What’s Wrong With It?
Last month, a quartet of academics published ”What’s Wrong With the Rorschach?” — attacking a test administered to more than a million people worldwide each year. According to recent surveys by the American Psychological Association, 82 percent of its members ”occasionally” and 43 percent ”frequently” use the test, in which subjects speculate about five colored and five black-and-white inkblots. Test-givers in turn interpret the answers to diagnose mental illness, predict violent behavior and reveal suppressed trauma. Their conclusions are applied to everything from child-custody disputes to parole reviews. According to James M. Wood, an associate professor of psychology at the University of Texas at El Paso and one author of the book, tarot cards would work almost as well.
Wood and his colleagues level basic criticisms against the inkblot test’s foundations. They say it lacks accurate norms to serve as benchmarks for comparing healthy and sick patients. Reliability is also at issue, because many scores are determined by test-givers’ subjective interpretations. And last, they contend that virtually none of the scores are scientifically valid, because they neither measure what they claim nor can be consistently correlated with other tests or diagnoses. The Rorschachers simply harbor a ”romantic” devotion to the test’s efficacy, Wood says, one based on ”an uncritical, even gullible, acceptance of ridiculous claims that the Rorschach is like a medical test, a sort of brain scan.” NY Times Magazine
As a psychiatrist, I am sometimes considered old-fashioned for my appreciation for, and frequent recourse to, “projective tests” such as the Rorschach which, by asking the patient to interpret ambiguous stimuli, bypass the usual censorship they apply when explicitly questioned about their mental contents to reveal unconscious content. Since I usually deal with severe, often psychotically, distressed patients, one might question whether one need use a test to get at subtle underlying unconscious processes at all when the dramatic findings are right out front. And one might wonder if my appreciation for the Rorschach is biased by the fact that psychotic thought disorder shows the most consistent relationship with Rorschach findings. The answers — yes and no, respectively. First, psychosis is not a yes/no question but a matter of degree and quality of “reality-testing” . It has urgent diagnostic and treatment implications but may be a subtle finding, not necessarily evident. Secondly, even in dramatic psychosis, the data derived from testing not about the presence or absence of a psychotic thought disturbance but about underlying character structure, personality patterns, and characteristic ways of doing business with the world (coping strategies, dynamics and defense mechanisms) is equally important, if not more.
To dismiss the methodology of projective testing because its interpretation is subjective is emblematic of the reductionism that castrates the field of psychiatry and the realignment of expectations of its practitioners in the eyes of its payors, corporate clients and to some extent, the public — that they be something more akin to technicians than artists or artisans. Throughout medicine, most so-called objective measures such as radiological findings or blood test results require subjective interpretation by someone who is clinically astute and familiar with the individual’s condition, unless the diagnostic question at hand is answered by a simple yes/no finding. Psychological testing can be good or bad depending on the training, experience and thoughtfulness of the testing psychologist. I’ve seen both insightfully good and uselessly bad test reports. My challenge has been to know how to be an intelligent consumer of these tests, weighing them in the balance. I would venture to say that most critics of the Rorschach are not challenged daily to care for desperately ill patients, needing to draw inferences from inherently faulty and partial data, and can safely criticize from a theoretical vantage point.
Indeed, despite its name, psychological testing is less like laboratory testing than it is like another time-honored aspect of medical treatment — that of the second opinion or consultation with a specialist. One hardly expects that to be “objective”; in fact, trusted consultants are sought precisely for their subjectivity. Moreover, since in psychiatry in particular the bodily systems in question are precisely those of thinking, feeling and relating, only a subjective relationship can get at the clinically pertinent parameters of the patient’s function and dysfunction. Let us hope I can remain old-fashioned, having skilled psychological test consultants to rely upon, as long as I continue to practice…