The Inkblots

by Damion Searls

  Let’s say Mr. Doe gave both of those Reflection responses, as well as four Pair responses, each coded “2”—this kind of response describes two things, “A couple of donkeys” or “A pair of boots,” symmetrically located on either side of the card but not parts of a single whole such as two eyes on a face or two blades of a scissors. Plugging those numbers into Exner’s formula would produce an Egocentricity Index of ([3 × 2] + 4) / 20 = 10/20 = 0.5: a bad sign for Doe, since anything higher than 0.42 suggested “intense self-focus which may contribute to reality distortions, especially in interpersonal situations.” A number below 0.31 would suggest depression. But all was not lost for John Doe: a host of other scores and indexes coming out of his test might modify the significance of this high number.

  In some cases, Exner’s new scores enabled the test to measure conditions and mental states that Rorschach had not considered, or that were not even defined in his day: suicide risk, coping deficits, stress tolerance. In other cases, the codes seemed to attach numbers for numbers’ sake. The important Exner score WSum6, for instance, measuring the presence or absence of illogical and incoherent thinking, was simply a weighted sum of six other scores dating back to the 1940s: Deviant Verbalizations (now coded DV), Deviant Responses (DR), Incongruous Combinations (INCOM), Fabulized Combinations (FABCOM), Contaminations (CONTAM), and Autistic Logic (ALOG). The new score provided a measurable threshold: research eventually concluded that WSum6 = 7.2 was average for adults, while WSum6 ≥ 17 was high, resulting in another point on the nine-variable PTI (Perceptual Thinking Index) that came to replace the earlier SCZI (Schizophrenia Index) with its high false-positive rate. A score of PTI ≥ 3 “usually identifies serious adjustment problems attributable to ideational dysfunction.” All of this was an extraordinarily elaborate way to restate the fact that If you say a lot of crazy things, you might be crazy.

  But this kind of quantitative framing was just what the times demanded. Exner was the Rorschach champion for an era after Klopfer’s: not a flashy showman but a collegial, solid technocrat whose expertise seemed to rise above the feuds. The Rorschach had to be standardized, stripped of its intuitive, emotionally powerful, and arguably beautiful qualities, to fit into the data-driven new era of American medicine.

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  In 1973, a year before Exner’s synthesis was published, President Richard Nixon signed into law the Health Maintenance Organization (HMO) Act. “Managed care”—a shorthand term for a complex new system of insurance rules and payment plans—aimed at efficiency by eliminating “unnecessary” hospitalizations and imposing cost-effective therapies at fixed rates. The family doctor was now a “primary care physician,” responsible for guiding the HMO member through a maze of specialists and authorizations, and increasingly caught between pressures to cut costs and the need to satisfy the consumers formerly known as patients.

  While managed-care policies provided better access to health care (more people had health insurance), the resulting cost increase (more people used health insurance) forced insurance companies to clamp down. In mental health care, the shift away from traditional personality assessment that had begun in the sixties accelerated. The need to establish “medical necessity” for a treatment naturally put pressure on any approach that didn’t involve prescribing a pill. Psychological assessment was less often reimbursed; preauthorization requirements and other paperwork made it harder to use assessment flexibly. Even in narrow utilitarian terms, one would expect that better initial assessment and diagnosis would lead to cost savings, but in fact it was likely to be one of the first things to go unless psychologists could prove it provided “treatment-relevant and cost-effective information” and was “relevant and valid for treatment planning.” National surveys of psychological practice in the managed-care era confirmed a widespread feeling among doctors that “marketplace-driven demands” had “created obstacles…that threaten[ed] the very existence of traditional psychological practice.”

  For better and for worse, Exner recast the Rorschach for this modern world. He couldn’t make the test quick and easy, any more than Molly Harrower had been able to in the forties, but he could make it numerical. This had always been part of the Rorschach test’s appeal, going back to Rorschach himself, who considered it “quite impossible to obtain a definite and reliable interpretation without doing the calculations.” Compared to psychoanalysis, what someone saw in the inkblots really was easier to code, count, and compare than their dreams or free associations on an analyst’s couch. There were times, such as when the inkblots were largely used as a projective method to uncover subtleties of the personality, that a more intuitive or qualitative approach would come to the fore, but whenever the pendulum in psychology swung back toward privileging numbers, the quantitative side of the inkblot test could always be emphasized. That said, Exner’s system was numerical like none before. And as the punch cards from Harrower’s era developed into ever more powerful computers—an integral part of the growing managed care bureaucracy—quantifiability was more important than ever.

  As early as 1964, four years after the term data science was coined, researchers had run the Rorschach responses of 586 healthy Johns Hopkins medical students through an early computer-indexing program and produced a 741-page large-format concordance. By the mid-1980s this corpus, plus the life histories available from long-term follow-ups with the test takers, made it possible to sidestep traditional Rorschach interpretation altogether. Computers simply counted up every occurrence of every word spoken in the tests and went looking for correlations between answers and later fates. An unnerving article from 1985, “Are Words of the Rorschach Predictors of Disease and Death?” claimed that those who mentioned “whirling” in any of the ten cards were five times as likely to commit suicide as those who didn’t, and four times as likely to have died of other causes.

  Exner brought computers into his own methodology as well. Beginning in the mid-1970s, he explored ways to “increase computer utilization as an aid in interpreting the test,” eventually resulting in the Rorschach Interpretation Assistance Program (1987, with numerous updates to follow). After an examiner coded all the patient’s answers, the program would do the math, generate complex scores, and highlight significant deviations from statistical norms. It would also offer a printout of “interpretive hypotheses” in prose form:

  This person appears to compare himself unfavorably to other people and consequently to suffer from low self-esteem and limited self-confidence.

  This person demonstrates adequate abilities to identify comfortably with real people in his life and appears to have opportunities to form such identifications….

  This person gives evidence of limited capacity to form close attachments to other people…

  Exner disavowed the computer approach by the end of his life, but the damage had been done. The Rorschach, once hailed as the most sophisticated window into human personality, could now be read by machine.

  Even when used exclusively by human beings, Exner’s system had a downside. Its rigorous empirical emphasis minimized what many advocates found most valuable in the Rorschach: the test’s open-ended ability to generate surprising insights. Strategies that generations of clinicians had found helpful and revealing—such as the idea that a person’s first answer to the first card says something about his or her self-image—found no place among Exner’s flurry of codes and variables. As a result, psychologists who had used the inkblots as a starting point for talk therapy or other open-ended explorations tended to either reject Exner or drift away from the Rorschach altogether.

  Yet Exner gave the test new respectability in the field, especially after 1978, when the more rigorous Volume 2 of his manual came out. His accommodating, synthesizing approach won over most holdouts practicing the earlier Rorschach systems, and even leading assessment psychologists who had long criticized projective methods as subjective started praising the rigor Exner brought to the Rorschach.

  Exner also pressed the reset button on the
history of Rorschach controversies: Arthur Jensen’s 1965 critique and all the other earlier attacks could now be dismissed as being directed at “earlier, less scientific versions” of the test.

  Exner’s private Rorschach Workshops in Asheville, North Carolina, starting in 1984, taught a generation of clinicians, and his textbooks replaced Klopfer’s and Beck’s throughout clinical psychology graduate programs. One exception, the City University in New York, remained die-hard Klopferian, but students there had to learn Exner’s system too, since they would be expected to use it in residencies and internships elsewhere. As thousands of Rorschach articles and studies continued to proliferate, Exner’s centralized Rorschach became the only source most practitioners ever had to look to.

  Bruno Klopfer had died in 1971, Samuel Beck in 1980; Marguerite Hertz passed the baton to Exner in 1986, calling his research “the first serious and systematic attempt to confront some of the unresolved issues that have plagued us through the years.” “Best of all,” she added, “Exner and his colleagues have brought discipline into our ranks and a sense of optimism to our field.”

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  Over the years, as Exner fine-tuned his formulas, the Rorschach test came to produce increasingly correct results—“correct” in the sense of labeling as, say, schizophrenia exactly what other tests or criteria labeled as schizophrenia. The inkblots were being used and judged as a standardized measure of known quantities, not an exploratory experiment.

  For all the benefits of integrating the Rorschach with the findings of other psychiatric methods, this tended to make it a more cumbersome, less cost-effective way to do what psychiatrists had other techniques for already. As with computerization, Exner increasingly denounced the search for “generalized truths” and criticized psychiatric reference works such as the Diagnostic and Statistical Manual of Mental Disorders (the DSM) as “bookkeepers’ manuals for classifying people in distress” and generating cookie-cutter treatment plans. He may have had reservations about how such standard classifications were used, but they were what his system provided—and what other tests and evaluations provided faster.

  The move toward more efficient tests predated Exner’s system. A 1968 survey of academic clinical psychologists, while showing that the Rorschach was still widely used, found that more than half the respondents felt that “objective,” “non-projective” methods were increasing in use and importance. One of these methods, in particular, was rapidly gaining ground.

  The Minnesota Multiphasic Personality Inventory, or MMPI, first published in 1943, pulled ahead of the Rorschach in 1975. It consisted of 504 statements—567 statements in the modified MMPI-2—that subjects were asked to agree or disagree with, ranging from the apparently trivial (“I have a good appetite”; “My hands and feet are usually warm enough”) to the obviously alarming (“Evil spirits possess me at times”; “I see things or animals or people around me that others do not see”). It could be administered to a group by a clerical worker and was easy to score. Each MMPI scale—the Depression Scale, the Paranoia Scale—had two lists of question numbers associated with it: the number of items from the first list that had been answered True, plus the number from the second list marked False, was the result. It was quick and it was “objective.”

  Technically, this meant only that it was not “projective.” A person’s True/False answer to “Some people think it’s hard to get to know me,” “I have not lived the right kind of life,” or “A large number of people are guilty of bad sexual conduct” could not be objective in any meaningful sense. People are not willing or able to evaluate themselves objectively—self-descriptions were often found to correspond only partially, at best, to what friends and family said about the test taker, or to what their behavior showed. Answers were not even meant to be taken at face value: Responding “True” to a lot of depressing statements and “False” to a lot of happy statements didn’t necessarily mean a person was depressed. There were scales to measure whether a person was likely to be exaggerating or lying; there were other ways one scale could affect the others. Interpreting MMPI results, too, was an art, requiring subjective judgment. But the slanted terms objective and projective certainly helped the MMPI’s fortunes.

  In the decade after 1975, the Rorschach fell from being the second most commonly used personality test in clinical psychology to fifth. It was now behind both the MMPI and several other projective tests: Human Figure Drawing (used primarily with children), Sentence Completion, and the House-Tree-Person Test.

  Results from these more limited tests were relatively self-explanatory. Drawing a human figure with a big head might suggest arrogance. Leaving out key body parts was a bad sign. Completing sentences with hostile, pessimistic, or violent words: not good. These tests were thus more vulnerable to “impression management”—subjects could know how to stage the impression they wanted to make, present themselves as they wanted to be seen. One New York City cop, given the House-Tree-Person Test during his hiring process, said that his buddies had told him beforehand: “The house has to have a chimney with smoke coming out, and whatever you do, make sure you put leaves on the tree.” That’s what he did. Whatever their weaknesses, though, these tests were quick and cheap, and so increasingly preferred.

  Popularity rankings among tests, usually based on sporadic surveys with small and unrepresentative samples, are not as precise or reliable as they sound. But the trend lines were clear—the ink was on the wall.

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  In this new landscape, assessment psychologists were starting to find the education system more welcoming than health care. Insurance companies were unwilling to shell out three or four thousand dollars for comprehensive testing in a hospital setting—in fact, psychiatric patients were rarely allowed longer hospital stays at all—but schools would still pay for evaluations. These were not the kind of blanket programs that Sarah Lawrence College had instituted in the thirties—for that there were thriving industries of their own, such as IQ and aptitude testing. Instead, these were psychological tests given to individual troubled teens or children who turned up in school counseling centers or were referred for evaluation.

  And so, as Exner continued to develop his Comprehensive System, he widened its range of applications. In 1982, he devoted a whole additional volume of his manual to children and adolescents. A child’s Rorschach responses usually meant much the same as an adult’s, Exner argued (for example, pure C and CF answers implied little emotional control), but the norms would often be different (lots of such answers would be normal in a seven-year-old boy but immature for an adult, while an adult’s mature profile would indicate “a probable maladaptive overcontrol” in a child).

  Exner emphasized that Rorschach testing was of limited use in cases of behavior problems, because the test’s conclusions did not translate directly into information about behavior. No specific Rorschach scores could “reliably identify the ‘acting out’ child or differentiate the delinquent from the nondelinquent.” In such cases, especially where there were environmental factors causing the child’s behavior, the test merely suggested the kinds of psychological strengths and weaknesses that might affect treatment. In the most common cases youth psychologists faced, though—students having academic problems—the Rorschach could help distinguish between limited intelligence, neurological impairment, and psychological difficulties.

  Many of the same market forces pushing clinical psychologists into education in the seventies and eighties also pushed them into the legal system. “Forensic assessment” boomed: evaluating parents in custody disputes, children in abuse cases, psychological harm in personal injury lawsuits, competence to stand trial in criminal cases. Exner’s 1982 volume included several cases serving as double illustrations of how to use the Rorschach with children and in legal settings.

  One of these cases involved Hank and Cindy, high school sweethearts who had gotten married in the midsixties when Hank was twenty-two. After a two-week honeymoon, he shipped out for Vietnam, where
he served for a year and was decorated for heroism at Da Nang. The first three or four years after he returned were happy ones for the couple, but not the years that followed. By the late seventies, their thirteen-year marriage had ended in separation and a custody battle. Hank charged that Cindy was psychologically unfit to have custody of their twelve-year-old daughter; Cindy filed a counterclaim that Hank had been “mentally brutal” to both her and their child and that to evaluate only her would be unfair. Evaluations were ordered of both parents, and of the child as well.

  Their marital problems showed up crystal-clear in interviews—Cindy complained about Hank’s “bitchiness,” admitted to spending sprees “out of spite”—while the Exner system findings were complex and technical. In the daughter’s Rorschach, “if the magnitude of the ep:EA relation has existed for very long” that would explain her recent problems in school. “Afr is quite low for her age,” so she might well be significantly withdrawn. Hank’s “extremely disproportionate a:p ratio suggests that he is not very flexible in his thinking or attitudes….The high Egocentricity Index, .48, suggests that he is much more self-centered than most adults, and this may have some negative effects on his interpersonal relationships.”

  Cindy seemed more disturbed. Her first answer to Card I was a spider, “which she later distorts even more by adding wings to it. If this is, in fact, a projection of her self-image, it leaves much to be desired….All three of her DQv responses occur to [colored] cards, [indicating] she is a person who does not handle emotional provocation very well.” Conclusion: “She is strongly influenced by her feelings and does not control them very well….It is probable that she does not experience needs for closeness in ways that are common for most people.” It was easy to understand how Cindy’s overemotional immaturity and Hank’s self-centered inflexibility, as revealed on their Rorschachs, might have caused conflicts in their marriage.