Abstract Level: Classification or Diagnosis Second Inferential Level: Theoretical Interpretation 2

First Inferential Level: Generalizing about Personality from Data² I Base Line: Raw Data

Abstractions Criteria³ Tests Observations

Figure 7-1 Pyramid of Diagnostic Inference, Reasoning, and Abstraction Source: H. Sargent, The Insight Test (New York: Grune &

Stratton, 1953). Reproduced by permission. Level I. Test scores, patterns, scatter, quantitative and qualitative signs (perceptual distortions, peculiar associations, content, over- or underresponse, etc.). Level II. Identifying characteristics: overalert, complaint, rigid, naive, anxious, disoriented, etc. Level III. Postulated mechanisms and processes such as projection, repression, regression, denial, isola- tion, introjection, etc. Level IV. Categories such as neurosis, psychosis, schizophrenia, hysteria, obsessive-compulsive;

"good" or "poor" candidates for profession, employment, etc. 2Intrinsic validity established by convergence of independent judgments. External validity established by pre- or postdiction of events or conditions from tests and observations checked against criteria (C). Sample criteria: life history, course of illness, progress in therapy, voca- tional adjustment, experimental behavior, etc.

superego (see stories of Streicher later in this chapter). Several other studies have noted similar T.A.T. characteristics of psychopathic defective criminals (Kutash, 1943) and of juvenile delinquents (Megargee, 1966a, 1966b; Purcell, 1956; Young, 1956). There are other cases where we would like to be able to make real infer- ences--for instance, if the potentiality (or actuality in the past) of antisocial acts ex- ist-and we wish to help predict future behavior. One such case occurred when the senior author (Bellak) was asked to help determine whether a young boy should be released from an institution. He had killed a small child, apparently in some sexual excitement. Institutionalized, he was a model inmate on a behavioral level--bland, noncommittal, and inaccessible to psychotherapy.

At the time of commitment and again when he came up for disposition at the end of a year, he was given the T.A.T. and other tests by the staff for help in understanding his problems. When none of the tests threw any light on the psychodynamics of the crime, he was referred to the senior author for the administration of a T.A.T. under the influence of intravenous

156 CHAPTER 7 IV

Paranoid Hysterical Psychosis Psychosis Abstract Level: -- III Second Inferential Level: ,2 2 2. g /' \ Base Line: y ",

Raw Data Test scores, patterns, scatter, etc. On ward, at activities, interviews, etc. Figure 7-2 Overlapping Diagnostic Pyramids Source: H. Sargent, The Insight Test (New York: Grune & Stratton, 1953). Reproduced by permission. Solid lines represent, for one case, the derivation of inference from raw data, interpretation from in- ference patterns, and abstraction from interpretations subsumed under the finally selected label. Dotted lines represent the same sequence for a second case. Note that a single first-level inference (e.g., anxiety) may be based on data fi'om several tests and/or observations and that a single test score may lead to more than one inference (e.g., test 3, perhaps the Rorschach). The interpretation that projective defenses are operating derives from not one but several inferred characteristics. Likewise, the diagnosis of paranoid schizophrenia or hysterical psychosis depends on a combination of theoreti- cal interpretations or conceptualized processes.

Amytal Sodium. After the intravenous administration of 71/ grams of Amytal Sodium and 1Vz grams of Nembutal orally, a marked psychomotor effect of the drugs was noted: general relaxation, drowsiness, slurring of speech, and occasion- ally such lack of motor control and sleepiness that the T.A.T. cards dropped out of the young boy's hands. Despite the action of the drugs, the boy gave 15 stories that, in no single instance, revealed any primary pathological evidence in the theme it- self that would have permitted one to pick out his T.A.T. as belonging to a notice- ably disturbed person. However, although it was impossible from his T.A.T. stories to predict his ac- tual behavior, small breakthroughs of original impulses came to light. For instance, he made one slip of the tongue in the following story to picture 8BM: These two boys have gone out hunting. They shot a lot of boys--I mean, animals, and decided to split up to get more pheasants. They agreed to meet at 8:30 at night to count the gane and to go home. This boy was standing in the bushes. Twenty feet from him he heard solnething move. He goes to look at what he caught and finds his friend and rushes him to the doctor. The doctor says the boy will be all right, and in the end the boy gets OK and for- gives him for what he did.

The slip bet: sorbed in a perle boy's injury. An ir the time for light time that his rant: picture 1 by sayin:

This boy doe He changes gave to picture H

An undertak, out one night and he can undo his w( In this stor buried, revealing incongruent guil There are c who had previou lowing story to 31

Is this a girl? I think there's a g[ doing so had fallex bor perhaps that st reason you'd have She'll have chang Although, : ing actually occu to her behavior, propriate: a girl impulse is easil} strong reason fo dislike. The stor murderer:

There's a p: eyes; seems to be morseful; seems t wasn't from natm Although in a "shock state previous story seems to be a cl Courtesy of Ms. B

CLINICAL AND OTHER PROBLEMS OF THE T.A.T. 157 ews, etc.

tsion. 'ore in- ,el. .'st score that ewise,

heoreti-kmytal of the asion- out of that, ne it- iotice- is ac- ance, and the aeard im to

for-The slip betrays the apparently original aggressive impulse that becomes ab- sorbed in a perfectly acceptable hunting story, then breaks through again in the boy's injury. An inquiry into the small detail of 8:30 at night revealed that that was the time for lights out at the institution and strongly suggested that it was at this time that his fantasies were permitted to emerge. Similarly, he started his stoW to picture 1 by saying:

This boy does not like to practice his trumpet--I mean he likes to play his violin. He changes a negative response immediately to a positive one. The stoW he gave to picture 15 is as follows:

An undertaker; he is very sad because he is putting to rest all these people. He goes out one night and looks with remorse at all the work he has done. He tries to find out how he can undo his work. He can do nothing about it. In this story, the undertaker behaves as if he had killed all the people he buried, revealing the original aggressive impulse only by what would otherwise be incongruent guilt feelings. There are other T.A.T.s of murderers that present similar problems. A woman who had previously attempted to kill her sleeping children by stabbing told the fol- lowing stoW to 3BM:x

Is this a girl? I think it's a girl; she seems to be crying; leaning against a bed. At her feet I think there's a gun. Well, it looks as though she had planned to use the gun and instead of doing so had fallen asleep. (?) Probably planned to shoot someone with it. (?) Well, a neigh- bor perhaps that she didn't like. (?) No one would know that but herself---can't imagine what reason you'd have for it except disliking them, maybe. I don't think anything will happen. She'll have changed her mind by the time she's more rested. Although, like all this woman's stories, the content is innocuous in that noth- ing actually occurs, and it would be impossible to make any concrete predictions as to her behavior, certain things do emerge. The effect in this story is grossly inap- propriate: a girl who had planned to shoot someone falls asleep instead. An active impulse is easily replaced by a passive one. There appears to be not particularly strong reason for the planned shooting of the neighbor except a vaguely expressed dislike. The story she tells to 13Mr is in some ways reminiscent of those of the boy murderer:

There's a picture of a young lady in bed and a man standing with his arms across his eyes; seems to be walking away from the bed.

Seems to me the lady has died and he is re- morseful; seems he is in a shock state of remorse over her death. (?) Nothing to indicate it wasn't from natural causes. (?) Husband; he'll have to go on alone. Although the woman in the picture died from natural causes, the husband is in a "shock state of remorse" over her death. (This resembles the undertaker in the previous story who is remorseful over the people he has buried.) In this story, there seems to be a clearer aggressive impulse and its denial.

Courtesy of Ms. B. Guttman, of the Psychology Department, Queens General Hospital, N.Y.

158 CHAPTER 7

Psychiatric Differentiation

Although attempts at psychiatric differentiation with use of the T.A.T. have been unsatisfactory in general, a good deal of recent work has supported our con- tention that various diagnostic groups differ clearly in certain of their ways of re- sponding to thematic stimuli. In a study of psychoneurotics, Foulds (1953) found that hysterics started stories more quickly than depressives and told longer stories at a quicker pace. Depressives produced more illness themes to picture 3GF than hys- terics, who produced more themes involving quarrels. Davison (1953) has de- scribed differences among certain diagnostic groups in the terms of the kinds of in- teraction described in their stories. He concluded that anxiety reactives produced a significantly greater number of themes of "man moving toward man, the depressive reactives of man moving toward woman, the hebephrenic schizophrenics of man moving against man, and the catatonic

schizophrenics of no relationship between man and woman." There have been only a few studies of thematic test characteristics of individ- uals who are mentally retarded (Hurley & Sovner, 1985; Montague, Jensen, & Wepman, 1973; Upadhyaya & Sinha, 1974). They mostly focus on the tendency to use concrete description of the picture stimulus, inflexible stereotyped narratives, and a paucity of words. Chapter 12 discusses thematic test studies of borderline pa- tients (Brelet, 1986), Rogoff (1985), and Western (1991a, 1991b) and of narcissistic patients (Abrams, 1993a, 1995; Brelet, 1981, 1983, 1986, 1994; Harder, 1979; Shulman & Ferguson, 1988; Shulman, McGarthy, &

Ferguson, 1988). Chapter 13 discusses thematic test characteristics of children and adults with attention deficit dis- order (Abrams & Bellak, 1986 edition of this text; Costantino et al., 1991). An important area of thematic test research is that of psychological trauma stud- ies. From Haworth's (1964b) important study of the thematic test characteristics in children who suffered the death of a parent, the emphasis in later research has been primarily on thematic test

characteristics of children and adolescents who have been the victims of child neglect, physical abuse, or sexual abuse (Henderson, 1990; Hoffman & Kuperman, 1990; Kalaita, 1980; Miller & Veltkamp, 1989; Ornduff et al., 1994;

Ornduff & Kelsey, 1966; Stovall & Craig, 1990).

The T.A.T. with Schizophrenics

Theoretical stress on the role of power concerns underlying paranoid symp- tomatology led Wolowitz and Shorkey (1966) to study power themes in the T.A.T. stories of paranoid schizophrenics and other psychiatric patients.

Paranoids' stories contained significantly more power imagery than those of the nonparanoids. Subdividing the nonparanoids into different diagnostic categories, it was found that paranoids were most highly differentiated, in terms of a greater number of power themes, from patients classified as anxiety neurotics, psychophysiological reactions, and nonparanoid schizophrenics. Karon's (1963) hypothesis, drawn from clinical experience--that mothers of

schizophrenics are unable to meet the needs of their children and use the children to meet their own needs by manipulating their behavior--has been analyzed by

means of the T.A. phrenic children dren on the tiation supported dominant and de specified needs pense of the depe of schizophrenic Contrary Eron's report (19 from the T.A.T. come to private ized schizophreni need a T.A.T. ambulatory schiz bance in the T.A. tent that did not to "reading withe tant symbolic awareness far T.A.T. stories, Certain signs for instance, ins and destruct trapsychic diagnosis of schi is the tendency family Piotrowski (19N treatment (Gok One may, artists who are examples of matic complain a happy and pr stories was tongue-in-cheel Kiss Me Any

Papa, when you kiss m, brace a bush, it philosophy is n( tration, which so Papa takes th, father.

Followin

,f the T.A.T. have pported our con- [ their ways of re- tlds (1953) found t longer stories at are 3GF than hys- a (1953) has de- of the kinds of in- zctives produced a an, the depressive )phrenics of man ttionship between

:eristics of individ- tague, Jensen, & .n the tendency to ,.otyped narratives, ies of borderline pa- l and of narcissistic t4;

Harder, 1979; 1988). Chapter 13 attention deficit dis- ., 1991). 1logical trauma stud- t characteristics in later research has 1 adolescents who tbuse (Henderson, rap, 1989; Ornduff

ag paranoid symp- [emes in the T.A.T. i Paranoids' stories he nonparanoids. s, it was found that

i

l

ological reactions, :--that mothers of d use the children been analyzed by CLINICAL AND OTHER PROBLEMS OF THE T.A.T. 159

means of the T.A.T. Mitchell (1968) has demonstrated that mothers of schizo- phrenic children can be differentiated significantly from mothers of normal chil- dren on the basis of T.A.T. responses. The criteria used for the successful differen- tiation supported Karon's (1963) hypothesis; if there was an interaction between a dominant and dependent individual and the dominant individual did not meet the specified needs of the dependent individual or met his or her own needs at the ex- pense of the dependent individual, the story was scored pathogenic. Most mothers of

schizophrenic children received higher pathogenic scores than control mothers. Contrary to findings by Rapaport (1946), and in partial agreement with Eron's report (1948), schizophrenia does not appear to be easily diagnosed as such from the T.A.T. We are speaking here of the ambulatory schizophrenics one sees as they come to private offices.

Rapaport's signs probably hold true primarily for hospital- ized schizophrenics, where there is such manifest pathology that one would hardly need a T.A.T. to make the diagnosis. However, in a considerable percentage of even ambulatory schizophrenics, one may find ample indications of the severe distur- bance in the T.A.T. stories. These indications may be either stories of bizarre con- tent that did not appear in ordinary communication, such as John Doe's reference to

"reading without eyes" in his story to picture 1 in Chapters 6 and 11, or very bla- tant symbolic expressions suggesting a closeness of the unconscious to conscious awareness far beyond the ordinary. Thought disturbances may become apparent in T.A.T. stories, when they are not discernible in conversation or in interviews. Certain signs may also be considered as suggestive, but not conclusive, indicators-- for instance, reference to deadness (e.g., with regard to the violin in story 1, and ru- ins and destruction in story 11). This type of response suggests a reflection of in- trapsychic consciousness of lack of affect severe enough to be consistent with the diagnosis of schizophrenia. Other studies of T.A.T. characteristics of schizophrenics is the tendency to avoid the nuclear family (Alkire, Brunse, & Houlihan, 1974), the family research of Werner and colleagues (1970), the case presentation of Piotrowski (1950), and the study of changes in T.A.T. stories at different points in treaUnent (Goldman & Greenblatt, 1955). One may, however, find these signs or criteria in the records of adolescents or artists who are not schizophrenic insofar as one can determine.

Following are good examples of stories given by a latent schizophrenic artist who was referred for so- matic

complaints. After fairly short-term psychotherapy, this man is now able to lead a happy and productive life. Since he is an artist, the grossly bizarre nature of his stories was influenced by his lack of conventionality and, possibly, a somewhat tongue-in-cheek attitude. Here is his story to picture 7BM, which he entitled, "Don't Kiss Me Any More":

Papa, your moustache, with its horrid, dirty color, feels unpleasant against my cheek when you kiss me. In fact, I feel uncomfortable when you come too near. Why don't you em- brace a bush, it has the same texture? And don't give rne your old philosopher's look, your philosophy is not objective enough, it's only based upon your own shortcomings and frus- tration, which all hark back to the fact that you were abnormally kind to your mother./Mad so Papa takes the son's advice and goes in the backyard to a bush, but finds that it is his own father.

Following is his story to picture 11:

160 CHAPTER 7

Liberatus has just flown from the womb which hangs lazily on the castle ramparts, swinging in the breeze. He dashes over the bridge pursued by three horrible mammoth turkeys, with beaks lined with alligator teeth. The bridge expanse between them crumbles, dashing the turkeys against the rocks below. Temporarily safe, he looks back at the womb and it now appears as a tremendous tongue with four webbed feet. But his safety is temporary, for his supposed refuge ahead is the City, gleaming not from the sun but from heavy phospho- rus powder, which having been put layer on layer on the outside of the building, appears sponge-like, and when viewed closely is not glamorous but dusty and deadish. The heroic view of the city from this distance is indeed deceptive.

The subject reported many dreams just like this story. His story to picture 12M follows:

The son with his sensuous upper lip drawn up, his feet languidly held apart, and his hand close to his genitals, seems to be in the midst of a very pleasant dream. The old man motions and chants, believing he has induced this dream and sleepy state. As the old man turns, one sees that he has no facial features. He wants the young man to awaken now, so he can suck some of his youth from him, vampirish or something like that. The old man feels that then perhaps he will have a face again. But when the young man finally gets up, he kicks the old man down and walks away.

An absence of facial features is another schizophrenic sign. Story 13MF:

The young woman stands nude on the model stand. But she is without detail, no facial features, no teats, no fingernails. The artist first paints small circles on her breasts of a very beautiful color, a wonderful coral, like the color in some shells he brought from Acapulco.

But as he paints in more details, she becomes less, rather than more, lifelike and finally falls down flat as if she were an unsupported mannequin. The artists feels very tired and sick in the stomach; all this work for nothing. He goes out into the streets and sees all his fellow mannequins mechanically moving about.

An indication of emotional impoverishment consistent with schizophrenia may be seen in the "mechanically moving about." Story 17BM:

Mike Jensen is climbing the thousand-foot rope that leads, though he does not know it, to Hell. He pauses on his ascent in the arena, as he notices a woman sitting in the second balcony, feet wide apart. Why is man always attracted to frustrating glimpses of women's thighs and hairy organs, when women happen to be a bit indecorous in the way they sit? Needless frustration, must train oneself not to be diverted by such things; the only worth- while thing is the whole salami. So upward he goes again, but he slips when he

unexpectedly comes to some thorns in- terwoven in the rope. Mad as he slips down the rope at a terrific speed, he is split in half, as he

unexpectedly comes to some thorns in- terwoven in the rope. Mad as he slips down the rope at a terrific speed, he is split in half, as he