Doctor's Review: Medicine on the Move

December 12, 2017
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Inkblot inklings

How an artist-cum-scientist dripped ink to paper and projected his way to psychiatric stardom

In the field of personality assessment, the Rorschach test remains a classic diagnostic tool used by psychoanalysts and psychologists around the world. Unfortunately, the man who created it didn't live to see the acceptance of his test, nor the current status it enjoys as a widely used tool for evaluating personality. Amazingly, while the number-one spot goes to the MMPI -- a test that has been revised several times over the decades -- the group of 10 old inkblots remains the same as the day a frustrated Swiss artist-cum-scientist dripped ink to paper.

 

In particular, the inkblot test is a valuable tool for diagnosing psychotic thinking in patients who do not readily admit or acknowledge it -- sort of a low-tech, lie-detector test for potentially dangerous patients. The results are also quite good at revealing the likelihood of other thought disorders and antisocial tendencies as well, though the interpretive nature of understanding results has caused some understandable skepticism. Indeed, standardizing the interpretation of the results would be the biggest battle Hermann Rorschach and his followers would face in finding widespread acceptance for this creative technique.


ARTISTIC BEGINNINGS
The man who would turn a meaningless childhood game into a meaningful psychoanalytic tool was born in Zurich on November 8, 1884. He came from a fairly affluent and well-regarded family, and his father Ulrich was an artist and art teacher. Though he never made much of a mark in the art world, per se, Ulrich likely passed on a love of painting and drawing to his oldest son. Hermann began his artistic education in earnest attending secondary school in the town of Schaffhausen, also developing an interest in the sciences throughout his adolescence. Despite the fact that both his beloved parents died while he was young, Hermann excelled in high school.

As a young student, Hermann developed a nickname among his friends: Kleck. It was a reference to his love of klecksography, a term derived from the German word for inkblot, which was a popular game among Swiss children at the time. Klecksography was the art of dropping spots of ink onto a piece of paper and then folding it in half to obtain interesting results, the goal being to recreate the forms of birds and animals. Though just a pastime for most, klecksography remained a preoccupation for Hermann when he entered medical school in Zurich in 1904.

A keen and enthusiastic student, Hermann excelled in all his classes. The combination of his interest in psychiatry and the fact that he undertook studies in Zurich, which was a hotbed for the medical discipline at the time, led Hermann to focus on clinical psychiatry. He was taught by such greats as Eugen Bleuler and even Carl Jung. After graduating in 1909, he began a residency at the mental institution in Munsterlingen, where he gained valuable experience working with patients. He soon met his future wife Olga Stempelin, a Russian woman who kindled in him a lifelong interest in her native land.

The couple married in 1910 and even planned to move to Russia. Meanwhile, they needed to save some money, so he accepted a position at the asylum in Munsterlingen. There, he became popular among the patients. As a clinician he was meticulous, keeping detailed records and even a photographic account of his patients. Rorschach believed in positive recreational experiences as therapy so he organized various entertainments and even adopted a pet monkey for the patients to enjoy. He became interested in art therapy, especially the sorts of work people with personality disorders created, and how their work might be interpreted. Freud's psychoanalytical theories were spreading like wildfire at the time, fueling Rorschach's own fascination with how they might be applied to his own research.


AN INKLING OF SOMETHING
It wasn't long before Rorschach's love of inkblots came to the surface once again and he began to informally study how children and the mentally ill interpreted the pictures he showed them. After a brief stint working in a Russian mental institution in 1913, Rorschach returned to Switzerland to work at a psychiatric hospital near Bern, and then moved shortly after to the one in Herisau, a Swiss town near Austria, since it afforded him a better chance to conduct research of his own. The research in question was inkblots.

He wasn't the only one -- psychologists Alfred Binet and Justinus Kerner had a passing fancy for inkblots, too -- but Rorschach was the first to create a collective system for applying the test and interpreting its results in order to make it a useful psychological tool in assessing patients' personalities and disorders. For years, he worked tirelessly to do just that, administering his inkblot test to countless patients and carefully recording the results. Though he began with a series of 40 pictures, he eventually honed the collection down to 10 symmetrical inkblot images -- five black-and-white cards and five cards containing some degree of colour. A patient's responses to the images were analyzed according to many factors, such as what associations were made, the details the subject focused on within the images, the time they spent answering, the degree of uniqueness, and so on.

To prove his point that valuable data and understanding could be extracted from the way patients projected their thoughts onto these ambiguous images -- and after much difficulty finding a willing publisher -- Rorschach published Psychodiagnostics: A Diagnostic Test Based on Perception in 1921, using data obtained from over 300 subjects, including results acquired from both sane people and patients with varying degrees of mental illness.

As was the trend at the time, his peers doubted whether personality traits such as introversion, extroversion, intelligence, logical reasoning abilities and psychological stability could be quantified in this way. They agreed instead that if there was any value to be found in Rorschach's inkblots, it would come from interpreting the free-associations the test would initiate in its takers. Undeterred, but shaken, Rorschach recommitted himself to finding new ways to standardize and interpret the results in a rigorously tested cohesive method.

At Herisau, he had risen to become the associate director of the asylum and was a well-respected psychiatrist throughout Switzerland. Despite his devotion to perfecting his life's work with the inkblots, Rorschach would be robbed of the pleasure of seeing its ultimate success. In 1922, he died in Herisau from peritonitis acquired after an unsuccessful appendectomy, at the young age of 37. He was in the middle of developing changes that would help his test gain the acceptance he so desired. Thankfully, several others believed in his vision and were happy to pick up the torch.


BELIEVERS IN BLOTTING
The problem, of course, was that Rorschach had not been able to give psychoanalysts and psychologists the objective interpretation criterion that would cement its usefulness and validity. Apart from some of Rorschach's devoted friends and students, a German psychologist named Bruno Klopfer would be the first to mount a serious campaign to resurrect and restructure the inkblot test. After being exposed to the test while studying with Carl Jung at the University of Zurich, Klopfer became convinced of its validity. He greatly improved the scoring system, and even went on to found the Rorschach Research Exchange and Journal of Projective Techniques in 1936, the publication that eventually would become The Journal of Personality Assessment.

Over the years, a new issue with the test had arisen. By the 1950s, Rorschach's test had been reinvented by at least four different proponents, causing great inconsistency in its application and understanding. Enter John E. Exner, an American psychologist who devoted himself to developing an overarching clinical approach to the Rorschach test, the results of which came to be known as Exner's Comprehensive System. Finally, this universal method allowed independent research to confirm the test's validity, opening the door for it to be taught in schools and applied the same way by clinicians across the board.

The Exner system of giving, understanding and scoring the inkblot test remains the gold standard in the field of personality assessment. To be fair, it is likely Rorschach himself would have been able to do so eventually. Still, the psychoanalytic community was finally ready for a revisiting of the once-maligned test and was therefore more open to its benefits once Exner came along and renewed interest some thirty years after its creator's death.

Though Rorschach test reached its zenith of popularity in the 1950s -- when its results were taken perhaps a little too enthusiastically and literally -- it remains a preferred way for mental-health professionals to be alerted to the presence of personality disorders and other problems. Not everyone's totally on board, though: its results remain for some a little too subjective to be taken as psychological gospel. Nevertheless, the simple question "What do you see here?" has entered the public and scientific consciousness as a subtle yet ingenious way to steal a glimpse into the mysteries of the mind...

 

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