of a staircase; might have been that the child fell down the staircase and the mother picked him up to see if he's hurt; looking him over very anxiously but I don't think he's hurt. The mother will be much relieved. (?) Tripped. This picture is usually seen as a woman attempting to choke another. The test taker who told this story identified with the older (maternal) figure but felt compelled to deny any element of aggression in the situation. Projection is one of the most archaic of the defense mechanisms. It belongs to that early stage in which everything pleasurable is experienced as belonging to the ego, while everything painful is experienced as being nonego. In one sense, of course, the T.A.T. deals entirely with projection, and some degree of this particular defense mechanism is to be seen in every T.A.T. story. However, in certain stories this element is particularly strong. When figures are introduced that are not in the pictures, this element can be said to be at work. In a story such as the following (to picture 13MF), the dynamic content (apparently killing the girl and directing the aggression against her) suggests the use of projection by this test taker. (The fact that he seems partially aware of his own guilt feelings does not obviate the use of projection.) It is as if he might say, "True, it's my fault, but it's hers even more!" This is a young man who is going to the local university.., a student .... He is very moralistic.., that is, very virtuous.., having a highly developed sense of what is right and what is wrong. He is also very religious .... He has been brought up very strictly and believes that one of the greatest sins that man can commit is to have sexual intercourse with a woman out of wedlock .... One evening, at a party, for some unknown reason, having taken too many drinks and feeling slightly lightheaded, be became very intimate with one of the girls present. He... his animal instincts came to the fore and he abandoned all his ideas of virtue, etc. He took this woman up to his room and went to bed with her. The next morning, after becoming sober and having regained his virtuous sense or whatever you want to call it... he looked over and saw this woman beside him in utter nakedness. He was filled with anger, and wild. Let's see (murmurs to hinself) . . . and bitter ion at what he had done. A profound hatred swelled up in his chest for this woman that lay next to him. He ordered . . . she by this time had become awake . . . and he ordered her to leave his room .... She, not understanding what had brought this attitude of his about, believed that he was joking, and refused to leave in a jocular manner. This man could think of nothing but to clear himself of this sin he had committed.., cleanse himself of this sin .... And as this

chanism and is thus to deny painful sen- ¢ to deny unpleasant ld we find many inan ordinarily seen as 's pregnancy with a fantasies were at the regnancy. equent defense. The tttempted to kill her ght have been that the )e's hurt; looking him e much relieved. (?) ke another. The test figure but felt corntnisms. It belongs to as belonging to the ;ction, and some de- every T.A.T. story. A/hen figures are in- [ to be at work. In a :ontent (apparently Its the use of projec- if his own guilt feel- it say, "True, it's nay udent .... He is very se of what is right and p very strictly and be- iaal intercourse with a nown reason, having intimate with one of andoned all his ideas her. The next morn- vhatever you want to :edness. He was filled ssion at what he had lay next to him. He red her to leave his s about, believed that think of nothing but sin .... And as this REVIEW OF LITERATURE RELEVANT TO THE T.A.T. 201 woman lay there laughing, and being overcome with his guilt, he seized her by the throat and strangled her. Rising from the bed, and putting on his clothes, he became.., he realized his predicanaent. He not only had committed a sin . . . a moral sin . . . but he had committed a greater sin by taking her life .... He gazed down as she lay there at her statuesque stillness and was filled with remorse. ing a few days earlier.., that a few days earlier he had bought a bottle of iodine, and which was now in the cabinet of the washroom, he went there and gulped down its contents (laughs) and consequently died. That was the end of that .... I just said that he strangled her because she was laying in bed next to him, and that was the easiest thing he could have done, by reaching over and grasping her neck. Repression is a relatively less archaic mechanism, a derivative of denial. It consists of an unconsciously purposeful forgetting or not becoming aware of internal impulses or external events that usually represent possible temptations or punish- ments for, or mere allusions to, objectionable instinctual demands. The purposeful exclusion of these facts from consciousness is intended to hinder their real effects as well as the pain on becoming aware of them. Sometimes, certain facts are re- membered as such, but their connections, their significance, their emotional value, are repressed. There are many neurotic attitudes that are obvious attempts to deny or to repress some impulse, or to defend the person against some instinctual danger. They are cramped and rigid attitudes, hindering the expression of contrary impulses, which sometimes nevertheless break through in various ways. The original opposite attitudes still exist in the unconscious; these secondary, conscious attitudes are called reaction formations. Both the conscious and the original, unconscious attitude are apparent in the following story told to picture 17BM: The man shown here is a circus performer and has been one for many years. His ambition has always been to be a solo performer instead of part of a trapeze trio. Until now he has not had the opportunity. In tonight's performance he will save a fellow trouper from a serious accident and as a reward for his bravery will be given the chance to do his act alone. In this story, the act of bravery, saving the fellow trouper, is the reaction formation, or disguise, for the unconscious aggressive wishes against this person. It is somewhat reminiscent of the overprotective mother who constantly fusses over her child to hide from herself her basic (unconscious) lack of acceptance of the child. Undoing is related to reaction formation. In reaction formation, an attitude is taken that contradicts the original one; in undoing, one more step is taken. Something positive is done which, actually or magically, is the opposite of something which, again actually or in imagination, has been done before. This mechanism can be most clearly observed in certain compulsive symptoms that are made up of two actions, the second of which is a direct reversal of the first. For example, a patient must first turn on the gas jet and then turn it off again. Obsessive elaboration is not uncommon in the stories of obsessive/compulsive patients. The following story was told to picture 13MF: A man and woman who may be in a bedroom or living room with a cot. She may have been ill and had been put to bed. The man may have seen to her wants or he may be a doctor who had been with her a long time, especially through the night, and is now very tired. The woman may be sleeping or resting or may have died, and the man, her husband or doc-

202 CHAPTER 9 tor, has just gone through a long siege, or if the woman is his wife who died, he shows sorrow, or if he is just sick, he shows fear and is tired. It may be that homicide has been committed and the man shows remorse and realization of the gravity of his act. Or there may have been cohabitation, the woman undraped in bed, the man having dressed. Also, a husband getting up early in the morning to go to work, not quite awake, while his wife is still asleep. In this case, at least four stories show a progression from a relatively innocuous apperception to breakthrough of plainly homicidal thoughts. Whether cohabitation is a further progression to an even worse crime in the mind of the test taker or whether it constitutes a renewed vigor of defenses that culminates in the utterly innocuous domestic scene could not be ascertained. Another mechanism of defense prevalent in compulsion neuroses is isolation. Here, the patient has not forgotten his pathogenic traumata, but has lost trace of their connections and their emotional significance. The most important special case of this defense mechanism is the isolation of an idea from the emotional cathexis that originally was connected with it. The patient remains calm while discussing the most exciting events. The following story, told to picture 2, is an excellent example of isolation: Very interesting picture. Is it a painting of some sort? The first idea that comes into my head is terribly Hollywoodish. (The idea, not the picture.) A man and a wife who work a farm and she looks as if her parents and forebears have also worked a farm. The girl in the foreground is the daughter who doesn't want to work the farm but who wants to lead a more intellectual life away from the burdens of the farm. The parents resent this. They seem to ignore her. She looks as if she's leaving them after an unsuccessful argument or discussion as to whether she's doing the right thing or not. I have no doubt she will leave them. The part where she's standing in the picture seems very rocky--whereas where the parents are standing seems very well worn. So we might say that her path may be uphill and that may be causing some of her parents' dissent. Well, the parents will continue in their way of life and the girl will continue on her rocky road and the way it always happens in Hollywood is that the girl always makes something of herself. (How does it happen outside of Hollywood?) It can be either way, but that's because ! really don't care. The last few words of the story--"I really don't care"--is the credo of the isolated person. By this defense mechanism, he has managed to detach himself from all his feelings. This detachment is also inherent in his opening words: 'Very interesting picture." The whole story has a cold, detached, intellectualized feeling tone common to stories of test takers who use the mechanism of isolation. Isolation and overintellectnalization usually go together. In fact, the normal protote of isolation is the process of rational, logical thinking, which actually consists of the elimi- nation of affective associations in the interest of objectivity. Compulsion neurotics, in their isolation activities, behave like caricatures of normal thinkers. Whenever a person meets frustration, there is a tendency for him or her to long for earlier periods in life when experiences were more pleasant, and for earlier types of satisfaction that were more complete. The intensity of this tendency increases with two factors that are closely interrelated: the degree of hesitancy with which the individual accepts newer modes of satisfaction, and the degree to which he or she is fixated to earlier types. However, very intense and sudden disappoint- ments and dangers may provoke regressions even in individuals without strong fixations.

REVIEW OF LITERATURE RELEVANT TO THE T.A.T. 203 who died, he shows sor- aomicide has been com- )f his act. Or there may ing dressed. Also, a hus- ke, while his wife is still m a relatively innocu- ghts. Whether cohabi- mind of the test taker [minates in the utterly n neuroses is isolation. t, but has lost trace of ost important special t from the emotional '.mains calm while dis- picture 2, is an excel: idea that comes into my a wife who work a farm rm. The girl in the fore- wants to lead a more in- nt this. They seem to ig- • gument or discussion as ill leave them. The part re the parents are stand- fill and that may be caus- their way of life and the in Hollywood is that the Hollywood ?) It can be eiis the credo of the iso- b detach himself from ing words: "Very inter- ctualized feeling tone ;olation. Isolation and al prototype of isola- ¢ consists of the elimi- ;ompulsion neurotics, thinkers. ncy for him or her to pleasant, and for ear- ity of this tendency in- ,ree of hesitancy with :l the degree to which d sudden disappoint- ls without strong fixaRegression is much more common in children than in adults who are not psychotic, since the precondition for the use of regression as a mechanism of defense is a weakness of the ego organization. The following story was told by a 9year-old boy in response to story 3 of the C.A.T.: Well, this lion is troubled by mice. He's sitting there and doesn't know what to do about the mice. He's tried everything, so he calls the exterminator and the exterminator says, "The only thing to do is to blow the mice out," but the lion says, "I've tried that and lost three houses." %Vhy not make traps?" "But the mice have certain things that disconnect the traps and they always get the cheese." "Why not try poison, then?" "But that's impossible because the mice know it's poison and they'll never come out." Finally the lion decides he will move to Florida, but when he gets there he sees now.., he's being troubled by worms coming through the floor. So finally he says, "I'll go back and live in the jungle where I belong." This little boy was troubled by his younger sibling. First he tried aggression, then agression with the help of someone else (the therapist), then withdrawal (moving to Florida), and when that didn't help either, he regressed to infantile habits (the jungle). The mechanism of displacement is employed when the anxiety aroused by a certain situation, person, or the like is displaced onto something else. There can be displacement of affect as well as displacement of object. In T.A.T. stories, this defense reveals itself by the use of far-distant times and places and by ascribing problems to people other than the hero, as well as by changing the nature of the anxiety. One test taker, of Jewish American stock, began his story to picture 4 as follows: This seems to be taking place in some isolated place. Maybe a South Sea Island. The same test taker started his story to picture 2 by saying: This girl, about 19 years old, would probably be named Olga, of Ukranian parentage and stock. Coping A concept broader than the one of defense is the concept of coping. It offers a useful way of viewing the evaluation of the T.A.T. (and C.A.T. and S.A.T.). Being asked to tell stories to the pictures is to perform a task. How does the test taker go about coping with this task? How does he or she respond behaviorally? Is she confused, frightened, negativistic? Does the story constitute a good coping effort? Does the test taker achieve closure? Are there different ways in which closure is being achieved? Is the first attempt at a story the most successful and the following two increasingly disorganized by uncontrolled drives? Or is it the other way around and the stories show improved coping effort, suggesting a potential of dealing with problems that were found overtaxing initially? In a broad sense, all of human behavior-including dreams, neurotic and psychotic symptoms, and "normal" behavior-can be usefully viewed as attempts at coping. Vaillant (1971, 1977) discussed the adaptational coping mechanism of sublimation, when one expresses undesirable feelings, such as aggressive anger, in an adaptive vehicle of self-expression, such as assertive playing of music, expressive dancing, or painting. Other coping mechanisms, according o Vaillant, are humor and wit (e.g., when one is able to laugh at

204 CHAPTER 9 one's own areas of vulnerabilities), anticipation, (when one actively prepares for a difficult task expected to be confronted in the future) and suppression (when one actively puts a distressing thought or feeling out of one's immediate attention and consciousness in order to be able to go about one's activities, such as when one is mourning the death of a loved one, but has to put this temporarily out of one's mind during the day at one's place of work). Vaillant has arranged about 30 different defense and coping mechanisms into a theoretical hierarchy of adaptational mechanisms. The hierarchy has four levels-psychotic defenses, immature defenses, neurotic defenses, and the abovenoted coping mechanisms. The model is based on a continuum of mental health functioning from severe pathology to psychologically healthy adaptation. Anna Freud (1936) outlined a developmental model of defense and coping mechanisms, beginning with those that are typical at infancy (withdrawal, avoidance, denial), early childhood (identification with the aggressor, displacement, reveral of affect, clowning, affectualization), elementary school ages (repression, reaction formation, isolation of affect, intellectualization), to those of adolescence (rationalization, asceticism, altruistic surrender, ive aggressive acting out, etc.). An important direction for future clinical use of thematic tests is to develop a clear way to score the full array of adaptational mechanisms of Vaillant's and Anna Freud's schemes with the same level of empirical specificity in Cramer's (1991a) work on projection, denial, and identification.

LI lore 1995: cus is of the chron ferent ture, in Ah a sto k, and lar cul thro inform Marcu erary s is an & Heis that famili, lywed ferent

CHAPTER 10 prepares for a ion (when one : attention and as when one is [y out of one's chanisms into y has four lev- nd the above- mental health ptation. Anna mechanisms, ance, denial), veral of affect, ,action forma- e (rationaliza- is to develop a nt's and Anna er's (1991a)

THEMATIC ANALYSIS IN THE STUDY OF NARRATIVE AND LIFE HISTORY The study of narrative has developed into an interdisciplinary field including psychology, sociology, political science, comparative literature, literary theory, folklore, anthropology, and many other fields (Cortazzi, 1993; Griffin, 1993; Mishler, 1995; Polkinghorne, 1988; Sarbin, 1986; Toolan, 1988; Young, 1987). The main focus is the study of different types of narrative behavior, which ranges from studies of traditional narratives of fairytales of different cultures (Child et al., 1958; Cramer, 1991a), myths, and children's storybooks (McClelland, 1961) to studies of the way narratives may function in the reporting of a rape (Abrams, 1991) or the chronology of a lynching (Griffin, 1993). From this perspective, the analysis of different forms of narrative behavior provides a framework for understanding a culture, an individual's identity, or the meaning of a significant experience. Cain (1991) suggested that the telling of personal life histories of alcoholism in Alcoholics Anonymous provides a very important opportunity for acquisition of a sense of identity and self-understanding. The content of the life story and how the story is told are both equally important, as Roy Schafer (1958) emphasized in a rare and valuable early contribution on the T.A.T. Anthropologists have often employed the method of learning about a particular culture by locating an articulate individual with whom to undertake an in-depth interview of the current way of life and personal life history. Other approaches in anthropology are to examine the relationship between the personal history of cultural informants and the anthropologist's manner of writing up these stories (Clifford & Marcus, 1986; Fabian, 1983; Geertz, 1988). Applying the tools of linguistics and literary structure analysis to examples of event structure models in ethnographic data is another application of the study of narrative to the field of anthropology (Corsaro & Heise, 1990) as well as to the field of sociology (Griffin, 1993). Good examples of this broader, interdisciplinary study of narrative behavior is that of Ochs and Taylor (1989), who compare the narrative structure of stories families relate at dinner to detective stories; the cross-cultural comparison of new- lywed stories by Veroff and associates (1993); or Michaels's (1981) research on different ways children relate personal stories during "sharing time" in day care and 205

206 CHAPTER 10 early school settings. Research on the structure and function of narrative was co ducted by Abrams (1977), Miller and Moore (1989), Miller and colleagues (199C and Sutton-Smith and colleagues (1981) in studies of how narratives are used by culture as part of the socialization process. Studies of the structure and function narrative in the psychotherapy process have been conducted by Spence (1982) at White and Epston (1990). One of the main organs of communication for this e citing interdisplinary field of narrative is the Journal of Narrative Analysis and L History. In this chapter, we provide an example how Bellak's Scoring System for tl T.A.T. may be extended to the study of other forms of narrative behavior, such dreams, folktales, narrative discourse in Alcoholic Anonymous meetings, or worl of literature. Since the T.A.T. is a group of short stories, perhaps the best examp we can provide is an analysis of several short stories of the author, Somers, Maugham. In this case, the artistic product serves as the primary data from whic inferences about the personality of the writer are made with the help of the star outline that we used for T.A.T. stories. Earlier, we touched on some of the differences between the creative proce under ordinary circumstances and in response to T.A.T. or C.A.T. cards (s( Chapter 2). We mentioned the difference in mental set, among other things. Th creative end product in the case of a published literary effort and a T.A.T. story als vary widely, of course. The published story may be the result of innumerable rewri ings and editing (from that standpoint, writers' first drafts may be the best sourc for analysis of their personality). Also, part of a writer's frame of reference is adat tive to the audience the writer wants to reach. Many writers may have developed style adaptively and, to a considerable extent, consciously, and may even have mad a concentrated effort to keep content referring to themselves personally out their work. Despite all these differences and caveats to be kept in mind, the end produc unless vitally affected by other than the author, is a product of one's personality, al belt modified by a variety of adaptive ego mechanisms. This product therefore ba sically lends itself to analysis as a personal document just as T.A.T. stories do, excep that one has to allow for special complexities and possible difficulties in arriving a correct inferences with regard to unconscious motivation. (Incidentally, the anal} sis of political documents and speeches with regard to the personality of the autho is also possible and may be extremely valuable in the future if the caveats abou ghostwriters, editors, and the like are ed.) Among writers, some alway write essentially about themselves, and every story is their own story. Others attemp to keep themselves out and supposedly "think up" stories totally unrelated to thei own experiences. Nevertheless, their product--in of choice of content ant with regard to expressive and cognitive style, aside from its susceptibility to study bl content analysis in the sense of counting the frequency of words, noun-verb ratio and so on--remains uniquely theirs and therefore lends itself in principle to ar analysis of their personality (Judson, 1963). Somerset Maugham's stories fall somewhere between the two extremes of di rect biography and self-exclusion. Manifestly, source material comes from all ove: the world---Europe, Russia, the Far East. However, Maugham's personality shine, thrgugh all of them.

f narrative was con- d colleagues (1990), ratives are used by a ture and function of y Spence (1982) and mication for this ex- tire Analysis and Life ring System for the ive behavior, such as meetings, or works ps the best example le author, Somerset ary data from which he help of the same the creative process ,r C.A.T. cards (see g other things. The nd a T.A.T. story also innumerable rewrit- y be the best source of reference is adap- ay have developed a may even have made es personally out of d, the end product, 3 ' " , ne s personahty, alidentally, the analy-

t

oduct therefore ba-

I T. stories do, except tculties in arriving at

. nality of the author lif the caveats about writers, some always Iory. Others attempt ' unrelated to

their ?ice of content and ptibility to study by • ds, noun-verb ratio, f in principle to an two extremes of di- :omes from all over s personality shines THEMATIC ANALYSIS IN NARRATIVE AND LIFE HISTORY 207 Thirty of Maugham's (1953) stories were selected randomly from two volumes, picked by the senior author's then &year-old daughter and by their numerical characteristics--l, 2, 11, 12, 21, 22. It will become quite clear that the themes and characteristics that become manifest in the selected stories have a great similarity to most of the rest of Maugham's writings, including his major work, Of Human Bondage, which is considered to be, in large part, autobiographical.

Somerset Maugham: Analysis of the Storiest The first story, luckily enough, is "Rain"--luckily, because it is particularly widely known both as a movie as well as the original short story. Descriptive Theme. A zealous missionary, driven by great religious fervor, has always resisted the ordinary feelings of comion, sex, and fear in his desire to rise above them for the sake of a stern religious morality. When he meets Sadie Thompson, a prostitute, he feels compelled to interfere with her activities in his efforts to save her soul (at the cost of great misery and actual danger to her). However, he finds himself increasingly attracted to her (note his dream of breast-like mountains, his remaining with her later and later into the night) and ultimately makes a sexual advance. He kills himself in consequence. Interpretive Theme. If emotions are very strong, especially sexual desire, and one tries to control them while in intense with a woman, control may be de- stroyed as well as oneself. Diagnostic Level. Presence of strong drives, aggressive and sexual. Attempted defenses are denial, repression, rationalization, withdrawal, and reaction formation. Adaptively tries to deal with his conflict by becoming a missionary. Fears loss of control over drives, especially sexual drive. Fears destruction by women. Concern about self-destruction; suicidal ideas are present. These bald statements leave out many subtleties of the story. For the sake of economy, we will point out only a few of the other features. The theme of the missionary is not the only one. He is not the only hero; Sadie Thompson is another. Descriptive Theme. A prostitute is reduced to a fearful clinging wreck by a zealous missionary bent on saving her soul, but she rises contemptuously when his moral principles collapse and ordinary lust shows through. Interpretive Theme. If a lustful woman meets a zealously moral man, she is reduced to weakness, but she recovers her strength if the man appears prey to lust. Quotations on pages 207-215 from Maugham (1953) are reprinted by permission.

208 CHAPTER 10 Diagnostic Level. Woman is seen as lustful, seductive. Moral man is seen as strong Man unable to control his desires is seen as contemptible by woman. Control is vet" important; its loss is contemptible. Another subtheme is concerned with Dr. Mahail. One must consider hin another identification figure for the author (of course, Maugham projects some o his own sentiments on all the figures). One may simply remark that the doctor ap pears comionate, but tries to remain uninvolved to avoid the discomfort of to much emotion. He tries to accept with ivity the missionary, his own wife, an the world around him but finds himself uneasy, lie engages in action in a desultor way (and with a good deal of conflict) only when he feels he can no longer avoid it. The minor female characters in the story appear as controlling, either by thei aggressive attitudes or by their moralistic ones. In fact, the most repetitive concer seems to be with emotions that could overcome one, especially with regard tc women who tend to control. One may anticipate some broader inferences here by .pointing out that the waitress, Mildred, in Of Human Bondage is not too different from Sadie Thompsor in her effect on the protagonist. Nor is the principle character, Philip, himself doctor, too different from Dr. Mahail. It is common knowledge that Maughar was a medical school graduate. "The Fall of Edward Barnard" In a general sense, one may describe this story as a not so gentle mockery of American culture, especially as seen through the bourgeois pretensions of wealthy women and their effect on men. Descriptive Theme. Edward Barnard is a traditional and upstanding young Chi- cagoan. Just as soon as he saves enough money from his work in Tahiti, he plans to return home and marry the beautiful, cultured, controlling, and ambitious Isa- bel. However, he comes to enjoy the easy and simple life of the islands, particularly the companionship of a halfcaste girl. Unlike Isabel, she puts him at ease. Bateman Hunter, in love with Isabel, but friend to Edward also, is vaguely puz- zled and distressed by Edward's change. He tries to persuade Edward to return home. When Edward renounces Isabel, Hunter himself returns to marry her. Isabel's dreams, as she embraces Hunter, are of business success, tea dances, and the look of distinction and solidity which horn-rimmed glasses will give her new fiancee. Interpretive Theme. If one is caught in the demands of petty bourgeois culture, as represented by controlling, ambitious women, one may find life much happier in an undemanding culture (which permits more ivity) and with simpler women (who are no threat and do not make one feel inferior). A selfless male friend helps out reliably. Diagnostic Level. An unease about cultural demands. Sees women of society as subtly controlling, demanding, ambitious. Sophisticated women of this kind produce feelings of unease, inferiority. Attempts solution of anxiety and conflict by with-

n is seen as strong. aan. Control is very must consider him m projects some of that the doctor ap- e discomfort of too ; his own wife, and ction in a desultory t no longer avoid it. ling, either by their : repetitive concern ally with regard to inting out that the aa Sadie Thompson .r, Philip, himself a :dge that Maugham gentle mockery of etensions of wealthy anding young Chi- n Tahiti, he plans to and ambitious Isa- !Islands, particularly him at ease. i also, is vaguely puz- e Edward to return urns to marry her. ess, tea dances, and will give her new fiourgeois culture, as ife much happier in with simpler women ss male friend helps omen of society as en of this kind pro- • and conflict by withTHEMATIC ANALYSIS IN NARRATIVE AND LIFE HISTORY 209 drawal (geographic and psychological) and by turning to more primitive women and less demanding societies. Uses rationalization, emotional isolation, and withdrawal as defense. A male friend is seen as selfless and dependable. Since we know something of the author's actual life history, we can add that his travels to primitive countries were adaptive ways of dealing with his problems. Writing was another way of dealing with his conflicts. He described writing Of Human Bondage as a cathartic experience. His friendships with men were often lifelong, his heterosexual relations apparently either transitory or distant and tempestuous (Judson, 1963). "The Yellow Streak" Descriptive Theme. Izzart, the handsome, English-educated son of a white fat.her and half-caste mother, is constantly unnerved by the thought that someone will discover his mixed parentage. During a mission with Campion, a visitor to the Malayan Jungle, the men are involved in a boating accident. Izzart is so intent on saving his own life that he ignores Campion's pleas for help. Miraculously, both men survive. Campion is publicly silent about Izzart's part in the near catastrophe but, triggered by Izzart's fear and guilt, makes it privately plain to him that he attributes his cow- ardice to the "yellow streak"-the "tainted" blood. Interpretive Theme. If a man is "tainted" by a (racially) inferior woman (mother), he fears his inferiority (the yellow streak) will emerge to his shame and peril. His fear that others will recognize this inferiority constantly haunts him. Diagnostic Level. Feels inferior. Projects his feelings of inferiority on others. Inferiority is blamed on a woman, specifically his mother. Woman is seen as something inferior as well as source of embarrassment and shame. The main concern is one of controlling emotion, particularly fear. "P & 0" Descriptive Theme. Mrs. Hamlyn is returning alone to England from the tropics after 20 years of happy marriage. Her husband has fallen helplessly in love with another woman. She and her husband both viewed the intrusion of his new love as one would an illness--it is uncontrollable, and one must bow before it. On ship- board, she meets the vital and forward-looking Mr. Gallagher, a retired planter, who is going home to begin a new life. Mr. Gallagher has left behind his native wife, after making what he considered generous financial provision for her. This wife, however, has become incensed and cast a spell upon him. When Mr. Gallagher sickens and dies on board, to the consternation of the ship's doctor, apparently as a result of this spell, Mrs. Hamlyn's own anger evaporates, and she feels great comion for the love that, like an unrestrainable force (a spell), befell her husband. Interpretive Theme. If love befalls one, it is like a sickness against which one is de- fenseless. If one fights'a (native) woman's love, she will kill one. It is best to bow to uncontrollable emotions.

210 CHAPTER 10 Diagnostic Level. Fear of emotion, particularly of heterosexual love. Fear of being overwhelmed by love (for woman). Fear of being killed by hate of woman. Defense used is emotional isolation and sublimation into comion. This story also involves the complexities of the caste system in British society, observations on emotional callousness, and selfless relationship between simple men. Once again, a doctor (the ship's doctor--a sympathetic character) is cast into a hopeless conflict between ivity and activity. "Mr. Harrington's Washing" Descriptive Theme. Mr. Harrington is the prototype of the proper Philadelphian. He has a strong set of morals and principles of behavior, which he takes with him into the upheaval of revolutionary Russia. There he comes in with Alexandra, "a mad Russian," who has had a powerful effect on all sorts of men and whom he significantly nicknames Delilah. Mediocre, resolute, stubborn, but rigidly sticking to his principles throughout, Harrington insists on getting his laundry before depart- ing from unsafe Petrograd. Alexandra, who loyally accompanies him on this last mission, is attracted by a street crowd. Harrington, trailing behind her, is attacked and killed. Interpretive Theme. If one has a strong set of moral and behavioral patterns, one is helped through many difficult situations. But one may also be led into absurdity. If one gets tangled up with a woman, she is likely to cause one's misfortune and death even though her intentions are the best. Diagnostic Level. Conflict between conventional and less rigid behavior. Gentle mockery of bourgeois mind in unresolved conflict. Woman is seen as powerful and dangerous. Even when she means to be loyal and protective, she may be fatal. "Footprints in the Jungle" Descriptive Theme. Bronson, a plantation man, takes Cartwright, temporarily down on his luck, into his home in order to lend him a helping hand. In time, Cartwright and Mrs. Bronson have a love affair, "swayed by turbulent ion." Although all three are basically decent people, Mrs. Bronson encourages her lover to kill her husband rather than risk discovery. The police chief learns of the crime, but there is insufficient evidence to bring the case to court. The new couple live on happily, since remorse for a crime does not seem to sit heavily if one can be absolutely sure one will not be found out. Interpretive Theme. If a woman comes between two men, she causes trouble and death. Sexual ion may be the motive for murder even though the people involved were, and remain, perfectly decent people. They may not even suffer remorse. Diagnostic Level. Sees women as causing trouble to men, as separating them, and as being fatal to them. There is the suggestion of an oedipal problem: one man must be .'killed for the other to get this woman. ion is seen as overpowering,

THEMATIC ANALYSIS IN NARRATIVE AND LIFE HISTORY 211 • Fear of being oman. Defense British society, ,etween simple ter) is cast into [adelphian. He ;with him into L Alexandra, "a t whom he sig- idly sticking to before depart- im on this last er, is attacked atterns, one is to absurdity. If une and death havior. Gentle ;powerful and }, be fatal. porarily down he, Cartwright Although all er to kill her

i me, but there Ve on happily, Ibsolutely sure

trouble and he people in- cen suffer reg them, and .m: one man .verpowering, threatening to transcend control, specifically control of aggression. An unintegrated superego condones murderous aggression as an uncontrollable force. "A Friend in Need" Descriptive Theme. A seemingly pleasant, kind, middle-class sort of man is approached by an irresponsible, happygo-lucky acquaintance, who is in desperate need of a job. The former casually sends him to his death by proposing to him a dangerous swimming feat as the price for a job--a job which in fact he doesn't have to offer at all. Interpretive Theme. If one is happy-go-lucky, one may be prey to the most incon- gruous hostilities of one's fellow man. This is probably due to disapproval and envy of an easy way of life and implied success with women. Diagnostic Level. Fear of and desire for drifting, ivity. Sees people as incongru- ously and often casually cruel. This ascription of cruelty may be associated with concern over their envy and disapproval of easy-going ways and of success with women. The latter are felt as dangerous. There is fear of helplessness, guilt over sexual desires, and ivity, and a great deal of cruelty is projected on others. "A Romantic Young Lady" Descriptive Theme. The beautiful daughter of a duchess falls in love with a poor young man who returns her affection. Her mother disapproves and begs for help from a countess who employs him as mule driver to her valuable and showy team. When the young man is made to choose between his beloved and his glamorous job, he chooses the latter. Interpretive Theme. If a man has to choose between a woman and an esteemed job (with animals), he rather callously chooses the job. Diagnostic Level. A sarcastic, low esteem is expressed for women. "There is not a pair of mules in the whole of Spain to come up to ours.., one can get a wife any day of the week, but a place like this is found only once in a lifetime. I should be a fool to throw it up for a woman" (Maugham, 1953). So says the young man. A subtheme is also concerned with the fact that the duchess and countess, though rivals previously, get together in this adversity. The beautiful young woman is met many years later, settled down comfortably as the stout, flaunting widow of a diplomat. "The Kite" Descriptive Theme. A young boy, in t venture with his parents, learns to love flying kites. As he grows older, this becomes the guiding ion of his and their lives. He meets a girl of whom his mother disapproves and, against her wishes, marries. His marriage is unhappy, his wife interferes with his kite flying, and in anger he leaves her and returns to hlg parents. In retribution, his wife smashes his best kite. He retaliates angrily by choosing prison to the alternative of paying her .

212 CHAPTER 10 Interpretive Theme. If a young man who has lived happily with his parents gets involved with a woman of whom they disapprove, the new woman may make him unhappy, interfere with his freedom, destroy the things he loves. Feels tremendous anger toward her. "tim see, I don't know a thing about flying a kite. Perhaps it gives him a sense of power, as he watches it soaring towards the clouds and of mastery over the elements as he seems to bend the winds of heaven to his will. It may be that in some queer way, he identifies himself with the kite flying so free and so high above him, and it's as if it were an escape from the monotony of life. It may be that in some dim, confused way, it represents an ideal of freedom and adventure. And you know, when a man once gets bitten with the virus of the ideal not all the King's doctors and not all the King's surgeons can rid him of it. (Maugham, 1953) These are the events commented upon by the narrator of the story. Diagnostic Level. Tends to see life with parents as peaceful in an infantile (sexually?) gratifying way. Woman is seen as making one unhappy, controlling one's life, interfering with infantile phallic pleasures and with man's freedom. Woman is seen as undermining his power. Conflict between monotony and adventurous, whimsical diversion. Woman is seen as plainly castrating, evil, controlling, interfering with narcissistic (sexual?) pleasures. "The Happy Couple" Descriptive Theme. An apparently insignificant couple, in love with each other and warmly devoted to their baby, are found to have been the one-time doctor and female companion to an old lady they killed. Her inheritance enabled them to be married. At their trial, the jury found them not guilty despite overwhelming evidence, supposedly because of the fact that they had not had sexual intercourse during their long premarital relationship. The woman had been willing to commit murder to marry the man she loved, but not to have an illicit love affair. Interpretive Theme. People are not what they seem. They may appear to be very decent people and yet commit murder. If people control their sexual desire, anything may be forgiven them. People are very strange. Sometimes one person must be dis- posed of for others to find happiness. Diagnostic Level. Suspicious of people, of their deceptive appearances, of their complex natures that may conceal murderous aggression. The problem is of reconciling aggression and conscience. Unintegrated superego. Sex appears more pro- hibitive than aggression. Oedipal problem. Sees people as odd. It is interesting to compare this story with "Footprints in the Jungle." In both instances one meets a quiet, pleasant, unobtrusive middle-aged couple, who have committed murder in order to live with one another. In both stories, the murderers escape punishment for their crimes and live happily (though somewhat furtively) ever after. Once again, in "The Happy Couple," a doctor is the protagonist and is under the sway of love for a woman. me

able and Natm ldllec sexu Main ject r obje(

THEMATIC ANALYSIS IN NARRATIVE AND LIFE HISTORY 213 parents gets in- ky make him un- els tremendous yes him a sense of er the elements as )me queer way, he tnd it's as if it were nfused way, it rep- nan once gets bit- Le King's surgeons story. infantile (sexu- alling one's life, • Woman is seen trous, whimsical interfering with each other and . doctor and fe- lled them to be .'rwhelming evi- atercourse dur- ling to commit tffair. tr to be very de- iesire, anything Ion must be disiances, of their !blem is of rec- }ears more proingle." In both ple, who have ries, the mur- agh somewhat is the protagoSummary Unconscious Structure and Drives (1-3)2 The author of these stories seems to have a continual struggle with his aggressive and sexual drives. He feels strongly that their control is vital. Death follows loss of control. The character structure that has resulted from his attempts to deal with these problems is one of emotional isolation and detachment. He is an onlooker, peering in from the outside with considerable puzzlement and much suspicion of the barely repressed feelings that lurk beneath the surface of his fellow men. And yet he is not without comion. There seems to be a conflict between active participation in the demands of the world, especially those of bourgeois culture, and the giving in to ive desires, to the call of simpler living under more primitive circumstances. From the attempted resolution of this conflict arises the beachcomber, the wanderer; albeit in this case a highly sophisticated one. The self- image that results seems that of a mildly ineffective person, who feels rather like a leaf in the wind and is not at all aware of his own strong emotions, especially of cruelty toward women. Conception of the World (4) Puzzling, demanding, to be faced with wary eyes, full of surprises and overwhelming situations. Urbane, mildly comionate, warily expectant, but uninvolved manifestly; latent, strongly aggressive, hostile feelings toward women, projected onto them. Sometimes there is aggression toward men, though often men are seen as dependable if not affected by women. Significant Conflicts (6) Control versus lack of control of aggression and sex. Conflict between activity and ivity, between conformity and nonconformity, between identification as a man and as a woman. Nature of Anxieties (7) To be dominated, constrained, controlled, especially by women. To kill or be killed in triangular conflicts. To be embarrassed. To lose control of aggressive or sexual drives. Main Dfenses (8) Reaction formation, emotional isolation, repression, and withdrawal from object relations. Extensive projection of aggression and sexual desires. Very superficial object relations. 2 Numbered headings correspond to those of the T.A.T. Blank.

214 CHAPTER 10 Superego Structure (9) An unintegrated superego; it is usually quite harsh, but occasionally, with a touch of cynicism or detachment, aggressive transgressions seem permissible, possibly more so than sexual ones. Integration and Strength of Ego (1 O) The well-constructed stories show an ego strong enough to attain some closure and to maintain control. However, control is attained at the cost of considerable emotional isolation, of constriction and stereotyping of experiences, and of tangential relations to people. The self-image is one of a good deal of ineffectual- hess, but identification with the role of an urbane, controlled Englishman serves adaptively to maintain adequate functioning, which is enhanced by a very high intelligence and vast experience with the world•

Final Report The author seems to have a continuous struggle with aggressive and sexual impulses, feeling strongly that their control is literally vital, as seen in the stories "Rain," "The Happy Couple," and "Footprints in the Jungle." The character structure that has resulted from his attempts to deal with these problems is one of some emotional isolation and detachment--an onlooker looking from the outside in, not without comion, with considerable puzzlement and a good deal of suspicion of the barely repressed feelings that may lurk under the surface in his fellow man, as seen through the eyes of Dr. Mahail in "Rain," the narrator in "Mr. Harrington's Washing," and in the plot of "A Friend in Need." There seems to be a conflict between active participation in the demands of the world, especially of the bourgeois culture, and the giving in to ive desires, generally, and the call of simpler living under more primitive circumstances, specifically, as in "The Fall of Edward Barnard" and "A Friend in Need." The self-image that results seems that of a mildly ineffective person, who feels somewhat like a pebble pushed about by the tides (e.g., "The Fall of Edward Barnard" and Mahail in "Rain"). Women are seen as domineering and demanding, such as Isabel in "The Fall of Edward Barnard," the women in "Rain," the wife in "The Kite"; or as leading to disaster, such as Sadie Thompson in "Rain" and Delilah in "Mr. Harrington's Washing." Women are also often seen as causing a feeling of inadequacy, either as Edward Barnard had in relation to Isabel or as in the case of Izzart's mother in "The Yellow Streak." Apparently, the author uses his defenses so extensively that he is not aware of his own strong aggressive feelings, projected especially on women. Continual conflicts between activity and ivity, conformity and nonconformity, and male and female identification are seen all throughout the stories, with fears of failure, embarrassment and shame and feelings of inadequacy constantly threatening to emerge. When one is aware of some of the writer's life history, it becomes apparent that his defenses indeed necessitated a certain amount of constriction of his life to a rather restless, tangential relationship to people, traveling a good deal, almost by design--an onlooker who "participates only vicariously via his notebook in stories which, as seen in the sample examined, center on a relatively narrow range of themes acce ished, was

thing that ital a great that h{ setting strictio especi ern Stylisti, There to the case of life. tried clues amon and derin life of loo, its one the pe here atic any than ing type on th{

THEMATIC ANALkSIS IN NARRATIVE AND LIFE HISTORY 215 asionally, with a )ermissible, posattain some clo- :ost of consider- .'riences, and of d of ineffectual- glishman serves y a very high inthemes. He was nevertheless able to function by conforming with a character quite acceptable within the setting of the upper-crust Anglo-Saxon society--urbane, pol- ished, knowledgeable, and, above all, not causing any difficulties by uncontrolled emotions. He was very sensitive and shy beneath this stiff-upper-lip front, and yet he was often involved in blood-curdling and sometimes coldblooded cruelties, as in his work as an intelligence agent. His own of his married life suggests something less than affectionate warmth. One wonders if the attempt to control all emotion may be related to the fact that some critics have spoken of Maugham as a great craftsman, rather than a great artist, feeling apparently that his stories lacked depth and were too neatly packaged. Could this same problem, especially in relation to women, also be related to his marital difficulties and to the fact that he wandered the earth so restlessly and aloof?.

Discussion ;sive and sexual n in the stories deal with these onlooker look- puzzlement and lurk under the il in "Rain," the td in Need." Lhe demands of ive desires, astances, specif.rson, who feels Fall of Edward bel in "The Fall br as leading to : Harrington's luacy, either as nother in "The y that he is not vomen. nd nonconfor- e stories, with racy constantly mes apparent )n of his life to cleal, almost by ook in stories .rrow range of The external features and the geographical settings of Maugham's stories vary a great deal. If one compares him, for instance, with Tennessee Williams, it is obvious that he is not constricted with regard to milieu. Williams ahnost always chooses the setting of the American South. However, Maugham shares with Williams the con- strictions of essential subject matter. Whether the adventures are in Malaya or India, Chicago or Petrograd, the theme and its treatment stay fairly constant. Control of the emotions, the difficulties people get themselves into if they do not control them, and especially the dangers to men in their feelings for women are the leitmotifs that gov- ern his work. A certain aloof comion goes hand in hand with urbanity. Stylistically, one always notes a form of prompt dispatch in the tightly organized plots. There is constriction and a measure of stereotype within the creative personality. Freud, in his paper on the poet, mentioned perceptual selectivity with regard to the causal relationship between a writer's productions and his personality. In the case of Maugham, it seems that his stories are the result of such a selective viewing of life. They are the product of the forms of adaptation and defenses with which he tried to deal with his own life and his own emotional problems. There are some clues as to what these emotional problems may have been: suggestive relations among his feelings for women, the loss of his mother at an early age, his aggression and his stammer, his personal shyness, his marital difficulties, and his restless wan- derings. However, these conjectures with regard to causal interrelations to the early life history are not of central concern and could not progress beyond the usual state of loose guesses on the basis of limited material. One is on safer ground if one limits oneself to inferences covering the relationship between literary production and the personality of the author. One may speculate further: In what way may the kind of story analysis done here contribute to the understanding and critical analysis of literature? The systematic frame of reference for analysis of literary products may be generally useful for any author's work. The range and depth of a literary piece are often at the center of critical appraisal, and a T.A.T. type of analysis may well give a more reliable than the customary free-style appraisal. Perhaps one of the reasons for widely differing critiques may be, at least in part, the lack of any base line of comparison. The type of psychological analysis presented here may well throw some interesting light on the relationship between an author's personality and his or her work.

CHAIER I1

OBJECT RELATIONS ASSESSMENT WITH THE T.A.T., C.A.T., AND S.A.T. Perspectives on Object Relations Theory From its beginning in Bellak and Murray (1941) and Bellak (1947) Bellak's T.A.T. interpretive method included a central fifth category of interpersonal object relations, also called Figures seen as, where one examines the story characters as to how father figures, mother figures, peers or siblings, and subordinates are seen in relation to the central figure in the story. One examines the types of personality of each character and the quality of interaction with the hero. An early attempt to develop a whole scoring approach around this single dimension was the Object Relations Technique of Phillipson (1955), which consists of photographs of people in different situations with relative degrees of ambiguity. Bellak revised the T.A.T. Blank in 1973 to include 12 ego functions under the tenth category of "Integration of the ego," one ego function being that of object relations. Since that period, there have been several specific assessment approaches to scoring aspects of this dimension. Truckenmiller and Schai (1979) developed a scoring approach for interpersonal relatedness. McAdams (1980) developed a thematic coding system for the intimacy motive. Thomas and Dudeck (1985) focused on the variable of "interpersonal affect." Abrams and Bellak (1986 edition of this chapter) presented a more specific approach to this dimension, looking at the different personalities of the "cast of characters" in each story and the specific types of relationship in each specifically stated or implied interaction between two or more The most detailed scoring approach for interpersonal object relations in the T.A.T. is that of Westen (1991b; Berends et al., 1990; Nigg et al., 1991; Westen et al., 1990a, 1990b). Westen's approach includes the four subcategories of (1) complexity of representations of people, which is also reported in the T.A.T. study of Leigh (1992); (2) a variation of Thomas and Dudeck's (1985) dimension of "interpersonal affect," which Westen calls "affect-tone of relationship paradigms"; (3) capacity for emofional investment in relationships and moral standards; and (4) the social cognition category of the understanding of social causality. Object relations 216

947) Bellak's rsonal object re- ters as to how b. seen in rela- ,nality of each pt to develop iect Relations ple in differA.T. Blank in gration of the pproaches to I developed a veloped a the- 1985) focused edition of this ring at the dif- ecific types of n two or more elations in the i Westen et al., (1) complex- study of Leigh o,,f "interper- ns ; (3) capac- .rid (4) the so- bject relations OBJECT RELATIONS ASSESSMENT 217 focuses on the types and quality of social interaction as well as the way these experiences of interpersonal relations are internalized as mental "representations" of different individuals and different types of relationships. The four subscales of Westen's scoring approach are detailed here. 1. Complexity of representations of people. Internalized self and object representations become increasingly more separate and differentiated from each other throughout child development to adulthood. The child's capacity to mentally represent one's self-image and one's images of others also becomes increasingly more complex. Polar extreme feelings of "all good" and "all bad" self and object representations and extreme affect states of love and hate gradually become more differentiated and integrated as the child matures. Westen's subcategory examines the level of differentiation of story characters and the extent to which an individual can see the self and others as having stable, enduring, and multifaceted qualities and subjective experiences. 2. Affect tone of relationship paradigms. Social relations in infancy begin in pleasure pain states and, in optimum circumstances, develop within increasingly more positive, interpersonally related experiences. Westen's dimension looks at the types of interactions in the T.A.T. stories along a continuum from malevolent, painful interactions to those that are more benign, enriching, caring, and loving. 3. Capacity for emotional investment in relationships and moral standards. This dimension considers the extent to which individuals are treated as ends rather than as means and the extent to which events are experienced as needfulfilling. This is the dimension of the capacity for empathy. Child development optimally proceeds from more narcissistic, self-centered relations based on meeting the child's basic needs and develops increasingly toward mutual love, respect, and concern for others. This scale also examines the extent to which relationships are experienced as meaningful and committed and the extent to which moral standards are developed and considered. 4. Understanding of social causality. As the child matures, there is an increasing understanding of the causes of actions, thoughts, and feelings within oneself and in others. The understanding of social causality becomes deeper, more complex, more abstract, accurate, and internal. Westen's scoring approach has been used to differentiate borderlines, manic depressives, and normals (Westen et al., 1990a), borderline adolescents (Westen et al., 1990b), and sexually abused girls ranging in age from 5 to 16 years (Nigg et al., 1991; Ornduff et al., 1994). A very interesting study of Berends and colleagues (1990) used the four Westen scales to compare T.A.T. stories, interview data, and stories told to the Picture Arrangement subtest of the Wechsler intelligence scale. Westen's scales are difficult to learn and rather time consuming to score. The scales may become more useful in clinical assessment if they could be simplified to some degree, so that scoring could be easier and quicker. However, the scales have been found to be very useful in quantiative research. The approach of interpersonal object relations developed out of Freud's psychoanalysis. Freud made that most concrete in his conception of the superego as being largely the result of inter3aalized parental images expressing strictures and in-

218 CHAPTER 11 hibitions. In The Ego and the Id, Freud (1923) showed how the superego is formed out of internalized identifications, primarily with the father for the oedipal-stage male child. And, in his paper on "Mourning and Melancholia," Freud (1917) suggested that one of the ways people become able to work through a mourning reaction over the death of a loved one is to develop an "inner image" or "introject" of the lost object. Melanie Klein, W. R. D. Fairbairn (1954), and other of the British school emphasized the importance of the earliest internalized objects. Klein (1948) developed a rather comprehensive picture of how a child gradually builds up inner images of family that then make up the child's internal fantasies of what these and other people are like. These then influence how the child experiences and relates to other people in his or her actual daily life. For example, if the child has a father who is extremely aggressive, the child may tend to build up an inner image of father figures as extremely aggressive and frightening. Other men similar in age to the child's father may then be experienced as if they were all as aggressive and frightening as the child's own father. Another example illustrated in Klein's clinical sessions with children is the way a child develops an inner fantasy of the parents' relationship to each other. This could be an image of a loving parental couple or of a couple who always fight and argue with each other. This interpersonal relationship of a parental pair is represented intrapsychically in the child's inner world. Sandler and Rosenblatt (1962) suggested the term representational world for the constellation of images of parents, siblings, relatives, and other significant individuals that exist in the child's internal, intrapsychic world. Another way of putting it is that the child's unconscious is not made up only of libidinal and aggressive drives and unconscious wishes. The unconscious is also made up of fantasy images of human beings that significantly influence the individual's everyday behavior. The many different characters in the T.A.T. stories produced by an individual may, then, be viewed as a window into the variety of self and object representations that made up the individual's representational world. They are the cast of characters within the individual's experience of actual people from day to day. The T.A.T. and its offspring, the C.A.T. and S.A.T., are suitable projective tests for the assessment of an individual's interpersonal and intrapersonal object relations. Since the individual is presented with a set of pictures of human beings or animals in social situations and asked to construct a fantasy story about each picture, the outcome of these tests provides rich material about the individual's ability to relate to others, his or her capacity for experiencing other people with an appreciation of their complexities, and the individual's manner of experiencing interpersonal relationships in his family, job situation, or circle of friendships. The T.A.T., C.A.T., and S.A.T. allow a deep view into an individual's level of interpersonal experiences, conflicts, and level of development and functioning. An Object Relations Approach to T.A.T. Analysis The method of analysis presented here is similar to the basic approach previously outlined in which object relations is viewed as one of the ego functions (Abrams, 1991, 1992;"Bellak, 1993a). One of the functions of the ego is to internally

OBJECT RELATIONS ASSESSMENT 219 o is formed ,edipal-stage (1917) sug- arning reac- introject" of { the British lein (1948) [ds up inner ies of what experiences if the child ap an inner men similar ts aggressive d in Klein's y of the par- ntal couple rsonal rela- nner world. world for the :ant individ- )f putting it 1 aggressive tasy images }ehavior. a individual esentations t of charac- ?. jective tests object rela- ings or an- !oh picture, bility to re- in appreciag interper- the T.A.T., ,ersonal exo 'oach previ- functions internally represent in fantasy the individual's actual and imagined interpersonal experience. For T.A.T. analysis, the clinician begins by making an inventory of the cast of characters in each story with a note or two about the personality of each character, like the program notes one reads before seeing a play. The next step is to make an inventory of the interactions among the characters with a few notes characterizing the type of each interaction. It is then a simple step to write a short summary of the object relations in each story and then an overall summary at the end of the protocol. A useful way of doing this is to set up separate columns for the "cast of characters" on the left and "type of personality" for each of these characters on the immediate right. Then one lists the different "social interactions" in the chronological order of the story on the left with a brief note on the "type of interaction" for each of these actions on the adjacent right side of the page. Often, it is helpful to list each action in the story under "social interaction," since many interactions are implied in a stated action, as the action of "throws a ball" may imply that someone else is these to "catch it." One then writes a brief summary of all these object rela- tional issues in a paragraph underneath these object relations columns. In the "overall object relations summary" at the end of the protocol, it is important to consider personality characteristics of the "main characters" and the degree of differentiation between the main characters and the "secondary characters." Relationships between child and father figures, with mother figures, and with siblings, grandparents, and peers are all important considerations in this final summary. To illustrate this method of analysis, we will present the T.A.T. protocols of two individuals, the first a neurotic early adolescent and the second an actively psychotic adult. T&.T. Protocol of a Neurotic Adolescent Boy The following protocol is from a 131/z-year-old boy, whose grades had gone down in the last year, and who was constantly getting into battles over completing homework assignments with his mother. He tended to withdraw into moody states of self-pity, and was often very demanding of expensive toys and other objects. 1: Once there was a boy and he was looking at his violin and thinking if he should play it. But he doesn't want to play it. But his Mom's going to make him and he's thinking about whether he should play it or not. He doesn't want to. End? His mother will make him play it for a year and then he gives it up. But they have a big fight over it. He's bigger than she is. So he wins the argument. Cast of characters Boy Mom

Social interactions Mother forces boy, who quits Type of personality Ambivalent, avoidant, argumentative, oppositional Controlling, demanding, authoritarian Type of interaction Controlling, oppositional interaction

220 CHAPTER 11 The story suggests this adolescent sees himself as locked in an oppositional battle with his mother, who is seen as demanding and controlling. The boy puts up with mother forcing him to play the violin for a year, then quits altogether. It may be that he tries to make deals (e.g., "I'll do it for only one year, then I'll quit"), so seems to be ambivalent over mother's demands, argumentative, and ultimately avoidant or withdrawing. The story ends with a wish that if he is bigger than mother, he could then prevail over her. The interpersonal object relation in this story seems to be that both of them relate in a controlling, oppositional manner. 2: This is a long time ago. This girl's sort of rich and she's being all snotty to this girl over here [on the right]. She just came from school and this guy back here is plowing with the horse. Next? Something. Nothing's going to change. End? Urn, I think some day she's to go and get hurt [the one on the left] and she [on the right] will make fun of her, because she made fun of her all those years. Cast of characters Rich girl Other less well-to-do girl Man plowing Horse Type of personality Snotty, makes fun of others (implied) Victim of teasing, but later retaliates No details given No details given Social interactions Snotty girl teases girl, who retaliates. Type of interactions Other girl is first ive victim (implied), but later retaliates by teasing rich girl back (talion type of "eye for an eye" retribution) Even though there are now three people in the picture, he again tells a story of a struggle between two people, in this case between the snotty girl who teases and her victim, the other girl, who ends up retaliating when the rich girl gets hurt. The opening statement that it happened "long ago" may be an attempt to distance himself from such ongoing struggles, or it could suggest that he is reporting something that happened a long time ago to him. The statement that "nothing's going to change" brings in depressive feelings of hopelessness, perhaps that he himself feels he will continue to be teased and hurt by peers. The retaliation at the end, then, may again be a wish to be able to retaliate in kind to hurtful peers. The style of interaction is one of uncaring, hurtful teasing and simple retaliation in kind. 3BM: What is this over here [points to gun-like object in picture)? They look like keys to me. This is an older girl, but she's crying because she can't get a car. She wants a car, but

OBJECT RELATIONS ASSESSMENT 221 ler. I'll

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her Mom won't let her get one. At the end, her mother lets her get the car after a long time, after a lot of crying. Finally, the mother can't take it, so she lets her get the car. Older girl Mom Cast of characters Type of personality Persistently demanding First depriving, later acquiescing Social interactions Demanding girl, depriving mother who later gives in out of annoyance Type of interactions Demanding, depriving, acquiescing Summary This stoW is similar to that on card I with one person being demanding while the other resists but he later acquiesces. In the first, the boy resists mother's de- mand that he learn the violin, but later acquiesces and plays for one year. In this story, it is reversed. Now it is the child who demands a car. The parent resists but ends up giving it to her. The type of object relationship is one of demanding, oppositionalism, and acquiescing out of annoyance. 4: Ok. He's leaving. They had a fight and she doesn't want him to go. But he goes anyway. She's got long nails. A few years later, they bump into each other and get back together again. In a different place. Some other city or state. All is forgiven. Boy Girl Cast of characters Type of Personality Argumentative, withdrawing Demanding but forgiving Social interactions Boy and girl fight over boy leaving Boy and girl get back together Type of interactions Demanding, withdrawing Forgiving reconciliation The theme of one person being demanding while the other is argumentative, resistive, and withdrawing is continued. The forgiving reconciliation suggests that he has a need to put a "happy ending" on many of his stories, which may be a reversal of affect to put on a happy face to cover over sad, angry, and other more uncomfortable feelings. It may also express a feeling that others leave him and he wishes for a happy, forgiving reconciliation. 6BM: This lady's worried about her son, who embezzled some money. She's looking out the window and she wants him to come back. He's the lawyer and he looks worried, too. Maybe he wants his money, too. The son goes to jail. Then he comes home and they're all happy and everything.

222 CHAPTER 11 Cast of characters Mother Son Lawyer Social interactions Son embezzles money Son is punished (jailed). Lawyer wants his money Son and mother reconcile. Type of personality Worried, lonely, object-longing Deprived, antisocial stealing Demanding Type of interactions Demanding, antisocial Punishing, boxing-in, restricting Demanding Happy, forgiving reconciliation This is further expression of one person and the other wanting the other to return. That the son embezzled money suggests this boy may feel deprived and feel that something or someone was taken away from him, "stolen" from him. The idea of the mother wanting the boy to return may be a wish in this boy for his mother to want him, since he seems to be progressively picturing her as demanding, depriving, and withdrawing. The lawyer is demanding of money. The son is punished by being jailed. But again he ends it with a "happy ever after" wish-fulfillment type ending that may represent a defensive reversal of affect to cover up his angry, deprived feelings and feeling of being boxed in and punished by others, perhaps for being overly demanding. 7GF: This girl has her doll and her mother's reading a story and she's daydreaming and looking into space with her dolly in her hands. I think the story will be about some Prince and someday her dream will become true. She's imagining the story in her own version, and then that happens. Girl Mother Prince Cast of characters Type of personality Daydreaming, fantasizing, wishing Intellectualized, fantasizing No details given Social interaction Mother reading to daughter Daughter daydreaming of Prince Type of interaction Intellectual, dreaming, withdrawing Withdrawing into fantasy world The story suggests this adolescent likes to withdraw from his mother into a fantasy world of marrying into a rich and powerful family, where all events end "happily ever after," everyone happily reconciles and all badness is forgiven. The story also suggests that he may see the mother as encouraging his withdrawal into fantasy away from Pne real world. The interpersonal object relation of mother and

OBJECT RELATIONS ASSESSMENT 223 onging ding stricting :iliation the other to tved and feel ira. The idea tis mother to :ling, depriv- punished by ent type end- gry, deprived tps for being ;daydreaming ,e about some a her own verng, wishing tzing 0 withsy world tother into a 11 events end :orglven. The thdrawal into mother and child is one of a rather distant, intellectualized, withdrawal into fantasyl rather than a genuine object-related and realityoriented interaction. 8BM: Oh God. These are doctors back there and they're doing an operation. They're taking something out. And this kid's worried about his father, who's on the table. His father gets alright and the whole family's all happy he's still alive, 'cause in those days most of them weren't so successful. His was successful, so they're all happy. Cast of characters Doctors Boy Father Social interactions Doctors cure ive father Boy worried over father's health Type of personality Successfully lifesaving Worried over potential loss of father ively helped Type of interactions Helpful, life-saving Caring or disguised anger? The story may express an actual worry over the subject's father's physical health or it could be a reaction formation of overt concern to cover underlying angry, death fantasies towards the father, who is seen as ively helped. Again, there is the "happily ever after" type of ending where everything turns out happily successful. His comment that this operation was successful, but in "those days they weren't always so successful," may express a depressive feeling that it is rare for things to turn out totally successful and happy. The idea that the doctors cure the father by taking something out of him may express a feeling that psychotherapy could cure him if something inside him was taken out, perhaps helping him get rid of troubling thoughts. 9GF: It was a long time ago and they lived in a log cabin and the girl is sneaking out. But the mother is going to catch her and whip her. No, she writes down how many times the girl gets in trouble in those books she has and she shows' em to her every time she gets bad. But she's going to get older and still be immature when she's older; keep on sneaking out and getting hurt. But her mother's going to catch her each time and spank her. Cast of characters Girl Mother Social interactions Withdrawing child/pursuing parent Naughty childpunishing parent Type of personality Withdrawing, gets in trouble Pursuing, punishing Type of interactions Approach avoidant, withdrawing Possibly sadomasochistic interaction This is further expression of the same theme of wanting to avoid and withdraw from mother's demanding pursuing and keeping track of all his misbehaviors. But

224 CHAPTER 11 this time, he does not end it with a happy wish-fulfillment. Instead, the pattern continues to be repeated of the misbehaving child sneaking out and the mother catching and spanking her. The child will still be immature, even when she is older. There may be a disguised wish in this boy for his mother to pursue and catch him. Perhaps he wants her to want to be with him and finds that he can get her to pursue and closely monitor him by doing bad things. 10: This is a priest kissing the guy coraing to confess. No; a father giving blessing to his son going off to college. After that he comes back from college and they rejoice. I like happy endings. Cast of characters Priest Guy who is confessing Father Son Social interactions Priest kisses sinner Father allows son to separate and return Type of personality Giving forgiveness to sinner Guilty sinner that's committed a sin Accepting of son's independence Able to separate and return to parents Type of interactions Accepting, forgiving, saving Accepting of autonomy and return The first association to this picture may be of one man kissing another, which may stir up homosexual fears in an early adolescent boy. So he turns it into a priest kissing a confessing man. But then retreats even more from this to make it into a father giving his son his blessing to leave home, perhaps to further distance from the idea of a man kissing another male. The conflict of autonomy versus dependency is typical of adolescence. So the idea of the father giving his okay for the son to leave home may suggest his perception that his father is more encouraging of his autonomy than what we have seen from his stories of his perception of his overin- volved and rather controlling mother. However, the rejoicing return from college as the "happy ending" may represent his reversal of affect wish-fulfillment covering over his inner conflictual feelings around independence/dependence. So this story may be a wish for his father to give his blessing for his growing up and leaving home. 13MF: Someone killed this guy and he's crying, 'cause he's the brother. The family grieves from then on. They're all sad and they go to her funeral and then... I don't know. They're all sad from then on and nothing's jolly or happy anymore. I can't make a happy ending for that one. Cast of characters Killer Dead malee Type of personality Aggressive, homicidal No details given

OBJECT RELATIONS ASSESSMENT 225 the pattern con- e mother catch- en she is older. ; and catch him. a get her to puring blessing to his .joice. I like happy "sonality to sinner committed a sin independence d return to actions g, saving aomy and return ng another, which .rns it into a priest to make it into a her distance from imy versus depen- is okay for the son encouraging of his ition of his overin- turn from college lfillment covering lence. So this story ag up and leaving brother. The family n... I don't know. can't make a happy personality nicidal Brother Other family Social interactions Killer kills guy Man grieves for deceased brother Grieving, sad, depressed No details given Type of interaction Aggressive, homicidal Grieving, sad, hopeless, depressed Hypothesis of homosexual ideation is suggested by his making the person in the bed into a "guy," when the uncovered breasts clearly show the person to be female in the picture. As an adolescent just at the point of puberty, he may be de- fending against heterosexual feelings by making the story into one of only males. The grieving brother, who is forever sad and depressed, may express real feelings of loss for a sibling from whom he is separated or perhaps this represents underlying depressive feelings surrounding his real ability to grow up, become truly independent, and leave home with love in a good way, rather than separating and leaving out of anger as if someone has died. Overall Object Relations Summary The main characters are predominantly adolescents, who seem stuck in demanding, needy, oppositional battles with their controlling, demanding, and over- involved mothers (stories 1, 3BM, 6BM, and 9GF) or who seem to be in an approach/avoidance conflict with a peer (stories 2, 4, and 13MF). The secondary characters of the mother figures are similarly seen as demanding and controlling, while the two stories that show father figures (8BM and 10) suggest that he sees the father as more helpful, accepting, and encouraging of independence and sepa- rateness. There is some suggestion that this is a daydreaming young adolescent, who is given to moodiness of sad, depressed feelings and who often withdraws into inner fantasies of happily-ever-after endings, when he is not locked in the more enmeshed oppositional battles with his mother. While there are not a lot of signs of differentiation between the adolescent characters and those of the mothers, the father figures seem to differ from the mothers in being more accepting of the two conflicting needs of autonomy and closeness in a young adolescent boy. Analysis of the social interactions in his stories predominantly are those of an enmeshed, oppositional battle of wills between mother and adolescent and of the approach/avoidance pattern with a sibling or peer. Fathers and older males are seen as more helpfnl and encouraging of independence. Hence, this boy might at first do better with a male, rather than with a female therapist. Reversal of affect and reaction fbrmation are very prevalent defense mechanisms, which he seems to utilize to put on a happy face to cover up underlying depressed and angry feelings and which help him retreat into wish-fulfilling fantasies away from the hard struggles of the everyday world. Overall, this boy's interpersonal object relations are age appropriate, as they center in the adolescent conflict between independence and dependence. The oppositional struggle with the mother and the tendency to see

226 CHAPTER 11 the father as more encouraging of autonomy is also typically seen in children at the dawn of adolescence, who are still very tied to dependency on the mother. Sex-role or homosexual/heterosexual conflict also tends to be age appropriate in early adolescents, whose chief conflict of identity versus role diffusion, as Erikson (1950) puts it, is also often seen in this area of sex-role gender and sexuality conflict. The diagnostic impression, therefore, seems to be adjustment disorder with mixed emotional oppositionalism, depressive mood, withdrawing, and approach/avoidant features. A short course of psychotherapy to assist him in these emotional adjustment difficulties is recommended and the prognosis of his accepting and being open to benefitting from psychotherapy is quite good.

T.A.T. Protocol of an Actively Psychotic Man This is the case of ']ohn Doe," male, age 25, and single, whose T.A.T. was previously described in Chapter 6, pages 107-121. The method of analysis is similar to the basic approach previously outlined in which object relations is viewed as one of the ego functions (Bellak, 1975, 1984). One of the functions of the ego is to internally represent in fantasy the individual's actual and imagined interpersonal experience. For T.A.T. analysis, the clinician begins by making an inventory of the cast of characters in each story with a note or two about the personality of each character, like the program notes one reads before seeing a play. The next step is to make an inventory of the interactions among the characters with a few notes characterizing the type of each interaction. It is then a simple step to write a short summary of the object relations in each story. 1: This child is sick in bed. He has been given sheet music to study, but instead of the music he has come across a novel that interests him more than the music. It is probably an adventure story. He evidently does not fear the chance that his parents will find him thus occupied as he seems quite at ease. He seems to be quite a studious type and perhaps regrets missing school, but he seems quite occupied with the adventure in the story. Adventure has something to do with ocean or water. He is not too happy, though not too sad. His eyes are somewhat blank---coincidence of reading a book without any eyes or knowing what is in the book without reading it. He disregards the music and falls asleep reading the book. Boy Cast of characters Parents of boy Classmates and teachers at school (implied) Type of personality Sick, withdrawn in bed, reads adventure novel instead of studying music, blank eyes, omnipotent (knows book's contents without having to read it) No details given No details given Social interactions Boy is given music to study Boy misses school Type of personality ive receptive objective relation Object hunger evident

hildren at the ,ther. Sex-role ; in early ado- ikson (1950) conflict. The mixed emo- 'avoidant fea- adjustment eing open to .T. was pre- is similar to ed as one of is to inter- "sonal expe- r of the cast ach charac- ) is to make :haracteriz- ,mmary of istead of the probably an aim thus oc- aps regrets Venture has Iis eyes are bat is in the 'k. tent thout relation Boy reads novel about ocean or water (desire to regress to "womb," to mother as narcissistic gratifying object) OBJECT RELATIONS ASSESSMENT 227 ive receptive object relation Sick, regressed, and ive/receptive self representation is given music to study, but instead withdraws into fantasy of regression to womb. Object representations seen as providing, but also as external superegq figures to check up on him if he is practicing music. Story ends with regression to 'womb" (ocean, water) resulting in merger with other (author of adventure novel) with symbiotic omniscience (ability to then know contents of book without reading it). Sequence of story suggests withdrawing from reality-orientation of music study others gave him to work on into "womb" fantasy of psychotic level of merger of reading other's mind. Story suggests tendency to schizoid withdrawal from current reality of others as an adult (blank affect and inner fantasy life) and to regress to being a sick child or fetus, to be omnipotently cared for by the mother, ive/aggressive anal level struggle for control seen in relation to parents, music, and school and statement of missing school are highest level of object relations noted. However, the fetal level of regression, somatization, idea of others attempting to control him, check up on him, and his knowing the book's contents without having to read it suggests a diagnosis of psychosis. 3BM: This is a girl in a cell and she has been jailed because she was found guilty of prostitution. She is in this position in the picture because she is very ashamed, not because of being arrested, because she is quite familiar with the police, but because of the fact that her picture and a newspaper write-up was being sensationally spread across the country. She knew that her sister, who was a nun, would suffer from it, and it made her feel very badly because she, at one time, had a chance and an opportunity to follow her elder sister's example but it was too late now. She grabs a concealed knife from under her blouse and stabs herself. Casting of characters Girl Police Sister of girl (nun) Type of personality "All bad," sexually promiscuous jailed for prostitution, and ashamed of national publicity (desire for grandiose level of exhibitionism) Superego representation that jail stops her from id discharge "All good," nun who suffers from problems of her sister Social interactions Girl jailed by police with whom she is quite familiar Type of interactions Police superego representation restricts and stops sexual drive discharge and exhibitionism of girl "M1 good" self-representation suffers Girl's sister, the nun, suffers due

228 CHAPTER 11 to girl's badness from threat of contamination by "all bad" self-representation, so "all bad" presentation must be killed off by suicide of bad girl prostitute Primitive splitting between "all bad" sexual representation of girl prostitute and "all good" sexless self-representation of nun sister of girl. "All bad" self- representation may seek grandiose level of exhibitionism, while "all good" selfrepresentation may suffer from such exposure and contamination. In order to preserve "all good" representation, solution offered is to kill off bad self by violent suicide. Since the patient is male, this could also be a homicidal desire to kill oedipal sexual mother, so as to preserve the need-fulfilling "all good" mother of infancy or fetal period. 4: The girl in the picture is half-caste. She is in love with the man who is going to leave her and return to his wife. They have spent quite some time together in intimacy. She is pleading with him to stay with her or help figure some way to plan for the coming of the child she is going to bear. She is in poor circumstances financially, and he tells her she should make arrangements to conclude the birth and thus everything would iron out because he is definitely determined to leave as the affair in his mind is at an end. She is very broken up by it. She pleads for him to spend one more night, which he agrees to, and in the middle of the night she sets fire to the house, thus solving the problems of all concerned. Cast of characters Girl Man friend of girl Unborn child Type of personality Poor, desperate about abandonment by man friend, pleading, suicidal, and homicidal No details given No details given Social interactions Girl pleading with man not to abandon her and her her unborn child, so she kills all of them Man friend wants her to kill unborn child Fetus in womb Type of interactions Panicking at threat of abandonment, so aggressive impulses erupt (symbolized by fire) and killing Homicidal interaction ive receptive object relation Panic re aggressive ' death) indicative of 6BM: derly actress, alogue in the which The boy is this was her sor pened. In the lice. But the She calls her "I think the (What kind faithful. Son of about Youn author Police author of his Son and o Youn Poor, desperate, pregnant self-panics at threat of abandonment by father of baby and kills self and others, which may express merger wish through shared death. Abortion and setting fire to all of them may represent a desire to rid self of demanding, dependent fetus self representation. Theme of fetus in womb is now stated directly, where it was only lmphed in story 1. primary breaks

ation by "all , so "all bad" lled off by itute irl prostitute J1 bad" self- 1 good" self- order to pre- lf by violent ; to kill oedi- er of infancy going to leave timacy. She is :oming of the er she should because he is broken up by middle of the onment by and )nment, so mbolized by y father of ugh shared rid self of )mb is now OBJECT RELATIONS ASSESSMENT 229 Panic reaction to threat of abandonment, outbreak of homicidal and suicidal aggressive impulses, and regression to fetal or merged and fused state (united in death) further suggest primitive object relations with lack of self-object boundaries indicative of psychosis. 6BM: This is a scene in a play. The two characters are on the stage; one is a famous elderly actress, who has a son about the age of the young man appearing opposite her. The dialogue in the play has suddenly taken on a new meaning for her: She sees now that the play, which was written by her son, has an entirely different meaning in this scene in the picture. The boy is telling the mother that he has just committed a murder. She understands now that this was her son's way of conveying to her the terrifying fact that that is actually what had happened. In the play, as her son had written it, the climax comes when the mother calls the police. But the famous actress decides to put her own climax into action after the play is over. She calls her son and says, "The climax of your play will have to be changed," She says, "I think the audience will prefer this one," so here she draws a revolver and shoots him. (What kind of murder was it?) Oh, a girl. Motive primarily to do with sexual. She had been unfaithful. Cast of characters Famous elderly actress on stage Son of actress who wrote play about murder Young man on stage same age as author of play Police Unfaithful girlfriend of play's author Social interactions Actress feels son tells her of his crime indirectly and punishes him by killing Son writes play for mother and others to act in Young man in play Girlfriend of play's author Type of personality Exhibitionistic, homicidal (kills son to punish him for murder he committed) Controls others (writes play they are in), homicidal, and is indirect (tells mother of his murder through his play she acts in) Twin fantasy? No details given No details given Sexually unfaithful Type of interactions Manipulative and homicidal object relation (retaliatory) Magically controls them ive, controlled by others Unfaithful to play's author The idea of a scene in a play shows patient's desire for some distance from the primary process of earlier stories by isolation of affect defense. But this quickly breaks away, as author of playmagically controls mother and others, is indirect (reappearance of ive/aggression of story 1), and has homicidal solution to girl-

230 CHAPTER 11 friend's being unfaithful to him (reappearance of homicidal retaliation for abandonment of story 4). "All bad" manipulative son is punished by mother killing him (reappearance of attempt to rid self of "all bad" self-representation by homicide as in stories 3BM and 4). The magical control of others, homicidal aggression, and suggestion of twin theme in young man actor, who plays author of play, again shows the primitive level of the patient's object relations. Again we see attempt to rid himself of the bad, sexual, and homicidal part of the self. 7BM: This would be a man and his son. The son is very depressed over his health. The father is telling him that as a young man he too had the same illness, and that it can be cured if the son has the will to cure it. The father tells the young man that he himself alone can cure it. The son believes that there is no hope, but replies that he will go away for a little while and think it over. The father replies, "You are not doing a favor to me by saying that. I am thinking about your getting well for the simple reason that you have a wife and children to , and in the event of your being bedridden, the responsibility for your family will be put entirely upon your mother and me." The young man finally concludes that he will take his wife and family with him and try to make things go better in a healthier climate. (What kind of illness did he have?) T.B. (Did he get better?) No, I don't think he does. After a few years he dies and the children are old enough to mother or perhaps he left insur- ance. Never ed father again. No correspondence. After not having heard from each other for a long time, the old man dies and leaves the children a large estate. This is his way of having repented. Cast of characters Father of son Mother of son Son Son's wife Son's children Type of personality Father identifies with son's illness Mother will resent taking care of son's family Son is depressed over health, feels helpless, withdraws to healthier climate Dependent, needing , but ends up ing mother? Children dependent, needing Social interactions Father tells son he had same illness and son should cure himself, so father and mother won't have to son's wife and children Children need and later they mother Type of interactions Father overidentifies (Patient's merger fantasies?) and relates by telling son what to do. Controlling of son and rejecting of him. Children dependent, but later reverse roles Continuation of themes of bedridden dependence, threats of rejection responded to by someone dying in this case through somatization, schizoid withdrawal (to g0 off and think), and withdrawal and regression to womb (go to health-

OBJECT RELATIONS ASSESSMENT 231 tban- him :le as twin level [, sexi. The cured S

nate !ends

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i port rger

le ywill will mate. ia few nsur- each ks way

nd

cerse n re- with- .althier climate). Primitive level of object relations, although this story shows more depression (oral dependency, turning aggression against the self, somatization, and object loss) than psychosis. Since this is the last story reported, it may mean that the patient is only capable of pulling himself out of psychosis to a level of severe depression. Narcissistic grandiosity is seen in comment that son can only cure himself alone. Overall Object Relations Summary The main characters in this man's T.A.T. stories are seen as sick, ive/aggressive, withdrawing, and regressively dependent (stories 1 and 7BM) or as sexually promiscuous and suicidal (3BM, 4, and 6BM). The secondary characters are very similar to the main characters. They tend to be controlling and rejecting (Parents in story 1, police in 3BM, boyfriend in 4, girlfriend in 6BM, and father and mother in 7BM), detached (sister in 3BM, father in 7BM), homicidal (mother in 6BM), or ive, withdrawing, and imitative (wife and children in 7BM). The lack of much differentiation between the main and secondary characters suggests (1) lack of much self-object differentiation and (2) little evidence of development of repression. This is always important in object relations assessment on the T.A.T.--to look at the within group differences among the main characters and the differences between these two groups of story characters in order to get a clinical understanding of the level of self and object differentiation within the patient's internal representational world. The primitive splitting of the all good nun sister and all bad prostitute sister in story 3BM further corroborates that the patient has not developed much differentiation between self and other beyond primitive splitting and that he tends to defend by primitive splitting, rather than with higher more oedipal level defenses, such as repression, ambivalence, and other related defenses. Analysis of the social interactions show that this man's object relations are very primitive. There is very little directly stated social interactions among any of the characters in his stories (1 and 3BM have the littlest interactions of all the stories). In story 4, the only stated interaction is in the pregnant girl's pleading with the father of her unborn baby not to leave her to return to his wife and her action of setting fire to the house killing him, herself, and the unborn baby. This tendency to react to threat of abandonment with panic and impulsive homicidal and suicidal aggression is a pre-oedipal response to anxiety, rather than the response of signal anxiety in individuals who have reached the oedipal and higher levels of development. 6BM has directly stated interactions of the son telling his mother he committed a murder, which now shows sequentially how the patient will follow the previous firesetting murder. The mother responds by shooting him (she abandons him and punishes him for his murder by killing him). The directly stated interactions in 7BM are the father telling the son to cure himself without anyone else's help including that of the father and mother. The son withdraws to a healthier climate with his wife and children, but later he dies and later the father dies. This shows a controlling and abandoning interaction by the father and a withdrawing somatiza-

232 CHAPTER 11 tion response of the son. Parallel action is seen in the son and family withdrawing together to the healthier climate and the son and father later dying. Withdrawal and imitative action is normal for a pre-oedipal age child. But the somatization response to parental abandonment by dying again shows the severe level of this man's depression. Failure of reality testing is seen in "reading a book without any eyes" or knowing what is in the book without reading it in story 1; the prostitute who cannot reform, be forgiven, and become a nun in 3BM; the idea that the son can control his mother's reaction to his crime by having her act this idea out in a play he wrote in 6BM; and the idea that only he alone by himself can cure his tuberculosis in 7BM. This man's level of reality-testing, therefore, is not as actively fluid, loose, and grossly distorted as in individuals in the midst of active psychosis. Instead, we find subtle, indirect evidence of failure of reality-testing and delusional thinking in the above examples characteristic of latent schizophrenia or a psychotic condition currently in some state of remission. Discussion of Implications of Object Relations In object relations theory, three areas are useful in determining whether this patient is actively psychotic: 1. The level of self-object differentiation. The self-object differentiation of primitive splitting is a more borderline level of psychopathology that is more developed than the delusionally fusing self-object lack of boundaries in actively psychotic conditions. Which is his level? 2. The level of reality testing. 3. The level of acting out of sexual and aggressive impulses. Clearly, in all these areas, this man's T.A.T. shows a psychotic condition. The lack of much difference between the main and secondary characters in his stories suggests little self-object differentiation and the reality-testing level shows delusional merger ideation. Finally, the level of acting out of sexual and aggressive impulses is extremely primitive with the imagery of prostitution, adultery, homicide, and suicide. The likelihood of acting out of these homicidal and suicidal ideations should be taken very seriously in treatment planning. In sum, this man has a latent schizophrenic or psychotic depressive condition currently in remission with some presence of self-object differentiation and some reality testing. However, his acting out potential of suicidal and homicidal impulses is at an extremely dangerous level, particularly since he believes others want to control him, abandon, and murder him. The patient definitely does not have a borderline disorder, since his self-object differentiation, reality testing, and control of acting out impulsivity are not at the level of borderline patients. If the patient is not currently on a psychiatric inpatient service, on antipsychotic medication, and under active suicide and homicide watch, these interventions should be immediately put into effect.

OBJECT RELATIONS ASSESSMENT 233 Conclusion This case example demonstrates an object relations analysis of a T.A.T. protocol, which highlights an individual's self and object representations according to the approach of Kernberg (1976) and Volkan (1976). We have attempted to emphasize the value of highlighting the cast of characters in the story with the type of personality of each character and of analyzing the types of social interactions among these story characters. The main characters can be viewed as the more conscious self, while the other, secondary characters can be viewed as the part of the self that is less available to immediate awareness. The presence of primitive splitting seen in characters in the same story of opposite qualities and the level of reality- testing can be investigated in order to determine the pathological level of these object relations in the T.A.T. protocol. Since object relations stems from Freud's ego function approach, the reader will note the similarity of this object relations analysis of this T.A.T. protocol with the earlier analysis of this case in order to illustrate the congruity of these two approaches and the diagnostic agreement in interpretation of the T.A.T. in clinical practice.

CHAFFER 12

B ORDERLINE AND NARCISSISTIC DISORDERS IN THE T.A.T., C.A.T., AND S.A.T. Brief Overview of the Diagnostic Concept of Borderline and Narcissistic Disorders Two very popular psychiatric diagnoses are the narcissistic personality disorder intensively studied by Heinz Kohut (1971, 1977), and the borderline personality disorder intensively studied by Otto Kernberg (1975, 1980). Other individuals made substantial contributions prior to, concurrent with, and subsequent to the contributions of Kohut and Kernberg. Their own prolific writings and those of a substantial number of disciples have stimulated several T.A.T. and C.A.T. studies (Abrams, 1993; Brelet, 1981, 1983, 1986; Harder, 1979; Rogoff, 1985; Rosoff, 1988; Westen et al., 1990a, 1990b). The significant factor in both diagnoses is the identification of a psychiatric disorder that is characteristically pre-oedipal-level rather than oedipal-level neurotic disorder (obsessive/compulsive, hysterical, or phobic neurosis), but is possibly, except for brief episodes, not psychotic. Earlier, the term borderline referred to an individual at the border between psychotic and neurotic disorders. This could be a stable disposition or a labile one. It was Kernberg's contribution to insist that borderline designated a specific diagnostic entity with distinct criteria in of object relations and defenses and called for specific therapeutic man- agement. Narcissistic pathology was also earlier thought of as referring to a psychotic patient's withdrawal into a fantasy world of his or her own without a realistic relationship to the needs, perceptions, and existence of other people. However, narcissistic features could also be seen in a neurotic individual, as in someone who wants a circle of noncritical irers or someone who marries a famous person. The dictionary defines narcissism as love of the self at the expense of love for others (as putting one's own needs above those of everyone else and a lack of empathy for and sensitivity to other people's feelings). This latter definition is the key factor in narcissistic personality disorder. In Kohut's theory, the development of narcissism follows a timetable*of its own, similar to and parallel with Freud's original libidinal de234

e and ersonality disor- terline personal- )ther individuals tbsequent to the Is and those of a ld C.A.T. studies 85; Rosoff, 1988; of a psychiatric edipal-level neu- iosis), but is pos- ,rderline referred disorders. This ,ntribution to in- .stinct criteria in herapeutic man:o a psychotic pa- realistic relation- wever, narcissistic e who wants a cir- person. The dic- ,ve for others (as empathy for and key factor in nar- of narcissism fol- ginal libidinal deBORDERLINE AND NARCISSISTIC DISORDERS 235 velopmental schedule. From this theory it derives propositions concerning the treatment of narcissistic personality. Neither Kohut's nor Kernberg's concepts are entirely accepted by psychoanalysts. The Kris study group (Abend, Porter, & Willick, 1983) on borderline conditions at the New York Psychoanalytic Institute did not find a circumscribed condition as defined by Kernberg and had doubts about the appropriateness and usefulness of his delineation. Psychoanalysis had usually accepted the coexistence of pre-oedipal and oedipal aspects in various ixtures and to varying degrees in virtually all neuroses and other conditions. Kohut's complex and rather idiosyncratic formulations have found similar critique. Nevertheless, the borderline concept as well as that of the narcissistic personality, without rigid definitions, have merit as heuristic hypotheses. Diagnosis of psychotic process in psychological tests in general is well covered by Weiner (1966). Psychotic process on the T.A.T. is seen in the presence of direct sexual and aggressive themes, themes of persecution, characters magically trans- forming from one thing to another, themes of omnipotence, magical power, figures being part one thing and part another, juxtaposition of extremes (angels and devils, acts of murder and loving tenderness), ideas of reference (thinking one card is connected to another card previously given), disorientation and confusion as to person, place, and time, lack of clear body boundaries, and gross deviation from the stimulus. The more one sees these indicators on psychological tests, the greater the possibility that the individual is either actively psychotic, has a latent psychosis, or has psychotic features. The frequency of indicators helps decide the severity of the condition. (See also the discussion of schizophrenic T.A.T. indicators on pages 158-161.) Another useful method was pioneered by Anna Freud (1965). Hers was a developmental approach to diagnosis, called the "Developmental Profile." The idea is to identify in the clinical material (social history, set of referring symptoms, therapy sessions, and psychological tests) the predominant level of development in the area of psychosexual phases (oral, anal, oedipal, latency, adolescence, etc.), aggression, interpersonal object relations, defense mechanisms, and other areas. A clinician who sees severely disturbed individuals for testing can begin with the item approach of looking for a large number of indicators of psychotic process and then consider a developmental diagnosis. Here, the key question is if the person tested is predominantly pre-oedipal (stuck on a level typical of a child from birth to age 3) or oedipal neurotic (3 years and above). Salient Indicators of Pre-Oedipal- and Oedipal-Level Functioning The following features are characteristic pre-oedipal versus oedipal diagnostic indicators: 1. Panic reaction when signal anxiety is appropriate. 2. Primitive splitting rather than anbivalence. 3. Denial and splitting as defenses, rather than repression to fend off awareness. 4. Part-object experi%n.ce and part-object perception, rather than whole-object experience and whole-object perception.

236 CHAPTER 12 B. Unstable internal object or lack of internal object, rather than stable, internalized object constancy (the ability to hold in one's mind an image of another person independent of being in the other person's presence). [J. Superego is split between extreme punitive "all bad" and libidinal "all good" images, rather than being flexible, reasonable, and appropriate, and in tune with society's ethical principles. 7. Affect states are extreme and "pure" forms of love, hate, fear, sadness, and joy, rather than a neutralized, modulated array of feelings and nuances of feelings in between. 8. Shame and humiliation is experienced rather than oedipal neurotic guilt. 9. Introjective/projective relatedness (Volkan, 1976) of self-object relatedness (Kohut, 1977) rather than identificatory relatedness or relating to others as independent, separate individuals. 10. Fragmentation and disintegration, rather than synthetic function (ability to organize experience and perception into integrated "Gestalt," or meaningful wholes). 11. Acting and reacting, rather than experiencing and acting with a presence of observing ego function (self-observation and self-monitoring). 12. Defenses of incorporation and introjection, rather than identification. 13. Immediate discharge of impulses in acting out, rather than delayed gratification. T.A.T. indicators of these characteristics of pre-oedipal versus oedipal developmental stages are the following. Panic anxiety rather than signal anxiety can be seen in characters in a story en- gaging in sudden, wild, frenetic, or repetitive actions in the face of danger or threat. A monster threatens and a small animal simply jumps up and down, runs, screams, or does an action over and over on the C.A.T. Or the smaller animal may simply "freeze," immobilized and overwhelmed with fear. A signal approach would be to mention a danger in the future and an attempt to plan, prepare, and cope with the danger, as in calling for help, building a fort, hiding, or working out a trap. In the chapter on neuropsychological assessment, we give the example of a child who symbolized the need for signal function by the need for the story figures to have a fire alarm to call the firemen to put out a fire in the kitchen. Primitive splitting rather than ambivalence is the key feature for borderline pathology according to Kernberg (1976). He defines primitive splitting as the keeping apart of extreme affects of love and hate, extreme impulses of aggression and libido, and extreme images of the self and of other people (called self and object representations) that are characterized as "all good loving" and "all bad hating." One sees T.A.T. characters that are either angels or devils, good guys or totally evil ones, without evidence of story figures who are somewhat good and somewhat bad, who have more than one side to their personalities. Volkan (1976) speaks of such fantasies of borderline patients as being all in black and white, rather than in tech- nicolor. Ambivalence is seen in the T.A.T. by such statements as "either this.., or that." Splitting in narrative style would be something more like, "It's this. No, it is only that" or."She hates him and wants to kill him. He is the only one she loves."

aan stable, inter- an image of an- esence). ,idinal "all good" iate, and in tune sadness, and joy, tances of feelings eurotic guilt. 3ject relatedness ring to others as ction (ability to ," or meaningful .th a presence of i). ttification. telayed gratificapal developmeners in a story ence of danger or and down, runs, aller animal may approach would epare, and cope irking out a trap. ample of a child i story figures to I1. if or borderline tting as the keep- [ aggression and 1 self and object Fall bad hating." ys or totally evil somewhat bad, speaks of such er than in tech- ther this.., or t's this. No, it is )ne she loves." BORDERLINE AND NARCISSISTIC DISORDERS 237 Part-object rather than whole-object experience and perception is seen on the T.A.T. in splitting, as just discussed, where there is not a development of characters that have a combination of different feelings, traits, and activities, but a juxtaposition of good versus bad characters. Object constancy is seen in the behavior when the toddler begins to be able to play alone, with the mother in the next room or having been left in the care of a babysitter. When the mother leaves, there is no longer the temper tantrum panic reaction to separation anxiety. The child can now realize that the mother still exists independent of the child's immediate perception of her. Prior to object constancy, the child experiences the separation as a death, "out of sight, out of mind." If the child doesn't see or hear his mother, then mother must be dead, hence the extreme level of panic and the extreme tantrums. The lack of object constancy can therefore be seen in T.A.T. stories as a theme of separation anxiety, upset shown when one figure leaves another. Right after leaving home, for example, the next action is falling and getting hurt (as in C.A.T. story 2 where one part figure lets go of the rope and the child on the other side falls and gets hurt, symbolizing separation from the parent), getting attacked by a storm or by a threatening figure, or getting sick. Object constancy could be seen in characters who leave others, who leave home, and can plan, use strategy, and use defenses to handle the dangers that occur in the future. Little Red Riding Hood telling the wolf along her path through the woods that she is going to grandma's house is an example in story form of maintaining an image in one's mind of the mother figure in the face of separation and threat. Pre-oedipal superego is seen in T.A.T. stories of extreme punishment for mild transgression, as when a character is jailed or killed because he urinated on the floor or falls down a cliff and dies because he just "didn't look where he was going." A more oedipal, neurotic, or normal level of superego exists when the punishment fits the particular crime. The child spills his food on C.A.T. story 1 and the mother asks him to clean it up and not spill the next time. Or one character calls the other a name and then apologizes for it. Pre-oedipal children do not usually think to say, "I'm sorry," because their punishment for a crime is much more extreme than that, they feel as if they should be--or are going to be--severely beaten for what they did. A mere apology is not in their scheme of things due to the lack of development of an oedipal level of the superego. Pre-oedipal superego is often split between this very primitive, punitive, extreme punishment for extreme and even very mild in- fractions and extremely, magically good, all-forgiving godlike features. The child violates a taboo, such as stealing the giant's belongings in Jack and the Beanstalk and the primitive superego punishment is seen in the giant trying to eat and/or kill Jack. The all-good superego is seen in the ending, where Jack has the giant's magical belongings to share safely alone with his mother "happily ever after." Extreme affect states rather than neutralized, modulated affect states are seen in T.A.T. stories in the use of extreme affect words, such as hate, love, devastated, or ecstatic, predominantly, rather than a range of gradations of affect words, such as somewhat saddened, a little annoyed, interested, surprised but understanding, and so on. This goes along with stories 2 (use of primitive splitting rather than ambivalence) and 4 (part- object rather than whole-object experience and perception).

238 CHAPTER 12 Shame and humiliation rather than guilt is seen in stories where the antagonist ends up with his pants down in front of an audience, slipping on a banana peel, or publicly embarrassed in some way. While guilt is seen in characters expressing remorse over actions that caused harm to others, expressing sorrow over a missed opportunity due to doing something reckless or stupid, or expressing self-criticism or self-recrimination for actions they feel interfered with the happiness of other people. Egocentrism versus role-taking ability is related here in that the pre-oedipal individual becomes more upset over shame and humiliation and seeks to avoid doing things that will humiliate himself, while the oedipal individual is more concerned about the feelings of others and more guilty over causing hardship to others. Introjective/projective rather than identifactory relatedness is seen in very young children relating to the mother as if they are an extension of the mother and as if the mother is an extension of them. The infant acts as if the mother is only there to feed and comfort him or should smile and laugh when he smiles and laughs. The toddler, when angry with the parent, may project this anger onto the parent and imagine the parent is a monster furious with the toddler. The young child treats the parent as a self-object, then, rather than as a separate individual with independent needs. The parent is treated as both part of the self and part of the other, part self and part the parent. This is seen in the T.A.T. in frequent changes of a character's identity, sex, changes of pronoun from singular to plural and back to singular, and magic transformations from one thing to another. The theme of eating up another or being eaten up on C.A.T. stories represents this oral incorporative, introjective attempt to obliterate the independent existence of the self and the other as separate individuals. The idea of one figure "reading another's mind" or having the exact same thought as the other at the same time is another example of this kind of symbiotic oneness characteristic of pre-oedipal individuals. This is seen in emphasis on symmetry or seeing "twin" context on Rorschach and also on T.A.T. as the theme of twins. Fragmentation rather than synthetic function is seen on T.A.T. in stories that are disted, aimless, and lacking in a sequential organization towards a logical ending. The story may begin about a little chicken eating and abruptly switch to a baby sleeping in its bed as in a free association without a clear connection between the two themes. Acting rather than acting with self-observation is seen on T.A.T. stories in which the characters simply do different things, while there is no attempt to reflect on meaning about the actions or the picture. The boy looks at the violin, tries to play it, then puts it down (on card 1) is an example of acting without self-observation. By contrast, having the boy thinking about what he should play, how long he should practice, if his parent is happy with his practicing, or comments about whether the picture reminds the storyteller of some of his own feelings, and so on, are examples of the observing function more characteristic of the oedipal level of development. Finally, defenses of incorporation and introjection rather than identification are seen in stories where a figure experiences a separation or loss and reacts by eating up the other, being eaten up by the other, or imagining one is seeing a ghost of the deceased, rather than dealing with loss by doing something similar to the deceased person's former activities, such as taking up an activity that used to be the hobby of

re the antagonist a banana peel, or ;rs expressing re- over a missed op- g self-criticism or .ess of other peo- e preoedipal in- ks to avoid doing more concerned p to others. very young chil- :her and as if the : is only there to and laughs. The ) the parent and g child treats the ith independent .e other, part self s of a character's : to singular, and ating up another ttive, introjective ae other as sepa- ar having the ex- [e of this kind of seen in empha- on T.A.T. as the ! stories that are ds a logical end- !switch to a baby ion between the ries in which the reflect on mean- is to play it, then !rvation. By con- I he should prac- Whether the pic- fare examples of levelopment. /cation are seen by eating up the a ghost of the to the deceased be the hobby of BORDERLINE AND NARCISSISTIC DISORDERS 239 the deceased. Acting out versus delayed gratification is seen in eating right away, screaming for something he wants, demanding something immediately, rather than waiting. The constellation of pre-oedipal characteristics can be illustrated in C.A.T. protocols of children of preschool age, who are still predominantly on a pre- oedipal level. The first protocol is that of a girl 4/2 years, whose father physically abused her.

CA.T. Protocols Illustrating Pre-Oedipal- and Oedipal-Level Functioning Card 1: There were three chickens pecking at the trees and then the tree falls down and then they'll have to get another tree. Oral emphasis is stated (pecking the trees) and theme of impulsivity, fragmentation, and panic anxiety is suggested by the tree falling down, as if the child seeks oral supplies from the parent (symbolized by the tree) and the parent falls apart. Card 2: A little, three little bears and they wanted to pull a rope to tie around a tree and then they tied another rope around a tree and then it will fall on the Daddy. Cotntn.ent Some desire for body boundaries and for synthesis is perhaps symbolized by the pulling a rope around the tree (a boundary to hold the self together), but in the end the tree falls continuing the theme ofimpulsivity, fragmentation, and panic reactions of becoming helpless and overwhelmed in the face of stress, rather than being able to mobilize coping mechanisms. That the tree falls on the father may indicate her anger at the abusive father or express something about the parents "falling on" each other in a sexual or aggressive manner that was frightening to the child, as if the world were falling down. Card 3: A big, big, fat Daddy lion and he killed a baby. A baby and then nothing happened. (She gets very excited and flings the card in the air.) Stuttering is a typical anxiety reaction in young children, which perhaps occurred in this child when presented the lion and mouse picture that is often associated by children as a father and child. The lion "kills the baby," which indicates extreme aggressive impulsivity coming from her life experience and also intensified from her pre-oedipal tendency to project some of her anger onto others, so that she sees the other as even more threatening and angry. Flinging the card is again a panic response of acting out and immediately discharging her impulses, rather than being able to verbalize her feelings or mobilize other defense and coping mechanisms.

240 CHAPTER 12 Card 4: Once upon a time there was kangaroos and they went in the forest and got lost. They went and then they got lost again. Comment Separation from the parents and loss is symbolized in this story, which states an oral level theme. Repetition in action is similar to stuttering, which indicates anxiety and acting out impulsivity, rather than acting with selfobservation. Card 5: Once upon a time there was a little crib and a baby. The baby wasn't sleeping, because it was his bedtime and he forgot to eat dinner. Oral neediness is stated again indicating a pre-oedipal level of psychosexual development, rather than an oedipal level which would be expected from her current age of 41/z years. Card 6: Once upon a time there was a little bear, little bears, and they wanted to eat frogs and then the frogs got hungry and they went into their place to eat the bears. They wanted to, but they couldn't do it. This is an excellent example of the self-object or introjective/projective relatedness typical of pre-oedipal-level individuals. The larger figures (adults?) want to incorporate, merge with, fuse with, and introject the littler figures (children?) and the littler figures want to eat up and incorporate the larger figures (the frogs want to eat up the bears). Following the sequence of her C.A.T. stories shows that she ato tempts to defend against separation and loss by primitive oral incorporation fantasies (to eat up or be eaten by the other so that the two of them are ed together). Card 7: That one! That's a funny one. I don't know. No story on that one. Comment This is a picture of the tiger attacking the monkey, which is first defended against by reversal of affect ("that's a funny one"), then denial ("I don't know"), and finally by avoidance and withdrawal ("No story on that one"). These are all typical pre-oedipal-level ego defenses, as opposed to more oedipal and higher level defenses of repression, reaction formation, rationalization, or sublimation, and so forth. Card 8: Nothing about that one either.... Once upon a time there were four little monkeys. They were standing and the mother monkey said to the father monkey one, "I would like to go outside and play with the baby monkeys." And then nothing else. The father one said yes. She starts with denial, avoidance, and withdrawal, but then manages to relate a mundane, everyday type of story. This type of trivializing is again a defense away from letting oneself go in free association and personally meaningful fantasy. It is similar tc¢zoncrete description of the pictures. It may suggest a denial of parental

ad got lost. rich states indicates 't sleeping, :hosexual her curated to eat ,ears. They :tive relat- ') want to ten?) and Frogs want aat she at- ation fan- oined to-

defended t know"),

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,four little :ey one, "I The father to relate ense away atasy. It is parental BORDERLINE AND NARCISSISTIC DISORDERS 241 criticism (the picture shows the mother monkey pointing her finger towards the child monkey next to her) and a desire for the mother to nurture and play with her without the abusive restrictions she experiences from her father in reality. The pause at the beginning can indicate denial or blocking defenses. Card 9: Once upon a time there was a little, a mommy rabbit, and she was so sad that nobody was home with her and then she cried. Comment The affect of sadness to loss is expressed directly. Card 10: Once upon a time there was two doggies. The baby doggy had to go outside and he went right there--he went in the toilet. The end. Comment We see a further denial of parental criticism in the failure to report the action in the picture on the card of a parent or adult dog spanking a puppy on its knee. The use of the word suddenly is typical of pre-oedipal-level thematic stories symbolizing the sudden outbreak of impulses, a panic reaction to stress. This story suggests the puppy first went to the bathroom where the puppy was when he suddenly had to go, which further expresses acting out impulsivity, rather than an ability to delay immediate gratification. But she then ends it with the puppy going to the bathroom in the appropriate place, a suggestion that she is able to move in the direction of oedipal-level development. C&.T. Summary This girl of 41/2 years should be within an oedipal, neurotic level of psychoso- ciat development. Instead, the C.A.T. suggests that the life stress within the family (parental strife, father's physical abuse) contributed to her staying primarily at a pre-oedipal level more typical of a child of 11/2 to 21/2 years of age. In of the pre-oedipal characteristics enumerated earlier in the chapter, her C.A.T. shows panic reaction rather than signal anxiety function (cards 1, 2, and 3 with falling trees and killing), impulsivity (cards 1, 2, 3, and 10 in stuttering, repeated actions, primitive actions, (use of "suddenly"), acting out rather than delayed gratification (card 10 with the going to the bathroom right where one is rather than in the toilet), dependency (card 2 with theme of rope tied to adult figure), themes of separation and loss (cards 4 and 8), regression to oral neediness (cards 1, 2, 5, 6 and 8), self-object relatedness rather than self and object independence (card 6 with the figures eating each other up), direct pure affect (cards 3 and 9), and pre-oedipal-level defense mechanisms of denial (cards 3, 7, and 8) reversal of affect (card 7), avoidance and withdrawal (cards 7 and 8), and blocking (card 8 with its pause). The child might be diagnosed, then, as having an adjustment disorder with pre-oedipal fixation or regression secondary to the family stress and abuse. Following is another typica_l, jpre-oedipal-level C.A.T. story to card 3 in a boy of 5 years of age, who is hyperactive.

242 CHAPTER 12 Card 3: I'm not touching that one! This once upon a time is about a big lion that's sitting in his chair alone. He got up, went outside, scared all the people, ate one people, and real scary! You know what made him friendly?--a magic ball. He first defends by avoidance and withdrawal (I'm not touching that one!"), then brings in the theme of oral incorporation (eating up people) and of panic anxiety (scaring everyone). Finally, he reaches for magical thinking in the magic ball that makes him friendly, which also suggests dependency upon the mother (perhaps symbolized by the round ball) and undoing (the scary one becomes magically friendly). This shows an ability in this child to respond to stress and anxiety with the mobilization of defenses, so this child is closer to an oedipal level of signal anxiety, rather than the predominantly pre-oedipal panic reaction to anxiety in the little girl of 41/z years above. But this boy's defenses are still pre-oedipal level defenses, rather than oedipal or higher ones. The following is a story of a neurotic level child of 5 years, which shows what we would expect to see in a C.A.T. when a child is no longer on a pre-oedipal level, but has reached the oedipal level and by age 5 years is already well on the way to resolving and working it through on an age-appropriate level: Card 7: Oh God! this is really scary.... OK, here I go .... Once upon a time there was a lion catching a monkey and the monkey was running away on his rope. Then he was climbing up the tree, and the lion was crying (he gestures a roar) like this, "Rhhhhh!" He sounded like my Dad laughin'. Every time ! go '%Vhoo!" to my sister, she runs. She thinks it's a ghost, but it's only me. In the night, in the dark, I do it, when there's not the light. Comment He is able to verbalize his fear of this card with the picture of the tiger attacking the monkey, "This is really scary," which pre-oedipal-level individuals often do not do. They step back from the card, turn it over, refuse to do a story, or express a story only of aggressive actions of chase and escape. This boy then does retreat first to the preoedipal defense of avoidance and withdrawal (the monkey running away), but then comes back with a superb example of the typical oedipal level defense of identification with the aggressor. The boy identifies the tiger (lion here) with his father's loud laughing (a reversal of affect or reaction formation defense) and then tells us that he identifies with the father's roaring in scaring his sister. The father scares him, so he scares his sister, which shows oedipal identification with a quality of the father and a tendency to deal with aggressive threat by turning pas- sive into active and becoming the threatening one to others, rather than remaining the helpless, panicked, ive recipient of threat from larger adults.

Specific Indicators of Borderline Pathology In this chapter, we can only provide an introduction to this developmental type of T.A.T. and C.A.T. diagnosis. Abrams (1977) and Sutton-Smith and associates (1981) suggest further developmental analysis of narratives. What is important for this chapter is tO.first distinguish the T.A.T. or C.A.T. protocol from psycho-

big lion that's sit- one people, and ng that one!"), ) and of panic g in the magic }n the mother becomes mag- ;ss and anxiety level of signal anxiety in the dipal level dech shows what .'-oedipal level, the way to re,on a time there e. Then he was "Rhhhhh!" He . She thinks it's lae light. ,f the tiger at- [ividuals often a story, or ex- then does re- monkey run- [ oedipal level er (lion here) tion defense) his sister. The lcation with a turning pas- an remaining velopmental ad associates is important rom psychoBORDERLINE AND NARCISSISTIC DISORDERS 243 tic process by using the list of psychotic indicators we suggested earlier in the chapter and then move on to distinguish whether the protocol is predominantly pre- oedipal or predominantly oedipal or above in developmental level in ego functions, defenses, and object relations. If the protocol has numerous psychotic indicators and is predominantly pre-oedipal, a diagnosis of psychotic process is to be considered (along with psychotic indicators on the other projective tests). If there are only a few indicators of psychosis or no indicators of psychosis, but the protocol is predominantly pre-oedipal, then a diagnosis of borderline disorder could be considered (providing the patient is over 8 or 9 years of age and there are signs of borderline pathology on other psychological tests in the battery). Borderline pathology is often identified with individuals whose level is predominantly pre-oedipal, but is not fundamentally psychotic. But one must also look for the following characteristics, as noted in the DSM-IV (APA, 1994): 1. Impulsivity or unpredictability in spending, sex, gambling, substance abuse, shoplifting, overeating, physically damaging acts (at least two of these) 2. A pattern of unstable and intense interpersonal relationships with marked shifts of attitude, idealization, devaluation, manipulation (consistently using others for one's needs) 3. Inappropriate, intense anger or lack of control of anger seen often in frequent temper tantrums 4. Identity disturbance manifested by uncertainty about several issues relating to identity, such as self-image, gender identity, long-term goals or career choice, friendship patterns, value, and loyalties 5. Affective instability: marked shifts from a normal mood to depression, irritability, or anxiety, usually lasting a few hours and only rarely more than a few days, with a return to normal mood 6. Intolerance of being alone seen in frantic efforts to avoid being alone (desperate calls to the therapist on Fridays before the weekend loneliness), depressed when alone 7. Physically self-damaging acts such as suicidal gestures, self-mutilation, recurrent accidents or physical figures; also periodic use of drugs, alcohol and overeating in the same manner 8. Chronic feelings of emptiness or boredom T.A.T. Protocol Illustrating Borderline Disorders with Some Psychotic-Like Features Adult Case of Borderline Disorder with Some Psychotic-Like Features The following T.A.T. is from a 30-year-old woman, who had one hospitalization for a suicide gesture in which she took sleeping pills. This case nicely illustrates the presence of a few psychotic-like features within a developmental level that is predominantly pre-oedipal. Key characteristics of borderline disorder, as defined by DSM-IV, further'substantiate the diagnostic impression that she is not

244 CHAPTER 12 fundamentally psychotic, but has a borderline disorder with mild psychotic-like features: 1: This little boy is, let me look closely. This is ambiguous. You'd have to be a genius to make what I'd like to about this picture. The boy is missing that, don't write that. Let's see. He just got this violin and he was told he had to play this musical instrument and he hates the violin. He just had a lesson and he's been practicing for hours and he's just taking a rest now, he hates the violin. I have two different endings--one's healthy and one's not. I don't know which one to go with. As he got older, one day he smashes that violin against the wall and broke it. Then another way of ending it, it is bothering him, so he practiced it so he could become a better player and he became a great violinist. But there's a little piece down here which could be broken, so he's upset that his violin could be broken. Oh, no! That's because he doesn't know how to play it and he doesn't want to play it. Primitive splitting is suggested by the juxtaposition of extremes--the "un- healthy ending" of smashing the violin against the wall and breaking it and the "healthy ending" of practicing and becoming a great violinist. In splitting, two opposite feelings or ideas are kept apart from each other. They could not be part of the same story, for example. So she makes two different endings. Splitting is also suggested by the juxtaposition of "genius" and the boy at the end who feels broken like the violin could be, "because he doesn't know how to play it (low self-esteem) and he doesn't want to play it (anal level oppositionalism)." Aggressive, angry impulsivity, grandiosity (great violinist, genius), and part-object perception ("little piece here") are borderline features. 2: Ah, this is the one I get stuck on, this picture. It doesn't make sense to me. Um, um... (pause) I'm much less anxious than I used to be when I talked about these pictures. This is a wierd picture. Urn, ah (heaves a sigh). This daughter's going to school. She's, the bus is coming from the left, but she's looking toward the right. Her mother's standing up against the tree that doesn't belong in the picture, facing another direction. The brother is plowing the field beside a horse and they're all in different zones. Well, very soon after the girl leaves for school, the mother starts.., what does the mother do? Urn, the mother does work that she has to do in the house and the son plows and takes care of the animals and they have lunch. Comment Pre-oedipal, borderline characteristics are predominantly the sense of fragmentation, part-object, or splitting in the idea that the tree "doesn't belong in the picture" and that each family member is in a "different zone" and the notable separation anxiety, when presented with this picture of a girl appearing to be leaving for school or coming back from school to the family on the farm. She gets stuck, blocks, becomes vague, pauses, and heaves a sigh presumably at the idea of the "daughter's going to school" (all indicators of high anxiety). 3: (... she sighs). This girl goes to school for, um, disturbed people and she's just there now in the student common room, upset. Wait, I think there's scissors on the floor next to her. (She puts the card down.) She's upset because everyone's out that night and she's the only one there.

BORDERLINE AND NARCISSISTIC DISORDERS 245 psychotic-like lave to be a ge- lon't write that. ical instrument hours and he's -one's healthy day he smashes it is bothering me a great vio)set that his vio- and he doesn't nes--the "un- ing it and the itting, two op- not be part of plitting is also ) feels broken w self-esteem) five, angry im- eption ("little ase to me. Um, these pictures. hool. She's, the !r's standing up The brother is soon afler the e xnother does ae animals and sense of frag- belong in the e notable sep- to be leaving he gets stuck, e idea of the and she's just the floor next at and she's the She goes to sleep early, she talks to a teacher, and then shortly after that, she flips out and leaves school. Could be a biography, but it's not. At the beginning, I was thinking she was pregnant and she was thinking she had to get an abortion and then there's another one where she kind of looks like a lesbian from the behind. I used to have pretty elaborate stories on these. Anxiety over separation is clear from the beginning hesitation, sighing, filler sounds (ah, uh, um), and the content itself. The defenses of avoidance and withdrawal are noted in her putting the card down and the action in the story of "going to sleep," which is also an oral regression. Panic and fragmentation then is expressed in the next action of "flipping out," and "leaving school" is another form of avoidance, withdrawal, and regression. The negation form of denial comes in the statement, "Could be a biography (about herself), but it's not." Having.an abortion may also continue the theme of separation anxiety and the idea of a "lesbian from the behind" expresses the possibility of sex-role identification confusion and identity disturbance often seen in borderline patients. 4: God!, these cards don't make much sense to me. (She holds the card up close.) This woman's husband just got home from work and.., he, I can't tell if he's happy. He looks like he's rushing off to somewhere. He's going to run upstairs, because he heard that his daughter fell out of a tree today and the wife's just trying to tell him that it's not that bad. That she's sleeping, but he wants to rush right up there. They all come downstairs in an hour at the end and eat dinner and the little girl's a lot better. 'fhe meaninglessness" of the cards may illustrate her use of denial (blocking off immediate awareness) and possible splitting. Separation anxiety is suggested by the idea of coming home and "can't tell if he's happy"juxtaposed with the contrary idea that "He looks like he's rushing off to somewhere." Primitive splitting may be present here with this co-existence of opposite feelings and thoughts. The daughter's accident and sleeping after it show borderline features of self-damaging acts, impulsivity, and depressive withdrawal. 6GF: Who makes up these pictures, anyway? . . . (pause) . . . This woman's sitting on the couch and her husband just came back behind her to ask her what drink she wanted for dinner. They're waiting for company to arrive. That's it .... Later on, the company comes, they have a nice time, and have one too many drinks and just get very intellectual and on and on. There's sort of a debate going on and then the company leaves. The company sort of staggers out, crawls, and that's the night. Pause suggests anxiety and blocking. Acting out impulsivity is suggested by having "too many drinks," possible defense intellectualization ("get very intellectual") and regression (crawling out). Some fragmentation of thoughts is evident by the fits and starts and disted ideas in the style of relating the story and in its overall narrative organization. 7GF: This mother's trying to talk to her daughter about, uh (long sigh) about her having to go into the hospital and her daughter's very upset. She can't even look at her and the daughter runs up to her room and spends the whole night there. She falls asleep, but the mother comes to say 'Goodnit' to make her feel better.

246 CHAPTER 12 Theme of separation anxiety is repeated here (leaving the mother and going to the hospital), which is reacted to with defense of withdrawal (runs up to her room) and regression to sleep (falls asleep). But she only seems to feel better when separation is removed by the mother coming back to her. 8BM: How many are there? Well, ah, this boy is imagining what's happening behind him. These two men are cutting open his friend behind him. He often imagines things like that that scare him and sort of, he gets engrossed in these fantasies. He ruined the whole room. These men ruin the whole room. These men do it all. They shoot holes in the windows, knock out the walls, cut open this man's intestine. Take it out and leave him there and he's in pain. No anesthesia. These guys aren't doctors. This boy is just dreaming the whole thing up. It's just his fantasy. It didn't really happen. Well, he acts out sometimes and in drawings or what he writes. That's not me talking. I don't have thoughts like that, don't you think? Acting out of aggressive impulses (ruining the whole room by shooting holes in walls, cutting open the man on the table) is defended against by displacement ("He ruined the whole room . . . these men ruin the room") and denial ("This boy is just dreaming the whole thing up. It's just his fantasy. It didn't really happen .... That's not me talking..."). The primitive and intense aggression and the preoedipal level of defenses against it are typical identifying features of the borderline disorder. 10: I don't understand this picture. I don't, I can't tell if it's two women or a man and a woman. They almost look alike. Like twins. Ah (she sighs), I don't know. These women are twins (she puts the card out at arm's length) and they were usually very close to each other here they're, they look very intimate with each other. Since they grew up as twins, they're always very physical with each other in a way, in a sisterly sense (she laughs embarrassingly) and here they haven't seen each other, because the funeral of a friend brought them together. Sex-role confusion and the theme of twins (self-object merger) are further example of borderline disorder in this story. She also suggests the presence of primitive splitting in the juxtaposition of the theme of merger (twins and intimacy) with the opposite theme of death, loss, and separation (the funeral). 13MF: Ah, I don't like this one, either. They had a "one night stand" and they just picked each other up at a bar one night. Urn, he's leaving after that, he has a hangover, and he's leaving. He's got all his clothes on. They never see each other again. He just leaves. Ah... I just thought of something else. She could be dead and he saw her and he's very upset. But why would she have no clothes on? Scratch that. Well, they weren't close before, but now he really cares about her, but she's dead. Acting out impulsivity and the borderline experience of intense, short-lived interpersonal involvements are expressed in the idea of "one night stands," during which they meet, presumably have sexual relations, and "never see each other again"--an experience this patient has had frequently. Then she shifts the thought

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just and up- ut ,ed lg er 'ht BORDERLINE AND NARCISSISTIC DISORDERS 247 to extreme loss through death either because separation often feels like a total death to her (as in the previous story) or because her anger at separation stirs up extremely primitive and intense aggressive impulses. Denial is then evident in her desire to "scratch that." Sm'nmary The T.A.T. protocol reveals the key features of a borderline disorder with psychotic-like features with the frequency and primacy of primitive splitting (cards 1, 2, 10, and 13MF), denial (cards 3, 4, 8BM, and 13MF), and separation anxiety (cards 2, 3, 4, 6GF, 7GE 10, and 13MF). Tremendous aggression, impulsivity, high anxiety, avoidance, withdrawal, regression and blocking are further identifying features. Sex-role confusion is seen on card 3BM suggested by the lesbian themes and stated very directly on card 10, where she is not sure if they are a man and a woman and then moves on to make them twins. The borderline patient is also at the border in ego boundaries, so that the self is experienced as part-self and part-other and others are experienced as part-other and part of the self. The borderline fuses, sep- arates, and refuses, back and forth. The borderline lacks cohesion of the self or ego integration and has unstable boundaries between the self and others. Therefore, at points of stress, the borderline's self becomes further fragmented, further disinte- grated, and further split into part-object and part-self representations and there is a further tendency to merge and fuss with need-fulfilling objects. Separation anxiety is a key issue causing panic outbursts in which the inappropriate level of intense anger and aggression may appear psychotic to others. The borderline may attempt to frantically merge with the separating love object, so that a family member or boyfriend or girlfriend of a borderline individual feels overwhelmed by this over- bearing demandingness. However, the borderline is often as terrified of closeness as he or she is of separation. So when the borderline begins to feel merged and intimate, he may begin to feel threatened with loss of the self, panic, and abruptly re- ject the love object so desperately desired. Because of these two deep fears of separation and of merger, the borderline's interpersonal relations are overly intense resembling the turbulent storms of conflicting needs for dependence and independence of toddlers and of adolescents. These abrupt swings between intimacy to the point of twinship and extreme isolation in themes of death are seen in this T.A.T. protocol as we read from one story to the next. The borderline's interpersonal relations are also overly intense, because of the extreme "pure" expression of affect. The anger is a pure, deep anger, as is the sadness or love. Affects are unneutralized, unmodulated by the nuances seen in higher functioning individuals. So others feel intensely drawn to, involved with, and also rejected by borderline individuals. These extreme mood and feeling states also swing from one extreme to the other, so they are in a deep, almost suicidal depression one hour or day, in ecstatic joy the next, and later apparently calm and normal. When calm and normal, they complain of emptiness and boredom, which is really due to the schizoid-like operation of the defense of primitive denial and primitive splitting (a'zlouding over of immediate awareness).

248 CHAPTER 12 The borderline individual may abruptly turn to self-damaging behavior, such as accidents, gambling, alcohol, or drug abuse, as a frantic attempt to feel alive again (after the schizoid emptiness and boredom has come upon him) or to calm the stimulus overload through drugs or alcohol (after the stimulating aspects of these behaviors have made him start to feel too alive and potentially out-of-control and fragmented). Because of this primitive splitting, mood swings, and swings between the schizoid emptiness level of denial and stimulus overload, the borderline individual typically is not consolidated enough to be an addictive personality, but uses drugs, alcohol, gambling and the lot in a fragmented and an intermittent manner. A continuing debate in the literature is over what is the key issue in borderline pathology. Some feel it is separation anxiety and the lack of appropriate reaction to anxiety, rather than having developed a signal function to anxiety. Some feel it is due to a fragmented, split, or "unintegrated' ego that needs to develop further towards integration (Winnicott, 1965). Some feel it may be fundamentally influenced by organic factors, such as neuropsychological dysfunction in the area of perceptual, perceptual-motor, and motoric integration so that the individual has basic deficits in synthesizing functions and is thus prone to fragmentation and unorga- nized panic under stress. Others emphasize the predominant use of primitive splitting and related defenses, such as denial, idealization, devaluation, and projective identification, rather than repression and its related defenses of reaction formation, rationalization, intellectualization, and sublimation. The reader will notice that these issues are the main characteristics of the pre- oedipal stage of development, which we listed earlier in this chapter. It is for that reason that Kernberg writes of the borderline disorder as the main disorder of pre- oedipally fixated individuals, who are not psychotic. He suggests that the disorder is due to a constitutional level of aggression that is higher than in normal individuals and to a failure to successfully resolve the rapprochement subphase of the separation-individuation process, when the child swings between intense separation and merger fears due to not having yet developed an inner image of the mother (object constancy). Kohut (1971), on the other hand, viewed narcissistic personality disorder as the central pre-oedipal disorder. Consequently, for him, the borderline disorder is a subset of the narcissistic personality disorder. Abrams (1991) suggested that while the pre-oedipal splitting seen in borderline patients is often seen as deriving from a constitutional overabundance of the aggressive drive (Kernberg, 1975), it may also derive from actual experiences of disrupted merger and separation beginning in the first year of life with the significant caretaker and coming to a turbulent traumatic crisis in the rapprochement subphase of Mahler's (1968) separation- individuation process. Westen and colleagues (1990a, 1990b) suggest the same view.

Specific Indicators of Narcissistic Pathology Since Kernberg views the borderline disorder as the central disorder of pre- oedipallx.fixated individuals, he views the narcissistic personality disorder and most

BORDERLINE AND NARCISSISTIC DISORDERS 249 havior, such o feel alive or to calm g aspects of t-of-control swings be- borderline ionality, but ntermittent ; in border- priate reac- ¢. Some feel lop further atally influ- area of per- al has basic nd unorga- mitive split- I projective :ion forma. of the pre- is for that :der of pre- e disorder rmal indi- base of the separation he mother

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,er of pre- and most other types of pre-oedipal pathology as a subset of the borderline disorder. Kohut (1971), on the other hand, views narcissistic personality disorder as the central pre- oedipal disorder. Consequently, for him, the borderline disorder is a subset of the narcissistic personality disorder. The characteristics of narcissistic pathology are similar to borderline pathology--difficulty in forming and maintaining relationships, little empathy for others' needs and feelings, grandiosity in unrealistic schemes, exaggerated self-regard, constant demandingness for attention, inappropriate idealization of certain hero figures, and intense envy of others. Extreme almost paranoid-like anger is often expressed, when the narcissistic person feels rejected or even mildly criticized, which is often referred to as exquisite narcissistic vulnerability. Also, there is an emotional aloofness at times and a sense of entitle- ment as the individual feels "splendidly isolated" from the common needs and world of other people. In the T.A.T. or C.A.T. protocols of narcissistically disordered individuals, one would expect to see the pre-oedipal characteristics we outlined earlier in this chapter, but without seeing the predominant borderline features of impulsivity, extreme mood swings, and indicators of fragmentation in storytelling style and content. The narcissistic patient is better organized and more stable. Brelet- Foulard (1986) gives an example of a T.A.T. protocol from an adult male, who sees himself as a hero on a grand theatrical stage putting on a "one-man show" without others, which masks underlying feelings of defectiveness and primary insecurity. The C.A.T. protocol below shows similar dynamics.

C.A.T. Protocol Illustrating Narcissistic Pathology This protocol comes from an 8-year-old boy, very handsome, superb in sports, basically a straight-A student, but whose teacher and parents feel lacks a fundamental sensitivity to other people's feelings. If someone is upset over something, for example, he will appear cold and indifferent. He is a perfectionist in school, insist- ing on getting only straight As, and throwing temper tantrums if he receives any grade that is any less than an A. He is similarly totally intolerant of criticism of any kind and throws temper tantrums when disciplined, criticized, or any time anyone tells him he cannot have something he desires. When he is in one of his bad moods when he feels rejected or unappreciated, he is extremely disrespectful of others, calls them bad names, and says he does not want any part of them ever in his life anymore. At such times, it would appear that he projects outward onto others his own degraded self-image. The parents reported that most people who meet him at first fall in love with him due to his good looks, seeming outgoing and friendly personality, and lively vitality, but then can neither understand his temper outbursts nor his lack of feeling for them and others. This results in his currently not having even one close friend. 1: Sometime, in a little cabin, there are three birds eating their breakfast and a big, big shadow of a hen. And then?And then Babe Ruth came along and asked them if they'd pinch run for him in the World Series. And they said, "Yes." And then it was the World Series and they were pinch running. But they didn't know how to do it. And they got out. Is that the end?Yes.

250 CHAPTER 12 Primitive splitting is suggested by the juxtaposition of the "little cabin" and the "big, big shadow of a hen." Lack of genuine, object-related with others is suggested by his referring to the larger figure as a "shadow of a hen," rather than speaking of this as a real mother chicken interacting with her children that most children his age tend to see on this card. A hypothesis is that he may experience his own mother as "shadowy," rather than being a real, concrete object with whom he can realistically interact. Grandiosity enters in his bringing in a famous baseball player, the legendary Babe Ruth, whom he has asking the little child figures of the baby chicks to substitute run for him, which is a grandiose wish for the little child figures to be able to do what a big baseball hero does, but even more so, he has them run instead of Babe Ruth doing the running. Defensively, this represents an omnipotent denial of the reality limitations of what a child can and cannot do. At the end, he reasserts reality-testing by saying that when it came to the World Series, the chicks didn't know how to pinch run for Babe Ruth, so they got out. 2: Once in the woods three bears were having a big tug-of-war and it was two against one. It seemed as if the person who only has two was winning. Although, the person, the two bears did fall in the mud. And that ended it. Who were they, the different bears? What were they like? Two very wimpy bears. They're all men bears. Some difficulty in object-related interaction may be suggested by the vagueness again in this story about the different animals in the picture. The phrase "the person who only has two was winning" may suggest a lack of self-object differentiation and a wish to be symbiotically merged with another, in this case the picture shows a child with a parent figure on one side of the rope. When asked to identify the bears, he says the two are 'ery wimpy bears," but then adds that "they're all men bears." This may point to some underlying feelings of low self-esteem, which was first expressed in the first story of the little chicks, who blow their first big chance to participate in the World Series. Here they end up falling in the mud. 3: Once in a house, there was a house and there was a chair with an old lion in it smok- ing his pipe with a TV watching the World Series in 1986 (laughs). And then ? Then he smokes his pipe so much that he starts to cough so he can't see a baseball game. So he falls to the floor, saying, "Hmm. This smells (laughs)." This protocol was istered in June of 1989, three years after the New York Mets team had won the World Series in 1986. Usually, this card brings out the interaction of the little mouse looking and interacting with the lion. In his story, he perseverates on the theme of baseball's World Series, which has now come into each of his first three stories. The fact that the mouse is not mentioned and that the lion is "watching TV" may continue to express the sense that this boy feels aloof, on the sidelines of the world of others, merely an onlooker, rather than a true, object- related participant. This may also suggest that he does not experience much genuine iny,olvement in his interaction with his own father. Primitive splitting is again suggested by the juxtaposition of the World Series theme with the old man, who

BORDERLINE AND NARCISSISTIC DISORDERS 251 a" and others .r than .t most ice his om he seball of the .' child ae has nts an do. At Series, against he two ere they ¢ague- e "the 'entia- icture entify 're all ¢¢hich st big td. smok- aaokes to the York ae in- y, he into it the if, on ject- !gen- igain l who smokes, can't see the TV, and ends by falling on the floor. The defense mechanism of reversal of affect is indicated by his laughing as he says that the old lion falls to the floor. So far, a distinct dynamic is his inner sense of low selfesteem, inability to do things successfully and to win, which he tries to defend against with omnipotent, grandiose denial, reversal of affect, and perhaps by keeping a distance from true emotional involvement with others. 4: God, this is hard. Once there were three kangaroos. One on her tricycle, one Mom bouncing, and one kangaroo in the Mom's pouch, and looks as though they're going on a picnic and here comes a house with its fire going and trees. Happen? They're going to eat their picnic food. The opening "God, this is hard" suggest further feelings of personal inadequacy to which he may want to appeal for help to the omnipotent God. The figures in the picture get their oral needs met, since they are said to "eat their picnic food." But nothing else is given to this card. He is not able to go much beyond this simple description of the picture itself, which may again suggest some conflict with his own mother around whether or not he feels he can genuinely interact with her beyond the level of narcissistic need satisfaction of simply getting fed by her. 5: Once there was a house with two baby bears sleeping in a bed and the house had three windows, one giant bed, a night table with a lamp on it, and a staircase leading down to the door. Anything happen next? Through the night, a mysterious killer comes into their room wanting to kill them. But then the baby says, "I'm Superman!!! (he stands up yelling this out). He chops off the killer's head, and that was the end of Dan Quayle (laughs). With this story, he brings in the idea that he may experience the world as suddenly and unpredictably threatening to him, threatening him with total annihila- tion in fact. He defends against the dangerous intruder with omnipotent, grandiose denial by having the baby jump up to turn into Superman. Superman kills the threatening killer, which he then turns into the current Vice President of the United States under George Bush, Dan Quayle, whom at the time of this C.A.T. was the butt of many jokes due to Quayle's apparent lack of competence. Therefore, this reiterates this boy's predominant dynamic of feeling basically inadequate underneath a cover of apparent good looks and seeming competence (one view of Dan Quayle). 6: Once in a cave there were one big bear and one little bear. There were lots of leaves in there. And suddenly came along a lion trying to rob all their money. So then the boy bear woke up and said, "Hey, you trying to steal my money?" So then the lion said, %Yell, you make a good point there. But I still want your money." So then there was a big fight. But then the lion, he whipped her butt. And that was the end. And then Little Bear said, "What you do to Big Bear?" And then the lion said, "Oh, I just chopped off her butt." He now begins this story by leaving out the third bear, which is often characteristic of pre-oedipally fixated, individuals--they tend to see their interperso-

252 CHAPTER 12 nal object relations as dyadic (mother/child), rather than the triadic (father/ mother/child) relations of neurotic level individuals. That he feels threatened by others is suggested by the lion that comes along to rob them. The mother bear seems to take charge and tell the lion not to steal their money, but to go and get his own money. The lion seems to acquiesce by swing, "You make a good point there," but reiterates his threat to take the money. So the mother bear now threatens to kill the lion, who ends by beating up and killing the nother. He seems to see his parents as basically ineffectual against internal and external threats and he feels basically unprotected. Defensive reversal of affect is again seen in the lion responding to the father's opening retaliatory threat with "You make a good point there." 7: Once in a jungle there was a big tiger trying to kill a monkey. There were lots of vines and trees in this jungle and the monkey was trying to escape. But the tiger was too fast and ate up the monkey. To this card showing a clearly threatening tiger, he can give only a short story where the monkey tries to escape, but ends getting eaten up by the tiger. This is further expression of the theme of feeling unprotected against an externally threatening world. 8: Once in a house with all monkeys, there was a picture of a monkey. And all the monkeys were sitting on a sofa and on a chair. And one was standing with what looks like an aunt monkey teaching him a lesson and two were drinking tea. And one was wearing a flower in her hair, one was wearing earrings and the monkey standing looks like he was going outside to play baseball. What happens next? Right when he was going outside to play baseball... um... he ran into... George Steinbrenner (at the time of this C.A.T., he was the owner of the New York Yankees baseball team, which had not done very well for several seasons). So he told George Steinbrenner, "Get lost, or else you're in trouble." So then George Steinbrenner said, "I can play baseball better than you!" So the monkey said, "Oh yeh! What about your stupid Yankees? How do you teach THEM to play?" kind then George Steinbrenner says, "You make a point there. You're right. I do stink." Is that the end? Yeh. On this card, he seems to recover and to bring back his defenses of intellectualization (listing all the figures and describing the details in the picture), isolation of affect (suggested by speaking of the "picture of a monkey" as if to distance himself from emotional interaction like the "shadow of a hen" in card 1), reversal of affect (the joking about George Steinbrenner), and identification with aggressor (George Steinbrenner tries to intimidate the child monkey, so the child monkey humiliates George Steinbrenner). Again the dynamic seems to be a famous individual who is supposed to have a lot of power, but whose competence underneath is shaky at best. Card 5 had Vice President Dan Quayle, this one has the former owner of the Yankees, George Steinbrenner, who often publicly acted very tough and controlling, yet never seemed to get his team to win on a very high level. 9: Hmm. Once in a house there was a room. Door slightly, ! mean with a door opened with windows with curtains, and a mirror, and a night table, and a rabbit in the bed going to sleep. Happen? Um. . . She's going to dream that she's in rabbit land hopping, hopping, hopping. But here% a strange part of the story. Suddenly, her boss comes and says, "What you

iadic (father/ threatened by mother bear go and get his [ point there," treatens to kill to see his par- l he feels basi- !n responding at there." ,ere lots of vines as too fast and g a short stoW ter. This is fur- ernally threatmd all the mon- oks like an aunt ring a flower in s going outside ay baseball . . . was the owner veral seasons). b then George :"Oh yeh! What I then George he end ? Yeh. ies of intellec- picture), isola- if to distance :d 1), reversal ith aggressor child monkey famous indi- e underneath as the former ed very tough gh level. a door opened ae bed going to ,ping, hopping, says, 'Vghat you BORDERLINE AND NARCISSISTIC DISORDERS 253 doing here?" Although her boss was a big fat guy, he didn't know how to do anything. He was just a lazy bum. So she just goes hopping along and she runs into an ice cream shop. So she buys ice cream and she tries to eat it. But instead of it melting, it melts her, and that's the end (laughs). C0rtnent This powerful dynamic of underlying feelings of inadequacy beneath a cover of boastful grandiosity is again repeated in the figure of the lazy bum boss, who "although her boss was a big fat guy, he didn't know how to do anything." Underlying fearfulness is also expressed by the beginning of the door opening, while the child rabbit is going to sleep. While the boss who seems to threaten the child rabbit at first is ultimately seen as harmless, the child rabbit ends up melting away after eating an ice cream cone. Reversal of affect is again employed to defend against this unfortunate ending of the child rabbit, whose food seems to do her in in the end. This could again express a feeling that his mother and the nurturance she gives to him seems like a good dessert, but is cold and annihilating in the end. 10: Once up in a bathroom (laughs) there was two puppies. One looks like he wanted to go to the bathroom. And the other looks like he wanted to keep the other one from going to the bathroom. So it looks like she wanted to cut his toe nail. But it wasn't that, she just had to go to the bathroom, too. Is that the end?Yes. The more common story to this card is of a child dog doing something wrong, such as drinking from the toilet bowl, so the parent dog gives it a spanking. To this scene, he instead leaves out the spanking, which may be an attempt to deny the punitive side of his mother that he seems to have expressed in other stories, particularly the previous one. He may wish to distance himself from this, so he changes it to the mother looking like she wanted to cut his toe nails, "but it wasn't that, she just had to go to the bathroom, too." It may look like the mother is punishing (or to him castrating), but she just wants to go to the bathroom as the child wants to keep the mother from going to the bathroom. Perhaps he sees himself and his mother or parents as in competition with each other over basic needs. Summary The overall picture is of a child with narcissistic pathology, who seems to feel very inadequate, unnurtured, unprotected, and threatened by a hostile and cold world. In such a world, people do not seem to be loving to each other and he does not appear to receive any genuine help and care from anyone. Other people threaten, boast, intimidate, and seem to give him unrealistic things to do that he feels totally inadequate attempting, such as Babe Ruth asking the baby chicks to pinch run for him in the World Series. In this type of world, everyone--the adult and the child figures--all seem to end up failing, falling in the mud, or melting away like cold ice cream. As Kohut (1971, 1977, 1984) pointed out, the narcissistic individual feels cold, isolated, criticized, unloved, incompetent, and highly vulnerable to attack from others underneath. The main defense against these inferior feelings is to erect an omnipotent grandiose sell=to use as a cover and to remain splendidly isolated from

54 CHAPTER others as if one does not have any need for anyone else. This child employs either fantasy omnipotent figures like Superman, real heroes like Babe Ruth, or real personnages like Dan Quayle or George Steinbrenner who have the veneer of power and success but who are not very successful and competent at what they are trying to do in actuality. While outgoing, lively, a straight-A student, and very handsome, this boy underneath feels rejected and empty. He seems to picture his parents as seemingly ineffectual, unprotecting, and unnurturing in any real way to him. There seems to be little differentiation of other people in his world, people are not distinct individuals with clear identities, but are shadowy, vague, caricatur- ish, and exaggerated characterizations, who strut about with large and noisy gestures but who basically seem dead inside. This child's C.A.T. is very similar to the dream ofa narcissistically disordered adult described in Kohut (1984, pp. 17-18) in which an individual is inside a cold, icy heart and attempts to appeal to a shadowy figure for help, but to no avail. It is also reminiscent of Shakespeare (Macbeth, Act V, Scene V): Life's but a walking shadow: a poor player, That struts and frets his hour upon the stage, And then is heard no more: it is a tale Told by an idiot, full of sound and fury, Signifying nothing. The T.A.T. protocol on pages 138-151 of a depressed man with significant narcissistic pathology shows many of the same above features.

ild employs be Ruth, or e veneer of hat they are t very hand- .ure his par- real way to rld, people e, caricatur- d noisy ges- milar to the p. 17-18) in o a shadowy Macbeth, Act h significant

CHAPTER 13

THE T.A.T., C.A.T., AND S.A.T. IN NEUROPSYCHOLOGICakL ASSESSMENT Some General Remarks on Neuropsychological Assessment An early view in psychological testing was that only intelligence and achievement tests measure cognitive functioning and only projective tests measure personality. When neurophysiological dysfunction was addressed, the Bender Gestalt was usually the only test examined, many psychological reports being limited to such single, general, and vague statements as "Organicity is evidenced (or ruled out) by the Bender." However, with the advances of biological psychiatry (Bellak, 1979; Rutter, 1983; Wender & Klein, 1981), learning disability assessment (Bakker & Satz, 1970; Golden, 1978; Hynd & Cohen, 1983; Kirk, 1983; Knights & Bakker, 1976; Pirozzolo, 1979), and neuropsychology (Golden, 1979; Heilman & Valenstein, 1985; Herron, 1980; Kolb & Whishaw, 1980; Luria, 1973; Rourke et al., 1983; Russell et al., 1970), signs of possible organicity in perceptual, auditory, motor, language, verbal reasoning, and other domains were assessed across the entire range of tests in the psychological test battery. The Bender Gestalt test is now understood as one of the tests in the overall battery that specifically measures perceptual-motor functioning and its subdomains of directionality, left-right orientation, perceptual attention to small details, visual tracking and distractibility, perception of and short-term memory for visual gestalts to rule out apperceptive agnosia, and fine-motor integration. Signs of perceptual-motor dysfunction on the Bender are then compared with signs of similar dysfunction in the perceptual- motor subtests of the Wechsler Performance Scale, the Beery Test of Visual Integration, the Benton Test of Visual Retention, handwriting from a handwriting sample and on the spelling test of the Wide Range Achievement Test-Revised, and projective drawings. The overall result is a more specific, more finely tuned, and more comprehensive approach to psychological testing, so that, today, personality characteristics are also assessed on intelligence tests (Rapaport et al., 1970; Rothstein et al., 1988; Santostefano, 1978; Zimmerman and WooSam, 1973) and on the Bender (Brown, 1965; Hutt, 1969). Cognitive, neuropsychological characteristics are also beginning to be assessed on the projective tests of drawings, the Rorschach, and the T.A.T. (Costantino et al., 1991; Johnson, 1994; Lezak, 1983; Rothstein et al., 1988). ' 255

256 CHAPTER 13 This chapter is a beginning sketch toward considering how neuropsychological characteristics may be expressed on the T.A.T., C.A.T., and S.A.T. After discussing Lezak's (1983) list of neuropsychological indicators on the T.A.T. and adding items from our own clinical experience, we will present two stories of a child and adult case with attention deficit disorder (ADD) as an illustration of a neuropsychological syndrome commonly seen in school and patient populations that was earlier referred to as minimal brain dysfunction (Bellak, 1979, 1985, 1994). Since research on the cognitive structuring of narrative organization in thematic tests does not yet have as extensive a history as form level and other structure scoring on the Rorschach, this chapter should be considered a beginning sketch for future research in this exciting new area of possible neuropsychological dimensions on the T.A.T. Since the first publication of this chapter in the fourth edition of 1986, there have been some studies of neuropsychological indicators on thematic tests that the list ot: indicators enumerated here. For example, Costantino and colleagues (1991) found that attention deficit disorder children tend to have more omissions of characters, objects, and events on the TEMAS, a chromatic apperception test for children, than their control group, and Johnson (1994) reports that Mzheimer patients tend to have a smaller number of words and to lose the in- structional set. In a comprehensive psychological testing assessment, the clinician looks to corroborate signs of difficulty on one test from signs of similar difficulty on as many other tests as possible. For example, an aggressively suicidal individual may see cut- off heads and wrists on the Rorschach; draw unattached heads and hands on human figure drawings; draw Bender designs very large with hard line pressure; and on Wechsler intelligence subtests have difficulty with the fragmentation of Object Assembly and Block Design (and perhaps also with the bright red color of the block design), with the missing elements of Picture Completion, and respond with suicidal ideation to Vocabulary subtest words and Comprehension subtest questions as if they were stimulus items on a word association or sentence completion personality test. Similarly, an individual with the neuropsychological syndrome of ADD typically shows difficulty on Wechsler intelligence subtests measuring attention to small details (Picture Completion, Coding or Digit Symbol, Arithmetic, and Digit Span), visual tracking distractibility (Mazes), and part-to-whole integration of visual-motor gestalts (Object Assembly and Block Design). Scores on timed subtests are often lower than those on untimed subtests due to the distractibility and lack of sustained and efficient focusing and attention. The Bender and projective drawings often show a lack of integration of fine details, difficulty with representing geometric shapes and perspective, and maintaining the size and spacing consistency of Bender designs 1, 2, 3, and 5. Left-right orientation difficulty is often seen in shape rotations on the Bender and in wobbly or leaning house, tree, and human figure drawings, which may also lack secure baselines. The difficulty in perceptual synthesis on the Wechsler Object Assembly and Block Design subtests is commonly corroborated by a significant inability to provide well-integrated Whole (W) responses differentiated into an adequate number of small details (Hd, Ad, d) on the Rorschach. Without a comprehensive assessment approach, it would be easy to mis-

T.A.T., C.A.T., & S.A.T. IN NEUROPSYCHOLOGICAL ASSESSMENT 257 )w neuropsychologi- md S.A.T. After dis- , on the T.A.T. and two stories of a child llustration of a neu- ent populations that .979, 1985, 1994). organization in the- :1 and other structure beginning sketch for hological dimensions :he fourth edition of tdicators on thematic example, Costantino :hildren tend to have MAS, a chromatic ap- ,hnson (1994) reports rds and to lose the in'the clinician looks to r difficulty on as many ndividual may see cut- ads and hands on hu- ard line pressure; and gmentation of Object red color of the block nd respond with suici- m subtest questions as completion personalbrndrome of ADD typi- tring attention to small netic, and Digit Span), ration of visual-motor led subtests are often and lack of sustained )jective drawings often epresenting geometric pacing consistency of y is often seen in shape :ree, and human figure ty in perceptual synthe- atests is commonly cor- d Whole (W) responses (Hd, Ad, d) on the it would be easy to misdiagnose the relative lack of integrated Whole responses and the sudden breakthrough of sexual and aggressive associations in the Rorschachs of ADD individuals-as if these individuals are more emotionally disturbed than they are in reality-- rather than seeing them as predominantly suffering from a physical condition chiefly characterized by attentional, impulsive, and perceptual synthesis difficulties. Just as perceptual form level (F score) is assessed on the Rorschach, the clinician can also gain a sense of form level on the T.A.T. by considering the degree to which each stoW has a well-connected beginning, middle, and end; a narrative consistency of one or two central characters; a logical organization of action sequences; language fluency; attention to salient details in the pictures; and appropriate grammatical usage. In a series of developmental studies of children's narrative competence, Sutton-Smith and colleagues (1981) investigated similar cognitive dimensions of story creating adapting scoring schemes from language development, Piaget's (1932) operations of logical thinking, literary criticism, and contemporary structural linguistics, which are most applicable towards a cognitive, neuropsychological assessment of the T.A.T. In an attempt to coordinate psychodynamic and neuropsychological assessment, Rothstein and colleagues (1988) pointed out that the T.A.T. is useful, neuropsychologically, as a way to obtain a sample of spontaneous language with which the clinician can assess such language dysfunctions as aphasia, dysnomia, aggramatism, and disordered syntax. It is also useful to ask a patient to write out one T.A.T. or C.A.T. card in order to obtain a sample of written language that can be checked for the presence of grammatical, spelling, and other language difficulties (Walter Kass, personal communication). Identifying Features of Neuropsychological Deficit in the T.A.T. and CA.T. Responses In a popular text on neuropsychological diagnosis, Lezak (1983) pointed out that "stories composed by brain injured patients possess the same response quali- fies that characterize organic Rorschach protocols." Following Piotrowski (1937) and Fogel (1967), Lezak lists the following characteristics: 1. Use of fewer words and ideas in relating stories. (Piotrowski [1937] calls this low R [low number of Rorschach responses]for the Rorschach test.) 2. Response times may be longer with several punctuating pauses (Piotrowski's T [response time] on Rorschach test). 3. Concrete description of the picture, rather than a free fantasy elaboration of one's own. Simple listing of items in the picture, such as table, chair, window, violin, and so on. (similar to Color Naming, Cn, on Rorschach.) 4. Tendency to provide a story that is trite with few characters and little action. (Piotrowski [1937] notes less M [less movement responses, M for Human Movement, FM for Animal Movement, and m for movement of inanimate objects] .) 5. Presence of confusion, misinterpretations of items in the pictures, and confusion in the stoW theme (similar to Piotrowski's finding a low form IF] level

258 CHAPTER 13 in the majority of Rorschach responses of those neurologically compro- mised). 6. Brain-damaged patients tend to give a few of the most common themes (few Popular [P] responses on Rorschach). 7. Perseveration of theme on several T.A.T. cards (Piotrowski's Rpt on Rorschach). 8. Automatic repetition of certain phrases or words (AP on Rorschach). 9. Inability to change an unsatisfactory response (Imp on Rorschach). ll). Expressions of self-doubt (Plx on Rorschach). 11. Inflexibility, concrete responses, catastrophic reactions, and difficulties in dealing with the picture as a whole. To a lesser extent, individuals with attention deficit disorder or specific language influencing learning disabilities will also tend to show this constellation of characteristics in C.A.T. and T.A.T. stories. The senior author has long noted the failure to recognize the violin in a small subset of individuals on picture 1 of the T.A.T. A study by Chamson (1983) suggested that this is one of the most reliable indicators of ADD in the T.A.T. She compared 49 high school students classified as emotionally impaired. She istered the T.A.T. and visual contrast sensitivity tests. Fifteen percent of the A.D.D. population failed to see the violin, while none of the emotionally disturbed group misperceived it. The visual contrast sensitivity test yielded significant differences at the .01 level. It would also be constructive to compare these disorders with story form items of the Communication Deviance Scheme (see pages 86-87). To the preceding list, we can also add the following additional characteristics from our own clinical experience: 1. Failing to report an obvious object in a picture that tends to be salient and organizing to most individuals without neuropsychological disorders (such as not mentioning the violin in T.A.T. card 1). This contrasts with the more psychogenic selective inattention, such as a child not mentioning that the dog is "spanking" the puppy on C.A.T. card 10, because of a desire to deny this perception out of one's own psychological conflicts around being punished. The individual with neurological dysfunction misses salient objects due to a deficit in attention and perceptual discrimination capacity. This can be measured specifically on the Bellak Scoring System in of noting the number of omissions of central and secondary characters. 2. Tendency to report a stereotyped story one has heard, read in a book, or seen on television, such as trying to turn C.A.T. card 1 into "Goldilocks and the Three Bears" or C.A.T. card 3 into "Old King Cole" or relating a movie plot to T.A.T. cards (similar to exclusive use of Popular [P] responses on Rorschach). 3. Inability to stick with one central character throughout. Individual may shift the story from being about one character, then change it to revolve around someone else. Children with attention deficit disorder tend to shift the C.A.T. story from being about a bear, to being about a lion, and the like, change the sex of the hero (he, she, he, etc.), and frequently change pronouns from he, it, us, you, and so on. This is also tbund on Rorschach content responses and is similar to the shift-

T.A.T., C.A.T., & S.A.T. IN NEUROPSYCHOLOGICAL ASSESSMENT 259 compro- emes (few Rpt on a). ficulties in pecific lan- tellation of i noted the re 1 of the reliable in- ;lassified as ,,t sensitivity vhile none it sensitivity istructive to h Deviance racteristics salient and such as not )sychogenic anking" the 3ut of one's :h neurolog- [ perceptual llak Scoring )ndary charn a book, or cks and the iovie plot to chach). lividual may dve around C.A.T. story he sex of the us, you, and r to the shifting, distracted level of attention of these individuals in academic settings and in social interaction with others. Their minds seem to wander and not to focus and remain sustained. 4. Inability to develop a parallel plot ("Meanwhile, back at the ranch .... "). The ability to do this requires keeping one idea in the back of one's mind, while relating another idea, and then coordinating the two ideas together in a logical, integrated manner. A high development of this is seen in Russian novels or in the so- called family sagas of popular American literature. 5. Tendency not to bring the story to an ending, to a logical conclusion. The story, in effect, is left hanging. This is seen in ADD children's tendencies not to finish things they start in school, not to finish homework, and so on, and in the tendency of adults with ADD to frequently change jobs. 6. Breakthrough of primitive sexual and aggressive comments and ideas (similar to direct mention of "blood" to the perception of red color or the naming of shapes as sexual objects on the Rorschach). Without a developed synthetic function of coordinated, integrated perception, and of a level of organized repression, such individuals are very open to the sudden intrusion of very direct sexual and aggressive feelings and associations being immediate expressed. This is considered to be an ego function in psychoanalytic personality theory, which may also be influenced by physiological deficits in the capacity to form perceptions into meaningful gestalts mediated by the visual and brain functions. 7. Frequency of impulsive actions by characters in stories, which could also be described as characters engaged in acting-out behavior, such as spitting, kicking, hitting, biting, urinating, defecating, and so on. This is seen in ADD children's tendencies to be impulsive, to have outbursts, and to lash out suddenly at those bothering them. 8. Characters in the story do not appear to plan, prepare, or anticipate in advance of action. They do not think before acting. There is an absence of asking someone for advice, looking at a map, or reading a book to prepare for a future action. Characters simply act and react. 9. Noticeable lack of a coordinated action sequence. The Fogel and Lezak list speaks of little action. Here, we stress the absence of a chain of first one action, then another related action, then another, and on to a logical conclusion. Preschoolers typically give stories of one or two actions, elementary school children will provide a series of actions, and early adolescents may add a parallel action. Braindamaged individuals or those with ADD or significant learning disabilities tend to give stories of no action, only a single action mentioned, or at the most, two actions. 10. One character may be described as dependent on another, clinging to another, or calling for help. This is due to need of such individuals for another person as a monitor of their impulsivity and as a guide to do what they feel they cannot do. Psychoanalytic theory calls this a need for an auxiliary ego. Separation anxiety may be present for this similar need (for an auxiliary ego) as a "container" of the individual's own impulsivity as well as for basic dependency behavior encouraged by a parent or due to the individual modeling dependency after a parent who is dependent. ,

260 CHAPTER 13 11. Characters in stories described as trying to learn, trying to do things, but failing to do so successfully may reflect some aspect of ADD Adults on the T.A.T. card 1 may tell of a story about a boy trying to learn to play a violin, but after trying, he gives up, or fails to learn it. Within the stories, there may be an expression of a character having frequent accidents or falls, which is typical of ADD individuals with hyperactivity and intense impulsivity. Another frequent theme within a story is getting lost and being lost, something they often experience in life when trying to follow directions for driving somewhere. This involves their difficulty in paying attention to the one who gave them directions, paying attention to the road, and spatial difficulties in discriminating left from right, up from down. 12. Relative absence of characters working together in groups in a story. Generally, the action involves one or two. This is like the phases of early childhood play starting with solitary play, going to parallel play or imitating play (one child imitates what another does), going to turn taking (tag), and moving up to Cowboys and Indians, or Space Creatures, or the like. Individuals with serious neurophysiological deficits or disorders have difficulty organizing in groups, as they do planning in advance or even organizing their everyday routines. 13. Sudden outbursts of impulsivity in some individuals may be expressed in their thematic apperception stories as an action occurring quickly without warning. Children use suddenly or all of a sudden in their stories, while adults may have a character coming up from behind and startling another, as in story 6GF. 14. Individuals with hyperactive impulsivity may symbolize their need for a container of their feelings of sudden outbursts, wild abandon, and restless energy by story themes of a character returning home to his or her "house," returning to "mother," or drawing a "boundary line" or "frontier line" (lines that protect and "bound" one group of people from another). The idea of keeping American Indians on a reservation or poverty-stricken minority people in ghettoes, or nuclear power plants in rural, unpopulated areas simply may symbolize a need to keep wild impulses localized, structured, and safely contained. Keeping the dead in coffins buried in the earth is another symbolization of the need for a container for fears in some individuals' projective stories. 15. Left-right orientation difficulty in some individuals may be expressed by tending to report an object on the right side of a C.A.T. or T.A.T. picture as being on the left side or vice versa.1 The first T.A.T. (card 1) from an adult with significant ADD shows some of these above characteristics: Once upon a time there was a little boy about 8 years old looking at something. Looks like a picture. But while he was looking, he was wondering about the future, more or less contemplating what the future would be like for him. He pictured himself having a family like the one he was in and since he was happy now, he figured he would always be happy. He was waiting to eat dinner one night, that's when he was looking at the picture of himself, his sister, and parents, and his dog. And as he was looking, he was thinking how happy he was and visualizing he would have the same kind of family himself. And as he was drifting off, his The authors are indebted'to Dr. Perry Faithorn of New York, N, for this valuable observation.

) things, but ,n the T.A.T. but after try- n expression DD individu- me within a life when try- 5culty in pay- to the road, 3. s in a story. rly childhood lone child im- p to Cowboys neurophysio- y do planning expressed in :bout warning. ay have a chareir need for a restless energy :," returning to tat protect and ?ing American Ioes, or nuclear ed to keep wild lead in coffins lner for fears in )e expressed by )ictnre as being shows some of something. Looks ,,, more or less con- aving a family like be happy. He was of himself, his sis- happy he was and as drifting off, his observation.

T.A.T., C.A.T., & S.A.T. IN NEUROPS¥CHOLOGICAL ASSESSMENT 261 mother called him and said dinner was ready, and this sudden burst of reality snapped him out of the thoughts he was having. Do you want to know my hidden thoughts? It reminds me of myself of when I was younger, dreams I had. But the mother calling is a good thing, snapping me into real- it-/. Just being called for dinner is nothing bad in itself, but just a symbol of accepting reality. Here, we see the tendency to wander offin thought, to become distracted. His mother snaps him back to reality, but he totally missed the object of the violin, which is generally a most salient, organizing object for most individuals for T.A.T. card 1. His mind drifts from the future to the past to the future, so that he is not grounded in the present reality. Teachers often describe such children as "in outer space," as never paying attention to what the teacher is trying to teach. While the story is long for an adult with ADD, we note that there are only two actions---looking at the picture and then hearing his mother call him to dinner. The action is not well coordinated and the subject fails to provide a logical ending to the story. There are few characters, only the boy and his mother, and the relationship seems to be one of dependency of the boy on the mother. The first action is really a description of the picture, which is repetitiously described for a long time until the second action of the mother calling him is introduced. There is very little action taking place in this T.A.T. story. Psychodynamically, we can speculate that while the mother of this adult may want to snap the individual into accepting reality and dealing better in the real world of everyday life, it is to come to dinner that is demanded, which could also express the mother's underlying desire to keep this adult dependent on her. (This adult, over age 34, lives at home.) ADD In Children Hyperactivity, impulsivity, and inattention in children has been widespread and was earlier described as "minimal brain damage" or "minimal brain dysfunction" (MBD). It is now referred to in the current Diagnostic and Statistical Manual of Mental Disorders of the American Psychiatry Association as "attention deficit disorder" (ADD), which is either 'With hyperactivity" or "without hyperactivity." The typical symptoms are inattention (failing to finish things the person starts to do, seeming not to listen, becoming easily distracted, and not sticking to a play activity); impulsivity (acting before thinking, shifting excessively from one activity to another, not organizing work, needing a lot of supervision or for the teacher to be right next to the child when working, frequently calling out in class, and difficulty awaiting one's turn in games and group situations); and hyperactivity (running about or climbing on things excessively, difficulty sitting still or fidgeting excessively, difficulty staying seated, moving about excessively during sleep, and being always "on the go" as if "driven by a motor"). Boys are 10 times more apt to have this disorder than girls. Psychological testing usually looks for significant difference between nonverbal, perceptual-motor tests and the verbal tests that are typically much higher. The Wechsler Performance Scale IQ is usually 10 or more points lower than the Verbal Scale IQ and the Bender-Gestalt test ually has numerous errors of shape rotation, shape distortion,

262 CHAPTER 13 perseveration, overlaps, figure integration, and size consistency difficulty. These are all signs of both spatial, visual problems, difficulty in integration of visual and motor functioning, inattention, and impulsivity. Spatial integration difficulty can also be seen on the Rorschach in the failure to provide many Whole (W) gestalt responses with good differentiation into many details (Hd, Ad, d). Typically, the responses are not whole-object, but part-object responses. The subject sees the inkblot not as a whole gestalt (W), but as a part (D). Color Naming (Cn) is both a sign of concrete description of the inkblot picture and a sign of impulsivity. Projective drawings also have few details, poor integration of the details into organized wholes, and may also have poor perspective. The C.A.T. and T.A.T. are highly useful in further corroborating the diagnosis of A.D.D. by looking for some of the 26 characteristics listed at the beginning of the chapter. C.A.T. Protocol Illustrating Attention Deficit Disorder Lisa, age 6 years 9 months, was referred for testing due to school adjustment difficulties and hyperactivity. She has a poor attention span, is frequently switching her seat in class, and functions below grade level. Among several tests istered, the C.A.T. revealed the following: CA.T. Protocol Card 1: Once upon a time there were three chicks eating porridge.Anything else? They were talking about their porridge, too. They said, "My porridge is too, too cold." (I repeat request for a "make pretend" story of her own, not something she heard, saw on TV, or read in a book). I don't have imagination. Anything happen next in the storyyou started?I don't know. Only how it goes in the story. Comment We see here lack of self-esteem in the comments, "I don't have imagination" and "I don't know." Tendency to give stereotype story she's heard or seen and tendency to describe in concrete only what is seen by her in the picture on the card are evident. Talking about their porridge suggests some ability to go beyond action itself and the idea of the porridge being too cold suggests feelings of being rejected or deprived. Card 2: I know this one--"Goldilocks and the Three Bears." (I again explained the nature of the test, the direction to provide one's own fantasy from your own mind, your own imagination, a make-pretend story, pretend the picture you see is part of a bigger story you make up yourself, etc.) I can't think of anything. They're trying to, if somebody falls down the hill, the second one gets to win. They fall down and they hurt theirself. Again we see the tendency to provide a stereotype tale and perhaps difficulity paying attention to the direction I gave her, as ADD children have difficulity paying attention to teachers irl, school. Low self-esteem is repeated in her comment "I

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T.A.T., C.A.T., & S.A.T. IN NEUROPSYCHOLOGICAL ASSESSMENT 263 can't think of anything." But then she manages to elaborate a fantasy of her own, which brings in a theme of trying to do things and failing (also her experience in school) and the theme of accident proneness (falling and getting hurt). There is also the theme of a chain reaction, if one falls down, the second one gets to win (is she the older of two siblings wherein she feels the younger, second born gets to win when she fails?), but at the end, "They fall down the hill and they hurt theirself." Presumably they all end falling down getting hurt. This could also suggest her perception of a divorce, since card 2 is often seen by children of separation and divorce as a struggle, tug-of-war between the two parents in which the child is asked to take sides. If so, does Lisa feel that when one parent left, the other won custody, but they all ended up losing? These are questions that could be explored in psychotherapy or verified from the social history. The C.A.T., like a dream, provides a way for children to express their feelings about their lives and then a way for us to hypothesize about what their feelings and perceptions might be about their lives. Card 3: I don't know any of these. It's a lion, but I can't even talk about it. But he was make pretending he was Old King Cole... What happens next?I don't see Old King Cole on TV. I imagine it is on the TV. And he called for his pipe and his bowl to eat and three fid- dlers. He has a cane, too There's a mice in the wall. Nothing else in the wall, either. Flowers are on the rug, too Anything happen there? I don't know. The mice is traveling around in the wall, putting his head out and back in, out and back in, back out and in again and again. She again brings in a stereotyped story and describes the details of the picture before her. When she notices the mouse, she perseverates, the mouse coming out, going in, out, in, over and over, suggesting the perseverative, driven, repetitive actions typical of ADD children in life and seen in their C.A.T. stories. It also suggest an approach/avoidance style with regard to fear of a potentially predatory larger animal that could attack the mouse if he stays out. Anxiety and fear also may stimulate the hyperactive, frenetic activity. Instead of being able to tolerate anxiety, she may engage in sudden, impulsive actions over and over in this driven, compulsive manner. Card 4: Two babies, one riding a bike and one in the mother's pouch. The nother's hopping with a picnic basket and pocket book and I see trees... Next? If she looks at her babies, lets go of her picnic basket, lets go of the baby in her pouch, all the food is going to be on the floor and cheese will be rotten. The baby lets go of the balloon and it flies away and the other one rides his bike and crashes into one of the trees there. The mother doesn't want that to happen. She moves aways from a beginning concrete description of the picture before her to provide some action and fantasy elaboration on the theme of letting go (separation of the mother from the children) and letting go of impulses (when the children are deprived of mother's holding and nurturance--food that drops and becomes rotten), the child crashes into a tree (aggressive assault on the tree with also potential for serious harm by Ntting the tree). The fact that she places this letting

264 CHAPTER 13 go in the hypothetical and adds at the end, "The mother doesn't want that to happen," suggests a desire to monitor impulsivity and develop signal anxiety (the ability to anticipate danger in the future), rather than react to danger with sudden panic, frenetic action, primitive impulsive outbursts, and feelings of being totally helpless, totally overwhelmed. Card 5: A bed, two beds, floor, a lamp, windows, curtains are there .... Anything happen next? The rain and the thunder and the lightning broke the window. Nothing else happened. It's making noise in the house by the rain and thunder and everything was wet and the crib was wet, too. Beginning with concrete description of the visual scene in the picture on the card, she moves into a theme of being overwhelmed by external danger. The storm outside intrudes and breaks into the house and overwhelms everything. This is a typical theme in C.A.T. stories of ADD children to experience the enviroment as impulsive and as dangerous as they feel their own feelings to be. On the one hand, this is an externalization of their own impulsivity onto the environment (they are not dangerously aggressive, it is the environment of the weather and big animals and adults that are aggressively threatening to them). On the other hand, this may be part of their actual experience. They act impulsively and the parents aggressively act out, which is modeled by the child in the child's hyperactivity. Usually, it is an interaction between the two participants, parent and child, and the two domains of physiologically increased activity level and that of emotional anxiety, lack of signal function, and lack of adequate defenses. The theme of everything wet at night also suggest the possibility of this child having encopresis, which is often seen in ADD children having very poor impulse control. Card 6: Two mother bears and one momma bear and the other father bear and the baby bear in the cave. They think it's winter. Then the wind blew in the cave and they got chilly... Anything else happen?They had to sleep cuddling together and all that stuff, 'cause it was cold together and all that stuff like I said before. The environment overwhelms again, comes into their home, which is defended against here by dependent clinging. While the previous story shows no defense against being overwhelmed, this story shows a step forward with the defensive coping mechanism of using another person as an auxiliary ego to cling to and to help one with ego control over one's own impulsivity. Separation anxiety is usually intensified in ADD children to some extent by the need for the adult figure as an auxiliary ego to monitor and control their impulsivity. It may also be increased due to the tendency of the parent to be somewhat rejecting of the ADD child. Card 7: One tiger is chasing the monkey. A monkey got afraid. Then the monkey climbed up a tree. But the tiger catched him and killed him.

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