Evaluating Objective and Projective Asessments

SIS J. Proj. Psy. &Ment. Health (2018) 25: 54-59

James M. Stedman, PhD, ABPP, Joshua Essery, PhD, ABPP and Cindy A. McGeary, PhD, ABPP, The University of

Texas Health Science Center at San Antonio, Texas (Corresponding Author: James M. Stedman, PhD ABPP, Department

of Psychiatry, University of Texas Health Science Center, 7703 Floyd Curl Drive, San Antonio, Texas 78229 – 7792,

Email: [email protected], Phone: 210-567-5488, Fax: 210-567-5677).

Keywords: Projective Tests, Rorschach, Thematic Apperception Test, Internship Training, Graduate Clinical Training

Projective Personality Assessment: Evidence for a Decline in Training Emphasis

James M. Stedman, Joshua Essery and Cindy A. McGeary

The following paper provides an overview and discussion of past and present trends in training related to

projective personality assessment. The authors summarize the historical use of projective testing (particularly the

Rorschach) and emerging research examining the use of projectives in both graduate and internship training

programs. The current state of the research suggests a decrease in emphasis in training with projective

techniques across both graduate and internship training programs. This paper further discusses the University of

Texas Health San Antonio clinical psychology internship program as one that continues to value and train interns

in projective assessment. The authors end this paper with a brief discussion of the reasons for the decline i n

projective assessment across graduate schools and internship sites.

Projective personality assessment, in its heyday, centered on a cluster of instruments: the Rorschach Inkblot Test, the Thematic Apperception Test, various figure drawing tests, and various versions of the Sentence Completion Test, and post WWII clinical psychology graduate training programs devoted considerable training time to teaching personality assessment with these instruments (see Weiner & Greene. 2008). With the advent of formal internship programs, training with these “projective” instruments extended until completion of the doctoral program.

The projective instruments were intertwined with psychoanalytic theory and were thought of as revealing the underlying dynamics, such as conflicts, drives, motives and such. However, the dominant test, the Rorschach, was also seen as having other functions, such as measuring a person‟s reality testing (Beck, 1944) and offering ratios to organize other more psychometric-like features (Klopfer& Davidson. 1962). While the TAT, drawings, and sentence completion instruments remained tied to their projective roots, the Rorschach underwent a major transformation „with the advent of the Exner scoring system (1969) which deemphasized psychoanalytic interpretation and shifted toward a cognitive

analysis emphasizing information processing, mediation, and ideation. These data are then organized into a structural summary and interpreted in relation to research findings related to personality characteristics. Exner‟s scoring method was designed to correct criticisms of several scoring methods in use at the time and rather quickly became the method most emphasized in the majority of graduate and internship programs. This tradition in Rorschach assessment has now been supplemented with the Rorschach Performance Assessment System (Meyer et al. 2011). Bram and Yalof (2018) offer a depth analysis of the pros and cons for CS versus R-PAS.

This brief (and hopefully mostly accurate) history sets the scene for discussion and review regarding current patterns of projective assessment training at both the graduate school and internship levels.

Graduate-level Assessment Training:

Piotrowski (2015) has provided a very comprehensive review of the status of graduate school training with the traditional projective techniques. This review highlighted 12 surveys, conducted between 1995 and 2014 on instruction with projective instruments. This analysis identified a

Training in Traditional Personality Assessment: 55

precipitous decline in training emphasis with projective assessment. An earlier study by Hilsenroth and Handler (1995), involving 166 graduate students, found that 50% completed two courses with the Rorschach and 32% administered 5 to 9 protocols. A later study by Belter and Piotrowski (2001) surveyed 82 APA-approved clinical doctoral programs and found that 60% required projective training, primarily with the Rorschach and TAT. Nevertheless, 50 % these training directors confirmed a decrease in instruction with projective instruments in the previous five years. Childs and Ende (2002) found similar results in a survey of 84 APA- approved clinical program and reported that 87% of respondents offered a least one course in projective testing, with training emphasizing the Rorschach and TAT.

Of special note is a recent study by Ready and Veague (2014) which investigated training in assessment across three training models (Clinical-Science, Scientist- Practitioner, and Practitioner-Scholar). They found that projective tests were rated significantly below “evidence-based” tests, that only Scholar-Practitioner programs tended to offer projective instruction, and that younger faculty was not interested in teaching projective techniques. This study is perhaps the most comprehensive attempt to gather needed information about current projective personality assessment teaching trends but was hampered by low response rates (32%). Nevertheless, it is the most comprehensive study to date and clearly demonstrated a decline in teaching traditional projective instruments.

Another rich source of data regarding current assessment training during graduate school is the APPIC Application for Psychology Internship (AAPI). Every year all applicants for internships fill in extensive data regarding their assessment training experience during graduate school, including course work, practica, and write-up/interpretation requirements. To date, two studies have mined this data (Stedman, Hatch, & Schoenfeld, 2001b; Stedman, Hatch, &

Schoenfeld, 2002). The earlier study used AAPI forms collected from multiple internship sites for a total of 238 clinical and 96 counseling students, most of whom were from different programs. The dependent variable was “number of test reports written” without reference to particular test. Results indicated that clinical students claimed a median of 18 reports and counseling students reported a median of 11. The second study of the same sample is of more direct relevance because it broke down “number of test reports written” by test. Findings were the following for clinical students and are reported as medians: Rorschach 4.3, TAT 1.5, sentences 2.0, and drawings 1.0. For counseling students, results were Rorschach 2.0, TAT 2.0, sentences 2.0, and drawings 1.3.

In summary, Piotrowski‟s review and the studies cited above offer some quantitative analysis of the status of graduate school instruction with the traditional projective techniques. Those studies and others (Piotrowski & Zalewski. 1993; Watkins et al. 1991) appear to show that graduate school teaching of the traditional projective tests declined in the 1990s, declined further during the later 2000s, and declined perhaps precipitously by 2014. However, it should be noted that none of these investigations captured the data needed to make a definitive statement due primarily to the difficulty related to obtaining sufficient samples.

Our suggestion is that systematic data collection from APPI forms would be the best way to capture the samples needed to ascertain current testing instruction patterns during graduate school. This would require multisite participation of graduate schools or an arrangement with APPIC to tap into samples of APPI forms or both.

Internship Training in Assessment:

There are many more studies of clinical instruction during internship training than during graduate school training. These investigations include all aspects relevant to clinical and counseling psychology, including

56: Stedman, Essery McGeary

testing, and tend to have better sampling of the population, hence, increased confidence regarding generalization. A review by Stedman (1997) noted that three studies in the 1980s (Durand, Blanchard, & Mindell, 1988; Piotrowski, 1984; Petzel& Berndt, 1980) documented that internship directors valued training with projective instruments but found less support for projective training by the “academic community”. Strong support for training with the Rorschach and TAT was demonstrated in a study by Stedman, Hatch, and Schoenfeld (2000). They asked internship directors to indicate the number of integrated test write-ups, including the Rorschach and TAT, they wanted from applicants. Results varied across internship settings but ranged from 1.0 (Counseling Centers) to 20.0 (Private Psychiatric Hospitals) for the Rorschach. Programs wanted fewer TAT reports but again ranged from 1.0 (Consortia) to 21.0 (Private Psychiatric Hospitals). An additional study by Stedman, Hatch and Schoenfeld (2001a) asked internship directors to rate the importance of pre-internship preparation in test-based assessment and psychotherapy. Although directors rated perpetration on objective testing instruments higher (range across types of sites 5.0 to 3.7 on a 5 point scale), still they rated training in projective assessment at significant levels (4.4 to 2.8, with most sites rating above 3.0). Hence, internships continued to value training with projective instruments. Other studies of internship sites, such as Piotrowski & Belter (1999) and Clemence& Handler (2001), found similar results.

There appears to be a gap in direct studies of internship training with projective techniques or methods between the early 2000s and very recently. In fact, Piotrowski asked the first author (Stedman) for an opinion about the status of projective training during internship in 2015, and I speculated that internship training with projectives had indeed declined. Piotrowski‟s question called for an empirical answer and one is now available. Stedman, McGeary, & Essery (in press) surveyed the

733 APPIC internship programs and obtained a 46% response rate (355 programs). These investigators asked internship directors to indicate the following: a) whether they expected personality assessment training during graduate school, b) whether they expected training with specific tests (MMPI, PAI, MCMI, Rorschach, Picture Story, Sentence Completion, Drawings) and their ratings of the importance of that training, and c) their own patterns of training with these instruments (the most important question for our purposes). Results were reported for three categories of internship programs: Adults Only, Child Only, and Mixed Child and Adult. Findings confirmed the speculation that internship programs have severely cut training with the traditional projective instruments. Training with the Rorschach occurs in only 26% of Adult Only, 32% of Child Only, and 33% (Adult rotations) and 35% (Child rotations) of Mixed programs. Training with story techniques (TAT, Roberts, etc.) is as follows: Adult Only 19%, Child Only 39%, Mixed – Child 41%, Adult 29%. Training with Sentence Completion instruments and drawings are even lower, although, as seen above, child programs tend higher.

These findings show definitively that rates of training with projective methods have declined to the graduate school levels. In this most recent study, we also tried to ascertain reasons for not providing instruction with these instruments. The response rate for these questions was rather low; however, those responding cited a lack of trained staff, “too labor intensive”, and questionable validity of these types of tests as reasons for not conducting training.

UTHSCSA: An Internship Program Continuing

to Teach Projective Assessment:

One example of an internship program continuing to train and teach projective measures is The University of Texas Health Science Center at San Antonio (UTHSCSA) which offers an APA accredited pre-doctoral internship program through the Department of Psychiatry. The internship operates from a

Training in Traditional Personality Assessment: 57

generalist training model whereby a number of sites in the area offer rotations for interns who also obtain training and learning opportunities at UTHSCA. Whereas the overall internship is generalist in model, UTHSCSA offers three different tracks in order to provide interns more in depth training in a desired area of specialization. The three tracts for the internship are 1) Forensic, 2) Cognitive Behavioral, and 3) Psychodynamic.

UTHSCA Forensic and Psychodynamic interns receive exposure to projective measures to differing degrees. Cognitive Behavioral interns do not receive training or seminars on projective tests. For the Forensic Track, interns have the opportunity to administer as well as score projective tests and write interpretive reports under supervision. Forensic Track residents work solely with an adult population. The psychodynamic residents are provided seminars on projective tests, case conferences where projective materials are discussed as well as opportunities to administer, score and provide written interpretation of projective tests under supervision. Psychodynamic residents work with mixed child and adult populations.

The most heavily utilized projective test across tracks and populations is the Rorschach. Supervisors have a diversity of training backgrounds with the Rorschach (i.e., Beck, Klopfer, Exner, etc.) but the primary two systems utilized are Exner and R-PAS. Other projective tests used are story telling tests (i.e. TAT and Roberts Apperception Test), sentence completion tests and projective drawings (i.e. House-Tree-Person, Family Kinetic and School Kinetic, etc.). These tests tend to be interpreted qualitatively utilizing a combination of developmental and personality theories to inform interpretation.

Interns for the psychodynamic track are taught to administer the Rorschach in a standardized manner utilizing both the Exner and R-PAS systems. Interns are also provided training in the Rapaport method, particularly with younger children or for those who may

have a difficult time with the query phase of the Exner or R-PAS approaches, usually due to memory or frustration tolerance. Instruction is provided on the limitations and criticisms of the Rorschach in seminars and interns are taught to administer the test only after deciding if the Rorschach is an appropriate measure for the referral questions being considered. Interns are instructed to be aware of context, age, cultural backgrounds, gender and linguistic abilities when utilizing the Rorschach and these variables are commonly discussed during supervision, seminars and case consultations. Rorschach interpretation methods taught utilize protocol scores as anchors for interpretation. Interpretive methods emphasize the Authoritative, Empirical and Conceptual approaches outlined in chapter 2 of Weiner‟s (2003) text, while what is referred to as the “Ouija Board” approach to interpretation is cautioned. Interns are taught a process of formulating their interpretations utilizing what Weiner (2003) outlines as structural, thematic, and behavioral characteristics as well as sequence analysis. Lastly, psychodynamic interns are employed to utilize developmental and personality theories to contextualize and interpret findings obtained from the earlier described process. This approach provides direction in providing relevant feedback and treatment recommendations to patients, parents and referral sources.

Projective Training Circa 1963:

For those who have not been in the clinical trenches 50+ years, it might be of some interest to know what the “hayday” of projective assessment was really like. That task falls to the first author, Stedman. So, I enrolled in the ”projectives” offering in the fall 1963, taught by Dr. John Napoli. His motto was, “Napoli‟s the name; Rorschach‟s the game.” So, we did the usual short review of the TAT and proceeded to the Rorschach. The personality assessment portion of a typical report for Professor Napoli and later during my internship went thusly:

58: Stedman, Essery McGeary

1. A paragraph devoted to the patient‟s

“reality contact” as determined by scoring

the protocol according to the Beck norms.

2. Further consideration of Klopfer ratios and

percentages, e.g., the ratio of Movement

responses to Sum C, the famous

Erlebenstype, indicating response to

external or internal stimuli; percent of F-

responses with F being Form scorings.

3. A lengthy paragraph or two regarding the

patient‟s psychodynamic issues as

determined first by the Rorschach and

backed up by the TAT, Sentence

Completion, and perhaps drawings. The

Rorschach was seen as getting at the

deepest level of psychodynamic conflict,

followed by the TAT. The Sentence

Completion and drawings were viewed, at

least in my programs, as more superficial

measures.

4. Rorschach analysis could occur in what

was called “sequence analysis”,

conducted on a card by card basis and, at

times, a response by response basis.

Certain cards had established “pull”. For

example, Card IV was the Father Card

and Card VII was the Mother Card. This

point was brought home to me during my

internship when, T, who we thought might

be having much conflict with mom, took

one look at Card VII, broke it across his

knee, and handed it to me. Analysis could

also be conducted by reference to the

book by Phillips and Smith (1953) who

had valuable psychodynamic

interpretations for individual types of

responses. We were told not to use this

text but with a wink.

5. After a lengthy session of puzzlement

over all these sources of data, you wrote it

all up as a comprehensive picture of the

patient.

Conclusions:

There is now little doubt that training with traditional projective tests has declined at all levels and with all instruments as noted by Piotrowski (2015, 2017) in his reviews. Piotrowski‟s conclusions also noted that researchers and the academic community in general began “hardened opposition” to the

projective test cluster in the late 1990s. In fact, as early as 2000, an APA Division 12 Task force recommended that projective techniques not be taught in clinical programs (Lilienfeld et al. 2000) and several authors recommended a” moratorium” for teaching projective instruments (e.g., Wood et al. 2000). Piotrowski speculates that this opposition, the effects of managed care, and other factors (we suspect that the move away from dynamic personality theory and toward behavioral and cognitive-behavioral approaches in clinical training is a strong factor) have contributed to this noteworthy decline. Nevertheless, at the internship level, some adult programs and more child program continue to use and teach at least the Rorschach and picture story techniques. Findings, based on hard data, are much less definitive regarding current training at the graduate school level. However, this training has not disappeared. Those seeking exposure to projective assessment can still find programs teaching and using projective assessment techniques.

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