In times past, before people could while away dull evenings at StumbleUpon, they amused themselves in other ways, employing whatever materials were to hand. In the 1890s a Swiss boy by the name of Hermann, the son of a drawing teacher, became intrigued by a then-popular pastime involving paper and ink — so intrigued that he was nicknamed “Inkblot” at school.
Hermann Rorschach grew up to become a psychiatrist. In 1921, the year before his death, he published the psychological diagnostic test based on ink blots that still bears his name.
About halfway between then and now, in 1963, the British child psychotherapist Theodora Alcock published her book The Rorschach in Practice, describing the use of the Rorschach test in psychiatry at that time. She describes the theoretical basis for the test, how to administer and score it, and how to interpret the results. There are several illustrative case studies, and an example of how the test was used in a research study.
To a CBT therapist with much more efficient and clear-cut ways to understand patients the Rorschach test is of little interest, and much of the detail in the book is horribly boring. Some of the descriptions, on the other hand, give a fascinating insight into psychiatry at that time, which was around the time when CBT was first being formulated. It’s these descriptions that I want to share here.
First, though, the basics of the test.
The Rorschach Test
The test involves looking at a standard sequence of ten inkblots printed on separate cards, and describing what you see in them. It is administered one-to-one by a trained tester whose job is to make it easy for you to respond to the blots in whatever way you want, to conduct the test in a highly controlled and standardized way, and to record the results (p. 24):
I use the following form of introduction: ‘What I am going to show you are cards which have got ink blots on them. They are special ones, and they are printed, but that is all they are, ink blots. People see quite different things in them: that is one reason why I write down what you tell me, and afterwards I ask you to tell me if I have got it down right, as you saw it.’
The conduct of the test is very formal, but relaxed. The reason for the formality is so that the results of the test can be compared with standardized results obtained in reseach studies. This is an evidence-based approach with a scientific foundation.
The theory behind the test is firmly psychodynamic, rooted in Sigmund Freud’s theories about the mind and personality. It is that unconscious aspects of your personality influence how you interpret the blots. By analysing the results in a way that can be compared statistically with results obtained from research studies, the test can reveal and characterize psychological disorders.
The test works best if you have not seen the blots before, so I will not show you an actual Rorschach blot here. For example, suppose you are mentally well right now and you look at one of the actual blots. Then in some years’ time you become mentally ill and your psychiatrist uses the Rorschach test to help in understanding your illness. Your memory of seeing the blot here might affect the test result.
Instead, I’ll show you a similar-looking blot that you can play with without affecting any future test result. The Rorschach blots are quite large, and you can click on this one to see a bigger version:
The interpretation of what you see is highly technical. It depends on all the results from all ten standard blots, and several different scoring systems have been developed from Hermann Rorschach’s original system. There is no direct link between what you see and any psychiatric diagnosis. Rather, it’s the overall balance of the types of thing that you see, compared with the overall balance obtained in research studies, that suggests a diagnosis.
The case studies cover a very wide range of disorders, from no disorder at all to incurable chronic psychosis. It’s probably true to say that in those days when psychotherapy was relatively rare, the cases that psychiatrists had to deal with were generally more severe than the average case that a psychotherapist would see today.
It’s clear from the general approach to treating all these patients that the basis of the test, and the basis of psychiatry, is seen as understanding the patient’s mental state, how things are from the patient’s personal point of view. This is quite different from the perception of the psychodynamic approach as a kind of ‘hands-off’ technique in which the patient does the work, and quite similar to the modern CBT approach.
Indeed, for any patient in the middle of therapy, a good question to ask is: “Who’s doing the work?” If you, the patient, are doing all the work in your therapy then it’s not clear what your therapist is getting paid for. In the kind of psychotherapy that this book describes, the therapist is just as much involved in determining the outcome as the patient, just like in modern CBT.
In contrast, the theoretical basis for treatment in the book is based on Freud’s ideas, totally alien to most CBT therapists, though perhaps really describing the same things in different language.
All of the cases presented in the book were followed up for some years after treatment to establish the long-term outcome. Just two of them describe complete recovery, and these are the ones I’ll outline here.
Michael had a scholarship to a grammar school, but his school work deteriorated after just a few months and he had to move to another school (p. 191):
The headmaster of this school, said to be a good judge of his pupils, reported that he found the boy stupid and could not imagine how he had got through a scholarship examination; [Michael] was also antisocial, showing ‘veiled aggression’.
At the age of fourteen, Michael was referred for psychological assessment. A Rorschach test was used, partly to rule out brain damage. The results showed a severe personality disturbance, aspects of which could be traced back to early childhood, with depression and emerging schizophrenia. On the other hand, it was noted that he was very intelligent and made a good relationship with the Rorschach tester. He was referred for psychotherapy.
After six months of psychotherapy two or three times a week, Michael was able to return to the grammar school. Supportive therapy continued for a time after school hours. His case was followed up for some years, and there was no relapse.
Theodora Alcock remarks (p. 203):
His case is, I think, a fair example of other intelligent children who are hampered in the use of education by disturbances of personality, and who can be helped, either by psychotherapy or, in less severe cases, by environmental adjustment, only if the nature of their disturbance is understood.
Although Michael’s therapy was more intense than typical CBT, it is notable that it had dramatic results after only six months. It is also notable that his relationship with the tester was felt to be significant, and that disturbed children in general can be helped only by understanding them. These qualities of the therapy used — the importance of relationship and understanding, and the resulting rapid change — are qualities that modern CBT aims for too.
It is comparatively rare for a psychologist to be asked to carry out a Rorschach on a case of anorexia nervosa. The disorder is a serious one, involving danger of death, so that a psychiatric request to interpret the Rorschach findings with reference to suitability for psychotherapy represents a grave responsibility.
At the age of fourteen Alison had been sent to a private boarding school, but she became depressed, solitary and withdrawn there and returned home. When the local grammar school she subsequently attended arranged a holiday ‘camp’ at a large house in Devon, she began to starve herself. She was treated in hospital, then in a psychiatric nursing home, but her weight continued to fall.
At the Tavistock Clinic in London, Alison took a Rorschach test to assess whether psychotherapy might help her. On the positive side it was noted that Alison had an extreme need for treatment, could work well with symbolism, and got on well with the tester despite being very guarded. On the negative side it was noted that Alison was very depressed, and she was withdrawn to a degree that could indicate the beginnings of psychosis.
After taking the test she was again admitted to a nursing home, where her condition continued to deteriorate. Once again, as in good CBT today, it’s the relationship with a therapist that turned out to be key (p. 146):
On discharge [from the nursing home], Alison told her parents that she wanted to try psychotherapy with the therapist she had seen at the Tavistock Clinic. Treatment was therefore undertaken at the girl’s instigation, and proved unexpectedly successful…
Once again, improvement was dramatic, and Alison was eating normally after just sixteen therapy sessions. Just as in modern CBT, effective treatment back in those days did not drag on for years without results.
Despite some setbacks, Alison had a job and was eating ordinary meals after a year (p. 147):
Two years later she became engaged, and married six months later. The marriage was a happy one.
Which must be about as close as you ever get to “and they all lived happily ever after” in a textbook of psychiatry.