Projective Personality Assessment of Anxiety: A Critical Appraisal



Dean McKay and Eric A. Storch (eds.)Handbook of Assessing Variants and Complications in Anxiety Disorders201310.1007/978-1-4614-6452-5_13© Springer Science+Business Media New York 2013


13. Projective Personality Assessment of Anxiety: A Critical Appraisal



Caleb W. Lack  and Shannon P. Thomason1


(1)
Department of Psychology, University of Central Oklahoma, 100 N. University Drive, 85, Edmond, OK 73034, USA

 



 

Caleb W. Lack



Abstract

Projective personality assessment is widely considered a major method of evaluation for numerous psychological conditions. Anxiety remains a central feature of the psychodynamic model. This chapter provides a critical appraisal of projective methods of assessment. The existing data on reliability and validity for projective measures does not generally support the use of projective methods for assessing and treatment planning for anxiety disorders.


The assessment of an individual’s psychological state—thoughts, feelings, behaviors—is an enormous part of a psychologist’s life. Indeed, the story of clinical psychology prior to World War II is the story of psychological assessment, from Lightner Witmer’s first psychological clinic to Army Alpha and Army Beta to the Wechsler-Bellevue intelligence test (Plante, 2011). Unfortunately, as is the case in the development of most scientific fields, not all early development was actually progressive. Many health fields in their infancy embrace non-supported (outside of anecdotal stories or personal experience) theories, treatments, or measures of assessment. In medicine, for example, we have humorism, which led to bleeding and cupping (Hart, 2001), or animal magnetism, which led to mesmerism and channeling the magnetic fluid (Baker, 1990). In clinical psychology, many today view the continued use of projective measures of personality to assess psychopathology as akin to a physician who uses trepanning to treat epilepsy—as a pseudoscientific practice which should have no place in a modern, scientific field. There are, however, numerous supporters of the use of projective techniques and tests to assess for psychopathology in both clinical practice and academia (Hogan, 2005; Hojnoski, Morrison, Brown, & Matthews, 2006).

The purpose of this chapter is to examine, using a scientifically skeptical but not cynical mindset, if the evidence supports the continued use of projective measures in the realm of anxiety assessment. To do so, we will first familiarize the reader with the historical and theoretical background behind the development of the most commonly used projective measures. Then, we shall examine the history of the controversy of their use, beginning in the 1950s and continuing to the present day. Next, evidence specifically concerning the use of such instruments for assessment of anxiety (both in general and for specific problems) will be summarized. Finally, conclusions and recommendations for clinical practice will be offered.

It is important to note at this point is that projective measures are often equated with psychoanalytic and psychodynamic theories of personality and psychopathology, particularly by persons unfamiliar with their history and development. However, not all measures (e.g., the Rorschach) were developed from a psychodynamic or analytic framework, although many were indeed later co-opted by clinicians and researchers from such a theoretical background. Readers should also be aware of the long-standing and ongoing controversies and debates regarding the validity and scientific status of psychodynamic theory, which has come under attacks from both within (e.g., Bornstein, 2001) and without (Fuller Torrey, 1986; Popper, 1963). There remain, however, many ardent supporters and promoters of psychodynamic theory and the usefulness of its treatment methods (e.g., Leichsenring, Rabung, & Leibing, 2004; Shedler, 2010).

Before turning to the history of projective measures, though, some terminology issues must be addressed. Types of measures used to assess for personality characteristics and psychopathology are often divided into two categories: objective and projective (Weiner & Greene, 2008). Objective tests make direct inferences about a person’s psychological state based on his or her self-report (or in some cases, report from significant others such as parents) to very clear questions. Projective tests, in which instructions or stimuli are more ambiguous and less structured, make indirect inferences about a person’s psychological state. The term “projective” itself comes from Frank (1939), who thought that using ambiguous stimuli would allow a person to project their “private world” onto such stimuli, and as such “interpret the material and react affectively to it” (p. 403).

This terminology can be seen, however, as heavily value-laden (e.g., “If one is objective, the other must be subjective!”) and may not be very useful. One task force of the American Psychological Association, the Psychological Assessment Work Group, even recommended replacing the label “objective” with “self-report instrument” and “projective” with “performance-based measures” (Meyer et al., 2001). Others recommended use of “self-report measures” and “free response measures” (Meyer & Kurtz, 2006). Such recommendations, however, have not been adopted by the majority of practitioners and researchers, and as such this chapter will retain usage of the more familiar term “projective measures.”


A Brief History of Projective Measures


Many persons who are only superficially familiar with the development of the various measures to be discussed below (the Rorschach Inkblot Method, the Thematic Apperception Test, figure drawings, and sentence completion) have the idea that the usage and interpretation of these measures are all based on Sigmund Freud’s theories of personality and psychoanalysis. This, however, is far from the truth. In fact, each measure described below has its own unique development, sometimes directly related to Freudian theories, sometimes influenced by them, and sometimes largely independent of them. Below, we will discuss the origins of four common projective tests (or classes of tests), focusing on the theoretical underpinnings of them and the scientific evidence for such theories. We will then discuss the basis and support for their use in clinical settings, ­particularly for assessment of anxiety.


Rorschach Inkblot Method


To gain an understanding of the strength of beliefs for and against the use of our first test, the Rorschach (also called the Rorschach Inkblot Method [RIM] has been described as being “the most cherished and the most reviled of all psychological assessment tools” (Hunsley & Bailey, 1999, p. 267). It is frequently listed as one of the most commonly used psychological measures by clinical and school psychologists (Archer & Newsom, 2000; Hojnoski et al., 2006) and frequently taught in clinical psychology doctoral programs (Belter & Piotrowski, 2001), although anecdotal evidence suggests a decline across the past decade. The Rorschach also holds a grip on the public imagination, as evidenced by the use of similar inkblots in media from comic books (“Watchmen” by Alan Moore and Dave Gibbons) to music videos (“Crazy” by Gnarls Barkley).

Hermann Rorschach’s development of the test that would bear his name is an interesting story. He was apparently intrigued as a youth (as was much of Germany) by a popular parlor game called Klecksographie (roughly “Blotto” in English), where one would drip ink onto a piece of paper, fold it in half, and then compete to give the most numerous or interesting answers (Exner, 2003). Psychological research using inkblots had been conducted by a number of researchers in the early part of the twentieth century, but had primarily confined itself to the areas of visual perception and memory processes, although Alfred Binet researched their use in measuring intelligence (Zubin, Eron, & Schumer, 1965). Rorschach, however, was either unaware or ignored these lines of research when, in 1918, he created his blots and developed their usage. He did, however, appear to be inspired by work conducted by a medical student in Zurich, who was unable to show success in distinguishing psychotic patients from non-patients using responses to inkblots (Gurvitz, 1951).

Rorschach’s inkblots were not what one would have seen in a game of Blotto, however. He appears to have painstakingly constructed them using ink and watercolors, rather than relying purely on chance or random drips and patterns (Exner, 2002; Morganthaler, 1954). Based on his only major work (he died at age 37, only 9 months after publication of it), Rorschach was particularly concerned with two factors in a person’s response to the blots: movement and color (Rorschach, 1921/1964). He does not appear to have been influenced by Freudian theories in constructing the inkblots or their interpretation, and instead had his own theory that the perception of movement and color would give insight into personality. In particular, he thought movement responses were related to introversion, while color responses were related to extraversion (“extratension” in his terminology).

The idea that perception of movement and introversion were related appears to be based in part on muscle movement and dream research by a philosopher in the 1800s named John Mourly Vold (Ellenberger, 1993). Rorschach took Mourly Vold’s idea that inhibition of movement during sleep would cause more dream imagery involving movement and applied it to the responses generated by his inkblots. In other words, his theory was that introverts should see more images that are moving in the blots, due to their being psychologically inhibited. Rorschach also outlined a theory that the perception and use of color in descriptions of the inkblots were related to affect and extraversion. In particular, those who used more color responses were more extraverted and likely to show high levels of emotion. Unlike with his ideas about movement, however, his theory about color seems to have been pulled from common vernacular (“black moods” for example) and personal opinion rather than any research or previous theories (Rapaport, Gill, & Schafer, 1946). Rorschach also seemed particularly interested in the balance of introversion and extraversion, called “Experience Balance” in English (abbreviated EB). The ratio of movement (M) to color responses, he believed, would reveal a person’s “basic experience and orientation toward reality” (Wood, Nezworski, Lilienfeld, & Garb, 2003).

Rorschach’s reasons for focusing on color and movement, therefore, need to be examined to see if they are actually supported by a preponderance of scientific evidence. A review of the literature shows that the answer is, for the most part, “no.” EB, for example, has not consistently been demonstrated to be related to introversion or extraversion (see Holtzman, 1950 or Wysocki, 1956 for disconfirming evidence; Allen, Richer, & Plotnick, 1964 for confirming), and Color responses have not been consistently related to any particular diagnosis such as depression (for a review see Stevens, Edwards, Hunter, & Bridgman, 1993). It should be noted, however, that some of Rorschach’s hypotheses do have some consistent support. For example, that a more intelligent person would provide higher numbers of M responses has been supported to a moderate degree (see Frank, 1979 for a review), as have some indicators of psychotic disorders (see Dawes, 1994; Lilienfeld, Wood, & Garb, 2001).

So, was Rorschach right? The answer is “mostly not” with the occasional “yes.” While his major hypotheses have not been shown to be correct, some minor ones have support. What does this mean for the test as a whole, then? Should it all be thrown out? These inconsistencies and concerns led to numerous within-group conflicts during the 1930s and beyond, as different groups of researchers and clinicians developed further types of scores, or refined the meaning of certain scores (see Exner, 1969 for a review of major systems of interpretation). It was during these conflicts that some began to use the Rorschach as a more psychoanalytically oriented test, interpreting responses to blots as if they were dreams (content approach) rather than relying on a more formal structural approach (e.g., following Rorschach’s methods). Furthermore, well-conducted research in the 1950s showed that the Rorschach was not more useful (and was in fact slightly less useful) than a more objective measure of personality, the MMPI, and appeared to highly overpathologize normal individuals (e.g., Little & Shneidman, 1959). Further research showed that it added little to nothing in the way of incremental validity if one already had access to biographical information and a person’s history (see Garb, 1998 for a review). By the beginning of the 1960s, most research-oriented and scientifically based psychologists thought the Rorschach was not a useful instrument (see critiques by Cronbach, 1949; Jensen, 1958).

Such criticism and lack of scientific support led directly to a number of reform attempts for the Rorschach. The most complete one, and the one that likely saved the Rorschach from being consigned to the graveyard of psychological tests, was John Exner’s Comprehensive System (CS; 1974, 1993). The CS included reviews of the literature, norms, and administration guidelines—all things that were lacking at the time. Exner also led extensive research into reliability and validity of the traditional scores, while at the same time developing new ones. Exner has been described as having “almost single-handedly rescued the Rorschach and brought it back to life” (American Psychological Association Board of Professional Affairs, 1998, p. 392). All the while, though, findings by researchers other than Exner or his associates began to appear, with results often in sharp contrast to those reported in the CS’s manual. In fact, the vast majority of the supportive studies cited in the latest CS manual (Exner, 1993) are unpublished studies conducted by Exner and his research team at Rorschach Workshops (Wood et al., 2003).

As research on the CS conducted by those without ties to Exner and the Rorschach Workshop began to accumulate in the 1980s and 1990s, numerous concerns that were identical to those raised by research in the 1950s and 1960s were raised: overpathologizing, low diagnostic accuracy outside of psychotic disorders, and lack of relationship to objective measures of psychopathology and personality (for a review see Hunsley & Bailey, 2001; Lilienfeld, Wood, & Garb, 2000). Even the norms of the CS were found to be seriously different from the results of other studies (e.g., Shaffer, Erdberg, & Haroian, 1999; Wood et al., 2001). Flaws within Exner’s own norms were even found, as over a third of his normative sample was found to not exist; from his own report, 221 of the 700 normative subjects were actually duplicate records (Exner, 2001). Of special note, the majority of supportive studies for the Rorschach have recently been published in the Journal of Personality Assessment, a well-respected journal that publishes large amounts of high-quality research. It also happens to be the official journal of the Society for Personality Assessment, which originated as the Rorschach Institute, and is almost exclusively staffed by editors who are very strong proponents of the Rorschach’s use.

What, then, can be said about the usage of the Rorschach in clinical settings? Interestingly, both opponents (Wood, Lilienfeld, Garb, & Nezworski, 2000) and proponents (Weiner, 1999) conclude that it should not be used diagnostically. To wit, “Rorschach data are of little use in determining the particular symptoms a person is manifesting…. Accordingly, the nature of these symptoms is better determined from observing or asking directly about them than by speculating about their presence ” (Weiner & Greene, 2008, p. 396). Clinically, there are some CS scores that are related to intelligence and psychotic disorders, just as Rorschach’s original system found almost 90 years ago (Wood, Nezworski, & Garb, 2003). But in terms of relationship to currently used diagnostic categories, there is currently no solid scientific evidence that using the Rorschach under the CS can accurately and consistently assist with the diagnosis of anxiety disorders in general, or any specific category of anxiety, such as GAD, PTSD, OCD, or phobias (Wood et al., 2000). It should be noted that one study found specific Rorschach indicators present in children with PTSD (Holaday, 2000), although the same indicators were found in children with oppositional defiant disorders, although to a lesser degree, it was a small sample, and the raters were not blind to the children’s diagnoses (as confirmed by objective measures). There is, however, a non-CS scale—the Elizur Anxiety scale—that relates to real-world anxious behaviors (Aronow & Reznikoff, 1976; Goldfried, Stricker, & Weiner, 1971), although not to specific disorders. Unfortunately, it is best regarded as a research instrument, given the lack of standardized norms or methods of administration (Wood, Nezworski, & Garb, 2003).

In summary, then, the Rorschach began life in 1922 as a theoretically shaky, non-empirically supported test for the majority of psychopathology (psychotic disorders being the exception). Despite almost 90 years of research and usage on it, and various iterations of scoring and administration criteria, the preponderance of evidence today indicates that it has changed little over years. There is not any reasonable, empirically supported reason to use the Rorschach as a tool to assist in the diagnosis of any anxiety disorder.


Thematic Apperception Test


The Thematic Apperception Test (TAT; Murray, 1943) has a history almost as long as the Rorschach, and, also like the Rorschach, it has a highly interesting development and history (see Cramer, 2004 for full details). The two major figures in the development of the TAT were Henry Murray and Christina Morgan. Murray was a surgically trained physician with a PhD in biochemistry before being hired on faculty of the Harvard Psychological Clinic in 1926. Although initially largely unqualified for such a position, Murray underwent extensive training in psychoanalysis, including meeting with Carl Jung, and intensive reading in psychiatric and psychological literature (Robinson, 1992). Morgan was an artist and certified nurse’s aide who was highly influenced by Jung’s theories on personality and psychopathology, having been analyzed by him personally (Douglas, 1993). Although unremarked on in many writings on the TAT (e.g., Groth-Marnat, 2003; Weiner & Greene, 2008), Murray and Morgan also engaged in a long-lasting extramarital affair that ended only with her suicide in 1967 (Douglas, 1993). Murray and Morgan may appear odd choices to develop a major psychological test, but the TAT ranks second only to the Rorschach as the most often used type of projective test by clinical psychologists (Camara, Nathan, & Puente, 2000). It is less popular, but still quite frequently used by school psychologists (Hojnoski et al., 2006).

Murray appears to have been the theoretical driving force behind the TAT, as it is based on his needs-press concepts of personality. For Murray, an individual’s personality is the result of an interaction between one’s needs (internal motivations) and presses (environmental or situational pressures that impact how one expresses those needs). Morgan, who is absent as an author from the officially published version of the test1 (Murray, 1943), assisted more in the preparation of the actual testing materials (the pictures on the test cards), some early administration of the measure, and writing the results for publication (Holt, 1949). The instrument itself (in the final version) consists of 31 black and white cards that have pictures of various kinds (14 show a single person, 11 show two people, three have a group of people, two have scenes of nature, and one is blank), although only 20 are used with each individual, since some cards are specific to age or gender. Examiners show the cards to the examinee and ask him or her to tell a story based on the picture. The stories that are told, according to Murray, reveal numerous aspects of personality and can be used to understand how someone thinks and feels in real-world influenced by Jung’s theories. Murray believed that these stimuli would also “expose the underlying tendencies which the subject…is not willing to admit, or cannot admit because he is unconscious of them” (p. 1, 1943).

The TAT manuals (Murray, 1943, 1971) provide very clear and detailed procedures for assessing 28 “needs” and 24 “presses” along a 5-point scale based on the stories told. However, similar to what happened with the Rorschach, numerous other systems and methods of using the TAT soon developed. Methods using a smaller number of cards than the standard 20 (often 8–12) became common (Karon, 2000), and a majority of practitioners do not appear to use any of the available scoring systems, instead relying on “intuitive” interpretations of the stories (Gieser & Stein, 1999; Groth-Marnat, 2003; Rossini & Moretti, 1997). In fact, surveys show that few users even follow Murray’s guidelines to present the cards across two different sessions (Vane, 1981) or even present the same cards in published research (Keiser & Prather, 1990). So, just as with the Rorschach, many users of the TAT, both historically and currently, are not using it as originally intended by the developers or even from the same theoretical viewpoint as them [e.g., Westen, Lohr, Silk, Kerber, and Goodrich’s (1989) psychodynamic, object-relations focused scoring system].

There have been several positive findings regarding scoring on the TAT and relationship to specific areas of psychological functioning, but they have all been found when using a particular scoring system. For example, one meta-analysis found TAT scores under McClelland’s system were superior to self-report scores in predicting long-term career outcomes, such as success in a one’s career and level of income (Spangler, 1992). Westen’s scoring system has been found to differentiate between those with and without personality disorders (Ackerman, Clemence, Weatherill, & Hilsenroth, 1999). Other scoring systems have shown TAT scores to be related to therapy attendance in persons with personality disorders (Ackerman, Hilsenroth, Clemence, Weatherill, & Fowler, 2000) and general symptom improvement in persons treated in an in-patient unit (Fowler et al., 2004). There have not, however, been any studies that have successfully used the TAT (in any of its scoring variations) to accurately assess anxiety, either in general or for specific diagnostic categories.

Unfortunately, as shown above and noted by many (e.g., Groth-Marnat, 2003; Hunsley, Lee, & Wood, 2003), the majority of those using the TAT clinically would not benefit from this information, since most practitioners are not using either standardized administration or scoring procedures. Add in the TAT’s lack of incremental validity (Garb, 1998), the high potential for overpathologizing normal populations based on TAT responses (Lilienfeld et al., 2000), and it can be seen why the TAT “rarely plays a prominent role in clinical diagnostic evaluations” (Weiner & Greene, 2008, p. 469). Indeed, the purpose of the TAT, as originally conceived, was not for it to be used as a diagnostic instrument, but instead as a method of exploring a person’s experience of the world around them and the underlying motives they attributed to others. It was not intended to assess for manifested symptoms seen in a psychological disorder.

So, in summary, we see that the TAT has some limited empirical support in assessing for personality disorders and achievement motives when using particular scoring systems. In none of these systems, however, has evidence shown it to be a useful tool to measure cognitive, emotional, or behavioral symptoms of any anxiety disorder. Further, given that few practitioners use the TAT in the standardized manner that it was intended to be used, those that do use it in a diagnostic fashion are undoubtedly relying on personal experience and judgment, rather than empiricism and sound research, with all the attendant biases and problems relying purely on personal experience entails (Dawes, Faust, & Meehl, 1989). In short, the TAT should not be used for the purposes of diagnosing any anxiety disorder.

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Mar 22, 2017 | Posted by in PSYCHOLOGY | Comments Off on Projective Personality Assessment of Anxiety: A Critical Appraisal

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