Rorschachiana 1/2017 by Hogrefe

Guest Editor: James H. Kleiger Editorial: A Rorschach Case Study: Multiple Psychoanalytic Models of Interpretation James H. Kleiger Rorschach Interpretation: An Object Relations Approach Bruce L. Smith Ego Psychoanalytic Rorschach Interpretation Irving B. Weiner

Volume 38 / 2017

Issue 1: Special Issue – Multiple Psychoanalytic Models Case Study

Volume 38 / 2017

Rorschachiana

An Interpersonal Approach to Rorschach Interpretation F. Barton Evans A Self Psychological Analysis of Rorschach Thematic Content Marshall L. Silverstein Attachment Theory Applied to Ms. B.’s Rorschach Ety Berant Discussion of Special Issue Articles “A Rorschach Case Study: Multiple Psychoanalytic Models of Interpretation” Jed Yalof Book Review: Disordered Personalities and Crime Marianne Nygren

Issue 2

Sex Assignment to Whole Human Responses in Rorschach Christian Mormont and Patrick Fontan Cultural Differences in the Emotional Indicators of the Two-People Drawing Test Ana María Tuset Bertran and María Teresa Fernández Nistal Emotional Perception and Distortion Correlates With Rorschach Cognitive and Interpersonal Variables Fabiano Koich Miguel, Marcia Caroline Portela Amaro, Eduardo Yudi Huss, and Ana Carolina Zuanazzi Book Review: Essentials of Rorschach Assessment: Comprehensive System and R-PAS Vera Campo

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ISBN 978-0-88937-546-8 90000 9 780889 375468

Rorschachiana

Investigating Personality and Psychopathology in Patients With Psoriasis Chiara Vari, Patrizia Velotti, Alessandro Crisi, Silvana Carlesimo, Antonio G. Richetta, and Giulio Cesare Zavattini

Editor-in-Chief Sadegh Nashat Advisory Editor Anne Andronikof Associate Editors Hiroshi Kuroda Gregory J. Meyer Fernando Silberstein Justine McCarthy Woods Book Review Editor Marianne Nygren

Journal of the International Society for the Rorschach

Contents Volume 38, Issue 1, 2017 Special Issue: Multiple Psychoanalytic Models Case Study

Editorial

A Rorschach Case Study: Multiple Psychoanalytic Models of Interpretation James H. Kleiger

Case Studies

Rorschach Interpretation: An Object Relations Approach Bruce L. Smith

Ego Psychoanalytic Rorschach Interpretation Irving B. Weiner

An Interpersonal Approach to Rorschach Interpretation F. Barton Evans

A Self Psychological Analysis of Rorschach Thematic Content Marshall L. Silverstein

Attachment Theory Applied to Ms. B.’s Rorschach Ety Berant

Discussion Discussion of Special Issue Articles ‘‘A Rorschach Case Study: Multiple Psychoanalytic Models of Interpretation’’ Jed Yalof

Book Review

Disordered Personalities and Crime Marianne Nygren

Ó 2017 Hogrefe Publishing

Rorschachiana (2017), 38(1)

Special Issue: Multiple Psychoanalytic Models Case Study

Editorial A Rorschach Case Study Multiple Psychoanalytic Models of Interpretation James H. Kleiger Private Practice, Bethesda, MD, USA

Roy Schafer (1954) began his classic work Psychoanalytic Interpretation in Rorschach Testing with the following statement: No matter how helpful a clinical tool may be, a psychological test cannot do its own thinking. What it accomplishes depends upon the thinking that guides its application. This guiding thought is psychological theory, whether explicit and systemized or implicit and unsystematized. (p. xi) Since Schafer spoke these words, the importance of integrating psychological theories of development and psychopathology into test interpretation has been recognized as a well-established axiom of diagnostic testing. However, we are often faced with the question of which guiding theory to use. Do we select the one that inherently appeals to us, that makes most sense and has the greatest explanatory power; or, like Fred Pine (1990), do we seek to evolve a unifying perspective among various models of the mind? At the 2013 Convention of the Society for Personality Assessment (Kleiger et al., 2013) and again at the 2014 International Congress of Rorschach and Projective Methods (Kleiger et al., 2014), distinguished panels of senior psychologists furthered this debate by presenting their interpretations of a single Rorschach protocol from multiple psychoanalytic theoretical lenses. The panelists not only demonstrated how they thought and how they used theory to make data come alive, but like the proverbial blind men describing different parts of the elephant, the contributors represented different theoretical perspectives or schools of thought, anchoring their inferences and formulating treatment implications within the parameters of the particular clinical psychoanalytic model they represented.

ÂŠ 2017 Hogrefe Publishing

Rorschachiana (2017), 38(1), 1â&#x20AC;&#x201C;11 DOI: 10.1027/1192-5604/a000089

J. H. Kleiger

Each contributor was given the Rorschach and Structural Summary from a patient referred to as Ms. B. and asked to interpret the data from one particular psychoanalytic model of personality. Contributors were asked to organize their presentations around the following questions: 1. How does your model aid in a diagnostic understanding of Ms. B.’s internal experience and personality functioning? What unique aspects of her functioning does your model address? 2. What features of her Rorschach (formal scores, indices, thematic content, behavior) lend themselves particularly well to your model? In other words, what Rorschach data help you form links with key constructs in your model? 3. How does your model guide you in addressing the referral questions and in making inferences about treatment issues based on Ms. B.’s Rorschach (e.g., type of treatment, intensity, potential transference–countertransference themes, need for supportive interventions)? The panelists, now authors, and their psychoanalytic models included: 1. Irving Weiner, PhD, psychoanalytic ego psychology; 2. Bruce L. Smith, PhD, object relations theory; 3. Marshall Silverstein, PhD, self psychology; 4. F. Barton Evans, PhD, Sullivanian interpersonal theory; and 5. Ety Berant, PhD, attachment theory. Dr. Jed Yalof served as discussant for each paper. His integrated discussion is included in this series of papers.

The Case of Ms. B Ms. B was an 18-year-old Caucasian woman referred for a psychodiagnostic consultation by her psychotherapist, Dr. X. Early in the spring, Ms. B. ingested a potentially lethal dosage of medication (Ambien and Oxycodone) in an attempt to take her life. Her suicide attempt occurred in the context of close communication with Dr. X., who had spoken to her not long before her overdose. Ms. B. and her therapist had been talking about her depression, but Ms. B. had reportedly reassured Dr. X. that she was safe; she denied plans and intentions to hurt herself. Additionally, she agreed that she would not act on any suicidal feelings without first talking to her therapist or someone else. After her overdose, Ms. B. was discovered by a roommate, who called 911. When Dr. X. eventually spoke with Ms. B. at the hospital, she was reportedly enraged that people were taking away her right to decide if she lived or died. Rorschachiana (2017), 38(1), 1–11

Editorial

Ms. B. was clear that she had attempted to kill herself. Although she initially refused a voluntary hospitalization, she reluctantly agreed to inpatient treatment after involuntary admission was presented as the only other option. Soon after she was admitted, Ms. B. was said to have calmed considerably. She was no longer voicing any suicidal thoughts or feelings. She was eager to return to classes and her dorm and carry on as if nothing significant had happened. Officials at her college were cautious about having Ms. B. return to school following a suicide attempt without psychiatric clearance. The question about whether she should be allowed to return to school added weight to Dr. X.’s questions about Ms. B.’s mental status, level of suicidality, diagnosis, and treatment recommendations. Thus, Dr. X. formulated the following questions for this psychodiagnostic consultation: 1. To what degree does Ms. B. still present a risk for suicide or self-harm? Should she be allowed to return to her dormitory? 2. Is there evidence of an emerging bipolar disorder, and to what degree does posttraumatic stress contribute to the diagnostic picture. Finally, is there evidence of a vulnerability to dissociation or psychotic symptoms? 3. What are the implications for treatment? What would be the appropriate setting and level of intensity to help Ms. B. address her problems? Ms. B.’s Rorschach responses (Appendix A), coding and sequence of scores (Appendix B), and Structural Summary (Appendix C), based on the Comprehensive System (Exner, 2005), are presented.

References Exner, J. E. Jr. (2005). A Rorschach workbook for the Comprehensive System (5th ed.). Asheville, NC: Rorschach Workshops. Kleiger, J. H., Weiner, I. B., Silverstein, M. L., Smith, B. L., Evans, F. B., & Yalof, J. A. (2013, March). Multiple psychoanalytic perspectives: A Rorschach case study. Symposium conducted at annual meeting of Society for Personality Assessment, San Diego, CA. Kleiger, J. H., Berant, E., Evans, F. B., Ikiz, T., Smith, B. L., & Weiner, I. B. (2014, July). Multiple psychoanalytic perspectives: A Rorschach case study. Symposium conducted at International Congress of Rorschach and Projective Methods, Istanbul, Turkey. Pine, F. (1990). Drive, ego, object, & self. New York, NY: Basic Books. Schafer, R. (1954). Psychoanalytic interpretation in Rorschach testing. New York, NY: Grune & Stratton. Received December 19, 2016 Accepted April 5, 2017 Published online July 13, 2017

Rorschachiana (2017), 38(1), 1–11

J. H. Kleiger

James H. Kleiger Private Practice 6320 Democracy Blvd Bethesda, MD 20817 USA james.kleiger@gmail.com

Appendix A Table A1. Rorschach Responses C-# V^@

Response

Inquiry

I-1

A goblin…(most people see more than one thing)

Could be…all I see is a goblin (take Whole thing, body, wings outstretched but it your time)…an angel without a didn’t have a head head Cat [immediately responds] I think the way the paint goes outward. Looks like whiskers, and nose pointed up here like a cat and the eyes (How much of the card?) uh [covers ½] like…I guess the white spots and the black width of paints strokes, the black (circle) it’s like a cat’s face (using top?) no not really

II-3

Used whole card, eyes, and fangs or something and horns and pointy ears, a pointy face

Or…two elephants dancing

Head, trunk, ears, black parts

Or the face of a moth

(How much?) Now it looks like cat but if red parts were eyes and weird pointy nose, I guess just upper part

III-6

Two people playing the drums

These are people and two drums and these are music notes or something (What suggested a drum?) Looks like tribal drums (tribal drums). Here, seems like motion or maybe one big drum or maybe two individual things next to each other (Musical notes?). Can’t see in real life but kind of looked like that. That’s why I thought playing drums, maybe singing as well

Or …..Someone with a really weird hairdo and a bow on top of their head, wearing sunglasses [puts down, face down and almost reaches for next] A dragon

Weird futuristic sunglasses, mouth, nose and weird pigtaily thing, braided up in some weird way and bow on top

Or a giant without any arms. Looks cut off

Looking at everything but thing in middle. Looks like head, and big feet and legs but it doesn’t have any arms

IV-8

Here there are the dragon’s wings and head sort of flying down towards someone, the way it looks to be going

(Continued on next page) Rorschachiana (2017), 38(1), 1–11

Editorial

Table A1. (Continued) C-#

V^@

Response

Inquiry

Or ….some sort of animal’s skeleton or skull like a horse or a dog [puts card down]

Everything right there, not giant’s legs but everything else. (What about it suggested that?) Water marks indicate eye socket or nose. Water marks indicated teeth and eye sockets (water marks?) the shading. It looks too elongated to be a dog. Here looks like ears are decaying. Looks like skin rotting off (skin rotting off?) doesn’t looks like defined skull still looks like some fur on there (fur, what suggests fur?). These extra lines on here [outlines] are mangy and ears still like a little draped, a little fuzzy

V-11

Bat

Looks like wings, whole, looks like wings as it is flapping down and weird ears and legs

VI-13

….[foot shaking]….[puts card face down] A uh….Great Dane

Everything but thing on top. Dark spots looks like its tiny dark eyes, and looks like Great Dane’s face looking right at you. Saggy face and cheeks (saggy?), the lines there and drool here because water marks are lighter and looks like a bone in its mouth like a dog looks at you for praise when it has something

Or a that giant Jesus on mountain in Rio de Janeiro

Never been there, on a big peak right here, big mountain and looks like Jesus like figure holding out arms like a statue is doing. (Mountain?) Looks like, the Jesus in Rio is on a mountain (Jesus) it looks like arms are stretched out

A Kachina doll

Same part. I have a bunch at home on wooden stands. And if I looked at it, the shading makes it look more tribal, like a tribal cloak, which looks like it is kind of spreading out and a mask because it looks like it has whiskers

Or an animal fur carpet

Whole (fur carpet)? Looks like an animal skin like we have at home. We have it in storage because we inherited it from a crazy relative. There’s a stripe in the middle in the shaded area that looks like an animal skin, where you can tell where bits of the animal were. And can also tell where hind legs were chopped off of it. Just the pattern on the bottom part reminds me of a deer skin (Continued on next page)

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J. H. Kleiger

Table A1. (Continued) C-#

V^@

Response

Inquiry

…..Or a volcano [puts card down, face down]

All of it. This looks like the tunnel where lava is shooting out of the opening and this is a volcano here and the top it looks like an explosion.

VII-17

Two women talking to each other

Looks like heads, facing each other, and this the bodies, sitting in front of each other. Reminds me of an Indian feather, some weird hairdos

Or a pile of rocks

Looks like, yea, looks like rocks stacked up on each other. I’ve seen pictures of rocks where there are boulders. Don’t know how they do that. How they get there. (What suggested rocks?). The dark color of Rorschach and … how the bottom pieces are big and get smaller so seems like a weird balancing thing

Or a necklace

Whole clunky thing without these. Clasp and big chunky part that is hanging down. Some gaudy necklace that I’d never wear, big fake jewels strung together. Big cheap gold thing

Or like lots of thumbs up [motions] Looks like thumbs up [motions] like, “Hey [puts card down, face down] good for you. Yeah, thumbs up”

VIII-21

A dress

Reminds me of one of this mid-1900 dresses, short sleeves and high collar and hugs waist and orange part would just flow out. You can’t see whole dress but would be there

Or uh…two iguanas climbing up a plant

Green part looks like branches and pink things looks like iguanas climbing. Almost looks like orange and pink part looks like a rock that they’re helping to get up on the plant (Rock?) Reminds me of Arizona or El Paso, somewhere in the Southwest when a sunset you see big rocks and they have cool colors. Kind of looks like a plant is springing out of rocks and there is stem there

IX-23

…..[shaking foot puts card down, face down] A blender exploding [humming softly]

Whole thing. Looks like clear part is the blender the glass part and all this stuff, when blenders explode they come out of top. But this looks like it is coming out everywhere, leaking out at bottom (Continued on next page)

Rorschachiana (2017), 38(1), 1–11

Editorial

Table A1. (Continued) C-#

V^@

Response

Inquiry

…….Don’t know… something else’s Just here, where the orange is leaking into the face. Like a wacky or goofy looking green. Chinese dragons’ faces always like Chinese dragon’s face goofy. Sometimes their eyes are crossed and here you see eyes crossed and there’s a nose and a weird mouth. And orange on top is sort of like the horns, maybe the dragon-shaped head

Or a chipmunk with too many acorns in its mouth

Just the green part looks like a face of chipmunk with too many acorns. The little white points look like eyes and rest of green is rest of face but it is too big because it stuffed its mouth too full

X-26

Bunch of sea creatures

Whole thing. Red parts are lobsters and the blue looks like crabs and little green things. Kind of looks like sea horses and then brown looks like different kinds of crab or weird shrimp. Just so colorful reminds me of different kinds of fish and aquatic life (lobsters?) big and red and looks like tails

Or Eiffel Tower

Used white in middle and this rod on top and it looks like the legs of Eiffel Tower and it’s connected in the middle and goes up and gets smaller

Or a man in sunglasses with a goofy mustache

Looks like his face and sunglasses and weird face flushed. Looks like a villain who has been baffled. Weird flushed cheeks and part in middle some goofy mustache (Sunglasses?) blue parts. Big round dots (Flushed cheeks?) some red looks like blushing (What suggests a villain?) I see a narrow face and sunken cheeks and long nose and sinister moustache, reminds me of Jafar from Aladdin or some suspicious European spy; almost comical. (Sunken cheeks?) Just imagine it because face looks triangular so it’s a very narrow face. (Baffled?) Just his look .… As if his evil plan had been foiled but he was determined to make another evil plan. Sort of like cartoonish

Favorite card?

II. Elephants because looks like having fun

Least favorite?

X. Because doesn’t have a super clear image and I had to make something

Rorschachiana (2017), 38(1), 1–11

J. H. Kleiger

Appendix B Table B1. Rorschach coding and sequence of scores Location and DQ

Loc. No.

Determinant(s) and Form Quality

WSo

(Hd)

3.5

GHR

Mpo

(H)

1.0

MOR, PHR

DdSo

F-

D+

Mao

5.5

FAB, COP, GHR

F-

4.5

D+

Ma.mao

WS+

FMau

(H)

Dd+

Mp.FY-

An, Hd

FMao

FMp.YF-

D+

Mpo

(H),Ls

FY.mpo

(H), Cg, Ay

FYo

W+

ma-

D+

Mao

Wv/+

YF.mpu

2.5

mp-

2.5

Ddo

Mpu

F-

W+

FMa.CF.mpo

W+

mao

Hh, Ex

Ddo

(Ad)

Ad, Fd

CFu

DdSo

F-

Sc, Ay

DdS+

Mp.FC-

Hd, Cg

Rorschachiana (2017), 38(1), 1–11

(2)

Content(s)

Pop

Z Score

Special Scores

Ad 2 2

H, Sc, Ay

4.0

GHR

Hd, Cg

5.5

PHR

(A)

2.0 P P

Hd, Cg

A, Ls

MOR, PHR

4.0

MOR, PHR

1.0 6.0

GHR PER, GHR

Ls, Ex 2

2.0

2.5

DR, MOR, PER

2.5 P

3.0

GHR

PHR 4.5 P

4.5 5.5

5.5 4.0

PHR

Editorial

Appendix C

Figure C1. Comprehensive System 5th edition structural summary.

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Rorschachiana (2017), 38(1), 1â&#x20AC;&#x201C;11

J. H. Kleiger

Summary Six experienced clinicians interpreted the Rorschach of Ms. B., an 18-year-old patient who had been referred for psychological testing following a severe suicide attempt. The clinicians each conducted a blind interpretation of Ms. B.’s Rorschach from six different psychoanalytic schools of thought, which included ego psychology, object relations, self psychology, interpersonal theory, the French psychoanalytic school, and attachment theory. In their interpretations of Ms. B.’s Rorschach, the clinicians organized their formulations according to the following set of questions: (1) How does your model aid in a diagnostic understanding of Ms. B.’s internal experience and personality functioning? What unique aspects of her functioning does your model address?; (2) What features of her Rorschach (formal scores, indices, thematic content, behavior) lend themselves particularly well to your psychoanalytic model?; and (3) How does your model guide you in addressing the referral questions and in making inferences about treatment issues based on Ms. B.’s Rorschach (e.g., type of treatment, intensity, potential transference–countertransference themes, need for supportive interventions). A discussant integrates the interpretations of Ms. B.’s Rorschach from multiple psychoanalytic perspectives.

Résumé Six cliniciens expérimentés ont interprété le Rorschach de Mme B., une patiente de 18 ans qui avait été renvoyée pour un test psychologique suite à une tentative de suicide. Les cliniciens ont chacun effectué une interprétation aveugle du Rorschach de Mme B. venant de six écoles différentes de pensée psychanalytiques, notamment la psychologie de l’ego, les relations d’objet, la psychologie du soi, la théorie interpersonnelle, l’école psychanalytique française et la théorie de l’attachement. Dans leurs interprétations du Rorschach de Mme B., les cliniciens ont organisé leurs formulations en fonction des questions suivantes: (1) Comment votre modèle aide-t-il à une compréhension diagnostique de l’expérience interne de Mme B et du fonctionnement de sa personnalité? Quels aspects uniques de son fonctionnement correspondent à votre modèle? (2) Quelles caractéristiques du Rorschach (scores formels, indices, contenu thématique, comportement) se prêtent particulièrement bien à votre modèle psychanalytique? Et (3) Comment votre modèle vous pousse à aborder les questions de recommandation et à faire des inférences sur les problèmes de traitement en fonction du Rorschach de Mme B (par exemple, le type de traitement, l’intensité, les thèmes possibles de transfert et contre-transfert, le besoin d’interventions de soutien). Un intervenant intègre les interprétations du Rorschach de Mme B. à partir des multiples perspectives psychanalytiques.

Resumen Seis clínicos experimentados interpretaron el Rorschach de la Sra. B., una paciente de 18 años remitida para una administración de tests después de un grave intento de suicidio. Cada clínico realizó una interpretación a ciegas del Rorschach de B. según seis escuelas de pensamiento psicoanalíticas diferentes, que incluían la psicología del yo, la teoría de las relaciones objetales, la psicología del self, la teoría interpersonal, la escuela psicoanalítica francesa y la teoría del apego. En sus interpretaciones del Rorschach de B., los clínicos organizaron sus comentarios de acuerdo con las siguientes preguntas: (1) ¿Cómo ayuda su modelo a la comprensión diagnóstica de la experiencia interna y el funcionamiento de la personalidad de la Sra. B? ¿Qué aspectos singulares de su

Rorschachiana (2017), 38(1), 1–11

Editorial

funcionamiento aborda su modelo? (2) ¿Qué características de su Rorschach (codificación, índices, contenido temático, comportamiento) se adaptan particularmente bien a su modelo psicoanalítico? (3) ¿Cómo le guía su modelo al abordar las preguntas sobre el motivo de consulta y al hacer inferencias sobre cuestiones relacionadas con el tratamiento, basadas en el Rorschach de la Sra. B (por ejemplo, tipo de tratamiento, frecuencia, cuestiones sobre transferencia-contratransferencia, necesidad de intervenciones de apoyo)? Un comentarista integra las interpretaciones del Rorschach de B. desde múltiples perspectivas psicoanalíticas.

要約６人の経験のある臨床家が、重篤な自殺企図により心理検査に紹介されてきた１８歳の女性である Ms.Bのロールシャッハ法の解釈を行った。臨床家たちは６つの異なった精神分析の学派からMs.Bのロールシャッハ法のブラインドアナリシスをそれぞれ行った。６つの学派には、自我心理学、対象関係論、自己心理学、対人関係論、フランス精神分析学派、愛着理論が含まれる。Ms.Bのロールシャッハ解釈において、臨床家たちは以下の疑問に答えるように彼らの解釈をまとめた。（１）あなたのモデルはMs.Bの内的経験やパーソナリティ機能を診断的に理解するのにどのように助けているか？彼女の機能のどのようにユニークな側面にあなたのモデルは対応するのであろうか？（２）彼女のロールシャッハのどの特徴（形態のスコア、指標、主題内容、行動）があなたの精神分析モデルに特に役立っているのか、（３）あなたのモデルはMs.Bの紹介されてきた疑問にどのように対応し、Ms.Bのロールシャッハに基づく治療上の問題ついてどのような推論をするか（すなわち、治療のタイプは、可能性のある転移—逆転移のテーマは、支持的な介入の必要性）。討論者は多様な精神分析の観点からのロールシャッハ解釈を統合している。

Rorschachiana (2017), 38(1), 1–11

Case Study Special Issue: Multiple Psychoanalytic Models Case Study

Rorschach Interpretation An Object Relations Approach Bruce L. Smith Department of Psychology, University of California, Berkeley, CA, USA

Abstract: This article presents an object relations theory interpretation of the protocol of Ms. B. Object relations theory is defined and the concepts of potential space and the introjective–anaclitic dimension are highlighted. The author suggests that Ms. B.’s protocol manifests a dissociative collapse of potential space, an introjective orientation toward defenses and coping, and a borderline level of object representation. The Rorschach data for these interpretations are discussed and the implications for treatment are highlighted. Keywords: object relations theory, psychoanalysis, case study

Object relations theory in the broadest meaning describes personality in terms of relationships between objects – both external and internal. The term encompasses the work of the Kleinians and neo-Kleinians, the British Middle School, including theorists such as Balint (1955), Fairbairn, Guntrip, and Winnicott (1971/1990), as well as American object relations theorists such as Mahler (Mahler, Pine, & Bergman, 1975), Kernberg (1976), and the intersubjectivists (e.g., Stolorow & Lachmann, 1980). For several reasons, this model is particularly useful for the analysis of the Rorschach and projective tests (Smith, 1990; Tibon, Handelzalts, & Weinberger, 2005; Tibon, Weinberger, Handelzalts, & Porcelli, 2005; Yazigi & Nashat, 2012; Zeligman, Smith, & Tibon, 2012). In the first place, its propositions are “experience-near” and thus more easily translatable into therapeutic recommendations. You will not catch an object relations theorist writing about the re-distribution of conflict-free attentional cathexes, as Rapaport once did in a test report I read. Statements about the nature of a patient’s internal object representations can effortlessly be translated into predictions about therapeutic transferences or the kinds of interpretations most likely to be helpful. Defenses, for example, can be recast in terms of interpersonal behaviors. Secondly, it allows for the integration of transference–countertransference observations with those from the protocols themselves. I would like to highlight in this brief contribution two concepts. The first is Sidney Blatt’s distinction between anaclitic and introversive psychopathology (Blatt, 1974, 1990; Blatt & Shichman, 1983), and the second is D.W. Winnicott’s concept of potential space (Winnicott, 1971/1990). Rorschachiana (2017), 38(1), 12–21 DOI: 10.1027/1192-5604/a000085

Object Relations Interpretation

Blatt conceived of psychopathology falling under two broad rubrics: Anaclitic disorders are those in which the primary conflicts lie around dependency and real or imagined object loss, while introjective disorders are those in which the individual’s sense of self is damaged. Anaclitic disorders include infantile personalities, hysterical personalities, and anaclitic depression. To quote Blatt: “Predominant… are preoccupations about the dependability of interpersonal relationships and the desire to be close and intimate and to give and receive care and love” (Blatt & Ford, 1994, p. 16). By contrast, the introjective disorders (e.g., paranoid personalities, obsessive–compulsive personalities, introjective depression) are characterized by a “preoccupation with issues of self-definition, autonomy, self-control, selfworth, and identity” (Blatt & Ford, 1994, p. 17). Anaclitic patients rely most heavily on avoidant mechanisms of defense such as denial and repression; introjective patients tend to utilize counteractive mechanisms such as avoidance, projection, intellectualization, and rationalization. To some degree, this distinction is similar to Balint’s notion of ocnophilic versus philobatic personality types, with the former referring to those who rely heavily on others and see abandonment as the greatest threat and the latter being those who rely upon themselves, and fear closeness and the potential for the loss of boundaries (Balint, 1955). This distinction has therapeutic as well as diagnostic significance; Blatt and colleagues have shown that introjective patients respond best, at least initially, to the cognitive or interpretive aspects of dynamic psychotherapy, whereas anaclitic patients respond primarily to the relational aspects of treatment (Blatt & Ford, 1994). Obviously, the quality of the therapeutic relationship is ultimately central to all patients, and interpretation will have its role in the treatment of both kinds of pathology; at least in the initial phases of treatment, there should be a different focus. Winnicott, one of the most important analytic thinkers of the twentieth century, defined a “third area of human living,” one that was neither experienced as inside the individual nor in the outside world of shared experience. This area he termed potential space, and it is where play and creative living occur (Winnicott, 1971/ 1990, p. 106–110). Potential space is the heir to the transitional object, something that is neither created nor found, but a bit of both. Winnicott likened potential space to the shore, a place that is neither sea nor land, but at once both and neither. Ogden built upon Winnicott’s notion and suggested that many forms of psychopathology can be understood as collapses of potential space (1985). In the psychoses, the reality pole of experience is collapsed into the fantasy pole such that fantasy is substituted for reality. Where the fantasy pole is collapsed into the reality, experience is robbed of all of its personal meaning. This is what occurs in severe obsessional states, alexithymia, and what McDougall (1985) referred to as “normopathic” conditions. Finally, the connection between reality and fantasy

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may be severed such that each is experienced as a separate but equal reality. This occurs in some perversions and in dissociative disorders. Some 25 years ago, I proposed that this model can be applied fruitfully to Rorschach testing (Smith, 1990). I argued that Rorschach responses are quintessentially transitional phenomena, in that they require the integration of reality and fantasy; reality in that the blot is real and has definite features of form, color, shading, etc., and fantasy in that the subject must use his or her imagination to make sense of it. A Rorschach protocol, thus, is a measure of how successfully the subject can manage this reconciliation of inner and outer. Tibon and her colleagues in Tel Aviv have developed a Rorschach measure – the Reality–Fantasy Scale – that can be used to measure how well potential space is maintained and what kind of collapses may occur (Tibon, Handelzalts, & Weinberger, 2005; Tibon, Weinberger, et al., 2005; Zeligman, et al., 2012).

How Does the Object Relations Model Aid in Understanding Ms. B.? I am not going to attempt a complete analysis of this protocol; rather I will focus on some features of the case that can be understood in terms of the concepts I have discussed. In this way, I hope to address the referral questions posed by Dr. Kleiger. This is a very rich protocol; there are many aspects that might capture our attention – the relatively high X−%, suggestive of failures in reality testing, for example, or the low WSum6, which would seem to indicate the absence of a formal thought disorder. Perhaps the high Zf, Zd, and Blends:R, which would seem to imply a lot of effort in organizing her perceptual world. Or the paucity of pair responses, which could be reflective of low self-esteem or – more likely – a sense of interpersonal isolation. What I want to focus on instead, however, are three basic areas: evidence for a collapse of potential space in the protocol, the anaclitic/introversive dimension, and the nature of her object and self-representations and, therefore, her object relationships. Is there evidence for a psychotic collapse of the reality pole of potential space? Although there is a high number of poor form (FQ−) responses, the absence of formal thought disorder as well as the presence of numerous responses of good quality would seem to argue against such a conclusion. As Tibon’s work has demonstrated, a collapse of the reality pole into the fantasy on the Rorschach involves numerous responses scored for formal thought disorder (e.g., FABCOM, Rorschachiana (2017), 38(1), 12–21

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INCOM, ALOG, etc.). At the same time, the Lambda value of .47, the Blends:R of 7:28, and the high EA and es would certainly rule out a collapse of the fantasy pole. The latter typically involve impoverished protocols with minimal embellishment. This is clearly not the case with Ms. B. What about the “separate but equal” hypothesis? Here it gets really interesting. A careful examination of this protocol reveals a remarkable oscillation between responses that would appear to be reality-based and those that are more or less pure fantasy. The most striking data point in the entire Structural Summary, in my view, has to be the D of −2 and adjD of +1. This is a startling difference. The conventional interpretation, of course, would be that she has “adequate coping resources, but is under situational stress.” For a number of reasons, this is woefully inadequate. In the first place the amount of situational stress that this would imply would be roughly akin to that of a person in combat. Secondly, we must keep in mind that she reports being in good shape, denies suicidal ideation, and is itching to get back to school. How then to account for these data? The protocol has five Y responses, suggestive of high levels of diffuse anxiety – yet she reports none. More importantly, there are seven inanimate movement (m) responses. Although m is typically interpreted as intrusive ideation, a more dynamic understanding involves a sense of forces out of the subject’s control. Keep in mind, inanimate objects have no volition and cannot therefore move of their own accord. I would hypothesize that the D and adjD scores reflect two distinct ego states for Ms. B. One state, represented by the high EA and the adjD, is her as a competent, “in control” young woman. The second, represented by the five Y’s, seven m’s, and the D of −2 is the impulsive out-of-control self. The high number of m’s in this formulation also represents her sense that there is a part of her that is operating outside her control. This view of two radically different ego states has further support if we consider the sequence of responses. It is interesting to note that all but one of her nine minus responses occur on even-numbered cards as do both of her Sum6 special scores. In other words, she alternates between reality-based percepts on the odd cards and fantasy-based ones on the even-numbered cards. In order to test this notion empirically, I calculated a couple of indices for odd cards versus even. There were 12 responses to the odd, and 16 to the even. While the Lambda was the same, the XA% was 92% for the odd cards and only 50% for the even. The responses to the even cards were not only less accurate, they were more complex as well. On the odd cards, the Zd was 1.0 and there were two blends in 12 responses. By contrast, the even cards showed a Zd of 9.5 with five blends in 16 responses. If we look at the responses themselves, we can see evidence for a similar process. Her first two responses demonstrate extreme splitting as a defense, © 2017 Hogrefe Publishing

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a key component of dissociative processes. She first sees a goblin with fangs – clearly an aggressive image – followed by its diametric opposite: an angel. On Card II, she engages in a radical shift in visual perspective – which as Lerner (1998) has pointed out is another aspect of splitting – when she sees the blot as “two elephants dancing” or the “face of a moth.” This process was repeated on Card VI, where she saw the “giant Jesus” from Rio or a Kuchina doll. In short, we have good evidence for a split or dissociation between the reality and fantasy poles of experience. This is an important finding for a number of reasons. In the first place, it helps explain the rapid shifts in her ego states or clinical presentation. It is also the case that patients who rely on extreme splitting or dissociative defenses are at risk for impulsive self-destructive acting out without warning. Turning to the second focus – the introversive versus anaclitic dimension, we can see from her EB that she is pervasively introversive. Indeed, despite the richness of the protocol, she has only three color responses, and none before Card VIII. We might say that she relies much more heavily on thought and fantasy in coping. Her experience of stress and discomfort is also weighted toward the cognitive as opposed to the affective pole. As I mentioned before, this has significant implications for the conduct of psychotherapy; Blatt has suggested that patients such as this require a more active interpretive approach, rather than a more relational one (Blatt & Ford, 1994). The lack of overt signs of psychotic thinking also suggest that she is likely to be able to withstand more active interpretation without decompensating. In fact, I would surmise that she might very well find such interventions organizing for her. Let me also add in passing that Judith Armstrong has observed that dissociative subjects are often introversive because of their heavy reliance on fantasy (Armstrong, 2002). Finally, let us consider what we can glean about her object relations from the protocol. Given the heavy reliance on splitting, it should come as no surprise that her object representations are at the level of part-objects. Indeed, she has only one pure H response, two (H) responses, and seven images of part-objects, namely, Hd and (Hd). This is, of course, paradigmatic for a borderline level of organization and suggests that in her relationships she is likely to see the other as “all or none,” that is, all good and nurturing, or all bad and rejecting, etc. As we know, this is a template for relationship instability. Another key finding is the fact that she has only four pair responses. This leads to an Egocentricity Index of only .14. Now this is usually interpreted as low selfesteem, but as Mihura, Meyer, Dumitrascu, and Bombell, (2013) have pointed out, the evidence for the validity of this index is weak. I prefer to see the absence of pair responses as reflective of her tendency to experience herself or others in isolation or as disconnected from each other. In other words, she does not easily represent relationships. If we look a bit more deeply into the data, we can see Rorschachiana (2017), 38(1), 12–21

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more clearly why this may be the case. In the first place, she has two of what I call Texture Denial responses. These are responses that appear to involve texture as a determinant, but are not scored as such because she either does not mention it or denies it in Inquiry. Such responses, in my experience, tend to reflect dependent or affiliative needs that are outside of awareness and deeply ego dystonic or conflicted. This is in the context of an Ma:Mp ratio of 3:5, suggestive of passive-dependent fantasies. In addition, Ms. B. has a food response, which may reflect primitive oral dependency that is divorced from the interpersonal context. An examination of that response, the chipmunk that has stuffed his mouth too full with acorns, would seem to bear this out, as it represents an apparent out-of-control greed. I would suggest that Ms. B.’s object relations are highly inconstant in large part because of her primitive level of object representation. I would further speculate that highly conflicted primitive dependency needs – needs that she assiduously denies – further contribute to her tendency to isolate herself and avoid intimate involvement. To the extent that this hypothesis is accurate, it has profound implications for psychotherapy in that she may be vulnerable to the development of a negative therapeutic reaction. In other words, the development of a positive therapeutic alliance may trigger intolerable anxiety and paradoxically drive her away from therapy. Finally, there are many evocative responses in this protocol, but as is often the case, there is one that stands out as a “signature” answer. For Ms. B., I believe this to be Response 23: “A blender exploding” [humming softly]. Upon inquiry: “Looks like the clear part is the blender, the glass part and all this stuff, when blenders explode, they come out of the top. But this looks like it is coming out everywhere, leaking out at the bottom.” I believe that this response captures her sense of her own psyche – a whirring, buzzing confusion that she has attempted to keep contained, but is now both “exploding,” and “leaking out.” Not only that, but the image of a blender – a device that takes items with distinct identities and homogenizes them into a single mixture – may speak to her own unconscious wish to have her own disparate identities forged into a single coherent self.

Answering the Referral Questions In any Rorschach analysis, the most crucial point is that it be useful. Thus, let me spend the rest of my time responding to the questions posed at the outset of the symposium by Dr. Kleiger. Does Ms. B. still pose a suicidal threat? The S-Con of 8 would seem to point in that direction, but as we know, the S-Con is of limited utility other than to point out a vague risk. What is more troublesome, however, is the evidence for splitting © 2017 Hogrefe Publishing

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and dissociative tendencies. Perhaps the most striking finding in the entire protocol is the D of −2 and adjD of +1 in the context of a woman who claims to be stress-free and without worry. This points to severe anxiety, depression, and impulsivity that is outside her awareness, or else is in the awareness of a different ego state. As a consequence, she is at significant risk, in my view, for self-destructive acting out with little or no warning. This observation is reinforced by her comments in the extended inquiry phase of the final response: “(baffled as if)… His evil plan had been foiled but he was determined to make another evil plan.” Can there be much doubt that this is a reference to that dissociated part of her and its self-destructive wishes? I find this response chilling in the context of her history. Diagnostically, I see her as organized at a lower borderline level with a likely dissociative disorder. I do not see a lot of evidence that would suggest a bipolar disorder, although I do believe that her pathology lies more in the affective sphere than the schizophrenic. Of course, these days the bipolar spectrum has been expanded so greatly that it seems to be used for everyone who is not otherwise diagnosed with attention deficit hyperactivity disorder. Finally, what can we recommend about treatment? I do believe that allowing Ms. B. to resume her education at this point poses an unacceptable risk. Although there is obviously a part of her that denies any disturbance, it is clear that she is deeply troubled. In the best of all possible worlds, she would probably do best in a residential setting in which she could regress safely if necessary, but failing that, some kind of treatment that is frequent and consistent. In answer to the question about intensity, I believe that she needs therapy that is frequent – that is, several times a week – but nonintensive; if that makes any sense. My impression is that she will require a fairly lengthy period to learn to tolerate the dependency that comes with a strong therapeutic alliance. Given her pervasively introversive style, this may best be accomplished by an active, interpretive therapeutic stance, but one that eschews transference interpretations for ones that focus more on Ms. B.’s life outside of the therapy. In such a way, she can be engaged without being threatened. I want to stress that this analysis in no way constitutes a comprehensive interpretation of the incredibly rich protocol. There are, for instance, many observations that might be made about Ms. B.’s thought processes, the nature of her depression, etc. Instead, I have chosen to highlight those aspects of the protocol that speak to a few specific issues derived from object relations theory and to attempt to demonstrate how useful inferences about the patient and her treatment might be derived from them. Hopefully, along with the other contributions to this section, a fuller picture of this unfortunate young woman will emerge. Rorschachiana (2017), 38(1), 12–21

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References Armstrong, J. (2002). Deciphering the broken narrative of trauma: Signs of traumatic dissociation on the Rorschach. Rorschachiana, 25, 11–27. Balint, M. (1955). Friendly expanses–horrid empty spaces. International Journal of Psychoanalysis, 36, 225–241. Blatt, S. (1974). Levels of object representation in anaclitic and introjective depression. Psychoanalytic Study of the Child, 29, 107–157. Blatt, S. (1990). Interpersonal relatedness and self-definition: Two personality configurations and their implications for psychopathology and psychotherapy. In J. Singer (Ed.), Repression and dissociation: Implications for personality theory, psychopathology and health (pp. 299–335). Chicago, IL: University of Chicago Press. Blatt, S., & Shichman, S. (1983). Two primary configurations of psychopathology. Psychoanalysis and Contemporary Thought, 6, 187–254. Kernberg, O. (1976). Object relations and clinical psychoanalysis. New York, NY: Jason Aronson. Lerner, P. (1998). Psychoanalytic perspectives on the Rorschach. Matawah, NJ: Analytic Press. Mahler, M., Pine, F., & Bergman, A. (1975). The psychological birth of the human infant. New York, NY: Basic Books. McDougall, J. (1985). Theaters of the mind: Illusion and truth on the psychoanalytic stage. New York, NY: Basic Books. Mihura, J., Meyer, G., Dumitrascu, N., & Bombell, G. (2013). The validity of individual Rorschach variables: Systematic reviews and meta-analyses of the Comprehensive System. Psychological Bulletin, 139, 548–605. Ogden, T. (1985). On potential space. International Journal of Psychoanalysis, 66, 129–141. Smith, B. (1990). Potential space and the Rorschach: An application of psychoanalytic theory. Journal of Personality Assessment, 55, 756–767. Stolorow, R., & Lachmann, F. (1980). Psychoanalysis of developmental arrests. New York, NY: International Universities Press. Tibon, S., Handelzalts, J., & Weinberger, Y. (2005). The Rorschach Reality-Fantasy Scale (RFS). doi: 10.1037/t03349-000 Tibon, S., Weinberger, Y., Handelzalts, J., & Porcelli, P. (2005). Construct validation of the Rorschach Reality-Fantasy Scale in alexithymia. Psychoanalytic Psychology, 22, 508–523. doi: 10.1037/0736-9735.22.4.508 Winnicott, D. (1971/1990). Playing and reality. London, UK: Routledge. Yazigi, L., & Nashat, S. (2012). Learning from the inkblot. Rorschachiana, 33, 214–235. Zeligman, R., Smith, B., & Tibon, S. (2012). The failure to preserve potential space in dissociative disorders: A Rorschach study. Psychoanalytic Psychology, 28, 188–205. Received June 1, 2015 Revision received August 31, 2016 Accepted December 19, 2016 Published online July 13, 2017 Bruce L. Smith Department of Psychology University of California, Berkeley 2041 Bancroft Way, Suite 310 Berkeley, CA 94704 USA blsmith@berkeley.edu © 2017 Hogrefe Publishing

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Summary The case of Ms. B. was analyzed from the perspective of object relations theory. Object relations theory is a psychoanalytic model in which psychological processes are understood in terms of the relationships with objects – both internal and external. In this article both the theories of the so-called British School – that is, Klein, Winnicott, Fairbairn, etc. – and the American object relations theorists – Mahler, Kernberg, and the intersubjectivists – are considered. Two important object relations constructs were highlighted, the concept of “potential space,” as articulated by Winnicott (1971), and the introjective–anaclitic dimension of pathology first described by Blatt (1974). The case was then analyzed in terms of three key issues: the possible collapse of potential space, the introjective–anaclitic dimension, and the level of object representation. Ms. B.’s protocol was seen as manifesting a dissociative collapse of potential space in which two distinct ego states existed side by side. This was used to explain her impulsive self-destructiveness. She was seen to be pervasively introversive, which has significance for the most appropriate psychotherapeutic approach. Finally, the Rorschach revealed that her level of object representation was consistent with a borderline level of ego organization. Recommendations for treatment were also derived from these analyses.

Résumé Le cas de Mme B a été analysé du point de vue de la théorie des relations d’objet. Cette théorie est un modèle psychanalytique dans lequel les processus psychologiques sont compris en termes de relations avec les objets, à la fois internes et externes. Dans cet article, autant les théories de l’école britannique - Klein, Winnicott, Fairbairn, etc. – que l’école américaine représentée par des théoriciens comme Mahler, Kernberg, et les intersubjectivistes, sont employées. Deux types de relations d’objets majeurs ont été mis en évidence, le concept « d’espace potentiel », énoncé par Winnicott (1971), et la dimension introjective-anaclitique de la pathologie décrite par Blatt (1974). Le cas a ensuite été analysé en posant trois questions clés : l’effondrement possible de l’espace potentiel, la dimension introjective-anaclitique, et le niveau de la représentation de l’objet. Le protocole de Mme B a été considéré comme manifestant un effondrement dissociatif de l’espace potentiel dans lequel deux états du moi distincts existaient côte à côte. Cela a été utilisé pour expliquer son impulsivité auto-destructive. Son style est introversif généralisé (pervasive), ce qui pose la question du meilleur choix d’intervention thérapeutique. Enfin, le Rorschach a révélé que son niveau de représentation de l’objet était conforme à un niveau limite de l’organisation de l’ego. Des recommandations pour le traitement sont également proposées.

Resumen El caso de la Sra. B fué analyzado desde la perspectiva de la teoría de relaciones objetales. Ésta teoría es un modelo psicoanalítico según el cual procesos psicológicos son entendidos en términos de relaciones con objetos, tanto externos como internos. Este artículo primero considera las así llamadas escuelas británicas (Klein, Winnicott, etc.) y el aporte de teóricos norteamericanos de relaciones objetales (Mahler, Kernberg, los intersubjectivistas, etc.). Dos constructos importantes en la la teoría de relaciones objetales fueron enfatizados: el concepto del ‘espacio potencial’, propuesto por Winnicott (1971) y la dimensión introyectiva-anaclítica de psicopatología, descripta por primera vez por Blatt (1974). Luego, el caso fué abordado a través de tres elementos claves: la

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possible claudicación del espacio potencial, la dimensión introyectiva-anclítica y el nivel de representación objetal. De esta manera se permitió observar que el protocolo de la Sra. B muestra un colapso disociativo del espacio potencial en el cual dos estados diferentes del yo existen simultánemante, lo que fue empleado para explicar su auto-destructividad impulsiva. También se pudo ver que la Sra. B es predominantemente introversiva, que tiene importancia con respecto al tratamiento adecuado. Finalmente, el Rorschach reveló que el nivel de sus representaciones de relaciones objetales corresponde a un nivel fronterizo de organización del yo. Recomendaciones para tratamiento fuero derivadas de estos análisis.

要約 Ms.Bのケースを対象関係論の観点から分析をおこなった。対象関係論とは精神分析のモデルであり、そこでは心理的な過程が対象–内的な対象と外的な対象の両方–との関係性といった見地から理解される。本論文では、いわゆる英国学派、すなわちクラインやウィニコット、フェアバーンなどの諸理論と、米国の対象関係論者–マーラーやカーンバーグ、そして間主観主義者—の諸理論の両方が検討された。二つの重要な対象関係論の構成概念に焦点が当てられた、ひとつはウィニコット（1971）によって明確にされた”可能性空間”の概念であり、もうひとつはBlatt（1974）によってはじめて記述された病理の取り入れ–依託の次元である。このケースは3つのカギとなる論点から分析されている、可能性空間が崩壊しているかもしれないこと、取り入れ–依託の次元、対象の表象のレベル、である。Ms.Bのプロトコルは可能性空間のあきらかな解離性の崩壊がみられており、そこではあきらかな二つの別の自我状態が併存していた。これは彼女の衝動的な自己破壊行動を説明することができる。彼女は広範的な内向型であるとみられており、このことが彼女に最も適切な心理療法のアプローチにとって重要であった。最終的には、ロールシャッハ法は、彼女の対象表象の水準は、境界性レベルの自我構造に該当していた。この分析から推奨できる治療法が導き出された。

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Case Study Special Issue: Multiple Psychoanalytic Models Case Study

Ego Psychoanalytic Rorschach Interpretation Irving B. Weiner Department of Psychiatry and Behavioral Neurosciences, University of South Florida, Tampa, FL, USA Abstract: This article concerns the utility of ego psychoanalytic perspectives in Rorschach interpretation. Psychoanalytic ego psychology focuses on how people cope with events in their lives and how effectively they can meet challenges to their sense of well-being. The way people deal with experienced distress constitutes their defensive style and determines to a large extent what kind of person they are. Adequate defenses against anxiety promote comfortable and productive adjustment, whereas ineffective defenses typically cause adjustment difficulties and susceptibility to psychological disorders. In Rorschach assessment, the nature and effectiveness of a person’s defensive style can often be identified with a sequence analysis that integrates the structural, thematic, and behavioral features in the protocol. In particular, the sequential quality of responses, especially preceding and following instances of cognitive slippage, can help identify causes of upsetting concerns, defensive efforts to alleviating these concerns, and the adequacy of these defensive efforts in restoring equanimity. This interpretive process is illustrated with attention to implications for differential diagnosis and treatment planning in the Rorschach protocol of a 20-year-old suicidal woman. Keywords: Rorschach interpretation, personality assessment, differential diagnosis, psychoanalytic models

Ego psychoanalytic psychology is sometimes dismissed as a theoretical relic of the past, long eclipsed in relevance and utility by more complex and sophisticated models for conceptualizing the intricacies of personality processes. To the contrary, however, ego analytic formulations are alive and well, and even in contemporary times they can provide valuable diagnostic and treatment planning guidelines that might otherwise not emerge in a clinical evaluation. The following paragraphs review the origins and basic tenets of psychoanalytic ego psychology, describe the application of ego analytic perspectives in Rorschach interpretation, and illustrate an ego analytic interpretive approach to Ms. B.’s Rorschach protocol.

Origins and Tenets of Psychoanalytic Ego Psychology Sigmund Freud (1923/1961) developed a structural model of the mind comprising id, ego, and superego components, and in The Ego and the Id he elaborated some Rorschachiana (2017), 38(1), 22–32 DOI: 10.1027/1192-5604/a000086

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implications of the relationship among them. As noted by Pine (1990), however, classical Freudian psychoanalysis remained primarily a drive-based theory, and the seminal contribution to psychoanalytic ego psychology is usually considered to be Anna Freud’s (1936/1946) The Ego and Mechanisms of Defence. Whereas S. Freud conceived of personality development in terms of drive-induced conflicts resulting in fixations and compromise formations, A. Freud emphasized the role in personality formation of the defensive functions of the ego that are employed to contain or defend against conflict-induced anxiety. This ego-psychological focus on personality development was subsequently expanded by Hartmann (1939/1958) in Ego Psychology and the Problem of Adaptation to include basic coping capacities as well as defensive maneuvers. Hartmann introduced the notion of a conflict-free sphere of ego operations (e.g., perception, thinking, memory, intention) that emerge independently of a person’s impulse life and affect the ability of people to adapt effectively to their life circumstances. In brief, then, the essence of ego psychology is the manner in which people cope with events in their lives and the adequacy of the psychological resources they can bring to bear when faced with challenges to their sense of well-being. The types of coping resources people employ determine to a large extent what kind of person they are, and adequate coping resources promote comfortable and productive adjustment. Insufficient coping resources or ineffective use of available coping resources, on the other hand, typically lead to adjustment difficulties, and some ineffective defensive maneuvers create susceptibility to particular types of psychological disorder. Excessive reliance on projection as a defense against anxiety can render people prone to paranoia, for example, and excessive reliance on denial is often a contributing factor in hypomania. Following A. Freud and Hartmann, the next seminal contribution to psychoanalytic ego psychology was Erik Erikson’s (1959, 1963) epigenetic formulations. In Childhood and Society, Erikson described distinct stages of the life cycle from infancy to late life, identified developmental demands that impinge on people during each of these stages, and proposed connections between how people deal with these demands and their emerging personality style and the quality of their adjustment. Two other classic books that elaborated the role of coping styles in shaping personality characteristics and adaptive capacity are Wilhelm Reich’s (1933/1949) Character Analysis and David Shapiro’s (1965) Neurotic Styles. More recent contributions of note in this area include George Vaillant’s (1995) Wisdom of the Ego, which discusses the lifespan development of defense mechanisms during the Eriksonian stages, and presentations by Thomas Beresford (2012), Fred Busch (1995, 2013), Paul Gray (1994), and Gertrude and Rubin Blanck (1994) of ego psychology guidelines for the clinical practice of psychotherapy. © 2017 Hogrefe Publishing

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Of further note with respect to the psychological assessment of ego mechanisms of defense are the development by Paul Lerner (2005) of the Lerner Defense Scale for use in Rorschach interpretation and by Phoebe Cramer (2006, 2015) of the Defense Mechanism Manual to enrich the interpretation of TAT stories.

Application of Ego Analytic Perspectives in Rorschach Interpretation The application of psychoanalytic ego psychology in Rorschach interpretation was pioneered by David Rapaport and Roy Schafer and first elaborated in Schafer’s 1954 book Psychoanalytic Interpretation in Rorschach Testing. Schafer emphasized in this book the interpretive benefit of integrating the structural, thematic, and behavioral data in a Rorschach protocol to identify the nature and effectiveness of a person’s preferred ways of defending against anxiety. To this end, he devoted two thirds of his book to the assessment of defensive style, the manifestations of preferred defensive style in certain personality characteristics, and the maladaptive consequences of excessive reliance on the defense mechanisms of repression, projection, denial, isolation, intellectualization, undoing, and reaction formation. Following Schafer’s lead, and with full acknowledgement of his contribution, I devoted separate chapters in my book Principles of Rorschach Interpretation (Weiner, 2003) to the structural, thematic, and behavioral variables in a Rorschach assessment and to their integration in a sequence analysis. As far as I know, mine was the only Rorschach text since Schafer’s 1954 book to provide a systematic description and illustrations of sequence analysis. Also of note, however, is a Rorschachiana contribution in which Baba (1995) compared a Rorschach Comprehensive System case interpretation with a psychoanalytic sequence analysis, and Peebles-Kleiger (2002) and Silverstein (2013) have more recently emphasized and demonstrated the often overlooked utility of a sequential analysis interpretive procedure. One particularly informative way of conducting a sequence analysis to identify the nature and effectiveness of a person’s coping resources consists of focusing on the minus form (FQ−) responses in a record. An FQ− response constitutes a cognitive breakdown in which some upsetting concern has apparently impaired the individual’s reality testing and evoked a percept that bears little or no resemblance to the portion of the blot where it is seen. The concerns that cause FQ− responses sometimes derive from disturbing aspects of the response immediately preceding them; sometimes from disturbing associations to the thematic Rorschachiana (2017), 38(1), 22–32

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imagery in the FQ− response itself; and sometimes from upsetting but unreported associations to features of the blot (e.g., female sexual anatomy suggested by the bottom center detail on Card VII; the bright red on Card II generating associations to blood, anger, or aggression; the dysphoric quality of the heavy dark shading on Card VI). An ego psychoanalytic sequence analysis considers the possible trigger of each FQ− response and then examines the responses that follow this response to determine (a) how the person characteristically attempts to reduce or escape from distressing thoughts, feelings, and impulses and (b) how successful the person is in overcoming the disruption reflected in the FQ− response and re-establishing an effective level of functioning.

An Ego/Defense Sequence Analysis of Ms. B.’s Rorschach To facilitate a sequence analysis of Ms. B.’s ego functioning, with particular attention to the nature and adequacy of her defenses against anxiety, there are nine minus form level (FQ−) responses in her 28-response record. Each of these FQ− responses constitutes a breakdown in reality testing, and the structural, thematic, and behavioral components of these nine responses and the responses immediately preceding and following them help to identify features of her personality functioning that have a bearing on the referral questions. 1. The first FQ− in the record is a cat in Response 3 on Card II. This response follows a Morbid percept in Response 2 on Card I of a goblin or angel without a head. The angel/goblin response suggests some distressing ambivalence in her self-image (good person/bad person, attractive/ugly, perhaps someone without a good head on her shoulders) that may have led to the cognitive slippage in the FQ− cat. She recovers well in Response 4 with two elephants dancing, which is an ordinary form Popular and a cooperative M. However, this good recovery has a regressive quality, in that it takes distance from people (although allowance must be made for the card pull of the animal Popular on this card). Of more concern is her inability to maintain this recovery, the fragility of which is indicated by her next response on Card II, which is another minus. 2. Still on Card II, then, her second FQ− is “the face of a moth” in Response 5. Once more she shows some good recovery, with Response 6 on Card III as people playing tribal drums, which is a good form Popular M. Of likely significance, however, is her inclusion of an Anthropology (Ay) feature in the response, which suggests reliance on intellectualization as a way of taking distance from situations that might be troubling.

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3. The third FQ− is a skeleton or skull seen in Response 10 on Card IV. This response follows a Morbid “giant without any arms” in Response 9, which could represent a fearsome object that she disempowers by taking away its arms, but remains distressed by it. Following the FQ− skeleton or skull, she recovers well on Card V with Response 11, a good form Popular bat. Notably, however, she achieves this recovery by shutting down. She limits Card V to just one response (there are multiple responses to all of the other cards), and she limits this single response to just one word, “bat.” This response style speaks to an avoidant, repressive manner of coping with distress, and the test behavior noted by the examiner is consistent with this impression. The examiner notes that she was shaking her foot at this point (suggesting tension) and that she put the card face down, which she was not noted as having done on any previous card and which speaks further to an “out of sight, out of mind” repressive style. 4. The fourth FQ− response is “A Great Dane” in Response 12 on Card VI. She hesitates in delivering this response (“A – uh . . .”) and says “everything but the thing on top,” and she then describes the Great Dane as having “a saggy face and cheeks” and being “like a dog looks at you for praise.” There are several sources of distress that could have contributed to her break with reality in this perceptually inaccurate response. Like the giant in Card IV, the Great Dane is a potentially dangerous figure to be feared (perhaps reflecting a sense of vulnerability); like the giant, however, it is rendered harmless, in this instance by being seen in the subservient position of pleading for praise (which along with the predominance of passive movements in her record may touch on some passive-dependent needs for succor and reassurance). Perhaps she was disturbed by the phallic resemblance of the top part of this blot, which she made a point of excluding from her percept. Whatever the source of her distress might have been, she recovers well with a perceptually accurate statue of Jesus on a mountain in Rio in Response 13 on this card, with the Ay feature of this response again pointing to defensive reliance on intellectualization. She continues this recovery with another intellectualized Ay but good form percept, the Kuchina doll in Response 14. However, she stays with Card VI, and her recovery is once more short-lived. 5. Following the slippage with the FQ− Great Dane (Response 12) and her recovery with the Jesus on a mountain in Rio (Response 13) and the Kuchina doll (Response 14), she gives another perceptually accurate response with the fur carpet percept in Response 14 on Card VI – although she again shows some concern about her vulnerability with the Morbid elaboration “you can tell where the legs were chopped off.” And then her reality testing slips once more with her fifth FQ− in Response 15, in which she sees a volcano Rorschachiana (2017), 38(1), 22–32

Ego Psychoanalytic Rorschach Interpretation

with lava shooting out of the top. Aside from whether she was still upset by the dangerous animal, the plea for praise, or the chopped off legs, she was quite probably upset anew by sexual associations to the “thing on top” now spewing lava. She is not able to muster any adequate intellectualized defense against her distress in this instance, and she instead resorts once more to repression by putting the card face down. This sequence carries over into Card VII, where in Response 17 she recovers from the FQ− volcano with the Popular response of women talking – but then disparages them by referring to their “weird hairdos.” On Response 18 she retreats to a vague impersonal pile of rocks and to card description (“how the bottom pieces are big and get smaller”), which are repressive ways of taking distance from what the blots might be suggesting, and then she slips into her sixth FQ−. Still on Card VII, she gives her sixth FQ− in Response 19 with a “necklace,” which she describes as a “clunky thing” with “fake jewels” and “a gaudy necklace I’d never wear.” By implying that other people might wear such a “cheap gold thing” but she would not, this second disparaging comment suggests she may have needs to bolster her self-esteem by putting down others and convincing herself that she is as good as or better than they are. Noteworthy in this regard are her Egocentricity Ratio of .14 and the four Morbid and five m’s suggesting that she feels weak, vulnerable, and helpless. Returning to the sequence here, she recovers quickly with Response 20 on Card VII, the good form M and optimistic “thumbs up,” to which she adds, “Hey, good for you!” Perhaps, however, this “thumbs up” response says more about her need for self-reassurance than about a generally positive outlook – and this recovery quickly fades when she begins Card VIII. Despite the easy Popular available on Card VIII, she starts in Response 21 with an FQ− dress, which she describes as a “mid-1900 dress.” Once more she takes distance with an intellectualizing Ay, perhaps because she was still upset by the women interacting in Response 17 or by the need for reassurance and forced optimism suggested by Response 20. However, the Ay intellectualization does not work in this instance, as indicated by the FQ− response, and once more she puts the card face down, which as previously noted is a repressive way of closing the door and shutting down. Both of the last two responses in the record are perceptually inaccurate and give further weight to inferences drawn from previous sequences. Her eighth FQ− is Response 27 on Card X, the Ay Eiffel Tower, which by virtue of distorting reality is an instance of ineffective intellectualization. The ninth FQ− occurs in Response 28, “A man in sunglasses with a goofy moustache” who in addition to being described critically (the goofy moustache) is fictitiously elaborated as “suspicious European spy” whose

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“evil plan has been foiled, but he’ll make another one.” This further unsuccessful effort at intellectualization is thus accompanied by the fantasy of someone who is potentially dangerous and not to be trusted. Her elevated Hypervigilance Index confirms the sequence analysis indications of concerns about being uncomfortable with interpersonal closeness and perhaps fearful of coming to harm at the hands of others. Of further concern is the fact that she has ended the record poorly, with two FQ− responses. Ending poorly in this way often signifies deteriorating psychological integrity and has negative prognostic implications, which in her case means that matters may be on the verge of taking a turn for the worse.

Diagnostic Implications and Treatment Recommendations In summary, this sequence analysis examining the precursors, onset, and subsequent impact of Ms. B.’s nine FQ− responses suggests that she is a psychologically fragile woman who is notably susceptible to losing touch with reality and exercising poor judgment when she becomes distressed. She defends herself by distancing, primarily in two ways that constitute an unusual combination – intellectualization (a relatively mature defense) and repression (a relatively immature defense). However, both defenses work only temporarily, neither is particularly effective, and their combination suggests that her behavior is likely to be inconsistent and difficult to predict. With respect to the referral question concerning suicide risk, the sequence analysis suggests that she is depressed and may be at risk for harming herself, that she needs monitoring and supervision, and that she should not merely return to her dormitory at the present time. With respect to diagnostic possibilities, the sequence analysis suggests that she is vulnerable to psychotic symptoms (her impaired reality testing) and to dissociation (her repressive style). Depression is in evidence, but there is little indication of hypomanic tendencies, which makes an emerging bipolar disorder unlikely. A possible role of posttraumatic stress disorder in her condition should be considered, because she shows fears of vulnerability and being harmed, concerns about being helpless, and hypervigilance. With respect to treatment implications, this appears despite her protestations to the contrary to be a situation calling for crisis intervention. Long-term treatment goals are readily apparent – improved self-esteem, increased comfort around people, decreased helplessness and fears of vulnerability – but what is called for now is frequent-session supportive therapy, with dependable supervision at home if she is seen as an outpatient. Rorschachiana (2017), 38(1), 22–32

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References Baba, R. (1995). A comparative study of the Comprehensive System and a psychoanalytic sequence analysis. Rorschachiana, 20, 64–92. Beresford, T. P. (2012). Psychological adaptive mechanisms: Ego defense recognition in practice and research. New York, NY: Oxford University Press. Busch, F. (1995). The ego at the center of clinical technique. Northvale, NJ: Aronson. Busch, F. (2013). Transforming the under-represented: The unacknowledged influence of ego psychology. Canadian Journal of Psychoanalysis, 21, 292–312. Blanck, G., & Blanck, R. (1994). Ego psychology: Theory and practice (2nd ed.). New York, NY: Columbia University Press. Cramer, P. (2006). Protecting the self: Defense mechanisms in action. New York, NY: Oxford University Press. Cramer, P. (2015). Defense mechanisms: 40 years of empirical research. Journal of Personality Assessment, 97, 114–122. Erikson, E. H. (1959). Growth and crises of the healthy personality. Psychological Issues, 1, 50–100. Erikson, E. H. (1963). Childhood and society (2nd ed.). New York, NY: Norton. Freud, A. (1946). The ego and mechanisms of defense. New York, NY: International Universities Press (Original work published 1936). Freud, S. (1961). The ego and the id. Standard edition (Vol. 19, pp. 12–66). London, UK: Hogarth Press (Original work published 1923). Gray, P. (1994). The ego and analysis of defense. Northvale, NJ: Aronson. Hartmann, H. (1958). Ego psychology and the problem of adaptation. New York, NY: International Universities Press (Original work published 1939). Lerner, P. M. (2005). Defense and its assessment: The Lerner Defense Scale. In R. F. Bornstein & J. M. Masling (Eds.), Scoring the Rorschach: Seven validated systems (pp. 237–269). Mahwah, NJ: Erlbaum. Peebles-Kleiger, M. J. (2002). Elaboration of some sequence analysis strategies: Examples and guidelines for level of confidence. Journal of Personality Assessment, 79, 39–52. Pine, F. (1990). Drive, ego, object, and self: A synthesis for clinical work. New York, NY: Basic Books. Reich, W. (1949). Character analysis (3rd ed.). New York, NY: Orgone Institute Press (Original work published 1933). Schafer, R. (1954). Psychoanalytic interpretation in Rorschach testing. New York, NY: Grune & Stratton. Shapiro, D. (1965). Neurotic styles. New York, NY: Basic Books. Silverstein, M. L. (2013). Personality assessment in depth: A casebook. New York, NY: Routledge. Vaillant, G. E. (1995). Wisdom of the ego. Cambridge, MA: Harvard University Press. Weiner, I. B. (2003). Principles of Rorschach interpretation (2nd ed.). Mahwah, NJ: Erlbaum. Received May 22, 2015 Revision received September 14, 2016 Accepted December 19, 2016 Published online July 13, 2017

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I. B. Weiner

Irving B. Weiner Department of Psychiatry and Behavioral Neurosciences University of South Florida 13716 Halliford Drive Tampa, FL 33624 iweiner@health.usf.edu

Summary Psychoanalytic ego psychology concerns the manner in which people cope with events in their lives and the adequacy of the psychological resources they can bring to bear when faced with challenges to their sense of well-being. The way people deal with anxiety constitutes their defensive style and determines to a large extent what kind of person they are. Adequate defenses against anxiety promote comfortable and productive adjustment, whereas ineffective defenses typically cause adjustment difficulties and susceptibility to psychological disorders. Excessive reliance on projection as a defense against anxiety can render people prone to paranoia, for example, and excessive reliance on denial is often a contributing factor in hypomania. A useful application of ego psychology in Rorschach assessment consists in identifying responses that reflect some upsetting concerns, observing how the person attempts to alleviate the distress caused by these concerns, and noting how successful the person’s defensive efforts are in re-establishing a sense of equanimity. Such patterns of anxiety, defense, and recovery can be assessed in a Rorschach protocol by a sequence analysis that integrates the structural, thematic, and behavioral data in a Rorschach protocol to identify the nature and effectiveness of a person’s preferred ways of defending against anxiety. One particularly informative way of conducting a sequence analysis to identify the nature and effectiveness of a person’s coping resources consists in focusing on the minus form (FQ−) responses in a record. An FQ− response constitutes a cognitive breakdown in which some upsetting concern has apparently impaired the individual’s reality testing and evoked a percept that bears little or no resemblance to the portion of the blot where it is seen. The concerns that cause FQ− responses sometimes derive from disturbing aspects of the response immediately preceding them; sometimes from disturbing associations to the thematic imagery in the response itself; and sometimes from upsetting but unreported associations to features of the blot. An ego psychoanalytic sequence analysis considers the possible trigger of each FQ− response and then examines the responses that follow this response to determine (a) how the person characteristically attempts to reduce or escape from distressing thoughts, feelings, and impulses and (b) how successful the person is in overcoming the disruption reflected in the FQ− response and re-establishing an effective level of functioning. The present article illustrates this interpretive approach with discussion of the nine FQ− responses in Ms. B.’s Rorschach protocol.

Résumé La psychologie psychanalytique de l’ego concerne la manière dont les gens font face aux événements dans leur vie et l’adéquation des ressources psychologiques qu’ils peuvent apporter lorsqu’ils sont confrontés à des défis pour leur sens du bien-être. La façon dont les gens s’occupent de l’anxiété constitue leur style défensif et détermine dans une large mesure quel type de personne ils sont. Des défenses adéquates contre l’anxiété favorisent un ajustement confortable et productif,

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alors que les défenses inefficaces causent généralement des difficultés d’ajustement et une susceptibilité aux troubles psychologiques. Une dépendance excessive sur la projection comme une défense contre l’anxiété peut rendre les personnes sujettes à la paranoïa, par exemple, et une dépendance excessive sur le déni est souvent un facteur contribuant à l’hypomanie. Une application utile de la psychologie du moi dans l’évaluation du Rorschach consiste à identifier les réponses qui reflètent certaines préoccupations, en observant comment la personne essaie d’atténuer la détresse causée par ces préoccupations et notant à quel point les efforts de défense de la personne réussissent à rétablir un sentiment de sérénité. De tels modèles d’anxiété, de défense et de récupération peuvent être évalués dans un protocole de Rorschach par une analyse de séquence qui intègre les données structurelles, thématiques et comportementales, pour identifier la nature et l’efficacité des moyens préférés de la personne à se défendre contre l’anxiété. Une façon particulièrement instructive de mener une analyse de séquence pour identifier la nature et l’efficacité des ressources d’adaptation d’une personne consiste à se concentrer sur les réponses de forme moins (FQ-) dans un enregistrement. Une réponse de FQ constitue une panne cognitive dans laquelle une préoccupation inquiétante a apparemment altéré le test de la réalité de l’individu et a évoqué une perception qui ressemble peu ou pas à la partie de la tâche où elle se voit. Les préoccupations qui causent les réponses de FQ proviennent parfois des aspects perturbateurs de la réponse qui les précède immédiatement ; Parfois des associations perturbatrices à l’imagerie thématique dans la réponse elle-même ; Et parfois des associations perturbatrices mais non signalées aux caractéristiques de la tache. Une analyse de la séquence psychanalytique de l’ego considère le déclencheur possible de chaque réponse de FQ puis examine les r eponses qui suivent cette réponse pour déterminer (a) comment la personne essaie de réduire ou d’ echapper à des pensées, des sentiments et des impulsions pénibles et (b) comment le succès de la personne consiste à surmonter la perturbation reflétée dans la réponse FQ et à rétablir un niveau de fonctionnement efficace. Cet article illustre cette approche interprétative avec la discussion des neuf réponses FQ dans le protocole Rorschach de Mme B.

Resume Psicología del yo psicoanalítica se refiere a la manera en que las personas a lidiar con los eventos en sus vidas y la adecuación de los recursos psicológicos que pueden aportar a dar cuando se enfrentan con desafíos a su sentido de bienestar. La forma en la gente a lidiar con la ansiedad constituye su estilo defensivo y determina en gran medida qué tipo de persona que son. Defensas adecuadas contra la ansiedad promueven ajuste cómodo y productivo, mientras que las defensas ineficaces suelen causar dificultades de adaptación y la susceptibilidad a los trastornos psicológicos. La excesiva dependencia de proyección como defensa contra la ansiedad puede hacer que las personas propensas a la paranoia, por ejemplo, y la excesiva dependencia de la negación es a menudo un factor que contribuye a la hipomanía. Una aplicación útil de la psicología del yo en la evaluación de Rorschach consiste en identificar las respuestas que reflejan algunas preocupaciones inquietantes, observando cómo la persona intenta aliviar el sufrimiento causado por estas preocupaciones, y observando el éxito de los esfuerzos defensivos de la persona están en el restablecimiento de un sentido de la ecuanimidad. Estos patrones de ansiedad, la defensa, y la recuperación se pueden evaluar en un protocolo de Rorschach por un análisis de la secuencia que integra los datos estructurales, temáticas y de comportamiento en un protocolo de Rorschach para identificar la naturaleza y la eficacia de formas preferidas de una persona de la defensa contra la ansiedad. Una forma particularmente informativa de la realización de un análisis de la secuencia para identificar la naturaleza y la eficacia de los recursos de afrontamiento de una persona consiste

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en centrarse en la forma menos (FQ-) respuestas en un registro. Una respuesta FQ- constituye una ruptura cognitiva en la que cierta preocupación molesto al parecer ha afectado prueba de la realidad de la persona y evocado una percepción que tiene poco o ningún parecido con la parte de la mancha donde se ve. Las preocupaciones que causan respuestas FQ- veces derivan de aspectos preocupantes de la respuesta inmediatamente anterior ellos; a veces desde las asociaciones inquietantes a la imaginería temática en la propia respuesta; ya veces de asociaciones inquietantes pero no reportados a las características de la mancha. Un análisis de la secuencia psicoanalítica ego considera el posible desencadenante de cada respuesta FQ- y luego examina las respuestas que siguen a esta respuesta para determinar (a) cómo la persona característicamente intenta reducir o escapar de los pensamientos angustiosos, sentimientos e impulsos y (b) cómo éxito de la persona está en la superación de la interrupción se refleja en la respuesta FQ- y el restablecimiento de un nivel efectivo de funcionamiento. El presente artículo ilustra este enfoque interpretativo con la discusión de los nueve respuestas FQ- en protocolo de Rorschach de la señora B.

要約精神分析的自我心理学は人々が彼らの生活の中の出来事に対処する仕方と、彼らの幸福感に対して脅威となるものに直面した際にそこに向けることができる心理的な資源の適切さに関係している。人々が不安に対処する方法は彼らの防衛スタイルを構成し、彼らがどのような人であるかについてかなりの程度を決定するものとなる。不安に対する適切な防衛は快適で生産的な適応を促進し、一方、効率的でない防衛は典型的に適応の困難と心理的な障害への脆弱性を高める。例えば、不安に対する防衛として過剰に投影に頼ることは、パラノイアになりがちにするであろうし、否認に過剰に頼ることはしばしば軽躁病の寄与因子となる。ロールシャッハ・アセスメントに自我心理学の役に立つ適用は、混乱している関心を反映している反応を同定することや、人々がこの関心によって引き起こされる苦悩をどのように緩和しようとするのかを観察し、平静さを再構築しようとするその人の防衛の努力がどのように成功しているかに注目することから成り立っている。このような不安と防衛と回復のパターンはロールシャッハ・プロトコルを継起分析することで査定でき、継起分析ではロールシャッハ・プロトコルの構造的、主題的、行動的データが、その個人の不安に対する防衛の好みの方法の性質と効果を同定するために統合される。その人の対処資源の本質と効果を同定する継起分析をおこなうひとつのとりわけ有益な方法は、記録にあるマイナスの形態水準の反応（FQ-）に焦点を当てることからなりたっている。FQ-反応は、そこでは混乱している関心が明らかに現実検討を傷害しており、その反応がみられるブロットの領域にわずかしか、あるいはまったく類似がない知覚を呼びおこすという認知的な崩壊を構成している。FQ-反応を引き起こす関心は、しばしばすぐさまにそのような現象を促進する反応の混乱している側面に由来している：しばしば反応そのものにある主題のイメージに対する混乱した連想に由来している：しばしばブロットの特徴に対する混乱しているが報告されることがない連想に由来している。自我心理学的継起分析はそれぞれのFQ-反応の可能性のある誘因をよく考慮し、そしてこの反応に続く反応を吟味して、(a)その人がどのように苦悩を与える思考や感情や衝動を減らしたり、そこから逃れたりする特徴的な努力をしているか、(b)その人がどのようにFQ-反応に反映されている混乱に打ち勝つことや、効果的な機能のレベルを再構築することに成功しているか、ということを見極めている。本論文は、Ms.Bのロールシャッハ・プロトコルにある９つのFQ-反応を考察する解釈アプローチを例示している。

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Case Study Special Issue: Multiple Psychoanalytic Models Case Study

An Interpersonal Approach to Rorschach Interpretation F. Barton Evans East Tennessee State University College of Medicine, Johnson City, TN, USA Abstract: In response to Kleiger’s (this issue) unique invitation to interpret a Rorschach case study from multiple psychoanalytic perspectives, I was asked to present a Rorschach interpretation from Sullivan’s interpersonal psychodynamic theory (IPT) perspective. In reviewing the literature, I found no theoretical papers specifically addressing IPT Rorschach interpretation. As such this article will be an initial attempt to integrate the Rorschach with IPT. I will present a brief overview of some of Sullivan’s most relevant IPT concepts, suggest where to find them on the Rorschach Comprehensive System (CS), and apply IPT Rorschach variables to the case of Ms. B. Special attention will be given to how the IPT model aids in the dynamic understanding of the Ms. B.’s internal experience and personality functioning; what formal features of the Rorschach lend themselves to key constructs in the model; and how the IPT model addresses the referral questions and adds to an understanding of treatment issues, including likely transference/countertransference themes. Keywords: Rorschach, interpersonal theory, Sullivan, psychodynamic

There has been much interesting research on aspects of interpersonal functioning on the Rorschach (e.g., Bornstein 2007; Bornstein, Becker-Matero, Winarick, & Reichman 2010; Moore, Viglione, Rosenfarb, Patterson, & Mausbach 2013; Rivera & Viglione, 2010) as well as attachment models (Berant, Mikulincer, Shaver, & Segal 2005). While Finn (2007, 2011) incorporates IPT into his conceptualization of therapeutic assessment, his work focuses more generally on its impact on psychological assessment rather that the Rorschach specifically. Exner (Exner, 2003; Exner & Erdberg, 2005) outlined empirically based variables interpersonal and self-concept functioning in two of the clusters from the Rorschach Comprehensive System (CS), but Exner eschewed a theoretical orientation to CS. I could find no systematic work specifically addressing IPT Rorschach interpretation, and James Kleiger’s invitation to serve on the “Rorschach Case Study: Multiple Psychoanalytic Models of Interpretation” panel presented me with a formidable challenge. What follows is my attempt to integrate the work of Harry Stack Sullivan into an interpersonal psychodynamic interpretation of the Rorschach. © 2017 Hogrefe Publishing

Rorschachiana (2017), 38(1), 33–48 DOI: 10.1027/1192-5604/a000087

F. B. Evans

Key Principles of Interpersonal Theory Harry Stack Sullivan Harry Stack Sullivan (1892–1949), an American psychiatrist and psychoanalyst working in the 1930s and 1940s, was the founder and chief proponent of a model of psychoanalytic thinking called variously interpersonal psychiatry or interpersonal psychoanalysis. Along with Erich Fromm (1996) and Karen Horney (1937), Sullivan is perhaps best known for his social psychologically based critique of Sigmund Freud’s psychoanalytic drive theory, in which Sullivan emphasized the role of social development and culture in the formation of personality. Harry Stack Sullivan occupies a unique and puzzling place in both the historical and contemporary thinking of psychodynamic theory and psychotherapy. On the one hand, his interpersonal theory (Sullivan, 1953) was formerly regarded by many mainstream psychoanalytic writers as superficial or incorrect as they believed Sullivan gave little regard to the importance of intrapsychic experience. The critiques of Edith Jacobson (1955) and Otto Kernberg (1976) are most representative of this point of view. On the other hand, important scholars of comparative psychodynamic theory have claimed Sullivan’s departure from classic psychoanalytic drive theory and technique as the other most important stream of thought in psychoanalytic theory along with Freud. Leston Havens (1973) has long noted the importance of Sullivan’s contributions, calling him “the most original figure in American psychiatry,” and stating that his thinking “secretly dominates” modern psychodynamic psychiatry in the United States (Havens & Frank, 1971, p. 1704). In their groundbreaking book on object relations theory, Greenberg and Mitchell (1983) consider Sullivan’s interpersonal theory and Freud’s drive theory to be the two most significant conceptual models of object relation theory. Greenberg and Mitchell (1983) stated that Sullivan presented ideas that “have resurfaced, at times in strikingly unaltered form, within the most important and popular Freudian authors of the past decade. Yet he [Sullivan] is rarely credited with originating these approaches and ideas” (p. 81). While it beyond the scope of this article to fully summarize IPT, the reader is referred to Evans (1997) for a comprehensive overview of Sullivan’s theory and approach to psychotherapy. It is also important to note that Sullivan (1954) provided one of the earliest systematic approaches to personality assessment, which he outlined in his most widely read book, The Psychiatric Interview. Sullivan focused on ways to conduct a detailed inquiry into the person’s interpersonal relationships, in terms of the person’s view of the self and others, problems in living, and the rest of the personality beyond the person’s problems. Unlike the more free-form psychoanalytic “blank screen” assessment approach, Sullivan advocated a methodic, Rorschachiana (2017), 38(1), 33–48

Interpersonal Rorschach Interpretation

semistructured interview procedure, which provided a systematic model for assessment and intervention. Through careful assessment of interpersonal dynamisms and style by means of the psychiatric interview, Sullivan crafted specific responses to his client’s dilemmas. In light of Sullivan’s deep respect for empirical approaches, modern Rorschach CS and other personality assessment methods are well within the general thrust of the IPT model. Interpersonal Theory: Some Basic Concepts Sullivan (1938) stated that psychoanalysis was the science of interpersonal living in which “personality is made manifest in interpersonal situations, and not otherwise” (p 32). This and other similar statements by Sullivan have likely given rise to a primary misconception – that IPT is only externally focused and does not include a theory of inner experience. Nothing could be further from the truth. Core to IPT is the centrality of individual “experience,” which Sullivan (1953) defines as: “anything lived, undergone or the like. Experience is the inner component of events in which a living organism participates in as such… Experience is not the same as the event in which the organism participates” (pp. 26–27). While IPT does not have the extensive conceptual structural underpinning of ego psychology, its elegance is its simplicity and straightforwardness. This in turn allows the psychoanalytic assessor to focus on the meaning of an individual’s experience, not as fitting into an a priori set of concepts, but rather starting with an individual’s experience as something to be discovered and not assumed. Further, Sullivan does provide important conceptualizations about inner processes. Sullivan (1956) stated: Everything that can be found in the human mind has been put there by interpersonal relations, excepting only the capabilities to receive and elaborate the relevant experiences. This statement is intended to be the antithesis of any doctrine of human instincts. (p. 302) He deviates from the object relations psychoanalytic language of self and object, instead using more experience-near concepts of personification and the self-system. The self-system is the dynamic self–other inner representations of interpersonal relations, which then become predispositions for engaging in ongoing interpersonal relatedness. Out of the experience of this dynamic interplay of self and other, the human develops personifications, the complex inner elaboration of experience of recall and foresight of interpersonal events. Personification is the essential way the infant comes to interpret the interpersonal world, through the formulation of a set of internal models, assumptions, ideas, and fantasies about © 2017 Hogrefe Publishing

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people and the self, based on interpersonal experience. As Greenberg and Mitchell (1983) pointed out, personifications are the “infant’s earliest organization of experience... based on the distinction between anxious states (bad mother) and non-anxious states (good mother)” (p. 97). Sullivan (1953) emphasized that personifications were internal representations of interpersonal experience and not veridical memory: “But I would like to make it forever clear that the relation of personifications to that which is personified is always complex and sometimes multiple; and that personifications are not adequate descriptions of that which is personified” (p. 167). Another aspect of the personification is the development of the self, or in Sullivan’s terms, the self-dynamism. While Sullivan defined personality as the entire interpersonal functioning of the person, his concept of the self involves the representation of those experiences about what one takes oneself to be. The process by which one develops this sense of self comes through interpersonal interaction. As Sullivan stated (1940/1953): “The self may be said to be made up of reflected appraisals of others” (p. 22), including internalized experiences of interpersonal cooperation or disconnection and consensual validation (development of common understanding about the meaning of interpersonal experience) or confusion and befuddlement. Sullivan posits that, because social relations are necessary for survival, humans have an inborn need for relatedness. He calls this biological imperative the need for tenderness, along with an in-built experiential warning system signaling separation, which he calls the anxiety. Self-personifications of “good me, bad me, and not me” are organized around these interpersonal experiences. When interpersonal relatedness is threatened and signaled by the experience of anxiety, the person engages in security operations, psychological and behavioral maneuvers organized primarily to reduce anxiety by escaping the insecurity of experiencing the self as bad me. When escape is not possible and anxiety is overwhelming, then inner representations of interpersonal experience are dissociated as not me. If this sounds similar to Bowlby’s attachment theory (see Holmes, 1993), it may be of interest that Sullivan’s developed his concept of anxiety over 20 years before Bowlby’s first publication on attachment. Indeed, Sullivan’s concept of anxiety may be justifiably considered the inner component of what Bowlby describes as protest and despair in response to separation. As will be discussed later in the case of Ms. B., Sullivan’s interpersonal developmental model emphasized the importance of interpersonal cooperation and consensual validation. Since, beginning from infancy on, all satisfactions and security require interpersonal cooperation where the experiences of interpersonal transactions are learned and inner representations of these experiences are

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formed. These experiences become represented interpersonally through language and meanings of experience can be spoken and shared. The child then begins the process of consensual validation of his or her experience with the experiences of others, in which common understanding about the meaning of experience develops. Communicative behavior (both speech and gesture) increasingly becomes the central way of comprehending the interpersonal world and this capacity dramatically grows with greater differentiation and precision as the human develops. One of Sullivan’s unique contributions was the dilemma of what he called the lonely child. The child with few peers and limited opportunities to experience the world outside the family entered the broader world socially underdeveloped. To compensate for his or her lack of social interaction, the lonely child by necessity constructed a rich fantasy life. As the child matured, it became increasingly important for the child to distinguish between his or her inner fantasy world and the socially agreed upon reality. Socially active children gradually learned the distinction between fantasy and consensual validated reality through social interchange and language. The lonely child’s rich fantasy life is only minimally subjected to consensual validation and he or she can become the object of misunderstanding and ridicule by peers. For Sullivan, this dilemma led the lonely child to a tentativeness with, or even withdrawal from, peers, which even further contributed to a partial arrest in interpersonal development. How Does This Model Aid in Understanding Ms. B.’s Psychological Functioning? With the theoretical framework of IPT in mind, I propose to show where the CS Rorschach is especially usefully to understanding the interpersonal world, including the inner personifications, of Ms. B. In the tradition of Exner’s cluster analysis, I conceptualize an IPT approach to Rorschach interpretation into four main clusters of variables: 1. Meaning of the individual’s inner interpersonal world; 2. Inner representations (personifications) of interpersonal relations and the sense of self as seen in the reflected appraisals of others; 3. Capacity for interpersonal cooperation and consensual validation; and 4. Interpersonal anxiety. I will elaborate these clusters through CS variables found in Ms. B.’s Rorschach and will summarize the findings at the end of each cluster. I will then apply these findings to the consultation questions posed by James Kleiger.

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Interpersonal Theory and the Rorschach of Ms. B IPT Cluster 1: What is the meaning of this woman’s inner interpersonal world as shown to us on the Rorschach? Three CS Rorschach variables immediately come to attention from an IPT perspective of Ms. B.’s inner interpersonal world: • HVI + all variables positive on the constellation; • CDI + with DEPI + ; and • PHR > GHR. Ms. B.’s Rorschach shows an HVI + with all variables positive on the constellation suggesting a highly prominent aspect of her inner world. The Hypervigilance Index (HVI) was Exner’s attempt at capturing the paranoid processes on the Rorschach, but has unfortunately not shown strong empirical support (see Weiner, 2003; Mihura, Meyer, Dumitrascu, & Bombel, 2013). While not necessarily paranoid, the HVI variables do capture the type of fearful insecurity and hyperalertness to danger found in the inner world of individuals with a wide variety of personal suffering. As an IPT assessor, I have found the HVI to have considerable clinical utility in bringing to life the client’s inner world regarding fearfulness and wariness (hypervigilance) about interpersonal relationships. The closer the relationship, the more the individual becomes inwardly alarmed, setting in motion interpersonal dynamisms that keep distance from others by guarding their personal space and having difficulty revealing their inner life to others. In IPT language, Ms. B. has a highly vulnerable self-system and her security operations are quite easily activated by the personification of relationships as likely to be hurtful, if not damaging. The next prominent finding regarding the inner interpersonal world in Ms. B.’s Rorschach is her positive CDI with a positive DEPI. The positive CDI strongly suggests that Ms. B. experiences herself as interpersonally inept, puzzled, and confused internally about how people think, feel, and behave, leading her to anticipate difficulty negotiating interpersonal relationships in a satisfying way. With CDI positive in combination with her positive DEPI, she is likely to have an awareness of her interpersonal ineffectiveness that gives rise to deeply painful feelings. From IPT, Ms. B. is likely mystified by how interpersonal relationships work due to ineffective early parent–child experiences (which Sullivan drolly termed “parental insanity”) and she painfully experiences of herself as bad me in close relationships, further reinforcing her hypervigilant anticipation of others. Providing additional evidence for Ms. B.’s experience of interpersonal ineffectiveness, her Rorschach indicated PHR > GHR. Exner incorporated and modified this variable in the CS from the work of Perry and Viglione (1991) and interpreted Rorschachiana (2017), 38(1), 33–48

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PHR > GHR as discriminating individuals with less effective interpersonal relationships from those with a well-functioning history. An important dimension of this variable that is frequently overlooked is that the criterion variable was interpersonal effectiveness ratings by others, with a preponderance of PHR in the Rorschach record suggesting an individual whom others find less competent interpersonally. Due to the strong predominance of PHR over GHR in her Rorschach, Ms. B. likely is seen by others as interpersonally awkward and ill at ease, reinforcing her own painful experience of herself as socially inept. Interpretative Cluster Summary: In terms of the meaning of this woman’s inner interpersonal world, Ms. B. is likely to be a deeply cautious, hypervigilant, and mistrustful woman who is interpersonally inept and readily seen by others as inept. She is sadly aware of her interpersonal vulnerability and awkwardness when in relationship to others and is likely to be despondent as a result. IPT Cluster 2: What are the inner representations (personifications) of interpersonal relations and the sense of self seen in the reflected appraisals of others – good me, bad me, and not me? The following CS Rorschach variables from an IPT perspective immediately draw attention to Ms. B.’s inner representations of interpersonal relations and sense of self: • Egocentricity Index Ego/R = .11; • MOR = 4, TC/R = .185; • S = 5, AG = 0, AgC = 6; • H: (H) + Hd + (Hd) 1:9; with (H) = 4, (Hd) = 1; and • Ma < Mp = 2:5 and p > a. What immediately draws us to the inextricably interactive questions of one’s internal view of self and others is the strikingly low score on the Egocentricity Index. Again, while the meta-analysis of Mihura and colleagues (2013, p. 24) found “the Egocentricity Index was not significantly related to criteria indicating Egocentricity,” I believe that this particular interpretation (and unfortunate name for the score) of this variable with a long and valuable history has led to some misconception about its meaning, which in the later version of the CS would come to indicate a seriously low lack of self-focus and self-concern. Based on the first cluster of variables, this finding is expected as an inner self-representation of her interpersonal ineptness. When the high MOR score is taken into consideration, it is likely that Ms. B. sees herself as a damaged woman. When the Trauma Content Index (TC/R; Armstrong, & Loewenstein, 1990) is taken into consideration, Ms. B. scores in the range similar to individuals who may have experienced emotional abuse in childhood (see Kamphuis, Kugeares, & Finn 2000). As such, we see the reciprocal process of Ms. B.’s lack of positive self-regard arising © 2017 Hogrefe Publishing

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from seeing herself as internally damaged, which in turn results from her marked fearful anticipation of emotional harm by others. Further, the quite high elevations on S (5) and AgC (6) support the idea that Ms. B. anticipates aggression as a frequent and central part of relationships and she naturally feels aggrieved about this. Unfortunately, with the absence of AG, Ms. B.’s resentment remains locked internally as she lacks a protective ability to use her own aggression and social skill to protect herself from a world where she feels bullied and hurt. Instead, because Ms. B. feels relationships in the world are unsafe and she is unable to protect herself, her Rorschach suggests she is likely to withdraw from the world of active interpersonal engagement into a passive stance about meeting her needs (p > a). Instead, she likely retreats from the interpersonal world into one marked with fantasy (Ma < Mp = 2:5), where her personifications are largely made up of unrealistic understanding of others (H: (H) + Hd + (Hd) = 1:9), largely based on markedly idealized expectations of being understood by others as represented by CS variables (H) = 4 & (Hd) = 1. Interpretative Cluster Summary: In terms of Ms. B.’s personifications (inner representations) of interpersonal relations and her sense of self (good me, bad me, and not me) seen through the reflected appraisals of others, she sees her interpersonal world as filled with emotional abuse and aggression. Her predominate sense of self as bad me, seeing herself as unworthy and damaged and she lacks a protective ability to use her own aggression or social skill to protect herself. As a result she has retreated into a passive approach in relationships in which a fantasized relationship takes preference over realistic interpersonal thinking. She is vulnerable to being easily overwhelmed and disappointed in relationships from which she increasingly isolates herself. IPT Cluster 3: What is her capacity for interpersonal cooperation and consensual validation on this Rorschach? As noted earlier, interpersonal cooperation and consensual validation are critical elements of interpersonal development for IPT. The following CS Rorschach variables tap these IPT constructs: • COP = 1 associated with a FAB; • HVI + analysis- Zf, Zd, Cg (60% minus form, sunglasses, cloak, masks); and • S minus (60% of S), M minus = 2. When viewing Ms. B.’s inner world through the lens of the Rorschach, we are struck by how previously described difficulties in living brought on by social ineptness, ineffective relationships, damaged inner sense of self, fearfulness of others, and retreat into fantasy will impair her capacity for interpersonal cooperation and consensual validation. The COP variable is a valuable indication of an interest in cooperative social interchange and, while Ms. B.’s protocol contains Rorschachiana (2017), 38(1), 33–48

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one COP, a closer look at this response reveals considerable interpersonal trouble. Her COP response is associated with a FAB, suggesting the possibility of the interference of cognitive processes. She sees an elephant dancing, not a truly troubling response, like the “bad COP” found in dissociative individuals (COP with LVL2 Special Score; see Brand, Armstrong, Loewenstein, & McNary, 2009). Nevertheless, Ms. B.’s COP is infused with childlike relatedness of imagined animals cooperatively interacting rather than a preferable human interaction. Additionally as we look more closely at Ms. B.’s positive Hypervigilence Index, we find all variables positive and all scores well above what is required for significance. This suggests a profound difficulty with interpersonal cooperation resulting from pervasive fear and suspicion of others. In particular, the high scores on Zf and Zd suggesting an enveloping need to look for danger signals in her interpersonal world, which likely requires enormous energy and leaves her quite depleted. When we look at her Clothing (Cg) responses, we find troubling contents of sunglasses, cloak, and masks, conveying an overwhelming desire to remain emotionally hidden from others lest she come under attack. In terms of consensual validation, we note a specific pattern in what is an otherwise overall adequate approach to reality testing. Her minus Form Level responses are mostly clustered around variables suggesting interpersonal relatedness – Clothing contents (Cg = 60% minus Form Level), anger (S− = 60% of S), and Human Movement (M− = 2). Together these findings suggest specific unrealistic thinking and cognitive/perceptual disruption leading to problems in a consensual approach to her interpersonal world. Interpretative Cluster Summary: Ms. B.’s capacity for interpersonal cooperation and for seeing real relationships as a source of cooperation and help is likely damaged and blocked. Feeling overwhelmed by personifications of others as primarily bad, arising from deep suspicions of others’ motives, she has problems with pervasive “hiddenness,” which interferes with her ability to see the possibility of interpersonal support and cooperation. Consensual validation of her experiences is likely hampered by unrealistic sense of others and perceptual distortion around angry feelings. Ms. B. appears to fit the lonely child pattern so eloquently elucidated by Sullivan. IPT Cluster 4: Where do we find interpersonal anxiety on Ms. B.’s Rorschach? IPT emphasizes the experience of anxiety as a key element in understanding interpersonal relatedness. As suggested by Evans (1997), this experiential aspect of Sullivan’s IPT later emerges in more systematic and articulate form in Bowlby’s attachment theory and concept of the internal working model (see Holmes, 1993), which suggests that chronic attachment disruption sets up a pattern of persistent anxiety and interpersonal dysfunction. I find the work of Berant and colleagues

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(2005) on Rorschach attachment dimensions to be a useful interpretative strategy in assessing anxiety. An analysis of their anxious attachment facet especially reveals substantial elevations on Diffuse Shading (Y = 5) and Inanimate Movement (m = 7), suggesting pervasive anxiety and a sense of foreboding. While she does not have an elevation of Food content (Fd = 0), I enhanced this item by using the more valid Rorschach Oral Dependency Scale (see Bornstein & Masling, 2005), which reveals higher than average yearning for a dependent relationship (ROD = .33). Additionally, we also see strong elements on avoidant attachment dimension with no Texture responses and the previously mentioned highly elevated Clothing content. Together these scores suggest a powerful conflict between interpersonal anxiety and avoidance on one hand and an intense yearning on the other hand, which impair her current capacity to tolerate distress and control impulsive acting out to relieve distress (D score = −2). Unfortunately, her adjusted D score of +1 suggests that she likely experiences her current adaptive strategy as ego syntonic, suggesting a rough road ahead in psychotherapy. Interpretative Cluster Summary: It comes as no surprise that Ms. B. is experiencing intense anxiety and uncontrollable distress in relationships with others (anxiety). She is currently emotionally overwhelmed, but likely returns to interpersonal adaptations that are troublingly chronic and ego syntonic. It is unclear from the case materials what is distressing and driving her to impulsive acting out. The question arises whether this distress is due to the uncovering of painful material in psychotherapy or to an external event she has characteristically not shared with her psychotherapist?

Consultation on Referral Questions and Treatment Recommendations With these interpersonal concepts and Rorschach findings in mind, let us explore the referral questions to find where IPT “lives” on Ms. B.’s Rorschach. Question 1: To what degree does Ms. B. still present a risk for suicide or self-harm? Should she be allowed to return to her dormitory? From a simple research and actuarial perspective, we can confidently assume Ms. B.’s suicide risk is high. She made a recent and potentially quite lethal suicide attempt, was discovered by a roommate rather than by seeking help herself, and failed to contact her therapist about her suicidal impulse despite agreeing with him that she would. After she was hospitalized, Ms. B. was angry that her right Rorschachiana (2017), 38(1), 33–48

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to kill herself was thwarted and taken away from her. No matter what her Rorschach tells us, it is safe to assume that Ms. B. continues to present as a high risk in spite of her later protestations to the contrary. When we turn to the Rorschach, we are first presented with a positive score on the CS Suicide Constellation, which has good research to support increased likelihood for suicide attempts within 6 months: (see Exner & Wiley, 1977). This score alerts us to the concern about suicidality, but does not give us significant insight into its inner roots and the interpersonal cooperation necessary to help her through this difficult time in her life. Using the IPT clusters noted earlier, we can say that Ms. B. is likely currently experiencing intense anxiety and feels powerfully overwhelmed to the degree that impulsive acting out is increased. As such, her Rorschach is consistent with her apparently impulsive suicide attempt and her equally hasty reassurance that she is no longer suicidal. Further, the IPT clusters on the Rorschach indicate that Ms. B. has deep interpersonal mistrust and the need to keep herself hidden emotionally. She sees herself as damaged, inept, and unworthy, which is deeply depressing to her. It is very likely that Ms. B. will find it difficult to engage in cooperative and collaborative relationships with the university and the psychotherapist on behalf of her own interests, including protecting herself from suicidal impulses. While the decision to return to college and her dormitory is ultimately an administrative matter and not a decision to be made by a psychotherapist, what we can say is that Ms. B. presents a significant risk of self-harm. Question 2: Is there evidence of an emerging bipolar disorder, and to what degree does posttraumatic stress contribute to the diagnostic picture? Finally, is there evidence of a vulnerability to dissociation or psychotic symptoms? Ms. B.’s Rorschach suggests little or no evidence of a manic presentation of bipolar disorder. While she shows the cognitive slippage and problems in reality testing found in bipolar manic clients, an IPT analysis suggests that her problems in living are focused around interpersonal concerns rather than diffusely present in her protocol. Even her elevation on DEPI appears primarily associated with CDI, suggesting Ms. B.’s pain arises from her difficulties with engaging effectively with others rather than as the result of a mood disorder. With regard to posttraumatic stress, Ms. B. does not show the classic patterns for posttraumatic stress disorder found by van der Kolk & Ducey (1989). With that said, the IPT approach to the Rorschach found clear indications that she likely experienced probable unattuned, perhaps aggressive, relationships in the past that have distorted Ms. B.’s sense of self and others, leaving her significantly © 2017 Hogrefe Publishing

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mistrustful, woefully socially underdeveloped, and feeling painfully inadequate. Ms. B.’s Rorschach suggests more a chronic pattern of instability in interpersonal relationships, self-image, and affect arising from experiences in an unsafe interpersonal world. Based on her Rorschach, Ms. B. does not appear to be at an elevated level of dissociation commonly found in trauma victims (see Brand et al., 2009; Kamphuis et al., 2000). With this said, she does appear to have a powerful conflict between interpersonal anxiety and avoidance on one hand and a powerful yearning for dependency on the other hand, to the degree that her desire for interpersonal connectedness is likely split-off from her awareness. Question 3: What are the implications for treatment? What would be the appropriate setting and level of intensity to help Ms. B. address her problems? Whatever the specific treatment approach ultimately taken, it is important to point out that the psychotherapy relationship with Ms. B. is likely to be complex and arduous. Fairbairn (1943, p. 37) knowingly remarked that psychotherapy is “a cure by the hair of the tail of the dog that bit you,” in this case anticipating Ms. B. will struggle in psychotherapy because of her fear of close interpersonal relations inherent in psychoanalytic treatment. It is my opinion that the treatment focus would be on what Sullivan called the paranoid dynamism. This dynamism is rooted in the client’s deep feeling of personal inferiority and fundamental mistrust of others. These self/other personifications then activate projection of her resentment and fear in the form of a transference (similar to what Sullivan called parataxic distortion) in which others are perceived as untrustworthy and dangerous. Her Rorschach indicates powerful mistrust likely arising from earlier unattuned, possibly aggressive, relationships in the past. As a result, she experiences fear and vulnerability in relationships that will be enacted in the psychotherapy hour and, in this case specifically, was demonstrated by her unwillingness to contact her psychotherapist before making a serious suicide attempt. Ms. B. likely experiences damage in her ability to choose between productive, positive relationships and harmful ones, which is shown by her rejection of her psychotherapist’s support. She likely fearfully withdrew from close peer relationships as suggested by Sullivan’s lonely child adaptation. As a result, she is interpersonally underdeveloped with significant difficulty in connecting socially, in large part because she has trouble engaging in consensual validation (i.e., finding common understanding) with her peers. Finding common ground with her psychotherapist will be a challenge for Ms. B. and her therapist alike. As closeness in the psychotherapy relationship develops, treatment is likely to trigger powerful feelings of inner distress, experienced largely through increased bodily sensations of anxiety that Ms. B. may have difficulty articulating to the Rorschachiana (2017), 38(1), 33–48

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psychotherapist. As such, the psychotherapist will need to carefully monitor and actively address her paranoid transference projections in psychotherapy relationships. Fromm-Reichmann (1960) cautioned psychotherapists that challenges to their sense of themselves as helpful and benevolent often produce powerful countertransference reactions that make it difficult for the clients with paranoid dynamisms to re-enact their inner worlds in the psychotherapy relationship. To work with Ms. B., her psychotherapist can never assume that this woman feels safe and attached in the psychotherapy relationship. As such the therapist must tolerate and metabolize Ms. B.’s powerful countertransference reactions associated with the therapist being experienced as abusive or disinterested. In order to further this level of exploration and emotional intensity, intensive outpatient psychotherapy of two to three times a week will likely be required, once Ms. B. is stabilized from her current crisis.

References Armstrong, J. G., & Loewenstein, R. J. (1990). Characteristics of patients with multiple personality and dissociative disorders on psychological testing. Journal of Nervous and Mental Disorders, 178, 448–454. Berant, E., Mikulincer, M., Shaver, P. R., & Segal, Y. (2005). Rorschach Correlates of selfreported attachment dimensions: Dynamic manifestations of hyperactivating and deactivating strategies. Journal of Personality Assessment, 84(1), 70–81. Bornstein, R. F. (2007). Might the Rorschach be a projective test after all? Social projection of an undesired trait alters Rorschach oral dependency scores. Journal of Personality Assessment, 88(3), 354–367. Bornstein, R. F., Becker-Matero, N., Winarick, D. J., & Reichman, A. L. (2010). Interpersonal dependency in borderline personality disorder: Clinical context and empirical evidence. Journal of Personality Disorders, 24(1), 109–127. Bornstein, R. F., & Masling, J. M. (2005). The Rorschach Oral Dependency Scale. In R. F. Bornstein & J. M. Masling (Eds.), The LEA series in personality and clinical psychology. Scoring the Rorschach: Seven validated systems (pp. 135–157). Mahwah, NJ: Lawrence Erlbaum Associates. Brand, B. L., Armstrong, J. G., Loewenstein, R. J., & McNary, S. W. (2009). Personality differences on the Rorschach of dissociative identity disorder, borderline personality disorder, and psychotic inpatients. Psychological Trauma: Theory, Research, Practice, and Policy, 1(3), 188–205. Evans, F. B. III (1997). Harry Stack Sullivan: Interpersonal theory and psychotherapy. London, UK: Routledge. Exner, J. E., & Wylie, J. (1977). Some Rorschach data concerning suicide. Journal of Personality Assessment, 41(4), 339–348. Exner, J. E. Jr. (2003). Basic foundations and principles of interpretation. The Rorschach: A comprehensive system (4th ed.). Hoboken, NJ: John Wiley. Exner, J. E. Jr., & Erdberg, P. (2005). The Rorschach: A comprehensive system: Advanced interpretation (3rd ed., Vol. 3, (3rd ed.). Hoboken, NJ: John Wiley. © 2017 Hogrefe Publishing

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Fairbairn, W. R. D. (1943). The repression and the return of bad objects (with special reference to the “war neuroses”). British Journal of Medical Psychology, 19(3–4), 327–454. Finn, S. E. (2007). In our clients’ shoes: Theory and techniques of therapeutic assessment. Mahwah, NJ: Erlbaum. Finn, S. E. (2011). Journeys through the valley of death: Multimethod psychological assessment and personality transformation in long-term psychotherapy. Journal of Personality Assessment, 93(2), 123–141. Fromm, E. (1996). The essential Fromm: Life between having and being. London, UK: Continuum International Publishing Group. Fromm-Reichmann, F. (1960). Principles of intensive psychotherapy (Vol. 49, . Chicago, IL: University of Chicago Press. Greenberg, J. R., & Mitchell, S. A. (1983). Object relations in psychoanalytic theory. Cambridge, MA: Harvard. Havens, L. L. (1973). Approaches to the mind. Boston, MA: Little, Brown. Havens, L. L., & Frank, J. (1971). Review of P. Mullahy, Psychoanalysis and interpersonal psychiatry. American Journal of Psychiatry, 127, 1704–1705. Holmes, J. (1993). John Bowlby and attachment theory. New York, NY: Routledge. Horney, K. (1937). The neurotic personality of our time. New York, NY: W. W. Norton. Jacobson, E. (1955). Review of Sullivan’s Interpersonal Theory of Psychiatry. Journal of the American Psychoanalytic Association, 3, 149–156. Kamphuis, J. H., Kugeares, S. L., & Finn, S. E. (2000). Rorschach correlates of sexual abuse: Trauma content and aggression indexes. Journal of Personality Assessment, 75(2), 212–224. Kernberg, O. (1976). Object relations theory and clinical psychoanalysis. New York, NY: Jason Aronson. Mihura, J. L., Meyer, G. J., Dumitrascu, N., & Bombel, G. (2013). The validity of individual Rorschach variables: Systematic reviews and meta-analyses of the comprehensive system. Psychological Bulletin, 139(3), 548–605. Moore, R. C., Viglione, D. J., Rosenfarb, I. S., Patterson, T. L., & Mausbach, B. T. (2013). Rorschach measures of cognition relate to everyday and social functioning in schizophrenia. Psychological Assessment, 25(1), 253–263. Perry, W., & Viglione, D. J. (1991). The Ego Impairment Index as a predictor of outcome in melancholic depressed patients treated with tricyclic antidepressants. Journal of Personality Assessment, 56(3), 487–501. Rivera, B. A., & Viglione, D. J. (2010). Conceptualization of children’s interpersonal relatedness with the Rorschach: A qualitative multiple case study. Journal of Personality Assessment, 92(5), 377–389. Sullivan, H. S. (1938). Psychiatry: Introduction to the study of interpersonal relations: The data of psychiatry. Psychiatry, 1, 121–134. Sullivan, H. S. (1940/1953). Conceptions of modern psychiatry, (2nd ed). New York, NY: W. W. Norton. Sullivan, H. S. (1953). The interpersonal theory of psychiatry. New York, NY: W. W. Norton. Sullivan, H. S. (1954). The psychiatric interview. New York, NY: Norton. Sullivan, H. S. (1956). Clinical studies in psychiatry. New York, NY: W. W. Norton. van der Kolk, B. A., & Ducey, C. P. (1989). The psychological processing of traumatic experience: Rorschach patterns in PTSD. Journal of Traumatic Stress, 2(3), 259–274. Weiner, I. B. (2003). Principles of Rorschach interpretation. New York, NY: Routledge.

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Received May 29, 2015 Revision received December 31, 2016 Accepted January 31, 2017 Published online July 13, 2017 F. Barton Evans Clinical & Forensic Psychologist Clinical Professor of Psychiatry East Tennessee State University College of Medicine Johnson City, TN USA fbevans3@gmail.com

Summary In response to Kleiger’s unique invitation to interpret a Rorschach case study from multiple psychoanalytic perspectives, I was asked to present a Rorschach interpretation from Sullivan’s interpersonal psychodynamic theory (IPT) perspective. In reviewing the literature, I found no theoretical papers specifically addressing IPT Rorschach interpretation. As such this article will be an initial attempt to integrate the Rorschach with IPT. I present a brief overview of some of Sullivan’s most relevant IPT concepts. I propose where to find IPT variables on the Rorschach Comprehensive System (CS) and offer a conceptualization of four distinct clusters with which to analyze these variables including: (1) meaning of the individual’s inner interpersonal world; (2) inner representations (personifications) of interpersonal relations and the sense of self as seen in the reflected appraisals of others; (3) capacity for interpersonal cooperation and consensual validation; and (4) interpersonal anxiety. Lastly I apply these IPT clusters to the case of Ms. B. and offer responses to the consultation questions. Special attention is given to how the IPT model aids in the dynamic understanding of the Ms. B.’s internal experience and personality functioning; what formal features of the Rorschach lend themselves to key constructs in the model; and how the IPT model addresses the referral questions and adds to an understanding of treatment issues, including transference/countertransference themes.

Résumé En réponse à l’invitation unique de Kleiger à interpréter une étude de cas de Rorschach à partir de multiples perspectives psychanalytiques, on m’a demandé de présenter une interprétation de Rorschach à partir de la perspective de la Psychodynamique interpersonnelle (IPT) de Sullivan. En examinant la littérature, je n’ai trouvé aucun document théorique traitant spécifiquement de l’interprétation de IPT Rorschach. En tant que tel, cet article sera une tentative initiale d’intégration du Rorschach avec IPT. Je présente un bref aperçu de certains des concepts d’IPT les plus pertinents de Sullivan. Je propose où trouver des variables IPT sur le système complet de Rorschach (CS) et proposer une conceptualisation de quatre grappes distinctes pour analyser ces variables, notamment : (1) la signification du monde interpersonnel interne de l’individu ; (2) les représentations intérieures (personnifications) des relations interpersonnelles et le sens de soi comme on le voit dans les évaluations réfléchies d’autrui ; (3) capacité de coopération interpersonnelle et de validation consensuelle ; Et (4) l’anxiété interpersonnelle. Enfin, j’applique ces

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clusters IPT au cas de Mme B. et je propose des réponses aux questions de consultation. Une attention particulière est accordée à la façon dont le modèle IPT aide à la compréhension dynamique de l’expérience interne et du fonctionnement de la personnalité de Mme B. ; Quelles caractéristiques formelles du Rorschach se prêtent à des constructions clés dans le modèle ; Et comment le modèle IPT aborde les questions de référence et ajoute à la compréhension des problèmes de traitement, y compris les thèmes de transfert / contre-transfert.

Resumen En respuesta a la invitación exclusiva de Kleiger para interpretar un estudio de caso de Rorschach desde múltiples perspectivas psicoanalíticas, me pidieron que presente una interpretación de Rorschach desde la perspectiva de la teoría psicodinámica interpersonal (IPT) de Sullivan. En la revisión de la literatura, he no encontrado ningún papel teórico abordando específicamente IPT Rorschach interpretación. Como tal, este artículo será un inicial intento de integrar el Rorschach con el IPT. Les presento una breve reseña de algunos de los conceptos más relevantes de IPT de Sullivan. Propongo dónde encontrar variables IPT en el sistema integral de Rorschach (CS) y ofrecer una conceptualización de cuatro distintos grupos con los que analizar estas variables incluyendo: 1 significado del mundo interpersonal interior del individuo: 2. representaciones internas (personificaciones) de las relaciones interpersonales y el sentido de sí mismo como se ve en las valoraciones reflejadas de los demás; 3. capacidad de cooperación interpersonal y validación consensual; y 4. Ansiedad interpersonal. Por último que aplicar estos clusters IPT en el caso de la Sra. B y ofrecer respuestas a las preguntas de la consulta. Se dará especial atención a cómo modelo IPT ayuda a la comprensión dinámica de la Sra. B experiencia interna y personalidad funcionando; ¿Qué características formales de la Rorschach se prestan a construcciones claves en el modelo; y cómo el modelo IPT aborda la remisión preguntas y se suma a una comprensión de las cuestiones de tratamiento, incluyendo temas de transferencia/contratransferencia.

要約多様な精神分析的観点からロールシャッハ解釈のケーススタディをおこなうというKleiger氏からのユニークな招待にこたえて、私はサリバンの対人関係理論（IPT）の観点からのロールシャッハ解釈をプレゼンテーションすることを依頼されている。文献をレヴューしてみたところ、IPTによるロールシャッハ解釈を特に扱っている理論的な論文は見あたらなかった。このような論文はロールシャッハ法とIPTを初めて統合しようとしたものであろう。わたしはサリバンのもっとも関連するIPTの概念のいくつかの簡単な概要を示している。私はロールシャッハ包括システム（CS）のどこにIPTの変数が見いだせるかについて提案をしており、以下の分析すべき変数が含まれている４つの別々のクラスターの概念化を提唱している。１．個人の内的対人世界の意味、２．対人関係の内的表象（人格化）と他者をどのように評価しているかに反映される自己の感覚、３．対人関係における共同と相互確認の能力、４．対人関係における不安。最後に私はこれらのIPTのクラスターをMs.Bのケースに適用して、コンサルテーション上の疑問に対する返答を提案した。いかにIPTのモデルをMs.Bの内的経験やパーソナリティ機能の力動的理解に役立てるかに特に注意が払われる。それは、ロールシャッハのどの形式的な特徴がモデルにおける鍵となる構成概念となりうるのか、IPTモデルが紹介の疑問にどのように答え、転移／逆転移のテーマを含んだ治療上の問題に言及を加えることできるのか、といったことである。

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Case Study Special Issue: Multiple Psychoanalytic Models Case Study

A Self Psychological Analysis of Rorschach Thematic Content Marshall L. Silverstein Richmond, MA, USA Abstract: In this discussion of the case of Ms. B., I consider this patient’s Rorschach responses from the theoretical viewpoint of psychoanalytic self psychology (Kohut, 1971, 1996). Using thematic content and sequence analysis, I demonstrate how the self psychological concept of the forward edge (Tolpin, 2002) may indicate how a selfobject transference emerges as a representation of thwarted legitimate developmental strivings that have been driven underground. I attempt to illustrate how such unrecognized selfobject needs may be reactivated on the Rorschach and how they may be understood as fragile tendrils of remaining healthy needs. Keywords: Rorschach, self psychology, forward edge, thematic content

I consider here some of Ms. B.’s responses to illustrate one of Heinz Kohut’s (1971) less well known self psychological concepts, one which he referred to as the leading edge but mentioned only briefly in passing. It was a concept he did not develop further during his lifetime, even as he expanded the scope of psychoanalytic self psychology beyond the narrow group of narcissistic personality disorders. Tolpin (2002), a close colleague of Kohut’s, proposed the term forward edge to describe further and extend the implications of Kohut’s concept. Tolpin regarded interpreting the forward edge as fostering the remobilization of normal but thwarted developmental needs to restart a developmental process that had been interrupted.

Key Principles of the Forward Edge in Psychoanalytic Self Psychology Kohut’s leading edge concept was first discussed in a paper by Jule Miller (Miller, 1985), an experienced classically trained psychoanalyst who consulted with Kohut on Miller’s own analytic cases to understand how Kohut worked clinically in conducting a self psychologically informed analysis. Miller related how a patient © 2017 Hogrefe Publishing

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animatedly told him some news he knew the analyst did not know, which Miller interpreted as a manifestation of competitive rivalry. The patient felt let down, which Kohut understood as an unintended rebuff in the transference of the patient’s pride and expectant wish to tell his admired father something that would allow him to join in with his father’s interest and thus feel admired and enjoyed. Kohut’s point was that predominantly interpreting defenses and conflicts was not necessarily therapeutic, which was one of the main reasons why he introduced the psychology of the self. He observed that there were two aspects to consider in an interpretation, one being the traditional defensive and conflictual components that represented the pathological aspects of a patient’s transference reaction, such as in the aforementioned vignette regarding Miller’s interpretation to his patient concerning rivalry. Kohut referred to this as a trailing edge in his consultation with Miller, although Kohut did not again refer to this term or to the concept directly in any of his writings. The other aspect of interpretation that Kohut called attention to and suggested to Miller was what he thought of as a leading edge – understanding and then interpreting a remobilization in the transference of a nonconflictual expectation in normal development, one that was thwarted or not responded to in childhood and that had gone into hiding. Kohut also did not refer to a leading edge in subsequent writings, although he regarded it as a therapeutically important part of an interpretation representing a legitimate selfobject need that was not itself a manifestation of a defensive or conflictual process, although it could be disguised as such and therefore could easily appear as part of a patient’s pathology. As mentioned, Tolpin (2002) introduced the term forward edge to further elaborate Kohut’s concept, including its implications as a selfobject transference, regarding the forward edge as a positive development or achievement. She regarded the forward edge as belonging with normal development and that it represented a reactivation of “fragile tendrils of remaining healthy needs and expectations [that] are not readily apparent on the surface” (p. 169). It is a failure to recognize and interpret the growth-fostering forward edge strivings that may lead to a formerly normal need becoming pathological in the face of chronic or pronounced misidentification. Kohut (1996) also commented that: Over and over again, I see in myself and others a subtle belittling of the patient when he sets aside … the analytic task by revealing the emerging assertiveness of his developing self. … When a proudly developing, unified self is presented and is unempathically rebuffed, … it is a break in analytic empathy to apply the drive and defense model at a time when …. the issue is that of a newly discovered self, which now shows itself cautiously and wants a response. (p. 220) Rorschachiana (2017), 38(1), 49–58

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It is important to keep in mind, however, that Kohut also emphasized that the forward edge occurs in tandem with drives and defenses, thus it was not thought about as replacing interpreting defenses or conflicts. Ideally, they would be interpreted simultaneously; however, it would not be uncommon for interpretations of the forward edge to precede defense and drive interpretations. Tolpin (2002) noted how often it happens that clinicians inadvertently obscure and thus do not: Support struggling tendrils of health and facilitate their emergence and growth. … We have to be primed to look for them… and tease them out from the trailing edge pathology in which they are usually entwined … and from intermediate defenses and compromise formations that protect the self but which at the same time inhibit and further compromise normal development. (p. 168f) Tolpin compared the forward edge to Anna Freud’s (1965) concept of regaining developmental momentum.

The Forward Edge Model and Ms. B.’s Rorschach With this in mind, I next consider several pairs of sequential responses reflecting a pattern consistent with an interpretation of forward edge strivings. Consider first Ms. B.’s responses on Card I. She began by seeing a goblin with fangs or horns. Apparently ready to stop there, when given the prompt to look some more, she showed signs of struggling to see anything else, saying, “all I can see is a goblin.” She then saw an “angel – without a head.” Thus, a possibly menacing or malevolent percept was followed, reluctantly so it seemed, with a percept often associated with benevolence, or as considered from a self psychological perspective, seeking a selfobject function to assist in restoring self-cohesiveness. Her initial difficulty seeing anything besides the potentially threatening goblin with fangs might suggest that recognizing a selfobject need did not come easily to her. Although she seemed to be searching for reparative or protective selfobjects, Ms. B. appeared more accustomed to a selfobject environment that was too ineffectual or unaware of her needs to do her much good – after all, her angel was seen without its head. One can see why a forward edge longing might appear with some hesitation, peeking out cautiously to test the waters. This patient tells us why it may be risky to hope for too much: If she turns to an angel, she runs the risk of getting one without a head. However, in spite of this risk, the selfobject need does not disappear, but it does need to be recognized and helped along so it may be © 2017 Hogrefe Publishing

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brought forward and become a part of the therapeutic work. As Tolpin (2002) said, clinicians may “have to be primed to look for” such forward edge tendrils. This configuration emerged again on Card IV, where Ms. B. saw a dragon flying down toward someone, followed by a giant without arms. A state of vulnerability or threat was again suggested, and as on Card I it was followed by what looked initially like a vigorous, powerful figure – a giant. But again, Ms. B.’s giant, like her angel, became immobilized because its arms were missing, thus her giant was impotent to do much to help her out. But unbeknownst to herself, she was telling us what she seemed to need. Interestingly, Ms. B. produced a third response to Card IV – a skeleton with its skin rotting off and its ears decaying. Although a rotting skeleton may have meaning regarding how endangered she might sometimes feel, despite its sorry state Ms. B.’s skeleton “still looked like [it had] … some fur on [it].” Hope may not spring eternal for this patient, but neither has Ms. B. entirely given up on the possible revivability of selfobject strivings. Interestingly as well, Ms. B. referred to fur on another card (Card VI) – a fur carpet. She added that she had one like it at home, but it was “in storage” because it was inherited from “a crazy relative.” It seemed to suggest that intimate longings were kept out of sight but not discarded, once again perhaps signifying a potential forward edge striving she had not necessarily abandoned. That the carpet was in storage because it came from a crazy relative does not follow logically, but it should come as no surprise that the logic of the unconscious follows its own rules. I am less concerned about the quality of her thinking here than I am curious about her juxtaposing fur tainted by craziness kept in storage perhaps for some potential future use. It is in this sense that storing away captures what Kohut and Tolpin thought of as an essential characteristic of the forward edge – a hoped-for availability of selfobject responsiveness that had been thwarted or ignored, but which remains as a potentially revivable longing, however fragile or in need of safeguarding it might be. We may be able to see why subtle forward edge strivings remain in the background. Consider that this patient’s response of the stored-away fur rug was followed by a response of an erupting volcano. Later, on Card IX, Ms. B. gave the response of an exploding blender, which was followed by a response of a chipmunk stuffing its mouth with too many acorns – another intimation of storing something away for future use. We cannot be certain whether she herself was erupting or whether she experienced her surround as caving in around her – like the blender on Card IX that is exploding “everywhere…out at the top [and] leaking out at the bottom.” Rather than necessarily representing destructive rage, a self psychological view of a response of an eruption or explosion alternatively might

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A Self Psychological Analysis of Rorschach Thematic Content

consider explosions as representing fragmenting self-cohesion that is experienced as coming apart at the seams or crumbling. Kohut (1996) phrased it like this: Drives in adults are generally disintegration products…. The baby cries, and then the baby cries angrily when whatever needs to be done is not done immediately. But there is no original need to destroy; the original need is to establish an equilibrium. (p. 199) However exploding is understood or interpreted, it is part and parcel of the trailing edge, signifying a self disorder. What I am suggesting here is that hearing how Ms. B. can feel unglued and fragmenting can easily dominate our thinking about her Rorschach responses: Our ears perk up because erupting volcanoes and exploding blenders on the Rorschach do that to us. Caught up by this kind of imagery and its implications may not blind us to what precedes or follows such responses, but we do have to pull ourselves away from it and attend to the broad context, part of which may entail listening for the selfobject needs being expressed and what an injured self needs for its survival or repair – such as an angel with a head or a giant with arms or keeping fragile aspects of a self securely stored until it is safe to peek out and expose what can feel like brittle forward edge strivings. There are other indications of the same dynamic in this patient’s Rorschach responses. For example, on Card VI she saw a Great Dane, which she elaborated as having a “saggy face, … tiny dark eyes,” and that it was drooling – thus appearing to diminish a breed of dog often noted for its imposing size and powerful features. Once again, she attended to the faults that undermined the Great Dane’s vigor, much like her headless angel and the giant without its arms. But note also how her Great Dane had a bone in its mouth “like a dog looks at you for praise,” possibly representing a desire for healthy needs to be noticed and responded to as such. She followed this response with one of an imposing statue of Christ (“a giant Jesus…holding out its arms”), reflecting another benevolent, protective, or nurturant image. The statue was on “a big peak”; the particular statue in Rio de Janeiro she refers to happens to be one of the tallest Christ statues in the world. Ms. B. did not express a connotation of Christ or the statue being particularly weakened or deidealized, although I did wonder whether its being positioned on a peak might make it seem far away or out of reach. I do not know that Ms. B. recognizes that she cannot count on a selfobject environment to come through for her at moments of need, nor do I think she realizes just how precarious it must seem to be left adrift when she needs selfcohesion. Indeed, it is this very precariousness that would probably anchor the interpretive work of a self psychologically informed treatment. Ms. B. does not feel © 2017 Hogrefe Publishing

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being abandoned or let down particularly; rather, she seems to take for granted but perhaps does not recognize the benign neglect all around her as she attempts somewhat haphazardly to shore up fragile self-cohesiveness.

The Forward Edge Concept in Psychoanalytic Self Psychology: Understanding Ms. B.’s Personality Functioning The injuries compromising self-cohesion represent the trailing edge of the psychopathology. As clinicians, we usually have a good sense about how to communicate what we see and understand to people, regardless of the formulation we may use – whether expressed through language of ego psychology, object relations theory, or the psychology of the self. However, it can be more difficult to find the words to talk to people about their expectations that legitimate needs for empathic understanding – including forward edge transference manifestations – will be responded to and heard. Interpretations may become therapeutically advantageous when, in addition to the trailing edge of defenses, they also include the ways people attempt to secure the necessary selfobject functions that may enable them to recover from waylaid developmental strivings. As such, forward edge interpretations attempt to address how normal strivings may become defensively submerged when they are not recognized as legitimate needs, particularly when people were made to believe that what may be normal empathic responses from others were instead childish or frivolous. From this vantage point, it is possible to reconstruct what happened after Ms. B. assured her therapist that she would not make a suicide attempt, having been in close communication with the therapist and speaking with him or her shortly before ingesting the pills. Certainly, all the right steps were taken and there is every reason to believe that the therapist was well aware of the degree of her depression and was empathically in touch with Ms. B.’s distress. Feeling at loose ends, understandably she turned to the therapist for help. But whether or not she recognized it, turning to her therapist when feeling endangered could have re-exposed Ms. B. to what she expected to happen when she would turn to the metaphorical benevolent angels or powerful giants in her past and find them unable to help her – in effect headless or without arms, as discerned from her Rorschach. There is much more in this Rorschach I could comment on, not the least of which were two responses referring to “weird hairdos,” a “clunky, gaudy necklace…something I’d never wear,” “a Kachina doll,” and I also omitted Rorschachiana (2017), 38(1), 49–58

A Self Psychological Analysis of Rorschach Thematic Content

discussion of the formal codings, including those for the responses that I specifically quoted. Thus, I did not comment on such codes as the shading/achromatic color of the skeleton and the Great Dane; the inanimate movement determinant of the swooping dragon, statue of Jesus, and erupting volcano responses; or the psychological implication of not coding for texture in both of the responses that made reference to fur. By focusing on content alone, I am not implying that that is all one should look at in a complete evaluation. But I am highlighting how understanding this patient’s self states, selfobject needs, and forward edge strivings complements what we understand about ego functions and adaptation that is best seen when attending to the structural variables (Silverstein, 2012).

Referral Questions: Suicidal Risk and Treatment Recommendations Framing my discussion of Ms. B.’s Rorschach around the forward edge concept allows for a deeper understanding of her psychological makeup and inner life. By itself, it does not carry specific implications regarding the referral questions concerning risk for self-harm, a possible comorbid bipolar or psychotic disorder, or the matter of whether she should return to school – questions that may be better addressed through a careful examination of structural variables. However, therapeutic attention to her fragile self states would seem to be important as her treatment continues, to forestall or contain disruptions of self-cohesion and its impact on returning to school and living in her dormitory. The vulnerability to a disturbance of self-cohesion would remain whether or not she continued at her college, of course; so too would her brittle self-cohesion stay with her wherever she would be living. Whether or not Ms. B. returns to school, probably the most critical consideration would be the importance of remaining in an engaged and empathically attuned treatment relationship, one that stays keenly alert to fluctuating self states. More specifically, from the standpoint of fostering recognition of unarticulated longings for a protective selfobject environment she can depend upon, a successful treatment may likely entail her capacity to risk emerging forward edge strivings despite the disappointments these led to in the past and her therapist’s recognition of such strivings and how they may be better realized in her life. The forward edge concept also provides a way of thinking about her treatment and the reactivated needs that precipitated her recent disturbance. For example, we cannot know for sure what might have gone awry or been misunderstood in the conversation with Dr. X. as he or she took all the right steps to safeguard this © 2017 Hogrefe Publishing

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patient. Probably Ms. B. was too agitated and impulsive to be able to wait for the therapeutic work to continue once she was in a safer place. Empathic breaches can indeed be subtle, barely perceptible in the moment, and difficult to repair when patients give few clues about what upsets them, all the more so if they are prone to impulsivity or compromised judgment when they feel dysregulated. It is possible that Dr. X.’s conscientious attention to averting a suicide attempt might have been perceived by Ms. B., in the fragile state she was in at the time, as restimulating a pattern of turning to strong or protective people who ultimately fail her. By not following the precautions Dr. X. put in place, she may have instead attempted to avert a pattern of forward edge strivings emerging only to be met with the ensuing hurt that results when she asks for help from someone she expects to come through for her and ends up feeling dropped or helpless. As Ms. B. seemed to convey through her Rorschach responses of headless angels rendered impotent, it is not necessarily that she is prone to feeling abandoned but rather that she can be left feeling high and dry. Ms. B.’s denying the seriousness of the suicide attempt or that there was anything wrong also might represent attempting to reconstitute self-cohesion the only way she knew how, by angrily insisting that she could take care of herself when she was unsure she could count on others. What might look like compromised or misguided judgment about what she had been through and how well she would be able to function at school or living in a dorm could also be regarded as the insistent self-determination she needs to exert by going it alone as she anticipates a selfobject world that is unable to be of much help. It is mainly through attending to what she feels has gone wrong that her therapist may better understand what she longs to feel more assured about. Viewing normal-enough needs as forward edge strivings is different from only regarding frustrated or angry longings as predominantly defensive or pathological reactions to be overcome. Sometimes people end up merely submerging or even feeling ashamed about thwarted normal developmental needs. Recognizing the forward edge may help Ms. B. see more clearly how she struggles with finding a dependably attentive selfobject environment she can trust rather than fear out of an expectation of profound disappointment.

References Freud, A. (1965). Normality and pathology in childhood. New York, NY: International Universities Press. Kohut, H. (1971). The analysis of the self. New York, NY: International Universities Press. Kohut, H. (1996). The Chicago Institute lectures (P. Tolpin & M. Tolpin, Eds.). Hillsdale, NJ: Analytic Press. Rorschachiana (2017), 38(1), 49–58

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Miller, J. (1985). How Kohut actually worked. In A. Goldberg (Ed.), Progress in self psychology (Vol. 1, pp. 12–30). New York, NY: Guilford. Silverstein, M. L. (2012). Personality assessment in depth: A casebook. New York, NY: Routledge/Taylor & Francis. Tolpin, M. (2002). Doing psychoanalysis of normal development: Forward edge transferences. In A. Goldberg (Ed.), Progress in self psychology (Vol. 18, pp. 167–190). Hillsdale, NJ: Analytic Press. Received June 3, 2015 Revision received December 17, 2016 Accepted April 5, 2017 Published online July 13, 2017 Marshall L. Silverstein P.O. Box 428 428 Swamp Road Richmond, MA 01254 USA msilver@liu.edu

Summary This paper discusses the Rorschach protocol of Ms. B. from a traditional self psychological perspective, based on the seminal ideas first formulated by Kohut (1971). I emphasize the thematic content and sequence of themes to illustrate a self psychological concept that Kohut noted in passing but did not develop systematically in his lifetime. This concept – the forward edge – was articulated more fully by one of Kohut’s colleagues (Tolpin, 2002), to show how a selfobject transference may appear as an indication of normal, legitimate developmental strivings that were insufficiently responded to by parental selfobjects. In this way, the forward edge represents a reactivation of fragile tendrils of remaining healthy needs. I demonstrate how forward edge strivings may be recognized in Rorschach content and how it may amplify important aspects of clinical understanding of this patient.

Résumé Cet article traite du protocole de Rorschach de Mme B. d’un point de vue auto-psychologique traditionnel, basé sur les idées formulées pour la première fois par Kohut (1971). Je souligne le contenu thématique et la séquence de thèmes pour illustrer un concept auto psychologique que Kohut a souligné mais n’a pas développé systématiquement au cours de sa vie. Ce concept – bordure directe – a été approfondi par l’un des collègues de Kohut (Tolpin, 2002), pour montrer comment un transfert d’objets primaires peut apparaître comme une indication d’efforts développementaux et légitimes qui ont été insuffisamment traités par les objets primaires parentaux. De cette façon, la bordure directe représente une réactivation des besoins sains restants. Je démontre comment les bordures directes peuvent être reconnues dans le contenu du Rorschach et comment il peut amplifier les aspects importants de la compréhension clinique de ce patient.

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M. L. Silverstein

Resumen Este documento examina la Rorschach Protocolo de la Sra. B. a partir de una perspectiva psicológica su cuenta tradicional, basado en las ideas primordiales formuló por primera vez por Kohut (1971). Me insiste sobre el contenido temático y la secuencia de los temas para ilustrar un concepto psicológica que sí Kohut señalaba en el paso pero no ha desarrollado sistemáticamente en su vida. Este concepto-el borde delantero-fue articulado más plenamente por uno de sus colegas (Tolpin, 2002), para mostrar cómo una transferencia selfobject puede aparecer como una indicación de normal, legítima de perfeccionamiento que no eran suficientemente reaccionado duramente por selfobjects parental. De esta forma, el borde de ataque representa una reactivación de frágiles de los Zarcillos de permanecer en buena salud necesita. Me demostrar cómo bordo antes de las aspiraciones pueden ser reconocidas a Rorschach contenido y cómo puede ampliar de importantes aspectos de comprensión clínica de este paciente.

要約本論文は、Ms.B のロールシャッハ・プロトコルをある伝統的な自己心理学の観点、最初にコフートによって定式化された発展の可能性の高い考案に基づく観点、から考察している。私は、コフートがたまたま注目したのであるが、彼の人生において系統的に発展させることはなかった自己心理学の概念を例証する、主題の内容と主題の連続性を強調している。この概念は—前端（the forward edge）—はコフートの同僚たちの一人〔Tolpin, 2002〕によって、より十分に明確にされたものであり、親の自己対象よって不十分にしか応答をしてもらえなかった正常な長期間の発達における奮闘の指標として自己対象転移がどのように表れるかを示している。こうして、前端は、健康な欲求にとどまるこわれそうな巻きひげの修復を表している。前端の努力がロールシャッハの内容にどのように認識されるか、それがこの患者の臨床的な理解の重要な側面を詳しく説明することができることを、私は明らかにしている。

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Case Study Special Issue: Multiple Psychoanalytic Models Case Study

Attachment Theory Applied to Ms. B.’s Rorschach Ety Berant Baruch Ivcher School of Psychology, Interdisciplinary Center, Herzliya, Israel Abstract: This manuscript addresses the case study of Ms. B. through the lens of attachment theory. Her Rorschach reveals her anxiously attached information. Her attachment anxiety contributes to her suicidal attempt, to problems in affect regulation, and to negative self-esteem. Ms. B. has problems in mentalization and low reality testing while being in emotionally charged situations. She needs mentalization-based psychotherapy. Keywords: attachment, Rorschach, mentalization

Ms. B. is a young patient who attempted suicide, despite the fact that she had promised her therapist she would not harm herself. The first referral question was whether Ms. B. still presented a risk for suicide or self-harm and whether she should be allowed to return to her dormitory in the university. I believe that understanding what triggered her suicidal act may clarify the referral question. Was the suicidal attempt related to her difficulties with emotion regulation? Had cognitive slippage affected her judgment? Or, was the suicidal attempt related to her relationship with her therapist and her efforts to signal to her therapist that she is distressed? I address the referral questions through the lens of attachment theory by describing how her attachment orientation may shed light on the suicidal act, and I also suggest implications for treatment. First, I review the key principles of attachment theory.

Attachment Theory Attachment theory describes the ways in which human beings develop and maintain close relationships and emotional bonds with significant others known as attachment figures who fulfill needs for safety and comfort (Bowlby, 1969/ 1982, 1988). Repeated experiences with attachment figures establish internal © 2017 Hogrefe Publishing

Rorschachiana (2017), 38(1), 59–70 DOI: 10.1027/1192-5604/a000091

E. Berant

working models or representations of the self and others. If the relationship with the attachment figures was generally positive and consistent and the persons have received comfort when they were distressed, then a secure model of the self and others is established. That is, the person feels worthy and believes that if he or she will need help, the expected help will be provided (Shaver & Mikulincer, 2009). However, if the attachment figure was inattentive, neglecting, or punishing, then insecure attachment orientations are formed. There are several insecure attachment orientations. Anxious attachment is characterized by intense efforts to get the attention and love of the attachment figure, while simultaneously harboring disbelief in the availability of the attachment figure, and persistent dread of being deserted. In such cases, the individual uses hyperactivating attachment strategies – that is, the individual does not give up on frustrating proximity-seeking bids, but in fact intensifies them to demand or coerce the attachment figure’s attention, love, and support. The main goal of these strategies is to make an unreliable or insufficiently available and responsive figure provide support and security. The anxiously attached individual pursues this goal by keeping their attachment system in a chronically activated state until support and comfort are attained. This involves exaggerating appraisals of danger and signs of the attachment figure’s unavailability and intensifying one’s demands for attention and care. Another insecure attachment orientation is attachment avoidance, which is characterized by developing a compulsive self-reliant coping style and believing it is dangerous to lean on or to rely on the attachment figure for comfort or support. Attempts to escape, avoid, or minimize the pain and frustration caused by unavailable, unsympathetic, or unresponsive attachment figures are common. In such relationships, a needy individual learns to expect better outcomes if proximity-seeking bids are suppressed, the attachment system is deactivated, and one attempts to deal with threats and dangers alone (see Mikulincer & Shaver, 2007, for review). The securely attached persons have a coherent and flexible thought process. They grasp reality accurately and tend not to project their own needs and conflicts on the surrounding. However, the cognitive function of anxiously attached individuals is characterized by difficulty with reality testing and thought disorders that are related to their sense of fragile ego boundaries and difficulties in forming a theory of mind. They encounter problems in affect regulation and distress, have a tendency to react with strong emotions to person–environment transactions, and lastly they perceive themselves as helpless, weak, and unworthy (Mikulincer & Shaver, 2007). Persons with avoidant attachment style reveal a lack of acknowledgment of their own need states, a disengaged orientation to the world, and maintenance of a defensive grandiose self-façade (Shaver & Mikulincer, 2002).

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Attachment Theory Applied to Ms. B.’s Rorschach

Before continuing with the case analysis, I wish to mention that Ms. B.’s attachment orientation was not examined using a self-report tool (e.g., ECR – Experiences in Close Relationships Scale; Brennan, Clark, & Shaver, 1998), a semi-structured interview (AAI – Adult Attachment Interview; George, Kaplan, & Main, 1985, 1996; Main, Kaplan, & Cassidy, 1985) or a projective test (AAP – Adult Attachment Project; George & West, 2001, 2004). However, her Comprehensive System Rorschach scores (CS; Exner, 2000) reveal a young woman with an insecure attachment orientation; and, moreover, it seems that her dominant attachment features are of attachment anxiety.

The Aid of Attachment Theory in Understanding Ms. B.’s Psychological Functioning The attachment theory model helps understand the motivation for the suicidal act. There is some research evidence suggesting that attachment insecurities are involved in such destructive acts. From an attachment perspective, this kind of suicidal behavior is an extreme case of anxious hyperactivation of the attachment system. For anxious individuals, suicide can be a possible means of gaining others’ love, compassion, and attention (Mikulincer & Shaver, 2007). A study with the AAI (Main et al., 1985) pointed out that suicidal patients revealed higher scores on preoccupied (anxious) attachment, and showed higher levels of disorganization in reasoning while discussing their attachment-related distress and trauma. The hyperactivating strategy of such clients may well reflect their belief that in order to gain the attention of their attachment figures, they should maximize their displays of distress (Wallin, 2007), and these efforts might also include attempts to self-harm. Hence, the CS Rorschach suicide constellation could be a reminder that she is still holding the same belief that in order to maintain the attention of her therapist she should magnify her distress. Attachment theory aids in understanding Ms. B.’s problems in affect regulation. A pervasive feature of anxiously attached individuals is their difficulty in affect regulation. Emotion regulation has been conceptualized as a process through which individuals modulate their emotions to respond appropriately to internal and environmental demands (Campbell-Sills & Barlow, 2007). Hyperactivating strategies undermine the development of affect regulation. In addition, habitual resort to hyperactivation (that is typical of anxiously attached individuals) may lower the threshold for triggering the sympathetic nervous system and diminish the capacity to exert cortical control over emotional reactions (Wallin, 2007). Attachment anxiety interferes with the down-regulation of negative emotions © 2017 Hogrefe Publishing

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and intense and persistent distress, which continues even after objective threats subside. As a result, people who score high on the attachment anxiety dimension experience an unmanageable stream of negative thoughts and feelings, which contribute to cognitive disorganization and fuel chronic worries and distress (Ein-Dor, Mikulincer, Doron, & Shaver, 2010). The implication is that anxiously attached clients may need the therapist to help them modulate their emotional reactivity and strengthen their capacity to manage their emotions by making sense of them (Wallin, 2007).

Ms. B.’s Rorschach Features The CS Rorschach scores show that Ms. B. exhibits difficulties in emotion regulation as exemplified by her Depression Index and (CF + C) > FC. Her affect regulation difficulties probably contributed to her inability to contain her disturbing feelings of being damaged and repulsive, as suggested by her evocative responses to Card IV of “rotting skin” and Card VI, “you can tell where his legs were chopped off.” Eventually, this sense of damage may have made her vulnerable to the suicidal act. It seems that she is more intense in expressing feelings; and since she is experiencing emotional problems, the magnitude of her emotional expression is likely to be intense (Exner, 2000). The dominance of her CF color responses points also to her immature relating to others manifested in difficulties differentiating between the self and others, accurately perceiving others’ attitudes, and their responses to her (Overton, 2000). It seems that her dominant attitude toward others is quite subjective and mainly based on her emotional experiences ([dominance of CF over FC]; Berant, Mikulincer, Shaver, & Segal, 2005; Overton, 2000). Another indication of her difficulties to regulate her emotional world is that five of nine minus responses are given to the colored cards, suggesting that when encountering affect-charged states, her reality testing is being distorted. Perhaps while being overwhelmed with emotions, she misjudged her options and chose the suicidal act. Other indications of the problems in affect regulation are Rorschach contents revealing her difficulties expressing aggression in conventional and socially accepted ways and her inability to neutralize her aggressive drives (e.g., Card VI, “volcano explosion”; Card IX, “a blender exploding – it is coming out everywhere,” and a variety of other aggressive contents such as Card I, “goblins,” Card IV, “dragon”; and her final response on Card X, “a villain with an evil plan”). Her CS Rorschach indicates also that she is presently experiencing high level of distress (Y = 5, m = 6), a finding that not only describes her current distress but Rorschachiana (2017), 38(1), 59–70

Attachment Theory Applied to Ms. B.’s Rorschach

also converges with research indications that anxiously attached individuals tend to have higher m, indicating constant feelings of distress, as if they always experience some situational distress (Berant, 2009; Berant et al., 2005). This finding is in agreement with research showing that anxiously attached individuals are frequently overwhelmed by feelings of distress, vulnerability, and helplessness (Berant et al., 2005). However, research shows that among anxiously attached individuals this sense of helplessness is not only an unwanted reflection of difficulties in emotion regulation, but also an instrumental means of eliciting others’ love and support – the main goal of the hyperactivating strategies of attachment anxiety (Mikulincer & Shaver, 2007). This strategy is being operated because anxious individuals intensely desire closeness and intimacy, but fear that their partners (in this case, perhaps Ms. B.’s therapist) may reject or abandon them (Mikulincer & Shaver, 2003). This combination produces an acute sensitivity to rejection, stress, and hurt. Overall and Lemay (2015) claim that anxiously attached individuals may exaggerate hurt expressions in order to extract guilt feelings and care from their partner. Perhaps the suicidal act was an attempt to elicit guilt feelings from people who were close to her including her therapist. Ms. B.’s fragile self-esteem is revealed by the high number of MOR responses, underscoring her pessimistic view of the self and the world. Anxiously attached individuals have a fragile self-esteem and tend to perceive themselves as worthless and helpless (Gillath, 2015). They describe themselves in negative terms, report low levels of self-esteem, and dismiss positive self-traits (Berant et al., 2005). The four morbid responses, indicating her negative thinking patterns, might hinder her rehabilitation because of her disbelief in her ability to be helped. It seems that she does not believe that she can cope in life because of her being damaged (e.g., her response to Card I, “an angel without a head”). It seems that the representation of the angel without a head may point to her perception that she is encountering problems in cognitively processing her thoughts and emotions. On one hand she is a flawless person – like “an angel” (suggesting idealization; Lerner, 2005) – but on the other hand, a woman who cannot collect her thoughts or engage her executive functions (“without a head” – a devaluation; Lerner, 2005). She believes that even the strong can get hurt (e.g., her response to Card IV, “the giant is without arms”). It seems that her human representations are missing important organs – head, legs or arms. It appears that these representations expose her feelings about herself as an individual who is lacking vital elements. More specifically, she cannot think, cannot have a stable basis, and cannot initiate actions. These negative thinking patterns may well have contributed to her suicidal act. And in this case too, we attend once again to attachment theorists, who claim that such negative self-view is sometimes an attempt to elicit another person’s © 2017 Hogrefe Publishing

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compassion and support of the anxiously attached (Shaver & Mikulincer, 2009). Hence, the therapist should explore with her the secondary gains emerging of perceiving herself in such a negative manner. Her dialogue with being feminine can be explained also in the frame of attachment theory. She is occupied with symbols of femininity and wonders whether she should be a doll (Card VI, “a Kachina doll”). It seems that one can detect her conflict regarding how to present herself as a woman (e.g., Card VIII, “A dress…one of these mid-1900 dresses, high collar and hugs waist…”). Also, one notices her pressure to be strict in morals (e.g., Card VII, “some gaudy necklace that I’d never wear”). Perhaps she is afraid that she might be perceived as a fake or a cheap woman if she dresses with jewelry, as she suggested by describing the necklace in Card VII as “big fake jewels…big cheap gold thing”. The aforementioned Rorschach responses converge with studies showing that attachment insecurities are likely to erode a person’s confidence in his or her sexual attractiveness and prowess (Mikulincer & Shaver, 2007). Higher scores on attachment anxiety and avoidance are associated with lower sexual self-esteem (Shafer, 2001) and lower self-perception of physical attractiveness and sensuality (Bogaert & Sadava, 2002). Attachment researchers claim that anxiously attached individuals may deny their own sexual desires and need in order to please their partners (Zayas, Merril, & Hazan, 2015). The presence of elevated scores on CDI and DEPI are further examples of her weak ego functions and fragility that contribute to her depression. These indices suggest that her depression might be secondary to her problematic object relations and her difficulty managing interpersonal relationships in a comfortable and rewarding manner. These findings may also be revealing her inadequate social skills. Many studies have shown that attachment-related anxiety is inversely related to well-being and positively associated with global distress, depression, anxiety, and personality disorders (Shaver & Mikulincer, 2009). Other indication for this weakness, which characterizes anxiously attached individuals, is her pervasive distortion of reality testing (high X−%) that occurs especially in emotionally loaded situations. A concept that is derived from attachment theory is the concept of mentalization – that is, the ability “to see ourselves as others see us, and others as they see themselves” (Holmes, 2009, p. 502). The ability to mentalize is an achievement that develops out of a secure attachment relationship characterized by affective attunement and accurate mirroring from the caregivers and the facilitating of affect regulation. The determinant M manifests the deep understanding of the subjective experience of another person and the self. However, M− (minus) manifests the difficulty of understanding people and social interactions, and it also

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Attachment Theory Applied to Ms. B.’s Rorschach

shows deficient empathy of the other (Weiner, 1998). The difficulty that anxiously attached individuals have with mentalization concerns mainly the inability to escape long enough from intense affects, such as fear of abandonment or losing another person’s love, and to reflect on the source of these feelings and fears – thus impairing the narrative coherence. Her score of M− = 2 emphasizes her risky situation. Clients who have difficulties with mentalization and empathy might also contribute to the therapist’s negative countertransference (Wallin, 2007).

Attachment Theory in Addressing Referral Questions and Treatment Recommendations The findings of the Rorschach combined with her attachment orientation indicate a young woman in distress and at risk for suicide and self-harm. Her anxious attachment point to the difficulties she has in down-regulating her distress and depression, as well as to her low self-esteem. Her attachment anxiety and the use of hyperactivating strategies contribute to her need to communicate her weakness and distress as a tool to draw people close to her. She has no motive to get better, because of her fear of abandonment. Her problems in mentalization might prevent her from expressing herself in a clear way to her attachment figures and perhaps not grasping and understanding their gestures toward her. Furthermore, being anxiously attached may cause difficulties in psychotherapy owing to the negative countertransference in her therapist. Ms. B. still presents a risk for suicide and self-harm, first because of the S-Con and other factors that highlight her ego weakness and difficulties in regulating and containing herself. Her low self-esteem and pessimistic state of mind are also concerning. As a result of all these factors, it seems that it is still too early for her to return to the dorms without supervision. Her problematic affect regulation, accompanied by reality testing distortion and problems in mentalization combine to make her a high risk for further self-harm. We cannot be sure about her post-trauma. Her inability to regulate her emotions, the emergence of threatening contents, and her hypervigillance in the Rorschach may point in this direction. Some of the damaged Rorschach contents also raise this question (e.g., her response to Card IV of “a giant without any arms,” and the image on Card VI of an “animal skin…where hind legs were chopped off”). Finally, regarding questions of whether Ms. B. might have an emerging bipolar disorder, we find no clear indication that this is likely to be the case.

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Therapeutic Implications Clients like Ms. B. who are anxiously attached present a therapeutic challenge. They are likely to report considerable distress and yet have difficulty in reflecting on their emotional experience, thus attesting to the powerfully dominant influence of attachment anxiety and chronic attachment system hyperactivation in their lives (Lopez, 2009). Because of her difficulties in mentalization, which are linked to problems in affect regulation, I would recommend a mentalization-based psychotherapy in addition to psychiatric consultation and follow-up. Allen and Fonagy (2002, p. 28) claim that depression and unresolved trauma can all be understood as examples of: “The mind misperceiving the status of its own contents and its own functions.” In such therapy we should generate multiple perspectives on experience rather than being embedded in only one, when we can relate internal and external realities rather than equating or dissociating them, and that we can make sense of each other and ourselves in terms of underlying mental states, then we can help our patients begin to do the same. (Wallin, 2007, p. 332) Regarding Ms. B.’s difficulties in mentalization, the therapist should encourage her to think about the way she feels (due to the distortion of reality in emotionally charged states and M minus responses). At times the therapist of anxiously attached clients like Ms. B. should do the thinking for the client (Wallin, 2007). The therapist should model mentalization, by making sense of Ms. B.’s experience, inviting her to think aloud about her own experience, and helping her to reflect on negative feelings that might lead to destructive behavior and self-harm. While treating Ms. B., one should focus on strengthening her ego functions, that is, enhancing coping and emotion regulation. This process is expected to be slow because of her pessimistic state of mind. The therapist must be aware that Ms. B. is afraid to be independent and should convey the awareness of how difficult it is for her to trust herself.

References Allen, J. P., & Fonagy, P. (2002). The development of mentalizing and its role in psychopathology and psychotherapy. Topeka, KS: Meninger Clinic. Berant, E. (2009). Attachment styles, the Rorschach and the Thematic Apperception Test: Using traditional projective measures to assess aspects of attachment. In J. H. Obegi & E. Berant (Eds.), Attachment theory and research in clinical work with adults (pp. 181–206). New York, NY: Guilford Press. Rorschachiana (2017), 38(1), 59–70

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Berant, E., Mikulincer, M., Shaver, P. R., & Segal, Y. (2005). Rorschach correlates of selfreported attachment dimensions manifestations of hyperactivating and deactivating strategies. Journal of Personality Assessment, 84, 68–79. Bogaert, A. F., & Sadava, S. (2002). Adult attachment and sexual behavior. Personal Relationship, 9, 191–204. Bowlby, J. (1969/1982). Attachment and loss: Vol 1. Attachment (2nd ed.). New York, NY: Basic Books. Bowlby, J. (1988). A secure base: Clinical applications of attachment theory. London, UK: Routledge. Brennan, K. A., Clark, C. L., & Shaver, P. R. (1998). Self-report measurement of adult romantic attachment: An integrative overview. In J. A. Simpson & W. S. Rholes (Eds.), Attachment theory and close relationships (pp. 46–76). New York, NY: Guilford Press. Campbell-Sills, L., & Barlow, D. H. (2007). Incorporating emotion regulation into conceptualizations and treatments of anxiety and mood disorders. In J. J. Gross (Ed.), Handbook of emotion regulation (pp. 542–559). New York, NY: Guilford Press. Ein-Dor, T., Mikulincer, M., Doron, G., & Shaver, P. R. (2010). The attachment paradox: How can so many of us (the insecure ones) have no adaptive advantages?. Perspectives on Psychological Science, 5, 123–141. Exner, J. E. Jr. (2000). Primer for Rorschach interpretation. Asheville, NC: Rorschach Workshops. George, C., Kaplan, N., & Main, M. (1985). The Adult Attachment Interview protocol Unpublished manuscript, Department of Psychology, University of California, Berkeley. George, C., Kaplan, N., & Main, M. (1996). The Adult Attachment Interview protocol (3rd ed.) Unpublished manuscript, Department of Psychology, University of California, Berkeley. George, C., & West, M. (2001). The development and preliminary validation of a new measure of adult attachment: The Adult Attachment Projective. Attachment and Human Development, 3, 55–86. George, C., & West, M. (2004). The Adult Attachment Projective: Measuring individual differences in attachment security using projective methodology. In M. Henson, M. Hilsenroth, & D. Segal (Eds.), Comprehensive handbook of psychological assessment: Personality assessment (Vol. 2, pp. 431–447). Hoboken NJ: Wiley. Gillath, O. (2015). The neuroscience of attachment: Using new methods to answer old and new questions. In J. A. Simpson & W. S. Rholes (Eds.), Attachment theory and research: New directions and emerging themes (pp. 39–67). New York, NY: Guilford Press. Holmes, J. (2009). From attachment research to clinical practice. In J. H. Obegi & E. Berant (Eds.), Attachment theory and research in clinical work with adults (pp. 490–514). New York, NY: Guilford Press. Lerner, P. (2005). Defense and its assessment: The Lerner Defense Scale. In R. F. Bornstein & J. M. Masling (Eds.), Scoring the Rorschach seven validated systems (pp. 237–270). Mahwah, NJ: Lawrence Erlbaum Associates. Lopez, F. G. (2009). Clinical correlates of adult attachment organization. In J. H. Obegi & E. Berant (Eds.), Attachment theory and research in clinical work with adults (pp. 94–117). New York, NY: Guilford Press. Main, M., Kaplan, N., & Cassidy, J. (1985). Security in infancy, childhood, and adulthood: A move to the level of representation. Monographs of the Society for Research in Child Development, 50, 66–104. Mikulincer, M., & Shaver, P. R. (2003). The attachment behavioral system in adulthood. Activation, psychodynamics and interpersonal processes. In M. P. Zana (Ed.), Advances in experimental social psychology (Vol. 35, pp. 53–102). New York, NY: Academic Press.

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Mikulincer, M., & Shaver, P. R. (2007). Attachment in adulthood: Structure, dynamics and change. New York, NY: Guilford Press. Overall, N. C., & Lemay, E. P. Jr. (2015). Attachment and dyadic regulation processes. In J. A. Simpson & W. S. Rholes (Eds.), Attachment theory and research: New directions and emerging themes (pp. 145–172). New York, NY: Guilford Press. Overton, C. G. (2000). A relational interpretation of the Rorschach color determinants. Journal of Personality Assessment, 75, 426–448. Shafer, A. B. (2001). The Big Five and sexuality trait terms as predictors of relationships and sex. Journal of Research in Personality, 35, 313–338. Shaver, P. R., & Mikulincer, M. (2002). Attachment related psychodynamics. Attachment and Human Development, 4, 133–161. Shaver, P. R., & Mikulincer, M. (2009). An overview of adult attachment theory. In J. H. Obegi & E. Berant (Eds.), Attachment theory and research in clinical work with adults (pp. 17–45). New York, NY: Guilford Press. Wallin, D. J. (2007). Attachment in psychotherapy. New York, NY: Guilford Press. Weiner, I. B. (1998). Principles of Rorschach interpretation. Mahwah, NJ: Erlbaum. Zayas, V., Merril, S., & Hazan, C. (2015). Fooled around and fell in love: The role of sex in adult romantic attachment formation. In J. A. Simpson & W. S. Rholes (Eds.), Attachment theory and research: New directions and emerging themes (pp. 68–96). New York, NY: Guilford Press. Received July 10, 2015 Revision received December 20, 2016 Accepted April 5, 2017 Published online July 13, 2017 Ety Berant Baruch Ivcher School of Psychology Interdisciplinary Center Herzliya Israel eberant@idc.ac.il

Summary The current case study exemplifies the contribution of attachment theory to the understanding of Ms. B.’s suicidal behavior and internal world. Ms. B. revealed in her Rorschach a picture of a woman with anxious attachment orientation. It seems that her suicidal attempt, beyond the high distress she was experiencing, could represent an effort to gain compassion and concern from her attachment figures including her therapist. Like anxiously attached individuals she displays a fragile ego, that is, has difficulties to reflect on herself, fragile boundaries, problems in affect regulation, distortion of reality while encountering emotionally charged situations, and a tendency to regress into fantasy. Herself is immature and she is also experiencing conflicts regarding her femininity. Her Rorschach points to her lack of social skills that contribute to her distress and dysphoric mood. Her therapy should be focused first on taking measures in order to address the suicidal threat. In addition, as in the case of anxiously attached clients, enhancing mentalization and affect regulation should be addressed, in order to strengthen her ego functions.

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Attachment Theory Applied to Ms. B.’s Rorschach

‫סיכום‬ '‫דרך ניתוח המקרה הטיפולי שהוצג לעיל ניתן לראות את התרומה של תאוריית ההתקשרות להבנה של ההתנהגות האובדנית של גב‬ ‫ נראה כי‬.‫ היתה של אישה צעירה בעלת דפוס התקשרות חרד‬.‫ התמונה שהתקבלה מן הרורשך אודות גב' ב‬.‫ ושל עולמה הפנימי‬.‫ב‬ ‫ יכול להיות מפורש כניסיון להשיג חמלה ודאגה מדמויות‬,‫המעשה האובדני שבצעה וזאת מעבר למצוקה שבה הייתה שרויה‬ ‫ כמו‬,‫ כמו אנשים אחרים בעלי התקשרות חרדה היו באבחון שלה אינדיקציות לחולשת אגו‬.‫ההתקשרות שלה כולל המטפל‬ ‫ עיוותים בבוחן המציאות בעת‬,‫ קשיים בוויסות הרגש‬,‫ תפיסת גבולות שבריריים‬,‫קושי בהתבוננות עצמית ויכולת של מנטליזציה‬ ‫ העצמי שלה אינו בשל והיא חווה גם קונפליקטים אודות‬.‫המפגש עם מצבים טעוני רגש ונטייה של רגרסיה לעולם פנטזיוני‬ ‫ דבר שיש להניח תרם למצוקה שלה‬,‫ ממצאי הרורשך מצביעים על חסך בכישורים בינאישיים וחברתיים‬.‫הנשיות שלה‬ ‫ בנוסף‬.‫ כדאי כי המטפל שלה ינקוט ראשית אמצעים להבטיח את שלומה על מנת שלא תיפגע בעצמה‬.‫ולרגשות הדיספוריים‬ .‫ כמו בטיפול עם אנשים עם דפוס התקשרות חרד חשוב יהיה לקדם מנטליזציה וויסות רגשי ובכך לחזק את תפקודי האגו שלה‬,‫לכך‬

Résumé L’ etude de cas actuelle, illustre la contribution de la théorie de l’attachement à la compréhension du comportement suicidaire et du monde interne de Mme B. Mme B, dans son Rorschach a perçue une image de femme avec une anxiété d’attachement. Il semblerait que sa tentative de suicide, au-delà de la grande détresse qu’elle éprouvait, pouvait représenter un effort pour obtenir la compassion ainsi que l’inquiétude de ses figures d’attachement, y compris son thérapeute. Comme des individus anxieusement attachés, elle reflète un ego fragile, c’est-à-dire des difficultés d’autoréflexion, des frontières fragiles, des problèmes de régulation d’affects, une déformation de la réalité face à des situations émotionnellement chargées et une tendance à régresser dans ses pensées. Son self est immature et elle éprouve aussi des conflits en lien avec sa féminité. Son test de Rorschach souligne son manque de compétences sociales, ce qui contribue à sa détresse et à son humeur dysphorique. Sa thérapie devrait se focaliser d’abord sur les mesures pour faire face à la menace suicidaire. En outre, comme dans le cas des clients avec des attachements anxieux, l’amélioration de la mentalisation et la régulation de l’affect devraient être abordées, afin de renforcer son ego.

Resumen El presente estudio de caso ejemplifica la contribución a la teoría del apego a la comprensión de la conducta suicida y del mundo interno de la Srta. B. La Srta. B muestra en su Rorschach la imagen de una mujer con una tendencia a los apegos ansiosos. Da la impresión de que sus intentos de suicidio, más allá de la extrema angustia por la que ella estaba atravesando, podría representar un esfuerzo para ganar la compasión y la preocupación de sus figuras de apego, incluyendo a su terapeuta. Como muchos individuos que poseen un apego ansioso, muestra un yo débil, es decir, dificultades para reflexionar sobre sí misma, fronteras frágiles, problemas en la regulación del afecto, distorsión de la realidad cuando encuentra situaciones cargadas emocionalmente y una tendencia a hacer regresiones en la fantasía. Su self es inmaduro y ella está teniendo conflictos respecto de su femineidad. Su Rorschach apunta hacia su falta de habilidades sociales, algo que contribuye a su angustia y a su humor disfórico. Su terapia debería enfocarse primero en tomar las medidas dirigidas al riesgo suicida. Además, como en los casos de pacientes con apegos ansiosos, se debe abordar la mejora de la mentalización y la regulación del afecto con el fin de fortalecer sus funciones yoicas.

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要約このケーススタディはMs.Bの自殺行動と内的世界を理解するのに愛着理論が役に立つことを例証するものである。Ms.Bはロールシャッハ法において不安な愛着の指向を有した女性という臨床像を示している。彼女の経験している強い苦悩を上回るものである彼女の自殺企図は、彼女の治療者を含めた彼女の愛着を寄せる人物から同情と関心を得るための努力を表しているかもしれないように見える。不安な愛着を有している人のように、彼女は壊れそうな自我を示しており、それは、自身についてじっくりと考慮することの困難さ、脆弱な境界、感情調節の問題、情緒的に負担がかかる状況に遭遇した際に現実を歪めてみること、空想への退行といったことである。彼女の自己は未成熟であり、彼女はまた彼女の女性性に関しての葛藤を経験している。彼女のロールシャッハは、彼女ソーシャルスキルの欠如を示しており、それは彼女の苦悩や不快性の気分に影響している。彼女のセラピーは彼女の自殺の脅威に対処するための手段をまずは講じることに焦点があてられるべきである。加えて、不安な愛着のケースにおいてそうするように、彼女の自我機能を強化するために、メンタライゼーションを向上させることと感情の調節に精力が傾けられるべきである。

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Discussion Special Issue: Multiple Psychoanalytic Models Case Study

Discussion of Special Issue Articles “A Rorschach Case Study: Multiple Psychoanalytic Models of Interpretation” Jed Yalof Department of Graduate Psychology, Immaculata University, Immaculata, PA, USA Abstract: Psychoanalytic theory offers multiple ways of organizing clinical data. In this paper, I comment on the preceding papers and offer an integrative discussion of Rorschach test analyses from the perspectives of object relations, ego psychology, interpersonal psychology, self psychology, and attachment theory. Each theory approaches the case somewhat differently, highlights different data points, and focuses on different inferences. In the end, however, each separate analysis reaches a similar endpoint with respect to the identification of core themes as manifested on the Rorschach test.

The papers comprising this special section (Berant, 2017; Evans, 2017; Kleiger, 2017; Silverstein, 2017; Smith, 2017; Weiner, 2017) speak directly and expertly to the value of diversity of psychoanalytic thought. In so doing, each author anchors to a specific theory, while also respecting Freud’s grand plan of a broad psychoanalytic scholarship, inferred from his chess-game metaphor (Freud, 1913/1981), in which multiple strategies (at times, overlapping each other) inform the analytic process. Freud’s architecture was of a large house with many rooms left open for exploration, as he introduced the ideas of conflict, ego, defense, object, narcissism, and attachment into what would become idiomatic to mainstream psychoanalytic thinking. Indeed, he left the rooms open to individual taste and décor, and this is what we see when we look at different analytic models – a similar focus on the unconscious and how it shapes or constructs internal and external realities, but not with the same primary, underlying motivational bases. Thus, as it relates to different psychoanalytic theories and how they each approach the Rorschach, we might surmise the following points. From the ego psychological perspective (e.g., Schafer, 1954) that Weiner (2017) represents, we see sadomasochistic behavior in which Ms. B. hurts herself and her therapist; this is followed rigidly by defensive denial and a seemingly manic flight into health. From the object relational/Winnicottian perspective that Smith (1990, 2017) represents, we see the spoiling of a good-enough maternal hold in which help is equated with toxic impingement and the periodic collapsing of transitional space © 2017 Hogrefe Publishing

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between self and object. From the self psychological/Kohutian perspective that Silverstein (1999, 2017) represents, we see the fragile, frightened, enfeebled, and fragmented self longing to revive healthy selfobjects, but only with trepidation. From the relational/Sullivanian (1953) perspective that Evans (2017) represents, we see Ms. B.’s massive insecurity and highly anxious interpersonal relationships at times overwhelm her ability to connect to others without anticipating setbacks. Berant (Berant & Wald, 2009; Berant, 2017) explains the meaning of Ms. B.’s Rorschach by drawing on content and structural variables in her analysis of Ms. B.’s insecure attachment style. This is the order in which I discuss and integrate the papers. In what follows, I offer a review of the case and then describe how each paper illuminates particular aspects of Ms. B.’s psychological status in a way that no single theory can capture in isolation.

Referral Issues and Interpretive Overview Regarding the specifics of the case, several referral questions emerged from Kleiger’s (2017) overview: First, is Ms. B. still at suicidal risk? Second, does Ms. B. have an emergent bipolar disorder? Third, is she vulnerable to dissociative and psychotic symptoms? Fourth, what are treatment implications? Fifth, and last, what is the best setting and level of intensity to help Ms. B. address her problems? These are weighty questions. Here, I refer to Bachrach’s (1974) article in which he described an if–then contingency model of diagnostic understanding. Using this model, we can reframe the referral questions not as dichotomies, but as contingency predictions; that is, under what conditions do her risks increase or decrease? From what we already know, she is depressed, impulsive, and angry, but quick to minimize her problems and the helping efforts of others. We also see that Ms. B. is conflicted over dependency, and therefore quick to enact high-risk behavior without first calling her therapist as she had promised to do. Indeed, once the dust settles, she seems content to move on while everyone around her picks up the pieces. In terms of treatment implications, there is much to address, including Ms. B.’s repression, denial, volatility, and seeming lack of psychological-mindedness. In such a lengthy record, the absence of Form-Dimensionality (FD) or Form-Vista (FV) responses (Exner, 2003) is telling. It raises a question about whether Ms. B. can reframe her perspective, generate usable insights, and make changes based on self-inspection. Without adaptive self-observing skills, we might expect proneness to action-oriented behaviors when stressed. Here, Freud’s (1981/1914) “remembering, repeating, and working through” provides a grounding for understanding Rorschachiana (2017), 38(1), 71–82

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Ms. B. because we suspect that her action-oriented defenses have as their adaptive aspect a wish to repeat and recover memories that hold the key to conflict and probably trauma. Thus, on the surface, it would appear that Ms. B.’s prognosis is not especially promising; however, she is still quite young, dealing with the developmental issues of a late adolescent, and trying to figure herself out in the process. The degree of psychological need evidenced in Ms. B.’s Rorschach suggested that it be might be best to keep her weekly treatment supportive, rather than insight-oriented and exploratory, although more frequent sessions or even residential care would probably help provide much-needed structure and containment as well as the foundation for an exploratory-interpretive approach. Given her history, there is also the matter of crises management. Thus, there are many possible treatment options, and, in keeping with an open-minded application of psychoanalytically informed psychotherapy, Ms. B.’s treatment will likely include elements of empathy, reassurance, psychoeducation, exploration, and interpretation, with timing and dosage contingent on her mental status and therapy alliance at any one point in time. Indeed, Ms. B. poses a diagnostic and therapeutic challenge. We might speculate that Ms. B. will try to complicate the therapist’s well-intentioned efforts at alliance building. Her therapist would also need to be aware of the transference pressure to take care of Ms. B., which she is quite likely to evoke, and decide how to respond in a way that is helpful. It is important to note here that Ms. B.’s failure to inform her therapist of her suicidal ideation, in spite of their reportedly close communication, tells us that Ms. B. might be at greatest risk for pulling back and stirring a crises right when she feels heard and understood. Further, her three White Space responses with minus form quality (S−%) and one Food (Fd) content response suggest counter-dependence, defensive states of self-sufficiency, conflict about being under professional care. Ms. B.’s various needs will no doubt fester into the therapy relationship and likely take the form of countertransference disappointment, pessimism, hurt, self-doubt, over-thinking, and anger, with projections targeted toward Ms. B.’s therapist and anyone else who offers to help. Ms. B. has a history of depression, which poses its own risk. Her elevated Depression Index (DEPI) and Suicide Constellation Index (S-CON) do nothing to downplay the probability of recurrent depressive episodes and suicidal ideation, but the presence of mania is harder to assess apart from her impulsiveness. Clearly, she would appear to need much structure, frequent meetings, and support. Rorschach data also amplify her vigilance, hyper-scanning, and an obsessive possibly hypomanic style, related to a control theme – although what she is trying to control is open to theory (i.e., aggression, separation, anxiety, or empathic failings). She has lowered self-regard, anticipation of negative outcomes, a pessimistic outlook, a weak anxiety signal, and feels damaged. © 2017 Hogrefe Publishing

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There is also evidence of a propensity toward disorderly thought, noted by her form quality minus (X−) and three White Space (S) answers with poor form quality. Ms. B.’s Perceptual Thinking Index (PTI), however, was 2 and there were no content indications of truly psychotic thinking. Rather, Ms. B.’s thinking is more apt to deteriorate to a point where she is likely to misperceive or misconstrue intent when angry, anxious, depressed, scared, and in need of rescue. In this context, there was one Morbid (MOR) response with a poor form-quality blend of movement and diffuse shading (Mp. FY−), suggestive of pessimism and a degree of anxiety that disrupts her thinking, along with a projective element in which she externalizes doom and gloom. Plus, Ms. B.’s ten passive movement responses speak loudly to how she might pull for extreme support and evoke a need to be rescued or resuscitated when feeling broken. But is she about to move into a more destabilizing mood disorder? We see the elevated Depression Index (DEPI), a D minus score of 2, and a deterioration in her ability to regulate affect, evidenced in her use of color in relation to form quality (FC, CF), as she moves from a CFo to CFu, and finally to FC−. Still, we might need more history and more evidence of extreme behavioral dyscontrol to conclude in favor of mania. Her impulsive behavior, given the elevated Suicide Constellation (S-CON), and equally quick recovery, suggests defensive splitting that takes the experiential form of “here today, gone tomorrow, but here again the next day and without much warning.” Maybe this is how Ms. B. feels: wanting to die one day, wanting to start life anew the next day, and so on. Her behavior could suggest a rapid cycling disorder superimposed on a borderline ego structure, although the latter seems more convincing. Ms. B.’s background may also include trauma, but whether or not she dissociates defensively under moments of acute strain is hard to know. However, a close analysis of Rorschach data provides some direction. There were an unusually high number of passive movement responses, which raises the following question: At what point does a wish to be rescued (Exner, 2003) drift into a state of extreme passivity and detachment? Does Ms. B. slip into dissociative and self-inflicted rage states, and then forgets what happened? Is this one type of mental state that Breuer and Freud (1981/1893–1895) were describing when they sought initially to explain dissociated states of consciousness? What do we make out of D = −2 and Adjusted D = +1? What do seven inanimate movements and five Diffuse Shading responses suggest? Is she fighting off demons? Are there two people at work here, disconnected from each other? It is hard to say, but clearly Ms. B. moves from states of potential collapse and fragmentation to moments of solidity, but this type of back-and-forth portends trouble for therapeutic containment and hints at a trauma history. Response content provides thematic support for damaged self-image, anger, and other signs of intense internal distress. Rorschachiana (2017), 38(1), 71–82

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As for her return to school, Ms. B. is presenting as the type of student who makes universities anxious. She needs support, direction, and extra attention. If she goes back to school, there will be many potential triggers that can exacerbate her problems. The extra stress of social exchange and a readiness to expect the worst tells us that the imperfect selfobject, impinging maternal object, confluence of displaced and conflicted oedipal strivings organized around competition, and conflicted attachments – all of which play out at school with teachers, peers, and the maternal symbolism of the university setting – will render her quite vulnerable to another setback. A residential setting might be a better container for her various conflicts at this point, with a return to school as a reasonable longer-term goal.

Theoretical Perspectives The aforementioned overview provides a Rorschach-based, psychoanalytically informed context for understanding Ms. B.’s psychological status at the time of testing. However, there are particular schools of thought under the generic psychoanalytic umbrella that offer different conceptual slants on similar data points. Indeed, there are many ways to think about Rorschach data psychoanalytically, as evidenced by the papers to which this discussion is directed. Each author takes the richness of the Rorschach and combines it with psychoanalytic theory to highlight different facets of Ms. B.’s experience. Ego Psychology Weiner (2017) anchors us to the history of ego psychology. Ego psychology is equated with defense analysis. Here, the work of Anna Freud (1936) is most relevant as she described how the defenses are so woven into character, that character cannot be understood without understanding the ego and its defenses. Hartmann’s (1939) work on the notion of innately conflict-free ego functions that becomes entwined with conflict is also a cornerstone of ego psychology. Erik Erikson’s (1962) work was an essential addition to ego psychology, highlighting how morality is shaped by culture and how culture imposes psychosocial pressure on development to create an added tier of conflict above the psychosexual conflict about which Freud wrote. Weiner looks at the form quality minus responses and then studies them in relation to how they fit with other preceding and subsequent responses as a way of understanding the conditions under which defenses become less adaptive and lead to decline and, in some cases, recovery of functioning. Indeed, all form minus responses are buffered by better responses, save for the © 2017 Hogrefe Publishing

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final two answers where there are consecutive minus answers, at which point her ability to recover appears to max out. Weiner’s content analysis elaborates eloquently the possible defensive implications of Ms. B’s responses. This is the essence of an ego psychological approach to personality assessment: Under what conditions are the defenses more or less adaptive, how might this knowledge inform an understanding of content themes that are more or less tied to conflict, and how does it inform treatment? I agree with his conclusions about Ms. B.’s mood disorder, posttraumatic stress disorder risk, and need for a very carefully orchestrated treatment approach. Object Relations Moving from ego to object, Smith (2017) covers main concepts in object relations theory, illustrating, for example, the Winnicottian notion of transitional space beautifully in his analysis of the apparent split in the quality of Ms. B.’s Rorschach. Demonstrating a uniquely creative approach, Smith studies Ms. B.’s responses to odd- and even-numbered cards to extend the curious finding of D = −2, but Adj D = 1. Smith uses content and sequence analysis to illuminate the defense of splitting by highlighting Ms. B.’s tendency to shift from deadening to enlivening transitional phenomenon. Smith then discusses Blatt’s introjective style (e.g., Blatt, Shahar, & Zuroff, 2001) and recommends an interpretive approach, but without a transference focus, using test data to support his recommendation. He elaborates Ms. B.’s object relations, noting her difficulty with relationships, commenting on the meaning of texture denial in connection with disavowed affiliative needs, underscoring her unstable internal representations, carefully tying her denial of dependency, using theory as a guide to her isolation and intimacy conflicts, and analyzing the “blender exploding” response as a reflection of Ms. B.’s internal chaos and not-well-integrated self. Interpersonal Evans (2017) offers a different theoretical position in his analysis of Ms. B. Emphasizing the application of Harry Stack Sullivan’s ideas to the Rorschach test, Evans reminds us of Sullivan’s significant contributions to psychoanalytic thought. This point is underscored by Greenberg and Mitchell (1983) in their book Object Relations in Psychoanalytic Theory, in which they devote an extensive chapter to Sullivan’s ideas about the importance of interpersonal relationships and security-driven behaviors in comparison with Freud’s drive-reduction position. Evans raises questions that relate to Sullivan’s thinking: How did Ms. B.’s interpersonal world find meaning on the Rorschach? How does she represent inner Rorschachiana (2017), 38(1), 71–82

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relationships? To what extent can she cooperate and where does her fault line lie with respect to interpersonal anxiety and attachment? He notes how the positive Hypervigilant (HVI), Depression (DEPI), and Coping Deficit (CDI) indices tell the tale of the tape: Ms. B. is scared, defeated, and has great difficulty coping with any degree of sustained effectiveness. Not having access to history about the mother– child relationship, one might speculate about the presence of instability and chronic anxiety. One might further speculate that there were other factors at play, possibly neurodevelopmental vulnerability, an unsettling father, and a series of setbacks from which Ms. B. could not recover fully without being submerged again in states of overstimulation or deprivation. Again, these are some hypotheses about Ms. B. that issue from a psychoanalytic conceptualization, but without access to specific information, they remain tentative. Evans uses a similarly sophisticated clustering of variables to respond to the question about Ms. B.’s inner relationships – her sense of self as damaged, resentful, expectant of slight, passively fantasizing about a better situation, readiness to feel disappointed, and unable to comfortably use her aggression to support selfadvocacy. We see how S−, HVI, CDI, and a Cooperative Movement (COP) with a FABCOM can be reconfigured in Sullivan’s language to describe Ms. B. as blocked, hindered, vigilant, and unable to trust. Evans also notes Ms. B.’s high anxiety level. Greenberg and Mitchell (1983, p. 99) discuss Sullivan’s “anxiety about anxiety” concept as being “at the core of all psychopathology and constitutes a basic organizational principle of the self.” We can see this hyper-anxiety in Ms. B.’s five diffuse shading answers in conjunction with the other variables that Evans integrates with the notion of interpersonal anxiety and attachment disruption. He sees Ms. B. at high suicide risk and in need of intensive psychodynamic treatment with goals related to Sullivan’s “paranoid dynamism” (i.e., a therapy approach that focuses on Ms. B.’s mistrust, vulnerability, view of self as inept, self-regulation, and attention to body cues). She is neither bipolar nor dissociative and there is no hard evidence to suggest otherwise. Evans thoughtfully leaves her decision to return to dormitory life to school administrators, while noting risks associated with this return that relate back to basic Sullivanian constructs associated with problems in living. Mistrust and a core disconnect will color her transference and the therapist’s countertransference, with potential enactments related to a false read on her sense of security. Self Psychology Silverstein’s (2017) eloquent review of Ms. B. in relation to Kohut’s concepts provides a self-psychological approach to the Rorschach that illuminates differences with other Rorschach approaches. Kohut’s description of the “forward © 2017 Hogrefe Publishing

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edge” concept is quite relevant here because Ms. B. is the type of patient who poses questions about the balance between, and timing of, empathic and interpretive interventions. More poignantly, Silverstein challenges us to become immersed in her experience of being a “goblin,” a grotesque creature afraid to move ahead unless prompted to do so, and then, when encouraged, being an “angel without a head.” With self psychology as his foundation, Silverstein invites us to “be Ms. B.”: What is it like to feel bad, try to reach out on the forward edge, but do so with great trepidation lest the longing be slapped down? This is somewhat similar to Fairbairn’s (1946) internalized object relational model involving the longing for the exciting object and the regressive pull against this longing by the internal saboteur. However, in self psychology, it is empathic failure, rather than conflict between internal objects associated with libidinal and antilibidinal drives, that is foundational to understanding the underlying basis of psychological distress. Silverstein uses content analysis to further highlight Ms. B.’s core needs. Ms. B. seeks to revive unempathic selfobjects, but is unable to reach, make contact, or fully engage, although she has not abandoned hope. Indeed, as Silverstein notes, Ms. B. is storing away the hope that damaged selfobject bonds can be restored. For example, his analysis of Ms. B.’s de-idealization of the Great Dane on Card VI, in which the Dane’s face was “saggy” and “drooling,” but looking for “praise” and had a bone in its mouth, illustrates the subjective state of: “I’m a mess, disillusioned, and need a strong figure to look up to. Will someone please give me a pat on the back, throw me a bone?” This is the meaning of the forward edge – keeping alive the desire to revive and reverse the reverse selfobject trend (Lee, 1988) by repairing others so they, in turn, can repair you. The goal here is to restore the self’s center of vitality, not gratify impulses, navigate separations, or revise internal working models based on attachment failures. Attachment To minimize the role attachment disturbance in Ms. B.’s life would, however, be misleading. Berant’s (2017) analysis demonstrates astutely how concepts that are central to attachment theory capture the essence of Ms. B.’s Rorschach. After reviewing basic attachment styles, Berant appears to settle on the “insecure” subtype as the best description of Ms. B.’s style. Clearly, Ms. B. is fragile (e.g., Morbid responses), anxious (e.g., m, Y responses), angry (e.g., Space responses), self-protective (e.g., response of “fangs”), and in need of a strong and stable therapeutic hold, but also fights against it. Here, a difference between ego psychology and attachment theory is noted, as attachment theory might be inclined to view Ms. B.’s fear of dependency not so much as reflecting a counter-dependent stance, but as a strategy for engendering support and tracking from her therapist Rorschachiana (2017), 38(1), 71–82

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in order to maintain the very connection by which she feels threatened. Berant also draws attention to gender-specific inferences in relation to symbols of femininity (e.g., Kachina doll, dress) and its implication for the way in which disturbed attachment affects sense of attractiveness. Other examples of how attachment theory is applied to Ms. B.’s case include the following illustrations. First, Berant notes how Ms. B.’s cognitive misperceptions, such as M− responses, FABCOM and INC responses, and multiple markers of affect dysregulation, such as a preponderance of poor-form quality color responses, reflect deficits in mentalizing and theory of mind. Both deficits render her at risk for concrete understanding and misinterpreting herself and others. Ms. B.’s Rorschach content is also interpreted in relation to affect dysregulation (e.g., “like a dog looking for praise” as reflecting neediness and desire for affirmation). Second, Ms. B.’s suicidal ideation is seen as reflective of an attachment preoccupation in which efforts to gain the love of others is a motivating factor in what might otherwise appear to be disorganized behavior. Third, Ms. B.’s Rorschach has several markers of distress, not uncommon among individuals with insecure attachment styles. Fourth, Ms. B.’s negative self-view, suggested by the presence of MOR responses and other content-based data, represents not so much the turning inward of anger, as might be the focus of an ego psychological approach, or the residue of failure of selfobjects to provide empathy, as might be seen in a self psychological approach, or even the triumph of the antilibidinal ego over the libidinal ego, as might be posited by an object relational approach, rather an attempt to secure the emotional support and stabilizing presence of another person.

Conclusion In conclusion, there are many ways to think about Ms. B.’s Rorschach psychoanalytically. The perspectives outlined in this paper reflect the consistency with which different Rorschach interpretive approaches augment each other and eventually lead to the same endpoint. A comprehensive overview of Ms. B.’s Rorschach would necessarily include history and information about the client–assessor relationship, and would describe the quality of her thinking, affects and affect regulation, capacity for empathy, defenses, self-esteem and narcissistic vulnerability, ability to manage separations, attachments, diagnosis, recommendations, and prognosis. The papers presented as part of this special section have captured comprehensively these points in relation to an identifiable approach to the Rorschach. Taken together, they deepen our appreciation for the complexity of analyzing a Rorschach and the value of remaining open to the wealth of ideas provided within a psychoanalytic framework. © 2017 Hogrefe Publishing

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Acknowledgments An earlier version of this paper was presented at the Annual Meeting of the Society for Personality Assessment, San Diego, California, March, 2013.

References Bachrach, H. (1974). Diagnosis as strategic understanding. Bulletin of the Menninger Clinic, 38(5), 390–405. Berant, E., & Wald, Y. (2009). Self-reported attachment patterns and Rorschach-related scores of ego-boundary, defensive processes, and thinking disorders. Journal of Personality Assessment, 91, 365–372. Berant, E. (2017). Attachment theory applied to Ms. B.’s Rorschach. Rorschachiana, 38(1), 59–70. Blatt, S. J., Shahar, G., & Zuroff, D. C. (2001). Anaclitic (sociotropic) and introjective (autonomous) dimensions. Psychotherapy, 30(4), 449–454. Breuer, J., & Freud, S. (1981). Studies on hysteria. In J. Strachey (Ed.), The standard edition of the complete psychological works of Sigmund Freud (Vol. 2, pp. 1–335). (Original work published 1893–1895). Erikson, E. (1962). Childhood and society. New York, NY: Norton. Evans, F. B. (2017). An interpersonal approach to Rorschach interpretation. Rorschachiana, 38(1), 33–48. Exner, J. E. (2003). The Rorschach: A Comprehensive System Vol. 1: Basic foundations and principles of interpretation (4th ed.). New York, NY: Wiley. Fairbairn, W. D. (1946). Object-relationships and dynamic structure. International Journal of Psycho-Analysis, 27, 30–37. Freud, A. (1936). The ego and the mechanisms of defense. New York, NY: International Universities Press. Freud, S. (1981). On beginning the treatment. In J. Strachey (Ed.), The standard edition of the complete psychological works of Sigmund Freud (12, pp. 123–144). (Original work published 1913). Freud, S. (1981). Remembering, repeating, and working through. In J. Strachey (Ed.), The standard edition of the complete psychological works of Sigmund Freud (Vol. 12, pp. 145–156). (Original work published 1914). Greenberg, J. R., & Mitchell, S. A. (1983). Object relations in psychoanalytic theory. Cambridge, MA: Harvard University Press. Hartmann, H. (1939). Ego psychology and the problem of adaptation. New York, NY: International Universities Press. Kleiger, J. H. (2017). A Rorschach case study – Multiple psychoanalytic models of interpretation [Editorial]. Rorschachiana, 38(1), 1–11. Lee, R. R. (1988). The reverse selfobject experience. American Journal of Psychotherapy, 42 (3), 416–424. Schafer, R. (1954). Psychoanalytic interpretation in Rorschach testing. New York, NY: Grune & Stratton. Silverstein, M. L. (1999). Self psychology and diagnostic assessment: Identifying selfobject functions through psychological testing. Mahwah, NJ: Erlbaum.

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Silverstein, M. L. (2017). A self psychological analysis of Rorschach thematic content. Rorschachiana, 38(1), 49–58. Smith, B. L. (1990). Potential space and the Rorschach: An application of object relations theory. Journal of Personality Assessment, 55(3–4), 756–767. Smith, B. L. (2017). Rorschach interpretation – An object relations theory approach. Rorschachiana, 38(1), 12–21. Sullivan, H. S. (1953). The interpersonal theory of psychiatry. New York, NY: Norton. Weiner, I. B. (2017). Ego psychoanalytic Rorschach interpretation. Rorschachiana, 38(1), 22–32. Received June 26, 2015 Revision received December 19, 2016 Accepted April 5, 2017 Published online July 13, 2017 Jed Yalof Department of Graduate Psychology Immaculata University Immaculata, PA 19345 USA jyalof@immaculata.edu

Summary This article reviewed a series of papers that analyzed Rorschach data from different psychoanalytic perspectives. The patient was a depressed, young adult female struggling with suicidal ideation, acting-out behavior, and a complex relationship with her therapist (Kleiger, 2017). Diversity of psychoanalytic thought was evidenced in each analysis, which varied in utilization of structural variables and thematic imagery, while offering a detailed analysis of Ms. B.’s problems: an understanding of her defensive operations from an ego psychological viewpoint (Weiner, 2017), object relational conflicts (Smith, 2017), core anxiety and interpersonal conflicts associated with pervasive insecurity (Evans, 2017), a self psychologically informed formulation of her fragile self-esteem (Silverstein, 2017), and extensive attachment needs with associated deficits (Berant, 2017). Thought organization, affect regulation, and core conflict areas were also identified. It was clear that a comprehensive understanding of Ms. B. required insights from each analytic perspective and served to enhance the overall case formulation.

Résumé Cet article a passé en revue une série d’articles qui ont analysé les données du test de Rorschach à partir de différentes perspectives psychanalytiques. La patiente était une femme adulte et déprimée qui luttait contre des idées suicidaires, de l’acting out (passage à l’acte) et une relation complexe avec son thérapeute (Kleiger, 2017). La diversité des pensées psychanalytiques a été mise en évidence dans chaque analyse, qui ont varié dans l’utilisation des variables structurelles et des images thématiques, tout en proposant une analyse détaillée des problèmes de Mme B.: Une

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compréhension de ses opérations défensives du point de vue psychologique de l’ego (Weiner, 2017), Les conflits relationnels d’objets (Smith, 2017), le cœur de l’anxiété et les conflits interpersonnels associés à une insécurité envahissante (Evans, 2017), Une auto-formulation de la fragilité de son estime de soi (Silverstein, 2017), les besoins d’attachements associés à des déficits (Berant, 2017). L’organisation des pensées, la régulation des affects et le cœur des zones de conflit ont également été identifiés. Il est clair que la compréhension du cas de Mme B. nécessitait les points de vue de chaque perspective analytique, ce qui a permis la formulation globale du cas.

Resumen Este artículo incluye una serie de trabajos que analizaron los datos de un protocolo de Rorschach desde diferentes perspectivas psicoanalíticas. La paciente era una mujer adulta joven, deprimida, que presentaba ideación suicida, conductas actuadoras y una compleja relación con su terapeuta (Kleiger, 2017). Cada uno de los análisis ofrece una gran diversidad de pensamiento psicoanalítico, que varía en el uso de las variables estructurales y de la imaginería temática, al tiempo que aporta un análisis detallado de los problemas de la Sra. B: una comprensión de sus operaciones defensivas desde el punto de vista de la psicología del Ego (Weiner, 2017); los conflictos de sus relaciones objetales (Smith, 2017); la ansiedad nuclear y los conflictos interpersonales asociados con una inseguridad persistente (Evans, 2017); una formulación psicológicamente informada de su frágil autoestima (Silverstein, 2017); y unas intensas necesidades de vinculación con déficits asociados (Berant, 2017). Se identifican también la organización de su pensamiento, la regulación de sus afectos y sus núcleos conflictivos. Se pone de manifiesto que una comprensión sintética de la Sra. B requiere conocimientos y perspìcacia desde cada una de las perspectivas presentadas y que todas ellas sirvieron para incrementar la riqueza de la formulación global de este caso.

要約本論文は精神分析的な観点からロールシャッハのデータを分析した一連の論文を吟味したものである。患者はうつ状態にある若い女性であり、自殺の考えと行動化、そして治療者との複雑な関係と苦闘していた (Kleiger, 2017）。様々な精神分析の考えがそれぞれの分析において明らかにされた。これらの分析は構造変数や主題イメージをどのように使用するかについて異なっており、Ms.B の問題の詳細な分析を提供している。それらは、自我心理学の観点から見た彼女の防衛操作の理解（Weiner, 2017）、対象関係の葛藤（Smith, 2017）、広範な安心できなさと関連した中核的な不安と対人関係の葛藤(Evans, 2017）、自己心理学的な情報に基づく彼女の壊れそうな自己評価の明確な説述（Silverstein, 2017）、関連する欠損に対する広範囲に及ぶ愛着のニーズ（Berant, 2017）。また、思考の組織化、感情の調整、中核的な葛藤の領域が同定された。Ms.B の包括的理解にはそれぞれの精神分析の観点からの洞察が必要であり、それはケースの定式化を全体的に高めることに役立つことは明らかであった。

Rorschachiana (2017), 38(1), 71–82

Book Review Disordered Personalities and Crime Marianne Nygren

David W. Jones. (2016) Disordered Personalities and Crime: An Analysis of the History of Moral Insanity London: Routledge ISBN (softcover) 978-041550-217-7, £30.99 ISBN (hardcover) 978-041550-206-1, £90.00 ISBN (ebook) 978-020349-374-8, £30.99 This is a remarkable and thought-provoking book, readable not only for those working in the field of forensic psychiatry/psychology, but also for everyone interested in the history of psychiatry and psychiatric/psychological assessment, and how society has dealt with criminal behavior related to mental disorders. The focus is on the development in the United Kingdom, from the eighteenth century to the present, but the course of events in the United States, Germany, and France is also elucidated. The book gives an engaging and informative picture of the development of psychiatry through interaction with the wider culture, an interaction grounded in the public interest in psychological processes. Both more optimistic and more pessimistic views of insanity have got social and cultural expression. The description of the development of concepts that have been applied to mental disorder related to criminal behavior, from moral insanity until today’s antisocial personality disorder, is rich in detail. The reader is invited to follow how ideas about a possible non-manifest insanity related to criminal acts took shape at the Central Criminal Court in England and Wales (the Old Bailey) during the eighteenth century. During the first half of the nineteenth century, psychiatry reached a strong position in the court system, offering expert assessment of moral insanity and of moral treatment. However, during the second half of the century, after the case of Daniel M’Naghten in 1843, this position grew weaker. M’Naghten, intending to murder the British Prime Minister Robert Peel, mistakenly shot Peel’s secretary, and was charged with the murder of the secretary. The verdict, not guilty on the © 2017 Hogrefe Publishing

Rorschachiana (2017), 38(1), 83–85 DOI: 10.1027/1192-5604/a000084

M. Nygren

grounds of insanity, created great public controversy. After a debate in the House of Lords, the M’Naghten rules, restricting the possibilities to be found not guilty on the grounds of insanity, were formulated and decided upon. To adapt to this new situation, psychiatry, having lost its strong position in the court system, had to adjust and find new territories. While the interest in possible social causes of mental illness was still prominent in literature this was not the case in a psychiatry that was becoming more biologically oriented. Theories of moral insanity took an organic form in the early twentieth century, later paving the way for theories and practices of eugenics leading to tragic consequences. The two world wars in the twentieth century made clear how trauma can affect otherwise healthy persons, and how violence and destructiveness is part of human nature and not restricted to genetically defective individuals. The interest in understanding psychopathy psychologically and/or in terms of a social context grew strong after World War II. The influence of psychoanalysis on psychiatry was strong in the United States, where the significance of narcissism, as formulated by Otto Kernberg and Heinz Kohut for understanding the DSM diagnosis of antisocial personality disorder, was forceful. In the United Kingdom, the diagnosis psychopathy was accepted and seen as a psychological state with social dimensions. This social understanding of psychopathy led to the development of therapeutic communities in Britain but also in other countries. These communities are now out of favor and closed down. With this book the author conveys the message that diagnostic concepts develop in interaction with the surrounding society. The concluding chapter deals with today’s debate of insanity and criminal acts. Diagnoses related to criminal acts develop in the junction between the legal system and welfare institutions and the wider public, driven by both curiosity and anxiety. With shifting names (such as moral insanity, psychopathy, antisocial personality disorder) this kind of diagnosis has existed for more than 200 years, albeit used in very different ways. The relations between the, always criticized, diagnoses of mental disorders and criminal acts are not stabile. The boundaries between criminal behaviors regarded or not regarded as dependant on insanity change, often in connection with acts of public violence attracting great public interest. Examples of this are what happened after the M’Naghten and the Hinkley trials. Today, however, results from longitudinal research should help to give meaning to the diagnostic concepts and to deal with the social problems often related to criminal acts. Can criminal behaviors be explained by an individual’s biology, by dysfunctions or illness in the brain, or by underlying stable personality traits? Or do we need to understand criminal and even other dysfunctional behavior in a wider social context? Perhaps there is a tendency to want to get rid of the insights gained after the two world wars, that violence and destructiveness is part of all of us, Rorschachiana (2017), 38(1), 83–85

Book Review

and to identify “the Other” as being the carrier of capacity for evil and cruelty. Today, advances in genetics and brain imaging have brought about a reinvigoration of biological criminology, named neurocriminality, receiving media attention. However, the author emphasizes the weaknesses in research on the neurological basis of psychopathy and warns of the danger in locating the sources of crime and violence in individuals, reminding us that history shows how biological reductionism can lead to catastrophic consequences. Finally, I can only congratulate both the author and the readers of this book, so filled with chronological details and facts and yet so skillfully presented that it becomes an often engaging – even entertaining – reading. Reviewer: Marianne Nygren, Private Practice, Stockholm, Sweden, marianne_nygren@telia.com, https://doi.org/10.1027/1192-5604/a000084

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Rorschachiana (2017), 38(1), 83–85