Personality Assessment in Depth - A Casebook (PDFDrive)

Personality Assessment
in Depth
Comprised of five unique and extended case studies, Personality Assessment in

Depth examines contemporary clinical problems that are familiar to clinicians,
but have not been explored extensively in the personality assessment field.
Each case study demonstrates the test protocols of the Rorschach test, The-
matic Apperception Test, MMPI or MCMI, and Human Figure Drawings.
Important clinical questions and areas of theoretical concern are examined,
including differential diagnosis of disorders of affect and personality in light of
contemporary viewpoints about these disturbances, personality and adaptation
accompanying neuropsychological deficit, and stages of development, includ-
ing differentiating these from personality characteristics viewed longitudinally,
the latter demonstrated by a noteworthy comparison of two evaluations of the
same patient, first as a 15-year-old adolescent and then as a 25-year-old adult.
A battery of performance and self report personality instruments are applied
to the cases, allowing the author to integrate findings across multiple tests and
thereby expose clinical psychology students to personality assessment in a broad
perspective. Cases are discussed comprehensively, relying on a thorough con-
sideration of thematic content examined alongside formal test scores. Further,
the Rorschach findings are examined using both the Exner Comprehensive
System and the recently-introduced Rorschach Performance Assessment Sys-
tem approaches. The cases are considered using a broad psychodynamic frame-
work for interpretation, employing classical ego psychology, object relations,
and self psychological theoretical perspectives. This is an essential casebook for
professionals and students, demonstrating the depth and richness of personality
considered alongside the empirical foundations of personality assessment.
Marshall L. Silverstein, PhD, is Professor of Psychology at Long Island

University. Dr. Silverstein is the author of two other books: Self Psychology and
Diagnostic Assessment and Disorders of the Self.
Personality and Clinical Psychology
Irving B. Weiner
University of South Florida
Series Editor
This series of books is intended to provide information about personality proc-

esses and their implications for the science and practice of clinical psychology.
To this end, the books in the series integrate conceptual formulations, research
findings, and practical recommendations concerning a broad range of topics,
including theoretical perspectives on the nature of personality; biological and
psychosocial influences on personality development; continuity and change in
dimensions of personality across the lifespan; personality characteristics likely
to foster adjustment difficulties; classification of abnormal personality patterns
associated with psychopathological conditions; assessment procedures for eval-
uating individual differences in personality and identifying types of psychopa-
thology; and methods of ameliorating adjustment problems, treating psycho-
logical disturbances, and promoting positive mental health.
Personality Assessment
in Depth
A Casebook
Marshall L. Silverstein
First published 2013
by Routledge
711 Third Avenue, New York, NY 10017
Simultaneously published in the UK
by Routledge
27 Church Road, Hove, East Sussex BN3 2FA
Routledge is an imprint of the Taylor & Francis Group, an informa business
© 2013 Taylor & Francis
The right of Marshall L. Silverstein to be identified
as author of this work has been asserted by him in accordance with
sections 77 and 78 of the Copyright, Designs and Patents Act 1988.
All rights reserved. No part of this book may be reprinted or reproduced
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registered trademarks, and are used only for identification and
explanation without intent to infringe.
Library of Congress Cataloging in Publication Data
Silverstein, Marshall L.
Personality assessment in depth : a casebook /
by Marshall Silverstein.–1st ed.
p. cm.
ISBN 978–0–415–80042–6 (hardback : alk. paper)–
ISBN 978–0–415–80043–3 (pbk. : alk. paper)
1. Personality assessment. I. Title.
BF698.5.S555 2013
616.89'075–dc23
2012025832
ISBN: 978–0–415–80042–6 (hbk)

ISBN: 978–0–415–80043–3 (pbk)
ISBN: 978–0–203–07530–2 (ebk)
Typeset in Baskerville
by Swales & Willis Ltd, Exeter, Devon
Contents
Preface vi
1 Empirically Based and Content-Based Clinical Interpretation 1
2 Personality Problems Associated with Affect Dysregulation 13
3 Personality Problems in Adolescence 76
4 Personality Problems in Later Life 138
5 Personality Problems Associated with Cerebral Dysfunction 193
6 Continuity and Change from Adolescence to Young Adulthood 268
Notes 320
References 326
Preface
One of my favorite descriptions of personality assessment is Schafer’s comment

about the main purpose of conducting psychological testing:
there is no other world quite like that created by the process of responding
to psychological tests. It is not the world of dreams or daydreams; nor is it
the world of everyday problem solving and human relations. Yet it shares
many of the properties of these other worlds and so is a basis for mak-
ing extrapolations or predictions from this world to the others. It is in the
leap from the one to the others that the psychodiagnostician encounters
much of his work’s difficulty and perplexity, and much of its satisfaction
and value.
(1967, p. 6)
But there and elsewhere, Schafer also wrote, more than half a century ago
(1948, 1954), that the field has yielded to demands for greater justification of
its efforts, sometimes giving short shrift to important deep experience by shift-
ing emphasis away from inner, private life. He wrote that “the inner world can
be an extraordinarily uncomfortable place to spend much of one’s time and it
is accessible most of all to those who can afford to pause from action for long
periods, meditate, and ask probing questions” (1967, p. 6).
It is in this sense of attempting to capture how the depths of inner psycho-
logical life can become such an “extraordinarily uncomfortable place to spend
much of one’s time” that I hope this book will provide a venue in our hurried
and sometimes frenetic times to “pause from action for long periods” and reflect
about people’s psychological depth, formulate and test hypotheses about its
potential impact on the structural aspects of everyday psychological life, and in
the process consider, revise, and reconsider the ways people’s adaptive struggles
lead them to manage through life as best they can. This book, therefore, mainly
examines the depths of psychological life and the “extraordinarily uncomfort-
able place” where so many people spend much of their time. As such, the entire
book consists of only five cases; however, most required more than 60 pages
to do justice to the clinical material, a response-by-response analysis of the
complete verbatim protocols from the Rorschach (Rorschach, 1981; originally
Preface vii
1921), Thematic Apperception Test (TAT; Murray, 1943), and Human Figure
Drawings (Handler, 1996; Kissen, 1986) findings, supplemented by either the
Minnesota Multiphasic Personality Inventory (MMPI-2; Butcher, Graham, et
al., 2001) or its version for adolescents (MMPI-A; Butcher, Williams, et al.,
1992), or the Millon Clinical Multiaxial Inventory (MCMI-III; Millon, 1997).
In so doing, I also am mindful that a reliance on thematic content analysis
in the way this was practiced at one time cannot adequately serve a purpose of
explicating depths of psychological life without considering how people func-
tion in their everyday lives to manage stress, think logically and solve problems,
regulate distressing affect states, and successfully interact with other people.
Theorists and clinicians using personality assessment methods have always rec-
ognized that neither aspect of psychological life should be ignored—which may
be another way of saying that personality assessment may need to consider for-
mal structural aspects of behavior and affect as well as thematic content analysis
to examine deeper layers of a person’s existence and psychological experience.
In the same way that Schafer pointed to the need to pause and reflect about
the uncomfortable places where many people spend their psychological time,
I want to emphasize that I am not attempting to frame the main issue around
formal scores vs. content analysis, but rather that the use of thematic content
is becoming something resembling a lost art. For this reason, as I sometimes
like to say, the Rorschach, Thematic Apperception Test, and Human Figure
Drawings are among my best friends.
It is not that the field has lost an appreciation of the rules of evidence and
clinical relevance that Schafer (1954) so compellingly articulated to guide using
thematic content, but rather that many contemporary clinicians have not been
exposed to or learned what he and others exemplified. Stated more explicitly,
this book attempts to provide that important context, by showing a way that it
can be achieved and integrated with the advances of contemporary personality
assessment.
I also use a modification of Klopfer and Kelley’s (1942) testing-the-limits pro-
cedure following the formal Comprehensive System (CS; Exner, 2003) inquiry
for the Rorschach method. Klopfer and Kelley’s method was intended to sup-
plement the inquiry under certain delimited circumstances, mainly to test spe-
cific hypotheses in a structured way or to clarify potential misconceptions about
the response process or the role of the examiner. Klopfer, Ainsworth, Klopfer,
and Holt pointed out that testing limits also may include broader procedures,
commenting that “there are always some questions still in the mind of the clini-
cian which he can answer in this way” and that their recommended procedure
“is by no means designed to limit the clinician in any way” (1954, pp. 14–15).
I thus use a testing-the-limits inquiry judiciously as a supplement only after the
CS inquiry has been completed, mainly to examine verbalizations or unusual
features a patient did not fully clarify or explain at certain points. In the ver-
batim text of Rorschach responses in the cases that follow, I have indicated a
testing-the-limits inquiry whenever that occurred by a shortline following the
formal inquiry. By way of annotating the verbatim responses in each of the
viii Preface
following chapters, patient verbalizations are denoted in italics and my queries
are indicated in regular text, across all tests. Regarding the Rorschach, specific
responses are indicated in sequential numbers (e.g. R1, R2, R3, etc.).
Thus, I examine recent methods of formally assessing personality using
instruments such as the MMPI-2 and MCMI-III in the self report domain and
the Rorschach Comprehensive System (CS; Exner, 2003) and Rorschach Per-
formance Assessment System (R-PAS; Meyer et al., 2011) in the performance
test domain—forming the essential outlines or skeleton for understanding per-
sonality. I follow these levels of analysis by emphasizing how a judicious use
of content analysis derived from the Rorschach, TAT, and Figure Drawings
enriches formal test findings in an attempt to get closer to understanding that
“extraordinarily uncomfortable place to spend much of one’s time,” while still
mindful of Schafer’s important caveats about evidence and clinical meaning.
In addition to the perspective of integrating findings from self report and
performance tests on the one hand, and empirically derived and content-based
clinical interpretation on the other hand, the five cases I chose to include all
represent either new conceptual approaches to psychopathology or an inter-
weaving of developmental aspects influencing personality and its impact on
psychopathology. These cases illustrate contemporary clinical problems that
are familiar to clinicians but have not been explored extensively in the person-
ality assessment field. For example, while it is not uncommon for clinicians to
assess affect states, attention, and thinking, it is less common to bring together
an understanding of such discrete domains for differential diagnosis, such as
differentiating between unipolar and bipolar depression or between dysthymia
and hypomanic temperament. As psychiatric disorders have become better
understood and reconceptualized in a descriptive sense, important advances
in neurobiology and neuroimaging, family history and genetics, and prognosis
and outcome have influenced the clinical research literature about many such
disorders.
Thus, one case (Chapter 2) features an atypical depressive-hypomanic clini-
cal picture not easily classified in the Diagnostic and Statistical Manual (DSM-
IV; American Psychiatric Association, 2000) on either Axis I or Axis II; together
with a comorbid attentional disturbance. Furthermore, prominent personality
disorder characteristics were interwoven among the affective features, suggest-
ing the possibility of a chronic pattern of dysregulated affective temperament
as first described by Kraepelin (1921). Indeed, because diagnostic comorbidity
and mixed states are more often the rule than the exception, personality assess-
ment has not fully caught up with the ways such disturbances appear clinically
and may be conceptualized using test findings. Thus, the case I chose to dem-
onstrate here presented formidable questions concerning differential diagnosis,
mainly in relation to a so-called “soft” bipolar spectrum. This type of disorder
is an illustrative example of a good use of personality assessment.
Another area I consider is the context of development in relation to personal-
ity assessment. Accordingly, two cases highlight concerns of particular develop-
mental epochs (adolescence and aging) in which a 15-year-old adolescent boy
Preface ix
(Chapter 3) and an 84-year-old man (Chapter 4) are examined. Interestingly, the
clinical and personality issues involved in these two cases are in some important
psychological respects quite similar. I consider in my discussion of these cases
how development influences the expression of personality characteristics and
how conflicts and deficit states are expressed in test material at various stages in
life—and how the expression of personality is not necessarily all that different
across the life cycle. I will emphasize more the impact of ingrained personality
features than stage of development to keep the focus on ascertaining the depths
of psychological life rather than a more obvious explanation of how conflicts or
deficits are manifested at different points in the life cycle.
In addition, I consider the matter of personality and development examined
longitudinally. As just mentioned, one chapter (Chapter 3) is devoted to the
psychopathology of a depressive disorder first appearing in a 15-year-old ado-
lescent boy, discussed in relation to prominent personality characteristics and
concurrent developmental concerns of adolescence. In a later chapter (Chapter
6), I present the clinical and assessment findings from a reexamination of this
patient, now as a 25-year-old young adult. Thus, in addition to an analysis of
his psychological difficulties and personality structure and their changes over
time, I examine the developmental influences impacting psychopathology as
this patient moved into a different stage of life. Here, I also address using per-
sonality tests longitudinally for evaluating developmental changes and assess-
ing stable personality characteristics and how these foreshadow personality in
adulthood.
Finally (in Chapter 5), I consider a case examining personality patterns and
adaptation in relation to brain dysfunction. This is an area of inquiry for which
personality assessment and clinical neuropsychology have not found common
ground, thus slowing progress in better understanding how personality may be
reorganized as a consequence of cerebral damage. My emphasis concerns the
interrelationship between neuropsychological deficits and personality, mainly
to understand how compromised neurological status impacts affect states,
defenses, and self-esteem as people manage to develop compensations in eve-
ryday life and these impact psychological life. Based on a comprehensive case
study of a 55-year-old woman with severe learning and cognitive problems who
developed considerable compensations and strategies for coping with them, I
consider the adaptive resiliencies this patient brought to bear on the real limi-
tations she faced. I emphasize how her chronic, pervasive attention deficit/
learning disorder problem fostered a lifelong personality pattern of exacting
self-discipline and overcompensation that against all odds enabled her to com-
plete a master’s degree and sustain a professional career.
I also note that I saw two of these four patients in weekly psychotherapy for
about 9 to 12 months each. Thus, having the benefit of working with these
patients added an important framework examiners usually do not have in most
consultative diagnostic evaluations, unless they practice in a therapeutic or col-
laborative assessment model (Finn, 2007; Fischer, 1994a). In view of the in-
depth psychological studies of these patients’ inner lives as seen in the clinical
x Preface
assessment material that follows, being able to consider the assessment findings
in relation to the course of treatment naturally adds an important dimension to
understanding their lives in greater depth. I had previously reported two cases
of the complete psychodiagnostic assessment protocols but without the context
of ongoing treatment (Silverstein, 1999) and select excerpts of diagnostic test
material (Silverstein, 2007a)—both considered from a self psychological view-
point—and a case of a diagnostic assessment performed on two occasions in the
context of an ongoing period of a four-year psychotherapy (Silverstein, 2007b).
Several of the cases I present in this volume represent complete diagnostic pro-
tocols accompanied by pertinent psychotherapy material, which, though influ-
enced by psychoanalytic self psychology, are not exclusively interpreted from
that theoretical standpoint.
I am very grateful to Dr. Irving B. Weiner who generously consulted with me
on difficult Rorschach codings. It will quickly be apparent that no one would
regard any of the five cases in this book as simple or straightforward. Having
the benefit of the advice and corrections that only a master clinician such as Irv
could provide was immensely valuable. Because the R-PAS appeared as I was
nearing completion of this book, it quickly became clear that it would be impor-
tant to learn this new method and to incorporate its interpretive contributions
alongside those of the CS. I am indebted to Dr. Robert Erard for graciously
reviewing my codes and interpretive conclusions so that the valuable corrective
advice he provided would lead to accurate inferences, particularly for a system
that is new and that takes time and experience to learn well.
I also gratefully acknowledge the painstaking efforts of Erica Langer and
Jessica Renz, two outstanding doctoral candidates at Long Island University,
who worked with me assiduously to make certain that Rorschach codes were
carefully checked and rechecked. Erica in particular deserves much gratitude
for learning the R-PAS before I could take the time to study it well and teach-
ing me a great deal about its workings and nuances. Debra Japko assisted me
in compiling and organizing references, and her meticulous attention to detail
and careful organization was much appreciated. I also wish to thank Ann Bone,
Marta Moldvai, and Richard Willis for their expert editorial assistance.
I am very grateful to Dr. Craig Earnest who carefully read the entire manu-
script in various stages of its development. His insightful comments and cor-
rective suggestions were extremely helpful every step of the way. As always,
I appreciate the support and encouragement of devoted friends, and I thank
Geoff Goodman, Joanne Marengo, Michael Simon, and Marian Tolpin for
their constant presence and availability. Marian Tolpin died as this book was
in progress; I dedicate it to her memory.
1 Empirically Based and
Content-Based Clinical
Interpretation
The interpretation of psychological tests of personality has long been a thorny

problem, it largely being a matter of whether to favor an idiographic (clini-
cal-impressionistic) approach, a nomothetic (empirically guided) approach,
or more typically one representing a combination of both. There are no easy
answers to the question of which method is preferable, in part because it may
depend on the purpose of an assessment evaluation, for example, to provide a
rich, characterological in-depth understanding of an individual or to provide
an answer to a relatively specific clinical question such as suicide potential or
disordered thinking. Frequently, the decision depends on the clinical tempera-
ment of particular examiners. Probably many test instruments, regardless of
their nature, will work well in the hands of particular clinicians because of their
experience or way of apprehending the material various methods yield. One
objective of this book is to revisit the still unsettled issue of achieving a scientifi-
cally and clinically sound balance using empirically based and content-based
methods of clinical interpretation.
For some of us, it is not really an issue at all, there being a great many clinicians
and investigators who subscribe nearly exclusively to one or another approach.
Thus, some clinicians rely substantially on reliable and valid approaches to test
interpretation, exemplifying what would be referred to as an evidence-based
approach, to use today’s parlance. Others may favor its polar opposite—an
exclusive or predominant content analysis approach—although there probably
are few adherents to such an approach in contemporary times. Most examin-
ers rely on some combination of the two. It is not my intention to advocate for
one or another method of interpreting personality tests. I simply demonstrate
my own clinical temperament, using a combination of empirically derived and
clinical-impressionistic approaches, regardless of the terms used to describe dif-
ferent approaches or the method at one time or another for obtaining clinical
data (such as projective vs. performance-based or empirically derived vs. self
report). It also will become clear that I personally delve quite far into thematic
content and in many respects I probably rely more on this source of data than
many others do, speculative though that may be. It is partially because I believe
that analysis of content is fast becoming a lost art that I undertook writing
this book, which is one of a small number of volumes of comprehensive,
2 Personality Assessment in Depth
response-by-response clinical case studies in the field. This book, however,
makes use of empirical scores and codes and self report methods far more inte-
gratively than the case studies I reported in previous works (Silverstein, 1999;
Silverstein, 2007a; Silverstein, 2007b).
Varying degrees of uncertainty surround the clinical work of personality assess-
ment examiners who practice different ways of combining empirical and clinical
data. Certainly, there is little consensus about balancing the two; when and how
to draw a line between empirically grounded formulations and clinical hunches;
how to construct theoretically informed clinical speculations from scores, ratios,
and thematic content; and when and how to modify how examiners use clini-
cal-theoretical approaches typically applied to other forms of practice—usually
psychotherapy—with the data of personality evaluations. We take comfort in
the research support afforded by the major self report instruments and reliable
and valid Rorschach coding scores, which undoubtedly is an important reason
underlying the confidence many have about using the Rorschach. It is of course
an important reason why most clinicians rely on Exner’s (2003) Comprehensive
System (CS) or Meyer, Viglione, Mihura, Erard, and Erdberg’s (2011) Rorschach
Performance Assessment System (R-PAS) for grounding clinical interpretation.
Nevertheless, even with this foundation examiners often augment interpreta-
tions by incorporating impressions derived from thematic content of Rorschach
responses and tests such as Figure Drawings (Handler, 1996) or the Thematic
Apperception Test (TAT; Murray, 1943) that do not usually yield formal scores.
Clinicians undoubtedly are of different minds concerning the kinds of clinical
situations impacting a decision to use or not to use thematic content material. Nor
does the field have a consistent approach to this issue; indeed, this may be an issue
that by its nature defies formulating consistent, reliable guidelines.
The matter of empirically based scores or codes and thematic content analysis
in clinical interpretation is undoubtedly best considered using the Rorschach
as an example. Unlike self report instruments—which are typically interpreted
almost exclusively using a nomothetic approach—the Rorschach exemplifies an
instrument that may be interpreted idiographically, nomothetically, or in both
ways. There do not exist empirical scoring methods for Figure Drawings or the
TAT that are in widespread use, despite there being a number of scoring proce-
dures for some tests such as the TAT (Jenkins, 2008). Thus, instruments such as
these resemble self report scales in that their interpretation is carried out mainly
in one way—idiographically in the case of the TAT and Figure Drawings and
nomothetically in the case of self report instruments like the Minnesota Mul-
tiphasic Personality Inventory (MMPI-2; Butcher, Graham, et al., 2001) and
Millon Clinical Multiaxial Inventory (MCMI-III; Millon, 1997). Consequently,
a tension between idiographic and nomothetic interpretation never existed for
most of these instruments, certainly not to the extent that it has characterized
nearly the entire history of the Rorschach since its introduction almost one hun-
dred years ago. I thus focus on the Rorschach test to trace the history of its
interpretive use and the conceptual viewpoints about clinical interpretation that
derived from the tension in the field over many years.
Empirically Based and Content-Based Interpretation 3
Although we usually think of Rorschach’s so-called “thought experiment”
and the inkblots he created as the beginning of the inkblot method, Zubin,
Eron, and Schumer (1965), in their classic review of the Rorschach and related
projective instruments prior to 1965, delineated precursors antedating Ror-
schach’s work with the method. For example, based on amorphous inkblot
and cloud imagery as a stimulus for artistic creation, Leonardo da Vinci and
Botticelli as early as the fifteenth century drew artistic inspiration from imagery
formed when a sponge containing various colors of paint was thrown against a
wall. Zubin et al. also noted that Shakespeare wrote a dialogue in Hamlet con-
cerning the meanings of shapes that could be discerned in cloud formations.
In relatively recent times, but still preceding Rorschach’s introduction of
his inkblot method in 1921 (Rorschach, 1981), Binet applied a psychometric
approach to the use of inkblot tests of imagination (Binet and Simon, 1908)—
quite possibly an early forerunner of current concepts of emotional intelligence
and creativity—with a view toward considering such tests among those Binet
developed as measures of intelligence. Other contemporaries of Binet and
Rorschach during the years between 1900 and 1917 also studied inkblot percep-
tion in relation to thinking and imagination. But it fell to Hermann Rorschach
to devise the inkblots and the basic method for using the instrument from the
standpoint of its intriguing opportunity for examining perception. He conceived
of the method as an experimental approach and he was particularly interested in
questions concerning individual differences for inferring personality structure.
Rorschach identified key characteristics to measure how individuals per-
ceived structure from the amorphous inkblots, and he regarded characteristics
such as location and determinants to be the primary measures of perceptual-
cognitive processes (Rorschach, 1981). He derived measures such as the Experi-
ence Balance (EB), comprised of the relative proportion of human movement
and color determinants, as a dimension of personality along which people dif-
fered in nature and degree. Rorschach also classified the contents of responses;
however his interest in content was confined only to categories of experience
(for example, human, animal, anatomy, etc.). He apparently did not regard
verbalizations per se as a subject of interest for interpreting inkblot responses, at
least not during the brief time he worked with the method before his premature
death. He recognized that content of associations was one property of verbal-
ized responses, but he treated it as something to be considered last. However, in
a posthumous publication with his colleague Emil Oberholzer, Rorschach had
begun to consider certain aspects of response content in relation to personality.
For example, commenting on the protocol of a politician, Rorschach observed
that the only response with kinesthetic movement involved gigantic gods cling-
ing to something and that this patient reported several responses with percepts
such as the inside or core of the earth, or the center of a volcano, about which
Rorschach wrote the following:
on the one hand we have gigantic gods and on the other the inside of the
earth and the germ from which all grows. These interpretations arouse the
“suspicion” that there are present ideas of re-making the world and show
how he became a politician, particularly how he became a constructive
organizer. Such experiences have taught me that the content of interpreta-
tions can have a meaning of its own . . .
(1981, p. 207)
Influenced by the growth of psychoanalysis, as the above example begins to

show, Rorschach compared his technique to the analysis of dreams, likening
percepts to the manifest content of dreams. Weiner (2003) also pointed out that
Rorschach seemed to vacillate between disparaging the method as a means of
discerning unconscious material and recognizing its potential value for exactly
this purpose.
Following Rorschach’s lead, developments following his death remained
predominantly focused on codifying details of the perceptual and cognitive
properties of the technique, both in Europe and North America. Exner (1969)
described how Beck, Klopfer, Piotrowski, and Hertz all developed scoring sys-
tems that frequently overlapped, although these systematizers also introduced
unique scores or variables that interested them. Content analysis did not figure
prominently in any of these approaches, with the possible exception of that of
Klopfer and Kelley (1942), nor was thematic content a major focus of Exn-
er’s CS. It was largely through the work of David Rapaport at the Menninger
Clinic that substantive work on thematic content originated.
Rapaport was a noted theoretician writing about topics in psychoanalysis at a
time when drive theory was evolving into the structural theory as an integrated
psychology of the ego and its functions and development. Psychoanalytic ego
psychology, beginning with Freud’s shift in emphasis during the mid 1920s, over
the next decade had become the established theoretical focus of mainstream psy-
choanalysis. Rapaport wrote extensively about thinking, affect, motivation, and
memory predominantly in the ego psychological tradition. Rapaport was instru-
mental in explicating how drives and defenses impacted cognitive and perceptual
functioning. He and his colleagues Roy Schafer and Merton Gill extended the
influence of ego psychology to psychodiagnostic test instruments, which included
intelligence tests, story recall, word association, and sorting tasks as well as the
Rorschach and other projective techniques. Consequently, one important focus
of Rapaport’s work integrated personality with general psychology.
Their work (Rapaport et al., 1968) described four major dimensions of the
Rorschach: the quantitative and qualitative wealth of the record, form level,
and verbalizations. They considered content and its analysis as the qualitative
wealth of the Rorschach, taking account of response content in relation to for-
mal or structural aspects of the response process—such as form, shading, and
color. Rapaport et al. also emphasized that the processes of perceptual organi-
zation and association were interwoven in Rorschach responses.
In Rapaport et al.’s (1968) description of the Rorschach dimension related to
verbalizations, they described disharmonies between perceptual and associative
processes. Here, Rapaport and colleagues incorporated three distinct but over-
lapping areas: (1) the analysis of traditionally defined content categories—such
as human, animal, anatomy, etc.—and their implications concerning patients’
preoccupations or concerns, (2) patients’ verbal communication of responses
in relation to determinants and location, which represented the scorable prod-
ucts of patients’ thought processes, and (3) symbolic references, which is the
aspect of content analysis, primarily thinking distortions, that Rapaport et al.
regarded as lacking a psychological rationale for explaining the relationship
between phenomena such as loss of distance or autistic thinking and the ego
functions subserving reality testing and adaptation.
Holt, in his edition of Rapaport et al. (1968), commented that the analysis of
verbalizations represented a hallmark of Rapaport’s contribution to interpreting
Rorschach responses, despite Rapaport’s own acknowledgment that a method
for analyzing verbalizations was not fully developed. Interestingly, however,
Rapaport’s ideas about the TAT actually seemed to better reflect his thinking
about content than did his writings about the Rorschach. He was interested in the
flow of material in TAT stories mainly to examine control of drives by the ego,
and he regarded rigid or inhibited as well as labile or impulsive stories as mark-
ers of poorly controlled drives. Rapaport et al. viewed interpreting TAT stories
as a person’s way of experiencing one’s personal world. By designating the TAT
for this purpose, they attempted to take advantage of this instrument’s capacity
to elicit “free-swinging fantasy” to discern conscious and unconscious thought
content (Rapaport et al., 1968, p. 468).
Schafer (1954, 1967), who extended Rapaport’s work on content analysis,
attempted to understand content material by applying a disciplined and con-
trolled application of psychoanalytic ideas, carefully eschewing what he called
idiosyncratic improvisation as a form of unsubstantiated interpretation. Schafer also
advocated a rigorous clinical sensibility concerning rules of evidence and clinical
relevance that should be crucial to clinicians’ attitude toward interpretation;
however he also recognized without apology that the way it operated and the
data it considered were not subject to formal empirical testing. He stressed the
importance of finding an optimal balance when analyzing the unique material
constituting personality assessment data and that of reality. He thus attempted
to take account of the tension inherent in describing one’s way of managing the
world of everyday life, with its emphasis on problem solving and relationships
with other people, while simultaneously attempting to apprehend the world of
inner life with its emphasis on the depths of internal psychological experience.
Schafer regarded psychological tests of personality as occupying a space inter-
secting both worlds, going back and forth between these realms of experience.
That being said, what then would it mean to apply the clinical sensibility that
Schafer spoke about to thematic content analysis? This is where his familiar
inferential thinking criteria for judging the adequacy of clinical interpretation
comes into play, developed by Schafer (1967) to distinguish between thorough-
ness and recklessness, to use his own characterization of the problem. A large
part of the difficulty concerns determining an appropriate degree of depth that
is logically and clinically supportable.
Primary among the criteria Schafer advised as a guide to clinical interpreta-
tion is that of sufficient evidence, by which he meant considering converging
lines of evidence, frequently based on several recurrences of a particular theme.
However, Schafer also considered associations to particular test responses as a
form of evidence for confirming or modifying interpretive leads. He compared
the interpretive strategy to navigating an airplane, in which a pilot steers a
plane by consulting instrument panels, his co-pilot, and his navigator, who in
turn rely on data and feedback from a control tower or other devices. Though
this was a useful metaphor, Schafer thought that the interpretive process using
analysis of Rorschach content was similar to the corresponding approach to
reconstruction in psychotherapy, in which patients respond to interpretations
by recalling memories, dreams, or associations that further amplify or modify
interpretations by steering them in a more accurate direction.
On the Rorschach, a particular response may strike an examiner as unusual
or atypical because it is a rare response or because it suggests something more
than what the scores themselves contain, particularly if it initiates or furthers
a hypothesis-generating line of thinking in the examiner. Moreover, it may
facilitate links with other tests, such as Figure Drawings or the TAT, analogous
to Schafer’s metaphor of a pilot consulting with a plane’s co-pilot. Sometimes,
content analysis may reveal more about intensity of affect states than that which
formal scores indicate. For example, a coding for aggressive movement may
not necessarily differentiate among nuances such as hostile vs. contemptuous
vs. menacing; similarly, a coding for cooperative movement generally does not
permit finer gradations or shades of cooperativeness, such as eagerly vs. grudg-
ingly vs. passive-aggressively vs. compliantly. Schafer, while making use of
subtleties such as these, also advised caution about how far to interpret mean-
ings of particular responses, although he considered the sequence of responses
within and between cards as providing potentially important information about
shifts in intensity of affects or defense operations and adaptability of defense
operations.
Probably his main emphasis in considering interpretive possibilities of con-
tent material was that both listening openly to potential meanings while simul-
taneously exercising caution about finalizing interpretations called for deli-
cately balancing the two, but what was most important was keeping the range
of options for clinical inferences broad rather than narrow. It is in this spirit
that one could say that Schafer’s position represented a disciplined openness
to experience, letting the examiner’s imagination roam over possible mean-
ings, but filtering such meanings through a coherent theoretical framework
rather than “flying blind,” to use his airplane pilot metaphor. Lerner (1991)
and Fischer (1994b) discussed a similar process in their approaches to gener-
ating theoretically sound, higher-level inferences from Rorschach scores and
verbalizations.
Schafer also took into account the depth of interpretation and manifest con-
tent of Rorschach responses as another consideration in using content analysis,
for example, equating a response of a mouth with oral longings or a contest
with Oedipal rivalry. Schafer was particularly cautious about such one-to-one
equivalences, but he did not ignore this line of thinking either. What he empha-
sized, however, was the crucial step of anchoring how he used links such as
these in a context that considered their regulatory functions. That is, interpret-
ing orality, dependency, or competitiveness would depend on how drives or
wishes such as these were expressed or modulated. Thus, merely mentioning
a mouth in a Rorschach response would mean less about oral longings per se
than, for example, whether the mouth was opened in anticipation of being fed,
closed either in stubborn refusal or as an expression of autonomy, drooping in
disappointment, spitting in disgust, pursed to inhibit affect, and so forth.
Schafer also privileged interpretations emphasizing defense operations over
interpretations based on specific conflicts, such as oral longings or conflicts
in the above examples, because defenses were more directly discernible as a
rule whereas conflicts were usually less evident. He applied the general prin-
ciple of psychodynamic psychotherapy to psychodiagnostic material in which
a conflict is usually not interpreted until the defenses against that conflict’s
conscious emergence are interpreted. Thus, Schafer argued that psychodiag-
nostic examiners should reserve inferences about underlying conflicts or their
intensity until the defenses that operate become clear in a Rorschach or assess-
ment protocol. As such, “the interpretation should not push below the level of
defense” (Schafer, 1954, p. 150). For a similar reason, interpretations based on
fixed, symbolic meanings—such as so-called “father” or “mother” Rorschach
cards—were almost always gratuitous, unless sufficient evidence was strongly
compelling—a very difficult criterion to achieve. Schafer called this use of
content “arbitrary, presumptuous efforts to deepen interpretation in spite of the
patient” (1954, p. 150).
However, the frequency with which a particular content emerges adds incre-
mental certainty that the dynamic giving rise to it is salient. Less compelling,
however, are more oblique indications of drives, for example contents about
Santa Claus, angels, or hands reaching heavenward as indications of oral long-
ings or dependency. Nonspecific thematic content such as these examples
indicate possibly may strengthen interpretations if more substantive evidence
exists; rarely if at all, however, should inferences be based on the absence of
mentioning thematic content references. Despite such caveats, Schafer clearly
attempted interpretations of drives or conflicts when he believed there was suf-
ficient evidence to justify doing so. In this sense, therefore, the test of depth of
interpretation was linked to the test of sufficient evidence. He was not opposed
to deepening interpretations beyond a level such as specifying defenses, but he
did believe that it was necessary to exceed a certain threshold level influenced
by cautious theoretically founded assumptions before doing so.
Schafer also described other criteria for interpretation of thematic con-
tent, such as relying on a theoretically conceived understanding of the relative
intensity or prevalence of specific psychodynamic patterns for determining the
hierarchic importance of particular personality patterns. He also addressed the
importance of specifying adaptive tendencies noted in test material in addition
to pathological interpretive impressions. Schafer thus laid a foundation for the
next generation of Rorschach theorists, who developed further approaches for
specifying criteria for integrating formal scores and content analysis, most nota-
bly Lerner (1991), Silverstein (1999), Smith (1994), and Sugarman (1986), all
of whom extended this work into the area of object relations, self psychological
theory, and related deficit models of psychopathology that were emerging as
important new theoretical viewpoints.
Lerner (1991) also emphasized the importance of a systematic strategy for
using thematic content and the cautionary approach that this form of interpre-
tation requires. He introduced a multi-step process of inferential thinking that
allowed for a deeper level of interpretation as examiners progressed through
various sequential inferential steps. He began a Rorschach analysis by search-
ing carefully for confirmatory evidence from other test findings and scrutiniz-
ing the material for internal consistency. Lerner, like Schafer, also attached
importance to the analysis of sequence of responses as an important component
of content analysis. Incorporating Schachtel’s (1966) emphasis on phenom-
enologic experience, Lerner regarded the sequence of Rorschach and TAT
responses as containing important clues about affect states and regressive shifts
that extended beyond discrete responses or TAT cards, devoting particular
attention to the sequence of form level for understanding regression and its
impact on reality testing, and for differentiating between conflict and deficit
models of psychopathology.
Aronow, Reznikoff, and Moreland (1994) also advocated a content-
idiographic approach that combined content analysis and formal scoring. Like
Schafer and Lerner, their approach was one of the more explicit descriptions
of a systematic approach for using content analysis in clinical interpretation.
Aronow et al. described three types or levels of inference, the first being infor-
mational in nature and which was expressed at a low level of inferential depth.
Their second level was concerned with symbolic associations that are amenable
to psychodynamic understanding. A third inferential level concerned complex
idiographic images derived from specific probes for idiographic associations,
such as what particular Rorschach percepts evoked or suggested. Although this
might be viewed as a somewhat radical departure from either the CS method
or the generally less formalized pre-CS approaches for conducting an inquiry,
Aronow et al. justified their approach insofar as it facilitated the process of psy-
chotherapy. They discussed safeguards for judging the validity of clinical inter-
pretations based on content, they advised against fixed meanings or mechanical
application of symbolic associations, and they also stressed careful attention to
examiners’ attention to blind spots. They discussed the cautious importance
of the analysis of sequence of responses, mainly as further associations to or
elaborations of patients’ internal experiences. Despite the generally accepted
use of some form of thematic content analysis by many Rorschach clinicians,
the work of Aronow et al. has not sustained enduring interest, and I suspect
that many students of the past decade or longer ago may be unfamiliar with
their work.
Among advocates of finding meaning in the analysis of Rorschach con-
tent, Schachtel (1966) approached the subject differently than did Schafer
and Lerner. In many respects, Schachtel’s position was closer to Exner’s in
that determinants, location, perceptual organization or articulation codes,
anomalies of thinking similar to Exner’s special scores, and form quality were
primary dimensions for understanding Rorschach responses. For Schachtel,
content—when defined as verbalizations and associations to responses—was
clearly secondary in importance. Much like Rapaport and Schafer, who also
worked fundamentally from an ego psychological theoretical framework,
Schachtel was particularly concerned about the perceptual and cognitive fea-
tures of the Rorschach. Thus his interest was closer to Rapaport’s emphasis on
perception and cognition in relation to affect and motivation.
Certainly every major Rorschach theorist, including Exner, was interested
in cognitive-perceptual features, affect, and motivation, although the method
or approach various theorists applied to understanding these relationships dif-
fered in emphasis. Schachtel’s particular emphasis, which he called experiential,
referred to fusing sensory or perceptual properties with affective or motivational
states. He devoted special attention to the formal properties of perception as
occurring first, for example perceiving contour or form. Schachtel considered
the perceptual process to be followed by a critical evaluation of goodness of fit
between percepts and reality, a process that led subjects either to accept their
Rorschach responses or to search for more suitable alternatives. Further, like
Schafer and Lerner, Schachtel took note of the interpersonal or transference-like
nature of the Rorschach situation.
What Schachtel emphasized in a somewhat different way than Rapaport,
Schafer, and Exner was the experiential component of the form-generating
process of arriving at responses. For example, he stressed how affect states such
as depression or boredom might interfere with the perceptual processing of
form, thus modifying how determinants, location, and organizational aspects
were used or verbalized. He also emphasized the meaning inherent in variables
such as color, shading, and movement as properties of perception modifying
form. Schachtel did not, however, regard content based on verbalizations and
associations to be suitable material for understanding drive states, defenses, and
adaptive efforts, and he deemphasized attributing specific meanings to par-
ticular cards. Although he suggested that scores and verbalizations were both
a means of comprehending people’s experience, he did not regard them as
equally important for this purpose. He seemed to regard thematic content as
potentially interfering with the basic interpretive function. Schachtel’s admoni-
tion of a too exclusive use of content analysis led him to limit its relevance to
that of a style of communicating.
While considering the essential Rorschach data to be what an individual
sees and how he or she sees such responses, Schachtel did not overlook “all
the emotional overtones and undercurrents that color what he saw . . . and all
the intellectual and emotional effort, its quality, its process, its smoothness, or
conflicts which entered into the work of perceiving, associating, and judging
the fitness of the percept” (1966, p. 261). He did believe that content reflected
defenses and adaptation more so than drives or conflicts, mainly because he
viewed Rorschach responses not as products of unconscious mental activity but
rather as adaptive responses to external stimuli.
Weiner (2003) traced the history of interpretive approaches, noting that
treating the Rorschach primarily as a measure of association (rather than as a
measure of perception) has had a controversial history. He advised a balanced
approach to the use of content analysis in interpretation, stating that when used
it is best integrated with formal scoring. In this sense, his viewpoint represents
one of complementarity in which the task of the Rorschach method involves
both perceptual and associational processes.
Weiner (2003) pointed out that Klopfer actually may have been the most
skeptical of content analysis—and fixed or symbolic meanings in particular—
even as an adjunct to a formal structural approach. On the other hand, Aronow
and his colleagues may have been more permissive than most about using con-
tent analysis, particularly in respect to symbolic meanings of responses and
their favoring an idiographic approach over nomothetic interpretation. Many
followers of the Rorschach technique, including Bohm, Beck, and Piotrowski, as
well as Rorschach himself, were simultaneously disparaging and curious about
content of responses for analyzing Rorschach findings. Weiner proposed what
he called an integrationist perspective, an approach that considered perceptual
organization and associative processes. It is an approach that was derived in
part from Rapaport’s thinking on the subject; Rapaport et al. had this to say
about how such an integration might come about:
Percepts derive their meaning from the associative processes in which

they become embedded; and associative processes cogwheel into reality
by weaving percepts, or imagery aroused by percepts, into their course.
. . . [t]hey bind the associative process to the necessities of reality, they pre-
vent them from running wild and being directed only by subjective wishes.
Thus percepts and associations in the smoothly functioning organism are
mutually dependent upon each other, mutually stimulate, guide, and limit
each other.
(1968, pp. 274f.)
Weiner (2003), in discussing where we are today, about 60 years later, consid-
ered that the CS (Exner, 2003) incorporated important contemporary develop-
ments in interpreting Rorschach responses. He regarded structural variables to
be better understood than thematic content formulations, which would have
to “wait their turn to be adequately examined and incorporated within the
system” (p. 14) In this way, he regarded the CS as a method of understanding
responses as indications of perceptual processes and as associations.
Undoubtedly, Exner’s (2003) introduction of the CS stands as one of the
most prodigious efforts to establish what has become the most solidly sup-
ported psychometric basis for the Rorschach technique to date. His focus on
standardization of procedures, reliability of coding variables, and establishing
a valid basis for interpretation secured a foundation for the future of the Ror-
schach in personality assessment. Because his efforts concentrated on refining
the Rorschach’s measurement properties, it is easy to overlook the fact that
Exner recognized the relevance and importance of a broader range of factors.
However, he certainly believed that some aspects of potential clinical interest
might better be expressed or at least anchored in a more secure, psychometric
foundation. Stated another way, Exner would have considered it reasonable to
regard aspects of responses that reflected the association process to potentially
enhance or facilitate interpretation. This would not necessarily mean that per-
ception mattered more than associations or that perceptually based inferences
mattered more than clinical hunches, inferences, or intuition. But it was a way
of alerting examiners to both realms of experience and that there should be
priorities to follow when constructing an interpretation.
I think that some of the best examples of Exner’s use of content analysis were
most clearly evident in his discussion of the self perception cluster in his Primer
for Rorschach Interpretation (2000), where he discussed at some length how he aug-
mented Structural Summary-derived clinical interpretations by considering
the content of unique responses. For example, Exner commented about two
types of projection in Rorschach responses, observing that although the tech-
nique did not by itself require projection, it nonetheless might occur. Exner was
conservative about the kinds of material that qualified as projection, however,
and he distinguished two forms: one that was associated with poor form qual-
ity responses, which involved misperceptions; and a second type, consisting of
embellishments in which a person departed from a commonly perceived trans-
lation of the stimulus field. For the most part, Exner reserved the second type
of projection for responses containing human content, movement, and special
scores such as morbid responses (MOR), aggressive movement (AG), and coop-
erative movement (COP). This approach contrasted with an approach such as
Aronow et al.’s or Schafer’s or Lerner’s insofar as Exner seemed to be recom-
mending a cautious integration of material based on certain relatively limited
types of responses. Thus, he wrote:
It is unusual for the projected material from any single answer to provide
a wealth of interpretive information concerning the individual. Instead, it
is the classes of projected material that generate the most reliable interpre-
tive yield. As embellishments or themes become redundant in a record, the
interpreter gains greater assurance about features of the individual that are
being represented.
(2000, p. 272)
Consequently, Exner described two approaches to examining projection, the

first involving reading through the entire record from beginning to end. This
approach represented the tradition of Schafer and Lerner. Exner noted an
advantage to this method insofar as it facilitated seeing the stream of activity
from card to card. But he also believed that this approach warranted caution
because many responses “do not include appreciable projected material and to
assume otherwise simply clouds the process” (2000, p. 273). Exner’s preferred
approach was a systematic examination of responses according to the specific
types of scores he considered to be more likely to contain projected material
that could be interpreted in a meaningful way.
Here are just two examples from one patient (p. 282): “some bones of a dead
animal . . . just some bones like a backbone and joints,” about which Exner
wrote “[a]lthough very speculative, it gives rise to a question regarding the
sturdiness of his self image.” Another response was “a person sitting in a row-
boat . . . the outline isn’t too clear for the person.” Exner noted that the move-
ment was passive and although a fishing pole was added during the inquiry, the
patient never said the person was fishing, just sitting. Exner observed that “[t]o
this point it seems impossible to avoid questioning about how unsure he may
be about himself and whether this gives rise to excessive caution.” A second
example was a response of “gnome like characters trying to lift this pole or stick
. . . weird looking with little legs.” Here, Exner emphasized the phrase trying to
lift rather than lifting, which both suggested a sense of uncertainty and added to
the impression already forming about the patient’s feeling unsure about him-
self. Although mentioned here out of context, I think these responses and Exn-
er’s comments about them give some indication about his use of content and
verbalizations, used conservatively together with Structural Summary findings,
to augment aspects of a patient’s uncertainty about his capabilities and the
cautiousness this led to in the patient’s life. More to the point, these examples
illustrate Exner’s approach to the use of content analysis.
Returning to the questions I posed about when, how, and how much to
integrate thematic content with formal scoring, I suspect that Rapaport would
have decided the issue much as Exner might have; so, too, might have Sch-
achtel, although Schachtel might have been less inclined to endorse content
analysis very much at all. Klopfer, Beck, Piotrowski, Schafer, Lerner, Weiner,
and Aronow et al. probably fall on different relative positions along this contin-
uum, and probably so do many contemporary examiners. Clinicians continue
to struggle with answering this question or resolving this lingering dilemma to
this day. Naturally, there is not an easy answer, nor do I think an answer will
clearly emerge any time soon. Revisiting the issue is certainly useful, and I have
tried to frame some of the history of the problem and to present some of the
more important attempts at a solution in this introduction. The field may not
be further along in arriving at an answer, and we may not be much further
along in 10 or 20 years from now either, but as the poet Rilke wrote in his well-
known work Letters to a Young Poet, I do not think that we will grow tired of trying
to love the question.
2 Personality Problems
Associated with Affect
Dysregulation
Differentiating among affective disorders is a complex matter because subtle

clinical features and the overlap among various conditions frequently compli-
cate diagnosis. Thus, for example, depression may occur as a full syndrome
(major depressive disorder) but it occurs just as frequently in attenuated or sub-
syndromal forms. Moreover, depressive disorders may be episodic or chronic,
and even episodic forms may resolve to chronic states such as a phenomenon
known as “double depression” (Keller & Shapiro, 1982) in which a major
depressive episode is superimposed on a low-grade but chronic depression
rather than reaching full remission. The relationship between dysthymia and
depressive (melancholic) temperament or personality remains unclear, particu-
larly whether these represent distinct disorders or variants of major depression.
Finally, differentiating between unipolar and bipolar depression can be quite
complicated, particularly when hypomanic states or hyperthymic temperament
form part of the clinical presentation.
Although some of these problems of differential diagnosis may not be central
to personality assessment, the field nevertheless must contend with differen-
tiating between indicators of a depressive syndrome and phenomena such as
prominent anergia, discouragement, or disappointment. Sometimes as well,
evaluating reality appraisal and its relation to psychosis becomes important in
relation to differentiating between unipolar and bipolar depression. This may
include identifying subtle types of disordered thinking and their nature (loose,
florid associations vs. impoverished thinking) and severity (formal thought
disorder vs. inefficiencies or fluctuations in quality of thinking). Assessing per-
sonality disturbances and their relation to syndromal affective disorders is fre-
quently problematic in personality assessment, and of course it is important to
attempt to identify bipolar or hyperthymic signs or nuances for differentiating
between unipolar and bipolar affective disorders. For the most part, personality
assessment instruments do a good job of reliably distinguishing between psy-
chotic and nonpsychotic presentations; however, there is relatively less atten-
tion devoted to differentiating among unipolar depressive disorders (including
their subsyndromal variants), bipolar spectrum disorders, and personality dis-
orders. Furthermore, although gross distinctions between unipolar and bipolar
affective disorder can usually be assessed more readily, particularly with the
benefit of a careful clinical history detailing prior illness episodes, there is far
less understanding of commonly occurring mixed states, mainly involving anx-
ious-depressive conditions.
Clinical course is also variable, and chronic, subsyndromal forms of depres-
sion often show a poorer outcome than episodic disorders. Unipolar and bipolar
depression have different outcome patterns, and the potential for subsyndromal
forms to go unrecognized usually prolongs compromised life functioning and
may potentiate shorter remissions and more protracted periods of relapse if epi-
sodes of affective illness are present. The presence of comorbid anxiety disor-
ders and the difficulty distinguishing between agitation and hyperthymic tem-
perament or “soft” bipolar spectrum disorders are particularly problematic.
Kraepelin (1921) laid the groundwork for one of the earliest clinical descrip-
tions of subsyndromal depression in his description of a melancholic tempera-
ment, dominated by a lifelong pattern of an introverted and brooding or pes-
simistic nature; and an anhedonic, overly serious disposition. Akiskal (1983)
added to Kraepelin’s description personality traits such as indecisiveness; a
hypercritical and petulant nature; self-depreciation; and overly ascetic, duty-
bound hyperconscientiousness. More importantly, Akiskal revived an interest
in the Kraepelinian tradition that considered the variation in clinical presenta-
tions of conditions such as depression as points on a continuum or spectrum
of a single (unitary) illness. Judd and Akiskal commented that “there are no
natural boundaries between depression at the personality (temperament), dys-
thymic, major depressive, minor and residual SD [subsyndromal depressive]
levels. They all appear to be part of a psychopathological continuum with the
common denominator of a depressive trait . . .” (2000, p. 5).
Akiskal and Weise (1992) also pointed out that clinicians sometimes devote
insufficient attention to affective lability (including even minor temper tan-
trums or “moodiness”), hypomania (especially by history), impulsivity, and
related affective dysregulation states—some of which are subtle, particularly
when family history reveals affective lability (a bipolar diathesis). Moreover,
when bipolar depression goes unrecognized, as often happens, suboptimal or
frankly incorrect treatment decisions may produce clinical worsening, such as
antidepressant-provoked mania (pharmacologic mania) or rapid cycling. This
problem exists even in subsyndromal forms, which Akiskal included within this
characterization of a “soft” bipolar spectrum. One consequence of untreated
or improperly diagnosed depression is the persistence of mild affective labil-
ity rather than euthymia. Kraepelin (1921) also observed that mild depressive
states occurred premorbidly in over 10 percent of manic-depressive (bipolar)
patients; as such he viewed mild depression sometimes as a precursor to manic-
depressive (bipolar) illness.
Mild or intermittent affective disturbances associated with unstable life his-
tories and sometimes accompanied by substance abuse often suggest charac-
terologic features of the personality. Such disturbances are often considered
to reflect borderline or related chaotic forms of personality disorder. Akiskal
et al. (1985) regard such chaotic or tumultuous clinical presentations as easily
Personality Problems and Affect Dysregulation 15
obscuring subtle hypomanic features, which may as a result more accurately
represent a variant of bipolar illness rather than personality disorder.
Attenuated forms of major depression that comprise a spectrum of depres-
sive disorders suggest that a genetic diathesis may predispose to varying sympto-
matic presentations or phenotypes of unipolar or bipolar mood disorder (Akiskal,
1983; Akiskal & Webb, 1983). Consistent with Kraepelin’s (1921) general point
of view, it remains possible that it is a melancholic, hyperthymic, or cyclothymic
temperamental predisposition to affective dysregulation that may be genetically
transmitted rather than specific affective disorders. As a result, temperamentally
based mood dysregulation in interaction with environmental or biological risk
factors may predispose to one or more forms of affective illness. Akiskal (1989)
also suggested that affective temperament predispositions may lead to interper-
sonal dysfunction that interferes with acquiring social or interpersonal supports.
Such disturbances may promote chronicity and in this way secondary personality
dysfunctions may function as sequelae rather than as causative factors.
The personality assessment literature has largely focused on test indications
of depression and less thoroughly on sometimes subtle characteristics of depres-
sive syndromes, particularly in respect to so-called projective or performance
tests such as the Rorschach, TAT, and Figure Drawings. The case below illus-
trates a good example of several of the diagnostic and conceptual issues noted
above. First, the case is relevant to matters of depression severity and chronicity.
Second, it considers depressive features alongside other test findings—in this
particular case, subtle hypomanic indications and disordered thinking—and
their implications for differential diagnosis. Third, this case demonstrates how
conflict-defense-self esteem dynamics influence and are themselves influenced
by problems of affective regulation and distortions of thinking.
This patient, Ms. A., a 30-year-old black divorced female with an 8-year-old
daughter, was referred by a psychotherapist for a neuropsychological evalu-
ation in connection with attentional and learning problems, and a history of
depression and obsessive-compulsive symptoms. The primary focus was to
establish whether an untreated disorder of attention was contributing to her
psychiatric problems. The therapist had first referred Ms. A. to a psychiatrist
three months previously for a medication consultation, which resulted in a trial
of olanzapine (Zyprexa®) and escitalopram (Lexapro®). The psychiatrist noted
the patient’s variable moods and fluctuating energy levels as more prominent
symptoms to consider treating. The patient, however, discontinued olanzapine
on her own accord because of its sedative side effect, although she remained
on escitalopram 10 mg. q.d. despite complaints of falling asleep early. She pre-
ferred her usual pattern of staying awake much of the night with the heightened
energetic thoughts she typically experienced at nighttime.
She described brief episodes (one or two days in duration) of bursts of mental
and physical energy, stated that “I had so many thoughts, I felt like superwoman
that I don’t need to sleep.” On examination, Ms. A. did not appear to have rac-
ing thoughts; however when asked about reckless activities or spending, she
mentioned bad judgment such as buying clothing when she knew she did not
have enough money to pay bills. According to her report, she did not believe
that such periods of heightened energy created problems for her or interfered
with her life. Ms. A. also had periodic but mild and short-lived depressions,
accompanied by diminished energy and appetite, but without insomnia, dimin-
ished interests, suicidal ideation, or feelings of worthlessness and guilt. Around
age 15, she was aware of but not apparently sufficiently bothered by obsessive-
compulsive symptoms such as frequently checking that the door was closed or
the stove turned off. These symptoms disappeared after five years; however, she
felt throughout her life that she was easily distracted and forgetful.
Neuropsychological testing revealed mild attentional disturbance, but the
findings did not appear sufficiently compelling to account for her current con-
cerns. In view of the history suggesting possible mood dysregulation and to dif-
ferentiate between an affective disorder and attentional disorder, a personality
assessment was recommended.
Millon Clinical Multiaxial Inventory (MCMI-III)

Ms. A.’s disclosure base rate score was 30, suggesting the possibility that avoid-
ing self-disclosure was a prominent response style. Taking this into account
by compensatory adjustments, the highest base rate scores for the clinical per-
sonality patterns were on the narcissistic (BR =83) and histrionic (BR = 72)
scales. Grossman facet scores indicated no specific components on the narcis-
sistic scale; the two highest facets (admirable self-image and cognitively expan-
sive) were both BR < 70. The histrionic scale components of some note were
the interpersonally attention-seeking (BR = 76) and expressively dramatic (BR
= 70) facets. There were no important elevations on scales assessing severe
personality pathology or major clinical syndromes (including thought disorder,
major depression, and delusional disorder).
A response style characterized by avoiding self-disclosure suggested either
a pattern of essentially normal functioning accompanied by downplaying situ-
ational stress, or a more pronounced personality disorder concealed behind an
image of adequate functioning she attempted to present to others. For reasons
discussed below in conjunction with other test findings, the latter impression
appeared to be the more salient interpretation of the MCMI findings. The
personality pattern so noted suggested, therefore, inflated self-worth and an
impression of imperturbability. Ms. A. could appear superficially charming;
however, she required considerable attention and stimulation often taking the
form of exhibitionistic or self-dramatizing behavior. Such features also would
be likely to affect her relationships with other people, which appeared to be
self-serving, shallow, and fleeting. She has probably realized that appearing
undependable and acting exploitatively offends others; however, she tends to
make light of how she comes across, relying on flimsy rationalizations, using
charm, feigned surprise, or acting self-righteously. Out of a sense of omnipo-
tence, she may be inclined to project blame onto others, feeling resentful about
being demeaned or offended herself.
Thus, being inclined to feel perturbed if she were shamed or embarrassed
by rebuffs to self-esteem could disrupt her assured composure, leaving Ms. A.
feeling empty or rejected. Being disposed to anger or depression, she would be
prone to withdrawing into herself to recover from what she probably would
experience as narcissistic injuries. As such, Ms. A. was adept not only at sensing
what pleased other people but also what made them hostile or rejecting. Con-
sequently, she likely used her interpersonal sensitivity to adapt her behavior to
what other people wanted, either by earning approval or by forestalling rejec-
tion because of her self-dramatizing or exploitative ways.
Human Figure Drawings

Ms. A.’s first drawing was of a female (Figure 2.1) which, like her drawing of a
person of the opposite sex, also was faint and barely perceptible to the exam-
iner. From the drawing, it was not clear whether the person drawn was male or
female, and on casual inspection the drawing seemed to represent a person with
long hair and spectacles standing with hands in pockets, connoting a casual
Figure 2.1 Human Figure Drawing (female)

stance. As she drew the figure, Ms. A. asked: “Do you need details, like a face?
Because usually I play with a pencil on the page, by playing with it I see part of
the image and then I can start to capture a full picture. I always, always start
drawing by messing around and then I see something come from that.”
Asked what the person was like, Ms. A. related the following in her spontane-
ous elaboration:
This is a girl, a very young girl. Still deciding what she wants to do in life. She’s very
smart and attractive, wears glasses and baggy clothing, but she’s very attractive under-
neath—she just doesn’t know it yet. She’s very smart; that’s going to be her foundation,
and she’ll get very far in life. She’ll realize her attractiveness later. For now, she’s just in
school—one of the geeks, is that what they call it? (Q) She’s very observant, a thinker.
Likes to analyze things, even at a young age. It’s a gift, I suppose. She’s not your normal
kid, she’s very much past her years in wisdom. So she’s smart and wise as well.
I asked her about the person’s fears, and Ms. A. commented:
She’s afraid of big things like the state of the world—poverty, homelessness. (About her-
self?) Not being the best. Because of her concerns about world issues, she wants to make a
change in the world and worries she won’t have an effect—people would think she’s just
a kid and what does she know! (Fears concerning herself?) Not being the best. High
expectations of herself. That she’s not good enough, even though she knows she’s smart.
I asked in turn what made the person unhappy or depressed, angry, and what
the person was doing in the drawing, to which she stated (commenting first
about unhappiness or sadness):
Big issues again—poverty. Even closer to her own life like people smoking, casual sex,
drinking, things the world sees as acceptable. (But what makes her feel depressed?)
[long hesitation] I don’t know. Not feeling she’s good enough, part of her self image.
(Angry?) Same as before—world issues.
(What about her personally or in her life?) Like I could have done better or
something else she could have done. (Doing in the picture?) Enjoying the day. She’s
a girl, lovely, she appreciates beauty. Walking and looking at trees and flowers, enjoying
everything around her. She’s really a joyous, happy person.
Ms. A. next drew the figure of a male (Figure 2.2), which looked like a boy. The
figure appeared casually dressed, with hands behind its back. Her spontaneous
description was as follows:
This boy is a jokester, probably a pre-teen. He doesn’t realize or understand much about
life yet. The class clown—that pretty much sums him up. He’s a smart boy, though, but
that’s probably not too evident yet because he’s always fooling around and joking. That
covers up any or all of his intelligence.
Figure 2.2 Human Figure Drawing (male)
Asked about his fears, Ms. A. said:

Being alone. His family being separated and ending up in a foster home. He wouldn’t run
away. He’s a loving boy, but that’s not evident yet. He’s an average boy. Probably gets in
trouble a lot in school, making jokes and being distracting. Maybe it began from the fear
of losing his parents—to push those feelings aside.
Ms. A.’s initial comments as she drew the female were somewhat unusual, inas-
much as most people either draw silently or make an apologetic comment that
their drawing skills are not well developed. But Ms. A. had something else on her
mind: she spoke of her casual approach to drawing as both playful and feeling
comfortable with ambiguity. Indeed, she seemed curiously insistent about doing
it in a certain way, almost savoring “messing around” before deciding what shape
her drawing might take or what meanings it might take on. I took note of her
emphasis on doing things a certain way, wondering whether she tended to antici-
pate either criticism or being urged by others to conform to a model of behaving,
one that perhaps might represent a conventional plan or starting point. I also
noted that “playing . . . messing around” was pleasurable for her, although she
could realize that others might be put off by her way of doing things.
I could not know at this point whether Ms. A. took the trouble to say what
she did in expectation of criticism or displeasure, but I did think that her verbal-
izing her way of approaching the world was intended to convey something about
herself. I could not discern whether she was making a defensive or self-protective
statement here or whether she was expressing that she did not particularly care
what anyone thought about her style. I did have the impression, however, that
there was a quiet confidence she felt about how she apprehended the world and
perhaps as well her inner life, as if she were saying confidently (though not neces-
sarily arrogantly or belligerently): “I’ll tell you who I am and how I do things, but
I won’t alter my ways according to what you want or think.”
Her initial question (“Do you need details?”) suggested, however, that
beneath an appearance of compliance there might coexist a subtly demeaning
or derisive tone, suggesting that others may require obligingly conventional
explanations that she might herself think of as petty or simple-minded. She
might compliantly defer to others’ expectations, but people would be left feel-
ing that she was tossing crumbs at them rather than acting genuinely coopera-
tively. As such, an initial appearance of self-confidence might simultaneously
have been tinged with derision. Thus, before she even delivered her first actual
response, a transferential expectation appeared to be operating.
Ms. A. drew the female figure as a young girl, a somewhat atypical identifica-
tion for an adult. Perhaps the basis for this unusual identification lay in her open-
ing comment: the figure was trying to figure out who she was and what she was
about. Ms. A. appeared to have no trouble recognizing that the girl was smart
and that she knew she was smart. But the girl as drawn was warily attractive—the
girl did not know that yet, concealing her concern behind an outward appear-
ance as awkward or “geeky.” Thus, the girl wore baggy clothing to deemphasize
her figure, she wore eyeglasses that would be anathema to many adolescent or
pre-adolescent girls, and she expressed a general sense of contentment burying
herself in schoolwork and turning away from her sexuality and a sense of budding
female attractiveness. There seemed to be little concern or defensiveness beyond
the obvious concealment of this aspect of her physical development, expressing
a relatively nondefensive contentment that this side of her female persona would
come in due time. That a child or adolescent of either sex would be portrayed as
unsure of oneself or awkwardly negotiating where she positioned herself as adult-
hood was approaching was not especially unusual; what was unusual, however,
was that Ms. A.—a mature, adult woman keenly aware of the responsibility she
has in caring for a child as a single mother—would seem to identify with a geeky,
unformed adolescent girl who was uncertain of her feminine identity.
Indeed, it may be worthwhile to compare her opening comments noted pre-
viously—her doing things her own way while perhaps indulgently complying
with others’ expectations for realistic plans or structure—with the image she
presented of devoting her attention to developing her mind while deferring the
physical side of female development. Once again, Ms. A. appeared to be say-
ing here that she had her own agenda in spite of knowing what others might
expect from her, and that she would get around to what external reality wanted
when she was good and ready and not according to other people’s timetable.
She did not express this sentiment in a willful or arrogant tone, but her firm or
determined stance seemed to suggest that she would resist being pushed very
far beyond her own way of doing things.1
Ms. A. turned appropriately inward when I directed her to imagine what
the figure’s personality was like, describing the person as being observant and
thoughtful beyond her age. This patient also attributed wisdom to the girl,
which she regarded as beneficial for her. Ms. A.’s actual word was “a gift,”
which may simply have been her way of denoting something beneficial and
adaptive, but it is also possible that she might have had in mind the word gift in
the sense of something special or unique, perhaps even inflated. Ms. A.’s refer-
ence to the girl’s having a gift together with the entire tone of her description of
the female drawing would be consistent with an impression of entitlement.
When asked to imagine the figure’s fears or concerns, Ms. A. referred to “big
things.” I focused the question once more in relation to the figure herself, at
which point Ms. A. expressed for the first time some doubt about what to this
point seemed like self-confidence and a sense of the figure’s efficacy in the world.
Thus, Ms. A. mentioned concern about “not being the best,” which she pro-
ceeded to clarify as the girl’s not being taken seriously for her accomplishments
or efforts. The concern seemed to be about being devalued rather than welcomed
or admired. She reiterated an emphasis on being the best, careful however to
step back from an intimation of grandiosity (“that she’s not good enough”). Nev-
ertheless, it was a thinly veiled attempt at modesty because she could not help
but add to this, “she knows she’s smart”—which was starting to sound more and
more as though she did not really doubt her capabilities and that she harbored
the idea that she really was the best. Thus, when asked to speak about fears or
concerns—hence, vulnerabilities—she mouthed the words but did not seem as
concerned about her capacities as not wanting to be taken for granted.
When asked what made the figure sad or depressed, she began as she did
before with “big issues,” referring to experiences “even closer to her own
life, like people smoking, casual sex, drinking,” which she then referred to as
things that the world sees as acceptable. Because this sounded vague I asked
how these things were closer to the person’s own life, to which she said—also
vaguely—that they referred to depression. The long hesitation that followed
may have represented confusion about what she meant herself, or perhaps that
she had revealed too much by overidentifying with the figure she drew, and the
hesitation may have reflected composing herself after a momentary loss of dis-
tance. She may have been only partially successful at that because her initial “I
don’t know” was followed by reiterating “feeling she’s not good enough.” (Note
also that it was only at this point that Ms. A. said “I could have done better
. . .”; although it may have been an innocent, commonly made slip and may
therefore not merit special interpretive significance, it is nonetheless worth not-
ing that it occurred and at what point it occurred.)
The vague non sequitur (“part of her self image”) seemed to suggest that
something concerning depression was sparked here, with a loss of distance
between herself and the figure she could not entirely overcome. She repeated
the same concern about “world issues . . . like I could have done better” when
asked about the figure feeling angry. Ms. A. did not appear to differentiate at
all among various affect states—which by itself is not very uncommon for many
people—but she did convey repeatedly that she experienced concerns about
feeling inadequate or not up to meeting her own or others’ expectations. She
attempted to isolate or externalize personal concerns by expressing altruistic-
sounding concerns about the unhappiness or problems of the world. When it
struck close to home, however, her defenses seemed to falter as she fumbled
in an attempt to reconstitute herself and return to the poised manner—albeit
reserved or distant—that characterized her demeanor throughout most of the
testing. This was reflected in her opening description of the female figure and
in her closing comment about what the figure was doing in the picture: “bright,
lovely, appreciating beauty . . . enjoying everything around her.”
I was left wondering how much of a facade a statement like “she’s really a
joyous, happy person” covered over a depression as Ms. A. fumbled to con-
ceal what was difficult for her, hidden behind the allusions to the problems of
the world and people’s lives to which she repeatedly returned. It was tempting
to wonder whether the drawing with the figure’s hands in its pockets repre-
sented her concerns about the figure’s efficacy or competence and whether the
eyeglasses represented not seeing clearly. However, I generally emphasize the
content of patients’ verbalizations more so than details about their drawings to
provide a more nuanced impression about internal affects and defensive posi-
tions to better understand a person’s psychological life.
Whereas the female figure was characterized as a young person or adoles-
cent girl wise beyond her years, Ms. A.’s male drawing seemed to be that of a
pre-adolescent boy who was not particularly mature. He was also “average”
in contrast to the female figure who was “smart . . . observant . . . a thinker”;
although he covered up his intelligence, it seemed more underdeveloped than
the female’s smartness. The male was less defined and nuanced (“the class
clown, that pretty much sums him up”) although Ms. A. imagined a darker side
to this jokester boy. Nevertheless, Ms. A. conveyed the impression that she may
perceive women as being more accomplished or psychologically robust than
men, and that young girls were wise beyond their years—or needed to become
that way—whereas young men or boys remained immature far longer.
Considered together, Ms. A. put forth what seemed like a determined or pos-
sibly even willful streak that might seem unconventional to some but more accu-
rately might represent her need or desire to have things her own way. Thus, she
did not seem unconventional for the sake of appearing negativistic or contrary.
Ms. A. appeared conflicted or uncomfortable about feeling competent—if not
actually superior—which appeared to coexist with feeling uncertain or unsure
of herself, wary that any vulnerabilities she might feel slipping through would
be evident to others and even to herself. Although at this point still speculative,
Ms. A.’s wariness may have extended to include a concern that other people
might undermine her sense of surefooted confidence if not actually exploit a
vulnerability, perhaps to make her come around to behaving differently. Of
course, a hypothesis like this must await confirming or disconfirming evidence
as the evaluation proceeds; nonetheless, there is no reason not to entertain this
potential interpretation because if supported further it would constitute just the
kind of subtle point that could easily be overlooked among other test findings.
Curiously, neither Figure Drawing was that of an adult, which raised a question
concerning where adults came into play in her life.
Rorschach
Ms. A. produced a rich, productive Rorschach protocol, one that was as
idiosyncratic as her Figure Drawings. I first present a discussion of the
Figure 2.3 Rorschach location sheet

Comprehensive System (CS) Structural Summary and R-PAS interpretation,
followed by a sequential card-by-card analysis of thematic content. Figure 2.3
shows the location chart for this patient’s Rorschach.
CS Interpretive Findings
The Sequence of Scores is shown in Figure 2.4 and the main interpretive sec-
tion of the Structural Summary is presented in Figure 2.5. This productive
Card Resp. Location Loc. Determinant(s) and (2) Content(s) Pop Z Score Special
No and DQ No. Form Quality Scores
I 1 Wo 1 FYo A P 1.0 MOR
2 Wo 1 C’Fo A P 1.0 MOR
3 WSo 1 Fo (Hd) 3.5 GHR
4 Do 4 Fo Ad INC
II 5 Wo 1 FYu A 4.5 MOR
6 DdSo 99 FY- (Hd) 4.5 PHR
7 D+ 6 Mao 2 A 3.0 COP, FAB,
GHR
8 DdS+ 99 FVu Ls,Id 4.5
III 9 Do 3 Fo A
10 Do 9 FC’o 2 H P INC, GHR
11 DSv/+ 8 YF- Na 4.5
12 DdSo 99 F- A,An 4.5 FAB2,
ALOG, INC
IV 13 D+ 7 Mao (H),A P 4.0 MOR, PHR
14 Do 1 Fo Ad
15 Ddv 99 VF- Bt
V 16 Wo 1 FY.FMao A 1.0 MOR, INC
17 Ddo 99 F- 2 A INC2
18 Do 4 Mau Ad INC, PHR
VI 19 Do 1 FY- A MOR, INC
20 Ddo 22 FYo Art
21 Ddo 26 Fu Ad
22 Wo 1 Fu Bt 2.5
VII 23 DSv/+ 7 Fu Na 4.0
24 D+ 6 Ma.FDu H,Cg,Ls 1.0 GHR
VIII 25 Do 6 FC- Cg
26 Dd+ 99 FMa.FC’o A,Id P 3.0
27 Do 2 Fu Ad
28 Do 6 FC- An
29 Do 4 F- Cg
IX 30 DS+ 8 FV- (H) 5.0 DV, PHR
31 Wv 1 C Art
X 32 Do 3 Fu Id
33 Do 2 CF- 2 A ALOG
34 Do 1 Fu 2 A
35 Dv 9 C An
36 Dv 6 C.Mp Hx AB, PHR
Figure 2.4 CS Sequence of Scores

RATIOS, PERCENTAGES, AND DERIVATIONS
R = 36 L = 0.57 FC:CF+C = 2:4 COP = 1 AG = 0

-------------------------------------------------------------- GHR:PHR = 4:5
Pure C = 3
EB = 5 : 6.5 EA = 11.5 EBPer = N/A a:p = 6:1
SumC’ : WSumC = 3 : 6.5 Food = 0
eb = 2 : 13 es = 15 D = –1
Adj es = 9 Adj D = 0 Afr = 0.50 SumT = 0
-------------------------------------------------------------- S = 7 Human Content = 6
Pure H = 2
FM = 2 SumC’ = 3 SumT = 0 Blends:R = 4 : 36
m = 0 SumV = 3 SumY = 7 PER = 0
CP = 0 Isolation Index = 0.22
--------------------------------------------------------------
a:p = 6 :1 Sum6 = 12 XA% = 0.61 Zf = 16 3r+(2)/R = 0.14

Ma:Mp = 4 :1 Lvl-2 =2 WDA% = 0.64 W:D:Dd = 7:21:8 Fr+rF =0
2AB+(Art+Ay) = 4 WSum6 = 38 X-% = 0.31 W:M =7:5 SumV =3
MOR = 6 M- =0 S- =4 Zd = –1.0 FD =1
P =5 PSV =0 An+Xy =3
M none = 1
X+% = 0.33 DQ+ =6 MOR =6
Xu% = 0.28 DQv =4 H:(H)+Hd+(Hd) = 2 : 4
PTI = 3 DEPI = 6 CDI = 1 S-CON = 7 HVI = Yes OBS = No
Figure 2.5 CS Structural Summary
record of 36 responses occurred in a context of neither an overstimulated nor

a particularly reserved degree of emotional engagement, although it indicated
that this patient was likely to experience appreciable affective disturbance. The
protocol was consistent with the presence of a prominent depressive syndrome.
Ms. A. showed a considerable degree of stress that seemed to impact her affect
life and also intruded on efficient thinking and perception. She might not be
fully aware of the extent to which agitation or depression affected her life, in
part because defenses might operate to insulate her from disturbing internal
emotion states. As a result, Ms. A. could be relatively disinclined to recognize
affects, sometimes attenuating their meaning and keeping emotions at a super-
ficial distance because she might have difficulty modulating emotional reac-
tions. She could process emotion states intellectually at some times and she also
could show intense outbursts that might seem immature or overreactive.
This disposition suggests that this patient’s depression-prone personality—par-
ticularly if accompanied by syndromal depression or heightened concern about
suicidal ideation or behavior—would make her more vulnerable to reacting
reflexively and possibly impulsively when a measured approach might be more
advantageous. This would understandably warrant cautious alertness to clinical
signs of mood dysregulation should life circumstances or the clinical intensity of
her reactions reach a sufficient level of concern. However, Ms. A. did demon-
strate some capacity to stand back and reflect on situations that might potentially
create problems for her. Nevertheless, effectively harnessing this kind of flexibility
might at some times be compromised. Suicidal ideation or potential warranted
watchful attention; however, on balance and in consideration of the entire test
protocols overall I did not regard this to be a prominent clinical concern.
This patient seemed to experience substantial intrusive emotional turmoil,
including oppositional resentfulness or anger, although she might not be aware
of such impinging affect states. Most of the time this patient’s coping mechanisms
were adequate, thus permitting her to manage life stresses well enough, in part by
remaining unaware of problems maintaining affective equilibrium or self-control.
Being somewhat removed from affective experience might create the impression
that Ms. A. had sufficient resources to manage stressors relatively well, albeit
not without some cost because persistent irritating affect states also were present,
such as dysphoria or tension, feeling helpless or unable to control situations, and
resentment or anger. This patient also appeared somewhat cautious about affec-
tive experience, making her disinclined to want to experience her emotional life
in depth and preferring simplicity and avoiding complexity. Her reserve also
reflected concerns about modulating affect states and containing their intensity.
Ms. A. lacked a consistent, well-defined style of coping which further compro-
mised her capacity to adapt flexibly to distress. She vacillated between thinking
through problems and having affective resources productively available to man-
age life problems, which left her prone to react unpredictably. Ms. A. seemed
to ignore her own needs, perhaps stemming from diminished self-esteem as she
could be critical of herself and thus feel undesirable or depreciated. She also
appeared vulnerable to problems maintaining a stable identity, which might
include limitations in the capacity to see others as whole objects. Self-esteem
and identity problems were likely to constrain her relationships with others in
addition to magnifying the distress she could feel about herself, contributing to
dysphoric mood. Moreover, this patient’s self-esteem disturbance extended to
include perceiving bodily functions as damaged or not functioning optimally.
Ms. A. also revealed a hypervigilant personality style, disposing her to feel
distrustful of others as she experienced her world as potentially threatening.
Keeping her distance from others, arising from an overly cautious if not actually
suspicious nature, caused Ms. A. to be particularly self-protective and as a result
reserved and guarded. She seemed much of the time to keep her own coun-
sel, out of a disinclination to allow herself to be open or to feel safe with many
people. Consequently, it was not easy for her to allow herself to depend on or
become intimate with many people. As a result, other people probably regarded
Ms. A. as hard to get to know and emotionally distant or aloof. While she had
neither predominantly antagonistic nor cooperative or rewarding relationships
with people, her relationships with others were more likely reserved or distant.
This patient devoted attention to scrutinizing events in her surround,
although she was inclined to attend to situations inefficiently. At times, she
might disregard potentially important information because she preferred to
avoid complex aspects of life. Ms. A. also was limited by a tendency to be con-
tent with imprecise or not fully articulated aspects of her experience, which
inclined her to favor dealing with relatively uncomplicated, clear-cut aspects
of situations. As such, a relatively casual approach to taking in what went on
around her would also lead Ms. A. to appear too uncritical of situations to
which she might more profitably attend. Paradoxically, this inclination seemed
antithetical to her hypervigilant style of scrutinizing situations around her.
Ms. A. could be prone to misinterpreting meanings of events and others’
motivations such that distortions might compromise good judgment. She also
was inclined to feel generally pessimistic and to anticipate unfavorable events,
which might intensify depressive affect and magnify inaccurate impressions
about people and situations. Disposed in this way to misinterpreting situations
and emphasizing negative outcomes, this patient’s thinking could appear illogi-
cal and difficult to comprehend. She was also prone to intellectualize troubling
emotions and this patient’s thinking tended to be scattered and inflexible, add-
ing to her difficulty thinking logically and adapting to stressful events in life.
R-PAS Interpretive Findings
ODL R-
Cd # Or Loc Loc # SR SI Content Sy Vg 2 FQ P Determinants Cognitive Thematic HR
(RP) Opt
I 1 W A o P Y AGC,MOR,MAP
2 W A o P C’ MOR,MAP
3 W SI (Hd) o F GH
4 D 4 Ad o F INC1 AGC
II 5 V W A u Y MOR,MAP
6 Dd 99 SI (Hd) - Y PH
7 D 6 A Sy 2 o Ma FAB1 COP,MAH GH ODL
8 Dd 99 SI NC Sy u V
III 9 D 3 A o F
10 D 9 H 2 o P C’ INC1 GH
11 D 8 SI NC Sy Vg - Y
12 V Dd 99 SI A,An - F INC1,FAB2,PEC ODL
IV 13 @ D 7 (H),A Sy o P Ma MOR,MAP PH
14 D 1 Ad o F
15 V Dd 99 NC Vg - V
V 16 V W A o FMa,Y INC1 MOR,MAP
17 V Dd 99 A 2 - F INC2
18 V D 4 Ad u Ma INC1 PH
VI 19 @ D 1 A - Y INC1 MOR,MAP
20 Dd 22 NC o Y
21 Dd 26 Ad u F
22 V W NC u F
VII 23 V D 7 SR NC Sy Vg u F
24 V D 6 H,Cg,NC Sy u Ma,FD GH
VIII 25 V D 6 Cg - FC
26 > Dd 99 A,NC o P FMa,C’
27 V D 2 Ad u F
28 V D 6 An - FC Pu
29 V D 4 Cg - F
IX 30 D 8 SI (H) Sy - V DV1 PH
31 W Art Vg n C
X 32 V D 3 NC u F AGC
33 V D 2 A 2 - CF PEC
34 D 1 A 2 u F
35 V D 9 An Vg n C Pu
36 V D 6 NC Vg n Mp,C ABS PH
Figure 2.6 R-PAS Code Sequence

Copyright © 2011–2012 by the Rorschach Performance Assessment System, LLC (R-PAS).
Reproduced by permission. All rights reserved.
g
Raw Raw Cplx. Adj. Standard Score Profile
Domain/Variables Abbr.
Scores %ile SS %ile SS CS
Admin. Behaviors and Obs. 60 70 80 90 100 110 120 130 140
Pr 0 Pr
Pu 2 Pu
CT (Card Turning) 20 97 128 CT
Engagement and Cpg. Processing 60 70 80 90 100 110 120 130 140
Complexity 96 86 116 Cmplx
R (Responses) 36 94 123 86 116 R
F% [Lambda=0.14] (Simplicity) 36% 42 97 53 101 F%
Blend 4 61 104 19 87 Bln
Sy 7 64 105 19 87 Sy
MC 11.5 89 118 66 107 MC
MC - PPD –3.5 34 94 40 96 MC-PPD
M 5 75 110 43 97 M
M/MC [5/11.5] 43% 33 93 34 94 M Prp
(CF+C)/SumC [4/6] 67% 68 107 68 107 CFC Prp
Perception and Thinking Problems 60 70 80 90 100 110 120 130 140
EII-3 1.6 95 125 93 122 EII
TP-Comp (Thought & Percept.Com...) 2.2 92 122 91 120 TP-C
WSumCog 38 99 137 99 133 WCog
SevCog 4 99 135 99 135 Sev
FQ-% CS FQ 31% 88 118 88 112 FQ-%
WD-% CS FQ 25% 82 114 81 113 WD-%
FQ-% CS FQ 33% 9 80 13 83 FQo%
P 5 44 98 31 92 P
Stress and Distress 60 70 80 90 100 110 120 130 140
m 0 16 85 16 85 m
Y 7 99 134 98 132 Y
MOR 6 99 134 88 132 MOR
SC-Comp (Suicide Concern Comp.) 6.3 91 120 82 113 SC-C
Self and other Representation 60 70 80 90 100 110 120 130 140
ODL% 6% 30 92 19 87 ODL%
SR (Space Reversal) 1 58 103 50 100 SR
MAP/MAHP [6/7] 86% 91 121 92 121 MAP Prp
PHR/GPHR [5/9] 56% 72 109 78 108 PHR Prp
M- 0 32 93 32 93 M-
AGC 3 52 101 39 96 AGC
V-Comp (Vigilance Composite) 5.0 91 120 25 110 V-C
H 2 49 100 21 87 H
COP 1 58 103 48 99 COP
MAH 1 64 105 41 96 MAH
Figure 2.7 R-PAS Summary Scores and Profiles—Page 1

The Sequence of Scores is represented in Figure 2.6, followed by the Page 1

variables in Figure 2.7. The complexity variable was above average; however, it
may not have warranted adjusting levels of other variables for this degree of psy-
chological activity. Nonetheless, Ms. A. sometimes might behave unresource-
fully when the degree of complexity she could engage exceeded her ability to
manage her life effectively. She probably had difficulty keeping herself from
becoming too freely drawn into complex situations developing around her, and
a heightened level of mental energy driving her active imagination could some-
times lead her to bite off more than she might be able to chew. Although she
showed a considerable degree of intensity or vitality as she became involved
with situations or people in her life, she more often than not became engaged in
ways that undermined her efforts and ultimately proved maladaptive.
R-PAS also suggested considerable difficulty maintaining reality-oriented
thinking. Judgment was compromised and this patient showed an impaired
capacity to effectively organize her thoughts. Even in the absence of overt
psychosis, the level and pervasiveness of disordered thinking seen in this record
would nonetheless be regarded as problematic.
Feelings of helplessness and generalized distress and dysphoric mood were evi-
dent; however, Ms. A. did not appear on the verge of losing self-control, although
it might come perilously close to such a point at some moments. Seeing herself
as flawed or damaged, compounded by a sense of helplessness, this patient was
prone to be on guard against potential threats. She also showed signs of appreci-
ably disturbed self and object relations, and as a result Ms. A. seemed unlikely
to readily interact with others maturely or congenially. There also was evidence
suggesting a quality of wary distancing in her relationships with people.
Thematic Content Interpretive Findings
Card I
1. It’s like a bat or something that was It’s more like hands or little mittens than
smashed. claws. Wings here, the middle part. It’s a
Just one answer? bat because of these wings.
It has little claws. (Smashed) If it was smashed that’s
what it would look like.
(What about the card makes it look
smashed?) The image is so smudged,
like something that was smashed.
(Smudged) The coloring isn’t fine, and
the outline is distorted.
(Coloring . . . outline?) The outline’s
kind of rigid, not like a straight drawing,
it’s messy. There’s dots like when some-
thing’s painted and they didn’t clean up.
(Smudged) The color, it looks kind of
pressed. The outlining especially—messy.
Just pressed. If it wasn’t it would be more
oval but this is messy, like it’s pressed.
——————
Like a gargoyle. A negative flying creature
that’s going to do harm. Like a destroyer.
(Smashed) One less demon. It doesn’t
mean much because there are millions,
zillions of them. Death, annihilation.
Ms. A. began conventionally enough with the percept of a bat, although the
morbid (MOR) special score seemed to announce from the very start that even
a casual impression of conventional experience was fraught with malevolent
overtones. It was not possible to know what her question “just one answer?”
meant this early during the Rorschach; however, the question suggested look-
ing for direction about how much or how little to say. Commenting that the
bat’s claws were little also suggested vulnerability.
She began the inquiry to this response by referring again to the claws, further
immobilizing the injured bat whose claws, as she had already indicated, were
too small to do it much good. Accordingly, she turned the claws into hands or
little mittens—not only a strained incongruous combination but, even more
important, the image of mittens suggested what little children wear over their
hands to protect them from the cold. Moreover, mittens are not like gloves: the
hands cannot do too much because the fingers are relatively immobilized.
It was difficult to clarify how Ms. A. saw the bat as smashed; at first she said
it was “smudged”—perhaps suggesting shading—but her vague comment that
the “coloring is not fine” and “it’s messy . . . they didn’t clean up,” and her vac-
illating between the form characteristics and the “color” created an impression
that she may have perceived shading while at the same time trying not to let
the shading quality into her experience, and by inference, to thus defensively
disavow or deny its affective import as helplessness or dysphoria. Certainly, the
content of her association during a testing-the-limits inquiry did not detract
from the impression that this patient was communicating a distressing concern
about her internal experiences. Considered alongside her vacillation about
a possible determinant such as diffuse shading contributing to the smudged
appearance, it was not difficult to grasp that she would do whatever she could
to avoid experiencing something associated with causing harm or destruction.
Moreover, Ms. A. volunteered not only that she perceived danger, but also that
there was no getting rid of it. As she implied when saying there are “zillions” of
malevolent demons, it must have felt to her that an escape was not possible.
The difficulty of pinning her down seemed to lead to a fruitless wild goose
chase as I attempted to clarify in the inquiry whether shading was indeed a
determinant. It probably should have been resolved after one or at most two
inquiry questions, but Ms. A. was not to be pinned down that easily. The
approach I took did not clearly resolve the question about shading but it did
lead to recognizing something important about Ms. A. that might not have
emerged otherwise: this was a woman who both alludes to distressing aspects of
her experience while at the same time tries to deny or expunge such affective
experiences, and trying to pin her down mainly provoked a need to retrench
and redouble her defensive efforts. Ms. A. defiantly would not budge, as she
seemed most comfortable flitting about the edges of her affective life, neither
settling into affect states she may not be comfortable with nor negating such
experiences either. Staying on the periphery allowed her to have a taste of
uncomfortable affect experiences she was not sure about without having to
commit to them. The stage was thus set with this very first response on the Ror-
schach. This quality of alluding to potential determinants characterized most
of what followed throughout the remainder of the Rorschach examination.
Further, my trying to seek clarification and her stubborn (but as I later came to
see, adaptively self-protective) attempts to resist this effort became a transfer-
ence-countertransference-like configuration predominating throughout much
of the assessment, certainly at least during the Rorschach where precision is
the main raison d’être that guides the conduct of the inquiry. I may have fallen
into a trap that I set for myself and I also may not have realized what was going
on until later on as I began to analyze the clinical findings. Although I was left
wondering why the inquiry seemed initially so fruitless, engaging in this trans-
ference-countertransference dance but then understanding what happened and
trying to make sense of what transpired between us ultimately enabled me to
comprehend something important about Ms. A. I would not conclude that this
dynamic could not have emerged in other ways on the Rorschach or on other
personality tests, but I would venture to guess that the richness of the dynamic
that transpired and the interpretive use I will make of it below would probably
not have emerged in quite the same affectively salient way in a more traditional
context. However, there can be little doubt that the content-derived interpreta-
tion that emerged from my understanding of the response process bears careful
attention. Perhaps some Rorschach clinicians might consider the manner of
inquiry I pursued to deviate too far from the objective of the instrument’s pur-
pose; however, I would argue that indeed this goes straight to the heart of what
is best about the Rorschach.
2. A really ugly butterfly that was The wings at the side. Because it’s dark.
smashed. When I think of a butterfly, I think of
Can I turn it? a lighter, brighter color. That’s why it’s
ugly. This isn’t an ugly color but for a
butterfly it’s ugly. It’s smashed, like it
was pressed down—even the white part
where it was pressed if they weren’t care-
ful. Mainly the wings, though.
(Dark) These splotches remind me of
blood, which reminds me of death. Like
creatures that are negative. Just the splat-
tering, the color.
(Splattering) The way the artist
splashed the paint. I don’t know if he did
it deliberately—just the specks around the
image.
In this second response to Card I, Ms. A. continued the theme of a smashed

object, thus generating the unusual situation of two morbid special score codes
in the first two Rorschach responses. In her first response—despite the MOR
code—this patient attempted to do all she could to seemingly run away from
what she said; however, in her second response she appeared unable to manage
this defensive operation successfully. Her butterfly was not only smashed but it
was also ugly, and her inquiry—which was entirely made up of her spontaneous
initial clarification when the response was read back to her—was nearly totally
dominated by her verbalization about the ugly dark color and the smashed,
pressed down appearance of the butterfly. She began by indicating that form
was a determinant; however, Ms. A. quickly mentioned the darkness and she
became so nonplussed by the dark, ugly aspects of her response that she seemed
to lose her focus. (Although not technically a deviant response, her lengthy and
spontaneously offered verbalization came quite close to becoming one.) It sug-
gested to me that she became so thrown off her guard that she seemed to need to
expend much effort to get on more solid footing; hence her closing comment—
seeming to come out of nowhere—that the response was determined by “mainly
the wings.” I thought that it actually represented how she was distracted or more
to the point, psychologically stunned by the dark, ugly quality of the butterfly.
Thus caught off balance, Ms. A.’s somewhat odd, out-of-context “mainly the
wings” comment seemed like an attempt to reconstitute herself.
In line with this formulation, note also that Ms. A. perceived the inkblot as an
artist’s rendering. She commented that the artist might not have been careful
about the drawing, which resembled her noting in her first response that the
drawing was messy, as though someone did not clean up properly. This patient
seemed to be conveying in these opening responses that she might not feel
herself on safe ground. Considered alongside the unusual occurrence of two
morbid special scores so very early on, Ms. A. seemed to emphasize the neces-
sity of exercising caution and being attentive to potential danger. Looked at in
this way, it would not be difficult to understand why she asked “Can I turn it?”
at the end of the response phase.
When queried about darkness as a determinant, she referred to “splotches,”
suggesting diffuse shading; however, she spontaneously commented that she was
reminded of blood and death. This sounded like an association to the affective
quality so strongly provoked by this card. Although her association sounded off
task, surely it was not tangential or irrelevant in any meaningful sense because
it indicated how powerful a stimulus this card was for Ms. A. Bordering on the
outskirts of being a color projection because of the strong connection between
blood and the color red, this reference did not appear to connote a perception
of chromatic color on this entirely achromatic card, particularly in light of her
earlier reference to “lighter, brighter color” as how she thought about butterflies
but not how she actually perceived the butterfly she described in this response.
I suspect that most examiners would struggle as I did deciding between ach-
romatic color and diffuse shading. Ms. A. seemed more destabilized on R2
than on R1, and as such this response may have represented the weakening of
a defense. Her evasiveness on R1 concerning shading or color gave way to a
particularly confusing verbalization on R2 that seemed to be all over the map,
so to speak. I suspected that the confusion I encountered about coding this
response may have reflected confusion she experienced about her own affective
experience. Thus, apparently no longer able to evasively withhold articulating
something about the coloration on the card and by inference an affective state
of some type, Ms. A. seemed to vacillate between potentially referring to ach-
romatic color and even chromatic color as color projection, finally settling—or
perhaps I should say that I finally settled—on a coding of C´F, representing on
the one hand affective constraint (which in the final analysis may not accurately
reflect the chaotic, all over the map affective experience that was actually trig-
gered) and on the other hand form as a secondary determinant.
This patient may have attempted to deliver this second response much like
her opening response, representing another exclusively form-based or at least
form-dominant percept. But it was possible, though still a speculative conjec-
ture, that this intention threatened to get away from her as she appeared to lose
her hold on the form-dominant determinant structure. Thus, her meandering
verbalization on the inquiry may have overwhelmed her struggle to suppress
an affect state she found difficult to tolerate, and in so doing also undermined
what I suspected would have been her preference to produce a form-influenced
response. As part of this process, her strained reference to blood and death
lent yet a further indication about the considerable sense of danger lurking
rather close to this young woman’s vulnerable grip on her psychological capaci-
ties—despite the superficial and deceptive presence in these first two responses
of Card I’s two most conventional and accordingly popular (POP) percepts.
3. The top of a mask for a costume The parts for eyes, and the stick is miss-
party, that you hold on a stick like a ing. I didn’t pay any mind to these white
masquerade. spaces on the bottom where the eyes would
be.
——————
Beautiful gowns, beaded gowns, danc-
ing or waltzing. A fine evening. Refined
people.
Beautiful gowns, waltzing, refinement: one would hardly think this was the
same patient discussed above! Granted, this was an association not from the
formal Rorschach administration but rather from a testing-the-limits inquiry
conducted after the formal inquiry was completed. Nonetheless, it came as a
surprise and surely it cannot be ignored. Coming after this patient’s two previ-
ous responses in which there were suggestive indications of this young woman
as a vulnerable, threatened person, the association to beautiful gowns and a fine
evening of dancing seemed to demonstrate how Ms. A. had managed to trans-
form her fearful, blood- and death-infused experience of herself and her surround
to “refined people . . . a fine evening”—just by putting on a mask. However, her
“masquerade” may still belie the fragility her earlier responses suggested because
“the stick is missing,” thus making it more difficult to support the mask.
Moreover, Ms. A. emphasized eyes in her explanation of the mask. The
“parts for eyes” and the “missing stick” were indeed the main form features of
the mask; furthermore, she seemed to go out of her way to stress that the white
space also explained how she saw the eyes, although she took great pains to note
that “I didn’t pay any mind.” Indeed, it is always interesting to speculate about
the meanings of eyes in Rorschach responses. From the preoccupation with
looking or being seen in relation to paranoid hypervigilance to the communica-
tive implications of eyes as a window to personality (such as eyes darting, shut,
squinting, averting one’s gaze, frozen in dread, looking longingly, eyes as deep
wells of sadness, and the like—not to mention the numerous literary references
to eyes, especially in nineteenth-century romantic poetry), Rorschach enthu-
siasts are frequently drawn to allusions about eyes and seeing on the inkblots
and discerning their meanings. Ms. A.’s reference to eyes seemed to suggest
both the main reason for seeing this percept as a mask and also an emphasis
on disregarding “where the eyes would be.” Thus, the eyes were noted but also
ignored. It was, after all as she appeared to say, a costume party. As such, the
mask was part of a costume, and a masquerade represents pretending to be
someone other than who a person actually is. But a masquerade also is a game
that others know exists for the purpose of make-believe and gaiety.
That being said, what might be made of Ms. A.’s costume party mask (with
its handle or lorgnette missing)? Masks sometimes represent a defense opera-
tion, indicating either hiding oneself or attempting to disguise or protect oneself
from being seen or having something revealed. Ms. A.’s mask response, how-
ever, was hardly typical of most mask responses that sometimes contain clues
concerning the type of defended-against content. Her mask response reflected
a festive quality in its emphasis on a party or costume ball. Her subsequent
association pertained to beautiful beaded gowns and a refined or high form of
festivity, adding to the impression that this patient had in mind a grand or gala
event. Moreover, this response followed two responses characterized by mor-
bid content and, in one, associations to blood and death. Ms. A.’s masked ball
content may thus have signified defensively turning away from the distressing
material surrounding the earlier responses.
This response also might be regarded as an indication of a hypomanic or
possibly grandiose defense—not in the sense of hypomania or grandiosity
proper but rather as a disturbance characterized chiefly by destabilization or
dysregulation of mood. I am referring here to the lability of her affective states,
mainly calling attention to the wide oscillations of experienced affect this patient
appeared to display even on just these first few Rorschach responses. Thus, I
refer here not to acute mood dysregulation (such as that seen in primary bipolar
illness) but rather to a more subtle oscillation of mood more in keeping with that
associated with a subsyndromal variant of bipolar depression or “soft” bipolar
spectrum. As such, the mask was more than a mask for hiding; it was also a
mask for a costume gala. In the preceding response, the butterfly was not only
ugly and smashed; this patient seemed preoccupied with the morose nature
of the shading and the reference to blood and death suggested a considerable
depth of despair. What I am calling attention to is the difficulty this and similar
patients have modulating affective experiences.
4. Part of the body of an insect. That This line in the middle of the insect, these
long line where the feces would be. The claws or hands or mitts. This middle part
sides look like wings. The spaces are looks like the stinger at the end.
the only part that makes me think it’s (Line in the middle?) It’s straight
not. down the middle, that fine black line. It’s
just because it’s in the middle.
——————
A negative color, maybe. It’s not a bad
color, I like the color. It’s just so unattrac-
tive, like a pest you wouldn’t want around
you, that’s going to do harm.
This final response to Card I was puzzling, mainly because it seemed particu-
larly odd: only a part of the insect was seen, white space was mentioned but not
really used in forming the response, “claws or hands or mitts” seemed to reflect
a progressively bizarre distance from an insect appendage as Ms. A. tried to
think of the name for this part of an insect, and she described a line she saw in a
highly unusual way as “where the feces would be.” Curiously, though, the for-
mal scoring of this response reflected none of the oddness of her verbalizations.
Thus, although it is rare for patients to refer to a part of an insect rather than
to simply say an insect, that did not merit a special cognitive score. Further, had
Ms. A. referred to an appendage as a hand or mitt, it certainly would be coded
as an incongruous combination (and probably at Level 2 for the mitt); however,
by mentioning claws initially and apparently not changing from claws to either
hands or a mitt, these additional elaborations probably would not have been
treated as lapses receiving a special cognitive score—although just barely. And
finally, because this patient did not actually see feces but rather commented
that the line indicated where feces might be, this odd association also did not
receive a special cognitive score. Perhaps as a tangential thought it might have
been considered a deviant response (DR), but even as a tangent it did not seem
sufficiently off track to be coded in that way. One might say that Ms. A. some-
how managed to slip between the cracks as she produced a response that fell
short of indicating distorted or disordered thinking. However, certainly this
response conveyed a strained, bizarre quality quite different from any of the
verbalizations of the previous three responses thus far. I could imagine that the
people in this patient’s surround would at least sometimes be perplexed by the
oddness of things she could say, yet people would probably not go as far as judg-
ing Ms. A.’s thought processes to be grossly illogical or bizarre.
Considering her responses on Card I in sequence, Ms. A. may have shown
an affective disturbance and perhaps in addition some degree of disordered
thinking. She began by announcing an internal struggle she may barely have
recognized. She started off with a conventional enough response but she could
not seem to keep out of her perception a sense of helplessness or vulnerability
that was readily triggered. It also seemed that she defensively attempted to
isolate the distressing affect as if she could speak the words but somehow man-
age to circumvent the feeling. This defense seemed robust at first, as repeated
inquiry attempts to elicit clarification were met with an intensified defensive
effort. But as she continued, Ms. A. seemed unable to dispel a sense of faltering.
Perhaps moderately overwhelmed by the affect state that emerged and caught
her unawares, she vacillated between recognizing some degree of turmoil and
trying her best to find a way to expunge what she was feeling.
In the end, this patient seemed to cave in as the affect state appeared to
predominate. Possibly presaging what occurred in her third response, Ms. A.’s
reference to a “lighter, brighter color” suggested how far she might need to go
to deny the “ugliness” she was faced with, by imagining (in the sense of hoping
for) color on this achromatic card to appear and thus relieve her of the disturb-
ing affect she was rather clearly having difficulty acknowledging and manag-
ing. As she progressed to her third response, Ms. A. managed to momentarily
escape from the vulnerability she was probably experiencing by transforming
the mask (with its usual connotation of defensive concealment) into a prop for
a gala party (although the stick that supports holding up the mask was notably
“missing”).
It also deserves noting that this patient’s reference in the previous response
to being “careful”—and even in her first response when she referred to messi-
ness resulting from not being careful to clean up—suggested a need to carefully
maintain control of disturbing affect states. Referring to the form as “rigid” (in
her first response) was consistent with this impression. However, by the time she
reached the third response her solution seemed to have a quality of whistling
in the dark,2 representing the lengths she needed to go to in order to achieve
this brittle solution—which she herself may have sensed to be a “masquerade.”
But it was in her odd final response to Card I that Ms. A. revealed a more
ominous side of her struggle to preserve a workable psychological organization.
This strained percept thinly concealed how fragile her thinking could become.
It should be noted that the formal coding of this fourth response, despite an
incongruous combination (INC) code, raised no serious red flags despite the
odd content, suggesting perhaps that while Ms. A. might sometimes appear to
people as a so-called “peculiar duck” she managed to not go too far over the
edge in her occasionally distorted thinking.
Card II
∨ 5. This could be some sort of insect. It’s pressed down, so the wings wouldn’t
It was smashed, two antennae at the top, almost be there, because it’s pressed. It
the stinger. Two legs, very large legs, and has fat legs, almost like a baby’s legs—
the face. piggish kind of legs.
(Pressed down?) Because the colors

aren’t clear, like a grayish black, not a
solid black or a solid white. The colors
are mixed in.
(Fat legs?) How thick they are, the
plumpness.
——————
(Insect with fat legs?) Something
negative. There’s a scripture in Rev-
elations that talks about a horse with a
man’s face—a negative creature that’s to
come. So, it’s like a piggish hamster with
wings.
Although this time her insect response was a whole insect (now, though, with
a face), the pressed or smashed quality persisted and Ms. A. no longer could
avoid letting in the kind of psychological experience represented by diffuse
shading. This was now the third time in five responses that Ms. A. referred
to a smashed or pressed down look, which in at least two of these responses
stemmed from perceiving shading.3 Her odd-sounding reference to “fat legs
. . . like a baby’s legs . . . piggish” fell short of being coded as an incongruous
combination (INC), although her saying that it was “almost” that and “piggish”
(as if to say it seemed to look like that, but not that it was so) left some doubt
about this comment representing a genuine, unequivocal INC. Certainly it had
a strange ring to it, prompting my testing-the-limits follow-up question which
resulted in both an odd association to a biblical half man/half animal portend-
ing something ominous and yet another odd and even stranger association (“a
piggish hamster with wings”).
Ms. A. seemed to be losing her grip on herself in spite of the response sounding
for the most part within a normal range of experience. My main comment here
rests with her trying to maintain a hold on generally conventional experience that
seemed more fragile than it appeared at first glance. Further, her tentative hold
on herself seemed to be undermined and may have been progressively weaken-
ing, driven by a sense of helplessness or vulnerability about herself.
∧6. A man’s face and beard, and his The beard, nose and mouth area, the red
eyes. splotches could be eyes. Like a very unique
Santa Claus. A fictitious character or image.
(Beard?) Men usually have that rough
beard. It’s dark and kind of—not
rough—just dark.
(Rough?) That’s not really the word I’d

use.
(Unique Santa Claus . . . fictitious?)
No one has red eyes like this, so it would
have to be unreal.
——————
(Unique Santa Claus?) Nothing
much. I don’t believe in Santa Claus, so
just something to attract children. Like a
cartoon, a fake.
This response represented Ms. A.’s first human percept, although it must be
qualified as a fictitious human and the percept was of the face only. Interest-
ingly, she made reference to the roughness of the beard, but she quickly and
spontaneously backed away from that textural quality—and possibly needs
for contact with people along with it, conveyed in a stilted way that bordered
on sounding imperious (“that’s not really the word I’d use”). Previously, on
R3, Ms. A. also used a stilted expression that suggested distancing (“I didn’t
pay any mind to these white spaces”). Referring to the man as fictitious was
consistent with the quality of emotional distance surrounding this response.
However, the more specific reference to Santa Claus seemed to represent
another quality, and indeed what this patient had to say was nothing like
the benevolent, gift-bearing, or jovial Santa Claus one might have expected.
Instead, Ms. A.’s Santa Claus was dismissed not only as cartoonish but also
as a fake. She may even have had in mind a malevolent view of Santa Claus
as an invention designed to trick children, if one might want to speculate
whether her using the word attract might even have contained a duplicitous,
possibly sexual connotation.
Equally speculative, though still worth considering at a hypothesis genera-
tion stage, was this patient’s statement “I don’t believe in Santa Claus.” Who, of
course, would expect an adult to believe in Santa Claus, so why then would she
have felt the need to state that? Did it contain a wish, however, for something
more benevolent that she needed to depreciate and keep at some distance from
her customary expectations of other people? This hypothesis may not seem
quite so far-fetched in light of her original reference to the rough beard—which
she quickly took back—shortly after mentioning the Santa Claus image. Rough
surely seems antithetical to the common association of a soft or fluffy Santa
Claus beard. Moreover, a fake is hardly most people’s immediate association
to Santa Claus. Both associations may have revealed how Ms. A. felt she was
treated by people—and possibly men in particular, although it was too soon to
know for sure at this point—potentially revealing what Ms. A. may have craved
but defensively kept at some distance.
∧7. Two rabbits in some sort of patty- Their hands and legs.
cake or something. Their hands are (Slapping each other?) They’re hav-
together in the middle like they’re slapping ing fun.
each other. The red splotches look like
some sort of distraction, it doesn’t make
sense to me. Like wings, these polka dot
wings. It doesn’t make sense.
Probably the most notable feature of this response was Ms. A.’s verbalization
at the end of the response proper, which may have signified confusion. I at first
thought it was a new response, but when I repeated this verbalization during
the inquiry she said,
I don’t know what this is—the red within the black. They used red and then they did the
black on top of it. (Wings, polka dot wings?) No, it isn’t. It just doesn’t make sense.
It appeared that she did not intend for this comment to be a response; how-
ever, the unusual nature of the verbalization was consistent with her other odd,
strained verbalizations that while raising an eyebrow nonetheless fell short
of indicating unequivocally disordered thinking. Indeed, when Ms. A. talked
about red splotches as a distraction, she may have been intimating that she could be
prone to being distracted by details of the blots she had difficulty ignoring. She
seemed lulled and distracted by the red areas superimposed on the black-gray
areas which led to a quasi-response that perhaps represented an attempt to stay
with the perceptual attraction it held for her. But in the end, she pulled herself
out of the distraction by rejecting her potential response of wings or polka dot
wings because it “doesn’t make sense to me.”
Apart from this not insignificant occurrence, the response itself was mainly
notable for its simplicity. This patient did not become absorbed by the percept
in any particular way, and the form and movement determinants (accompa-
nied by the cooperative nature of the movement) were not unusual. “Slapping
each other” sounded as if it could have aggressive intent; however, on inquiry
it appeared not to be the case. Nevertheless slapping, even in a playful context,
is a forceful word and although it may not have had aggressive intent, Ms. A.
still was describing energetic play, which might be another indication of hyper-
thymic temperament, albeit probably a modest indication.
∧8. This could be a pathway, like green- Here’s the tower, the path is narrow and
ery or parts of a landscape. A tower here, then it widens like looking at it from a
and a doorway. distance. And the dark area’s a landscape
or trees where it’s dark and now it’s com-
ing into the light.
(Greenery?) That same area.

(Doorway?) It’s long, it’s at the bottom
of what seems to be a tower.
(Dark . . . coming into the light?) As
it’s further along it’s darker, and as you
come closer it gets brighter and brighter.
——————
A kingdom—not a negative place. (Q)
Some place free, with no distractions like
a city.
Here Ms. A. perceived a scene in perspective, making use of shading features to

suggest both a landscape and gradations of lightness. It was the first of a large
number of vista responses, a specific type of shading response, in Ms. A.’s pro-
tocol—three in total—suggesting self-depreciation. The reference to a tower
caught my attention, thus leading me to test the limits. It seemed that Ms. A.
had in mind an idyllic, fanciful quality such as a fairy tale world of kingdoms
and towers where all is “free” (by which she seemed to mean uncomplicated
and easygoing, and possibly also serene). Ms. A. volunteered the association
to distractions such as a city, and of course her comment or quasi-response
just preceding this one also referred to a distracting element on Card II—the
red “splotches”—which she ultimately dismissed as not making any sense. Her
attempting to eliminate distractions seemed to be continuing, distractions that
appeared to perturb her possibly by threatening to destabilize the adaptation
she struggled mightily to preserve. I wondered whether her referring to distrac-
tions was a euphemism for affective instability or possibly, mindful of the vista
coding on this card, devaluation.
Overall, Card II revealed just how much effort it cost Ms. A. to maintain
what looked like a tenuous hold on affective equilibrium. Even more so than
on Card I she seemed to be struggling to steady herself in an attempt to remain
afloat. On Card I, Ms. A. essentially announced her vulnerability in her initial
response as she resisted what felt to her like being pinned down. The defensive
effort she displayed began to wear down as her responses proceeded, straight
through to the rather odd quality of her last response on Card I. If her defensive
efforts were beginning to weaken even by this point, they clearly continued on
Card II in which none of her responses was without some indication of further
signs of struggling, either in the form of strained thinking or feeling that she was
combating affect states experienced as “distractions” she tried to drive away.
Consistent with and following upon the main clinical indications from the
Structural Summary and R-PAS, the detailed analysis of thematic content and
sequence of responses as elaborated above provided further elaboration of this
patient’s affective experience. In particular, Ms. A. barely had a moment when
she was not experiencing vulnerability as she tried to diminish the impact of
intruding but unrecognized affective states. She seemed unaware of the con-
siderable effort it cost her to keep away what she preferred to think of as dis-
tractions. This patient succeeded insofar as her overtaxed defenses managed
to maintain that effort, but the toll it took was starting to get the better of her,
even by Card II. She also showed several cognitive anomalies and other spe-
cial scores in addition to MOR (such as AGC and MAP (mutuality of auton-
omy—pathological form) in R-PAS). Although these special codes were clearly
apparent, they may have been of the sort that casual observers in her life might
overlook or disregard merely as idiosyncrasies.
Ms. A.’s productivity (eight responses on just these two cards alone) and her
elaborations of these responses were rather energetic in quality—the vividness
of her descriptions and fantasy material, the transformation of the mask from
something associated with disguise or defense to a gala ball, and the asides rich
with associative content but which seemed to annoy Ms. A. as distractions she
continually worked hard to disregard. What I here called an energetic quality
is what I also kept an eye on as the protocol further unfolded, entertaining the
possibility of some degree of affective dysregulation consistent with a “soft”
bipolar spectrum disorder.
Card III
9. A butterfly in the middle. The shape of it. I could have said a bow
tie.
10. These two dark figures could be The face, nose, the shape goes out—here’s
monkeys or foreign women like Africans, legs, and a hand or paws area. African
from the features. women because of the long neck and the
shape of the head and chest area.
(Dark figures?) Just because this other
one is pink and this is gray, that’s all.
(Monkeys or foreign women?) The
top half is mostly human-like but the bot-
tom half is more animal-like.
(How do you see it?) I’m seeing both.
Mostly human but the leg is animal-like.
The butterfly was her most conventional-sounding response thus far, but even
that was spoiled by her odd comment, “I could have said a bow tie.” Oddness,
however, is relative to the context in which it occurs. That is, no one would
think much about such a statement had it been said in ordinary conversation,
but as part of a Rorschach response it would be noticed because examiners do
not encounter such verbalizations very often. To my ear, it again fell just short
of being coded as a deviant response (DR); it would not be difficult to see why
other examiners might have coded this comment in just that way. Perhaps what
was more important than whether it was or was not a DR was taking note of just
how often this patient seemed to skirt the edges of odd or atypical thinking.
Ms. A. next produced a response that was reminiscent of her opening response
on Card I: she referred to dark figures or coloration while at the same time indi-
cating that the darkness was an incidental detail. She clearly emphasized form
on the inquiry and probably would not have mentioned the dark color spontane-
ously. Even the women were seen as African “because of the long neck.” When
I inquired about the dark figures, this patient seemed to indicate that she used it
to differentiate it from the chromatic color and minimized its significance further
by adding, “that’s all.” As on Card I, she seemed both to perceive dark color and
simultaneously to back away from it, tossing it off—indifferently, so I thought—as
if it had registered with her but from a distance and without any affective engage-
ment, which was not incompatible with the interpretive meaning of C´. There-
fore, just as she did previously on Card I, Ms. A. seemed to convey a defensive
posture suggesting having it both ways: she could be remotely aware of unsettling
affect states without having to really undergo or get too close to the actual affec-
tive experience. As she herself said, these were “foreign women”—the dark areas
that looked African—another oddly stated expression.
It should not be overlooked that Ms. A. was herself a black woman. Thus,
while it may be possible that she conveyed some distanced aloofness about being
black, her distancing should not be understood as simply that alone. Ms. A. was
mainly conveying her characteristic defensive posture about dealing with distress-
ing affect states. Although I did not pursue the matter of the dark areas vs. gray
color on inquiry, I could easily imagine that it would mainly have led to the same
kind of stubborn evasiveness I saw on the first response to Card I when I tried
to clearly establish whether she was using diffuse shading or achromatic color.
I doubt that I recognized in the moment that I had learned my lesson with her
about pushing too vigorously on inquiry, but I do wonder now whether some-
thing about that nevertheless registered with me, and that my reticence may have
been a reason why I seemed content to take what she said at face value.
Finally, Ms. A.’s monkeys or African women were half-human and half-ani-
mal, adding to the sense that there was indeed something “foreign” or alien and
not quite real about aspects of her affective experience. Perhaps it reflects how
far she had to reach to achieve the distanced but alienated comfort level she
probably needed to muster at many times.
11. Water here, because the shade is a Ripples, like water. The way it’s painted,
little lighter, like a reflection, sort of. it’s not consistent because there are spaces.
And it’s lighter, like something clearer.
This dark part could be like a reflection
of the people.
(Reflection of the people?) No, it’s

not a reflection. It doesn’t match up with
the way the heads are shaped.
∨12. A cat. The ears aren’t very large or The belly, the cat’s face, but cats don’t
evident. The hands are here, and on his have arms. This white splotch looks like
belly there’s a butterfly—a butterfly heart a cat’s nose.
or something. (Butterfly heart?) This is his heart
area because it’s in the middle. It’s like
his heart is gentle like a cat, which doesn’t
make sense. It’s a heart just because it’s
in the middle.
(Butterfly heart?) The heart of the cat
looks like a butterfly.
Both of these last two responses to Card III had a somewhat representational
or metaphorical quality about them: A perceived physical object became trans-
formed to convey an ephemeral quality. In the response of the ripples in the
water, the emphasis concerned impressionistic qualities of the water—none of
which could really be seen or were palpable. Spaces, lightness, clarity, a reflec-
tion-like quality—all of these images suggested a painting because the language
connoted how one might describe a work of art. Thus, spaces represented the
unevenness of ripples, lightness was used to connote clarity of an image, and
the dark features were used to suggest a reflective surface. Ms. A. may have
gotten carried away when she referred to “a reflection of the people” but when
I brought her back from her dreamy reverie, so to speak, by asking her what she
meant, she seemed to come back to reality and retracted the reflection because
the veridical perception did not fit well.
The words this patient used suggested apprehending an affective experience in
a visual, sensory manner. Note also that a moment ago I used the word “palpa-
ble” to convey the idea that the imagery Ms. A. lavished on this response could
almost be touched, such as feeling the water’s ripples or the lightness-darkness of
clarity and reflectiveness. I am not at all suggesting anything about texture as a
formal determinant (and I hesitate to even say palpable for this reason); however,
I do wish to call attention to this quality which occurred to me. I will only men-
tion this association at this point in passing, fully admitting that it is my associa-
tion entirely, and only weakly grounded at that in anything about the response
proper. But I bring it up because I have already mentioned and will return again
to the matter of Ms. A.’s distanced affective experience and how affects appeared
to be unarticulated in her psychological experience. Note also that this response
contained Ms. A.’s only reflection response. I call attention to this curious
confluence of factors as I continue trying to make sense of what this texture-less
protocol might indicate about this patient’s inner life, particularly given the three
vista responses she produced and her curious way of sometimes verbalizing but
also at other times seeming to dance around (or away from) diffuse shading and
the particular affect states these determinants typically represent.
Ms. A. followed this response with a credible enough percept of a cat, but
she seemed to casually include a detail of the card that she oddly called its
“butterfly heart . . . because it’s in the middle” and because the detail that she
called the heart resembled the shape of a butterfly. Moreover, she also referred
to the heart as being “gentle.” In a technical sense, the heart merits a special
score for inappropriate logic (ALOG in CS; PEC in R-PAS) for its location in
the middle as the rationale for its being seen as a heart and for its resemblance
to a butterfly as the main rationale for its being seen as a “butterfly heart.” The
“butterfly heart” also represented a fabulized combination (FAB2).4 Apart from
these serious cognitive special scores, this “butterfly heart” verbalization rep-
resented a careless loss of distance, by which I mean that Ms. A. seemed to be
speaking more about the heart as a metaphor for a gentle-natured cat than as
a veridical perception of a heart shaped in that way and located in a particular
position. She did not take the trouble to make it clear that she seemed to be talk-
ing metaphorically, but I think the main emphasis in this response needs to be
placed on the significance of expressing a tender affect—which seemed to slip
through—and which as a result may have caught Ms. A. off guard. (One also
could say that just about every response seemed to have caught her off guard
in one way or another!) After the affect slipped out, Ms. A. quickly seemed to
attempt once again to back away from her response (“[it] doesn’t make sense”)
as she focused on its location in the middle and the appearance of its form as
the basis for its looking like a heart and its being shaped like a butterfly. What
I also would like to emphasize here is that when vulnerable affect was aroused,
this patient temporarily could become immobilized, until she could manage to
defensively attempt to diminish its importance.
Card IV
13. It could be a giant. Two big feet The feet and the large body. The back of
on the sides, the hands are really odd— the giant because the animal he’s carrying
maybe it’s the back of the giant carrying we’re seeing from the back.
an animal he slaughtered, or two animals (Hands really odd?) They’re an odd
he slaughtered. [Holding card flat shape, but if it’s an animal he’s carrying
and parallel to desk surface, turn- then it’s just the way they’re hunched over
ing card] I’m trying to see if I can make as he’s carrying it.
out an image where the light is but the ——————
dark is very distracting and I can’t see He’s just trying to eat. He may not be so
anything in it. bad as his outward appearance.
14. Some sort of head, there’s eyes and Head, eyes or eyelids, whiskers or horns
two large whiskers or something. even.
(Whiskers or horns even?) Just
protruding out the side of the face under
where the eyes are.
(What kind of a face?) Some kind of
an animal.
——————
Like a snake, a very large snake.
∨15. This could be trees but I’m not It reminds me of greenery, this whole dark
sure where it starts or ends. part. But there’s no way to make an out-
line of trees.
(How do you see it?) Because it’s a
little darker and lighter, like when you’re
looking at land from up in a helicopter. I
didn’t see it at first that way, from a dis-
tance, but now I do when I try to explain
why it could be that way.
Ms. A. reported here a common enough percept for her first response to Card
IV—indeed a popular (POP) response—although seeing an unreal, oversized
human-like figure raised the possibility that once again her sense of vulner-
ability was readily triggered. This was her fourth human content response
thus far, three of which were coded (H) for human-like figures, and this one
was seen from behind. Seeing a misshapen hand led to her explanation that
the giant slaughtered an animal; thus aggression was incorporated in the
response. This response was her second human movement response, both
of good form quality, though like before it was compromised both by the (H)
content code and the presence of troublesome special scores (MOR and in
R-PAS, MAP also).
However, the plot thickens. Because of these concerns, I solicited further
elaboration by testing limits, and I was surprised to hear this patient talk about
the giant slaughtering its prey in a way that attempted to justify the aggression.
However, the tone was not apologetic or defensive; rather, it sounded as if she
were saying the giant had to get by in the world just like everyone else. Conse-
quently, the malevolent intention was rendered comprehensible in a way that
made empathizing with the giant not especially difficult.
It was noteworthy that Ms. A. immediately followed her comment about
slaughtering animals by holding the card in an idiosyncratic way, turning it at
different angles and explaining that she was trying to see something in a lighter
shaded area “but the dark is very distracting.” Indeed, more distraction! This
patient again experienced a sense of what she has now called “distraction” a
number of times; moreover, when she followed this by saying “and I can’t see
anything else” she seemed to be saying that she was stuck. Recall how difficult
it was to get her to clarify what I suspected was a dark shading feature on her
very first Rorschach response, and more generally how she seemed perturbed
by diffuse shading and what it appeared to stimulate affectively for her. It was
becoming increasingly clear that distraction meant something like intrusion to her,
and diffuse shading was particularly difficult for her to tolerate. Trying to get
away from it to see something else—as she wanted to do at this moment—was
unsuccessful. It also provides a useful reminder that not every instance of dis-
tractibility is attentional in nature.5
However, Ms. A. was not immobilized because she did manage to produce
two more responses on Card IV. The first of these (R14) was more or less con-
ventional; however, I was not content to leave it at that and chose to test limits
with this response, too. Again, I was surprised, although in a different way than
I was on R13: the animal head with whiskers was actually a snake. And her
final response to Card IV was a formless vista response—yet another surprise
considering that Ms. A. had so much difficulty dealing with diffuse shading in
her Rorschach responses.
The intensity of the affect suggested by diffuse shading may have in some
sense overcome Ms. A. because try as she might she could not summon up
any details to find form or structure in this response. She attempted to create
some distance for herself by noting dimensionality, although Ms. A. clearly
indicated that she did not perceive the dimensionality during the response
proper or at the start of the inquiry. I think it is fair to conclude that she
managed to find a way to recover from what perturbed her, at least to some
degree. But more than anything else it seemed that the story of Card IV for
this patient concerned attempting to deal with the overwhelming vulnerabil-
ity brought on by the giant-sized image of R13 that had slaughtered its prey.
Despite Ms. A.’s at first unsuccessful effort to find something in the light areas
to get away from the affect that seemed to overcome her and her attempt
to soften the impact of the slaughtering giant “who’s just trying to eat,” she
somehow managed to soldier on. But her animal head with whiskers (that
she managed to conceal seeing as a snake, until I tested the limits) and the
pure V coupled with “no way to make an outline” could not dispel the extent
to which she struggled to keep uncomfortable affect states at bay. I might
also add that her external composure gave no clue about what I could only
imagine was a deeply distressing albeit submerged and on the surface well-
defended sense of anxious perturbation.
Card V
∨ 16. A smashed insect—they all look The feet, ears, back of the head, wings.
like that. An insect with large wings, just (Smashed?) The way the colors aren’t
taking flight or already in the air. The clear or sharp—kind of smudged.
head has really large ears and the weird
feet.
∨17. Two peacocks. The head of a flamingo, large wings.

(Head of a flamingo?) It’s long and
thin.
(Peacocks?) They’re not as thin. (Q)
The head is a flamingo and the rest of it is
a peacock—part flamingo, part peacock.
——————
A fictitious character, something in a
movie. Like “Big Fish” where every-
thing’s exaggerated or odd. Things aren’t
real, like a girl with a cat’s body. It’s
weird but it’s fun, very interesting.
∨18. A horse’s foot and tail. The foot and tail and the rear end or leg,
like the horse is diving.
——————
Something weird again—not seeing the
whole body. And diving, which horses
don’t do, that’s also weird. But maybe
it’s pretty normal—just like it’s the
horse’s rear end and tail.
I frequently regard Card V as one that provides an opportunity for patients

to reconstitute, particularly if their responses to Cards I through IV suggested
that distressing psychological states were triggered. The unusualness of the
Rorschach task right from the start on Card I with its dark and gray tones,
the “blood” red pull of Cards II and III, and the sometimes perceived impos-
ing or looming figure on Card IV often stimulate psychologically compelling
affect states with little or no relief across these first four Rorschach cards. By
contrast, patients sometimes react to the relatively innocuous Card V as if it
provided some degree of relief, which is a quality (or perhaps even a capacity) I
am inclined to watch for. Surely Ms. A.’s 15 responses to this point indicated a
considerable degree of psychological strain, and thus I begin a discussion of the
three responses to Card V—all of which were delivered in the inverted posi-
tion—with this consideration in mind.
Ms. A. seemed to show barely any indication of what might be regarded as
relief or reconstituting adaptive resources. She delivered a response of another
smashed insect (her ninth diffuse shading determinant out of 16 responses thus
far, which was itself immediately preceded by a response with the rarely coded
V). This response was followed by a percept of peacocks which she had difficulty
holding together during the inquiry. Apparently pulled by the shape of the
head or neck which she could not reconcile with the percept of a peacock, she
seemed unable to resolve this incongruity in a way that avoided a fused image
of a “part flamingo, part peacock”—which was at least the second time thus far
that she fused incongruous elements (most clearly on Card III and possibly ear-
lier on Card II as well when she commented on the “piggish” legs of an insect).
Moreover, R18 also presented her with a problem of reconciling disparate ele-
ments of the percept of a horse diving as she tried to decide whether the image
was incongruous or possibly normal. Each of these three responses earned a
special cognitive score for an incongruous combination (INC), and form quality
ranged from good to poor but in an overall sense could not be considered much
better than marginal in accuracy.
Although Ms. A. appeared relatively comfortable with so much “fictitious
. . . exaggerated, odd, not real . . . weird” imagery, I was not convinced that
what she let pass as fanciful elaborations could be as much “fun” as she prob-
ably wanted to believe. (I would also note in this context that Ms. A. showed
no observable or apparent indication of distress or affective strain throughout
the entire Rorschach administration.) My index of suspicion remained on
the alert that this patient experienced troubling affects internally that she
attempted to rationalize. Many times, her way of attempting to expunge psy-
chological distress came at the cost of compromised thinking or perception.
Despite the markedly elevated WSum6 and comparable R-PAS variables, I
did not regard the loss of distance these variables implied as representing the
disordered thinking of a psychotic-like illness, although it did seem to indicate
the degree to which a great deal of her ongoing experience could become
overtaxed to preserve effectively operating defenses. Considered as well from
the standpoint of an examiner listening to a nearly steady stream of psycho-
logically “loaded” content, it would not be difficult to imagine that the people
in Ms. A.’s world often would think of her as strangely idiosyncratic—the
proverbial peculiar duck.
Card VI
∨>∨19. Looks like someone sliced a Like it was sliced and opened out. The
hamster down the middle. arms, legs or feet, head.
(Sliced?) This dark and light area looks
like when something’s cut.
——————
Nothing in particular. Just death, that’s
all.
20. Feathers like the kind Indians The light and dark, and the ruffled-out
wear. shape.
There occurred more card turning at the beginning of Card VI than usual,
perhaps representing her trying to find a position to get away from something
she did not want to see. Still, Ms. A. produced a rather gruesome-sound-
ing response. The MOR code—her sixth thus far—coupled with still another
diffuse shading determinant provided a further compelling indication of a
sense perhaps of herself as damaged goods accompanied by an affect state
signifying helplessness or dysphoria. Perhaps most telling was her offhand
comment during testing the limits (“just death, that’s all”) as if to indicate
that the danger and helpless affect state were no big deal—and thus walled
off from ongoing affective experience. One must wonder by this point why it
apparently was so dangerous for this patient to let in any direct experience of
her affect life. Stated differently, it was quite striking that Ms. A. received as
many MOR and diffuse shading determinant codes as she did while appear-
ing all throughout as cool as a cucumber. It was indeed remarkable that she
could appear so flippant and unaware of the affective quality underlying what
she saw and how she elaborated her Rorschach percepts. Testing the limits
seemed a particularly invaluable method for discerning this aspect of disso-
ciation about her affect life.
21. Whiskers. This thin line, the way it’s protruding.

(Protruding?) It’s coming out of this top
part, sticking out.
∨22. A distorted outline of the inside of Below the ground, where the root is. Just
a flower or plant. And this part might be the shape of the rest of it and it’s connected
what’s below the ground. to a stick which could be the stem.
(Distorted?) The flowers are a little bit
fuller.
(Fuller?) No, not really. It’s not really
distorted, just a unique flower, not torn or
ripped. Just its shape.
These two responses seemed to depart from the first two responses on Card
VI mainly because diffuse shading apparently was not used. The protrud-
ing line of the whiskers might have been influenced by shading, but there
was no indication to that effect. Having produced two consecutive responses
using diffuse shading, Ms. A. could have clammed up at this point, which
seemed consistent with Ms. A.’s defensive organization. The distorted flower
percept added to this impression, particularly inasmuch as it was seen—or
perhaps more correctly, not seen—because it was “below the ground” and
also because of the curious denial during the inquiry concerning its distorted
condition. This patient replaced “distorted” with “fuller”—suggesting if any-
thing, vitality—but apparently Ms. A. could not entirely maintain this defense
because when asked about the flower being fuller she returned, unprompted,
to refer to its distorted condition. She appeared to try again, and thus the dis-
torted flower became a unique flower, but by immediately and spontaneously
following this statement by saying “it’s not torn or ripped” she again revealed
the precariousness of her capacity to sustain a workable defense. I was by now
wondering whether Ms. A. was losing her grip on a tightly defended personal-
ity organization.
Card VII
∨23. The middle could be a body of This area here looks like a reflection. Not
water. a reflection, I mean ripples, because of the
spaces and lines here.
(Body of water?) The white space—
an open space. Otherwise it’s nothing in
particular.
(Ripples?) Just because the way the
lines are, the white space in between.
∨24. A person walking through a path A woman walking through a path, like
of trees. something she’s coming from, like a king-
dom. She has a tall hat like an Egyptian,
strolling through the path. The shaded
area could be trees.
(Shaded area?) No, it’s just because
of the things around it, like the woman.
(Path?) Just because the way it’s drawn,
to have this space here the artist wants
you to look at it like there was a dis-
tance—drawn from a distance—because
the image is smaller.
Both of this patient’s responses were viewed from the inverted position. She
had done the same thing on Card V, which I did not comment on at that point
because I could not be certain what potential significance it held, particularly
because there she might have simply inverted the card and left it in that orienta-
tion, and thus no particular interpretive significance need necessarily be attrib-
uted to its repositioning. This patient had already inverted three of the four cards
by that point and then again on Card VI, so it was not unusual for her to view
the cards from multiple orientations. However, now on Card VII she repeated
what she had done on Card V, and I could no longer ignore the possibility that
inverting the cards from the position in which they were presented to a position
that she herself chose or preferred seemed to contain potentially important mean-
ing. I wondered in fact whether this might represent yet another manifestation of
having things her own way, not unlike my impression about her comment before
starting the Figure Drawings (“Do you need details, like a face? Because usually I
play with a pencil on the page, by playing with it . . . I always, always start draw-
ing by messing around . . .”) which I initially thought had to do with complying
with a request. It did mean that, but it also meant something more: Ms. A. was
announcing that she had her own ideas or intentions. It was no longer my test;
she was going to do it the way she wanted it to be.
Recall also the inquiry on her opening response to Card I: Before I knew
what was happening and as I later came to see, by trying to investigate shad-
ing as a possible determinant—an unsuccessful effort at that—she and I were
engaging in a transference-countertransference “dance” related to who was in
charge of administering the Rorschach! Further, first on Card V and now on
Card VII, the same “dance” appeared to reemerge, albeit more subtly, appar-
ently reflecting Ms. A.’s need to assert autonomy and protect herself from what
she imagined to be any attempt to undermine or threaten that autonomy. In
this regard, it also deserves mentioning again (cf. note 1) how difficult it was to
set appointment times with Ms. A. We would agree to a time which she would
say she would, or would try to make, but invariably she was late even when she
knew in advance how much time I had for the appointment. Although at first
I thought she was just chronically very late for things, after more than enough
latenesses (longer than 30 to 45 minutes) I began thinking that there was a dif-
ferent message being communicated—it reminded me of a cartoon showing a
doctor’s receptionist telling an irate patient that while his appointment with Dr.
X was for 2:00, Dr. X’s appointment with him was for 3:00!
Thus, I was getting the impression that her way of asserting control at the begin-
ning of the Figure Drawings and at the beginning of the Rorschach inquiry repre-
sented a self-protective measure she had cultivated to manage anxiety surrounding
uncertainty and control over unfamiliar or potentially threatening situations. In
regard to repositioning Cards V and VII (perhaps to convey that her positioning
of the cards—and not mine—was how she intended to view them), I considered
the possibility that it might represent another attempt to take control (mainly of
herself) as her responses seemed to continually unravel—despite, I would like to
repeat, there being no visible outward indication that anything was the matter.
Ms. A.’s first response involved both the white space of the card and what
was mentioned at first as a reflection—which she quickly took back—suggesting
overvaluing her wishes or needs while perhaps disregarding or acting uncon-
cerned about those of others. The same combination of a white space response
(on the CS) and a retracted reference to a reflection also occurred previously
on Card III, and both percepts referred to water. The water percept on Card
VII was not as richly elaborated as her Card III response, although it was fol-
lowed by a response that clearly elicited more imaginative, fanciful imagery—a
woman with an Egyptian-looking hat coming from a kingdom and strolling
through a path surrounded by trees. It conjured something almost otherworldly
and there were allusions to several potential determinants.
However, as I noted concerning her avoiding diffuse shading several times
before in other responses, Ms. A. referred rather directly to diffuse shading in this
response but just as quickly retracted that she really meant shading—just as she
retracted the reflection in the previous response. She did elaborate dimensional-
ity (FD) in referring to the person walking through the path and a space represent-
ing something seen from a distance; however, I was left with the impression that
the richness of this fanciful response was not captured fully by the formal codes.
Considering both of these responses to Card VII, it is possible that this patient’s
inverting the card may have succeeded in providing her a defensive, self-protec-
tive haven that eluded her on most of the preceding cards.
Card VIII
∨25. The fashion designer, Betsy Pieces of one of her outfits. It’s not even
Miller—she has very outrageous, very all together. This could be a blouse, this a
colorful clothing. pair of shorts—pieces that would go with
an outfit just laid out, sort of in disarray.

Which is how her clothing is: beautiful
colors but just kind of busy and discon-
nected. Like she couldn’t stick with one
idea.
>26. An animal, its legs stretching or The legs, and because it’s connected to
reaching to walk. Here’s a part of his this light area it looks like a shadow.
shadow. (Shadow?) Because it begins where the
leg touches here, and it’s long.
(This lighter area?) That too, not
necessarily because it’s light or dark but
because it’s a different color
∨27. The face of a dog. The ears, nose, and mouth area.
∨28. The inside of someone’s body, Because the lines across look like a skel-
like a skeleton. It’s very colorful for some eton, and the line down the middle. A
reason. colorful version of a skeleton.
(Colorful version?) To attract people
to pay attention to it. Most aren’t very
attractive or interesting, but with the
colors it makes you want to look.
∨29. A pair of panties. The shape of it.
This patient continued her pattern of inverting the cards on Card VIII, never
returning to view the card from the orientation in which I initially presented
it to her for any of the five responses she produced. Notably, the tone of the
thematic content was certainly more benign than many of her earlier responses,
which seemed to be the case as she settled into a pattern of routinely inverting
the card position for most of her responses after Card V.
R25, however, was characterized by the disarray of the clothing outfit. It
was dominated by “outrageous” colors, and as she herself commented, “she
couldn’t stick with one idea.” This response suggested a rather compelling
hypomanic quality—perhaps more controlled (albeit “busy”) than chaotic,
and also strongly characterized by an emphasis on color. The well-modulated
use of color (FC) suggested a capacity for regulating or managing affect in the
midst of this “outrageous . . . disarray” representing the disorganization of a
flight of ideas (“she couldn’t stick with one idea”). Despite its poor form quality
and hypomanic characteristics, the response itself showed no odd or disordered
thinking, and no intimations of morbid quality.
Ms. A. followed this response with the popular response of an animal; how-
ever, its shadow, seen in a lighter area, while technically coded as FC´ had me
wondering what she actually saw and where her verbalization was really lead-
ing. I felt that she was toying with diffuse shading, and that perhaps she was
able to play with the idea of going there because she had by this point on the
Rorschach found a way by inverting the cards of turning the Rorschach into
what she wanted to make it whether or not I wanted or expected something
else. Thus, saying “not necessarily because it’s light or dark but because it’s a
different color” left me thinking that Ms. A. was pointing in a different direc-
tion to lead me off the track of the lighter color verbalization I was attempting
to clarify in the inquiry. Metaphorically, like the cowboy or movie westerns of
another period, her “it went that-a-way” misdirection had an elusive “saved by
the bell” quality, possibly more successfully so than her attempts to be elusive
about shading responses on earlier cards. After seeing the pattern that Ms. A.
seemed to have established by this point in the Rorschach, I do not think that
my hypothesis here was all that unreasonable, though I recognize how conjec-
tural it must appear.
Her next response of a dog’s face was unremarkable—one of the very few
such responses in the entire Rorschach protocol—but the response following
the dog face (a colorful skeleton) merits further comment. Although anatomical
drawings often may be colorful, medical illustrations of skeletons rarely are.
Indeed, as Ms. A. said herself, “most aren’t very attractive or interesting.” Ms.
A. continued what she seemed to do on her earlier response of the animal and
its shadow: she apparently responded to a quality of shading or light-dark con-
trast but tried to turn it into chromatic color. I wondered whether this response
and verbalization represented another example of a hypomanic defense, much
like the one she showed overtly on R25 and more subtly or elusively on R26.
Moreover, when queried about the colorful version of a skeleton, Ms. A. com-
mented that the intention was “to attract people to pay attention . . . the colors
make you want to look.”
Color, so it seemed, mattered to Ms. A. as representing attracting attention
or as a way to enhance interest and draw one in; it seemed to reflect intention-
ally making others look and take notice. It was not essentially different than her
earlier response of “outrageous”—colorful clothing in which the color also had
an active or energetic quality intended to create interest and attention (rather
than outrageous in the sense of repulsive). The clothing was intended to be looked
at, and the colorful skeleton response (“the inside of someone’s body”) may have
connoted looking internally or inwardly. Ms. A.’s lively and even energetic,
attention-enhancing use of color was one aspect of what I am here regarding
as a characteristic of hypomanic excitement or energy, or a milder manifesta-
tion of hypomania such as the hypomanic temperament associated with “soft”
bipolar spectrum affective illness.
The particular responses I have been emphasizing may suggest this personal-
ity quality; however, there were other ways in which Ms. A. used (or avoided)
color that also deserve mention. For example, on R4 she spoke ambivalently
and with some distance during a testing-the-limits inquiry (and as such, was
not coded) about “negative” color. She stated, “it’s not a bad color, I like the
color, it just looks unattractive,” referring to an insect with “that long line like
where the feces would be” (elaborated late in the inquiry as a “fine black line”).
Despite referring to achromatic color, which is a different dimension psycho-
logically than chromatic color, my point here is to highlight this patient’s wary
use of color—color that is both seen and not seen—that this patient apparently
wanted to defuse.
Further, Ms. A. also reported a percept of peacocks/flamingos on R17. What
seemed unusual here was her reporting a percept on an achromatic color card
of a bird usually seen as brightly colored and whose colors also connote attract-
ing attention. This patient could not seem to resist producing as evocative a
color-influenced response as a peacock, which she also transformed into a half
peacock-half flamingo. Thus, color was used either in a bold and direct way as
a determinant or as a thought behind the scenes though still influencing how
this patient perceived her world. When she would allude to or comment about
chromatic color, it appeared that Ms. A. simultaneously concealed its influ-
ence, sometimes in ways that eluded its being coded. This idiosyncratic way of
both responding to and also elusively playing with lively or energetic affective
experience may have been part of this patient’s defensively inhibited, self-pro-
tectively diminished way of experiencing her affect life, perhaps at moments
when energetic, “outrageous” feeling states might take over and become bigger
than life, thus threatening to overcome her capacity to contain what she felt.
It was sounding increasingly more persuasive that by discovering a way
to get through the Rorschach by doing it the way she wanted to might have
reflected a strategy for getting through life such that she could better control
what impacted her and experience emotional reactions when and how she
felt comfortable doing so (such as a peacock on an achromatic card) and thus
attempt to contain or otherwise modulate her emotional reactions to keep
them from getting beyond her control. Looked at in one way, it might seem
as if she might have found a way to have her cake and eat it too, but her strat-
egy for managing emotionality could also be taken to represent Ms. A.’s way
of living inside of herself rather privately, allowing herself a richer or more
vivid and possibly more emotionally passionate existence while still safeguard-
ing herself from becoming overcome by emotion states that could get away
from her.
Before finishing my discussion of Card VIII, I want to comment about what
looked like a relatively simple, straightforward final percept of panties determined
by shape alone. This response, curiously enough, in its way may have represented
a continuation of Ms. A.’s colorful skeleton response in which the color was
intended to attract attention and induce people to look at it. Panties, however,
are undergarments that are private and concealed, typically just the opposite of
attracting attention or inducing people to look. But they could also be thought
of as part of sexual attraction or initiating sexual desire or responsiveness, and
as such another implication having potential meaning or significance relative to
the way panties are usually described or thought about. In a conventional sense,
therefore, panties, like skeletons, are not normally noticed and do not attract
much attention. I wondered whether this patient’s nondescript response of pan-
ties was similar to that of her skeleton, in which she took something as uninterest-
ing or unappealing as a skeleton and by making it colorful turned it into some-
thing more appealing, something intended to draw people in to look at it.
Furthermore, a skeleton also stands for something that has died. Making it
colorful to draw attention to itself seemed to introduce the possibility of revival
of life or liveliness, and it was possible that panties, with its second and poten-
tially concealed meaning, might also belong in the same context of bringing
about a more psychologically alive existence. It seemed to turn on its side this
patient’s earlier response of brightly colored clothing calling attention to itself,
juxtaposing something “outrageous” with something private and concealed. As
a result, colorful skeletons, panties, and outrageous colorful clothing represent
extremes, possibly not unlike Ms. A.’s affect life (sometimes bold and provocative,
sometimes quiet and concealed) and her sense of constricting a desire for a more
vivid, psychologically lively or energetic existence, one that could stay within safe
bounds that she could manage or contain before its getting the better of her.
Card IX
30. A person and these three shadows The superior one and there’s three body-
where it could be three other people at the guards in the background—something
sides. Their arms at the sides. A little ajar from “Outer Limits.” Three roundish
as soon as we see that space. The colors outlines on top and the darker one that
are very nice. looks closer, and these three are in the
background or following him. They’re
like spirits, definitely out of this world.
They’re light, almost like ghosts. They’re
kind of hidden, like the shading of them,
like they’re fading away.
(Ajar . . . that space?) It’s more like a
figure and the arms are at the sides.
(Ajar?) They’re bent, not straight
down—the arms.
(Space?) Just the figure, where it is.

(The darker one looks closer?) The
ones in the back are lighter so they look
further away. The other one looks closer,
not because it’s darker necessarily, but
because it’s closer to the colors.
——————
Like demons or thieves in the night.
They’re definitely negative. He’s just the
leader and it’s like they’re protecting him.
They’re there to do what he says.
31. A splash of someone’s painting. It just doesn’t look like anything in partic-
Water color and they splashed it. ular, and so they just splashed it. Water
color paint. Very beautiful colors.
Inexplicably, Ms. A. no longer continued what seemed to be emerging as her

pattern of routinely inverting the cards as she had done on the last two cards.
There was the same amount of card turning before delivering her first response
(as she did characteristically on all of the cards except for Card I), and she also
turned Card IX several times before delivering her second response. However,
both responses were generated in the position in which the card was handed to
her. And indeed, these percepts showed some of the loose organization of the card
details that characterized her responses prior to Card VII. Granted, for many
people finding responses to Card IX can be difficult, and it is particularly difficult
to produce a well integrated response to the whole card that does not take the form
of an explosion or a similarly problematic response. Ms. A. was only partially suc-
cessful in rising to the occasion here. Perhaps the challenge of Card IX’s stimulus
properties got the better of her hard-won defense of inverting the card by turning
it into a stimulus of her own and thus taking control of the response process.
That being said, her first response brought back her tendency to produce
responses of a fanciful-sounding nature, but which in truth—like most of her
other similar fanciful percepts—was actually more disorganized and destabi-
lized than imaginative. Representing another non- H response and also one
of marginal form quality, Ms. A. produced her third vista determinant of the
total protocol. Moreover, referring to arms as ajar was quite odd indeed; her
clarification following my two inquiry questions—I clearly needed to ascertain
what she meant by this, even at the risk of what she might perceive as boxing
her into a corner—was confusing and not at all illuminating, and indeed it only
made matters worse. Vacillating between coding DV and DV2 I settled with
some misgivings on DV, although her use of ajar was not easy to reconcile with
its referent of arms. Even this patient’s opening phrase (“a person and these
three shadows”) would raise most examiners’ eyebrows; when she followed this
statement by adding “where it could be three other people at the sides” I was
not really reassured. Furthermore, although I was not certain whether her add-
ing “the colors are very nice” at the end of the response phase might have been
simply a nonspecific observation, when I realized during the inquiry that she
really seemed to mean shading and not chromatic color at all, it seemed quite
odd that she would refer to shading—and particularly V—as colors that are
“very nice.” Finally—and perhaps most important—the imagery of an other-
worldly superior figure with hidden bodyguards (“they’re faded away”) that are
like spirits or ghosts suggested that by having bodyguards this patient’s need to
feel above or possibly apart from others—perhaps in order to feel secure or pro-
tected—was ephemeral and thus vulnerable, considering that the bodyguards
were fading away.
Coupled with the significance of vista as a determinant, this patient could be
vulnerable to feeling depreciated when finding herself undermined or weak-
ened. I raised the possibility earlier in connection with her vista response on
Card II that Ms. A.’s response about an idyllic existence of a kingdom might
signify getting away from perturbing experiences she found threatening. Here,
too, the vista response on Card IX added to my impression about her in which
withdrawing into magical fantasy attempted to enable Ms. A. to feel insulated
from destabilizing experiences. However, such withdrawal did not seem to pro-
vide enough safety, and consequently her feeling fortified was undermined and
she was left reexposed to feeling vulnerable and devalued. I also commented
at the end of Card VIII that Ms. A. sometimes used color in a bold way and at
other times she seemed to allude to color (as she did here on Card IX) to sub-
merge and thus defensively diminish the distracting but nonetheless internally
painful affects she could experience as threatening.
With this in mind, consider now this patient’s second response: a formless,
pure C response of a splash of colors. Ms. A. also seemed drawn into the trap
of coming up with a reasonably integrated response to the whole card. It also
deserves mention in this context that four of Ms. A.’s six MOR special scores
occurred when the W location was used. Although there was no morbid content
indicated here, the patient’s amorphous pure C response of a “splash of some-
one’s painting . . . they splashed it . . . very beautiful colors” seemed to represent
a return to being so strongly influenced by color that it dominated her response.
Whether it was the “outrageous” colors of Card VIII or the “colorful version
of a skeleton . . . to make you want to look” later on that same card, the use of
color emphasized its being noticed. But at other times, the red eyes of the Santa
Claus (Card II) dominated the figure’s being seen as “fictitious . . . unreal”
because “no one has red eyes like this . . . I don’t believe in Santa Claus,” which
was followed on the same card by a quasi-response of “red splotches look like
some sort of distraction, it doesn’t make sense to me” that never coalesced into
an actual response.6
Thus, this patient seemed to show two contrasting patterns of responding to
color: she either emphasized it prominently or studiously avoided using it. Color
may represent the Rorschach cornerstone of affect life, and Ms. A.’s use of color
seemed to indicate extremes of affective experience. Thus, color was either very
present and riveting for her—consistent with the hypomanic activation pattern I
suggested earlier—or it was avoided, minimized, or covered over by a different
kind of affective experience—the vista shading quality suggesting painfully look-
ing inward, characterized by devalued or depreciated affect. This pattern was
consistent with the depressive quality permeating much of this protocol.
There is another interesting observation concerning this second response
to Card IX. This was not the first time Ms. A. referred to the Rorschach blots
as though they were paintings by an unseen artist who was either “messy . . .
they didn’t clean up . . . they weren’t careful” (Card I, R1and R2) or “the artist
wants you to look at it like there was a distance” (Card VII). Even on Card VIII,
although it was only implied, “the inside of someone’s body . . . a colorful ver-
sion of a skeleton” was elaborated in a way to suggest that someone colored the
skeleton “to attract people to pay attention to it . . . makes you want to look.”
Using the Rorschach cards to represent artists’ paintings was a way for Ms. A.
to distance herself from and thus externalize affect states.
Card X
∨32. A boomerang. Or a sling shot. The shape—partially tri-

angular. It looks like a wishbone almost.
∨33. A chicken doesn’t really look like It’s not shaped like one. Just because it’s
it, but it’s yellow. yellow, like little chicks. Both sides.
34. Lobsters. The large middle, and the legs.
∨35. Flesh. It’s just pink. Just the color and what
I think of as the inside of my skin, this
color.
——————
Just because it’s not connected to any-
thing. It’s not really different than the
other things, like the chicks, lobsters, or
anything.
∨36. The blue reminds me of something The color is a refreshing color to look at.
tropical. Water, something refreshing. It reminds me of peace, tranquility. It’s
clean, fresh.
(What do you see?) Just the impres-
sion, the color, the blue. A refreshing
color, the tranquility.
The five responses to Card X were in several respects unusual—one response

that received a score of CF– also contained a serious special cognitive score
(ALOG in the CS and PEC in R-PAS), and two responses were coded C. Four
of these five responses were seen from the inverted position; however, on this
card repositioning how she looked at the card did not work to her advantage as
it may have on several previous cards. If it could be hypothesized that invert-
ing the cards served a self-protective function for Ms. A., this time the attempt
seemed to fail as it did previously on Card IX as well. It perhaps may be stretch-
ing a metaphor she herself introduced: however, her possibly defensive pattern
of inverting the cards may have “boomeranged” on her. Certainly, Ms. A. had
quite a bit of difficulty producing enough form-based percepts on this card.
Her response of chicks strained logic too much as she based her decision to see
chicks almost totally because of the yellow color; however because she seemed
aware that form was a meaningful consideration and also because she men-
tioned something about form twice (during the response phase and once again
during the inquiry), the CF code seemed appropriate. It was as if she decided
to throw caution to the wind, apparently swayed by the color that seemed to
override her better judgment and thus compelling her to respond as she did.
This might be one example of her preferential extratensive style sometimes
leading her down a misguided path. Following a better formulated response
of lobsters, Ms. A. ended the Rorschach protocol with two successive formless
responses also representing giving in to the pull of the colors. It is possible that
an extratensive disposition in some patients, Ms. A. perhaps being one, might
reflect a manifestation of a hyperthymic temperament. In such a case, color
might capture her attention in such a compelling way that it overrides form and
in so doing compromises good judgment.
The first of her two final responses on Card X was “flesh,” an internal anat-
omy response determined by the pink color because it suggested to her “what I
think of as the inside of my skin.” On testing limits, her comment that the flesh
was seen “just because it’s not connected to anything” did not clarify her think-
ing and by adding that perceiving flesh was not different than her other per-
cepts (for example, the chicks and the lobsters) she managed to further confuse
the matter. She seemed to be saying that this response was not fundamentally
different than her other responses, but I was not convinced she really believed
that. Ms. A. seemed indifferent about her response and particularly how she
elaborated it on inquiry, not seeming to care how it might sound to another
person’s ear. It may have represented another instance of color taking over the
response process so thoroughly that reasoning was nearly absent (“flesh . . . just
because it’s not connected to anything”).
Previously, Ms. A. seemed more uncomfortable rationalizing seeing chicks,
emphasizing the disparity between the shape and color of the chicks. Consider-
ing both responses together, I wondered whether she indiscriminately delivered
these responses without the same degree of consideration she seemed to give to
her other responses up to this point. Perhaps the predominance of color with
less regard for form disposed this patient to a way of experiencing her emotional
life that was influenced by indiscriminate thinking. At such moments, logic and
rationality mattered little and took a back seat to affective experience. Impaired
(or perhaps more accurately, unconcerned) judgment may have taken over,
and her extratensive disposition began to take on the character of impulsive or
uncritical thinking. An extratensive disposition (in which affect has an impor-
tant influence on thought and action) combined with compromised affective
modulation (FC: CF + C = 2:4, in which three of the four CF + C responses
were pure C) by itself would certainly be problematic. I would argue that this
feature, combined with the character of several of her responses noted earlier,
might well account for the hyperthymic temperamental disposition that might
have been present though easily undetected, even by clinicians who might have
known her well—thus missing clinically identifying an important aspect of this
patient’s affective experience.
It is probably also worth noting that Ms. A., who was African-American,
produced a percept of flesh based on pink color, which potentially might have
further clinical significance. Notwithstanding that her response was based on
the inside of the skin rather than the skin color itself, the relationship between
internal experience that is “skin deep” and external appearances reflect-
ing something else deserves note. Its psychosocial significance as a comment
reflecting attitudes about race or racial differences should not obscure the more
important psychological meaning suggesting that what was felt on the inside
was not the same as that which was seen on the outside.
The response that followed, which was Ms. A.’s final response in this fairly
lengthy protocol, was most notable for the calmness it conveyed. In the context
of my interpretive emphasis at this junction—anchored around mood variation
and its regulation—this patient’s final response appeared to indicate a capacity
for rapid stabilization in spite of the fact that this response had another pure
C as its sole determinant. Notwithstanding the tranquility that Ms. A. repeat-
edly emphasized, it should not be overlooked that what might appear in one
sense as reconstituting herself following affective destabilization may not be
as prognostically favorable as it might seem. That is, the verbalization with its
emphasis on calmness was superimposed on a formless use of color. Moreover,
reflecting how Ms. A. ended this Rorschach protocol, it may subtly encapsulate
much of what I have noted throughout the discussion of her responses on most
of the cards: a surface appearance that all is well (sometimes assisted by gener-
ally workable defenses that either bolster self-control or deflect a deeper sense of
distress) coexisting alongside potentially destabilizing ego weaknesses.
Thematic Apperception Test
Card 1
He’s feeling guilty about stealing the violin and he could hardly pay attention in class.
He was told to bring in something for show and tell, and even though he had the best
show and tell piece he’s not as happy because he knew he was going to get in trouble. He
wanted to bring in the best thing in his house to impress his classmates. He feels isolated
and that’s why it’s dark around there. His mind wandered until finally he looked around
and realized he was the only one in the classroom.
(Only one in the classroom?) Because he was so bothered about stealing that when
the teacher called on him, it was his turn, he didn’t hear her. He just sat looking like that
so eventually the teacher just left him alone until the class was over.
(He didn’t hear her and realize the class was over?) His mind was so way out,
just wondering what would happen when he gets home.
(Outcome?) He was able to bring it back home and not get caught. His mother did not
realize it was stolen, and he sees you don’t always get caught. However, I may end it that
he goes home and he tells his mother. And she allows him to bring it back the next day and
the teacher allows him to make the presentation. And he doesn’t get the best grade because
I don’t want him to be rewarded for dishonesty.
(Why steal it?) She was a famous violin player and it was a prized piece of hers. It
belongs on a shelf or a cabinet, it’s like a display or a prize. He knew if he asked her she’d
say no. (When he was so out of it in the classroom, what did the teacher do?)
She just walked over to him and called him. She probably wasn’t the best teacher, she
didn’t really follow up and see if anything was wrong. She just continued with the class
and thought, just let him sit by himself.
(When class ends and he’s the only one left, what did she do?) She said the
class is over and she walked out and she just left him to himself.
This was an atypical and highly unusual story to Card 1. It highlighted Ms. A.’s
concern about being the best, impressing others, and also how far she could be
willing to go in order to accomplish her objective or achieve the level of admi-
ration or specialness she seemed to need. Perhaps even more evident than the
exploitative, attention-getting gesture was the expression of profound remorse
and the price one would have to pay for carrying out such a bold act or trans-
gression. At once sounding sociopathic and narcissistic, Ms. A.’s story on the
one hand suggested stopping at nothing to achieve the admiration of others,
and on the other hand her emphasis on contrition seemed to make a case that
the deep sense of wrongdoing she expressed in her story led to being nearly
immobilized by guilt.
There also was a devil-may-care tone about this TAT story. Ms. A. went to
great extremes to show a desire to have the best and most exemplary object of
display, however risky or precarious stealing it might be. She seemed to convey
how difficult it could be for a person to modulate needs and ambitions. Another
unusual aspect of Ms. A.’s story was the extreme indifference she attributed to
the teacher, which arguably was a representation of a parental figure. It was
striking how she matter-of-factly stated how neglectful and blind-sighted the
teacher’s action had been, and with little expression of surprise or comment
Ms. A. conveyed a sense of naturalness that a person could ignore an obvious
indication of distress. It was nearly a mirror image of Ms. A.’s description of
the mother’s reaction to the boy’s telling her that he took her prized possession
without her permission: the mother simply allowed the boy to bring the violin
to school the next day. Just like that! The impression about the mother was just
as incredulous as that of the teacher; it makes one wonder whether her imbuing
a striking emotional absence or indifference to the teacher and the mother indi-
cated that for all intents and purposes they were the same person—uncompre-
hending, emotionally vacant and insensitive, and in the final analysis capable
of acting indifferently.
Card 2
Here’s a girl who looks like she’s not happy in her environment. There’s a woman who
looks pregnant, leaning against a tree. This girl could be these people’s daughter and she’s
on her way to school. She’s going to go to school and make sure she gets an education so
she doesn’t have to be in this other woman’s place. It may not be a bad place, but from the
look on the girl’s face it doesn’t look like something she’s too happy about.
(Outcome?) The young girl continues her education.
(Relationship like with them?) She’s a nice girl so she has a good relationship, a good
camaraderie with the people around her. She’s a sweet girl but she doesn’t seem content.
(Not content?) Maybe she wants more out of life.
As rich and productive as was her story to Card 1, Ms. A.’s story to Card
2 was by contrast sparse and limited. However, unlike Card 1, her story on
Card 2 was common; it was also far less elaborated. The patient indicated at
the outset that the girl in the foreground was unhappy. From what was said,
the girl was not as interested in her education as she was interested in getting
away from an unhappy environment. She also suggested that despite a “good
camaraderie” with the parents there was little internalization of the mother as a
viable object for her. Indeed, camaraderie is an odd way to describe a relation-
ship with one’s parents. Curiously, the patient mentioned that the mother was
pregnant, representing several possible meanings—for example, joy, feeling
displaced from a privileged position, limited or divided interest from the mother,
or feeling pressed to stay and help rather than strike out on her own, among
still other possibilities. Whatever else it may have meant for the girl, the way
Ms. A. seemed to convey the relationship with the mother was anything but
maternal in nature. Instead, it was cordial and outwardly agreeable, suggesting
a relationship of limited engagement or depth rather than one characterized by
heightened maternal feeling.
It also resembled the mother depicted on Card 1 insofar as the quality of
involvement was vacant. Furthermore, it suggested how the teacher on Card
1 was portrayed—unempathic and apparently unconcerned. As such, Ms. A.’s
story here was notable mainly for its depiction of important people in one’s life:
people in maternal roles were present but distant and psychologically limited.
When this patient ended her story by saying that the girl “wants more out of
life,” Ms. A. may have been signifying a need for a more psychologically enli-
vening existence, as she seemed to indicate about the boy of Card 1 who was
intent on having the “best show and tell piece.” Ms. A. seemed to be speaking
here about a need for something more than the compliant “camaraderie” she
may experience with the important people in her life.
Card 3BM
The first thing I thought was this is someone who’s bulimic because it looks like someone
over a toilet, but it’s more like a seating area, like a sofa. And this child, probably a boy it
looks like, just seems to be tired, but not abnormally. I can picture him coming home from
school and just flopping down, kind of worn out. Maybe overly stressed out, or emotion-
ally maybe something’s wrong and he’s depressed. It’s not your normal thing, looks like
he’s overwhelmed.
(Led up?) It could be emotional because it is a child, probably going through something
emotional that no one can understand.
(What overwhelmed him?) Maybe he gets depressed a lot. Maybe he wants to par-
ticipate with the other children who are lively and active and playing. Maybe he wants
to be doing that and he can’t do it, he doesn’t know why—maybe inside, emotional, that
he has no control of.
(Like what?) He wakes up every day feeling alone, like he doesn’t fit in, maybe depressed,
maybe tired—even when he’s not been very active. It could be Friday, the end of the
week—no, maybe it’s Monday, the first day of school for the week and he’s already tired.
This is probably something ongoing and his parents don’t even know what it is and they
think he’s being lazy.
(Outcome?) It probably continues, unfortunately. There’s probably no result to it, he
probably never figures out what it is.
Ms. A. returned to the theme she expressed on Card 1 in which a child was
experiencing troubles that no one could understand. The parents in her story
here not only failed to comprehend what the boy in the story felt but they
also were unaware that there was a problem making him unhappy (“they
think he’s being lazy”). The outcome was pessimistic: the boy remained in
a distressed state, not knowing what he felt and surrounded by people who
failed to recognize his plight, reflecting probably this patient’s difficulty
putting words to the experience of the boy’s depression. On Card 1 as well as
throughout the projective protocols generally, Ms. A. showed a good capacity
to use a rich imagination, but here—and also to some extent on Card 2—she
seemed at a loss to imagine or explain much beyond surface details or repeat-
ing what she had already said. Rather, all she could say was that the boy was
depressed, tired, and that he had little energy. Perhaps Ms. A. was indicat-
ing that she could not herself get close enough to the subjective experience
of depression, focusing in its place on its somatic-vegetative manifestations.
This estrangement from depressive affect may be an important reason why a
depressive cast did not appear prominently in her Rorschach responses and
Figure Drawing verbalizations, although the MCMI and Rorschach Struc-
tural Summary both indicated scores pinpointing a probable depressive syn-
drome. The TAT is more transparent in this respect compared to other tests,
when administered using inquiry questions to foster elaborating on internal
states, relationships, and motivations.
Consequently, examiners may be surprised to hear TAT stories that empha-
size depression or feelings of depletion and diminished enthusiasm when such
affects are not as immediately apparent on other tests—notwithstanding formal
scores suggesting otherwise. This may be one way of identifying how some
patients judged as depressed may have only a vague sense of unhappiness or
malaise but otherwise may be relatively alienated from their affect life. Ms. A.’s
initial perception of a bulimic sitting by a toilet, apparently purging, might also
reflect a way of somatically deflecting troubling aspects of internal life. Some-
times defenses may conceal a deeper sense of difficulty, as Ms. A. had already
shown in some of her Rorschach responses concerned with diffuse shading and
also as she did on Card 3BM. Note, for example, that she seemed to defensively
minimize the boy’s distress, at first describing him as “tired, but not abnormally
so.” It was not long afterwards that she commented that “he’s overwhelmed
. . . it’s not your normal thing.”
Ms. A. also seemed to convey, as she did as well on Card 1, a deeply embed-
ded sense that there was no place to turn for help with emotions she could not
understand but that could overwhelm her. She appeared to feel that no one
could understand what she experienced, let alone take her distress or unhappi-
ness seriously. On Card 1, the boy was immobilized by his guilt and he was left
frozen and barely able to function. Here, on Card 3BM, the boy wanted to be
a part of an activity but he was too overwhelmed by depression and lethargy
to do so. He thus was left on the sidelines not fitting in and probably lonely.
Feeling inadequate and deficient because he was unable to function normally,
the boy was doubly burdened by feeling that no one grasped his unhappiness
and lack of motivation, which was further compounded when others mistook
the anergia of depression for laziness and then blamed him for being that way.
Though not presented as a formal complaint, I suspect that this kind of experi-
ence probably characterized much of this patient’s interpersonal relationships.
Her defenses partially protected her from feeling acute distress; however, this
probably came at the cost of being relatively isolated.
Card 7GF
This could be a single mother reading to her daughter, trying to capture her daughter’s
attention. And this girl is clearly not paying attention because she is thinking about
her father. Maybe her father’s not in her life and she has a void and wishes he was
there, wondering what he’s like. Even though her mom—who looks like she’s a working
mother—she looks like she’s probably trying her best. Looks like she takes care of her
daughter. Her daughter looks very well groomed, her clothing and her hair, and she has a
toy so maybe her mother gives her things also, she tries to treat her. Yet, something is still
missing, it’s not enough for this little girl to be happy.
(Not enough?) Maybe as a single mother she’s so wrapped up in work and taking care
of her daughter, she may not realize the extra emotional needs and things like that.
(Outcome?) I would like to say it ends with this girl finding her father, making it her
mission even as a child that she’s going to find out who her father is. But fortunately it
may end that she replaces her father with another male figure. She looks like a pretty little
girl, she’s attractive, so she may make herself available to other males to fill that void with
her father not being in her life.
Once again here was a story of unhappiness, and as conveyed on Card 2, a

sense that unmet needs and an ensuing void had to be buttoned up behind
a surface appearance of gratitude that one’s basic needs were met. Also
as she indicated on Card 2, this patient seemed to suggest that one should
not expect much in the way of attentive or knowing maternal involvement
because mothers are themselves overburdened. Although Ms. A. spoke about
yearning for an absent father, what she was missing sounded abstract more
than something she remembered and now missed; thus I could not discern
exactly what she felt to be missing to compel emphasizing this as much as she
did in her story. I was left wondering how much she was really pining for an
absent father or whether the story about a longed-for relationship with the
father actually concealed a more subtle, deeply submerged disappointment
or disinterest in the mother. Thus, I remained unconvinced that the meaning
behind Ms. A.’s story represented something profoundly missing from some-
one she may never have known. I believed that it represented instead a defen-
sive smokescreen to avoid recognizing submerged longings for a mother who
either failed to see her needs, had no time for indulging in “extra emotional
needs and things like that,” or was in some way unaware of or indifferent to
her needs.
Card 7BM
Maybe the older gentleman looks kind of sneaky and he’s trying to influence the younger
one’s statements on something that’s going on. Maybe he’s trying to get him to lie about
something, or be dishonest or deceiving in some way. It looks like the younger guy, his
conscience may be bothering him. He knows it’s wrong, that he shouldn’t, but at the same
time he’s hearing his mentor telling him to just do this or say this because that’s what we
do. And the younger man’s trying to decide whether to do the right or the wrong thing.
(Outcome?) The younger one makes the right choice, whatever it is, whether he’s his
father and he’s influencing him the wrong way or whether he’s his employer. I think it
ends with the younger man making the right choice.
(How does he feel about the older man?) Maybe he’s come to a time in his life
where maybe he can climb the ladder by being deceptive and following what this older
man has done, but he looks like he’s going to make the right decision, no matter what it
is.
Card 4
Here’s a very attractive-looking woman and kind of a hard-looking man. He looks like
a working man. Oh, no, no, no—hey. I thought it was husband and wife, but in the
background it seems to be a photo of a woman half dressed, so maybe it’s some kind of
sexual environment, like maybe a whorehouse. Now I’m looking at the woman and she
looks very bold, also her fingernails look like they’re painted. So it may be some sort of
whorehouse situation, maybe she’s trying to get him to stay. He wants to stay but he also
wants to do the right thing because his wife is at home with his children. But he looks like
a working man, they may not really match completely. He looks like he made a decision to
leave and she’s trying to pull him back, but he’s definitely going to leave because it looks
like this is something that’s been bothering him. Maybe his wife has started questioning
his whereabouts and he knows it’s wrong.
(Outcome?) It ends with him going back to his family. He looks like a hard working
man who probably just got tempted and kind of swerved.
(She’s trying to get him to stay?) They had an emotional relationship. Probably
there was something lacking in his relationship with his wife, or maybe there was some-
thing he didn’t see—something sexual—maybe he wanted her to appreciate him more,
like how much work he’s doing, because he looks very hard working. Maybe he wanted
more emotional attention—you know, loving, praise. Maybe they don’t see each other
enough so maybe she doesn’t realize she’s not doing that enough. And so it was probably
easy for him to stray to this mistress.
Both of these stories, as did Card 1 previously, emphasized a theme of wrong-

doing—either in deed or in thought—which the stories’ protagonist recog-
nizes, struggles against while acknowledging competing desires, and ultimately
resolves by making a morally correct choice. One could speak about this patient
as showing a virtuous nature or a well-developed superego, but I also was curi-
ous why so many of her stories involved such a dilemma. Her stories had a qual-
ity about them that sounded like preaching about morals but they also seemed
to sidestep why so much of the time Ms. A. appeared to be preoccupied with the
theme of being tempted and having to turn away from legitimate desires—for
admiration (Card 1), wealth or power (Card 7BM), or feeling appreciated or
praised (Card 4). This patient seemed to be subjugating longings because she
never made it clear whether these wishes were ever achieved through the moral
solutions she characteristically indicated. The boy of Card 1, wishing to be
admired for the best show and tell project, was instead ignored and overlooked.
The man of Card 4 relinquished the mistress with whom he felt emotionally
enlivened, although in taking the virtuous route Ms. A. provided no indication
that the man’s needs would be met with his wife. On Card 7BM, it was not
made clear whether the protagonist could “climb the ladder” in his own, hon-
est way or whether he had to sacrifice success by being honest. These stories (as
well as the stories to Cards 2 and 3BM) all suggested unmet or unsatisfied needs
left in limbo. Sublimating needs to virtue did not seem to get close enough to
resolving what appeared to be the core problem for this patient: meaningful
needs remaining thwarted, important people in her life remaining psychologi-
cally unavailable or unresponsive, and isolating or defensively concealing emo-
tionally salient needs that as a result left her vulnerable to emptiness and feeling
deprived.
Card 14
This is nice, I really like this. Except I don’t know what it is. Okay, this man is sitting
at a window sill—he’s either breaking in or trying to get in, or he is inside looking out
the window. He’s outside in the dark, probably admiring some female that he is attracted
to. Maybe she leaves her window open and doesn’t even realize she’s being watched. If
he’s inside looking out, I don’t have much to say about it [laughs]. I’ll stick with the
first one.
(Outcome?) He comes back there one day and she’s gone. He never really pursued it,
he was so timid to approach her, so he had to watch her in secrecy. He probably couldn’t
bring himself to speak to her, he’s too shy. (How does he feel then?) That he lost the only
person that he maybe would have loved.
(What happens then?) [laughs] You’re pushing. He probably stays alone. He has
an apartment full of photos of her. He probably obsesses over her, but if he obsessed over
her he’d probably try and find her and finally gain the strength to approach her. He feels
heartbroken like he actually was in love with this woman, that she was going to be his.
Once again, because he didn’t speak out or he wasn’t strong, he lost, like he’s been so
many times in his life. Maybe at work he’s abused or pushed around and he doesn’t speak
up. At the supermarket, he’s in line and people cut in front of him. But this time he said
no, he made up his mind that he’s not going to lose her. He’s determined, and this is going
to be the beginning of him standing up for himself and being a strong man.
I chose this card to administer to Ms. A. because of the elevated S-CON from the
Rorschach CS. Although in this case I had already decided that suicidal ideation
was not an appreciable clinical risk, administering a card with some pull for a
suicidal impulse such as Card 14 was nevertheless a prudent idea. Not only did
Ms. A. not take the bait, so to speak, but her atypical albeit rich story to this card
revealed more about what I have already been commenting on to this point:
thwarted needs concealed behind a thin veneer of naively summoning strength of
character to achieve a virtuous but platitudinous resolution—as if it were that sim-
ple! This patient began by going back and forth concerning whether the man was
on the inside looking out or on the outside looking in; however, it hardly seemed
to matter because the main point was that either way, the man, paralyzed by
inaction, had lost something profoundly meaningful. (Recall in this context how
the boy of Card 1 was frozen in inaction as he sat unresponsively by himself.)
It was perhaps no small wonder that her initial comment signaled being
drawn in (“I really like this”) by the theme of loss or unmet needs as her story
was about to unfold and also needing to conceal the sadness it seemed to trig-
ger (“. . .except I don’t know what it is”). Ms. A. constructed her story around
a loss, perhaps more directly than she had only implied in her earlier, more
covered over stories. When I inquired in a routine way about the outcome, in
much the same way I did on the other TAT cards, Ms. A. perceived my ques-
tion here as “pushing,” her nervous laughter notwithstanding. (Recall also the
inquiry to the opening response to Card I on the Rorschach, particularly my
impression that Ms. A. would not let herself be pushed despite my intent ques-
tioning to establish whether shading was used.) Whatever she may have felt, this
patient again produced an empty platitude in order to avoid speaking about the
depression the man on Card 14 perhaps felt (as she also was able to do on Card
I, by managing to strenuously and probably self-protectively contain what she
said about her response).
Card 13MF
This doesn’t look like a normal couple’s room, it looks like it’s her room. No, maybe his
room. This woman, if she’s alive—no, it looks like she’s dead. He probably brought this
woman back, he lured her in and got her to undress and he killed her. Maybe she’s a pros-
titute. He’s still dressed, he has on a tie, he may be a businessman. Now he’s ashamed.
(What led up to it?) He could be possessed. He probably has an urge, or an obsession,
something against women, probably. Maybe his mom abused him verbally when he was
younger, and he may be kind of a weakling, and maybe that’s his way to pay his mother
back—to get to women like her, and then he takes out his anger on them.
(Outcome?) He probably kills himself. He may be possessed. He’s not even proud he
accomplished this, like he premeditated this and the plan was great. It worked, but he’s
ashamed. Like it’s not him, it’s probably like something takes him over. He switches back
to his normal self and he realizes, “No, it’s not me.” He ends up being so tormented on
the inside that he kills himself.
Here, Ms. A. returned to a theme of guilt and contrition following a wrong-
doing. As was the case previously on Cards 1 and 4, when guilt surfaced a
character in Ms. A.’s stories suffered some consequence. Each of these three
stories involved considerable internal anguish, and although all three were
male figures, not all of the patient’s stories about men involved this specific
dynamic configuration. The two stories involving adult protagonists began
with the patient seeing a man and woman as a married couple, but she soon
realized with surprise that the woman was a prostitute and the man had
secured her services. In the present story, Ms. A. made note of a rarely men-
tioned detail—the man was wearing a tie—which she incorporated into her
story perhaps to attempt to apologetically dignify his loss of self-control by
seeing him as respectable.
The patient also seemed to make allowances for what seemed like an impul-
sive act by commenting on his being “possessed,” implying that it was not his
fault that he murdered the woman because he was badly maltreated by his
mother. Thus, Ms. A. seemed to regard men as taking advantage of women
because they were ignored or badly treated by women themselves. It was of
some interest that Ms. A.’s stories did not touch at all on the women or how
they themselves suffered (in one case being abandoned, in the other murdered).
Perhaps she could ignore these women’s plight because she had denigrated
them to begin with by making them prostitutes, and she barely gave a thought
about them or what came their way. Ms. A. seemed to show no interest in or
sympathy for these prostitutes, focusing all of her interest in her stories on the
men and their internal torment, remorse, and the reasons they became the way
they did. Indeed, on Card 13MF Ms. A. went on and on about how tormented
and badly treated the man felt, seeming to elicit in a listener sympathy for this
man that she appeared to feel quite intently, all the while not seeming to care
in the least, if it even had occurred to her, that the woman in her story had lost
her life.
It was particularly striking in this regard that this patient’s female figures in
her other stories were depicted as uninvolved or aloof—the teacher on Card
1indifferently ignored the boy who seemed distressed, the mother of Card 7GF
seemed unaware of her daughter’s longing for her missing father, and the mother
and daughter on Card 2 seemed to inhabit different and nonintersecting worlds.
Interestingly, the daughter on Card 2 left her pregnant mother, and the daugh-
ter on Card 7GF—who showed little interest in her mother—appeared to live
only for filling the void of her lost father by seeking male replacements. The girl
in the story was depicted as seeming to experience an empty void in the relation-
ship with the mother, and the mother’s attempts to give the daughter whatever
she could manage did not seem to count for very much in the daughter’s eyes.
On Card 4 the man sought out a prostitute because his wife had too little time
to pay attention to his needs. Over and over, Ms. A. seemed to be saying that
women had little to offer or that they did not count. It was the men’s lives that
captured her interest and sympathies and it was in men that she apprehended
depths of psychological feeling, troubled and conflicted though they were—the
anguished boy of Card 1, the chronically depressed boy of Card 3BM, the “pos-
sessed” murderer of Card 13MF, the conflicted but well-meaning man who
strayed from his wife on Card 4, and the insecure man of Card 14 who was
devastated when the elusive girl of his dreams suddenly disappeared. In contrast,
the women and girls of Ms. A.’s stories were not richly drawn; they were treated
dismissively as being self-absorbed and easily overlooked or forgotten about as
she focused her sympathies with the men who came into their lives.
Discussion
In summarizing the main clinical assessment findings, I consider the person-
ality findings in a context of regulation of affective symptoms. In particular,
I emphasize somewhat subtle oscillations that are suggestive of a so-called
“soft” bipolar spectrum of affective illness as a useful way of demonstrating
the interplay of need states, defenses, personality organization, and depressive-
hyperthymic temperament. This is the context of differential diagnosis which
is important not only for differentiating among variants of affective syndromes
but also as a means of understanding this patient’s attentional symptoms, possi-
bly as a manifestation of hyperthymic temperament rather than as a comorbid
attentional disorder. A related implication is that by not recognizing oscilla-
tion in mood states, adequate treatment of an underlying affective disturbance
might be compromised.
Empirically Based Scales (MCMI-III, and Rorschach CS and

R-PAS)
The MCMI-III did not identify prominent Axis I psychopathology, including
affective or thinking disturbances. Instead, personality pathology emphasiz-
ing mainly narcissistic characteristics was highlighted, such as calling atten-
tion to herself, shallow interpersonal relationships, making light of exploita-
tive or undependable ways she could behave toward other people. Ms. A. was
seen as vulnerable to self-esteem injuries if her assured composure was threat-
ened, sometimes potentiating depression, anger, or withdrawing into herself
to recover from such narcissistic injuries. The Rorschach CS findings, on the
other hand, emphasized depression (including identifying greater than average
risk for suicidal ideation or behavior) in a personality characterized mainly by
relying on feeling states of the moment to guide her actions.
Although Ms. A. was not particularly reflective, she was likely to respond to
people and situations based on her prevailing emotional states of the moment,
sometimes without even realizing affect states she might be experiencing. She
generally was disposed to manage stressful situations well enough, although
helplessness or anger might create difficulties in her relationships with people,
which she managed by distancing herself from others.
Like the MCMI-III’s emphasis on problematic narcissistic difficulties,
the CS and R-PAS also identified a problem of balancing self-esteem with
entitlement, in which her narcissistic presentation could be understood as a
defensive attempt to protect her from feeling devalued. As such, mood fluc-
tuations might appear if defenses were threatened. Accordingly, Ms. A. was
inclined to feel distrustful and watchful of others when she experienced them as
undermining, sometimes compromising intimacy by keeping a distance when
feeling unsafe or unsure about people. As a consequence, people probably
experienced her as aloof and this patient’s defensive isolation could contribute
to her misinterpreting others’ intentions and compromising her thinking.
Considered together, these empirically based interpretive impressions were
not far apart. Both a self report and a performance-based instrument empha-
sized aspects of personality functioning that were problematic for this patient,
stemming from vulnerable self-esteem and a defensive narcissistic exterior. Both
also identified proneness to depression when self-esteem was threatened. Ms. A.
also was inclined to emphasize feeling states of the moment over a more delib-
erate thinking through of events around her, creating interpersonal difficulties
and a veneer of distance or reserve around people about whom she felt wary.
Content Analysis (Figure Drawings/TAT/Rorschach)

Amplifying much of what the MCMI and CS and R-PAS findings indicated,
Ms. A.’s comments from the outset subtly foreshadowed what would continue
to appear as a fundamental personality dynamic. Thus, before even complet-
ing the first Figure Drawing she announced a quiet confidence about being
independent or doing things her own way. Although her apparent independent
spirit coexisted with acting cooperatively, before long it shaded almost imper-
ceptibly into a well-concealed, obliging tone suggesting willfulness or arrogance
alongside the compliant manner she showed. People in her midst might not
notice any hint of an air of imperturbability about her, although I could imag-
ine people feeling antagonized by Ms. A. without knowing why. Outside of her
awareness, Ms. A.’s understated agreeable veneer deftly managed to conceal
how she had her own timetable about doing what others expected of her, prac-
tically defiantly challenging others to try to prevent her from doing what she
wanted until she was good and ready.
Although sounding at first as a passive-aggressive or narcissistic characteris-
tic, it appeared that feeling helpless or vulnerable underlay what at first glance
might look like willful arrogance. This veneer appeared to represent a defensive
effort to protect self-esteem, thus attempting to wall off disturbing feelings when
she could. But isolating affect, undoing, and denial were probably overtaxed
and consequently brittle defenses for Ms. A.
There was good reason to suspect that this patient’s difficulties with affects
and her fragile defenses to keep affect states at bay would have been influenced
by an early environment she seemed to perceive as profoundly uncomprehend-
ing or indifferent to her distress. Ms. A. painted a picture of an emotionally
vacant and insensitive mother who appeared not to notice clear signs of Ms.
A.’s unhappiness. Despite appearing outwardly agreeable, her relationship with
her mother may have been limited and uninvolving. She may have attempted
to seek out more psychologically enlivening relationships to compensate for the
indifference that seemed to characterize much of her psychological develop-
ment; however, Ms. A. also seemed unsure what she might be searching for.
It is rare to see on Card 1 of the TAT, for example, a depiction of an adult
ignoring a child in the way Ms. A. related it in her story, a theme that carried
through in a similar way on other TAT cards as well. Apart from the gross
neglect or indifference, what was so particularly bizarre and unsettling about
her story was that Ms. A. appeared nonplussed by what she was saying. She
seemed to think that the indifferent way the teacher acted was normal and
expectable, as if the adult had no further responsibility other than merely notic-
ing that something was not right. Ms. A. seemed to be describing what she
herself perhaps experienced, expecting that intensely felt affect states would not
be recognized by the important people in her life, and all that she could do was
put affective experiences in cold storage as long as she could until they simply
dissipated.
Ms. A. also appeared to convey a quality of what might look like entitlement
to take whatever she wanted for herself, regardless that it was not hers to take,
perhaps justified in her mind as permissible because it was vitally important to
her. Thus, a need state could become so prepotent that it seemed to take over
her behavior and thoughts, perhaps misleading one to think that it represented
narcissistic entitlement. After all, the same parents who failed to recognize and
then ignored her distress very likely also failed to instill the idea that her own
needs must be balanced against others’ needs. She could mouth the words
showing an understanding of what was morally wrong and she comprehended
guilt and remorse, but the anticipatory signal anxiety associated with superego
development seemed to have been short-circuited and not internalized. Thus,
defensively rationalizing or sublimating needs as she spoke about virtuous ways
to behave in life was not the same thing as compensating for what may have
been experienced as a fundamentally unresponsive or uncomprehending envi-
ronment. Thus, thwarted emotional needs concealed behind a veneer of empty
platitudes expressing strength of character served only to mask submerged dis-
appointment or longing. Accordingly, it certainly could be possible that Ms.
A.’s acting in ways others might regard as cavalier or inconsiderate actually
might have reflected her feeling deprived.
Her story to Card 3BM on the TAT added important information concern-
ing this issue: in addition to (if not actually because of) a parental failure to
recognize and minister to a state of emotional distress, it seemed difficult for
Ms. A. to put words to affects she struggled to grasp. For example, in her story
she could describe somatic and cognitive manifestations of a depression but she
could not seem to get close enough to the subjective quality of the feeling or the
events, relationships, or motivations precipitating the depression. The capacity
for imagination and fantasy she showed in many other places on several tests
seemed strangely unavailable to her on Card 3BM, where she seemed unusually
stumped explaining why events in her story transpired as they did. She appeared
to expect that deeply distressed emotional states would not be understood and
consequently that there was no place for her to turn when she felt overpowered,
ultimately leaving her isolated from her affective experience. It was of some
interest that this patient was disposed to be sympathetic about the plight of men
she perceived as injured, whereas she was indifferent or unconcerned about
women who were neglected or overlooked. Ms. A.’s dismissiveness of women
being mistreated appeared to reflect her defensively distanced experience of
maternal unavailability. What seemed to reflect a solicitous concern for men
might have represented her seeking out a longed-for, lost father to alternatively
secure a more responsive or attentive object. More likely, however, it may have
had more to do with escaping from feeling deprived or ignored.
This patient’s vigilant and thus reserved manner in respect to the people
around her, coupled with her idiosyncratic and very likely off-putting thinking,
sometimes could be subtle and easily missed. I also came to understand why this
patient showed a particularly strong need to assert autonomy. Ms. A.’s exerting
control seemed to represent her attempting to protect herself when she felt that
her grip on holding herself up securely was slipping. In unfamiliar or novel situ-
ations, logical thinking seemed to elude her, thus reexposing this patient over
and again to threatening or uncomfortable affects she normally tried to keep in
check by isolation or distancing. When Ms. A. could become so destabilized as
thinking and reasoning faltered, she also was prone to faulty perceptions and
odd, distorted views about events and people. As a result, she probably came
across to others as idiosyncratic, all the more reason for people to feel wary in
her presence and to keep some distance from her. People very likely experi-
enced Ms. A. as touchy, moody, and probably also off-putting, paralleling her
own wariness.
When she felt particularly threatened or vulnerable, potentially unraveling
her capacity to maintain a secure footing, Ms. A. would resort to what I would
for lack of a better term call her entrenched elusiveness—becoming vague or
elusive and digging her heels in—which was the best way she had developed
to protect herself when she felt herself on shaky ground. She also seemed to
self-protectively steer others in a direction away from what she felt vulnerable
about—a defense that had a “they went that-a-way,” “saved by the bell” qual-
ity. She might resort to this kind of defense when she needed to extricate herself
from uncomfortable affect states that threatened to close in on her—when,
for example, on several Rorschach chromatic cards she used color but then
seemed uncomfortable and needed to find a way to back away from affects it
may have triggered.
Indeed, color attracted her, perhaps to represent drawing others in to take
notice, as an attention-enhancing or narcissistic wish to be seen and admired.
Ms. A. in this way used color to vitalize her affect life, thus accentuating her
responsiveness to energetic, lively internal experience. Color use on the Ror-
schach, driven by a hyperthymic temperamental predisposition, probably also
underlay her extratensive stylistic preference. In this way, she could easily
produce a Rorschach percept of clothing with “outrageous,” attention-getting
colors alongside another percept of a colorful skeleton “to attract people to pay
attention.” For a similar reason, I suspect, she delivered a percept of peacocks
or flamingos—on an achromatic card.
However, color was a double-edged sword for this patient because it also
potentially stimulated affect states she might strive to deny when they repre-
sented more disturbing or threatening emotions. At such moments, Ms. A.
tried to shut down affective experience. Color thus seemed to reflect extremes
of affective experience—sometimes strongly present and riveting but at other
times covered over or minimized. I think she probably preferred to more freely
experience affect states, reflected for example in some of her Rorschach percepts
suggesting playfulness or an imaginative opening up of internal experience.
Whether the appeal of color is viewed as a manifestation of her preferential
extratensive style or as a marker of a hyperthymic temperament, its signifying
an openness to a free rein of affective experience might also present a problem
because affective stimulation threatened to destabilize how well she modulated
affect; it also seemed to perturb orderly, logical thinking. Stated another way,
while a hyperthymic temperament could be energizing and expand imaginative
thinking for some people, for others such as this patient affect states that might
be too readily stimulated could expose a vulnerability to affective dysregulation
that might precipitate a sense of danger or threat.
This clinical evaluation began with the question of a differential diagnosis
between attentional disorder and a bipolar affective disorder. Having ruled
out appreciable neuropsychological deficit that would have been sufficient to
account for the patient’s symptom picture and history, the examination cen-
tered on the pattern of psychopathology and personality suggesting distinctive
affective and personality disorder characteristics. Diagnostically, there was rea-
sonable evidence to consider there being an affective syndrome superimposed
on a personality disorder. Some clinicians might consider the depressive and
hypomanic indications to be subclinical, others might regard them as sugges-
tive but subthreshold from a clinical diagnostic standpoint, and others might
regard the test signs of affective disturbance as predominant manifestations of
a personality disorder. I was particularly interested in the affective indications
because, although they suggested subtle depressive and hypomanic features,
the test findings did not suggest that either affective polarity was unequivocally
prominent.
Some may regard the bipolar indications I called attention to in this case as
too speculative; nevertheless, I would argue that their subtle nature is consistent
with a quality of bipolarity or mood dysregulation that could easily be over-
looked entirely in a diagnostic examination. This is precisely what is meant by
a so-called “soft bipolar spectrum” that has attracted clinical interest in recent
years—particularly inasmuch as its features, including overactivity, may be
clinically indistinct from prominent attention deficit (ADD) and/or hyperactiv-
ity (ADHD) disorder symptoms.
in Adolescence
Many psychological perspectives on adolescent development regard this often

turbulent period of life as one of transition between childhood and adulthood
(Larsen & McKinley, 1995; Offer et al., 1981). Whether or not the appearance of
oppositionality, rebelliousness, or alienation are present either in normal devel-
opment or as part of a clinical presentation, adolescence is a stage of life when
consolidating identity and values is a fundamental task, and it also is a period
during which complex cognitive and social-interpersonal growth proceeds at an
accelerated rate. Although many adolescents appear to demonstrate periodic
phase-specific stresses in such areas, most do not appear to present clinically
significant difficulties or sustained problems maintaining affectionate or coop-
erative relationships with parents, friends, and teachers (Kimmel & Weiner,
1995; Offer et al., 1981). Nevertheless, difficulties establishing efficacious peer
relationships and mature patterns of communication may place adolescents at
risk for personality problems or psychopathology—including internalized defi-
cits such as depression or isolation, or externalizations of maladjustment such
as delinquent or antisocial behavior (Kimmel & Weiner, 1995).
Psychoanalysis has in the main devoted relatively sparse attention to both
normal developmental strivings during adolescence and pathological manifes-
tations of this life period. Freud had little to say on the subject beyond its rela-
tionship to the latency period and the maturation of psychosexual stages. Anna
Freud (1965) devoted greater attention to problems of adolescent development,
according greater importance to puberty as an influence on character structure
in conjunction with the structural theory’s emphasis on maturation and inte-
gration of ego functions. Erikson (1950) regarded psychological development
as an ongoing process throughout life, one that was not confined exclusively to
psychosexual stages and the libido theory. He stressed the importance of estab-
lishing a stable sense of identity during adolescence, including consolidating
values and ideals, and thereby securing a self concept with continuity between
past and future.
Among the most influential psychoanalytic contributions to the study of
adolescence was Blos’s work (1962, 1968), which like Erikson’s considered ado-
lescence as part of a framework of normal psychological development, particu-
larly in respect to development of character structure. Blos articulated a series
Personality Problems in Adolescence 77
of developmental challenges involving the relations between ego and drive
functions following resolution of the Oedipal configuration that was central
to Freud’s drive and structural theories. In Blos’s view of adolescence, there
occurred a regressive reemergence of pre-Oedipal instinctual drives that led
to a more stable resolution of the Oedipal conflict than the original childhood
resolution. Blos (1967) regarded this resolution, which he termed the second
individuation process of adolescence, as achieving a solidified balance between ego
and superego.
The case below is somewhat unique because the patient appeared suffi-
ciently well functioning not to trigger a need for clinical attention. However,
this 15-year-old boy sought a referral for treatment on his own accord. It could
be said that he fell at an intersection between what might appear to have been
a relatively normal progression of adolescent development and a pathological
process straddling the fence between a depressive syndrome and an emerging
personality disorder. I will revisit this patient in Chapter 6, to discuss a reevalu-
ation of the personality assessment findings after ten years, when the patient
was a 25-year-old young adult.
This chapter sets out the case of this adolescent boy who presented with
complaints of depression accompanied by somatic-vegetative signs, but also
with troubling thoughts and dreams dominated by anger and destructiveness.
This youngster, named Carl, was a 15-year-old Caucasian high school sopho-
more, living with both parents and an older brother. Carl began to experience
unrelenting feelings of frustration about the pointlessness of doing schoolwork
soon after the beginning of the current school year. He recognized that he was
depressed and spoke to his mother about seeking treatment. Carl also reported
insomnia three or more times each week, diminished appetite, and slowed
concentration. His main affect states besides subjective depression, boredom,
and lethargy (mainly centered around being at school and doing homework)
included periodic upsurges of anger which left him feeling agitated. However,
he did not see himself as on the verge of losing self-control despite the fact
that he was troubled that many of his thoughts and dreams were “weird,”
containing content concerning violence such as killing teachers he disliked or
scenes of war.
Carl believed that his teachers picked on him and he was concerned how
he fit in with his friends, believing they were less interested in being his friend.
He also commented that he thought his father was too tired or depressed to
show much interest in him. Carl felt hopeless about the future, anticipating that
because he had no interest in any particular line of work he would wind up with
a boring, unsatisfying job after finishing high school, remaining stuck at such a
job for the rest of his life. Because he was lethargic and disinterested in school,
Carl anticipated doing poorly academically, in spite of his grades having been
at least average in middle and elementary school. He felt that now that he was
in high school, he should have some idea about what he wanted to do in life.
I treated Carl in a weekly psychotherapy extending over a period of nine
months. I administered a personality assessment as part of an initial treatment
plan to ascertain whether a psychotic or developing borderline disorder under-
lay his destructive fantasies, and more generally to evaluate Carl’s capacity for
impulse control, resiliency of ego functions, and to understand the meaning
of his angry thoughts and dreams. Shortly after completing the psychological
assessment, I referred Carl to a psychiatrist for a medication consultation. The
psychiatrist prescribed sertraline (Zoloft®)) 25 mg. q.d., and Carl showed a favo-
rable response to this dose, which he continued throughout the period of time
I saw him in treatment. I had one follow-up session with him about six weeks
after the start of his junior year in high school. I briefly discuss the course of
psychotherapy later in this chapter.
Minnesota Multiphasic Personality Inventory (MMPI-A)

Validity indicators revealed elevated F and F1 scales (T = 60 and 70, respec-
tively; F2 was unremarkable) suggesting a mild tendency to endorse extreme
symptoms or problems. This implied inconsistency of responding, a reading
problem, or exaggerating symptoms. Carl’s scores on VRIN and TRIN were
within normal limits, which argued against the likelihood of response inconsist-
ency or reading problems. His L and K scales were low (both < T ~ 40), which
together with Carl’s greater than average symptom endorsement suggested a
potential tendency to seek attention about problems.
The main clinical scales revealed a 1–7 configuration (Hs = 79; Pt = 78). The
high Hs represented an infrequently occurring scale elevation in both normative
and clinical populations. The 1–7 configuration with both scales elevated > T =
75 suggested an intense but varied symptom pattern characterized by an anxious,
worrisome nature accompanied by appreciable concerns about health. Carl’s
overall psychological adjustment was potentially compromised by internaliza-
tion of conflict characterized by rigidity and perfectionism, intellectualizing, and
a tendency to experience panic-like reactions easily as well as a variety of anxiety
symptom features. There also were scale elevations on D and Pd (both T = 75),
although all of the clinical scales except Mf were within the 66–70 T score range.
The elevated A (Anxiety) supplementary scale (T = 76) and most of the content
scales (9 were > T = 65, with 3 being ≥ T = 75 (school discomfort, self-esteem,
and aspirations)) suggested appreciable difficulties impacting a broad range of
school-related functions, including low academic performance, disinterest in
participating in school activities, negative attitudes about school and school suc-
cess, possible truancy, and diminished interest in succeeding in school beyond
socializing with friends. However, Carl’s socially distant nature seemed to make
it hard for others to get to know him, and he apparently did not feel liked or
understood. He also appeared to have difficulty starting projects, being inclined
to give up easily when the work became uninteresting or difficult.
Carl endorsed a number of items reflecting low self-esteem, and he reported
feeling unattractive and that his abilities were limited. Consequently, he believed
he could not do well at anything. He seemed prone to being easily dominated
by others, and he reported symptoms associated with depression alongside
somatic complaints and health concerns. Personality problems as revealed on
the PSY-5 scales indicated that some unusual beliefs might dispose Carl to mis-
interpret events or other people’s actions and that he often felt isolated. Thus,
his elevated Psychoticism scale (T = 67) raised a question about delusional idea-
tion or disordered thinking which, coupled with an elevated Introversion scale
(T = 66) and somewhat high Negative Emotionality scale (T= 60) suggested
that anhedonia and a pessimistic outlook about his life and future added to
Carl’s sense of alienation and ennui.

Carl’s first drawing (Figure 3.1) was more atypical than most. Although he first
drew a figure of the same sex as himself, Carl’s male Figure Drawing was strik-
ing because of its considerable emphasis on brawny, pumped-up arms which
immediately reminded me of the kind of robotic, brainless, menacing-looking
characters represented in cartoons that exist mainly for their brute force—just
exactly the sort of heroic figure some adolescent and pre-adolescent boys might
be inclined to admire. Mindful of the importance of cautiously differentiating
an examiner’s impressions from patients’ own descriptions, I took care to hold

my own association in reserve, though not without allowing it to register inter-
nally for possible interpretive use later on. In this case, however, Carl’s descrip-
tion of the figure was remarkably close to my own impression.
Some type of warrior type dude. Like a soldier, in really good shape and eager to blow stuff
up or something. He’s mellowed, but when he has to be he can get nuts.
(Nuts?) Extremes of mood, if he’s attacked by something. If he’s like a soldier and
attacked by the enemy, he’ll defend himself.
(Eager to blow stuff up?) You know, like to get into a war or whatever. Like that
movie “The Fight Club,” I saw it the day it came out. He hates his job and moves in with
Brad Pitt and they just beat each other up, and even though they’re fighting each other they
feel there’s a point of their existence. They didn’t have Vietnam or a Depression or World
War II where everything in their life revolves around that. I don’t have anything like that
either that defines my life.
(What does fighting do for them?) They don’t think about anything when they
fight—or like me when I’m playing video games—you’re like a general in the army and
you have to blow the other guys up and your whole point of being is to win.
I then asked Carl what made the person in the drawing anxious or fearful, and he
at first said, “ Nothing.” I queried by rephrasing the question, to which he said:
He doesn’t care about anything. He doesn’t like to be bored, he always wants to do

something.
Although he still did not address the question, I decided at this point to leave it
be in spite of Carl’s apparent ability to become engaged with the projective fan-
tasy stimulated by the drawing. I then proceeded to ask what made the person
sad or depressed, to which he said:
Not having anything to do. If his commander tells him something like he should open up
boxes, he’s bored out of his mind. But if he’s told to fight or something like confront the
enemy then he’s entertained.
Carl’s description of a “warrior type dude” was consistent with my impres-

sion from looking at the drawing: this soldier stood ready “to blow stuff up.”
But he then surprisingly volunteered that the warrior-soldier was “mellowed,”
immediately adding that “when he has to be, he can get nuts.” This youngster
seemed to be saying that to “get nuts . . . blow stuff up” was for a self-protective
purpose—as needed rather than as a characteristically impulsive, aggressive
urge. He appeared to emphasize its function as a state of readiness or being
prepared for attack, implying that the soldier-warrior figure was not by nature
combative, which is what he may have meant by “mellowed.” Carl may have
been drawn to the warrior image for its vigor and robustness as an aspect of
male identification, possibly representing an idealization of something noble or
strong. Even the word warrior seemed to connote commanding respect; it did
not appear to be associated primarily with aggression or force.
Moreover, although Carl’s association to the film Fight Club at first suggested
brutish hostility, as he elaborated it further that connotation quickly changed
to one suggesting that the brute force represented by fighting was little more
than male bravado. That is, the core of the fighting for its own sake might have
been an attempt to carve out a meaningful purpose in life such that “there’s
a point of their existence.” The film evidently meant a lot to him because he
commented that he saw it as soon as it was released. Most importantly, Carl
was insightful insofar as he seemed to recognize that he was talking about his
own need to have something he could point to “that defines my life.” He spon-
taneously introduced this insight himself, indicating that it was readily acces-
sible and stabilizing for him. It was also prognostically important because a
capacity for insight might be mobilized in treatment to show him that fantasies
of destructiveness and force might defensively conceal vulnerable self-esteem
concerns not far from the surface of his experience about what it means to be
an effective man.
Thus, Carl did not appear essentially as an angry, disinhibited young man
with a short fuse ready to go “nuts” at the slightest provocation, notwithstand-
ing the possibility that he might experience “extremes of mood.” In this way,
I modified my first impression based on looking at the drawing—a cartoonish
image of a brainless brute ready to pick a fight—to one more like that of the
kinds of dogs often preferred as guard dogs that make a lot of angrily threaten-
ing noise but quickly become docile once they are made to feel assured that a
threat is not real. At this point, I would not have said that I was yet ready to see
Carl as a docile, sweet-natured young man playing a character in Fight Club, but
neither did I feel that I was dealing with an explosive powder keg of uninhibited
rage that could potentially come apart at the seams.
It also seemed evident that Carl either was not responding to my questions
about affects, for reasons I could not at this point understand but also felt it best
not to pursue too vigorously; or alternatively, he might have filtered my ques-
tions asking him to differentiate among affect states into a single emotion—
boredom. He seemed to experience this affect regularly, often feeling unenthu-
siastic but wishing to feel more enlivened. He faulted those in authority (such as
the soldier’s commanding officer, or when he slipped into his own sentiments
about not liking teachers), conveying the painfulness of feeling “you’re ruining
or wasting your time and it’s the most horrible waste there is.”
In contrast to this drawing, Carl’s drawing of a female (Figure 3.2) was gener-
ally unremarkable. His description of the drawing was as follows:
She’s happy. I don’t know, I can’t make up as much stuff.

(Encouraged him to say some more) She isn’t as deep as him. Just everyday stuff.
She doesn’t ponder the meaning of life or stuff. She just thinks and reacts. She’s not as
deep as him, the soldier. He analyzes everything, she won’t.
(What does she think/feel?) Nothing much, just everyday stuff. She probably just
has a boring job or stuff.
Carl’s verbalization was considerably more sparse than that for the male draw-
ing. Furthermore, the female was defined almost entirely in comparison to the
male. Although the verbalization accompanying this drawing suggested a simi-
lar state of quiet desperation as that of the soldier he described earlier, Carl
seemed less interested in fleshing out the woman’s psychological motivations.
However, as little as he said, he did nevertheless manage to say, twice, that
“she’s not as deep as him.” Perhaps Carl was at a stage of life in which he
was too unaware of or uncertain about what women or girls were like; thus
his experience or involvement with them might have been too limited to
imagine much about women’s needs or motives. Carl did convey the same
degree of disaffection about the female drawing as he did about the male Fig-
ure Drawing, but apart from that probably all that could be said was that his
level of interest or awareness was still premature. Perhaps what might be dis-
cerned from this description was that this young man’s understanding about
motivations and psychological states was focused almost entirely on himself as
he struggled to make sense of what he felt internally and how he was progress-
ing in developing a male identification. A self-absorbed preoccupation like this
would not appear at all atypical during this period of adolescence.
Rorschach
Figures 3.3 and 3.4 show the Rorschach location sheet for Carl and his CS
Sequence of Scores, followed by Carl’s Structural Summary (Figure 3.5) and a

I 1 Do 1 Fo 2 Hd PHR
2 D+ 1 Mau 2 (H),Cg 4.0 DR, PHR
II 3 D+ 3 Mp.mp.FC’- (Ad),Hx 3.0 MOR, PHR
III 4 D+ 1 Mpo 2 H,Hh,Sx P 3.0 GHR
5 Do 3 Fu An
IV 6 Wo 1 FVo (A) 2.0
V 7 Wo 1 FMa.FDo A P 1.0
VI 8 Wo 1 Fo Ad P 2.5 MOR
VII 9 D+ 2 Mpo 2 Hd,Cg P 3.0 COP, GHR
10 Do 4 FD- Id
VIII 11 W+ 1 Ma.mp.CF- 2 A,An,Fi 4.5 MOR, DR2,
FAB, AG,
PHR
IX 12 D+ 2 Mp.mp- 2 H,Ad,Hh 2.5 INC2, PHR
13 Do 6 FC- An MOR
X 14 Dd+ 21 CF.mp- (Hd),Bl,Cg 4.0 MOR, PHR
15 Do 2 FCo 2 Bt MOR
16 D+ 7 mp.CFu 2 A,Fi,Id 4.0 FAB, MOR
17 Dv 13 C.Y Fi
18 D+ 1 FC.FMau Bt,(A) 4.0
R = 18 L = 0.20 FC:CF+C = 3:4 COP = 1 AG = 1

-------------------------------------------------------------- GHR:PHR = 2:6
Pure C = 1
EB = 6 : 6.0 EA = 12.0 EBPer = N/A a:p = 4:9
eb = 7 : 3 es = 10 D = 0
Adj es = 6 Adj D = +2 Afr = 0.80 SumT = 0
-------------------------------------------------------------- S = 0 Human Content = 6
Pure H = 2
m = 5 SumV = 1 SumY = 1 PER = 0
--------------------------------------------------------------
a:p = 4 :9 Sum6 = 5 XA% = 0.61 Zf = 12 3r+(2)/R = 0.44

MOR = 7 M- =3 S- =0 Zd = –0.5 FD =2
M none = 0
X+% = 0.39 DQ+ =9 MOR =7
Xu% = 0.22 DQv =1 H:(H)+Hd+(Hd) =2:4
PTI = 4 DEPI = 4 CDI = 2 S-CON = 5 HVI = No OBS = No

synopsis of its main interpretive findings. This is followed by a detailed analysis
of content.
Carl produced an interpretively valid protocol, which contained one signifi-
cant constellation (PTI ). Notwithstanding his chief complaint of depression
and anxiety, DEPI was not elevated. He demonstrated an ambitent coping
style, characterized by vacillating inconsistently between ideation and emo-
tional responsiveness as the major modes of responding to events impacting
his psychological life. Although coping skills were not appreciably under-
mined, dealing with life demands more predictably and thus beneficially
seemed to elude him.
Thinking and concentration could be compromised at times, and thus
other people might occasionally not fully comprehend certain of his thoughts
or actions. Carl was prone to intrusive thoughts that he experienced as trou-
blesome but which he could generally manage effectively. Such thoughts typi-
cally concerned unmet needs or involved people or events unduly influencing
him, about which he could be rigid or have a closed mind. His thinking also
leaned toward escapist fantasies rather than realistic problem-solving. Carl
could thus allow his imagination to hold sway, consequently distorting how
he understood the meanings of situations or others’ actions. Accordingly, he
could abandon acting responsibly in favor of giving in to feeling helpless or
dependent when he felt manipulated. He could as a result feel pessimistic
about his fate and discouraged that any good might come from his efforts to
turn things around for himself. Consequently, Carl’s tendency to misinterpret
others’ intentions interfered with thinking logically and clearly, ultimately
confusing others just as he himself could appear confused about his thoughts
or feeling states. The quality of his thinking was more immature than it was
idiosyncratic or grossly disordered.
Carl showed a well-developed degree of openness to experience, both inter-
nally and in respect to events in his surround. He was drawn to ambiguous
situations, and he could be inclined to make interactions with people or events
less straightforward and more complex than they needed to be. Although Carl
might wish to take in wide-ranging interests that attracted him, he could also
fall short of striving to reach ambitious aspirations he set for himself. He showed
a good balance between being self-interested and remaining aware of others;
however, his self-awareness could sometimes lead him to be overly self-critical,
contributing to dysphoric mood.
Adaptive ego assets functioned adequately for this boy, despite his feeling
that being unable to control or manage inner distress was getting the better
of him. He could be vulnerable, however, to expressing somewhat intense,
unmodulated affective experiences that he might freely vent as they emerged.
Although unconstrained emotionality did not typically get out of hand for
him, Carl could be prone to difficulties surrounding feelings of helplessness
as he perceived others to be controlling his life, which he himself seemed to
recognize.
Carl also appeared comfortable with a fantasized as well as a realistic sense
of his experience of himself and others; however, identifications did not appear
particularly stable nor did he show a securely based self-image. He also was
likely to intellectualize how he viewed himself, which seemed to extend to
including overly critical or distorted views about his body image. Carl was
interpersonally passive, and he was inclined to accommodate his needs to
those of others. He tended to have others make decisions for him despite
simultaneously feeling distant from, rather than close with many people. Carl
showed no particular disinterest in other people, although he could feel uneasy
interpersonally and sometimes threatened. Carl was not distanced from affect
states, nor was he particularly uncomfortable with experiencing or expressing
emotions.

The Sequence of Scores is represented in Figure 3.6 and the Page 1 variables
are shown in Figure 3.7. Carl’s primary problem appeared to concern aber-
rant thinking, mainly associated with preoccupations with damage or destruc-
tion. However, although the impact of these concerns appeared substantial, an
R-PAS interpretation of this area of functioning remains tentative at the
present stage of understanding and interpreting adolescent norms for some of
the important elevated variables such as EII and TP-Comp (Thought and
ODL R-
(RP) Opt
I 1 @ D 1 Hd 2 o F AGM PH
2 D 1 (H),Cg Sy 2 u Ma DR1 PH
II 3 D 3 (Ad) Sy - Mp,mp,C’ MOR PH
III 4 D 1 H,Sx,NC Sy 2 o P Mp GH ODL
5 D 3 An u F ODL
IV 6 W (A) o V AGC
V 7 W A o P FMa,FD
VI 8 W Ad o P F MOR,MAP
VII 9 D 2 Hd,Cg Sy 2 o P Mp COP,MAP GH
10 D 4 NC - FD
VIII 11 W A,An,Fi Sy 2 - Ma,mp,CF DR2,FAB1 AGM,MOR,MAP PH
IX 12 D 2 H,Ad,NC Sy 2 - Mp,mp INC2 PH
13 D 6 An - FC MOR ODL
X 14 Dd 21 (H),BI,Cg Sy - mp,CF AGC,MOR PH
15 D 2 NC 2 o FC MOR
16 D 7 A,Fi,NC Sy 2 u mp,CF FAB1 AGC,MOR
17 D 13 Fi Vg n C,Y
18 D 1 (A),NC Sy u FMa,FC AGC


Pr 0 Pr
Pu 0 Pu
R (Responses) 18 39 96 11 80 R
Blend 8 91 120 83 115 Bln
Sy 9 80 113 65 106 Sy
MC 12.0 91 120 84 115 MC
MC - PPD 2.0 83 114 85 115 MC-PPD
M 6 85 115 73 109 M
M/MC [6/12.0] 50% 43 97 45 98 M Prp
(CF+C)/SumC [4/7] 57% 56 102 56 102 CFC Prp
EII-3 2.5 99 135 99 134 EII
WSumCog 21 93 123 91 120 WCog
SevCog 2 93 122 93 122 Sev
FQ-% CS FQ 33% 91 120 91 120 FQ-%
WD-% CS FQ 29% 89 119 89 119 WD-%
FQ-% CS FQ 39% 19 87 21 88 FQo%
P 4 25 90 18 86 P
m 5 96 126 94 124 m
Y 1 52 101 43 97 Y
MOR 7 >99 139 89 138 MOR
ODL% 17% 82 114 82 114 ODL%
MAP/MAHP [3/3] 100% 95 125 85 125 MAP Prp
PHR/GPHR [6/8] 25% 92 121 90 119 PHR Prp
M- 0 96 122 95 125 M-
AGC 4 71 108 88 106 AGC
H 2 49 100 35 94 H
COP 1 58 103 59 104 COP
MAH 0 26 90 26 90 MAH

Perception Composite). Nevertheless, there was good reason to infer that a

disturbed view concerning how he regarded himself and perceived or related to
others underlay many of his thinking problems.
Carl appeared to show a high level of mental energy (M, Blends, Sy, MC,
MC-PPD) that could potentially represent a favorable indication of utilizing
available ego resources; however, his functioning could still appear substan-
tially compromised (half of his human movement responses were FQ–, and he
had one C response). Although the indications in this record pointed to mod-
erately pronounced distortions of thinking, it also was possible that a provoca-
tive playfulness or exaggerated dramatizing of distress states could account
for at least some of the more disordered thinking he could show, including
the morbid, destructive ideation that appeared rather often in the Rorschach
protocol. Further, distorted impressions about his own need states and other
people’s motivations could have contributed more to interpersonal problems with
people than did primarily aggressive impulses or pathological dependency. The
very high number of morbid (MOR) codes included two of this boy’s three M
responses that were associated with a MOR code (which also were coded as
FQ–). However, the pathological significance of several important variables
may be questionable until there is greater certainty about normative reference
values for child and adolescent records.
Carl’s appreciable thinking and perception problems, including an inclina-
tion to misinterpret others’ intentions, were consistent with his sole elevated
constellation (PTI) on the CS. The CS finding regarding a predominantly
ambitent coping style, vacillating inconsistently between thinking through
and reacting emotionally to situations precipitating stress, might be consist-
ent with Carl’s elevated EII on the R-PAS. However, interpreting EII in
adolescent patients also remains uncertain because the normative reference
values are not yet firmly established. (The same problem exists for the CS;
thus its emphasis on coping skills not appearing appreciably undermined also
was tentative, in spite of Carl’s inclination to react unpredictably and conse-
quently not always in the most optimal manner to life demands.) It also was
likely that Carl’s thinking was more immature than disordered, a possibility
that was scrutinized carefully in the response-by-response content analysis
that follows. Both the CS and R-PAS detected Carl’s feeling helpless or that
circumstances in his life could provoke his feeling less than a desirable level
of control; however, once again, substantiating this inference must await
further research on normative values before arriving at a more unequivocal
conclusion.
Openness to complex or ambiguous experience as judged from the CS was
generally consistent with the level of complexity seen on the R-PAS; however,
Carl’s interactions with people appeared to be more complex than many situa-
tions called for. The balance Carl showed between self-interest and an aware-
ness of others’ needs was comparable in both approaches.
Card I
1. It’s not much of anything. Can I look The shape of hands, the thumb and fin-
at it this way? [∨∧] Two hands. gers together.
——————
Like getting ready to fight, the way the
hands are going off like that.
2. Monsters, maybe. Demons. I don’t The head, torso, skinny waist. Like a
know if they’re hugging or attacking. dress-type bottom, like a skirt. And they
They have wings. I can’t really tell if have boots on. Or they could be going like
they’re angels or monsters, just something they’re ready to fight when they get real
with wings. close to each other, like arch enemies type
of thing.
(Monsters, demons, angels or
monsters?) They look cool and they
always have wings, and you can’t tell if
it’s angel wings or demon wings. Either
way they’re humanoid. You can’t tell.
Like the movie “The Prophecy.” It’s like
a civil war of the monsters. Raphael’s the
archangel and he’s mad at God and he’s
rebelling because he thinks God loves the
humans more than the angels. And he and
the rebel angels get into a fight with the
other angels.
(Hugging or attacking?) They could
be hugging but I think they’re going to
attack. They’re not attacking but they’re
about to, like they’re standing off each
other.
(Standing off each other?) Like they
have some kind of reason to hate each
other and they just want to fight, like they
have to fight. Like a final showdown type
thing.
It was certainly a far cry from Carl’s opening comment (“it’s not much of any-
thing”) to the “civil war of monsters” he ended up with by the time he had fin-
ished Card I! His initial comment suggested difficulty making sense of the amor-
phous figure; however, in short order he certainly had no trouble doing what the
Rorschach asks of people. Carl’s question (“can I look at it this way?”), while on
the face of it asking me how much liberty he had in the situation, also seemed to
be asking permission to allow himself free rein to make the Rorschach situation
his own.
He began innocuously enough with a response of hands—a response of good
form quality albeit one that is rarely reported in isolation from a larger figure.
The shift from this straightforward percept to one of monsters or angels ini-
tially described as hugging or attacking appeared to represent feeling betwixt
and between contradictory sentiments, perhaps best represented when he
said “they’re ready to fight when they get real close to each other.” Indicating
more than the ambivalence represented by opposing sentiments pitting good
against bad, Carl seemed to be expressing that intimacy was intertwined with
aggression. While not necessarily illustrating splitting of all-good and all-bad
object representations (Kernberg, 1975)—a pre-ambivalent position—Carl
seemed to be conveying the idea that what might be construed as intimate
or perhaps stereotypic feminine qualities (hugging, dress-type skirt, closeness
to each other) could not easily be kept separate from connotations reflecting
fighting or adversarial qualities. Certainly, confusion and uncertainty seemed
to underlie how Carl experienced potent affect states.
This adolescent boy may have tried to make light of his uneasiness by
defensively whistling in the dark (“they look cool”), diminishing its impor-
tance (once again his opening comment, “it’s not much of anything” and
his cute-sounding or possibly smart-alecky reference to “a civil war of the
monsters”), or distancing himself from his experience (“either way they’re
humanoid”). He may also have tried to deal with his confusion or discomfort
by intellectualizing, another form of emotional distancing, when he referred
to a conflict between God and the archangel Raphael, rebelling against a
higher or supreme authority over the love of angels vs. mankind, and angels
in conflict with “rebel angels.” When I addressed what might have passed for
his ambivalence with the inquiry question about hugging or attacking, Carl
seemed to stand back somewhat from the connotation of aggression (“I think
they’re going to attack”; “they’re not attacking but are about to”)—but not
entirely (“they’re standing off each other”). My further challenge of his appar-
ent compromise position of a standoff led to his expressing what I regarded
as a feeling of inevitability about the outcome (“they have . . . reason to hate
each other . . . they have to fight”) in which Carl seemed to convince himself
that hostile urges had a certain legitimacy about them. Whatever underlay
what I presumed to reflect his discomfort with aggression remained unclear at
this point, but what may be more pertinent at this still fairly early phase of the
personality evaluation was how uneasy Carl could feel about unacceptable
impulses and the defensive maneuvers he developed to conceal or manage
aggression.
Understandably, many adolescents on the threshold of adulthood find asser-
tive, rebellious, and even overtly aggressive feeling states difficult to compre-
hend. Indeed, normal adolescence is for many a period of discovering how
to deal with and understand potent affect states. Such emotional confusion
or uncertainty creates further difficulty in knowing how to express or contain
impulses while still being dependent on adult authorities for protection and
support. It was not possible at this point to clearly interpret this second response
(R2) as a normal or pathological manifestation of adolescent development, a
decision that would begin to emerge as interpreting the protocol continued to
unfold.1
Card II
3. Which way should I look at it? It’s The nose looks like a reptilian nose, the
kind of a face at the bottom, like a crying crying eyes, and the dragon has those
dragon. Like it’s upset about something. things coming down from its chin. The
You know, like a Chinese dragon. The black stuff could be smoke coming down
rest doesn’t look like much. from its nose, but I don’t think it is.
(Crying dragon?) Because it goes down
like it’s sad and it’s eyes are closed.
——————
Maybe his kid dragon died or something,
like maybe someone dying.
(Crying dragon?) A paradox, like a
powerful giant thing reduced to tears. (Q)
I feel like I’m enemies with my school and
there’s no way I could beat my school.
And I wish there was some way I could
reduce the giant powerful thing to tears.
Like it’s something stronger than you. You
want to stop it but you can’t.
Carl’s passing question before he delivered his response to Card II (“which

way should I look at it?”) seemed to shift subtly from the question he asked
at the start of Card I about gauging how far he could go with responding to
the inkblot. Here, at the start of Card II, Carl was more uncertain. He no
longer was asking for permission; rather, he seemed to be asking for direc-
tion. I wondered whether he was surprised if not even alarmed by what he
was seeing, and that he now was asking for help about how to proceed. The
only assistance he received was the usual “it’s up to you,” and the response
he produced (a crying dragon) undoubtedly continued exposing a psycho-
logically salient and evidently disturbing affect state. His closing comment
(“the rest doesn’t look like much”) recalled his opening comment before the
start of Card I (“it’s not much of anything”). Of course, it simply could have
been his manner of speaking or a comment about trying to make sense of the
amorphous inkblots, but it was equally plausible that Carl’s comment at this
point reflected his having had enough and that he might not want to provoke
any further disturbing affects. In either case, the comment was worth noting
and remembering.
It also was noteworthy that Carl perceived achromatic color when he men-
tioned black smoke, but then added, “but I don’t think it is.” This determinant
was not mentioned during the response phase and it first occurred at the end of
the initial clarification part of the inquiry. Moreover, in an effort to take back
what he saw, Carl attempted to minimize if not actually disavow that the black
color influenced his seeing the area as a crying dragon. He seemed to be trying
to distance himself from the affective experience of sadness inasmuch as the
dragon’s eyes were closed and he made a tentative reference to death. Carl may
have been conveying how difficult it was for him to tolerate distressing affect
states, which he appeared to allow into his experience only tentatively before
attempting to purge them as best he might.
Carl seemed to experience the image of “a powerful giant reduced to tears”
as a “paradox”—an apparent incongruity he could not easily resolve. The
commanding figure represented by the dragon had been weakened; from this
imagery, Carl’s associations led to his problems with his life at school, talking
about his existence there as undermining. He wished to overcome the situation
by beating it down, seeming to equate the school system he could not success-
fully “beat” as a “powerful giant” he wished to take down in defeat but felt
unable to stave off.
It was beginning to sound like the “civil war of the monsters” he described
so metaphorically on Card I—with sides drawn up and braced to do bat-
tle against enemies—signifying an adolescent representation of life and its
struggles in Carl’s mind. Winning seemed to mean having to fight for his
autonomy against a powerful force he felt unable to stand up against. For
Carl, coming into his own appeared to mean having to overcome a loom-
ing giant and “reduce it to tears” in order for him to feel that he could hold
his own.
Card III
4. Two women and a big pot in front The breasts in front. They’re bent over a
of them. They’re leaning over it or table or a pot or a rock. I don’t know what
something. they’re doing, they’re just looking at it.
5. Some kind of organ or something, like They just have those shapes.
a stomach with an esophagus, and maybe ——————
kidneys or something. Like they were taken out of a body or
something, from a dead person. They’re
not in a person so they had to get taken
out somehow.
Carl seemed to settle down with his first response to Card III, a conventional
percept with no notable elaboration. His noting that the figures were female
because of the breasts was not particularly unusual; this was supported fur-
ther by the GHR code for good human representation, good form quality,
and there being no special scores (although it received a thematic code for
ODL using R-PAS). His next response also seemed unremarkable, despite
the FQu code. I often ask for additional elaboration of anatomical responses
when testing limits because such percepts tend to provide clues about self
states or more generally, a sense of bodily integrity or somatic manifestations
of psychological states that are not easily expressed. In this testing-the-limits
inquiry, Carl used the phrase “taken out” twice, which appeared to place
some degree of emphasis on these organs being removed from the body they
came from.
Perhaps what was most striking about this card, as well as the previous card,
was the absence of color determinants. While that is uncommon but not nec-
essarily unusual in a context of few or no color determinants representing a
defense against affective overstimulation, I was not as inclined to dismiss the
absence of color in Carl’s responses to Cards II and III because the content
and fantasy material of his earlier responses provided compelling indications of
appreciable affective involvement. It also is quite possible that affective involve-
ment or stimulation need not be represented solely by the use of color as a
determinant.
To be sure, Carl’s verbalizations during the testing-the-limits inquiry
suggested that there was far greater affective responsiveness than absent
color determinants might imply. His opening response to Card I (hands)—
while innocent enough by itself—led to a reference to fighting, and the
response that followed the percept of hands was about monsters, which alter-
nated between the monsters attacking and hugging. Even what might be
construed as a standoff as a compromise position did not entirely keep Carl
from seeing aggressive intent in these figures representing enemies. Card
II continued the theme of enemies—though only when the inquiry probed
further upon testing limits—yet Carl’s original association of a crying dragon
also made it clear that this youngster’s affective experience was hardly
silent and out of his awareness. He may through various defensive positions
have attempted to keep his affective experience contained and present only
in the background—what I like to refer to as a slow simmer—especially on
Cards II and III where the striking red color is particularly provocative
and difficult to ignore. That Carl could keep salient affect states in check is
surely important, which speaks to the intactness of defenses and ego func-
tions operating to balance reality demands with affective urges. Of course,
containing affective expression does not imply that intense affective upsurges
were absent or that they were not salient features of this boy’s internal
experience.
Card IV
6. It looks like kind of a big Godzilla-like The bottom of his feet and it’s a different
monster. You’re looking up from below, color and shading. And that’s the view,
like he’s standing over you. He’s got a tail like 3D. The tail and you just see this
and claws part. These claws or tentacles are like
droopy things that must hang down in
front. A weird-looking head. Just like a
big freaky monster dude.
(That’s the view, like 3D) The lighter
and the darker, when you’re drawing.
Like if you want to make a 3D effect.
(Standing over you) That’s the view.
The way the ink falls on the card. Because
you see the bottom of his foot and it makes
it seem like he’s positioned over you.
——————
Like he’s real goofy. I wouldn’t be scared
of him. He’s real cheesy, not very threat-
ening. Like those angels in the other pic-
ture—that would be threatening. But this
is stupid-looking.
This card contained Carl’s first use of determinants other than form or move-
ment. Vista, suggestive of a painful sense of looking inward, often connotes
experiencing self-depreciation, and on this response it appeared in the con-
text of a percept of another monster figure—initially appearing to be standing
above, requiring that an observer would have to look at the monster from a
subordinate position. Before long, however, Carl seemed to immobilize this
figure that first seemed to appear dominating: it was now reduced to having
“droopy” appendages and being “weird-looking . . . a big freaky monster
dude”—almost like a pal he might get a kick out of being around to pass the
time.
Carl added two additional comments of some note during the testing-the-
limits inquiry. First, the monster was “goofy . . . stupid-looking,” which not only
was consistent with cutting the monster down to size, but in addition seemed to
further denigrate the figure. Secondly, he volunteered that it was not threaten-
ing and that he had no fear of this monster, differentiating it from something
he found threatening about the angels/monsters he described previously on
Card II as enemies preparing to fight it out in a final showdown. Reminiscent
of the comment he made on the testing-the-limits inquiry on Card II (“I wish
there was some way I could reduce the great powerful thing to tears . . . you
want to stop it but you can’t”), I speculated that in a subtle, disguised way Carl
might have been conveying through this vista determinant something further
concerning the emotional threat he experienced when he felt dominated or
overcome by others’ power. Moreover, and still speculative at this fairly early
point in the evaluation, Carl may have signaled how in response to feeling
diminished he might wish to turn the tables around and immobilize or devalue
potentially threatening objects.
Card V
7. It looks like a bat, or a big bug like a It’s flying. The head, antennae, the wings
moth or a butterfly. And it’s an overhead going out.
view. (Bat or a big bug like a moth or a
butterfly) A bat, probably. It’s flying
and you’re looking down on it. It’s flying
below you.
——————
(Looking down on it; it’s flying
below you) Even though it’s high,
you’re still higher than it. Some kind of
weird symbolism like that.
This response, while conventionally popular, also contained an unusual refer-

ence to perspective concerning the flying bat in respect to an observer. That
is, it seems that an observer should be looking up at the flying animal but
instead “you’re looking down on it . . . it’s flying below you.” Notwithstand-
ing the unusualness of a bat flying below a person watching it, this response
did not receive a cognitive special score because it was not unequivocally
incongruous. But it did seem to demonstrate how important it must have
been for Carl to come out on top. His emphasis on being above the flying bird
undoubtedly must be considered in the context of the response preceding it,
in which Carl described a “big Godzilla . . . you’re looking up from below,
like he’s standing over you.” By the end of the inquiry, however, this looming,
threatening Godzilla monster was considerably diminished—it was reduced
to a “goofy . . . stupid-looking . . . not very threatening . . . freaky monster
dude.” Now on Card V, Carl seemed to relish how he was on top and he was
intent on staying there.
Note also that Carl was at first undecided whether the figure was a bat or a
smaller, weaker creature such as a moth or butterfly. When during the inquiry
I asked which he saw, Carl decided on the bat—a potentially more overwhelm-
ing animal than the smaller and relatively innocuous moth or butterfly. I won-
dered whether he by now could feel comfortable seeing a bat because he felt
secure in his ability to keep in check a fear of being dominated or overwhelmed,
as he did when he successfully transformed the Godzilla monster of Card IV
into a goofy, “freaky monster dude” that was incapable of threatening anyone.
Considered also in relation to his response to Card II, Carl seemed to have
found a way to experience himself defeating what he feared might overpower
him (“there’s no way I could beat my school . . . something stronger than you,
you want to stop it but you can’t”) by transforming a powerful dragon into a
crying dragon (“I wish there was some way I could reduce the giant powerful
thing to tears”).
If Carl’s responses to Cards IV and V could be considered a successful
victory from which he emerged triumphant, this sequence of responses also
revealed a phase-appropriate adolescent fantasy of imperturbability and invul-
nerability. On the one hand, it was possible to detect the threat of domination
and control from outside himself and the need to protect himself from being
overcome and thus diminished. This youngster was braced from the outset
for a fight (“hands . . . getting ready to fight”), a fight (albeit with notable
ambivalence) that seemed to represent less about attacking or hostility than it
represented standing up to powerful forces to secure his holding on to a posi-
tion of importance. Though metaphorically disguised as a conflict between
the rebellious archangel Raphael and God over who was the more favored
or valued, Carl appeared to regard the struggle he experienced internally as
one that had to be resolved by drawing up sides in a fight to a showdown.
Adolescence as a time of bucking up against stronger authorities may well be
a step toward autonomy and eventually resolving a conflict between compli-
ance (as being weakened, giving up, or having lost or failed at something
important for sustaining self-esteem) and autonomy (experienced as achiev-
ing a victory or overpowering others perceived as dominating). Framed thus,
Carl’s bracing for a fight appeared to be his solution in fantasy for resolving
this developmental challenge of adolescence, and he appeared to measure
its success by overpowering the forces around him that might potentially
dominate him.
Card VI
8. It looks like an animal skin spread out, It’s spread out to dry it out. Kind of messed
like a rug you’d make out of a dead ani- up. This here is like a tail or something,
mal. That’s about it. nothing real specific.
(Dry it out) Like when you kill a deer
or something, you have to spread it out to
clean it out.
(Messed up) The way they cut it, a lit-
tle jagged.
Card VII
9. Two kids with Indian-like headbands, The hair is curly in front, there’s a head-
with feathers sticking out, looking at each band with a feather, and the nose is in
other. front. They have chubby cheeks, like
baby fat. The neck and chest here, and it
doesn’t show the rest of it.
(Chubby cheeks) Like they were young.
Young, cute-looking kids playing Indian,
and they stopped playing and just said,
“let’s go kill someone.”
10. Like the corner of a box, like you’re It looks like a 3D image. Like a line here
seeing it from the side. I don’t really see and part of a box.
much of the rest of it. (3D image) It just looks like that, the
way a corner looks.
(Show me how you see it) It looks like
it’s only part of what you see, it doesn’t
mean it has to be three-dimensional. It’s
just what a corner looks like.
(Line here) Just because it’s straight
down. The corner of the box.
——————
When I’m in class and bored, and I’ll
draw a square and then another and then
connect them. I do that all the time. It
also looks like razor blades [bottom
third] or kids holding big meat cleavers
[same D area as above plus bottom
third as meat cleavers]. Like a Jef-
frey Dahmer-type thing. I don’t know if
they’re going to fight or something, maybe
they’re just playing, but they’re holding
it. A cartoony-like thing, another funky
paradox: these innocent kids with meat
cleavers, that I don’t think they’re going
to attack each other, but they look at each
other like “let’s go kill somebody.”
This sequence of three responses on Cards VI and VII, while continuing the
theme of fighting and impulse control, also pointed to Carl’s somewhat over-
the-top way of delivering his responses. He managed to convey in his language
and tone considerably ear-catching dramatic or exaggerated provocativeness.
Thus, while he could just have reported seeing a cut-open or spread-out ani-
mal skin on Card VI, Carl went farther than that by adding, “like when you
kill a deer or something,” and in so doing provided a certain added twist that
somehow registers with a Rorschach examiner, however subtly, as just a bit
too much.2 Whether it was adolescent bravado, a whistling-in-the-dark coun-
terphobic nonchalance, or just wanting to say something startling, I was left
with the impression that Carl did not have killing on his mind as much as he
wanted to provoke a listener to pay attention to something about him—possibly
desecration or more likely, vulnerability. This youngster’s earlier description of
internal organs “taken out of a body . . . they’re not in a person so they had to
get taken out somehow” (R5) smacked of a similar cavalier, nonplussed manner
of talking about dissected or dead bodies and body parts. Of course, this might
just have been a manner of speaking having no connotation of being anything
other than that; with adolescents it is always difficult to know when to take cer-
tain verbalizations seriously or when to dismiss them as simply an adolescent’s
bold or fearless thinking.
On the following card, Carl’s responses conveyed an over-the-top provoca-
tiveness not easily overlooked: appearing to arise from nowhere in particular,
both responses ended with a comment to “go out and kill somebody.” In his
first response to Card VII (R9) Carl’s spontaneous comment at the end of the
inquiry about children saying “let’s go kill someone” arrived as a shock all the
more because the response content of children described as having “chubby
cheeks . . . baby fat . . . cute-looking” suggested imagery of an innocent, che-
rubic quality. He made it sound as if the children’s motivation was mainly for
sport; curiously, Carl repeated a nearly identical comment about casually kill-
ing someone in his next response to this card. Although on R10 that comment
appeared at the end of a testing-the-limits inquiry, I wondered whether he
made the provocative comment to be sure that what he said was being heard.
This second response (R10) was notable for several reasons. First, the content
was that of a box—emphasizing seeing mainly just a corner of the box—visual-
ized that way because of its dimensionality (FD). He seemed to be conveying a
feeling of being boxed in or cornered, and his association on a testing-the-limits
inquiry to this unusual response began with a comment about boredom. Carl
thus referenced the main affect state surrounding his chief complaint—leth-
argy or listlessness regarding his experience of school and the directionless,
unmotivated goals he felt about his life and future. He seemed to be conveying
a link between his predominant affective experience of boredom and feeling
psychologically stuck or trapped. Then, Carl suddenly produced an additional
quasi-response (albeit one that technically would not be scored)—razor blades
or children holding meat cleavers.
As he proceeded to describe this image further, it led to an association to a
notorious serial killer (Jeffrey Dahmer) known for murdering and then mutilat-
ing his young male victims. Carl then appeared to take some distance from what
was emerging as he tried to decide whether the figures were playing or attacking
(which was reminiscent of his trying to decide on R2 between demons or angels
and between hugging or attacking), finally commenting that the image was “car-
toony.” Furthermore, as he did on R2 with the allegorical image of the archangel
Raphael in conflict with God, Carl resorted to intellectualizing by describing what
he talked about as “another funky paradox,” not unlike his earlier witty-sounding
side comments such as the “civil war of the monsters” (R2) and “a powerful giant
thing reduced to tears” (R3), which he also prefaced by describing as a “paradox.”
By the time Carl finished with R10—which started out as an innocuous corner of
a box—he appeared to continue the same affect state as that of the responses he
gave to Card VI and his first response to Card VII: hostile impulses emerging sud-
denly and without apparent provocation from an incongruous source (on Card
VI, cherubic children with cute faces playing Indian; and on Card VII, the corner
of a box). It is also possible that the reference to Jeffrey Dahmer—whose gruesome
murders involved mutilation and cannibalism—as well as the somewhat cavalier
way Carl spoke about dead bodies with the organs “taken out of the body” (R5)
and an animal skin “when you kill a deer or something” (R10)—reflected dismiss-
ive, counterphobic reactions to feeling vulnerable himself.
Whether the “innocent kids” with meat cleavers were braced to attack each
other or to kill others (R10), it was difficult to know precisely what Carl meant by
“innocent” in the context of this associative embellishment. Thus, for example,
he could have meant that he felt innocent in the sense that the hostile impulses
on his mind were not his but belonged to others, or that they were innocent in
the sense that children, mainly boys, sometimes have such thoughts but that
they are not serious thoughts. Alternatively, Carl could have been indicating
that the thoughts themselves were innocent, that is to say not seriously intended
or that he was not on the verge of losing control of his actions. It is also possible
that Carl might have seen himself as an innocent victim in the sense that he
felt at the mercy of others’ hostile intentions. It also should not be discounted
that he was talking about his own feeling states that could feel overpowering
or confusing to him—dissociated such that the hostile fantasies were not really
coming from within. Whatever “innocent” meant to Carl, certainly he was try-
ing to signal or convey a sense of feeling troubled, possibly in a provocative way
or with a dramatic flair to make sure he was heard loud and clear. His speak-
ing about over-the-top hostile, murderous impulses thus need not necessarily
reflect Carl’s own fantasies but rather may have functioned as a smokescreen
concealing a belief that he would only be heard if he announced distressing
mental states in a dramatic way that no one could overlook or ignore.
In light of these possibilities, it should not go unnoticed that in the CS approach
the prognostically favorable FD determinant on Response 10, like the similar
form dimension response of a bat “flying below you” on Card V, may suggest
that psychologically vulnerable states were sufficiently accessible to Carl, imply-
ing that he should be amenable to talking about and reflecting on interpretive
meanings in psychotherapy concerning ways he might feel vulnerable. Although
in the CS, FD responses may suggest such a capacity for introspection, in R-PAS
the interpretive significance of this determinant is less clearly established.
Card VIII
11. It looks like two lizards or monkey- The rib cage and its skin like hanging
looking things crawling up the carcass of there and they cut him open. The bones
something dead that’s hanging on some sticking out, and it’s over a fire like they’re
type of fire. A gutted animal and it’s cooking him, and the two things crawling
hanging and they pulled out its insides. on the side.
And they’re crawling up on top of it. (Dead animal cut up) Like he’s hang-
ing on a hook, like maybe tortured or
something. They’re holding the skin, too.
And everything’s ripped out and sort of
hanging there. I guess I’m a morbid kind
of guy. I like to see pictures of dead people,
like I’ll look on web sites for pictures of
murder victims. I don’t think that’s bad,
some people are like that. I’m not like a
gore hound. I wouldn’t go to crime scenes
but I’d look at pictures. I’m sure I’d freak
out if I saw a dead body. I like violence
on computer games, too.
(Fire) I don’t know if it’s to scare him or
to cook him. Like there’s fire to scare him
or they’re executing him.
(Show me how you see it) The red
or orangish colors. It doesn’t have the
shape of it, but I guess it could pass for
fire.
——————
This dude’s like me—I’m tortured
because I hate school and these bizarre
things could be classmates I don’t like,
crawling up over me and ripping me apart
while they’re doing it.
(Fire) Like total humility, some state you
don’t want to be in and you have to claw
up to get away from.
(State you don’t want to be in)
I don’t know, like embarrassment or
unpopularity. And everyone tries to get
away from that. I don’t think they had
to rip out the guts, they could have just
climbed over me.
It is important to note that beginning with Card VIII, seven of the eight
responses to the final group of chromatic cards contained a color determinant.
Indeed, one contained no apparent form content and was thus coded as C, and
three of these responses were coded CF. Carl had no color determinant codes
on the earlier chromatic cards (Cards II and III). Perhaps this youngster’s ini-
tial responses showed greater constraint or inhibition of affect than his later
responses, notwithstanding the disinhibited content contained in his early Ror-
schach responses. As Carl progressed through the cards, however, he seemed
to be continuing down a path of increasingly disinhibited responding. Such dis-
inhibition might even have been more than Carl felt comfortable reporting,
notwithstanding my impression about his appearing shocking or over the top in
order for others to comprehend his distress. This might be one potential expla-
nation for the lack of color determinants on Cards II and III—representing pos-
sibly an effort to constrain affect—and a considerably pronounced use of color as
a determinant on Cards VIII, IX, and X—representing an outpouring of affect,
a good deal of which would not be considered to be well modulated (FC: CF + C
= 3:4). Note, however, that on R-PAS (CF + C)/SumC was within normal limits
(SS = 102). By contrast, the elevated EII-3 (SS = 134) variable, largely an index
of perceptual-thinking anomalies (although normatively uncertain in adoles-
cents), suggested that adaptation—which may include affective modulation—
was vulnerable mainly when thinking selectively impairs adequate functioning.
This boy’s very complex response to Card VIII was in equal parts intriguing
and disturbing. What was disturbing involved this being Carl’s first color-deter-
mined response (and at that, one of his CF responses); its content also implied
unraveling in a way that seemed to escape Carl’s control. The overelaborated,
rich thematic content of R11 also seemed to continue if not actually extend the
transparently revealing concerns that began to appear with particular vividness
on Card VII.
That being said, this response appeared less disturbing when considering the
broad context of the entire protocol thus far. Carl’s preoccupation with morbid
details—including their emphasis or exaggeration—has already been noted in
several of his other responses. Thus, the over-the-top, provocative quality of his
verbalization in this response was no longer particularly shocking or necessarily
difficult to understand. I speculated earlier that this was a youngster who might
feel that in order to be listened to and taken seriously he must announce his
distress indirectly but still loudly and dramatically. Looked at in this way, more
than sounding alarming or as cause for clinical concern, it could be possible to
recognize the lengths to which Carl had to reach for his surround—mainly, one
would suspect, his parents—to listen attentively to his unhappiness and then to
respond empathically to his distress. Certainly it was possible that Carl could
have sacrificed self-control when he felt a need to send such distress signals. On
the other hand, diminished self-control might signify unraveling, consequently
portending a more disturbing decompensation process. However, the gener-
ally adequate adaptive capacities noted on the Structural Summary appeared
to favor a more benign view of this issue. The R-PAS interpretive approach
might result in a more pessimistic view of the matter, suggesting that when his
thinking strays too far from reality or compromises how he interprets people’s
motivations or relates with people, his judgment and effective adjustment may
falter, consequently getting the better of otherwise adaptive ego functions.
With some caution, I lean toward the hypothesis that Carl’s response proc-
ess might be reflecting an exaggerated expression of distress in an environment
that may be characteristically unobservant of relatively subtle indications of
his feeling troubled. Individuals who have learned to expect that their needs
may be ignored, or who experience their caretakers as psychologically limited,
sometimes internalize their distress and consequently withdraw into themselves.
Clinicians, however, are regularly accustomed to listening for subtle signals.
Patients may be surprised that the clinicians they see read their concerns fairly
quickly and often quite accurately. Sooner or later such patients may recognize
that they do not have to shout, because their therapists are not as psychologi-
cally hard of hearing, so to speak, as their caretakers.
This is indeed how I was starting to take the measure of Carl through his
over-the-top expressions of feeling injured and vulnerable. Thus, when he said,
“I guess I’m a morbid kind of guy . . . I don’t think that’s bad, some people
are like that, I’m not like a gore hound,” Carl appeared to realize how he was
sounding and then attempted to reconcile what he felt about himself and how
that might be misconstrued. Probably for a similar reason he went on to say,
“I wouldn’t go to crime scenes but I’d look at pictures. I’m sure I’d freak out if
I saw a dead body.” He seemed more comfortable with the safety of distance
(“I like violence on computer games, too”) than he felt thinking about what
he was describing in this response—which may also explain what appeared to
represent Carl’s distancing himself from the affective intensity expressed in his
previous response (in his reference to meat cleavers, razor blades, and Jeffrey
Dahmer) which in the end he managed to turn into a “cartoony . . . funky para-
dox.” Notwithstanding the DR2 code for the overelaborated, tangential nature
of this extended verbalization, I remain unconvinced that it represented any
fundamentally disordered quality of thinking. Rather, the affective intensity
that underlay the deviant verbalization more likely characterized the intense
degree to which Carl was emotionally stirred as he himself listened to and proc-
essed what he was saying. Quite possibly, his overelaborate wordiness reflected
a need to recover from the affective disconstraint triggered by his response.
Most tellingly, in the testing-the-limits inquiry, Carl expressed what he felt
about his existence quite clearly and unequivocally:
This dude’s like me, I’m tortured because I hate school, and these bizarre things could be
classmates I don’t like crawling up over me and ripping me apart . . . like total humility,
some state you don’t want to be in and you have to claw up to get away from . . . like
embarrassment or unpopularity . . . I don’t think they had to rip out the guts; they could
have just climbed over me.
Thus, feeling tortured, humiliated and embarrassed, and ripped apart, Carl
accordingly spoke of his unhappiness and distress. Nothing was concealed; to
my ear it was perfectly evident to this boy (and to anyone who would listen,
I suspect) that he was talking about a profoundly felt internal state. He had
clearly been building up to this degree of emotional release for several Rorsch-
ach cards already, and it may have been the presence of chromatic color that
provoked the kind of affect that emerged on this response.
The FMa code might connote arousal of drive states and the mp code added
the connotation of an internal tension state possibly related to passivity or feel-
ing helpless. Certainly, the combined effect of these movement codes was con-
sistent with an impression of this boy as emotionally riled up while simultane-
ously experiencing helpless resignation. It also deserves noting that with several
special scores (including MOR and in particular cognitive special score codes
of DR2 and FAB) and a CF code, it would be difficult to imagine that the form
quality of such a response would be anything other than very poor. For a simi-
lar reason, the PHR code was not surprising to see, nor were the MAP and AGM
codes on R-PAS unexpected.
Card IX
12. It kind of looks like a person. Their The person bending over with a deer head
head, they’re looking at you. Their back’s growing out of the person. And like a
here, squatting over. It seems like there’s a blanket type thing in front, blowing in the
deer head coming out the side of it. wind. It’s just weird.
(Deer head growing out of the per-
son) Some freaky mutant thing. It’s com-
ing out of the back of their head, sort of.
(Show me where the person is) One
person mirrored or it could be two per-
sons. It’s two persons. The face here, and
the body, and the deer’s head and antlers
coming out of the back of the head.
(The deer head growing out of the
back of the person’s head; help me
see it like you do) The way people
want to be animals and not care about
anything. And he’s like breaking apart—
part human, part animal.
(Breaking apart) More like it’s a part of
the person, just growing out of the head.
(Blanket like thing) It’s just kind of
an abstract looking thing. A blanket looks
like that.
(Help me see it) It just looks like a
blanket flapping in the wind.
13. They’re on top of what looks like a A big head, it’s pink. The undeveloped
fetus on the ground. Like an aborted fetus arms and body.
on the bottom. Like what they take out. ——————
Abortion. I think it’s a bad thing, but you
have to live with it. So I’m for it just as
much as I’m against it; I support it even
though I’m against it.
Notwithstanding the odd, incongruous response of a person with a deer head

growing from its head (R12), by this point in the protocol the shock of Carl’s
bizarre responses had lost its punch. It seemed that he saw a person squatting,
and he then saw a deer head in the same or an adjacent area. Rather than
taking the trouble to separate these images, I could imagine that Carl might
have thought that delivering a strange combination such as a person with an
animal growing from its side would get my attention and he would just leave
the response as it stood. He might also have thought that this strange-sounding
response might appear imaginative, appealing to an adolescent’s defiance of
reality or what people might be expected to think or say.
That being said, understanding what Carl was trying to convey about
his experience of himself and the world he found so troubling was probably
more important at this point in the evaluation than merely restating what had
already been noted about the quality of his thinking or his not being able
or caring enough to censor his thoughts. Thus, for example, Carl’s comment
about “breaking apart . . . people wanting to be animals and not caring about
anything” may have been more pertinent as a communication about himself.
I did not think that Carl was concerned about breaking apart in the sense of
decompensating, but rather that he had something in mind closer to the idea
of breaking out or growing out from. He spoke about the deer head not as a dis-
sociated part of the person, but rather as an integral part of the person trying
to become or form something else—something related to being carefree or
without responsibility.
Carl’s reference to a blanket flapping was also odd; he could no more explain
what made it look like a blanket than he could articulate why it was there. His
best attempt was to say that the blanket represented an abstract quality about
the card. However, Carl already showed that he was capable of imaginative use
of abstract imagery and self-reflection, thus his appearing stuck when asked to
elaborate on the image of a blanket was not characteristic of his style of manag-
ing complex imagery on previous Rorschach responses. I was puzzled by this
aspect of the response, and thus reserved judgment about its possible meaning.
It was tempting to tentatively speculate, however, that because blankets usu-
ally cover up things, Carl’s motivation here might have been concerned with
concealing or not seeing.
Carl’s next response (R13), an aborted fetus, was somewhat surprising
because it was not something I would have expected to be very much on an
adolescent boy’s mind. Furthermore, considering how provocative the subject
of abortion often can be, Carl had surprisingly little to say about it. Equally
surprising was Carl’s apparent willingness to leave this response relatively
unembellished, considering how he described many other responses. True,
he made use of the color determinant; nevertheless, I would have thought
that the image of an aborted fetus would have stimulated his imagination as
much as several of his previous responses did. Even his comment transitioning
from the previous response of the person with the deer head and the blanket
to the aborted fetus (“they’re [the person with the deer head] on top of what
looks like a fetus on the ground”) raised the possibility that he might overinclu-
sively have incorporated these disparate images—but uncharacteristically for
him, he did not take the bait. Indeed, Carl was fairly terse in his verbalization
despite the modulated use of color (FC), possibly signifying some degree of
affective stimulation.
Surely, I thought, something was up, which prompted my testing-the-
limits question about the aborted fetus, but I did not feel that it opened up
much more. Interestingly, in two places Carl commented about his ambiva-
lence about abortion without indicating what his reasons were. He seemed to
feel that it was a necessary evil, reluctantly accepting its necessity while simul-
taneously struggling with the idea. I had no knowledge whether the subject
had any personal meaning for him. I knew that Carl had no strongly devel-
oped religious sentiments and that he had never had a girlfriend. On one level,
this response appeared to reveal a struggle concerning holding two oppos-
ing sentiments in mind simultaneously. Further, neither the response proper
nor its elaboration during the testing-the-limits inquiry elicited prominent con-
cerns about guilt or morality despite his comment that it was a “bad thing,”
and nor was there a marked preoccupation with morbid bodily processes despite
his reference to the fetus’s undeveloped arms and body. Carl also noted—twice,
in fact—that the aborted fetus was “on the ground” and “on the bottom”;
he also commented that “it’s what they take out,” recalling similar responses
of bodily parts removed from a dead organism on Cards III and VIII (R5
and R11).
Carl’s comment about the fetus being “on the ground” might simply have
represented another way of saying “on the bottom,” but it did sound odd, par-
ticularly as a way of describing an aborted fetus. Although I could not imagine
what being on the ground might mean in this context, somehow it must have
escaped my attention, for otherwise I surely would have inquired further about
the meaning of this odd verbalization.
In both this response and R5 Carl referred to gutting, more as an incidental
comment than an exaggerated embellishment of a response such as R11. Con-
sidered together with the unusually high number of morbid (MOR) responses
in the total record—five out of seven of which occurred on the final three
chromatic cards—it was clear that Carl seemed quite concerned about body
intactness. Several responses referred to gutting bodies, which also was salient
in respect to his reference to Jeffrey Dahmer on R10—a response that began as
a box but upon further elaboration during a testing-the-limits inquiry led first to
an association to razor blades, then children holding meat cleavers, and finally
Jeffrey Dahmer—a notorious serial murderer who cannibalized several of his
victims. I raised earlier the hypothesis that such responses might have been
intended to dramatically indicate distress, perhaps because he felt that ordinary
signaling to others that he was troubled or vulnerable would go unheard. I
wondered in addition whether Carl felt gutted in a psychological sense—ripped
open and left emptied out.
I cannot be any more certain about the interpretive meaning of this response
than the speculative comments I raised above. What it revealed concerning
Carl’s inner psychological life was not immediately transparent. Note, however,
that it was followed by five responses on Card X, which contrasted with there
being no more than one or two responses on all of the preceding nine cards.
Moreover, all of Carl’s five responses to Card X contained a color determinant,
two of which were CF and one of which was C. Three of these five responses
also contained a MOR code. As I discuss below, a more nuanced comment
about the meaning of the response of the aborted fetus emerges in the context
of what follows this response on Card X.3
Card X
14. The head of some freaky evil doctor, An elongated head, the eyes, the nose here.
like a super villain type guy. He’s sort of A hat or something, and shoulders.
got big shoulders and a trail of blood com- (Trail of blood coming from his
ing from his hands, and some wires. hands) It’s red and spilled like blood.
And wires from the side of his head going
to his shoulders.
(Wires) Just because they’re wiry.
They’re long and slender.
(Show me how you see it) They
come out of his brain, to look more super
villain-like.
15. Two flowers on the bottom. Daisy things, the orange surrounded by yel-
low. Kind of messed up, disproportionate.
(Messed up, disproportionate) Just
screwed up, not a perfect flower. There’s
something screwed up about it.
16. Two dead crabs next to the blood over They’re holding torches. The shape with
here. the legs coming out.
(Dead) Just the way they’re lying.
(Torches) They have torches with fire
coming out of it, holding it in their claw.
(Fire) The color and it’s blowing out to
the side.
——————
Like an artist just picked these weird
things and put them together.
17. Fire, a little bit, over here. I don’t really see it any more. The color-
ing, orangish, like a darker flame.
(Darker flame) It’s smokier looking, it
just looks darker.
(Darker) The color, a dark orange.
18. A big monster bug, scary looking There’s its mouth. It’s really hard to point
thing. It’s holding a leaf. out. Tentacles, appendages.
(Scary looking) Not really scary, it’s
more goofy.
(Holding a leaf) Because it’s got a leaf
shape and it’s green.
——————
Fanning the evil doctor guy. He has little
evil minions.
As just noted, Carl’s opening response on Card X (R14) appeared salient in

relation to the immediately preceding response of the aborted fetus on Card
IX. He mentioned a trail of spilled blood, possibly suggesting an image of abor-
tion as a procedure associated with bleeding and sometimes even a “freaky evil
doctor.” His mention of wires running between the brain and shoulders was
not elaborated much beyond providing a form determinant and noting that the
wires added to the figure’s villainous look. These elaborations were in line with
several of Carl’s earlier verbalizations, for example the “freaky monster dude”
on Card IV, a person with a deer head growing out from its side on Card IX,
and a crying dragon on Card II.
R15 might have seemed like a welcome relief for Carl after a long series of
responses with dramatic elaborations of thematic content—but not for long,
however. Almost immediately after noting the colorful flowers, Carl com-
mented about their looking deformed and “screwed up.” Despite its morbid
content, this response remained form-dominant and its good form quality also
was preserved. It suggested not as much that an initial appearance of good
integration began to falter (by introducing the morbid content material) as it
suggested instead that this youngster seemed to need to stir up the pot, as it
were, perhaps because he was not content to produce straightforward responses
without calling attention to something distressing about his experience in the
process. He may have needed to maintain a focus on the quality of dramatized
urgency that characterized so much of his response style almost from the very
beginning of the Rorschach—and the Human Figure Drawings, for that mat-
ter, which preceded the Rorschach administration.
The next response (R16)—dead crabs holding torches—also was coded for
morbid content and it received a special cognitive score (FAB). It also contained
a content code for fire, although the fire appeared to be contained because
it was bound within the confines of the torches. I did not think that Carl was
progressively losing control of his affective experience, but rather that as he
indulged a need for exaggerating distress he sometimes could take his drama-
tized displays too far. He did not seem to know when to stop embellishing his
responses with dramatic asides and as a consequence it may have been hard to
keep things from getting away from him. Carl seemed to have trouble reining
in a tendency for such over-the-top expressions of distress.
In his next response (R17) of a fire, however, Carl may indeed have gone
too far even for his own level of comfort. Thus, Carl qualified the fire as being
“a little bit” (and then as he began the inquiry, saying “I don’t really see it
any more”). He sounded as if he wished to undo the fire he (metaphorically)
started himself. Consistent with this impression about approaching the edge
and then backpedaling, the following response (R18) showed him maintaining
the cautious position to which he wanted to return, softening as he delivered
a response that was more in keeping with generally typical adolescent fantasy
and verbalization.
Recapitulation
What I am mainly suggesting—not only considering this sequence of responses
on Cards IX and X, but also incorporating the pattern of the entire Rorsch-
ach protocol with its over-the-top verbalizations—is that the appearance of
strained thinking, disconstraint, and faltering ego controls that the CS and R-
PAS revealed may have reflected Carl’s need to push well beyond customary
margins of affective expression to convey the emotional plight he experienced.
As also indicated on the Structural Summary and R-PAS interpretation, Carl
could manage to pull himself back from the brink, as it were, when he sensed
he was reacting too provocatively or becoming too disinhibited in his think-
ing. As I will now attempt to demonstrate using his TAT responses, I formed
the impression that Carl’s predilection for exaggeration functioned mainly as
a noisy distress call to make a generally unresponsive environment sit up and
listen to what he was trying to say about feeling vulnerable and troubled.
Card 1
I guess this kid’s at violin lessons and his parents made him go, but he didn’t want to go
and he’s just sitting there, listening to this teacher go on and on. But he didn’t care, he’s
just listening, and class will end and he won’t care. Maybe he’ll pick up a thing or two
about the violin but it’s really meaningless to him. He doesn’t want to be there.
(What led up to it?) It’s probably like an after-school thing, or in school, whatever—
you know what I mean, an extracurricular activity, whatever they call it at school.
(How does he feel about it?) He’s bored out of his mind. He’s just a little sleepy
because it’s so boring.
(What else does he feel about it being boring?) He feels obligated to do it by his
parents, or the school made him do it. He really doesn’t want to.
(What about his parents?) I think maybe his parents understand that he really doesn’t
want to do it, but you know that they’re saying that you have to do it. Like the same way
I am with school. I know it sucks, they know I know it sucks, but you just have to go and
get it over with.
(How does he feel about what his parents say?) He understands it.
(Outcome?) The lesson will end and he’ll just go home. He repeats the process whenever
he has the next lesson, doing the same thing.
Carl began the TAT with an identification with the figure portrayed on Card
1, attributing to the boy—unsurprisingly—the same ennui that characterized
his presenting complaint. Carl seemed particularly interested in grappling with
the issue whether studying violin was required or optional, which I suspect
mainly reflected his feeling that he had no real options. He seemed bored and
disinterested either way, believing he had to comply despite feeling that the
activity was meaningless. He could only say that he was “bored out of his mind”
and right after saying that he added, “a little sleepy.” Carl could not seem to
articulate affect states any more specific than saying he felt bored, and his solu-
tion appeared to represent metaphorically going to sleep and thus attempting
to shut out the emotion he probably experienced.
Because I did not want him to affectively go to sleep on me, I repeated the
question about the affect of the boy in the story. Although Carl apparently
could not delve any deeper than what he had already said, he did seem to talk
about his own experience of his parents when he observed that not only could
the boy not find an interest or motivation to engage in the activity in the story
but neither could the parents provide any salient motivation or compelling
meaning to interest him. He also seemed to be expressing, albeit indirectly and
outside of his awareness, that his parents provided little emotional nourishment
or engagement he could draw upon. Thus, when he said, “I know it sucks, they
know I know it sucks, but you have to go and get it over with,” Carl seemed
to mean that he and his parents both recognized that school was a game to be
played and that he should not expect to find enjoyment, meaningfulness, or
interest there. When I asked how he felt about the situation and he said, “he
understands it,” Carl sounded resigned and, so I thought, disillusioned.
The parents in Carl’s story to Card 1 were portrayed as responsible inso-
far as they saw that their child followed the rules, but they did not seem to
show an understanding of wanting more for him or of providing encourage-
ment or stimulating aspirations. Those were ideas that seemed outside of their
experience or expectations for their children. This TAT story could readily be
understood from the vantage point of what it expresses about the inner life and
perceptions of the important people in a patient’s existence. Examining Carl’s
story from this vantage point, it would not be difficult to see him believing that
his parents’ fulfilling a duty meant little more than an empty obligation without
a corresponding sense of enthusiasm. There was little in Carl’s home life to fuel
the fantasies of a child’s normal sense of greatness or imagination out of which
a normally tamed sense of pride and balanced self-esteem might unfold. Carl’s
limited aspirations and concern about feeling dissatisfied with school and the
work life that lay ahead in his future appeared to be as inspiring as visiting the
dentist or eating one’s spinach.
After seeing the rich quality of his Rorschach responses, certainly no one
would conclude that Carl’s inner psychological life was mundane. However,
the kind of energetic mind that led to such imaginative richness belied his inter-
nal struggles more than it revealed an avenue for channeling the kind of imagi-
native seeking that drives interests. Indeed, Carl seemed to struggle against
the empty depletion he seemed to find everywhere he looked. I suspect that
a nascent though simultaneously deeply submerged desire for enlivenment
remained unknown to him. Looked at in this way, Carl’s story was revealing
in large measure because it hinted at what was missing in his life or self-experi-
ence, making it possible for clinicians to imagine what was lacking and then to
understand the kind of psychological function that might be clinically necessary
to restart. Opening up directions to enthuse Carl’s life might well be therapeu-
tically advantageous because it seemed increasingly so that the quality of the
depression Carl brought to treatment could readily be translated into his need-
ing to come alive in a psychological sense.4
It seemed fairly clear that the central psychological theme of Carl’s story was
the depletion and diminished, listless affect of boredom. It may indeed be spec-
ulating beyond what reasonably could be inferred from this story to attribute
special significance to the role of the parents as playing the game, as it were, at
least in Carl’s eyes. However, in consideration of Carl’s Figure Drawings and
Rorschach, I do not believe at this juncture that such an interpretation would
be gratuitous or overreaching. Carl was indeed a youngster who felt empty and
afraid of facing a life ahead bereft of goals or ambitions. Equally important,
what was difficult for him to comprehend was how feeling empty boredom
was connected to his struggle to find a direction or purpose for himself that felt
affectively engaging when the emotional substrate of his family life was char-
acterized chiefly by diminished responsiveness. As a result, Carl probably felt
stuck or trapped. His story to Card 1 was thus principally one concerned with
emptiness and parental disengagement—not out of lack of concern but rather,
out of incomprehensibility. Understanding what was deficient in his relation-
ship with his parents provided a more cogent and clinically sophisticated win-
dow to apprehend what this boy appeared to need in treatment.
Card 2
I guess that’s her dad and she’s going to school, and that person over there’s her mom. Her
dad’s a farmer and her mom’s a farmer’s wife. She goes to school and she wants to be
better than her parents and have a better life, and they want the same for her.
(What’s her relationship with her parents like?) It’s nothing weird or any-
thing. Maybe they didn’t go to school or whatever, and they want her to. It’s a regular
relationship.
(Outcome?) She just goes to school.
On Card 2, Carl went in a direction that appeared to continue his story from
Card 1: after expressing a sentiment of feeling trapped in a meaningless activity
on Card 1, he then on Card 2 expressed the possibility of being able to secure
something better. In this story, the parents showed a benevolent outlook on the
protagonist’s decision, although “want[ing] the same for her” or not standing in
her way was not the same thing as assisting, encouraging, or in some sense psy-
chologically fostering a developmental step—which I imagine would not have
been an idea to which Carl would readily gravitate. Interestingly, Carl’s story
actually did contain an awareness that the parents might not understand the
need behind the girl’s wish to better herself, as seen through his mentioning that
“maybe they didn’t go to school” and how the mother was defined simply—or
perhaps, merely—as “a farmer’s wife.”
I was surprised after asking Carl about the relationships among the people
in the card that he said “it’s nothing weird”; however, I did not know what to
make of this comment. Why, after all, would he think my question about the
relationships might suggest that there was anything amiss or “weird”! There
was no suspicion heretofore about anything unusual about the family situation,
unless possibly Carl’s still puzzling Rorschach response on Card IX about an
aborted fetus left something unsettled or uncertain. It remained possible that
my question took him by surprise not because there was anything the matter
but mainly because he was not accustomed to thinking about people’s rela-
tionships with one another. Consequently, from that standpoint, my question
might have sounded odd to him.
It was also noteworthy that Carl’s solution for achieving a better life was
rather vague: the girl “just goes to school,” as if something was supposed to hap-
pen to her. Absent was an idea of a particular ambition or goal; further, there
was no fantasy or expectation expressed about what might have changed after
going to school. Perhaps that level of thinking might be too much to expect
from of a 15-year-old adolescent, who might think that getting an education
was a commodity like going to a store to buy something. Nonetheless, Carl’s
vague and nonspecific concept of bettering oneself by going to school was
somewhat surprising given the vividness and complexity of the internal fantasy
life he revealed on the Rorschach and Human Figure Drawings. His imagina-
tive thinking, albeit sometimes odd or strained, was so far not apparent on the
TAT, a test that potentially reveals more about a person’s capacity for inferring
motivations and interrelationships among people and their needs.
Card 3BM
What is that, right next to her? I can’t even tell. This is some girl; she just came home from
school or work or something. Something really bad happened. I don’t know, maybe some-
one died or something, and she just collapsed. She’s freaked out and is crying like crazy.
(What led up to this?) Maybe the mother died, or the grandmother died, or the dog
died, or something.
(Make up a story.) Someone dies, something close to her. She’s separated from it. She’s
really upset about it.
(Outcome?) She just keeps crying and eventually she gets so sick of crying that she just
falls asleep and goes on with her life.
With Card 3BM, Carl clearly could identify that the situation he described on
this card represented appreciable emotional upheaval. He apparently grasped
the emotional significance about the card right away, although he seemed to
show the same limited perceptiveness about what underlies people’s motiva-
tions and feeling states that he hinted at on Cards 1 and 2. Carl’s opening
verbalization (“what is that, right next to her? I can’t even tell”) indicated his
noticing an object alongside the person that is sometimes ignored by people,
often defensively, but he had trouble imagining what it might be and therefore
could not integrate it with the rest of his story. His inability to make sense of
the object in the context of the story was not one of indifference, such as adding
the colloquialism “whatever” which he would sometimes say when he could
not figure out something but did not care very much about the subject—for
example, on Cards 1 and 2, and subsequently as well. Further, Carl had no
difficulty integrating incongruous objects on the Rorschach (for example, the
“civil war of the monsters” on Card I when he could not decide between seeing
the figures as angels or monsters, or a person with a deer head coming out of its
side on Card IX). But here on Card 3BM, Carl could not find a way to integrate
the object alongside the figure with his story—suggesting more that the integra-
tion failure represented a defense operation than it represented a problem of
perceptual acuity. He appeared thrown off guard by what he saw on Card 3BM
and what it may have signified.
As Carl proceeded to tell a story about “something really bad,” it was notable
that together with his description of something catastrophic involving a death
he tried to defensively minimize if not actually denigrate its significance. Thus,
for example, Carl added that the girl in the figure was “freaked out” and “cry-
ing like crazy,” and ultimately “so sick of crying that she just falls asleep and
goes on with her life.” Even more telling was Carl’s comment that “maybe the
mother died, or the grandmother died, or the dog died or something”—the
progression becoming increasingly remote in degree of emotional concern as
he tried to distance himself from what must have represented a disturbing affect
state. I guessed that the potential thought about his own mother dying might
underlie his anxiety about Card 3BM (hence my carefully worded question,
“the mother died or something?”), to which Carl responded thus: “someone
dies, something close to her, she’s separated from it, she’s really upset about
it.” The “someone” was vague and nonspecific; it then became “something”
to attempt to depersonalize its emotional significance. Moreover, he attempted
to defuse the anxiety still further by introducing the idea of separating. In the
end, all of his attempts to create distance failed to sufficiently insulate him from
anxiety because the girl in the story was left feeling “really upset.” Eventually,
Carl resorted to the marginally effective emotional distancing brought on by
anesthetizing himself through sleep and the emotional insulation that comes
with the passage of time.5 It speaks to a vulnerability not quite seen previously
in this assessment protocol—at least not in as dramatic or desperate-sounding a
way as it appeared here—as Carl contemplated a theme of separation through
death and how psychologically exposed the prospect made him feel.
It was somewhat puzzling why Carl’s vulnerability was triggered at this point,
and why the Rorschach did not entirely capture this “raw nerve.” Indeed, so far
the TAT revealed aspects of defenses and vulnerabilities he mainly succeeded
in keeping in check on the Rorschach. That it was more apparent on the TAT
than the Rorschach certainly speaks to the value of using a battery of tests, with
each test contributing unique value to a complete evaluation. That being said,
this boy’s unanticipated response to Card 3BM seemed now to reveal a more
urgent side of Carl’s personality and functioning that was not as evident on the
other tests.
Understanding Carl’s response to Card 3BM also involved considering the
sequence of responses preceding and following it. Recall that on Card 1, Carl’s
story about unenthusiastically going through the motions of something one had
to do was paralleled by a picture of parents appearing to overlook or bypass
emotional needs, offering no better a solution than the sense that life consisted
of obligations one is not necessarily supposed to enjoy. And on Card 2, Carl’s
story also appeared to convey a picture of parents who mainly were on a child’s
side but still not really comprehending emotional needs. Here, on Card 3BM,
Carl tried to conceal a deep sense of distress, a concern sufficiently troubling
that he barely could produce much of a story. While a person was depicted as
resigned to one’s lot on Card 1 and moving in a direction of seeking something
better for oneself on Card 2—without entirely understanding what these peo-
ple in his stories were looking for and with parents who, while supportive, did
not comprehend what motivated them—Carl now seemed lost and floundering
on Card 3BM. Something about loss or death managed to escape his defenses,
and it appeared that he was trying to keep the floodgates securely shut.
But why on Card 3BM? Certainly, this concern was not a prominent fea-
ture of Carl’s Rorschach, which overall seemed to suggest a reasonable albeit
sometimes shaky capacity for psychological resilience, certainly insofar as his
capacity for managing defenses was concerned. Something was up but it was
not clear why at this point and why now. The next TAT card, however, seemed
to reveal more of the story.
Card 6BM
This is like a middle-aged man and his mother. She’s crazy or sick or something, and he
wants to do something about it. Either he puts her in a hospital or gets her help, and he
doesn’t know how to approach her about it. I think she’s sick, not crazy, because she knows
she is, too, but she’s so set in her ways that she doesn’t want to change anything. And she
knows that she doesn’t have much time left. He just wants her to be comfortable but at the
same time he wants her to be secure, so that’s maybe why he wants to put her in a nursing
home or something like that. And he’s not going to do anything about it and just go on.
(Why does he decide not to do anything about it?) He has trouble talking to his
mother about stuff.
(How so?) I don’t know, maybe he’s intimidated by her or something.
(In what way?) He just doesn’t feel like he knows his mother enough or feel comfortable
around her, I don’t really know why it would be.
(Make up a story; what would you imagine?) I don’t know, a closed mother. She
never treated him very well as a kid or whatever. They were never very loving and now he
feels guilty because they were never close and she’s probably going to die and now he feels
that if only things were different [long hesitation] but they’re not and now it’s too late.
(Outcome?) He leaves, he goes on. Seems like nothing happened. Eventually she dies.
He feels real bad.
It was undoubtedly clear in this story that Carl was expressing a conflictual and
deeply ambivalent level of engagement with what by now I assumed probably
represented his relationship with his mother. What he started opening up about
somewhat cryptically on the previous TAT card appeared to continue on Card
6BM, and the nearly paralyzing inhibition exposed earlier was now revealed
more fully. Carl’s unusual, atypical story suggested not only how “intimidated”
he seemed to feel about his mother, but also his inability to resolve his fearfully
distant approach to his mother in any way other than removing himself nearly
totally from her influence. I think I would probably rephrase his word intimi-
dated to convey a different sentiment, one closer to the extreme detachment
he appeared to feel regarding his mother, a state that would leave him feeling
emotionally frozen in his relationship with her. Carl seemed to feel profoundly
unknown by her, and he also appeared not to know her either.
Note the highly idiosyncratic way Carl managed the affect states triggered
by this TAT card. Initially, there was a strikingly dark and distant sense of
his mother as an emotional stranger—which must indeed have seemed quite
“crazy” to him as he attempted to decide whether the mother in the story was
crazy or sick. Carl then expressed how removed and ultimately estranged he
seemed to feel about this mother, which left him unable to act, largely immo-
bilized by his feeling emotionally frozen and unable to do anything besides
remove himself from the mother. Attachment theorists might well regard a
TAT story such as this as reflecting elements of ambivalent and/or detached
attachment.
Considering Cards 6BM and 3BM in sequence, it might now seem plausible
that the shock of Card 3BM gave way initially to a paralyzed emotional reac-
tion that was quickly followed by an emotional reaction of profound distress
that he tried but ultimately failed to bring under control. His reference to “the
mother died, the grandmother died, the dog died” on Card 3BM reflected, I
would now surmise, the desperateness of his attempt to find some degree of dis-
tance to purge the intensity of the feeling state that seemed to overwhelm him.6
Carl did not, however, succeed in this effort, and when reexposed to a similar
psychologically demanding conflict situation on Card 6BM, Carl continued to
experience the perturbation that was presaged on Card 3BM, showing even
greater affective distress. His unwillingness or inability to relate a story to this
card besides simply saying “she’s sick” or “he has trouble talking to his mother
about stuff” prompted me to conduct a more vigorous inquiry than I might
otherwise have done, essentially pushing Carl hard by my repeated questioning
about his “trouble talking to his mother.” Asking “how so?” or “in what way?”
and ultimately the command “make up a story” followed by a slightly more
tempered or softer question (“what would you imagine?”) failed to generate
much more than different variations of feeling “intimidated” by her or uncom-
fortable around her, about which he could only manage to say, “I really don’t
know why.” Pressing him further would have been unproductive and prob-
ably hurtfully provocative. The inquiry did however reveal the depth of Carl’s
affective alienation, while also substantiating what the Rorschach indicated
regarding Carl’s capacity to sustain defenses in spite of the degree of affective
upheaval these two cards appeared to trigger.
Carl could not manage to get any closer to the “crazy” situation of the moth-
er’s decompensation on Card 6BM, preferring a solution of removing him-
self from the emotional turmoil by placing her in a nursing home in his story,
where her comfort and security remained for others to manage. The mother
was further described as “closed” and their relationship as “never very loving.”
Ultimately the man in the story left and moved on, feeling it was too late for
anything consequential to happen. There was no resolution for Carl beyond
“he feels real bad.”
Considering Carl’s response to this card together with the previous card,
there certainly seemed to be some highly provocative situations that caught
him off guard and exposed a raw nerve. He was at such moments left nearly
frozen in affect states he could do little more than tolerate, waiting them out
until they dissipated with time. His experience of his mother and their rela-
tionship clearly was one such powerful trigger, but the reasons underlying his
surprisingly angry, disinterested pulling away from her at times of her need or
distress remained a mystery, even at this late point in the evaluation. Carl could
otherwise manage to coast along in a fairly affectively detached way in many
other situations, such as those represented on Cards 1 and 2.
Card 7BM
I think that’s some older relative. That’s a guy in his thirties just talking about things
they did when they were younger and just chatting about stuff. They’re probably at some
family gathering or whatever, just talking about nothing.
(Who are they?) I don’t know, maybe it’s just some guy and his older uncle or his father
or something like that.
(What’s their relationship like?) They probably like each other a lot, and you know,
talk about whatever.
(About what? Make up a story) It’s weird, it could either be they’re talking friendly
or it could be someone interrogating a guy. I think that’s what the picture is trying to show,
but I didn’t see that right away. It could be like he’s questioning him about a murder or
whatever, and he’s nervous about it and he’s trying to make him slip up.
(What led up to this?) Just because he’s [points to younger man] sitting like that and
he looks nervous and the other one’s standing.
(Outcome?) Well, in version A, they’re talking like at a big family gathering, and they
go on and talk to other people, that’s how it ends. In version B, I think this guy doesn’t
slip up and he doesn’t crack and he doesn’t let them know any information that they need.
And he wins, you know, he gets away with whatever he did.
(Going back to the first story, what’s their relationship like?) They get along
alright, they don’t see each other much. They remain distant relatives or something, just
talking now.
On Card 7BM, Carl seemed to have reconstituted after the previous two cards
by returning to a casual, nonconflictual situation of easy conversation between
family members. Perhaps light banter between males was easier for Carl to
manage, carrying little or no conflict for him. His initial reference to a conver-
sation between an uncle and a nephew was somewhat unusual, although Carl
followed this description by noting that it could be a father and son. Even so
minor a comment (“some guy and his older uncle or his father or something”)
should probably not pass unnoticed; its significance remained uncertain, but
it did suggest the possibility that Carl’s relationship with his father was not
particularly close.
It is always interesting when patients begin a TAT story in one way and
then shift gears in the middle of the story, a pattern suggesting that either the
“modified” story or the original story was the real story and that the other story
represented a defensive operation intended to disguise conflict. There may be
additional significance to such shifts as well, but story shifts bear close attention
in the analysis of the TAT regarding personality mechanisms and defensive
processes. Carl’s switching gears actually represented adding a story alongside
the one with which he started, judging from his own decision to provide an out-
come to both stories. Whether or not the shift contained a particular meaning
in relation to Carl’s uncertainty about the older man in the story being an uncle
or a father, it was evident that the nature of the relationship between the two
pictured men had changed from one of pleasant reminiscing to an adversarial
nature in which one man tried to challenge and trip up the other. The younger
man was now under attack and he had to be on guard against deceptive under-
mining by the older man. It was certainly a situation in which the younger
man felt unsafe, and Carl might have been indicating by his story shift that the
appearance of a friendly, easygoing family interaction concealed an underlying
feeling of threat at home. Carl’s story also suggested that despite some concern
or danger he managed to protect himself adequately (“he doesn’t slip up and
he doesn’t crack”).
I should also note that Carl may have perceived my probing inquiry on the
previous two cards as if he were being “interrogated” and that I was trying to
make him “slip up” or “crack.” I cannot be certain whether “Version B” was
linked to “Version A” by the idea of feeling threatened or undermined at home
despite appearances to the contrary, or whether it was entirely a transferential
manifestation of how he felt at this point during the TAT. In either case, this
youngster demonstrated a return to his pattern of recovering from situations
that triggered anxiety, thus succeeding in reconstituting his defenses. This is a
particularly salient point to note in light of Carl’s obvious distress and nearly
immobilized psychological reaction to Cards 3BM and 6BM in relation to a
maternal figure.
Card 7GF
That’s a mother and a daughter, and the daughter’s holding a doll. She’s just telling the
daughter about what she did when she had a doll when she was a little kid, too. The
daughter doesn’t really care, she’s just looking off in the distance. And the mother is just
like blah, blah, blah, and the mother keeps talking and the daughter’s just sitting there
listening even though she doesn’t care.
(What is their relationship like?) They’re okay. The mother thinks they’re closer
than they really are, and the daughter just doesn’t really care much. She probably wants
to do something else right now or go somewhere or something, and the mother’s still talk-
ing. She doesn’t want to be rude. The mother just thinks she knows a lot more about the
daughter than she really does.
(How can you tell?) I don’t know, just things that are going on in her life. Like who
she’s really friends with and things like that.
(Outcome?) Eventually the mother just stops talking and the daughter leaves.
This is a card I like to administer regardless of gender, mainly because it readily

stimulates the quality of intimacy of a mother–child relationship. I am particu-
larly interested in the story patients tell to this card when their stories to Cards
6BM and 7BM are sparse or insufficiently enlightening about how maternal
and sometimes paternal objects are perceived. Carl’s story to this card was
consistent with the theme suggested in his previous TAT stories concerning
emotional disengagement and distance in his relationship with his mother.
Although this should come as no surprise, I wanted to see if this card’s pull for
mother–child intimacy might reveal more than what had been detected thus
far, even a glimmer of longing or at least ambivalence. But that was not the case
here: Carl chose to portray a relationship in which the mother did not recog-
nize subtleties of the child’s affect state, presuming a degree of closeness with
the child that the child did not actually experience.
This story at first added a perception of the mother as out of touch with her
child. It was very much a picture of empathic failure. The story also revealed
something important about the child’s reaction to the parent’s empathic
breach: the child seemed on the surface compliant rather than angry or rebel-
lious, apparently adapting to the mother’s unawareness of the child’s emotional
needs by resigning herself to the situation. There was a hint that it was all
too familiar to the child and consequently experienced as beyond repair. This
kind of familiarity or adaptation might indicate a state of chronic psychological
unavailability in which the child seemed to give up on getting through to the
mother by trying to press her case or by angrily protesting. For some people,
playing along represents an adaptation to keep the peace or prevent matters
from becoming worse, sometimes giving way to apathy or chronic depression.
(I have more than a few patients in psychotherapy who are fond of the expres-
sion, peace at any price, in reference to their close personal relationships.)
Carl’s adjustment may not necessarily have been the kind of apathetic depres-
sion suggested on Card 7GF; however, his regularly recurring description of
parents who, while available, were nonetheless psychologically unaware or
unknowing implied the predominant expectation that his psychological needs
would go unnoticed. I further suspected that Carl kept much of his psychological
life submerged, perhaps because he did not experience his relationship with his
parents as conducive to exposing what he probably felt to be painful. From his
Rorschach, Carl had already shown himself to be fairly imaginative, although
laying bare complex psychological experiences was not a part of his emotional
vocabulary. The emotional undertones of his imagination, however, were quite
close to the surface of his ongoing experience. The problem may have been
that Carl could not find a receptive or comprehending audience to hear him
out, but I doubt that that was the case. His reluctance to give voice to deep (and
even not particularly deep) layers of his psychological existence was more likely
self-protective. As long as Carl could keep needs and affects either contained or
submerged he probably could manage to get by relatively unscathed.
Perhaps, however, the depressive anomie he now felt rather acutely cov-
ered over intrusive affect states he mainly kept in check but now confused
him, increasingly overwhelming his capacities to deal with the psychological
demands cards such as 3BM and 6BM seemed to trigger. Card 7GF, in con-
trast, may have represented Carl’s customary way of adaptively subjugating
potent psychological affects underground, compliantly tolerating whatever
unhappiness was not too troubling for him to live through. Thus, for example,
on Card 7GF, the outcome to Carl’s story was that the child simply left while
the mother finished her “blah, blah, blah . . . and keeps talking,” which was
the same outcome of Carl’s story to Card 6BM, a card that was particularly
disconcerting for him. On Card 7GF, the child merely put up with the moth-
er’s unawareness with apathetic disinterest until she could leave the situation;
on Card 6BM, the son did nothing to help his ill mother, and just left when
he could break away. Carl’s compliant understatement probably led to the
quality of deadened emotionality that covered over his unhappiness, but more
recently he may have been experiencing greater distress in relation to school
and his future such that his customary defenses may have insulated him less
effectively from an affectively detached, uninvolving existence. It might also
be possible, though still speculative, that anger surrounding his mother’s una-
wareness and unavailability was increasingly becoming more problematic for
Carl to deal with.
It is possible that I have taken some speculative liberties on Card 7GF. How-
ever, I arrived at this interpretation in consideration of this card being the last
in a sequence of three consecutive cards in which the stories depicted a surface
appearance of accord or politely going through the motions of relationships
with parental figures that consistently revealed a subtle but nonetheless unmis-
takable layer of disengagement and emotional withdrawal. This was a sequence
of stories that, when combined with the indication of parents’ imparting a sense
of joyless obligation (Card 1) and their uncomprehending acceptance of a psy-
chologically complex decision (Card 2), created a firmly established impression
about Carl’s experiencing a grudging sense of his parents as estranged from
him and unable to grasp what was important in his psychological depths. Ulti-
mately, he seemed rather alone in the world, fending for himself without a real
sense that his parents were behind him or deeply enough involved with him.
Carl did not feel overtly angry with his parents nor did he feel neglected
or abused. For some time until recently, he also did not even feel particu-
larly alone; nor did Carl seem to know that he felt dissatisfied or that he was
especially troubled. Instead, Carl appeared to go through his life feeling rela-
tively little: perhaps bored (on Card 1), unenthusiastic or uninvigorated (on
Card 2), and casually connected or self-protectively cautious (on Card 7BM)—
all of which barely registered on his emotional radar screen. More psycho-
logically difficult or strained involvements with his mother (on Cards 6BM and
7GF) registered perhaps only slightly more so in his awareness, but Carl seemed
to lack a clear sense of articulated feelings about his mother beyond vague dis-
content. He seemed content to deal with his unhappiness (or anger or distress
or disappointment—or whatever he might happen to feel) by insulating himself
from affective experiences, thus depicting an adaptation to the psychological
complexities and painfulness of his relationship with his parents dominated by
the relief of escape rather than by a resolution that came anywhere close to
approximating closure or understanding.
Probably it is worth reemphasizing at this point that there are limitations
about what degree of self-awareness and adaptation might be expected from
a 15-year-old adolescent. Carl did recognize, however, that he was troubled
and unhappy and he possessed enough concern about the things that bothered
him to ask his mother to inquire about psychotherapy for him. Carl neither
externalized his problems nor did he feel acute symptomatic distress. Instead,
he knew on some level that something was wrong and that he desired some help
with his vaguely expressed chief complaint. It is of course telling that his mother
did not notice a problem or feel a need for Carl to see a psychotherapist; the
impetus for seeking treatment arose entirely within Carl himself, which was all
the more surprising because not that many adolescents are self-referred. My
main point in noting this is to provide another context for the interpretive com-
ments I mentioned above. Carl was a youngster who was asking to understand
some things about his life. Although he could not have known it, he also may
have been seeking a relationship in which he could talk about his distress and
unhappiness without feeling rebuffed or feeling that he had to submerge painful
affects, as he may have felt with his parents.
Card 18GF
It’s someone holding a dead body. I don’t know, it looks like it could be that she killed the per-
son and slashed its throat or whatever, even though you can’t see blood. It’s probably her hus-
band, and she was upset with him. Maybe the husband was cheating on her, and she slashed
his throat. And now she’s got to hide the body, so she’s going to put the body in a bag and stick
it in the trunk of her car and drive it somewhere and stick it in a hole. And she doesn’t really
feel regret for killing her husband because she thinks she was justified in doing it.
(What’s their relationship like?) They loved each other at first but they grew more
and more distant. Then eventually she caught them, she caught him with another woman
and it confirmed that he was cheating on her, so she killed him. She feels a little bit of
regret, but she feels like it had to be done. And she was right in doing it. She hides the
body and gets away with it.
Card 13MF
It looks like he was just beating her and she’s unconscious on the bed and he’s like, you
know, rubbing her forehead because he was smacking her around or something and he
doesn’t know what he did. He was probably drunk or something.
(What led up to this?) I don’t know, maybe it’s his wife. He had a lot to drink, or was
on drugs or something. He’s not thinking right. Maybe she said something that bothered
him, or she didn’t do anything at all. He just went nuts and knocked her out. Then he felt
bad about it and laid her on the bed and put the blanket on her.
(Outcome?) She wakes up in the morning. She’s still mad at him but she’s too scared to
do anything. He’s not going to really remember what happened. He knows he did some-
thing wrong. He’s going to feel bad, but he won’t care. He’ll still drink, he’ll do drugs,
or whatever things he does.
Card 5
That’s that same woman from before who killed her husband. Now she’s walking in on
her husband with another woman, and she’s scared and she’s shocked, but she opens the
door and she sees them but she doesn’t want to let them know that she saw them. And
she’s going to wait and then later on she’s going to kill her husband. Like in that other
picture.
(How does she feel?) She feels betrayed because she never really saw it coming. But
she’s really upset.
The stories Carl told to Cards 18GF and 13MF contained themes of anger, but
of a particular quality—uncontrollable or impulsive rage between a husband
and wife, initiated on Card 18GF by a wife and on Card 13MF by a husband.
Furthermore, both people felt little or no remorse about their actions, despite
recognizing that their actions were wrong. The wife’s murdering her spouse felt
justifiable, whereas the husband’s violence left him with no qualms or regrets
even though it was an unprovoked action. Carl dispassionately related these
stories in a rather matter-of-fact manner, and the verbalization in both stories
suggested a tone of indifference or, probably more to the point, psychological
distancing. He related his stories in a way that seemed to say something like: this
happened, then that happened, he/she felt this way or that way, and then it’s over and done
with. For example, there was as much of a focus in Carl’s story to Card 18GF
concerning the woman’s problem about how to dispose of the body as there was
about why she murdered her husband or how she felt. Similarly, Carl’s story to
Card 13MF sounded like an apologia for the consequences of substance abuse
on judgment and self-control—as if that was its own justification. I suspected
that the emotional distancing from the aggression in these stories reflected how
uncomfortable anger was for him.
Like the over-the-top, dramatic quality of several of his Rorschach
responses, Carl’s excesses of fantasy—in both the Rorschach imagery and
the extremes of aggression expressed on these TAT cards here—appeared
to represent an exaggeration or caricature of aggression. It mainly served to
create a degree of psychological distance that Carl could hide behind, as if
to suggest that no one would ever think he could feel that excessively rageful
or dyscontrolled. Stated differently, what Carl’s exaggerated rageful fantasies
may have signified was more the difficulty he had recognizing normal levels
of anger than it may have aroused concern about his potential for extreme
destructive rage.
That Carl might be more distressed by the affect he tried to disguise also
was evident in his response to TAT Card 5, in which he referred back to the
story that led up to the murderous jealous rage he described on Card 18GF.
Evidently, he could not psychologically let go of the affect that seemed to
drive that story as well as the story he told to Card 13MF, too. The emotional
salience of aggression and finding either justification or a reason to excuse
feeling so rageful was compelling for him. But note that in Carl’s continua-
tion on Card 5 of the story he told to Card 18GF, he added that the woman
was “scared . . . shocked . . . betrayed . . . really upset,” all of which seemed
to reflect indicators of Carl’s confused psychological reaction. The varied
affects he expressed appeared to represent how difficult it was for Carl to
articulate what he could sometimes feel, making it difficult for him to under-
stand exactly why he could feel angry and what to do with such confusing
feelings. The story to Card 5, therefore, seemed to represent the persistence
of a troubling affect state he was still trying to work out for himself by finding
an explanation he could comprehend for what he was experiencing and how
to react.
It can be difficult to know how seriously to consider themes of anger or
impulsive murderous rage as they emerge in psychodiagnostic testing mate-
rial, particularly in adolescents. Carl’s TAT stories on these three cards, cou-
pled with his many references to anger, fighting, and killing on the Rorsch-
ach, raised an important clinical concern about a primary problem with rage
and its dyscontrol. I previously posed an alternative possibility about Carl’s
Rorschach responses, suggesting that such responses might signify overdram-
atized concerns about confusing feeling states that were expressed in an over-
the-top fashion as the only way a 15-year-old youngster might have at his
disposal to make people in his life sit up and pay attention to his distress. I
favor the latter interpretation for several reasons. First, Carl’s MMPI-A and
Rorschach structural indicators did not point to appreciable problems with
disinhibition or anger. The MMPI-A F scale suggested a tendency to endorse
extreme symptoms or problems not attributable to inconsistent responding.
It more likely reflected a tendency to gain attention for his problems, empha-
sizing particularly anxiety represented by internalization of conflict and an
overintellectualized defensive style rather than externalization of anger or
irritability. Similarly, the Rorschach CS and R-PAS revealed considerable
internal stress that was generally well controlled, although he could show a
vulnerability to expressing unmodulated affect states. Secondly, Carl’s clini-
cal presentation did not emphasize appreciable concern about losing control
of anger; it was not part of his presenting complaint, and his “weird” thoughts
about fighting and aggression were more confusing than representing his fear
of losing self-control.
Naturally, this does not mean that Carl was not angry or discontented, but
I did not feel that the evidence was sufficiently compelling to elevate his hos-
tile and at times murderous fantasies to a level of concern about losing self-
control. I did wonder whether the aggressive content of these TAT responses
emerged in relation to the story content suggesting how difficult it may have
been to make meaningful contact with his parents, particularly his mother. His
main overt affective reaction was one of emotional blocking, disposing him to
seem frozen or immobilized about his emotional involvement with his mother,
including difficulty recognizing how angry or betrayed he could feel in response
to what seemed to reflect this degree of psychological distance or diminished
empathic responsiveness.
Card 16
I don’t know, I keep thinking about stories from plots of other stuff and things like that.
For some reason I keep seeing this guy from the video games. I can’t remember, I can’t
really come up with anything. There’s just too many things, you know what I mean?
There’s too many thoughts running through my head, and if there is a drawing or some-
thing I could probably put something there. I can’t just make up a story out of nowhere.
I need some direction. I picture this guy from a video game, it’s actually the same game
like a dream I had. I picture a guy standing on top of a pile of dead bodies. I think they’re
humans and he’s an alien, but he’s a good guy or something, and he’s got two big blades
coming out of his fists, laser blades or whatever, and he just hacks them all to death. He
was just fighting them all off, they had guns or whatever, and he’s fighting them. He’s
standing on top of their dead bodies because they’re supposed to hate each other because of
a land conflict or whatever. He won, he took out twenty or the head guy or whatever. He’s
standing on top of their dead bodies. It looks cool.
This final TAT card—a blank card to which patients are asked to imagine a
picture and then make up a story about that imagined picture—exposed Carl’s
discomfort with unstructured situations. Certainly, considering the free rein he
brought to his Rorschach responses that hardly lacked a capacity for imagi-
native thinking, here Carl had great difficulty undertaking the task demand
presented on Card 16. Significantly, he asked for guidance (“I need some direc-
tion”). Prior to asking for direction, he floundered considerably before launch-
ing into the story. It seemed that Carl could become nearly immobilized when
left feeling on his own without someone in his corner to catch him if he stum-
bled or to function as a guiding, supporting, or companionate presence when
he felt unsure of himself. Once he found his footing, Carl chose for his story a
dream he himself recently experienced.
His dream was in many respects not unlike a number of his dramatic-sound-
ing Rorschach responses, once again invoking the exaggerated, dramatized
manner Carl seemed to need to make it loud and clear just how perturbed he
sometimes could feel. Before he reached the point of relating his story in the
form of a dream, all of the extensive verbalization prior to the story proper
could itself be viewed as a reflection about how he felt when he was in an
ambiguous situation reexposing him to a state of helpless distress with no imme-
diate way out.
After this initial dynamic unfolded as he began to settle into formulating
what he decided would make for an acceptable story, Carl described someone
who was an alien among humans. He depicted this person as virtuous and
basking in victory after defeating evil forces in a battle where the odds seemed
stacked against him. By this point in the evaluation, however, I was inclined
to suspect that Carl was describing a fantasized quality of affective experience
that represented more a wished-for emotional or self state than it represented
anything close to his actual feeling state. Throughout much of the evaluation,
Carl frequently described emotions suggesting how vulnerable he often felt
concerning being diminished or belittled, while wishing that he felt more like
the idealization he seemed to be characterizing in his story/dream as victori-
ous, accomplished, and being admired. In contrast, much of the time this boy
experienced himself as removed from feeling proud or accomplished. Thus,
Carl’s story/dream may well have reflected a wish, something that was not easy
for him to readily experience. Perhaps it was easier to give freer rein to express-
ing an idealized self-representation on Card 16—a blank card—notwithstand-
ing the difficulty he showed getting started. Carl’s marked difficulty initiating
a story may thus have represented something more than difficulty tolerating
ambiguity; it may have represented that he did not feel surefooted and that he
needed guidance or direction to support him in expressing what he wished to
feel about himself and the course of his life.
It would not be difficult to imagine that Carl’s idealized wish to emerge
victorious might not feel like a reliably secure self state he could sustain, as
he metaphorically came out on top by standing over a “pile of dead bodies.”
Though perhaps tentative, it probably should not be overlooked as represent-
ing a hoped-for striving to achieve a confident, securely autonomous feeling of
well-being. Stated another way, it may now be more clear what Carl struggled
with and tried to convey throughout the various tests in the battery. He thus
seemed to finish the evaluation by echoing the discomfort he felt and a longing
for what he needed, trying to make others comprehend and take note of his
unhappiness without feeling diminished or humiliated.
Summary of Treatment
In addition to subjective depression and anxiety, Carl presented with a depres-
sive syndrome that included insomnia (on most week nights but not on week-
ends), diminished concentration and motivation, and intermittently decreased
appetite. His lack of motivation, boredom, and shifting school friendships con-
tributed to feelings of worthlessness. Further, he experienced dreams about kill-
ing teachers and a preoccupation with violence that confused and disturbed
him. However, he did not feel that he was at risk of acting on such fantasies,
nor that he was troubled by losing self-control. I considered the possibility of
a psychiatric consultation for pharmacotherapy depending on what might
emerge about the persistence and severity of his anxious depression, and a psy-
chodiagnostic evaluation to understand the meaning of his aggressive fantasies
and their relationship with ego functions and self-cohesion depending on Carl’s
capacity for insight and introspection in the course of a weekly psychotherapy.
In the early sessions, Carl spoke about not having any special skills, and
his associations seemed to include references to his father being too tired or
depressed to show much interest or involvement with Carl. He saw little point
to the future, anticipating academic, social, and athletic failures in high school
and expecting an unsatisfying work life after school. He had no aspirations to
attend college, feeling mainly that college offered few advantages for him. My
interpretive comments centered around pointing out the emptiness pervading
most areas of his life that he seemed to keep to himself, feeling that conveying
his depressed, anhedonic feelings would fall on deaf ears. I explained to Carl
that he seemed to conceal a wish for greater responsiveness from his parents,
particularly concerning the feeling that he could not do anything well. Appar-
ently directed more toward his father, Carl began to see that his defensive reti-
cence about approaching his parents with his worries added to their not seeing
how concerned he felt. I thought that his enduring lack of pleasure in school
activities left him feeling alone with his unhappiness. Carl’s responsiveness to
such interpretive comments provided an important indication about his defen-
sively submerged longing for involved, understanding selfobjects.
Carl’s depression changed slightly over the first month of treatment; how-
ever, his dreams about killing teachers persisted, although somewhat less fre-
quently. He agreed to a psychiatric consultation, was administered sertraline
(Zoloft®) 25 mg. q.d., reported no troubling side effects, and he began to report
a sustained diminution of agitation and of the urgency of his concerns about his
future. I conducted the psychological testing concurrently but at different times
than his regularly scheduled psychotherapy sessions.
Carl began speaking about a movie, Office Space, a comedy that parodied
the frustrations of an office environment while also conveying aggravating and
disillusioning aspects of work. Carl felt that this film captured his worries about
a boring adult life, and he was eager for me to see it to know what he felt. I saw
Office Space and as we talked about the film and the importance of my seeing it,
it became clear that Carl felt people did not recognize what troubled him unless
he in effect could give them a road map.
This led to his talking more about his parents, mainly how they had their
separate interests and friends and spent little time together other than at fam-
ily gatherings. He recalled a time when they were having an argument, which
frightened Carl because he was accustomed to seeing them uninvolved with
each other and he did not know what his parents’ arguing meant. He told me
about an incident about five years ago when he felt deeply hurt by a cutting
remark his alcoholic aunt made about him; he was provoked to tears and ran
to his room. What was particularly notable was that Carl’s uncle—and not his
parents, who dismissed the incident as trivial and familiar—recognized how
upset Carl felt and went to him, offering to take him to an arcade to play games.
(In this context, recall Carl’s story to TAT Card 7BM.) When I pointed out
that I thought it was significant that it was Carl’s uncle, and not either parent,
who realized that Carl was hurt and made the effort to try to comfort him, Carl
appeared surprised. It seemed clear that Carl expected an emotional discon-
nection between his parents and himself, and he could not easily imagine their
being able to comprehend the depths of his unhappiness. I also thought that
Carl himself had trouble recognizing much about his own emotional life.
I once received a phone call from Carl’s mother during the early months of
treatment, when she did not remember Carl’s appointment time that day. She
told me that Carl also could not remember the time, which she mentioned as an
example of Carl not being as responsible as he should be. I remembered think-
ing to myself that probably many parents kept better track of their children’s
appointments than did the children themselves, even as adolescents, and I was
mildly surprised that Carl’s mother seemed to place that responsibility entirely
on Carl and that she did not seem to feel in any way responsible. I wondered
whether this phone call also might have reflected Carl’s feeling that his par-
ents ignored what was important for him. As we discussed both his and his
mother’s forgetting the appointment time later that day, Carl mentioned that
as a small boy he used to be frightened of sleeping alone in his room, worrying
about noises or something coming to grab him. He often slept in his parents’
bedroom, even though they minimized his fears, and he outgrew his fears and
“stopped caring” around age 12. I talked with Carl about the significance of
sleeping in the same room as his parents as a way of trying to make them see
what he felt, and that “outgrowing” his fears by not caring any more was not
the same thing as feeling that his parents tried to understand his concerns or
worries. Thus, not caring represented a defensive turning away from his par-
ents as he wrote off their seemingly limited capacity to grasp his needs.
After we started working together, Carl began to develop a new set of friends,
becoming disenchanted with many of his former friends whom he now viewed
as stupid and uninteresting. He once described risking a potential altercation
between himself and his new friends with some other boys. While he was fear-
ful that a fight might ensue, I also thought that Carl sounded stimulated by
the situation, which contrasted with his more customary monotony. He also
began to talk about his father, realizing for the first time that he disliked him
for his indecisive and complaining nature. I once saw the father, who came to
pick up Carl after a session. I was surprised to see that he was missing an arm,
which Carl had never mentioned. I asked Carl what had happened, and he told
me his father lost the arm in an industrial accident. He had no further com-
ment—as if it were a fact (like having brown or blue eyes) without any emotional
significance—which I could only imagine was characteristic of his relation-
ship with his father. Around this time, Carl once fantasized what it would be
like being one part Franklin Delano Roosevelt, one part Bill Gates, and one
part a “real cool guy who built a whole empire from a comic book.” He seemed
to be searching for invigoration or inspiration, and during this period of his
treatment it seemed that Carl was attempting to turn away from people he
found lacking.
Carl was not particularly athletic; however, he thought he should try out
for one of his school’s teams because he felt he needed to stand out or have an
identity at school in some way. He picked wrestling, but he was not selected
for the team. He seemed depressed about not making the team, not as much
because it represented failure or inadequacy but rather because he did not
know how to fill the time he set aside for the team. Carl felt he lost an oppor-
tunity to show that he had a special ability and the motivation he had recently
begun to mobilize in treatment wavered. He returned to feeling that working
hard was futile and he was angry that others would not be able to appreci-
ate his importance or admire him for some special ability. He was sick for
two days but feigned illness—which he thought his parents believed—to stay
out of school the week after hearing he did not make the wrestling team. He
was feeling listless and angry, but mainly I thought he felt diminished as he
spoke about frequently feeling unnoticed. Carl also mentioned that he felt
that he was taking care of himself or raising himself—which reminded me
of his mother’s expecting Carl to remember his appointment time when she
did not herself remember the time, citing it as an example of Carl’s not being
responsible.
As we talked about his diminished self-esteem alongside dashed aspirations
for being acknowledged or admired, Carl gradually began to feel more ener-
getic and he started to look again for friends with whom he could feel he had
an important place. He befriended other students and he reconstituted feeling
better about himself because he felt solidly accepted by these friends. Carl felt
he could make his new friends laugh, which gratified him, and he also became
friendly with a girl who, he was told, liked him. Carl pursued a relationship with
this girl, feeling that they were much alike. He became unconcerned about his
mother’s complaining and his father’s disinclination to spend much time doing
things with Carl. As we talked about his new friends and the girlfriend, I pointed
out how important it was for him to feel desired and valued, which seemed to
contrast with his parents’ apparent unawareness of his needs. Carl also seemed
to come to life when we talked about his needs, which I increasingly recognized
as being an unfamiliar experience in his life. Feeling responded to by people
more attuned to his internal affective experience appeared to ameliorate the
injured, depleted self-cohesion with which he struggled. I kept relatively quiet
about his not being affected by his parents’ apparently diminished attunement,
considering that his defensive aloofness or indifference to his parents’ unaware-
ness was less therapeutically important to emphasize at this point. I favored
instead focusing on Carl’s needs for attuned responsiveness.
Carl was settling into feeling better about himself, and he was far less depressed
save for occasional moments when he would feel “glum” as he worried that his
friends might lose interest in him. He was becoming aware that girls started to
seem interested in him, which motivated him to try to exercise more and lose
some weight. Carl continued to feel disinterested in school, but he was wor-
rying less about his future. Upsurges of anger became much more infrequent
and did not trouble Carl as they had at the beginning of the school year. He
gradually became more open to interpretations about his needs feeling ignored,
and in treatment he expressed more openly feeling “irritated” by his parents’
obliviousness but also seeing their limitations more clearly. Nevertheless, Carl
still remained distant from his parents and he seemed disinclined to want to talk
with them about what mattered to him. As he derived increasing self-esteem
from his friends and a budding interest in girls at school, Carl became increas-
ingly aware that he distanced himself from his parents as he simultaneously
sought out friends who valued his role in their social group. As the school year
was coming to an end and he had a summer job lined up as a camp counselor,
we stopped regular sessions for the summer, agreeing to speak again once school
started up in the fall to see how he was doing and whether to resume meeting.
During that time, Carl reported two dreams. In one, the Virgin Mary slashed
her wrists but blood was coming out of her eyes as tears flowed from her wrists. We
talked about this dream in relation to Carl’s becoming increasingly aware of his
affect states rather than stifling emotions, despite sometimes feeling confused by
what he might feel. This dream of course contained several other interesting and
undoubtedly important elements, which I noted to myself might possibly be pur-
sued at a later time if Carl wished to resume treatment. In Carl’s second dream,
he was locked in a bathroom trying to get out while the bathtub filled with water.
He thought a person might be in the bathtub, but he could not see a person. He
“punched” the water to scare the imaginary person. In talking about this dream,
referring to an imaginary person he could not see, Carl mentioned that not very
long ago he would have been afraid to accost someone who might threaten him. I
merely commented for the time being that although he still could feel vulnerable,
he also could imagine protecting himself rather than giving in to despair.
I saw Carl once in the fall. He told me that he enjoyed the summer job, kept
up with his friends, and that he had a girlfriend over the summer. He felt he
was trying to be more assertive with his parents about his needs, and although
he thought his mother listened to him a bit more he still felt some frustration
but wanted to keep trying himself. He still was bored at school, but he was less
angry and his frustration was less troubling. We agreed that Carl could contact
me if he wanted to talk further or if there was any change concerning sustain-
ing the progress he had made. I had not heard further from him until nearly
ten years later when he contacted me at age 25 in connection with frustration
and uncertainty about a career path. At that time, I saw Carl for two visits to
talk about his life in the intervening years. In connection with this volume, Carl
consented to repeat the psychological assessment ten years after I first saw him
for an initial evaluation at the beginning of his treatment at age 15. I present
the comprehensive assessment findings from age 25 in Chapter 6, together with
a discussion of the assessment findings in relation to those contained in the
present chapter from age 15.
Discussion
Carl presented for treatment with complaints of depression, ennui, and a strong
dislike for school, and “weird” thoughts about anger and destructiveness. He
perceived little purpose or motivation to strive for much in his future, and was
confused by angry thoughts he could not understand or easily dispel. The blus-
ter and bravado he showed at the onset of the evaluation in his Figure Draw-
ings continued throughout most of the Rorschach and much of the TAT. His
test presentation could be viewed in a more favorable light as a kind of brash
manifestation of male adolescent fantasy, or alternatively as a more serious
indicator of disordered thinking and/or dyscontrol of aggression. In this sec-
tion, I will summarize why I did not primarily view Carl’s problems in either
of these ways, emphasizing instead a view that focused mainly on a progressive
unfolding of a need to conceal how troubled he felt, and that his parents seemed
not to grasp his distress. I begin with the structural test findings that provided an
anchor for the basic personality organization before considering the meanings
underlying this patient’s presenting symptom picture.
Empirically Based Scales (MMPI-A and Rorschach)

Carl’s MMPI-A pattern highlighted the anxious, perturbed mental state he pre-
sented at the beginning of treatment. It also suggested that his functioning was
likely to be compromised by rigidity and perfectionism, and that intellectuali-
zation and possibly somatic concerns might be present, although somatization
was not suggested in the Rorschach findings or by history or on clinical pres-
entation. The overall pattern was consistent with a disorder chiefly involving
internalized conflict rather than externalization or acting out, which also was
consistent with the turmoil seen on the Rorschach. These test findings indicated
that Carl’s anxiety and internalized distress were for the most part adequately
contained, perhaps because coping skills were not particularly undermined.
Although neither depression nor anxiety were prominently evident on his Ror-
schach, Carl nevertheless was disposed to aberrant thinking often concerned
with the thoughts he expressed as being problematic for him, thoughts about
damage or destruction. He was inclined to respond to distressing ideas and
affect states inconsistently, and it was also possible that the intense affective
reactions and intrusive disturbing thoughts he experienced reflected his exag-
geration of what he felt sometimes dramatically or for provocative effect.
Carl’s primary difficulties understandably centered around school, which
was the focal point of the major adaptations facing him in life. On the one hand,
academic performance and interests begin to converge on preparation for adult
working life or a career, which for a 15-year-old would understandably begin to
assume increasing importance. In addition, school represents the major arena
of friendships and socialization. Carl had of late become increasingly concerned
about both areas of adaptation to life at school. The MMPI-A highlighted his
negative attitudes and diminished interests about school success, and perhaps a
growing distance from friends and its consequent impact on feeling disliked or
misunderstood. Adding to this impression was the Rorschach finding bearing
on Carl’s characteristic passivity and his inclination often to accommodate to
what others wanted rather than being mainly concerned about his own needs.
Thus, a deferential disposition in which he typically would allow others to make
decisions for him further compounded his feeling of being uncomfortable or
threatened around people.
Carl also struggled to manage self-esteem, which extended to feeling unat-
tractive and that his abilities were limited, consequently contributing to his
depression and ennui. He also could appear self-critical by harboring distorted
views about body image, which could have contributed to the impression about
somatic concerns as identified by the MMPI-A.
Carl’s distressing thoughts may have disposed him to misinterpret events or
other people’s actions, leading to a feeling of isolation from others. This prob-
ably contributed to anhedonia and alienation as well as a pessimistic outlook
about his life and future. Carl’s thinking, which contained immature escapist
fantasies rather than realistic solutions to problems, in addition to ideas about
damage or destruction, likely also disposed him to distort people’s intentions,
particularly when he felt pushed or manipulated. A sense of pessimism per-
vaded his thoughts about finding a way out of dilemmas, which also probably
added to the confused or troubling thoughts he had about his future.

Beginning with his first drawing of a “warrior type dude” standing ready “to
blow stuff up,” and continuing throughout most of the Rorschach and TAT,
Carl announced something important about the way he needed to see or feel
about himself. This image and verbalization, as well as the many references to
raw aggression throughout most of the tests, appeared to suggest that Carl was
filled with aggressive urges he either defended against or struggled to contain.
Nevertheless, his MMPI-A profile suggested a predominantly internalized anx-
ious-dysphoric clinical picture with no prominent indications of emergent dys-
control. Moreover, the Rorschach (both using the CS and R-PAS approaches)
showed no prominent indications of decompensation. Inspection of the content
of his responses fostered an impression that bravado and Carl’s manner of com-
municating his inner life in an exaggerated, over-the-top way had become his
way of expressing feelings of distress. His often dramatic responses compelled
one’s attention, not because they represented boisterous narcissistic demand-
ingness, but rather because they appeared to originate out of a need to make
others realize that he felt distressed, seeming to need their understanding or
concern.
Carl’s proneness to distortions reflecting confused ideas about people or situ-
ations—a prominent inference from the Rorschach structural findings—prob-
ably should be reconsidered in light of the thematic content of the Rorschach
and the other tests in the protocol. Carl was not particularly anxious by what
he saw on the Rorschach, nor by the stories he told on the TAT. Thus, his
responses were not destabilized by his over-the-top fantasies. Sometimes he
went too far and needed to restrain his thoughts, but the way he reined in his
fantasy life did not appear to characterize a youngster genuinely frightened of
losing self-control. Rather, he seemed to need to exceed conventional expres-
sions of his affect states to drive home the emotional plight he experienced,
thus making his distress loud and clear to somehow make what I thought might
reflect a generally unresponsive environment listen and take note.
Carl was not fundamentally struggling to hold on to himself or to contain
impulsive, aggressive urges, despite sounding as if he was ready to explode at
many moments. Thus, Carl did not appear essentially as an angry, disinhibited
young man with a short fuse ready to go “nuts” at the slightest provocation.
What may have sounded like thinking distortions thus may not have reflected
disordered thinking as much as confusion about what he thought or felt at any
given moment. In a related fashion, Carl’s apparent ambitious overstriving or
taking in more of what went on around him than he might be able to absorb
very likely added to the strain of managing orderly thought quality and being
self-critical of his thoughts and ideas. As a result, Carl seemed to resort to noisy,
overdramatized distress calls as he tried to make sense of affect states he had
trouble recognizing within himself and subsequently conveying to others. Quite
possibly, what he needed others to recognize so that he might better understand
and then tolerate his intense emotional life may only have backfired and thus
obscured what he hoped to make others see. He thus became lost in the dra-
matic way he tried to communicate his anxiety, which very well may have been
dismissed as adolescent overreacting.
Carl therefore appeared to inhabit a world where people were psychologi-
cally hard of hearing and thus he had to shout in order to be heard. The more
he turned up the volume, the more he probably was seen as overemotional.
As a result, his vulnerability and feeling of being “ripped apart,” for which he
sought help or understanding, probably was overlooked and remained ignored,
while Carl would try to calm himself down on his own. I considered the unu-
sual way Carl came to psychotherapy to belong within this context: Because he
was feeling increasingly depressed and unhappy about school, and because the
people in his life may not have been listening to or comprehending his unhap-
piness, Carl asked his mother if he might see a therapist. Not many 15-year-old
boys initiate a referral for psychotherapy; more typically a parent notices a
problem and thus seeks treatment in the hope that their child will agree to see
a therapist.
Looked at another way, it was Carl who recognized that he had a problem,
one that his parents may not have understood. To continue the metaphor I
suggested above concerning shouting to be heard in a tone deaf environment,
examining his Rorschach and other projective test verbalizations led me to con-
sider the possibility that what underlay Carl’s overembellished, overelaborate
responses reflected an unrecognized desire to find an environment that was not
as hard of hearing, so to speak. His manner of responding seemed to reflect not
knowing when to stop (or, metaphorically, how loud he needed to shout) more
than it represented disinhibition or thought disorder—even when, indeed, it
seemed that he had gone too far out on a limb.
At several points on the TAT, his stories created the impression that his
parents’ life echoed in certain ways Carl’s chief complaint of diminished enthu-
siasm and feeling uninvolved or disinterested. He also appeared to indicate
that his parents could provide little psychological nourishment that Carl him-
self might be able to draw on to stimulate his own enthusiasm. He seemed as
resigned to a life of limited enjoyment as the sense he had about his parents’
view of life as going through the motions of what one is expected to do and that
one should not expect to feel fulfilled about one’s life. He also seemed to feel
little encouragement to expect more for himself or to aspire to a better life, per-
haps because it was outside of his parents’ experience, which may have limited
what they could instill or inspire.
Despite his chronic feeling of ennui, which I imagined was influenced by
an empty and uninspiring home, Carl clearly had a rich inner life, as seen on
his Rorschach and Figure Drawings. He seemed to come up against a stone
wall as he tried to find a way to channel his vivid internal life into something
meaningful in his daily life. More by what was left out than by what he said
in his Rorschach and TAT responses, I surmised that Carl’s ongoing experi-
ence of feeling “bored out of his mind,” as he described it in one TAT story,
represented the frustration of feeling stuck and not knowing what to do to feel
more invigorated. Thus, without realizing what he felt or what he was strug-
gling with, Carl seemed unable to imagine an existence or a future that was
any more invigorating. Moreover, the depletion he seemed to find in his par-
ents—and probably extending beyond his home life to include friendships and
school as well—very likely offered little for him to turn to, wish for, or to aspire
to become. It is from just this kind of psychological existence that a distur-
bance of normal idealization may originate, thus fueling the empty, depleted
self-cohesion that easily coalesces into what Thoreau popularly described as
quiet desperation. Clinically and theoretically, this quality of empty depletion
represents the developmentally interrupted maturation of the idealizing sector
of the self and interferes with self-cohesion. Kohut (1971, 1977) regarded ide-
alization disturbances as an important substrate for diminished ambitions and
ideals, feeling adrift or chronically unanchored in life, or in more pathological
forms taking the form of disintegration products such as rage, addictions, or
sexualizations of painful affect states.
The lack of a steady presence of vigorous or enlivening selfobjects in Carl’s
surround and internal psychological life represented a developmental deficit
but it also pointed to a direction in which to search for tendrils of striving for
a reparative selfobject experience. For example, his references to a warrior in
several places in the thematic content may have represented an idealization of
something noble or strong. Carl may have been drawn to the warrior image
epitomizing a wished-for admiration of its vigor and robustness as an aspect of
male identification, notwithstanding his somewhat crude-sounding depiction of
a “warrior dude” strutting with bravado for show or being dominated by brute
force aggression. Notably, at other points, Carl expressed the importance of
something he could point to “that defines my life,” potentially suggesting that
he was psychologically open to talking about self-esteem needs. It was also prog-
nostically significant because mobilizing thwarted idealization needs in treat-
ment might facilitate talking with Carl about how his fantasies of destructiveness
might defensively conceal vulnerable self-esteem concerns. For example, that
Carl could not decide whether he saw monsters or angels on Card I and his
difficulty reconciling their being “ready to fight when they get real close to each
other . . . hugging or attacking” might help explain why his “weird thoughts”
about aggressive preoccupations constituted an outward presentation that con-
cealed a wish for closeness or caring. Consider also in this context Carl’s sponta-
neous comment during the Figure Drawing of a male when he spoke about his
admiration for the film Fight Club: “Even though they’re fighting each other they
feel there’s a point of their existence. They didn’t have Vietnam or a Depres-
sion or World War II where everything in their life revolves around that. I don’t
have anything like that either that defines my life.” What also might not be far
from the surface of his experience was a longing for a needed model, such as an
idealized selfobject, to solidify a vigorous image Carl could internalize and draw
upon to bolster the meaning or purpose he seemed to crave.
Consider as well, for example, TAT Card 1, in which the boy faced a
“meaningless” requirement at school, and felt “bored out of his mind.” The
boy was pictured by himself; however, Carl introduced into his story that the
boy’s parents told him that he had to comply with the requirement, saying
that “I know it sucks, they know I know it sucks, but you just have to go and
get it over with.” In one respect, this story reflected the depleted self state Carl
experienced so powerfully, but why, I wondered, did Carl introduce parents
into the story? It may have represented turning to them for some psycho-
logical function. However, the parents he described, although present in the
background and sympathetic, could not offer much useful guidance. Thus,
silently and alone, Carl seemed to feel that he could do little but go through
the motions of a life that felt empty and disinteresting. His parents to whom
he might wish to turn for vitalization or nourishment appeared to have little
to provide as idealizing selfobjects, perhaps because they experienced their
own lives much as Carl himself did.
Carl’s relationship with his parents seemed to involve more than their not rec-
ognizing his need for idealization. Carl appeared to feel considerably detached
from his mother, as if she were an emotional stranger to him, presuming a level
of closeness or understanding that Carl felt to be false. He mainly perceived his
mother as being out of touch. He was not overtly defiant towards her, perhaps
because he did not fully recognize how alienated and angry he could feel about
her. Behind a surface compliance, Carl defensively walled off much of what he
felt, although this defense did not totally insulate him from his anger and the
ensuing anxiety he could experience as a result. His anxiety gave rise to a state of
feeling frozen and immobilized, with little adaptive capacity to do much besides
tolerate the discomfort, at some times as if someone else were experiencing the
emotion while he simply and dispassionately stood apart from affect states. Carl’s
appearance of distanced nonchalance actually belied more discomfort with hos-
tility than it reflected the casualness he may have wished to portray.
Indeed, Carl may well have adapted to a perception of his mother’s apparent
unavailability in which he was resigned to a state of chronic apathetic dissat-
isfaction rather than hoping to get through to his mother in a different way or
by protesting angrily. Carl was also on guard in relation to his father, feeling
tentatively comfortable but wary that a congenial give-and-take could quickly
become adversarial. He appeared to self-protectively take some distance con-
cerning his father in order to avoid feeling deceived or threatened. It was not
likely that Carl could comfortably express desires for closeness or affection with
either parent, given the wariness he seemed to experience with them both.
It is noteworthy that Carl’s inability to resolve emotional discomfort other
than by withdrawal or defensively insulating himself from affect states left him
ill-prepared to manage difficult emotional states. Probably as his parents did,
Carl would sit tight while riding out any anxiety he felt until it passed. He was
in effect left to his own devices, much like the boy of Card 1 whose parents
could offer no further help other than the wan sentiment that the boy had lit-
tle recourse but to grin and bear unpleasant situations until they passed. Carl
appeared to see his life in just this way, probably not knowing that any other
way of adapting might even be possible. He seemed alone with his feelings of
unhappiness and ennui, perhaps not being able to recognize or articulate other
nuanced affects such as feeling psychologically dropped or abandoned and pos-
sibly even betrayed or angry. Such complex affects probably did not register
fully for this boy, and nor did it appear that he would easily recognize feeling
vulnerable or exposed as his closed off parents could not seem to be psychologi-
cally present at his side. Consequently, with parents he experienced as present
but whom he also dimly apprehended as psychologically unknowing, Carl very
well may have become estranged from his psychological needs, expecting lit-
tle from those to whom he would naturally turn for understanding. He thus
submerged his own needs and in the process felt his existence to be devoid of
hopeful anticipation and his relationships to be uninvigorating.
The caring concern Carl seemed to crave was most telling in his Rorschach
percept of a crying dragon, which he called a “paradox,” by which I think he
meant that he felt confused and uncomprehending that something big and pow-
erful could simultaneously be weak and vulnerable. The image of the “powerful
giant reduced to tears” led immediately to an association of his unhappiness
with his life at school, feeling undermined and demoralized. Carl seemed to
be saying that he needed to defeat what he found oppressive by reducing the
“powerful giant” of the dragon to tears. He seemed to view his life as going
to battle, where winning meant having to defeat something big and powerful
against which he could not easily hold his own. Perhaps he was making sense of
the situation as best he could in the mind of an injured, vulnerable adolescent;
thus going to war and fighting battles was Carl’s way of viewing the problems
in his life. Life’s problems seemed like looming giants, and problem-solving
seemed to mean overpowering and denigrating adversaries. In the process, this
boy did his best to keep in check affects he felt surrounding feeling threatened
or vulnerable, which sometimes were concealed behind defensively denigrating
adversaries to protect himself from feeling diminished. Whether thwarted ide-
alization needs were unmet or whether he found it difficult when he got close
to affect states he might feel momentarily but then quickly disavow, it seemed
that Carl’s telling omission of himself from the Kinetic Family Drawing (a test
I sometimes add that asks patients to draw a picture of everyone in their family
with everyone doing something) may have signified not only that he saw himself
at some psychological distance from his family—which by itself may not be par-
ticularly unusual for an adolescent—but also that it reflected his distance from
a family environment that could not hear his distress and could not adequately
provide the kind of idealization he craved.
This case illustrates several points that deserve comment about life-span or
developmental aspects of personality assessment. For example, high school age
and younger children almost always live at home with their parents, they may
be required to observe certain curfews or restrictions, and the possibilities for
independent relationships outside of the family sphere are also relatively lim-
ited, including romantic involvements. Moreover, economic dependence on
the family limits youngsters’ resources, and they have not yet entered the world
of full-time employment—another important arena prominently impacted by
personality and psychopathology. Nevertheless, the personality characteristics
and level of adjustment in adolescents are in many respects not substantially dif-
ferent from those of adults. Predominant conflicts and maturity of defenses and
adaptation are largely established by this age. What is not as clearly established
is the range of adaptive resources that are possible or the availability of oppor-
tunities for independent behavior in which to enact psychological conflicts or
deficits. But what it is possible to discern in young women and men nearing
independent adulthood are their predominant personality characteristics and
the potential psychopathologic vulnerabilities that would undoubtedly emerge
as independent living, relationships and friendships, and the world of work
increasingly come into play. Such personality characteristics and vulnerabilities
are usually present at least in a nascent form and are frequently discernible by
later childhood. Core aspects of personality thus form the substrate for subse-
quent adult functioning.
Erikson’s (1950) emphasis on adolescence as a period of consolidating ideals
and firming up a self concept would have represented a precarious psychologi-
cal task for Carl, considering the changes adolescents normally experience in
relation to a shifting of the secure anchors of childhood and the uncertainty
about negotiating a predictable sense of the future. A more probable outcome
for Carl was interference with a process Anna Freud (1958) described as loosen-
ing of infantile object ties and which Blos (1968) further described as a normally
occurring disengagement of libidinal and aggressive cathexes from infantile
objects. Carl seemed to have problems modulating aggression, which follow-
ing an ego psychological interpretation of adolescent development such as A.
Freud’s or Blos’s, would suggest that the object relations of earlier childhood
had not become structuralized in a way that fostered strengthening of the ego
and consolidating ideals and goals, an ego ideal or superego function.
Carl was struggling to find a way to make his way in the world as he
approached the end of high school and began to question what kind of a life he
saw ahead for himself. His interests were not well formed—which by itself is not
especially atypical among contemporary youth—but Carl seemed to approach
this stage in his life with a sense of dread. He found little meaning or purpose at
age 15 and he felt despair at facing a life ahead with little enthusiasm. Increas-
ingly alienated and distant from people, Carl found it difficult to look to others
with admiration or for others to provide a stable direction to hang his hopes on
as he struggled to find satisfying goals for his life ahead. Lacking such idealizing
selfobjects, compounded by a limited awareness of his affect life, Carl barely
comprehended how he aimlessly clamored to make himself heard to an emo-
tionally unresponsive world. He seemed without an enlivening, vigorous model
he could turn to with enthusiasm and expect to be heard.
Carl’s aimless discontent also seemed to cover over his anger. However,
anger emerged as a reaction to an unresponsive surround he tried to rattle into
understanding through his noisy, over-the-top protests. His was not the anger
stemming from uncontrollable impulses requiring control or inhibition. What
he seemed to need was the comforting presence of someone he could look up to
or admire, out of which he might come to feel settled and thus less aimless. He
needed to find within himself a direction that enthused or interested him, all
the while feeling the encouraging presence of someone who could understand
what he needed and also be on his side. It will be clear that the interpretive
approach I favored in the above analysis of Carl’s test findings was compatible
with Kohut’s self psychology (1971, 1977). Of course, other approaches provide
alternative viewpoints, examining the same data from different perspectives.
As I noted earlier, Carl contacted me ten years after this psychological evalu-
ation and the period of psychotherapy that lasted throughout his sophomore
year in high school. I report on the findings from that subsequent clinical evalu-
ation in Chapter 6, which repeated the psychological tests of personality to
compare his test findings and responses at age 25 with those reported in the
present chapter at age 15. It will become evident from the conclusions of the
evaluation at age 25 that, while Carl may have seemed less overtly troubled
than he appeared at age 15, in a deeper sense not very much of the core person-
ality characteristics and dynamic configurations had changed substantially.
The clinical case that follows in Chapter 4 reports the test findings and inter-
pretation of an 84-year-old man (Mr. B.). Both he and Carl were struggling
with psychological difficulties embedded in but in many ways also independent
of their respective developmental contexts—adolescence in the case of Carl at
age 15 and the geriatric period in the case of Mr. B. at age 84. Interestingly, Mr.
B. faced a developmental and clinical challenge not very different than Carl’s.
Moreover, in Chapter 6, where I present the psychological assessment findings
of Carl at age 25, I will emphasize how the problems of adolescence largely per-
sisted, perhaps in a somewhat different form in young adulthood. Although the
course of Carl’s life had not brought about a successful resolution of the prob-
lems identified above at age 15, their persistence reflects the characterologically
ingrained albeit not necessarily intractable nature of need states throughout
life. Carl’s life certainly was not over at age 25, but his relatively unchanged
personality organization did not bode favorably for a more optimistic outcome.
Perhaps disappointment or failure might still reawaken the same motivation to
seek help that he presented as a 15-year-old adolescent, and perhaps as well he
might yet become aware at a deeper level of more unhappiness about his life
and future than he had displayed as an adolescent.
4 Personality Problems in
Later Life
Concepts about the stages of life and the developmental trajectory through
the life span have intrigued students of behavior, and descriptions of poten-
tial life phases have strong roots in philosophy and literature. Studying stages
of development has largely been the province of developmental psychology.
Clinical studies of psychopathology or psychoanalysis focusing on development
are quite rare. This has been particularly the case in the field of psychoanalysis,
which has been influenced mainly by Sigmund Freud’s specification in 1937 of
psychosexual stages in childhood (Freud, 1968) and Anna Freud’s (1936) exten-
sion of this work in her studies of a developmental sequence of psychosexual
stages. However, their conceptualizations barely approached and extended no
farther than adolescence.
Abraham in 1919 (Abraham, 1953) and Jung (1933) were among the earli-
est psychoanalytic theorists to take issue with Freud’s limitation of the psy-
chological developmental trajectory to the childhood years, favoring instead
a position that suggested that development proceeded in a lifelong manner.
Erikson (1963) was one of the foremost among psychoanalytic writers who
emphasized crucial developmental tasks at a variety of points throughout life.
Like Rapaport (1956) before him, he also called attention to a developmen-
tal frame of reference throughout the life cycle. He proposed eight distinc-
tive stages, each with its primary developmental function and a discussion of
consequences of failures to accomplish such stage-dependent tasks. Erikson
emphasized achieving generativity as a fundamental developmental goal of
older adulthood, a psychological task he contrasted with its relative failure,
stagnation. He articulated what he described as an epigenetic principle, in
which successive life stages build upon previous stages, thus modifying and
influencing ongoing growth and development. More recently, important con-
tributions to the definition and explication of middle and older adult devel-
opment also have emerged (Gould, 1978; Levinson, 1978, 1996; Neugarten,
1979; Pollock, 1980; Vaillant, 1977).
To the extent that Freud considered advanced age it was in the context of
his belief that psychoanalytic treatment was generally inadvisable at older ages,
even past age 50, because he was skeptical that there was sufficient elastic-
ity of mental processes to sustain a psychoanalytic treatment (S. Freud, 1953).
Personality Problems in Later Life 139
Despite Freud’s misgivings on the subject and an inclination for many psy-
choanalysts to follow suit, in recent years the field has turned its attention to
considering treatment of older adults and to better understanding concerns
pertinent to this stage of life. Forrest and Cote (2002), for example, described
what they termed a mortal stage in life, which centered on the loss of denial of
mortality that is normally maintained to prevent becoming aware of the illusion
of immortality. King (2005) regarded aging as precipitating disintegration in
persons who are outwardly successful but have prominent narcissistic personal-
ity structures as they became increasingly aware of diminishing sexual potency,
replacement of work roles by younger people, and growing dependency. She
and Teising (2007) also emphasized the significance of one’s death as a potent
trigger for narcissistic disequilibrium or fragmentation. Kohut (1977) described
the potential for undeveloped mental structures to resume growth following
interruptions by developmental failures or self-cohesion deficits, a phenomenon
Chessick (2009) regarded as an important consideration when undertaking the
treatment of older adults. Valenstein (2000) emphasized that throughout the life
cycle, epigenetic sequences of development reactivate earlier conflicts, mobiliz-
ing different adaptational demands. These included the importance of a narcis-
sistic loss of self-sufficiency and pervasive loneliness accompanied by a need for
attachment, particularly in patients who had lost a primary attachment object.
Valenstein also commented that among the oldest patients in treatment, regres-
sion to primary anaclitic needs was particularly notable.
Psychodynamic considerations about aging have generally emphasized
diminished adaptability of mental processes and increased rigidity, accompa-
nied by brittleness of defenses. Older adults were often regarded as showing
deficiencies more than resilience. Frequently, they were seen as regressing into
the past while also being preoccupied with their approaching death, and mem-
ory impairments were viewed as facilitating repression of unhappiness. Balint
(1957) regarded the reactivation of psychological issues stemming from infantile
sexuality as potentially weakening defenses intended to oppose sexual drives,
noting that excessive hypersexuality, religiosity, or somatization sometimes fol-
lowed in its course.
Whereas younger individuals are typically more preoccupied with strivings
that lead to a predominant future-oriented direction that includes the denial of
death, with aging there tends to occur some degree of withdrawal that includes
aversion to competition (which often was idealized), increased aggression and
guilt, and an increased interest in sexuality that sometimes may appear as per-
verse sexual behavior (Georges et al., 1980). Internalized hostility also may dis-
pose elderly persons to increased depression and self-contempt. Georges et al.
commented that competition or energetic activity; whether intellectual, physi-
cal, or sexual in nature; may represent a need to reinvigorate self-esteem as
declines begin to emerge and take hold. However, narcissistically based com-
petitive strivings or assertiveness may recede as conferring a meaning on one’s
life becomes increasingly important. Georges et al. also considered more patho-
logic resolutions, including reactivation of a childhood neurosis.
Contemporary psychodynamic perspectives on aging also have emphasized
the significance of adverse changes in this life stage, noting that such events, par-
ticularly loss and increased stress, are more frequent and occupy a more salient
role in the elderly compared to younger individuals (Neugarten, 1979; Pollock,
1980). Further, maintaining constancy in the face of change and coming to terms
with the meaning held by their lives—both in the past and in respect to a sense
of purpose in the years remaining—are also important considerations in under-
standing clinical issues of the elderly. Pollock (1980) emphasized the perspec-
tive elderly patients brought into treatment as a beneficial aspect in clinical work
because such patients had greater distance from traumatic experiences earlier in
life. This distance might thus facilitate facing and examining conflictual relation-
ships that could not easily be addressed at a younger age. The conflicts or self-
esteem difficulties themselves were essentially unchanged; however, they might
be expressed differently in advanced age. Relinquishing and mourning formerly
held fantasies of omnipotence from one’s youth may be an important considera-
tion in successfully navigating the older adult years. Pollock (1980) and Cohen
(1982) noted the importance of relaxing defensive structures, while also calling
attention to mourning, although not necessarily as a pathological process. Relax-
ing defenses has also been regarded as an adaptive characteristic associated with
the increasing interiority (Neugarten, 1979) that often comes with aging.
The patient, Mr. B., whose personality assessment I consider in this chap-
ter, revealed a pattern of reactivated conflict that appeared to be lifelong. The
conflictual pattern illustrates concerns related to loss and declining abilities
similar to predominant clinical issues of elderly patients as I briefly reviewed
them above. Curiously, however, in a particularly interesting way this patient’s
TAT might sound as if it were that of an adolescent struggling with concerns
suggestive of separation and individuation issues. It is an especially interesting
juxtaposition in relation to the case presented in Chapter 3, a 15-year-old boy.
Mr. B.’s case thus illustrates psychological concerns that would be regarded as
pertinent to the stage of life of a man of advanced age but it also highlights that
the same concerns may be universal phenomena occurring at any age, despite
variation in their expression or clinical presentation. The fundamental issues
of personality organization may appear in somewhat different ways at various
stages in the life cycle, and as a result clinicians must struggle with disentangling
relatively fixed personality features with a slow rate of change from features that
seem specific to a particular developmental period.
Mr. B. was an 84-year-old white married male who was initially referred for a
neuropsychological evaluation subsequent to his involvement in a minor auto-
mobile accident within the past year. His wife was insisting that he stop driving,
and she asked a physician to examine Mr. B. for this purpose. Mr. B. complied
with her request, although he wanted to continue driving because it made it
possible for him to see friends at a nearby senior center and to travel to various
activities he enjoyed. Driving short distances was his lifeline to maintaining
these activities and socializing. He felt that his wife was limiting his involve-
ment in activities he enjoyed, wanting him to stay at home more. An internist
referred Mr. B. to a neurologist, who observed age-related but apparently not
serious cognitive problems. Mr. B. was then referred for a neuropsychologi-
cal evaluation for further study, which I conducted. Mr. B. was otherwise in
reasonably good health, save for benign prostatic hyperplasia which had been
treated surgically ten years previously and was now moderately well stabilized.
After finishing high school, Mr. B. worked for 25 years in several delicates-
sens, two of which he owned and managed himself, mainly preparing food and
serving as a counterman. Around age 50, Mr. B. began attending college and
he received a B.A. in English. He then worked as a food inspector in a school
system for 12 years until retiring about 15 years ago.
To briefly summarize the neuropsychological findings, Mr. B. displayed aver-
age intelligence (WAIS-III full scale IQ 103), although index scores indicated that
verbal comprehension (VCI = 110) was superior to visual-spatial abilities (POI
= 86), working memory (WMI = 90), and processing speed (PSI = 88). Although
most of these abilities were at a low average level (18th to 25th percentile ranks)
relative to a normative age-matched reference group, select WAIS-III subtests
and other neuropsychological tests of visual organization (Hooper Visual Organi-
zation Test, Rey-Osterreith Complex Figure Test) and motor fluency (Finger
Tapping) were slightly more adversely affected. Attention, concentration, and
select aspects of memory were mainly at a low average level; however, other
aspects of learning and memory functions as well as concept formation and exec-
utive functions fell below that level and thus were marginally compromised.
Because Mr. B. appreciated the potential risks of driving at his age and
because he understood the circumstances surrounding the accident he was
involved in, I concluded that his judgment was not substantially compromised.
However, because motor and attentional capacities showed modest impair-
ments despite otherwise mainly low average to normal cognitive abilities, I
recommended that he try to arrange for others to drive or accompany him
while driving whenever possible. Rather than suggesting that driving by him-
self should be discontinued entirely, I recommended that his driving should be
minimized and limited to side streets and at circumscribed times, road condi-
tions, and distances. I also recommended that his driving should be observed
periodically and that if necessary, partial neuropsychological reevaluation in
about 12 months might be warranted.
It became clear early on in the evaluation that Mr. B. seemed afraid of his
wife, and he fearfully expressed how unhappy he felt and that he was always
on guard to protect himself from what he saw as her criticism and belittling.
This was Mr. B.’s third marriage, the earlier two ending in the deaths of his
wives from carcinoma. Although he did not say as much, it gradually emerged
that Mr. B. believed he had made a mistake in remarrying after his second wife
died. However, he worried about being alone at an older age, despite having
two adult children from his first marriage. He felt that he could do little more
than try to tolerate his wife’s complaints, keeping some distance from her even
though they already spent relatively little time together because they each had
different interests and activities. Mr. B. also thought his wife wanted him to
stay closer to home, that she discouraged his outside activities, and that she
did not like him being friendly with neighbors. Mr. B. commented that he had
been walking much more slowly in the past few years, but his wife walked more
quickly and would not wait for him to catch up with her. He also mentioned
that he used to have a strong sex drive, which bothered him because he was now
impotent as a result of surgical treatment for benign prostatic hyperplasia.
I was left with a strong impression that Mr. B. sounded like a trapped boy
looking for a way out while living in fear of a controlling and unsympathetic
mother. It seemed that he was afraid to rock the boat, fearing that he would get
into trouble if he stood up to her. It deserves mention that I once telephoned
the patient to change an appointment, and his wife answered the phone. She
stated that I could make the appointment change through her, and therefore I
would not need to speak with Mr. B. directly. She also said that the matter of his
driving was no longer a concern because “I don’t let him drive.”
Mr. B. was friendly and engaging, his thinking was lucid, and there were
no obvious distinctive difficulties in comprehension, memory, orientation, or
attention. Although the primary referral question concerned neuropsychologi-
cal status, Mr. B. appeared sufficiently depressed and anxious that I decided to
include a personality assessment in this evaluation, which was performed after
the neuropsychological examination was completed. Because of the extensive
length of the neuropsychological evaluation, to which I added a comprehen-
sive personality assessment, I decided only to add the additional burden of a
self report assessment such as the MMPI-2 or MCMI-III if the projective test
protocols were sparse or unrevealing. As will be seen shortly, the personality
tests yielded a rich and thorough picture of this patient’s personality; thus, as a
result, an objective personality measure was not included.

Mr. B. first drew a male figure (Figure 4.1), about which he said:
A young man, he came from a farm, a lot of hard work. He had a lot of disappointments,
hoping his crop will be okay. It depends on the weather if he can sell it. He’ll buy a
mechanical plow, not the kind you have to push by hand. He wishes he was some place
else, not in the country. He wishes it was more lively. He’d like to be a city boy with
entertainment, supermarkets, malls, things to do.
I asked him to talk about the figure’s personality, and Mr. B. said the
following:
He’s been locked into the farm, his father and grandfather had it and he can’t get out of
the rut.
(How does he feel about that?) He’s hoping to make enough money to buy a home
in the city so he can get away from all this.
(What does he feel?) There’s no way of telling his emotions. There’s nothing to indi-
cate how he is on the inside, even a trained psychologist can’t tell. You have to talk to
them, ask them questions.
I then asked about the person’s fears, followed by questions about other pre-
dominant emotions, to which Mr. B. responded:
He looks up at the weather and hopes the rain will come in time.
(What else?) That his wife would get tired of him and run away with someone else
because he led a dreary life.
(What makes him sad or depressed?) Things are not going so good, they’re not as
good as you expect them. The mortgage is coming due.
(What kinds of things make him angry?) When people come on his farm and steal
his apples.
(What is he doing in the picture?) Standing and trying to figure out what to do
next.
Inasmuch as Mr. B. was 84 years old, it was noteworthy that the apparent
object of his identification was that of a young man expressing discontent while
simultaneously aspiring to attain a goal. Looked at in one way, Mr. B. might
have been conveying disappointment about his own life. What was particularly
striking, however, was his capacity also to imagine what he might still like to
attain. Consequently, his was not a story about looking back, either with regret
or disappointment, as much as it was a story about imagining a different direc-
tion for himself. But it was also a story conveying feeling unable to move in a
different direction. Nonetheless, despite feeling “locked in . . . can’t get out of
the rut,” Mr. B. may not have felt entirely trapped or immobilized because
he could still imagine desiring to reanimate an empty (“dreary”) existence by
seeking something “lively.” But he seemed unable to find a way to “get away
from all this” through his own efforts. Instead, he passively waited for a change
in circumstances outside his control—such as “it depends on the weather,” or
for “his wife to tire of him and run away with someone else”—so that he might
then realize his aspirations, and perhaps like the object of his identification in
the drawing be a young man again.
However, what might have sounded like passivity might not necessarily have
been so at all. Mr. B. seemed to need an external event to occur, such as rain
or his wife leaving, to serve as a catalyst for him to feel free to seek out what
he could easily imagine in fantasy. That is, Mr. B. was not without thoughts or
ideas about what would animate him (“entertainment, supermarkets, malls,
things to do”) but he may have needed a spark to start him on his way. Per-
haps that spark to propel his aspirations came in the form of a turn in events
or a stroke of good luck—a change in the weather, for example. However, it
was more difficult to know what his wife’s leaving him represented. Knowing
about the tension between Mr. B. and his wife, I considered the possibility at
this point that his verbalization about the man’s wife tiring of him and leaving
might have signified as much a wish as a fear because he did not convey anxiety
about being rejected or being left alone. He almost seemed to view the thought
of her leaving as being as favorable an outcome as rain coming to improve
the crop, with both sounding fortuitous for Mr. B. as a way out of the rut he
experienced.
Finally, I wondered about Mr. B.’s comment that “even a trained psycholo-
gist can’t tell” how he felt. Rather than being necessarily evasive or defensive, it
might actually have been a playful way of conveying an interest in talking about
his plight, although perhaps not without some ambivalence. It was possible that
his comment here reflected some relief, albeit guarded, about being able to
discuss his concerns about his wife’s interest in restricting his driving.
The quality of the female Figure Drawing (Figure 4.2) was noticeably poorer
than that of the man. The lines appeared ragged, making it difficult to clearly
identify the main body parts, particularly how the arms were connected to the
torso and the relationship between the left arm and the side of the head. The
left arm actually appeared detached at the elbow. The legs had markings and
lines that made it difficult to discern what they meant. The shoes looked oddly
shaped, which contrasted with the clearer image of the shoes on the male draw-
ing. I could not determine clearly whether the figure was wearing a dress or
slacks. Most tellingly, the head and face were strikingly unfeminine in appear-
ance. Had I not known that the drawing was intended to be that of a female, I
would have thought that it more likely was a man because of the facial features.
A somewhat heavy line above the mouth area even suggested the possibility of
a moustache.
Mr. B.’s initial, spontaneous description of the female figure was noticeably
sparse, particularly in comparison to his description of the male figure:
An average run-of-the-mill woman. A housewife, went to the supermarket to shop.

When I then asked him to describe the figure’s personality, he said, I thought
surprisingly nonchalantly:
She goes home to her husband and children. When her husband’s not home, she fools
around a little bit.
I asked him to elaborate, after which he said:
She’s not happy with her life too much, it’s a dreary life. A little romance makes the world
go ’round. Too many temptations—the butcher, the baker, the candlestick maker—they
all come around to see if they can take her.
I asked Mr. B. to elaborate further on “a dreary life,” and he said:
Nothing exciting. The top floor of a ten-story walkup and she’s got to carry groceries to the
top. The husband doesn’t make too much money so it’s not an exciting life.
I asked how the woman felt about that, and Mr. B. replied:
She’s very unhappy that she couldn’t have done better. Her mother told her to marry a rich
man but she didn’t listen, she wanted someone she loved. But she’s a married woman, she
has no prospects to go into.
Asked how the woman felt about her husband, Mr. B. said:
She accepts him. He was the only one who knocked on her door, so she accepted him. She
was a widow and her husband left her with a nice apartment. She had a three-bedroom
apartment, he had a one-room apartment, a studio, so they moved into her apartment. She
always hoped that next year would be better.
Here, Mr. B. seemed to continue two of the themes he introduced in his draw-
ing of the male figure: the figure’s unhappiness about a “dreary life” and the
woman seeking affairs because of her dissatisfaction with the husband. Fur-
ther, this patient continued expressing a tone of passive acceptance about an
unsatisfactory situation in the verbalization accompanying the female drawing,
but without the undercurrent of hopefulness or imagining a way out that he
expressed about the man in the previous drawing. True, the woman’s affairs
provided some “romance that makes the world go ’round,” but it did not sound
convincing as a means of affording much in the way of a sustaining relief from
the “dreary . . . unhappy . . . not exciting” tenor of her life, a life with “no pros-
pects.” Indeed, Mr. B.’s opening comment after completing the female drawing
was that it represented “an average run of the mill woman.”
Against this backdrop, it came as a surprise that in practically the very next
breath Mr. B. had the woman indulging in affairs. Paraphrasing a popular
nursery rhyme known as “Rub-a-Dub-Dub,” Mr. B. depicted the woman of
his drawing cavorting with “the butcher, the baker, the candlestick maker,”
which appeared to represent an attempt to make light of the matter. Whether
defensively concealing feeling injured or whether it reflected a genuine indif-
ference or lack of concern, Mr. B. seemed to join in the woman’s denigra-
tion of what might be taken for a representation of himself—someone who
“doesn’t make too much money,” someone she married not because she
wanted him or decided to marry but rather someone who was “the only one
who knocked on her door,” and finally, someone worth less (“a one-room
apartment”) than what she had on her own (“a three-bedroom apartment”).
There was no real expression of sympathy for the woman’s plight, which he
described as drudgery (“she’s got to carry groceries to the top floor . . . of a
ten-story walkup”). Mr. B. was not much more sympathetic to the plight of
the man he drew earlier, but there he managed to imagine at least a possibil-
ity of something better.
Comparing the two drawings side by side, they created a predominant
impression of Mr. B. as going through the unsatisfying motions of an exist-
ence that he himself captured best in his own words when he described these
people’s lives as “dreary.” Life seemed filled with disappointment and held
little to look forward to except perhaps in fantasy, but even that must have
felt elusive and without any real basis in reality. There being no place to go
to escape from his unhappy fate, Mr. B. appeared to experience life as either
monotonous hardship or as falling into circumstances leading nowhere. Per-
haps that is why his verbalizations about affairs or running away with a lover
came as a shock to the ear in light of his descriptions of the man and woman
he drew: he could indulge reckless abandon as far as he might take it but in
fantasy only, throwing caution to the wind in an idealized imagined state of
making “the world go ’round.”
Rorschach
The location chart for Mr. B.’s Rorschach is shown in Figure 4.3. Below fol-
lows the Structural Summary and a discussion of the CS interpretive findings.
Although Mr. B. produced a valid record of 17 responses, it included what
amounted to a rejection on Card IX. He did not reject that card by indicating
that he saw nothing; however, his response of naming colors was judged to
characterize a comment about the card rather than an actual scorable response.
The Structural Summary and R-PAS interpretations that follow thus proceed
with appropriate caution because of the implicit card rejection.
Mr. B.’s Rorschach CS Sequence of Scores and Structural Summary are pre-
sented in Figures 4.4 and 4.5, respectively. The positive Coping Deficit Index
(CDI) dictated the cluster strategy for interpretation, beginning with capacity
for control and stress tolerance, and then proceeding sequentially to consider
the affect, self-perception, interpersonal functions, processing, mediation, and

finally ideation clusters. The clinical interpretation began by taking note of
some degree of compromised functioning, perhaps influenced by a balance
between coping resources and demands or stressors that was less than opti-
mal. Mild albeit chronically overtaxed adaptive capacities likely undermined
his management of difficult externally or internally generated tension states.
I 1 Wv 1 Fu H,Id MOR, PHR
2 Do 2 Fu A
3 Do 2 Fo A MOR
II 4 W+ 1 Ma.CFo 2 A,Bl P 4.5 DV, FAB,
AB, MOR,
COP, GHR
III 5 D+ 1 FMau 2 A,Fd 3.0 AG, PHR
IV 6 Wo 1 Fu A 2.0
7 Do 2 Fo Hd DR, PHR
8 Do 1 mp- Hd,Sx PHR
V 9 Wo 1 FMpo A P 1.0 ALOG, MOR
VI 10 Do 1 F- Fd
VII 11 Wv 1 Fu Fd DR
12 Wo 1 F- Fd 2.5
VIII 13 D+ 1 FMa- A,Fd 3.0
14 D+ 1 FMa.FCu 2 A,Bt P 3.0 DV
X 15 W+ 1 FMapo 2 A,Bt P 5.5
16 Do 12 Fu Ad
17 D+ 1 FMao 2 A,Bt P 4.0 FAB
This kind of difficulty probably disposed Mr. B. to impulsivity or emotional

overreactivity in response to transient but still chronically appearing states of
overload and their consequent threat to affective regulation. In addition, intru-
sive thoughts appeared to perturb concentration and efficient problem-solving,
and he could be vulnerable to dysthymic mood contributing to problematic
relationships with others.
Mr. B. was not particularly self-reflective, and thus his understanding of his
own motivations and those of others was limited. Consequently, he was prob-
ably unaware of the effect of his actions on other people. He also appeared
troubled about somatic functions, which extended as well to concerns about
sexual functioning. Seeing his body as dysfunctional undoubtedly added to this
patient’s inclination to feel pessimistic and dysphoric.
Mr. B. showed difficulty managing relationships with people, feeling
simultaneously dependent on others for direction or support while also being
uncomfortable about demands placed on him. He appeared to relate to others
in a needy manner, which was coupled with not carefully considering others’
needs or appreciating subtleties in interpersonal interactions. Mr. B. probably
also experienced but may not have understood people turning their back on
him. He was thus left vulnerable to feeling spurned and resentful toward the
people he thought ignored his needs, which was superimposed on a tendency to
R = 17 L = 1.13 FC:CF+C = 1:1 COP = 1 AG = 1

-------------------------------------------------------------- GHR:PHR = 1:4
Pure C = 0
EB = 1 : 1.5 EA = 2.5 EBPer = N/A a:p = 6:3
eb = 7 : 0 es = 7 D = −1
Adj es = 7 Adj D = −1 Afr = 0.42 SumT = 0
-------------------------------------------------------------- S = 0 Human Content = 3
Pure H = 1
m = 1 SumV = 0 SumY = 0 PER = 0
a:p = 6 :3 Sum6 = 7 XA% = 0.76 Zf =9 3r+(2)/R = 0.29

MOR = 4 M- =0 S- =0 Zd = +1.0 FD =0
M none = 0
X+% = 0.35 DQ+ =6 MOR =4
Xu% = 0.41 DQv =2 H:(H)+Hd+(Hd) = 1 : 2
compare himself unfavorably with others as a result of diminished self-regard.

Together with his inclination to misinterpret situations and his own and oth-
ers’ motivations, Mr. B.’s interactions with people were probably substantially
compromised, leaving him feeling rejected and alienated.
Being preoccupied with unmet needs surely intruded on his thinking
and probably added to what seemed to be a predominantly pessimistic
outlook about life. Because his thinking, while conventional in nature, was
often not logical or responsive to realistic perceptions of events, Mr. B. prob-
ably could appear scattered or difficult to follow. He more likely came across
as coherent in well-defined situations requiring straightforward responses.
Ambiguity or complex inner states or interpersonal events probably strained
his capacity for effective understanding and appropriate responding. Indeed,
uncertainty about how to think about and respond effectively to complex
affects or emotional situations probably confused him and thus interfered
with adaptation. This state of affairs was surely compromised further by other
people’s apparent inclination to keep some distance from Mr. B. when he
acted in confusing ways, thus isolating him further from what he needed from
others.

The R-PAS Sequence of Scores is shown in Figure 4.6 and the Page 1 vari-
ables appear in Figure 4.7. Because the complexity variable fell within normal
ODL R-
(RP) Opt
I 1 W H,NC Vg u F MOR PH
2 > D 2 A u F
3 < D 2 A o F MOR,MAP
II 4 W A,BI Sy 2 o P Ma,CF DV1,FAB1 ABS,COP,MOR,MAP GH ODL
III 5 D 1 A,NC Sy 2 u FMa AGM,MAP PH
IV 6 W A u F
7 D 2 Hd o F DR1 PH
8 D 1 Hd,Sx - mp PH
V 9 W A o P FMp PEC MOR,MAP
VI 10 D 1 NC - F ODL
VII 11 W NC Vg u F DR1 AGC ODL
12 W NC - F ODL
VIII 13 D 1 A,NC Sy - FMa
14 D 1 A,NC Sy 2 u P FMa,FC DV1
X 15 V W A,NC Sy 2 o P FMa-p
16 V D 12 Ad u F AGC
17 V D 1 A,NC Sy 2 o P FMa FAB1 ODL

limits, there were no adjustments necessary to any of the Page 1 or 2 values.

Judging from the prominent elevations, the emphasis for interpretation using
R-PAS would begin with this patient’s idiosyncrasies of thinking and unusual
or odd beliefs, and his sense of deteriorating or feeling damaged. He seemed
to regard people and situations in a simplistic or straightforward way, which
might work well enough for him as long as involvements with people remained
relatively undemanding. However, adaptive resources were limited, thus mak-
ing him vulnerable to greater problems in overall functioning as more compli-
cated emotional responses confused him and compromised judgment, leading
to idiosyncratic, strained thinking.
Although adaptive demands could trigger distorted ideas or beliefs, the
thinking and perceptual anomalies Mr. B. was prone to show were not present
at a level of severity consistent with a psychotic disturbance. For the most part,
he managed to keep his idiosyncratic ideas contained, but probably just barely
and almost certainly not without problems facing realistic problems he would
encounter in relationships with other people.
Feeling damaged undoubtedly contributed to a pessimistic, dysphoric out-
look pervading much of his experience and how he thought about his life. While
this very likely accentuated dependency, which appeared to be pronounced,
Mr. B. was not someone who expected to be taken care of or nurtured. Indeed,
he was inclined to act dismissively toward others, probably not recognizing
how he acted with people or even that need states were heightened. This
patient did not seem to know what to do with need states he barely recognized
were present. Provoked by needs or cravings that eluded him and defied his

Pr 0 Pr
Pu 0 Pu
R (Responses) 17 30 92 44 98 R
Blend 2 33 93 42 97 Bln
Sy 6 53 101 67 106 Sy
MC 2.5 12 83 24 89 MC
MC - PPD –4.5 26 90 20 89 MC-PPD
M 1 16 85 25 89 M
M/MC [1/2.5] NA M Prp
(CF+C)/SumC [1/2] NA CFC Prp
EII-3 1.3 92 121 94 124 EII
WSumCog 21 93 123 94 124 WCog
SevCog 1 80 113 80 113 Sev
FQ-% CS FQ 24% 70 108 73 109 FQ-%
WD-% CS FQ 24% 80 112 81 113 WD-%
FQ-% CS FQ 35% 11 82 9 80 FQo%
P 5 44 98 43 98 P
m 1 48 99 52 101 m
Y 0 19 87 32 92 Y
MOR 4 95 124 95 125 MOR
ODL% 29% 94 123 94 121 ODL%
MAP/MAHP [4/4] 100% 95 125 94 124 MAP Prp
PHR/GPHR [4/5] 80% 94 124 95 126 PHR Prp
M- 0 32 93 32 93 M-
AGC 2 36 94 43 97 AGC
H 2 24 89 32 93 H
COP 1 58 103 70 108 COP
MAH 0 26 90 26 90 MAH

ability to comprehend them, Mr. B.’s dismissive behavior probably grew out
of his imagining himself as more self-reliant than he actually was, which was
an aspect of the unresourceful ways he could ill afford to show. Thus, unknow-
ingly, he probably was his own worst enemy, consequently compounding his
depressed, damaged feelings about his life as he alienated the people he needed
to have in his corner. Accordingly, his relationships were colored by imma-
ture, negative attributions, and his tendency to expect others to be devaluing
or unsupportive almost certainly would have made it difficult for such rela-
tionships to be mutually rewarding. Mr. B. was not about to approach peo-
ple approvingly, nor were people likely to want to engage with him in any-
thing other than a way that surely he would have experienced as hostile or
rejecting.
Card I
1. What you’d look like if you fell from Arms outstretched and a body shape. Not
the sixth floor and fell flat on your face. really a body shape but something like it,
and the feet spread out.
——————
Suicide. Someone committing suicide,
what else could happen! What’s there to
thrill about! About ending it all—depres-
sion, or bad dreams or ailments, there’s a
million reasons why someone would kill
themselves—bad luck, repulsion from the
opposite sex.
(Q) If you fall in love with someone and
they don’t reciprocate, it’s hopeless.
(Bad dreams?) Like if something hap-
pens in a dream and you wake up and
you don’t know if it happened or it was
a dream. Like a child having nightmares.
Mr. B. seemed to begin just where he had left off with the Figure Drawings—
defeated and fallen. What a way to start off! His opening comment conveyed a
self-image of failure—the person fell flat on his face. More than just failure, the
expression fall flat on one’s face also suggested humiliation as well. Naturally, this is
the kind of response for which testing limits would surely be indicated, and Mr.
B.’s verbalization upon querying at the end beyond what was necessary for cod-
ing this response did not disappoint in the association it yielded—suicide. Then
in the very next breath he spoke about life as “nothing to thrill about” and shortly
thereafter, “repulsion from the opposite sex.” Considering that both drawings
conveyed the impression that he felt that the only happiness in an otherwise unsat-
isfying life was the excitement of a sexual or romantic affair, I am speculating that
Mr. B.’s percept and associations to R1 represented a sequence of psychological
experiences that began by his expressing the sense of emptiness and depression in
life as he lived it day by day, followed by desiring to replace that emptiness with
the kind of psychological experience that would revive being able to feel invigor-
ated or enlivened. For this patient, that need or wish for invigoration—or as he
put it, “life’s only thrill”—was represented by sex. Sex, however, appeared to
stand for more than sexual gratification alone. In a broader psychological sense, it
represented feeling alive and vibrant. Thus deprived of life’s only “thrill,” Mr. B.
felt humiliated in failure and an object of “repulsion,” feeling there was nothing
else left for him (“suicide . . . what’s there to thrill about! . . . it’s hopeless”).
Moreover, it was not difficult to detect ambivalence in this sequence of
verbalizations. The unremarkable CS S-CON of 5 argued against a compelling
indication of suicidal despair, which also was consistent with Mr. B.’s verbaliza-
tions to the Human Figure Drawings and his wondering whether Card I was like
a “bad dream” from which one might awaken. It might be more pertinent to
understand his reference to suicide as a statement about experiencing his life as
depleted and dominated by a joyless, uninvigorated existence. Mr. B. might pos-
sibly waver between feeling defeated and hopeful, much as he did in his descrip-
tions of the figures he drew. Curiously, however, in both of his drawings the only
intimation of hope or satisfaction in the context of an otherwise dreary life was
associated with a woman having an affair—in the case of the male drawing, the
woman would have run off with another man, thus leaving the man alone to seek
his own happiness; in the female drawing, the woman remained in her unsatis-
fying life but she found a way to secure some momentary satisfactions. In both
scenarios, the man (presumably Mr. B., assuming his identification with the male
figure) was left out of the “thrill.” The satisfaction was not his for the asking;
instead, it happened around him and in spite of himself.
Mr. B. also mentioned ailments as a reason to kill oneself; indeed R1 con-
tained the first of four MOR codes occurring throughout this record. He thus
began his Rorschach by introducing the idea of damage or deterioration. This
opening response also was this patient’s only full human percept (H), suggesting
a limited sense of himself and other people as little else but damaged. (His other
human percepts—both coded as Hd—were of a man’s feet, elaborated during
inquiry as a woman’s view of men as “all feet and all sex”; and in the response
immediately following it, a percept of a penis hanging down, elaborated as
“when a man’s having sex, his penis stretches.”) Thus, for Mr. B., it seemed
that so many of his eroticized references were primarily expressing preoccupa-
tions about damage, detumescence (failure), humiliation, rejection and even
more strongly—repulsion. Hearing what sounded like sexual preoccupations
did not therefore belong primarily in a context of aging or a developmental
issue appropriate to the geriatric period, which I believe would miss the mark.
That is, when Mr. B. spoke about sexual failure or there being “nothing to thrill
about,” he did not mean the sexual frustrations of aging as much as he seemed
to be saying more generally, what’s there to live for!
Devitalization such as this, coupled with Mr. B.’s four MOR codes through-
out the Rorschach record, certainly is consistent with an interpretation empha-
sizing damage or decline. These are frequent if not ultimately inevitable con-
sequences of aging; as such, an elevated number of MOR codes makes sense as
a developmental, life course consideration. However, it is also possible that the
occurrence of a MOR special score on R1 in relation to a person falling and
their body splattering could be difficult to differentiate from associative content
about there being no “thrill” in life and of being rejected sexually, particularly
in relation to the interpretation I suggested above regarding feeling uninvigor-
ated. That is, a body splattered on the ground following a fall might reflect
either a damaged state or an outcome of feeling beaten down and devitalized.
The meaning of the three remaining MOR codes will be important to consider
to help firm up a more nuanced differentiation between these hypotheses.
>2. A dog. The head, ears, jowls, legs.

——————
Like it’s chewing on a bone. A dog
feeding.
<3. This could be a donkey with a cut A little short piece for a tail, the long
ear and a cut tail. ears.
(Cut ear, cut tail?) For some reason,
someone chopped its ear or it could have
been bitten off by another animal.
(Show me how you see it) If a donkey
was owned by a man who had a whip
and he whipped it so hard, it cut off his
ear.
——————
It’s very obstinate, if it doesn’t want to
move, it braces its feet and stays put. It’s
very docile and it’s a good work horse if
you treat it right.
Following Mr. B.’s opening response to Card I, I was surprised to hear this
relatively uncomplicated, straightforward response of a dog. Probably because
I did not expect him to settle down quite so soon after R1, I was curious—and
probably suspicious as well—to see whether R2 was indeed as straightforward
as it sounded. That was my reason for testing limits on R2, which otherwise
was a mainly conventional-sounding response. Considered in isolation, what
emerged about R2 was not particularly unusual (“chewing . . . a dog feeding”),
however it was the first of 6 of his 15 remaining responses concerned with food,
eating or feeding, or fighting over food. Chewing on a bone possibly might
suggest a relatively aggressive form of eating or feeding, but that must remain
speculative at this point. My main observation about this response was to note
that the reference to feeding or chewing followed a powerful response contain-
ing themes of falling, suicide, and repulsion. It would remain to be seen whether
feeding represented recharging or recovery, obtaining nourishment or relief, or
devouring or aggressive eating both in relation to the intensity of the previous
response and in respect to this patient’s many other food responses throughout
the entire Rorschach protocol.
R3 contained another MOR special score (two of Mr. B.’s four MOR codes
thus occurred on Card I), possibly suggesting a continuation of the theme of
damage or deterioration. It also contained an indirect reference to oral aggres-
sion (“it could have been bitten off”). A possible implication concerning impaired
sexual function was also apparent (“a little short piece for a tail”), although
equally compelling was an indication from Mr. B.’s description that the animal
was diminished because of it. Moreover, the animal was a donkey—an animal
often singled out for ridicule because of its presumed stupidity (it is also some-
times called an ass for the same reason) and also for its obstinacy.
On a testing-the-limits inquiry, Mr. B. confirmed the stereotypic implica-
tion concerning a donkey’s obstinacy, and he also mentioned its docile nature.
However, as he described the donkey, docile seemed to mean passive or com-
pliant—“a good work horse if treated right.” Thus, Mr. B. appeared to express
opposing characteristics as represented by the donkey—not wanting to do
what is wanted of it but also compliantly doing what it is told, as long as it is
not mistreated. It is compelling to regard this characterization as an expres-
sion of his predominant self-image—mindlessly going through life doing what
is asked of him as long as he is not mistreated, but also stubborn and opposi-
tional when feeling pushed or maligned. This man seemed to be saying that
it was his customary nature to passively, mindlessly go about his business, but
Mr. B. mainly seemed to feel treated abusively and thus felt damaged. However,
for Mr. B. feeling damaged was expressed as feeling sexually impotent. In the con-
text of R3, he seemed to be conveying feeling as though he were psychologically
castrated, with his “little short piece for a tail,” which defined how he felt about
himself and his life. As before, I was uncertain whether an unnatural or distorted
state represented damage or deterioration—reflecting the customary understand-
ing of MOR responses—or whether it represented depletion in the sense of feeling
that the “thrill” had gone out of his life, leaving him feeling diminished. Of course,
the two interpretive views could reflect different sides of the same coin, and also
either view may be especially salient in a context of life-span development.
Card II
4. Two animals kissing. And all the red The lips are together. Two heads.
is mostly blood. I can’t figure out what (Blood?) Instead of kissing, they’ve been
the blood has to do with them. The blood fighting. The two on top—the red is an
on the head and the feet and between their analogy for kissing, the lipstick.
mouths. (Kissing/fighting: help me see
it) They’re trained, they can’t shake
hands before they fight, so it’s like that
[laughs]. Dogs don’t do that.
——————
I never see animals kissing, you see love birds
kissing. They’re trained, they learned how to
kiss. It’s part of the act or something.
(Dogs don’t do that) A dog fight, dogs
bred for fighting. A lot of people enjoy their
dogs being viciously superior to other dogs.
Here, in this sole but complex response to Card II with no less than six CS
special scores, Mr. B. juxtaposed kissing and fighting, interspersed with red
color representing in one area blood and in another lipstick. The presence
of the FAB code was mitigated by his realization that animals do not kiss,
and thus the AB for the red color as “an analogy for kissing, the lipstick”
minimized somewhat the pathological significance of the FAB code. Nonethe-
less, Mr. B. verbalized an incongruity, and thus the coding stands as is; how-
ever, equally important was his comment on the testing-the-limits inquiry—
“they’re trained, they learned how to kiss. It’s part of the act.” I suspect Mr.
B. was mainly expressing a feeling that powerful affective experiences seemed
contrived or artificial rather than genuine. Whether considered as fusing of
libidinal and aggressive drives or as signifying a sense of confusion or unre-
ality about his affect life, it was clear that Mr. B. had difficulty reconciling
ambivalent, opposing affect states.1
Considered in the context of his three powerfully expressed responses to
Card I, Mr. B. may have conveyed here on Card II just how affected he could
be by emotionally prepotent and also confusing psychological states. Continu-
ing in the same vein as his responses on Card I, Mr. B. also appeared to convey
just how destabilizing his internal life had become. There was a quality about
his verbalization in this response that led me to wonder whether he was also
trying to communicate feeling as if he were being run through a ringer or that
he felt himself to be on an emotional roller coaster.
Thus, for example, Mr. B. mentioned kissing first, then blood, which was fol-
lowed by experiencing the confusing incongruity these images suggested. When
he said “I can’t figure out what the blood has to do with them,” he seemed to
mean something like I can’t figure out what is going on inside to make me see (or experi-
ence) such things. Mr. B. did not resolve the confusion during the response phase,
and even during the inquiry he seemed to avoid commenting on kissing and
blood, although he mentioned lips and heads. When I drew his attention to
his reference to blood, Mr. B. could no longer avoid the incongruity. He dealt
with it by seeming to minimize the animals’ kissing in favor of an activity more
in line with blood, namely that the animals were fighting. But he appeared to
become confused once again as he tried vainly to reconcile the ideas of fighting
and kissing. I did not really follow what he meant by the intellectualized-sound-
ing “the red is an analogy for kissing” and I could not tell whether he was differ-
entiating among the red areas of Card II or struggling to integrate and explain
the contrasting, persistent images of kissing and fighting. Apparently, the
aspect of his response pertaining to kissing was not going away, and although
he could not integrate blood with kissing his perhaps more reality-oriented
attempt to integrate blood with fighting left him confused. Although he seemed
to integrate blood with kissing via a comprehensible reference to lipstick, just as
he managed to explain blood and fighting, this patient nevertheless was exposed
to conflictual drive states he could not easily reconcile, apparently creating
anxiety. The MOR code appeared to reflect more a sense of something dam-
aged or injured than it concerned feeling diminished. The damaged or injured
animal of R3 did not suggest deterioration in the sense of advanced age or
wearing out; rather, the quality of this response in relation to damage or injury
may have represented mainly the confusion and distress this card probably
triggered.
My next inquiry question (kissing/fighting: help me see it as you do?)
attempted to address the effectiveness of ego functions in relation to intrapsy-
chic conflict. Although he managed to find a partial way out of the dilemma
and perhaps also its attendant anxiety (“they’re trained . . .”), he did not man-
age to resolve the incongruity between kissing and fighting other than by deftly
diverting attention away from the issue I sought to clarify with him. However, I
returned to this issue during the testing-the-limits inquiry to see whether a more
open-ended query might provide a closer look at his psychological functioning.
At that point, two interesting associations emerged. First, Mr. B. compared the
animals being trained with an act—something contrived or manufactured that
was made to appear real but which was in actuality only an outward disguise.
He then introduced the idea of people enjoying animals fighting to represent
being “viciously superior.” Perhaps this again suggested a clever, resourceful
dodge—and simultaneously an adaptive or resilient defense such as sublima-
tion of aggression. The idea of superiority, however, suggested something
else—perhaps an aspect of narcissism, but equally likely it might have suggested
healthy pride or taking pleasure in one’s abilities.
Card III
5. Two very lanky animals. They’re They’re both holding a piece of meat.
fighting over something they both want The forepaws, rear paws, tearing apart
and they’re both opposite each other, like the food.
mirror images. (What makes it look like meat?) It’s
here, in between them.
This response contained another reference both to eating or food (as in R2) and
fighting (as in R4). The animals in R5 were adversarial as they tore apart food
they both wanted. However, the aggression was not clearly hostile in intent;
consequently, the animals might not have been fighting against each other but
rather fighting competitively for the bounty they both wanted. In the latter
case, the fighting might connote assertiveness more than anger or assertion in
the sense of fighting for survival.
Perhaps Mr. B. was in effect saying here that you have to fight for what you want
in life; however, he also might have been saying something like may the better
man win. Simple truisms such as these may mask a more fundamental prob-
lem, however. Thus, both interpretations, premised on the idea of a contest
or struggle to win something—possibly representing Oedipal strivings—stood
in contrast with the impression that emerged on previous cards concerning
this patient’s difficulty integrating oral needs and aggression. Thus, some cau-
tion may be in order before regarding the thematic content as an indication
of Oedipal strivings, which might have represented a more developmentally
advanced or mature psychological organization than one dominated by oral
aggressive impulses.
Card IV
6. A blotch put together on both sides. A mirror image of the same animal. The
Like an animal cut in half, the paper was ears, back legs, elongated body. The
cut and was folded over. body’s short for an animal.
7. A person’s feet. An animal doesn’t have feet like that. A

man’s shoes, a man’s feet. If this was a
woman representing a man, she’d say he’s
all feet and he’s all sex. That’s the way
women think of men.
8. An impression of a penis hanging When a man’s having sex, his penis

down. stretches.
On this card, Mr. B. produced multiple responses, as he did on Card I, which

contrasted with the single responses he gave to both of the intervening chro-
matic cards. Whether or not the constricted productivity on Cards II and III
reflected difficulty integrating the red color and what that might imply about
affect management, two of Mr. B.’s three responses on Card IV contained
prominent undisguised references to sexuality, both of which raised some con-
cern about his level of psychological maturity, as I also suggested at the end
of the discussion of the previous response. Mr. B. began on Card IV with a
response of an incomplete or malformed figure (“an animal cut in half . . . the
body’s short for an animal”), which was reminiscent of this patient’s response
on R3 when he referred to the donkey’s “little short piece for a tail.”
Mr. B. then proceeded to deliver the two responses with sexual references. The
first of these responses was convoluted: what he saw was a man’s feet, which led
him to comment first that they were not the feet of an animal, and then about a
woman commenting about a man’s sexual drive. The links between these refer-
ences sounded quite odd. Perhaps the oddness had something to do with the imme-
diately preceding response (R6), but there was no compelling reason to believe that
to be the case. Mr. B.’s comments suggested strained reasoning, which became
even worse when he also said, “if this was a woman representing a man . . . .”
This nearly incomprehensible comment seemed to be indicating that he was
referring to how a woman might think about a man (rather than referring to
confusion about whether the figure was a woman or a man, or something con-
cerning a woman impersonating a man), and it probably had much to do with
this patient’s imprecise use of language to express more clearly what he was
trying to say. Nonetheless, his awkward choice of words—coupled with the
opening comment that the feet did not look like those of an animal and the
aside about women believing that men are preoccupied with sex—suggested
that Mr. B. became progressively destabilized as he elaborated on this response.
Probably the associative link concerned equating feet with a penis, which was
the next response (R8) in this sequence of three responses. Mainly though, Mr.
B. created a rather clear impression that his verbalizations pertained to feeling
criticized or demeaned by women. It might be possible, however, that Mr. B.
had difficulty expressing concerns about feeling incomplete or imperfect, which
could have been conveyed in clumsy, if not crude, sexualized ways. Feeling
confused about what he struggled with and not knowing how to talk about what
mattered very much to him appeared to lead to sexualizations of his psycho-
logical experience—which probably would be just as confusing to other people,
mainly the women in his life, as they may have been to Mr. B. himself.
His next response (R8)—a more unambiguous sexual reference—was pos-
sibly prompted by the immediately preceding percept of a man’s feet, even
though the associative links to that response did not become evident until the
inquiry for R7. Such a chain of events would be a risky assumption, although
by this point in the Rorschach and Figure Drawings analysis, Mr. B. seemed to
have made it quite clear that sexual functioning, or sexuality in general, were
in the forefront of much of his thinking. Certainly, R8 by itself expressed fairly
bluntly how Mr. B.’s perception of sexuality was associated with sexual potency
and adequacy. The combination of poor form quality and passive movement
further indicated how compelling this dynamic must have been for him. Mr. B.
stated in the response phase that he saw the penis “hanging down,” suggesting
detumescence, and the passive movement code perhaps might connote invol-
untary movement or possibly even loss of control. It also was noteworthy that
Mr. B. said during the response phase that he saw “an impression of a penis.”
This rather stilted or fussy way of describing what he saw was not characteristic
of the way he spoke, and he generally tended to report what he saw on the cards
with little uncertainty or tentativeness. Thus, it suggested taking intellectualized
distance from his response. Mr. B. may have been uncomfortable about what
he was seeing—a less than robust state that the penis connoted—and thus a
defensive distancing would not be surprising.
The sequence of these three responses was noteworthy. He began by describ-
ing a malformed or incomplete animal, which he followed by an oddly elabo-
rated response of a man’s feet standing for a strangely reasoned way of voicing
how women perceive men as “all sex.” This patient then produced an overtly
sexual response of a penis that was seen (anxiously, perhaps) as detumescent;
however, by also saying that it “stretches” he appeared to be again expressing
how much sexual function was on his mind. Mr. B. might easily have been
describing an anxious sense of abnormality, deterioration, or incompleteness,
and attempting to find a way to undo or ameliorate what he felt, which at
times was expressed as a preoccupation with sexual functioning (sometimes
accompanied by strained reasoning) but at other moments took the form of
concern or doubt about restoring potency. Looked at in one way, Mr. B. might
have been expressing how thoroughly he regarded his identity as bound up
with seeing himself as sexually adequate. He thus alternated between a self-
image represented metaphorically by the image of a detumescent penis and
a self-image represented by a view of himself as sexually (if not hypersexually)
potent. Another way of viewing this sequence of responses and its dynamic
import might be to regard Mr. B. as feeling depleted and undermined, strug-
gling to recapture a self-image of vigor with which to fortify a faltering sense of
self-esteem.
Card V
9. A butterfly with outspread wings. It’s The wings are spread out and it’s so flat,
been flattened out. It’s in demise, dead. that’s why it’s dead.
Mr. B.’s sole response to Card V—characterized by good form quality, and also
a commonly seen popular response—nevertheless contained a special cognitive
code for illogical reasoning (ALOG in the CS, PEC in R-PAS). Furthermore, R9
received another MOR code, Mr. B.’s fourth MOR out of nine responses thus
far. His stilted-sounding phrase (“it’s in demise”) bordered on but probably fell
short of a code for DV. It did not reflect Mr. B.’s characteristic way of speak-
ing, and it too may have represented an intellectualized, distancing defense to
manage the anxiety surrounding seeing the butterfly as dead, consistent with
my impression about defensively intellectualized distancing on R8 in relation to
his response of a detumescent penis. Considering R8 and R9 together, I would
cautiously entertain the possibility that for Mr. B. diminished sexual potency
was nearly equivalent to death.
There was relatively little to add about this response that has not already
been addressed. I would note, however, that with the exception of only one of
this patient’s four responses containing a MOR code, the remaining responses
were accompanied by a special cognitive score in addition to the MOR code. It
thus was becoming increasingly clear that Mr. B. frequently experienced some
degree of destabilized thinking when concerns about damage or traumatic
death were triggered (a fall from a building to the ground on R1, a bloodied
animal on R4, and now a flattened-out butterfly on R 9). Note also that none
of these same four responses were accompanied by achromatic or chromatic
color codes. (In fact, chromatic color appeared sparsely throughout the entire
protocol and, interestingly, there were in fact no achromatic determinant codes
at all.) Furthermore, the verbalizations accompanying these four responses
were distinctive for the absence of expressed affect or even implied emotional-
ity. Despite their morbid content, in these four responses Mr. B. seemed to
experience anxiety associated with deterioration or impairment in a way that
appeared detached, sometimes intellectualized, and sometimes characterized
by irrationality. Such responses appeared to typify his customary way of think-
ing and managing troubling affect states rather than signifying a new psycho-
logical development. Consequently, Mr. B.’s MOR responses concerning dam-
age or destructiveness seemed to reflect characterologically ingrained patterns
of long standing.
Card VI
10. [long hesitation] A lamb chop. It’s a stretch of the imagination. It’s not
much the shape. A mirror image of two
pieces of meat. No specific shape, just the
two halves.
——————
Dinner, a meal.
Card VII
11. Three pieces of meat cut up. Could be any shape, the way it comes off
the carcass. If it was connected together by
the bone, it wouldn’t split apart.
(Connected?) It’s an uneven cut. A
butcher uses a special kind of meat axe,
not a knife. He really hasn’t separated
it, it’s like incomplete cuttings. He hasn’t
wrapped up his cutting.
12. Some vegetables cut in half and The way it looks, a resemblance to pota-
cooked, potatoes and carrots. toes and vegetables.
All three of these responses contained references to food. Indeed, R10 was the
first of four consecutive responses receiving a content code for food, three of
which were of very poor form quality. It may be possible to be somewhat forgiv-
ing about the poor form quality because Mr. B. acknowledged that R10 was “a
stretch of the imagination” and R11 contained a code for vague developmental
quality. Nonetheless, his judgment about delivering poorly formed responses
such as these still could be questioned. It might be possible that the intensity
of Mr. B.’s neediness reflecting a state of psychological hunger (or at least mal-
nourishment or possibly neglect) may have been a sufficiently compelling psy-
chological dynamic to override this patient’s judgment about apprehending
more commonly seen objects on Cards VI, VII, and VIII. Recall also that Mr.
B.’s work life was spent entirely in the food services industry, initially in food
preparation and as proprietor of a delicatessen, and later as a food inspector.
Thus, interpretations concerning dependency, neediness, or oral gratification
or frustration must be considered in this context. This does not mean, however,
that interpretations about oral needs need to be discarded entirely; instead,
they should still be considered as meaningful although their intensity or prima-
riness might require tempering.
R10 was introduced by an uncharacteristically long hesitation and it came as
something of a surprise. Given Mr. B.’s preoccupation with sexuality and the
moderately strong pull on Card VI for triggering responses concerning sexual
organs or activity, I would have expected Mr. B. to have responded accord-
ingly. However, he did not, although the long latency to produce what turned
out to be his sole response to this card gave pause to speculate about why this
card provoked the hesitation it did. It was tempting, although still speculative,
to wonder whether he did in fact see something other than what he reported (“a
lamb chop”) but suppressed a different response, and hence the long latency.2
Because the response itself seemed unusual to me—certainly, at least, it was
uncommon—I chose to poke around some more to see what else might be
involved in Mr. B.’s “a stretch of the imagination.” However, on a testing-the-
limits inquiry he said nothing further beyond confirming that a lamb chop was
food for a meal. In the absence of any other clinical suggestions concerning the
response of a lamb chop, it seemed prudent to simply note the reference to food
as an exclusive content and conclude nothing further at this point.
Although nothing very definitive could be concluded about this response
apart from the speculations just noted, Mr. B.’s next response (R11) was also
about pieces of meat—except here they appeared to be described as if seen from
a butcher’s perspective. Technically the content category remained that of food;
however, the way he described the meat emphasized the way it was cut from the
bone of the animal carcass. His focus centered on the formlessness of the pieces
of meat and how they were uneven and not connected, by which he appeared to
mean separated or split apart. Mr. B.’s description of unconnected, incomplete
parts was never explained in a way that made the percept sound less vague. He
seemed to be saying when he used the word incomplete that the job was not finished
or that it was not done properly. Thus, even after saying “not connected . . . split
apart . . . separated . . . incomplete”—all psychologically loaded words—Mr.
B.’s words still left me uncertain about what he was trying to express. It sounded
as if he mainly meant that something was unfinished or incomplete, perhaps
standing for his experience of himself and how he felt about his life. It seemed to
parallel something about his existence that remained unarticulated: pieces of his
life felt disconnected or unintegrated, or that there remained unfinished business
or something Mr. B. needed to do. This elusive something was neither compre-
hensible to him nor articulated clearly in words. It did seem, however, that it
was necessary for him to complete something before he could metaphorically
“wrap[ped] up his cutting,” a phrase which also was curious. I could not be sure
whether it took on psychologically symbolic meaning in relation to finishing up
something per se or finishing up something before dying (wrapping things up),
or simply whether it was mainly a phrase a butcher might use.
Card VIII
13. Some kind of insect. Eating a leaf. Four legs. The shape is
mostly like rodents. They wouldn’t eat
leaves, insects eat leaves.
(Eating a leaf) Here, this could be a leaf
they’re eating.
——————
They’re hungry. But then animals are
always hungry.
14. An animal and a repeat of itself The shape, elongated like rodents. Their
here. Climbing up a tree, two feet clinging back legs. Both are holding a leaf with
to leaves. their paws, climbing up something.
(Climbing up a tree, clinging to
a leaf) They’re climbing up something,
it looks like a tree and it’s mostly green.
They’re clinging to a leaf and climbing
up the tree.
Here it might seem that Mr. B. let go of the preoccupation about food and
eating, but he actually may not entirely have done so. Eating was more subtly
present in R13 and the reference to clinging in R14 potentially suggested a not
unrelated psychological dynamic. These animal responses, while technically
two discrete responses, seemed mostly to be a variation of the same animal
figure in the D1 area. In R13, the insects were seen eating a leaf, although Mr.
B. appeared to be seeing these insects mainly as rodents, which is the way he
described the same D1 area in his next response. However, it also seemed that
their eating a leaf was important to the response, and when Mr. B. realized
that rodents do not eat leaves it appeared that he thought about an animal
that did eat leaves so the response made sense. His reasoning process was fairly
clear: “the shape is mostly like rodents . . . they wouldn’t eat leaves, insects eat
leaves.” Thus, even though what he probably saw was the form of rodents and
not insects, it was important for him to keep in a part of the response he needed
to retain—the idea of eating or food.
Changing the animal to one he probably did not really see then became a
secondary consideration, and he implied as much when he commented that
rodents do not eat leaves but insects do. This reasoning process was reminiscent
of R4 when he rationalized that the animals kissing were trained to do that
because “dogs don’t do that.” Moreover, the importance of eating was further
implied when, on the testing-the-limits inquiry, Mr. B. not only observed that
the animals were hungry but also commented on the intensity of that need
state (“animals are always hungry”). Considered alongside his comment on
R7 (“she’d say he’s all feet and he’s all sex, that’s the way women think of
men,” Mr. B. seemed to be suggesting that need states like hunger and sex
were the most important psychological motivations, if not the only things that
mattered, as if to say that animals were only interested in food and men were
only interested in sex. Apart from the leap in reasoning from one instance
of an event to a conclusion about every other occurrence, Mr. B.’s equating
the intensity or primacy of hunger and sex as drive states indicated the extent
to which he may have felt deprived. Though speculative, by seeming also to
equate men with animals (and specifically rodents on Card VIII), Mr. B. may
have been conveying a malevolent quality or animalistic intensity about grati-
fying need states. Recall also that on R5, the animals fighting over a piece of
meat were described as “lanky,” suggesting the idea that they were undernour-
ished. Also, their “fighting over something they both want . . . tearing apart the
food” sounded more primitive in the sense of grabbing for their survival than
it sounded competitive.
What I am suggesting here is that Mr. B. may have been communicating
that he felt more starved than hungry; further, some of his descriptions of eating
sounded more like devouring. The difference in intensity of the need reflected
in this distinction might provide further insight into what Mr. B. meant when
he said on R14 that the animals were “clinging to leaves” while climbing a
tree. The tone here implied that these animals were not about to let go of the
leaves—which represented food in the previous response—conveying once
again the urgency of needing to hold on to what one has acquired. Further-
more, Mr. B. repeated the response of animals clinging to a leaf on Card X,
which also was characterized by describing them as not wanting to let go of it.
Recall also that in an earlier percept (R4), Mr. B. vacillated between promi-
nent oral content (kissing) and fighting, conveying a substantial degree of inten-
sity that he defensively resolved by laughingly dismissing the tension created
between the red color as both lipstick and blood (“it’s part of the act . . . they’re
trained”). Thus, simply eating a leaf readily and repeatedly turned into clinging
to it, in the same way that simply eating because one was hungry readily turned
into devouring or fighting to hold on to food out of a fear that otherwise it might
disappear. One could infer that Mr. B.’s appetite, psychologically, was raven-
ous; moreover, he seemed to have to safeguard every morsel.
With this in mind, reexamining Mr. B.’s three food responses on the previous
card bears reconsideration. While at first sounding like a preoccupation with food
or eating that likely represented concerns about dependency longings, consid-
ered now in the context of the above impressions about his responses to Card
VIII, Mr. B.’s responses to Cards VI, VII, and VIII together appeared to reflect
this patient’s tenuous hold on what he needed to achieve a secure sense of well-
being. Thus, as inferred from the intensity expressed or implied in several of these
responses in which eating turned into clinging, Mr. B. appeared wary of losing
what he had managed to hold on to, while struggling to secure what he needed
to sustain himself. Although Mr. B. seemed defensively unaware of the extent
of his anxiety as he minimized its import, the intensity that emerged created an
impression that he sensed that what he needed for his survival was drying up. It
resembled a person feeling hungry, who then begins to eat and is surprised to feel
hungrier than was sensed at first, and ultimately begins to worry where the next
meal will come from. This is how I came to see what mattered most to Mr. B.:
He seemed like a person unaware of the intensity of his needs or how deprived he
often could feel, but as he began to get closer to gratifying need states it did not
take long for him to apprehend both their intensity and fragility.
Considered from this standpoint, what might now be inferred about Mr. B.’s
reference on R11 to disconnected, incomplete cuttings? Might this somewhat
peculiar verbalization reflect his concern that the intactness (hence, viability) of
the meat as a source of food (as sustenance or gratification) was threatened or
undermined? Further, did his references to sexual preoccupation or that women
saw all men as interested only in sex represent a clumsy-sounding attempt to
convey his struggling to hold on to and thus preserve feeling energetic or vigor-
ous about his life and how he felt it slipping away from him? Although still a
tentative impression, what may have seemed confusing earlier concerning Mr.
B.’s somewhat odd-sounding digression about incomplete cuttings and wrap-
ping up cuttings was beginning to make more sense.3
Card IX
A blot with three different colors: green, Just green here, and purple and yellow.
purple, and yellow.
At best a color naming response, I ultimately decided that this verbalization

on Card IX was not a genuine, scorable response. Perhaps impacted by his
compromised visual-spatial abilities as noted on the neuropsychological exami-
nation, Mr. B. was unable to formulate a coherent percept from the colors he
perceived and named. Failure to generate any response to a card, sometimes
leading to an overt card rejection, occurs most frequently on Card IX. Thus,
while not an entirely unexpected finding on this card, Mr. B.’s inability to pro-
duce a response was not common either. Its meaning was probably indeter-
minate considering the various possible interpretations it might suggest; thus I
will not comment further about the verbalization reported here or about this
patient’s failure to produce a scorable response.
Card X
∨15. A lot of insects. Two insects and two crustaceans or crabs.

Small insects being carried along by two
others, holding on to a leaf or something.
(Insects being carried along?) The
larger insect is going for a larger piece of
the leaf and the other one’s just clinging to
it. Not intentionally, it just doesn’t want
to let go and the larger insect moves to the
leaf to eat it. The smaller insect’s just
being carried along.
(Leaf?) This long piece, right here.
∨16. A fish claw, a crab’s claw. But it The shape, sharp-toothed.

doesn’t look like a crab. ——————
Feeding. The sharpness, they cut through
whatever they’re eating and they chew it.
∨17. Two crustaceans eating some- The fact that they have a lot of legs and
thing, a leaf. they’re eating a leaf, the green thing.
R15, a common (POP) response on Card X, also was notable for the active-pas-
sive movement coding, which interpretively might suggest ambivalence. This
patient once again described animals clinging to a leaf (the active movement
part of R15), but he also described animals holding on to the leaf (the passive
movement part of the response). Moreover, Mr. B. described “just clinging to
it . . . not intentionally, it just doesn’t want to let go”). His attempt to downplay
the significance of clinging was not convincing: saying just twice, rather than min-
imizing the clinical import represented by the idea of clinging instead served
only to emphasize it. Mr. B. also described the larger insects as wanting more of
the leaf to which the smaller insects were clinging, again indicating the struggle
he seemed to experience between aggressively taking and holding on to what
one has so as not to lose it. Furthermore, his use of the phrase not intentionally
seemed to imply that something could not be resisted—perhaps another indi-
cation of intensity of need, like clinging. In addition, saying not intentionally also
suggested the possibility of a defensive attempt to disavow its presence; how-
ever, it also might have represented attributing fault or blame.
R16 was another response about eating, although this aspect of the response
did not appear until a testing-the-limits inquiry. The eating also was aggressive in
nature, in which Mr. B. emphasized the sharp claw for cutting, biting down, and
chewing. Thus, like R5 and in part like R4 and R11, oral aggression was again
triggered. Although color was not used as a determinant in any of these responses
except for R4, all but one involving oral aggression occurred on chromatic cards.
R17 also concerned animals eating, although as scavengers it was unlikely that
leaves formed a typical part of crustaceans’ diet (thus the FAB code).
Recapitulation
Although I have focused primarily on Mr. B.’s preoccupation with food con-
tents and responses involved in eating and his multiple references to clinging, I
have not overlooked his opening response with its striking association to suicide
or related themes of revulsion and self-depreciation. I regarded this patient’s
unusual opening response not as a direct reference to suicidal thinking per se
but instead as a statement about how Mr. B. felt about his life. He felt spurned
and demoralized and as such the association to suicide on the testing-the-limits
inquiry represented his way of conveying desperation.
Mr. B.’s way of expressing desperation could be clumsy at times, reflecting
what I noted earlier in the R-PAS and CS interpretations about his neediness
and how that might blind him to the effect of his actions on other people. When
he might need others most, Mr. B.’s sometimes odd or unresourceful expres-
sions of neediness might only work to his disadvantage by alienating others and
thus provoking people to turn away from him. For example, what Rorschach
examiner, upon hearing an opening response about suicide, would not psy-
chologically step back, listening with an ever greater cautious reserve as the
protocol unfolded!
As he managed to convey during the initial neuropsychological evaluation I
very quickly had the impression that he needed to make a connection with any-
one who would listen to him, as he talked first about his walking slowly and that
his wife would not wait for him to catch up to her faster pace. Before long, he
was telling me how his sex drive had diminished and that he was impotent, and
soon afterward he began speaking about his wife’s trying to curtail his activities.
Mr. B. sounded like a trapped boy looking for a way out of his dilemma as he
was under the domination of a mother he feared and from whom he desired to
break away.
Taking note of the desperate quality of this early clinical impression, it should
not really be so surprising that this patient’s opening response on the Rorschach
would refer to suicide. I thought he was expressing a fervent desire for someone
to take note and listen. But even on the Human Figure Drawings preceding the
Rorschach administration, Mr. B. expressed feeling defeated and demoralized.
That sexual potency and drive had come to stand for feeling invigorated was
not difficult to see, and that there being “nothing to thrill about” in his life left
him vulnerable to falling “flat on his face” also was comprehensible as a natural
outcome of feeling depleted. That being said, I also thought it followed fairly
clearly that his preoccupation with eating and at times oral aggressive themes
represented not only that this patient felt deprived and psychologically hungry
but also that he appeared to feel that he had to fight for what little he could hold
on to in his life.
Card 1
This little boy, Tom, is looking at a violin, and he’s trying to remember how to do the
composition he was studying. He’s a little perplexed, kind of worried. He’s got a dark
expression on his face because he’s afraid his teacher will come in and he won’t know the
composition he’s supposed to play. He’s sitting in a chair cogitating. He has both his arms
on the table, which is very poor manners.
(Outcome?) He says, “Ma, I’m tired now, I’ll take some more lessons tomorrow.”
(What happens next?) His mother leaves him alone. He’s a big enough boy to take
care of himself. He didn’t practice because he’s not writing anything down, because he’s
still engrossed in thinking. This is an off day; some days you just can’t think. He’ll have
a chance to remember what he’s supposed to know. Sometimes you remember better when
no one’s peering over your shoulder, because you’re more relaxed.
(How does boy feel about not remembering?) You can’t read his mind. (Q)
Well, he looks worried. He’s not too happy here.
(What does he feel?) Helpless, like it’s too much for him, he’ll never get this. He gets
frustrated, he’s not even picking up the bow. He’d sooner not do it at all and go watch
TV or read a book.
(Mother leaves him alone?) She’s not there, she wants him to study by himself.
(How feel that mother leaves him alone?) Like he’s getting away with something.
He’s not practicing. He don’t [sic] look very happy here. She says, “Wait until your
father comes home, he’ll show you with a hickory stick.”
Mr. B.’s story, reflecting one of the more common themes about this card,
began by acknowledging an expectation to perform responsibly: the protago-
nist was unprepared for a lesson and thus experienced guilt. The outcome to
the story was an appeal to the boy’s mother for understanding; however, the
mother unsympathetically left him alone with his problem. Mr. B. seemed to
highlight what might be regarded as a clash of developmental expectations:
the boy sought help, which the mother declined to offer, believing that he was
old enough to deal with the problem himself. I wondered whether Mr. B. was
attempting to convey feeling that he was not psychologically ready to take on
responsibilities expected of him. He also may have been communicating dismay
about a mother who was not willing to consider the boy’s appeal that, despite
being “engrossed” in trying to work out the problem, sometimes a person does
not perform at their best (“some days you just can’t think”).
Later, as I probed what being helpless meant, Mr. B. observed that “he won’t
get it . . . it’s too much for him,” suggesting that he had reached the limit of
his capacity. When he then said “he’d sooner not do it at all and go watch TV
or read a book,” I was not left with the impression of laziness or disinterest. It
seemed that Mr. B. was mainly describing an off day; however, he might also
have been describing trying very hard to master a developmental challenge he
did not realize he was not yet ready to undertake.
Mr. B. therefore seemed to be describing difficulty meeting an expectation
that may have been misunderstood as being within his grasp, perhaps because
a parent expected him to take on responsibilities before he was sufficiently
equipped to do so. Further, what Mr. B. may have been describing was his
mother’s inability to notice that he was not yet developmentally ready. When
I asked about the mother in the story leaving him alone, he responded that
“she’s not there, she wants him to study by himself,” suggesting that the mother
thought the boy was mature enough to solve the problem. But from Mr. B.’s
description of the boy’s dilemma it seemed that the boy was genuinely stymied
rather than shirking a responsibility. Mr. B. also felt that the mother leaving
him alone made him feel that he was “getting away with something” when he
actually may not have known what to do or how to begin.
The mother’s misplaced view about laziness or irresponsibility, which the
boy probably had no other way to understand, was then treated as misbehav-
ior deserving punishment (“wait until your father comes home, he’ll show you
with a hickory stick”). For good measure, the boy also was criticized for placing
both arms on the table, indicating “bad manners,” which was an interesting
observation because, while that might be a criticism of table manners, there is
no etiquette guideline for sitting at a table while thinking about how to solve a
problem. I could not be sure whether Mr. B. had in mind table manners, thus
in an oblique way referring once again to eating as he had done so often in
many of his Rorschach responses. Whether bad manners or bad table manners,
Mr. B. implied feeling criticized in this odd-sounding comment.
Mr. B.’s criticisms of the boy’s failure to have his lesson ready and his bad
manners suggested an internalization of the mother’s admonitions, which
appeared to be more compelling for him than his futile attempt to appeal for
sympathetic understanding—as if to say, metaphorically, come on, have a heart!
However, the responsibility to recognize what a child cannot yet do may fall
more appropriately with a parent. For example, parents frequently have to
listen and intuitively sense what their children are capable of adequately mas-
tering, differentiating accurately between requirements that may be too much
to expect and accordingly stepping back, and requirements that are develop-
mentally appropriate and then encouraging or admonishing their children to
step up to the plate. I had the impression here that Mr. B. could not find a way
to indicate that the boy was genuinely having trouble with something, tried to
make his mother understand, which she did not seem to grasp or care about,
and because the boy did not have the wherewithal to understand what was a
legitimate expectation he was left feeling disobedient or lazy.4
I suspect that this story expressed Mr. B.’s early experience, leaving him
feeling that he was disobedient or no good when instead he mainly felt he was
unheard. Being heard or empathically understood was probably not something
he could rely on or anticipate, and I would imagine that he grew up with the
expectation that one does what one is asked to do, ready or not, and that there
was no such thing in his surround as responsiveness to developmental readi-
ness or the corrective attempts parents make upon misunderstanding their chil-
dren’s needs. Echoing what emerged on the Figure Drawings and Rorschach,
I imagined that Mr. B. lived most of his life the same way, and that the unhap-
piness represented by “there’s nothing to thrill about” reflected what for him
was a normal expectation of feeling ignored or misunderstood. He also felt
criticized and depreciated—just as he was feeling recently with his wife who, as
he probably believed, took away what was left in his life that he might be able
to “thrill about.” Perhaps his wife was being appropriately protective of him,
as Mr. B.’s mother may have been, but apart from what actually transpired he
probably was often left feeling unheard and demeaned.
I also wondered what Mr. B. had in mind when he said at one point, “some-
times you remember better when no one’s peering over your shoulder.” Con-
sidering that he was mainly describing a mother who left the boy alone with
his dilemma, where could this comment about someone being involved (or
perhaps intrusive) be coming from? I immediately thought about Mr. B.’s wife
whose intrusiveness he feared, recalling my own phone conversation with her
when she told me that his problem had been solved by her not letting Mr. B.
drive. Might he be saying here that he was accustomed to being left alone with
his problems—possibly more than was necessary—and that he was now unpre-
pared to deal with a maternal object he found too overinvolved and interfering?
Alternatively, could Mr. B.’s comment about remembering have referred to
his cognitive problems, particularly in a context of others—including myself—
observing his problems more closely than he wished? Both possibilities remain,
therefore, as potential concerns to continue listening for as the TAT analysis
proceeds and when interpreting the integrated test findings.
At a point when I asked him how he felt about the situation in his story, his
initial response (“you can’t read his mind”) echoed what he said on the Fig-
ure Drawings when I asked a similar question: “There’s no way of telling his
emotions. There’s nothing to indicate how he is on the inside, even a trained
psychologist can’t tell.” Thus, he revealed a defensive evasiveness concerning
his affect life, suggesting that such matters are off limits and accordingly should
remain untouched. Mr. B. proceeded to speak—perhaps superficially or only
in a general, somewhat distanced sense—about feeling worried, unhappy, and
helpless. However, it was his initial reaction to my question that left me with
the unmistakable impression that he was not interested in thinking about his
emotions, preferring instead to leave that area of his psychological life unexam-
ined. His evasiveness here would not necessarily indicate that affect states were
unavailable or sealed off, but rather that examining his emotional reactions
should be undertaken cautiously. Moreover, considering the question I raised
above concerning a sensitivity about intrusiveness, Mr. B.’s references to others’
reading his mind or there being no way to know his emotions or thoughts—that
not “even a trained psychologist” could see—might reflect a way to protect his
perhaps vulnerable autonomy against what he experienced as unwanted, and
possibly also unaccustomed, incursions.
Finally, it was of more than passing interest that Mr. B., who was able to use
words like cogitating, peering, and engrossed and to perceive nuances of the picture
such as “a dark expression on his face,” also used the phrase “he don’t look . . .”
It pointed to the disparity between this patient’s lower middle class roots and his
interest in reading and curiosity about learning as an adult (including starting
college in his fifties, earning a bachelor’s degree in English). Mr. B. also worked
full-time starting at age 15 to help support his family while still attending high
school; he had to continue working full-time after finishing high school, which
prevented him from attending college.
Card 2
A young girl coming home from school. The mother’s watching the farm hand working
with his horse. The woman’s supervising and she doesn’t look up at her daughter com-
ing home from school. The farmer’s doing a pretty good job, he’s about finished. The
girl is not looking at the young man and neither is the mother. The girl—her head is far
away—she’s thinking about someone else she likes better than this boy.
(Outcome?) She goes in the house, the mother will follow her, and they’ll all have
supper.
(Her relationship with the mother?) You can’t say, because they’re not looking at
each other. The girl looks like she can’t wait until she gets in the house, and the mother’s
just watching the farm boy planting the seeds. (Q) They’re not very close.
(Why is that?) They’re not even looking at each other. The girl’s also hungry. She came
from school and she’s wondering what’s to eat.
(How come they’re not close?) Plenty of families are like that. The mother’s jealous
of the daughter who is younger and prettier, and the mother’s looking backwards when she
was younger how she’d do things differently. The daughter’s mind is also far away, like
this coming Friday there’s a dance and she’ll meet a boy.
(Mother thinking about, doing things differently?) She wouldn’t be tied down to
the farm, she’d come and go as she pleased, like the daughter.
(Daughter feel about mother?) She’s not very affectionate. The daughter has a cold
look about her, she’s not the type to go over to her mother like “I’m here” and give her a
kiss. She maybe has a book to read or maybe helps make supper.
(How come not affectionate?) She comes from a cold family. See, the mother has
her nose in the air. She’s cool and calculating, and the daughter becomes that way—like
mother, like daughter.
This story, like the previous one, was about a mother–child relationship that
appeared remote, unaffectionate, unequivocally unhelpful, and seemingly
absent of nurturance from the mother’s side. Neither story referred to a father,
and the story to Card 2 even contained an undisguised expression of jealousy in
which the mother envied her child’s youth and opportunities. The mother was
portrayed as “supervising,” which in the context of this story sounded more like
watching over things than controlling—perhaps a more benign form of looking
over someone’s shoulder than Mr. B. represented in the previous story. The
male figure was merely a hired hand, a person he made a point of mentioning
as being present but unimportant (“the girl is not looking at the young man
and neither is the mother”). Mr. B. also observed that this unimportant male
figure was “doing a pretty good job” despite being barely noticed by the female
figures. Apparently only Mr. B. took the trouble to notice that man, as if he
momentarily stepped into the picture to stand up for the man’s worth, almost
surely representing his sentiment about his own life, as if to say and don’t forget
about me!
Twice Mr. B. mentioned that the mother and daughter did not look at each
other when they interacted. To say that this relationship was cold or distant and
even “calculating . . . with her nose in the air” is one thing, but to say also that
they avoided eye contact—and twice at that!—sounded as if Mr. B. was turning
cold and distant into a psychological deep freeze, so to speak. Regardless of his
layman’s sense about familial transmission of personality traits (“like mother,
like daughter”), Mr. B. was conveying here what I could only characterize as a
good example of a TAT representation of the cold, angry maternal introject so
well described in the British object relations theorists’ portrayals of schizoid and
paranoid phenomena (Klein, 1930; Fairbairn, 1944; Guntrip, 1969). Building
on his depiction of what I described as a distant, uninvolved and perhaps unem-
pathic mother—not unlike my comment about the psychologically unrespon-
sive mother he portrayed on Card 1—the quality of an angry, envious, and vin-
dictive mother who could not nurture her child’s needs (a hostile or malevolent
maternal introject, to use the Kleinian term to characterize this kind of internal
object representation) should also be considered in thinking about this patient’s
picture of his relationship to maternal figures.
When I asked Mr. B. to elaborate on this mother–child relationship, as he
did on Card 1 (“you can’t read his mind”) and on the Figure Drawings (“there’s
no way of telling his emotions”), Mr. B.’s initial comment (“you can’t see”)
also reflected his way of keeping people from seeing what he felt.5 However,
once he got past this initial defensiveness, he spoke not only of the daughter’s
hunger—undoubtedly a metaphor for feeling needy and deprived—but he also
indicated that the daughter wondered what was available for her to eat—almost
certainly a metaphor for questioning whether her mother had the wherewithal
to meet her needs. Interestingly, Mr. B. said little more about the daughter
being hungry as his next thought about her referred to a reverie about meeting
a boy—which I suspect represented a more hopeful solution to her “hunger”
than what Mr. B. depicted the mother being able to offer. Equally interesting,
Mr. B.’s next thought about the mother concerned her jealousy of the daugh-
ter’s freedom to “come and go as she pleased” while the mother felt confined
(“tied down to the farm”). The depiction of the mother’s envy together with her
coldness and limited capacity to provide nurturance was particularly consistent
with the idea of the so-called bad breast in Klein and her followers’ conceptu-
alizations of psychopathology.
Recall also how many of Mr. B.’s Rorschach responses pertained to food and
eating, representing at various times intense neediness, self-protective clinging,
and oral aggression. Further, he sometimes acted as though he had to hold on
for dear life to whatever he could secure. It was not that this patient felt starved
of affection necessarily—although he seemed not fully aware of how voracious
his needs could be, feeling starved rather than hungry—but rather he feared
that he had to fight hard to hold on to whatever he could secure lest it be
taken away or elude his grasp. Thus, with Mr. B. feeling emotionally starved
and needing to hold on tightly to what he could, it was not difficult to link this
kind of deprivation or vulnerability to the way he characteristically referred to
women as humiliating or belittling, even expecting their demeaning rejection
of him, as for example on the Figure Drawings; or as unavailable, coldly dis-
tanced, and non-nurturant, as on these first two TAT cards. It was becoming
clearer how Mr. B.’s needs for affection and self-regard developed and how
they had played out in his life. Feeling spurned and thus left to fend for himself
might easily have created an expectation that life, like obtaining nourishment,
consisted of subsisting on morsels. Moreover, he may have come to view his
existence as mainly doing what he could to hold on to what little came his way.
Indeed, at the core of his experience of life was a deeply rooted sense that there
was little available for him to feel satisfied and that even that little amount did
not come without a struggle. I could now more easily imagine how Mr. B.
could feel like the image of a small insect clinging to a leaf it has secured, as he
described several of his Rorschach percepts, and sometimes fending off a larger
insect that wanted to take the leaf away for itself. Indeed, this might well repre-
sent the defining metaphor characterizing Mr. B.’s life.
Card 3BM
Here’s a young lady standing by a tub, she’s got some appliance by her feet. She must be
very discouraged, because she’s crying that she can’t do the work that she expected to do. I
hope it’s not a major catastrophe—to get a woman to cry—but it doesn’t look very good.
(Outcome?) She’ll wait for her husband to come home and she’ll give him hell for not
fixing it, and he’ll fix the tub or whatever was leaking.
(She’s discouraged?) She’s holding her head in her hands, it looks like she’s crying.
(She’s crying?) Because she couldn’t do what she thought was going to be easy, and
now she finds it’s not so easy. And a woman, when she can’t do nothing, the first thing
they do is cry.
(She’ll give her husband hell?) That’s what my wife would do if I don’t do something
right. [At this point, Mr. B. launched into the following story, which was
intended as a joke] A wife complains about things in the house that are broken—some-
thing on the front stoop’s hanging down—and she asks her husband to fix it. He says to
her: “Do I look like a carpenter?” and he goes out and plays golf. While he’s gone, a nice
young man comes to the house to sell something she doesn’t want to buy, and he notices
the thing hanging down and offers to fix it. She gives him a hammer and nails, then asks
him in to give him something to drink and she asks him what she can do for him. And he
says, “I don’t want any money, but you can bake me a cake or make love to me.” Later,
the husband comes home and sees it’s fixed and asks her what happened, and he asked her
what kind of a cake she baked for him. And she says to him, “Do I look like a baker?”
(Husband feel that the wife gives him hell?) When a woman’s frustrated they have
to take it out on somebody. The nearest person’s the husband.
(He feel about that?) Not very happy. He feels she’s a nag. (Q) She might have been
in a bad mood, so he has to forgive her. You can’t condemn her all the time, you have to
forgive her because women don’t understand not being forgiven.
Mr. B.’s story certainly was atypical for Card 3BM. I cannot recall ever having
heard as idiosyncratic a story to this card before. This story also was unusual
for its odd form—including using the image depicted on the card mainly as
a starting point for a story in which its highlights were nowhere intimated in
the picture but instead existed entirely in this patient’s imagination. Further, I
do not think I have heard a patient tell a TAT story in which they inserted a
joke midway through the narrative. Nonetheless, it was a psychologically telling
story, one that was foreshadowed in his verbalizations on the Human Figure
Drawings.
Mr. B.’s starting point was not unusual—a person was depicted as being
discouraged. He described the person, a woman, as helpless, and in his own
form of what today would be considered sexist thinking (although that would
not have been unusual in his day), Mr. B. added what he probably grew up
learning, namely that women were characteristically helpless to the point of
tears. Furthermore, also in keeping with the mores of his day, Mr. B. portrayed
the helpless woman as doing the only thing women of the time were taught
to do—turn to a man for help. His story did not necessarily reflect needing
to demean or patronize women, but he did add a twist to the expectation of a
woman’s turning in helplessness to a man—she would “give him hell,” placing
the blame on him for being inattentive or unresponsive. As the story continued,
Mr. B. seemed to confirm the woman’s expectation that the husband was inept,
or at least unable to solve the problem. However, he also confirmed his own
expectation that the woman would approach the man in an attacking, critical
manner.
It was at this point in his story that Mr. B. associated to the joke about another
man—a more capable man—who was responsive to the woman’s needs and
flirtatiously conveyed that she was a desirable woman. In contrast, the hus-
band not only was unable to fix the problem but also acted indifferently to the
woman’s need or distress, ultimately walking away while uncaringly leaving
her holding the bag and having to fend for herself. But the husband’s attitude
backfired, when in the joke the woman found a more capable man and in
angry retaliation for his indifference deflated the husband’s arrogant intimation
that she would not cheat on him or that she would not be seen as desirable to
another man. Perhaps here Mr. B. was describing both parties in defensively
retaliative adaptations to each other—essentially depicting an intersubjective
dynamic reflecting a mutually self-defeating cycle of anger and depreciation.
For Mr. B., so it seemed, anticipating being scornfully treated by women led
him to show scornful indifference in return (as if he were in effect saying, I’m
out of here, it’s your problem).
It was noteworthy that the wife’s solution—as conveyed through the joke—
recapitulated Mr. B.’s descriptions of the woman he drew in the Human Figure
Drawings, in which the woman’s depleted existence, brought about by her hus-
band’s deficiencies, was revitalized by an affair. Card 3BM appeared to suggest
that this patient regarded his relationships with women to be built on mutual
scorn, indifference, and retaliation. Moreover, Mr. B. appeared oblivious to the
psychological intensity behind the powerful affects brought on by this kind of
interaction in which he made light of the woman’s frustration and distress in his
story by patronizingly dismissing what mattered to her. I could not be certain
whether there was additional significance to relating this dynamic through the
unusual device of telling a joke as an association to a TAT card. Interjecting a
joke might have indicated that Mr. B. needed a degree of defensive distance lest
he get too close to an awareness of the affective states this seemingly innocent
joke reflected.
Card 6BM
A younger man and an older woman and they’re waiting for the daddy to come home,
because she’s looking out the window and he just figures daddy must have something
going on because he’s got a worried look on his face. And also he’s wearing a new suit,
and his new suit is all stained, and his father wouldn’t be too happy to see he spoiled a
brand new suit.
(Outcome?) It ends with the father saying, “I can’t trust you to do anything.” Maybe
he went out to look for a job, and being all stained like that he didn’t do so well and
that’s why he has such a pained look on his face. The woman says, “Don’t worry, son,
everything’ll be all right, your father won’t be so mad, we’ll go to the tailor and clean it
and everything will be okay. Things are going to get better, it can’t get worse, it can only
get better.”
(How does he feel?) So far, he feels better when his mother talks to him that way, but
he’s still not happy. He has to ask the father to fix the clothes because he can’t afford to
pay for it, and we’ll say the father’s not such a wonderful person who takes this with a
smile. He figures it’s about time he made his own living and not be so dependent on the
father and mother.
(How does young man feel about this?) He doesn’t look happy or joyful or expect-
ant, he looks downcast, his chin is all the way down.
(Relationship with his mother?) Well, it’s her darling son so she doesn’t look wor-
ried. She looks inquisitive, wondering how it will turn out. She’s looking out the window,
waiting for the father to come home from work. (Inquisitive?) Well, her son is unhappy
and she wants him to be happy. It’s her favorite son, her only son. (She’s looking out
the window?) She can’t wait for the father to come home. She expects him to straighten
it out.
It sounded odd to hear this story beginning with a theme of a mother and
son in relation to the “daddy,” which suggested an immature, regressive qual-
ity about the young man’s relationship with his father. At the end of Card 1,
Mr. B. referred to a mother threatening her misbehaving son with his father’s
wrath; now on Card 6BM, Mr. B. again implied that the father would dis-
approve of what the young man had done. Perhaps, referring to the father
as the “daddy” represented an attempt to minimize the threat or ridicule its
impact—or even attempt to appeal to a softer side of the punitive, disapproving
father by portraying the young man as if he were a small child rather than an
adult. Although the mother was portrayed as attempting to be comforting and
optimistic, the son in this story did not feel reassured or comforted (“he doesn’t
look happy or joyful or expectant”) as he faced his father’s scornful disapproval.
Instead, he was left feeling like the failure his father considered him to be (“he
looks very downcast”). Regardless of his mother’s best hopes for him, it truly
was the father whose say mattered most.
This situation stood in contrast with the impression that had emerged on
previous cards and on the Rorschach and Figure Drawings. Mr. B. seemed
to feel resentful about being controlled or dominated by women, and he typi-
cally portrayed female figures as cold or indifferent. On Card 6BM, however,
Mr. B. portrayed the mother figure sympathetically, if perhaps ineffectual.
Indeed, it was possible that an image of a maternal figure as ineffectual might
be what Mr. B. attempted to convey on this card—a mother who would like
to nurture but was herself stymied or held back by a critical, unsympathetic
father. Considering how much this patient’s Rorschach was dominated by a
preoccupation with eating, being fed, and a clinging or grabbing approach to
holding onto whatever sustenance he could, it would not be surprising that a
maternal representation would be closer to that represented on Cards 1 or 2.
What emerged instead on Card 6BM was a more ambivalent image of a giving
or caring maternal introject who either could not follow through herself or had
deferred her capacity to respond in a maternal fashion (“she can’t wait for the
father to come home; she expects him to straighten it out”).
In another respect, the mother’s reaction resembled that of the woman on
Card 3BM who could not fix the appliance, felt deeply discouraged, and turned
first to her husband but ultimately to another man to solve the dilemma. Nor
was it appreciably different than the way the woman on the Figure Drawings was
portrayed—stuck in an unhappy situation with a man who was himself trapped,
unhappy, and going nowhere while her own happiness was tied inexorably to
men who were portrayed as failures. In both instances, Mr. B. described a way
out whereby these women turned with interest or anticipation to another man to
feel enlivened. Previously I considered this outcome as Mr. B.’s wish to rid him-
self of a situation that felt like a weight on his back that either held him back or left
him feeling injured and depreciated. Both might be plausible interpretations.
Considering the importance of the father—who was unseen on Card 6BM
but nonetheless was an important psychological presence, both for the son
and the mother—it might not be so surprising that Mr. B. devoted about as
much effort to describing the unseen father’s reaction as he did the mother’s.
Recall also how Mr. B.’s story on Card 2 began with his giving credit to the
man who occupied an unimportant role in the story, a role incidentally about
which the women in the story seemed indifferent. Mr. B.’s characterization of
“the daddy” centered around the young man’s damaged suit and his depend-
ing on the father to “fix the clothes,” his failure to get the job because of his
unkempt appearance, and the father’s patronizing but also devaluing attitude
(“the father’s not such a wonderful person who takes this with a smile”). It was
possible that Mr. B. felt unprepared to assume adult responsibilities, which the
“daddy” failed to notice, believing instead that the young man was old enough
to be more independent. The mother also did not seem to respond optimally
to the son’s plight by fostering his dependency. The young man may have felt
trapped between an ineffectual mother whose solution was to rush in with a sug-
gestion that did not promote his development—and which also was a solution
she could not accomplish on her own without the father’s endorsement—and
a father who also failed to comprehend what was psychologically necessary to
facilitate the young man’s confidence or independence. The father’s patron-
izing scorn seemed to instill in the son that he was a failure, echoing Mr. B.’s
description of the man he drew on the Human Figure Drawings. This “daddy”
seemed not to understand that confidence and independence do not simply
appear at a certain age; he may not have understood what was called for to
foster such maturation.
Card 7BM
An elderly man and a younger man. They must be very close because their heads are close
together and they’re discussing something very important. They both have serious looks on
their face. This would be that same younger man we just saw with the mother, and now
he’s telling the father all his troubles. And the father’s thinking how he’s going to pay for
it, and he’s wondering what kind of help can he give the young fellow to alleviate this
problem. The father’s a white collar worker because he’s wearing a shirt and a tie. He’s
not a worker with his hands because his clothes are pretty clean. He’s not very happy over
this prospect of an unemployed son who causes so much trouble.
(Outcome?) He says, “Come to my office, I’ll get a job for you there.”
(What is their relationship like?) Well, you can see it’s very close, the son’s got his
head on the father’s shoulder. And the father doesn’t look that unhappy over it, so it can’t
be a bad relationship.
Although it is somewhat unusual for patients to continue a story across two or
more TAT cards, neither is that an extremely rare occurrence. Understanding
such a sequence of responses probably would involve recognizing that while
a patient may be attempting to convey an important psychological theme or
affect state, to do so may have to make use of a figure on another card or a pre-
vious theme already expressed. Sometimes the pertinent dynamic configura-
tion is better conveyed through another figure, albeit on a different TAT card.
Mr. B.’s story—which continued the theme he began on Card 6BM about
“that same younger man we just saw with the mother”—was particularly tell-
ing because the young man was depicted as turning to his father for something
he seemed to find lacking in his relationship with his mother. I already sur-
mised regarding Card 6BM that Mr. B.’s experience of his relationship with
his mother and father may have influenced how he attained crucial steps in his
psychological development, a theme I continue to explore here in relation to
how this patient perceived his capacity to make a success of himself in life.
Previously, I commented about the mother on Card 6BM who appeared inef-
fectual and deferred to the father “to straighten it out,” and thus was not por-
trayed as helpful or capable of resolving the son’s concerns—just like the woman
of Card 3BM who also could not solve a problem and became overwhelmed
by her plight, ultimately turning first to her husband for help but eventually to
another man for a successful resolution. Granted, the mother figure described
on Card 6BM was more sympathetic to the son than the maternal figures, or
for that matter any other female figures he had previously referred to on the
TAT and Figure Drawings. The women Mr. B. had previously described were
typically seen as indifferent or insensitive, perhaps stemming from a more pro-
foundly felt image of women as being bitterly disappointed or neglected by the
men in their lives. Nevertheless, despite the more sympathetic, well-intentioned
characterization of the mother described on Card 6BM, Mr. B. still seemed to
see this mother figure as unable to do much to help her son.
Against this backdrop of regarding maternal figures as having little to offer,
Mr. B. may have turned to the father figure in his story to Card 7BM, possibly
expectantly or hopefully (“now he’s telling the father all his troubles”). The
father—who was previously represented as simultaneously patronizing and
critically disparaging of his son as a failure—here was depicted more benevo-
lently, although not without at least some ambivalence (the father was “won-
dering what kind of help can he give the young fellow . . . an unemployed son
who causes so much trouble”). This representation echoed the father’s senti-
ment expressed on Card 6BM that “it should be about time he made his own
living and not be so dependent on the father and mother.”
Mr. B. seemed to be suggesting that if there were to be any way out of his
dilemma, it would require a beneficent paternal figure to make it happen—
even if the father had some misgivings or expressed displeasure. Note that the
father was represented on Card 7BM not only as potentially helpful, but also
as a paternal figure Mr. B. could imagine turning to for soothing or nurtur-
ance (“the son’s got his head on the father’s shoulder”6)—the “daddy” of Card
6BM who was both comforting and infantilizing. He even began his story to
Card 7BM by commenting that “they must be very close because their heads
are close together.” Although the father was not described as rejecting or dis-
paraging of the son’s need, neither did he seem to understand the son’s plight
(“the father doesn’t look that unhappy over it”). Thus, it was a paternal figure
more than a maternal figure to whom the son felt he could more comfortably
turn—for both realistic help and as a comforting presence—even though the
father was ambivalent and did not know how to understand the son’s emotional
needs. In the end, Mr. B. did not state that their relationship was good; rather,
he observed that “it can’t be a bad relationship.”
Mr. B. appeared to emphasize that the father was a white collar worker in a
clean shirt and tie rather than a blue collar worker whose hands might become
dirty. Recall that on the surface, the central dilemma of Card 6BM was the
problem of the young man’s stained suit. It appeared that Mr. B. regarded the
father as accustomed to a settled, possibly professional status but that the young
man was unaccustomed to a suit and what it signified. I suspect the significance
of this distinction represented a developmental step he was not yet prepared
to take, and as I intimated earlier, it may also have represented longing for a
settled, confident father to guide him in a direction he aspired to reach while
feeling insecure about knowing how to attain it. Particularly pertinent to con-
sidering Mr. B.’s experience of his parents preparing him for the developmental
transition to responsible adulthood, it appeared that references to white collar
vs. blue collar and a clean look vs. a stained suit represented feeling either
ignored or neglected, first by a mother who could not do very much unless
backed up by the father and then by a father who seemed unaware of how to
help a son make such a developmental transition. Interestingly, it bears noting
that Mr. B., who worked for most of his life as a delicatessen counterman, later
in life earned a college degree and became a food inspector. Thus, almost 30
years since his own young adulthood, Mr. B. somehow managed to find the
wherewithal to move from a blue collar to a white collar status, a not insignifi-
cant albeit deferred developmental milestone.
Card 7GF
A mother and a daughter, she looks out for the teenager and the mother’s telling her the
facts of life. So she can learn how to behave and attract men, so she can eventually find
some weak-willed fellow who will marry her.
(Weak-willed?) Yeah, strong-willed men are not so fast to get married. When it comes
to women, all men are weak-willed. But the main thing is the mother says to her, “You
find a nice young man—who has a job and makes a nice salary—and you be a good wife
to him, and he’ll take care of you.”
(Weak-willed?) The mother says to the daughter that she should find a man who makes
a nice living, is good-looking, and she’ll be all right. And the daughter’s still carrying
around a doll, so she’s not so emotionally mature.
(Weak-willed man?) Well, the mother says the main thing is that the man should
make a good living and treat her right, and she’ll be okay. If he’s not weak-willed but a
strong-willed man, then he might not want to work or he won’t treat her right and she
might not be so happy in her marriage.
(Outcome?) The girl grows up, meets a nice man from the Rockefeller family, and does
very well in the long run.
(How does she feel about the mother’s advice?) She listens to everything the
mother says, she doesn’t want to face the mother but she listens. She thinks she’s a little
too young, she’s still holding on to her doll, which is not a sign of maturity. But she listens
to her mother because it’s the best she can do.
(Their relationship?) It’s got to be a good relationship because the mother gives advice
to the daughter and the daughter listens to it. So what else can she do?
Being unsure what Mr. B. meant by the girl finding a weak-willed man, which
he seemed to imply represented a favorable outcome, I asked him to elabo-
rate—no less than three times, and still I wasn’t sure what he meant! Think-
ing his evasiveness might indicate defensiveness, I persisted with this line of
inquiry. However, with each attempt I made it seemed either that the defense
was impenetrable or that he did not understand what I was asking him about
“weak-willed.” This was puzzling to me because so far on the TAT there had
not been any difficulty inquiring about responses or verbalizations. As best as I
could determine, what Mr. B. was saying was that for a woman the advantage
of a weak-willed man was that such a man would be malleable and could be
molded according to what a woman might want or need, whereas a strong-
willed man would be a problem because a woman would have nothing but
problems. The critical factor behind the mother’s advice was that a marriage-
able prospect should be responsible as a breadwinner, take proper care of his
wife, and otherwise make few demands on a woman.
Understandably, Mr. B. at age 84 grew up at a time when this view of what
made for desirable qualities in a husband and of married life was taken for
granted. What was not necessarily as understandable was his internalization
of the idea that being weak-willed was to be his lot in life and that it was not to
be questioned. In this respect, although on the face of it Card 7BM dealt with
a mother–daughter relationship, Mr. B. also was speaking here about how he
himself was expected to behave, perhaps compliantly assuming that it was a
husband’s role to make a good-enough living and that it was a wife’s role to run
their life together. Perhaps that was the reason he did not respond more directly
to my three attempts to have him focus on what he meant by “weak-willed”; for
him, perhaps, it was crystal clear and he might not have understood what I was
having trouble understanding.
Note how Mr. B. emphasized the lack of congruence between the mother’s
advice and the daughter’s developmental readiness to hear her mother’s words.
The girl obediently listened and took in the message, but Mr. B. stressed that
she was not yet ready to absorb its meaning. He did not say so directly, but Mr.
B. seemed to be implying that the mother was psychologically out of step with
the child’s development, assuming greater readiness than the girl herself felt.
He appeared to be continuing the theme I suggested earlier in my discussion
of cards 6BM and 7BM, namely that of a young person not yet psychologically
prepared for a responsible adult role and that the parents did not recognize
this.
Mr. B.’s story ended with the girl marrying a “Rockefeller.” By this somewhat
joking but also ironic story outcome, Mr. B. could have been registering how
incredulous it must have seemed for a parent to be carrying on about marriage
to a girl more interested in playing with dolls. His closing remark (“so what
else can she do!”) surely seemed to convey that something important about the
mother–daughter communication and their relationship was psychologically
amiss, notwithstanding Mr. B.’s saying that their relationship was good because
the mother gave advice and the daughter listened obediently. Mr. B.’s story
also implied—rather than expressed directly—that the daughter did not want
to face the mother7 and that the daughter seemed to understand something her
mother could not. That is, the girl seemed aware that it was premature for the
mother to be talking to her about managing a marital relationship while the girl
was at a developmental stage where “she’s still holding on to her doll”; thus she
could not expect her mother to accurately and empathically comprehend her
developmental need.
Mr. B.’s experience may well have been rather similar as he, too, like the girl
in his story, compliantly but uncomprehendingly listened to what he was told
to do but without understanding why. Chronic parental misattunement to a
child’s psychological development interferes with maturation and understand-
ing of one’s inner life. Consequently, it would not be difficult to reconstruct how
Mr. B.’s emerging sense of himself as a developing youngster could have been
impeded in a way that would probably have disposed him to feel uncertain or
confused about what he was prepared for in life and how confident he could be
in his abilities. So burdened, it would not be surprising that this patient would
face similar uncertainties throughout life, hampered by being able to accurately
appraise how he experienced himself and other people. At his present stage in
life, Mr. B. was again on his own without an empathically responsive surround
to help anchor him psychologically as the autonomy he valued and the activi-
ties that held meaning for him were being threatened or undermined.
Like the girl in his story, Mr. B. silently acquiesced, all the while voicing
internally how confused he felt about what he was experiencing and seem-
ing not to know how to respond in a way other than passively going along
with events happening around him. Interestingly, the adolescent youngster
described in Chapter 3 also appeared to be struggling with a somewhat similar
psychological experience. That boy, Carl, seemed to feel left adrift as his par-
ents did not appear to grasp the emotional distress he felt. Unlike Mr. B., how-
ever, Carl’s solution was not one of passive acquiescence as he tried to shake up
the people in his life to take note and listen. Mr. B., on the other hand, seemed
to feel like the girl who felt “it’s the best she can do” as he accepted parental
misattunement as normal. He would not have questioned or tried to make his
parents listen to him, feeling again like the girl in his story whose reaction to an
empathically unresponsive or unattuned environment was, “so what else can
she do!”
Card 13MF
Here you see a young woman, and this is her bed. This fellow, I wouldn’t say he
killed her, but he could have because he’s got remorse of some kind. He’s saying, “What
will tomorrow be like? Will you think down on me tomorrow after having a good time
tonight?” Nobody seems to be very happy here. She’s lying down, she appears to be
exhausted, she didn’t have time to get dressed. This must be in the girl’s house. The girl’s
got books on the table, she must have been reading the book before he came.
(Outcome?) You want me to become a novelist here! I think he’s saying goodbye to
her because she’s too easygoing. She let him have his way with her, and now she’s busy
reading books and relaxing. So he’s going to leave and that will be it. She’ll have to look
for somebody else.
(Why does he leave?) Because his mother told him that boys don’t marry easy girls.
On Card 13MF, Mr. B. went from having killed the woman to leaving her
because “she’s too easygoing” and “boys don’t marry easy girls.” As it was in
his day, the young woman was damaged goods—apparently even if she was
well-read! Interestingly as well, Mr. B.’s invoking social mores of the day was
expressed according to his mother’s say-so. Mr. B. seemed to be indicating that
his mother called the shots—another indication concerning Mr. B.’s accepting
what his parents said without questioning, regardless of how he might other-
wise have felt.
Although a theme of murder is not uncommon on this card, I do not know
why it triggered a thought of murder for Mr. B.—no matter that he felt
remorse “of some kind”—but he did not return to that thought as his story
unfolded. Perhaps leaving the woman as a result of the man’s mother’s killing
his desire was enough to take care of that! When the young man expressed
shame as he asked “will you think down on me tomorrow after having a good
time tonight?” I was surprised that it seemed to matter more how he would
be thought about rather than the woman, who might actually have had more
to lose. Indeed, the woman was described as being relatively unconcerned
about it all, more interested in getting back to her reading than having to find
someone else to marry—which in Mr. B.’s story sounded more like an incon-
venience than her being bothered by anything more important.
Even his remark that “you want me to become a novelist here!” sounded
like another defensive dismissal of the psychological importance of what this
card stimulated in him. When he said, “nobody seems to be very happy here,”
I was reminded of his joke on Card 3BM: the woman was unhappy while her
husband was dismissively indifferent, going off on his own to hedonistically play
golf while the woman was left stranded with her problem.
Card 18GF
That’s a woman with a child—no, it looks like a grown man. She’s holding him. You
don’t know if he’s hurt or what, you can’t see his face. I don’t know if he fell down the
staircase and she’s consoling him. It could be he hurt himself or he could just be tired. She
has compassion in her face. He just got his Dear John letter from the government that he’s
been accepted. She’s telling him things could be worse—maybe they’ll reject him, maybe
he won’t pass the test. She’s very wily.
(Wily?) You can tell from the expression on her face. His reactions you can’t see, but it’s
not very good, he’s not very happy about it, not very exuberant. So it can’t be good news.
(Outcome?) He has to go in the service anyway, like it or not. And he’ll get through
with it and come out all right. Or he won’t get through with it, they’ll make her a Gold
Star mother. (Q) They used to call it that. If a man got killed, they’d give the mother a
gold star.
(Is she his mother?) She looks old enough. I’ll assume it’s his mother, because who
else would be so worried.
(How does he feel about going in?) He’s got his head back, so he’s not gung ho and
doesn’t want to go fight for his country, for his rights, or charge the enemy. He looks kind
of dejected, he doesn’t like the prospect of going away.
(Why is that?) Because he’s a coward at heart [laughs].
(What does she feel?) She might lose him. No mother wants to lose a child, war or
no war.
Mr. B. was initially unsure whether he saw a boy or a man, but eventually
settled on the figure representing a man. I at first thought he was describing
the woman as a consoling wife or girlfriend, in part because his reference to
a Dear John letter implied a rejection or the end of a romantic relationship.
However, much later on in his story and after the confusing reference to a gold
star mother, Mr. B. offhandedly clarified that the woman who was consoling
and compassionate could be the man’s mother (“I’ll assume it’s his mother,
because who else would be so worried?”). Although it would not necessarily
be that unusual for a man to turn to his mother for comforting, nonetheless
it sounded odd to be hearing a story from an 84-year-old man about being
comforted by his mother. However, looked at another way perhaps it should
not be surprising because nowhere in the projective test protocols did Mr. B.
ever perceive a woman he described as a wife or girlfriend as being consoling or
compassionate. Indeed, as Mr. B. himself said, what other woman did he feel
showed any concern about him! Although he saw maternal figures sometimes
as benevolent, the consoling mother he described on Card 18GF seemed no
more successful at providing comfort than the mother he described earlier on
Card 6BM. Moreover, also like the mother on Card 6BM, the maternal figure
on Card 18GF appeared unable to offer the man any more comfort than the
sentiment that things could have been worse.
The man in this story was unhappy because he was being drafted into the
military. Mr. B. probably meant to say that the man received a letter from
Uncle Sam instead of a Dear John letter. In his day, a letter from Uncle Sam
meant an order to report for military service, and a Dear John letter meant
that a woman was breaking off an engagement with a man. Whether or not
he forgot or confused these two phrases, he still seemed to have the theme of
the previous TAT card on his mind, one that concerned a romantic rejection
even though in his story the man had left the woman. Mr. B.’s initial confusion
about the figure being a boy or a man may have represented his own uncer-
tainty about his capacity to function as an adult male—another TAT theme
that appeared in several stories. I suspected that his conflation of a Dear John
letter and a letter from Uncle Sam concerned questioning his adequacy as a
man who could keep a woman in his corner or acquit himself competently as a
soldier. In this regard, note also how Mr. B. initially saw a boy, then changed
it to a man who either had fallen or was tired, and finally a man about to be
drafted. Further, this patient’s concerns about being drafted centered entirely
around being able to survive and “get through with it,” feeling disinclined to
want to attain anything more noble “because he’s a coward at heart.” (At the
point in time Mr. B. would have been called for the Selective Service draft, a
different standard of patriotism prevailed compared to some other generations.
Thus, “get[ting] through with it” would have been atypical.)
Mentioning that “he doesn’t like the prospect of going away” was reminis-
cent of Cards 6BM and 7BM, expressing doubt about feeling confident that
he could go out on his own and not feeling sufficiently prepared to succeed in
a world of adult responsibilities. Consequently, staying close to home and not
“going away” may have been linked to Mr. B.’s story about the young man
wearing a stained suit and losing a job opportunity because he did not know
how to present himself well. Despite being 84 years of age, Mr. B. may have
been signaling that he never managed to achieve a comfortable degree of sepa-
ration and individuation.
Card 4
It’s a couple closer in age, looks like a man and his wife or a man and his girlfriend.
He’s telling her this can’t go on, he turned his head away. He doesn’t want to hurt her
feelings, but he can’t afford to let this go on. He’s got another girlfriend or he’s got a wife,
and he told her his wife will find out and they’ll have a lot of trouble. He’s got a troubled
look in his eye.
(Outcome?) There’s two stories. You need two pictures to tell how it’ll end. How could
it end if he’s unhappy that he’s leaving her! She’s looking at him like “How about it,
haven’t we been close enough to each other?” She doesn’t look like she plans to lose him,
but she probably will. She’s got her arms around him, she’s holding him tight, and she
doesn’t want to let go. So how could it end! Either they’ll get back again or they won’t get
back again. It’s yes or no, that’s all I can say.
(What will happen?) He turned away from her. He knows they had a good relation-
ship, but now he’s got other prospects in mind. And he’s not ready to make something
permanent.
I rarely administer Card 4, but I did ask for Mr. B.’s story to this card because I
wanted to further ascertain his capacity for intimacy, however underdeveloped
or driven underground that might have been. Many of Mr. B.’s characteriza-
tions of intimate relationships involved one person two-timing the other. Mr.
B. seemed almost to take this for granted, because rarely if at all did he express
the idea of one person trying to conceal another relationship from the other.
Often, the reason had to do with one person seeking revenge, attention or car-
ing, or enlivenment or animation in a relationship. Most of the time it was the
woman who sought an extramarital relationship, usually to spite her husband
who was portrayed either as a failure or as inconsiderate, and even at times
brutish. Typically, the affairs Mr. B. referred to were flaunted in the face of the
aggrieved party, as if to drive home how inadequate that person appeared to
the person seeking gratification through the other relationship.
On Card 4—a card with a strong pull for a story concerning intimacy or
closeness—Mr. B. not only repeated this already familiar theme of two-timing,
but he also expressed for the first time a sentiment of regret or consideration:
The man did not want to hurt the woman’s feelings and he felt unhappy to be
leaving her. Notably, on other TAT cards and on the Figure Drawings when
I asked Mr. B. to say more about how a character felt about some aspect of
the story, he was coyly or jokingly evasive. He could not easily be drawn in to
speaking about emotional states. I could not be certain why on Card 4 he spon-
taneously and without prompting spoke about feeling regretful or unhappy,
although the card pull for psychological intimacy may partly have influenced
this. Another possible reason might be that by this point in the TAT, Mr. B.
already had laid bare, albeit unwittingly, hints of strongly felt sentiments about
long forgotten, frustrated longings. Coy about relating the outcome of the story,
his Lady and the Tiger–like resolution seemed to convey ambivalence and,
perhaps more to the point, the emotional confusion he might have felt by his
unaccustomed words of unhappiness and regret.
When I pressed him—fairly gently—to provide an outcome and thus resolve
the dilemma, true to form Mr. B. reverted to his familiar position of withdraw-
ing emotionally (“he turned away from her”), thus defusing the intimacy and
gratification the man was searching for in the first place by turning toward the
woman in the picture. Mr. B. explained in his story that the man’s reason for
leaving the woman was to avoid trouble at home, yet he implied that his mar-
riage was limited or unsatisfying. Note also the words Mr. B. used to take his
leave—“he’s got other prospects in mind . . . and he’s not ready to make some-
thing permanent.” Although sounding as if he was just getting ready to move
on and repeat the same dynamic configuration all over again, I thought that the
problem reflected something more than simply fearing commitment. Rather,
I suspect that as he showed in so many places throughout the Rorschach, Mr.
B. mainly seemed to be expressing how he put his longings for something more
gratifying behind him as he turned his back on his needs and returned to the
familiar but unsatisfying emotional life to which he was accustomed. His was an
existence of someone starving while grabbing on to whatever he could manage
to hold on to, as suggested so compellingly on the Rorschach. But Mr. B. also
seemed to expect that whatever he could attain or accomplish for himself was
not secure or durable.
Card 14
Why is this young man in the dark, by an open window? And he’s looking out the win-
dow like he’s contemplating suicide. If he’s contemplating suicide, he’s climbing out the
window. If he’s not contemplating it, then he’s coming back in. You can’t tell if he’s in or
out. He’s half in and half out. And with all the black all around him, he’s probably con-
templating suicide because of the dark picture. The dark side of things. His best girlfriend
rejected him, his friend ran away with his girlfriend, and he has nothing to look forward
to. And he goes out the window and says goodbye to it all.
(What does he feel?) He can’t be feeling very well, a person without prospects. (What
particular feelings?) He’s not feeling happy, that’s all I can say about it.
This, too, is a TAT card I generally give only when there may be a lingering
question of suicidal ideation. I was not really concerned about that, but because
of Mr. B.’s opening response on the Rorschach I thought it might be the prudent
thing to do. That being said, although Mr. B.’s story to Card 14 was one of the
common stories to this card, his story initially emphasized the person’s ambiv-
alence not unlike the previous TAT card in which he vacillated between the
man’s leaving the woman or staying with her. However, his initial noncommittal
“he’s half in and half out [the window]” gave way to resolving the ambiguity in
the direction of the person committing suicide, influenced at least partially by
“all the black all around him . . . the dark picture . . . the dark side of things.”
Although the TAT is not the Rorschach, one cannot help but wonder whether
the same penchant for dysphoria, resignation, and affective constraint that
underlies Y and C' determinants on the Rorschach comes into play here as well.
Nonetheless, the verbalizations about darkness, having “nothing to look forward
to,” and saying “goodbye to it all” clearly compelled an interpretation empha-
sizing despair, despite Mr. B.’s by now familiar emotionally shallow responses
to inquiry questions intended to flesh out affect that were no more illuminating
than simplistic generalities such as “he can’t be feeling well” or “he’s not feeling
happy.” Indeed, his annoyance with such inquiry questions may have prompted
him to append the statement, “that’s all I can say about it,” indicating that he
had had enough of my inquiry questions along this line.
It is difficult to differentiate between active suicidal concern and appreciable
despair on psychological tests, particularly when it occurs throughout a battery
in more than one place, as it did in this case. Certainly, a story with a theme of
suicide would not necessarily be sufficient to raise a prominent concern about
suicidal ideation, in the same way that I did not consider Mr. B.’s mention of
suicide on the testing-the-limits inquiry on the opening response of the Rorsch-
ach to be cause for alarm. Surely, such verbalizations should not be ignored,
all the more so because there occurred two references to suicide on the test bat-
tery. Mr. B. did show a vulnerability to affective dysregulation, accompanied by
impulsivity, dysthymic mood, and intrusive thoughts. However, there were no
prominent clinical features of a depressive syndrome, the CS suicide constella-
tion and R-PAS suicide concern composite (SC-Comp) were not elevated, there
were no vista determinants on the Rorschach, and no other signs or verbaliza-
tions throughout the record strongly suggested a preoccupation with suicide or
the quality or degree of despair that might warrant more serious concern about
imminent self-harm. However, Mr. B.’s occasional impulsivity coupled with
at least a transient dysphoric nature should not be discounted. One can never
be certain about predicting a suicidal gesture or behavior or even how promi-
nently to raise such a concern; generally, determining degree of depression,
impulsivity, and pervasiveness of experiencing profound despair are probably
better earmarks of the kind of psychological states out of which active suicidal
potential emerges. Reminding oneself or a referring clinician about suicidal
ideation as a potential concern to keep in one’s clinical awareness to thus moni-
tor was all that should be necessary at this point, along with the customary
advisory recommendation to remain alert to any clinically significant changes
in mood, impulsivity, or ideation should any of these occur.
That being said, I proceeded to examine the meaning of the sense of despair
and hopelessness Mr. B. expressed on Card 14, without however couching my
interpretation in a framework of a predominant concern about suicidal thinking
or behavior. I remained mindful that anyone faced with a sufficiently prolonged,
acute state of despair could of course be vulnerable to suicide. However, I did not
think Mr. B.’s mental state or degree of vulnerability was at that point.
Mr. B.’s despairing story centered around the loss of a girlfriend who left
a man at the instigation of another man. By now, this was a familiar theme,
although what was not familiar was that, instead of indicating indifference if
not actually relief, here for the first time Mr. B. expressed a theme conveying
futility. This was not consonant with the TAT story to Card 3BM, for example,
about the husband who behaved indifferently to his wife who was just as indif-
ferent when she told him she had slept with another man to spite him. Nor was
the futility and despair in the story to Card 14 similar to Mr. B.’s description of
the husbands’ apparently uncaring reactions on the Figure Drawings about the
wives who cheated on them or ran away with other men. Perhaps this might
mean that the shallow-sounding, flippantly evasive responses to my questions
concerning the emotions felt by the people in his other TAT stories concealed
a degree of feeling wounded or diminished that was heretofore hidden, a result
of a lifetime of putting emotional reactions to events in a kind of psychological
cold storage. Perhaps Mr. B.’s rather undisguised expression of futility repre-
sented a momentary breakthrough of an affect state that was ordinarily well
defended, provoked by one TAT stimulus after another unrelentingly exposing
his innermost vulnerabilities. It was difficult to be sure. However, the despair-
ing sense he expressed on Card 14 revealed how Mr. B. felt when his defenses
weakened or were provoked by an upsurge of affect beyond a point he could
effectively manage.
Note, however, how Mr. B. ended this story. Showing a capacity for some
recoverability from a momentary upset, he referred to “prospects”—a word
that also appeared in his previous story, used there to suggest a sense of
having resources to get beyond the unhappiness or regret he felt on Card 4
about leaving the woman. Although here on Card 14, Mr. B. described the per-
son in the story as being without prospects, in the context of the entire assess-
ment protocol I was not left with the overriding impression that Mr. B. felt so
totally bereft or that he could not at least seek out resources to try to recover
from hurtful situations, including those that seemed to strike a chord of despair
and futility as powerful as that which emerged on Cards 4 and 14.
Discussion
Mr. B. presented a rich, vivid picture of his personality dynamics across all of
the projective test protocols, despite there not being a self report assessment. My
discussion will first summarize the major empirical findings from the Rorsch-
ach Structural Summary and R-PAS, followed by a content analysis of the Ror-
schach and other projective tests, before proceeding to consider this patient’s
personality structure and the developmental characteristics discerned in the test
material that influenced or were influenced by his personality organization.
Empirically Based Findings (Rorschach CS and R-PAS)

This patient appeared to suffer from a moderate degree of compromised func-
tioning influenced by a less than optimal balance between coping resources
and the demands or stressors he faced. Thus, adaptive capacities were overbur-
dened, representing a chronic, lifelong vulnerability undermining his overall
functioning and ability to manage anxiety. Mr. B. was prone to act impul-
sively or to display heightened emotional reactivity when he felt that situations
became too difficult to manage, particularly complicated emotional interac-
tions with the people in his life that left him confused about what he was feeling
or how to act. Troubling thoughts also seemed to perturb concentration and
efficient problem-solving, and he was vulnerable to dysthymic mood at times.
Seeing his body as dysfunctional and concerns about managing sexuality also
influenced his feeling of depression and pessimism about life.
Not by nature introspective, Mr. B. was limited in being able to accurately
or effectively grasp what he himself was feeling and how other people thought
about him. This patient’s thinking, although usually conventional, could be
illogical and as a result difficult to comprehend. Situations that were emotion-
ally complicated or that strained his capacity to understand what was happen-
ing tended to provoke scattered thinking or confusion. Thus, odd or idiosyn-
cratic ideas, often concerning thoughts about damage or deterioration, could
sometimes dominate his thoughts.
He seemed to have little sense about ways his own behavior impacted the
people in his life. This patient thus appeared to have difficulty negotiating rela-
tionships with people, feeling dependent and in need of support but also resent-
ful about expectations others had of him. His dependency was not matched,
however, by a good capacity to understand what other people needed from
him. As a result, Mr. B. probably felt people turning away from him, adding
to his confusion about why others might seem aloof or withdrawn, especially
when he needed to depend on others. Consequently, not being sensitive to
subtleties of interactions with the people in his surround, Mr. B. was prone
to feel spurned and rejected, and possibly in retaliation he responded in kind,
feeling angry as he perceived people ignoring his needs and ultimately feeling
diminished or devalued as a result.

Mr. B. experienced much of his life as unsatisfying, feeling as though he lived a
“dreary” existence with little to look forward to, and from which he could not
imagine any satisfactory escape. Life felt monotonous and it lacked a “thrill,”
as he put it, to provide a stable sense of invigoration or enthusiasm. While
this might appear to resemble dysphoria, he appeared to experience more a
sense of devitalization than depression, mainly representing a chronic state of
disillusionment about his life and future. In fantasy, he could imagine escaping
from the “dreary” predicament he experienced most of the time, although the
content of his solutions was usually sexualized such that sex stood for invigora-
tion or feeling alive. A lack of sublimatory potential seemed evident, and this
man’s incapacity to imagine satisfaction other than through sexual excitement
signaled his inability to secure a more suitable channel for relief from the rela-
tively empty or depleted psychological existence permeating his life. At the age
of 84, such a failure to have achieved a workable sublimatory capacity was all
the more problematic for him.
Mr. B. seemed to regard invigoration about life as being bound up nearly
totally with a view of himself as sexually adequate, leaving him vulnerable to
readily feel depleted or underpowered as he struggled hard to reconstitute a
vibrant, vigorous level of self-cohesion. Something felt missing or incomplete,
though I doubt that Mr. B. experienced this lack in a way he could articu-
late. The sense of self appeared to be experienced as fractionated or discon-
nected from his earlier life, when he could imagine feeling more enthusiastic or
stimulated—for example, channeling an interest in reading to finding the
wherewithal and determination to earn a college degree past age 50, after more
than 30 years of work behind the counter of a delicatessen. Speculating that in
his younger years he felt a hunger for learning or intellectual stimulation, Mr.
B. now seemed to feel his needs and yearnings more like those of a starving and
greedily ravenous man clinging or grabbing with animalistic intensity to hold
on to what he could, going after any morsel for stimulating a depleted self that
might come his way.
Eating and feeding became potent metaphors he unwittingly used to convey
seeking satiation of an undernourished psychological state. Mr. B. seemed to
feel that he had to devour what he could get his hands on and at whatever cost,
because there might be nothing left for tomorrow. When Mr. B. spoke about
suicide, I doubt that he meant it in the usual sense of killing oneself. I think what
he meant to convey was the demoralized, desperate sense that his life had lost
its “thrill” and that it was hardly worth the effort of soldiering on in the depleted
course his life seemed to be taking. What few satisfactions remained felt threat-
ened and undermined. When he said “what’s there to thrill about,” I think he
really meant that what little remained was slipping away from his grasp.
Feeling rejected and depreciated, it was becoming increasingly hard to feel
like the donkey that is “a good workhorse if you treat it right,” putting up with
the misery of life so long as he was treated reasonably well. Casting about for
a sympathetic ear, for someone who would understand what he felt and try
to explain it to him, Mr. B. indeed sounded like a trapped boy looking for a
way out from a critical, envious, and coldly unsympathetic mother. This was
represented currently in his life by an ever-watchful wife who seemed intent on
curtailing his autonomy and keeping him close to her apron strings, perhaps
either not grasping or caring about his efforts to find a way to communicate
how hard his life had become.
Made to feel disobedient while he mostly felt unheard, Mr. B. seemed to
grow up with the expectation that one does what one is expected to do, and that
there was little tolerance for not feeling secure about one’s abilities to negotiate
developmental challenges. Furthermore, it probably was his experience that
parents had no time to indulge their children’s need to learn how to do things
or ease them into a state of readiness or feeling of confidence.
Mr. B.’s relationship with his father also may have been disappointing and
ambivalent. Perhaps finding little comfort or understanding from his mother, it
would not be surprising that he might turn to a father when needing help with
situations in life he could not figure out or manage himself. This patient may
have wished for a father who could provide a sympathetic ear, hoping that such
a father might be able to offer a solution or point to a direction Mr. B. could
follow to buttress confidence or independence. It appeared that he found his
father at best marginally able to comprehend what Mr. B. needed, and he may
have reacted with patronizing scorn when as a boy Mr. B. turned to him for
guidance to help him come into his own. Whether the father meant well but
could not understand what Mr. B. needed or whether he was too unavailable or
unable to help his son find his way in life, Mr. B. appeared to have a relation-
ship with the father in which he saw the father as more helpful or comforting
than he actually was. His was a father who was either ambivalent himself about
what he could give his son or he simply could not comprehend the boy’s emo-
tional needs. Mr. B. may not have been able to convey his needs as a young
boy to parents who either were limited, too busy, or otherwise disinterested
or unavailable to take the time to listen and understand what he needed from
them. Perhaps as a result, Mr. B. grew up having difficulty reading other peo-
ple’s psychological states or expressing his own in a way that might lead people
to be drawn toward him rather than turning away.
Mr. B. experienced women as humiliating or belittling, and also distanced
and thus non-nurturant. He portrayed women as being unhappy and stuck
with him, perceiving himself also as trapped, unhappy, and going nowhere. He
perceived women experiencing him as an inadequate failure, and he seemed
to understand—with a sense of relief in fact—why they might spurn him and
turn with anticipation to other men who were competent and could give them
more. His sense of relief at the prospect of being abandoned by women in favor
of other men may have felt like a burden being lifted, notwithstanding that he
would simultaneously feel injured and alone.
Chronic parental misattunement naturally interferes with normal develop-
ment, which for this patient seemed to revolve around solidifying confidence in
his abilities and taking the necessary developmental steps toward mature inde-
pendence. Mr. B. must have felt hindered in knowing what his needs were and
figuring out how to make them known to others to get people on his side. So,
too, did Carl, the adolescent boy I described in Chapter 3. Carl’s solution was
to exaggerate his emotions, thereby unwittingly signaling his distress. Mr. B., in
contrast, now at age 84 and probably also as an adolescent, drove his distress
underground as he compliantly and passively tried to go along with the expec-
tations laid out for him. As a result, he probably was disposed to uncertainty or
confusion about what he was prepared for in life and how confident he could
be in his abilities. Just as he surely must have struggled to solidify an emerging
sense of himself as a confident, developing youngster—normally an expectable
outgrowth of an emotionally responsive parental environment—it would not
be surprising that Mr. B. would face similar uncertainties now as the autonomy
and wherewithal to remain involved with activities he found meaningful were
slipping away and thus under threat.
Associated with Cerebral
Dysfunction
The field of clinical neuropsychology has grown from a relatively specialized

area within clinical psychology and behavioral neurology for much of the last
century to becoming an established discipline in its own right, mainly within
the past 50 years. It is an interesting curiosity that the discipline has shown
relatively limited interest in addressing the interrelationship between cerebral
dysfunction and personality or adaptation, apart from either reacquiring or
developing compensatory functional skills. I consider the issue of personality
development in cerebral damage in this chapter, which presents findings con-
cerning personality patterns and adaptation in a 55-year-old patient with a
longstanding learning and attentional dysfunction she attempted to keep secret,
which had never previously been evaluated.
Problems affecting attention certainly are well known and easily recog-
nized, and the perpetuation of attentional problems into adulthood also is well
acknowledged as a frequently expectable outcome. Disturbances of attention
may take the form of distractibility, or even its opposite in which affected chil-
dren and adults may have difficulty disattending when it is advantageous to do
so. Their focus of attention often favors impersonal objects or activities that
are experienced as absorbing or entertaining, while children and adults with
an attentional disturbance frequently have greater problems focusing on tasks
they find difficult, less interesting, or in situations that are more interpersonal in
nature. Levin (2002, p. 343) summarized the fundamental problem by describ-
ing such persons as “extremely loaded down with the weight of having to work
many times harder than most people to organize themselves . . . [which] is
really the major key to understanding their dilemma. This has been called the
general problem of monitoring input and output in order to maintain inner
organization within optimal levels.”
Cerebrally impaired individuals are frequently observed to experience
shame concerning their cognitive difficulties, and if they are of school age, sub-
par academic performance. Often failing to live up to expectations for school
success and achievement in their work life that others manage far more eas-
ily, such people display self-esteem problems and may feel themselves to be
imposters (Levin, 2002). A variety of emotional reactions are commonly seen,
often involving anxiety-depressive symptoms in anticipation of not meeting
performance demands. Such patients characteristically misplace objects, forget
obligations, are chronically late, grossly underestimate time in relation to car-
rying out necessary functions, and often are disorganized.
There is an extensive literature on prognosis and course, family history/
genetic factors, and neurocognitive and neuroimaging mechanisms in disorders
of attention (Barkley, 1997; Posner & Raichle, 1994; Spencer et al., 1996). From
twin and adoption studies as well as molecular genetic studies, there is reason-
ably good evidence to regard such disorders as heritable. Familial disturbances
when combined with predisposing factors such as obstetric complications or
poor parental psychosocial adjustment (including unstable or conflictual home
environments or psychiatric disorder) constitute important risk factors. In addi-
tion, dysregulation of frontal-subcortical circuits has been noted, predomi-
nantly in males, and dopamine and norepinephrine neurotransmitter systems
also appear unstable in disorders of attention (Castellanos et al., 1996; Filipek et
al., 1997). Such patients are also at risk for comorbid psychiatric disorders both
in childhood and adulthood, and neurocognitive deficits affecting intellectual
performance, academic achievement, and social functioning are well-known
associated sequelae. Comorbidity is an important predictor of impaired out-
come, including persistence into adulthood, a common observation.
However, there is far less attention devoted to this area in the person-
ality theory and assessment literature and from psychoanalysis, particularly
in clinical presentations of attentional disorder in adults. Gilmore (2001)
regarded the main problems in children with attentional disorders to be
those involving integrating affect or self experience, an impaired capacity
to reflect on discontinuities of internal experience, modulating impulsivity,
and managing overstimulation, including that associated with intimate object
relationships. Although Gilmore was mainly writing about children with
attentional disturbances, her comments regarding intolerance of change and
transitions (including distractibility and fragmentation following unexpected
changes) would seem equally applicable to adults with attentional disorders.
Similar problems also exist more generally among patients with acquired cer-
ebral impairment for whom dysregulated affect presents problems, includ-
ing hyperexcitability that sometimes may be expressed as breakthroughs of
sexual or aggressive impulses.
One defensive resolution may involve the use of obsessional defenses as a
means of attempting to manage internal experiences that elude self-control,
leading inevitably to disturbances of object relations as well. As a result, nar-
cissistic fragility and the need to be in control often may emerge as associated
problems, which frequently lead to experiencing relationships as disorganiz-
ing and conflicted. Gilmore (2000) commented that histories of children with
attentional deficit disorder (ADD) from early infancy often include reports of
their appearing hard to reach, comfort, or affectively modulate; such infants’
motor movements are overactive and they also seem to have the kinds of tem-
perament that foster attachment difficulties for their mothers. She considered
all of these problematic concerns as central characteristics of a fundamental
Personality Problems and Cerebral Dysfunction 195
disturbance of developmentally acquired ego synthesis, organization, and inte-
gration. Gilmore also speculated that these aspects of compromised ego func-
tions confound what appear to be defenses with dissociated affects and drive
derivatives.
I focus on a comprehensive study of one patient’s personality organization,
conflicts, defenses, and self and object relations in respect to the cognitive-
perceptual compensations and learning and work strategies this patient devel-
oped in an attempt to meet academic demands, and later on, the cognitive
demands of the workplace. Although it is nearly impossible to disentangle
premorbid personality characteristics from the influences of compromised
neurological status on motivation, affect regulation, and self-esteem, I con-
sider in depth the predominant aspects of this patient’s personality struc-
ture—inextricably confounded by premorbid and comorbid factors though it
may be—to examine the interrelationship between neuropsychological deficits
and personality, a relatively neglected area in both personality assessment and
neuropsychology.
The patient whose personality assessment findings I present in this chapter,
Ms. C., was a 55-year-old white female, who was initially referred for a neu-
ropsychological consultation. She followed that evaluation by seeing me in psy-
chotherapy for 13 months. That by itself was not very unusual, but the reason
she sought treatment certainly was—and this will become clearer shortly after
I present this patient’s history. The reason for referral for the evaluation was
straightforward enough. She had a debilitating ear and nose infection following
an episode of pneumonia that led to complaints of memory and concentration
problems. She was having difficulty learning new material and a neurologist
advised neuropsychological testing following a recent MRI of the brain and
EEG, both of which were normal. I saw her for an interview while she was
still recovering from the ear and nose infection but waited to conduct the neu-
ropsychological evaluation until these conditions were stabilized and eventually
resolved.
As I reviewed the main findings with Ms. C., she revealed something she had
never told anyone before. Because of the comprehensive nature of the cognitive
functions assessed with neuropsychological tests, she realized that I was able to
see the scope and magnitude of cognitive deficits that had plagued her practi-
cally her entire life. Apparently, she had managed to conceal these cognitive
difficulties from teachers and even from her parents as a child—at least so she
thought, and I had no reason or suspicion to question her report over the period
of time we worked together—and then later in adulthood from employers and
colleagues at work. Ms. C. apparently had a severe learning deficiency which
she now recognized in retrospect had been present since starting school about
50 years before, at a time when learning and attentional deficits received noth-
ing resembling the degree of scrutiny and diagnostic attention they have come
to receive over the past decade or two. In the late 1940s and early 1950s, chil-
dren who had trouble learning were for the most part considered “slow” or not
especially smart. Feeling deeply humiliated by her learning problems—even as
early as age 5 or 6—Ms. C. developed a pattern of studying that she maintained
throughout her entire school career, a pattern involving taking careful notes
during classes (understanding little or nothing about what she was hearing in
the moment during classes or lectures), copying over her notes, reading them
over and over in small bits until she comprehended the material, and memoriz-
ing what she could to be able to pass tests.
Quite clearly for Ms. C., doing homework was unlike the way most other
children and young adults did homework or studied. For her, homework and
studying had become a way of life, consuming nearly all of her after-school
time. Indeed, in her work life, Ms. C. would typically arrive early and stay late,
taking work home with her at nighttime and on the weekends, and she would
devote hours upon hours going through her meticulous pattern of completing
work she could not do during the workday but that her coworkers managed
to finish during regular work hours. Her life for all intents and purposes was
devoted to work—not especially because of a passion for her work, but because
she felt she had no choice but to do so because it took her about three times as
long to complete her work responsibilities as it did for most other people. I had
the impression that Ms. C. seemed to be holding down three full-time jobs!
Over the years, I have seen many ways and patterns used by people to com-
pensate for a wide variety of learning and attentional problems, as well as many
ways used to cope with the sequelae of neurological and psychiatric diseases
that have compromised cognitive and perceptual abilities. Ms. C.’s way, how-
ever, was something I had not seen previously—certainly not ingrained to the
extent it became for her. Even more striking was her motivation to succeed,
such that she not only managed to get through enough school to earn a high
school diploma, but in addition she went on to earn a college degree and a mas-
ters degree in speech pathology. She applied the same time-consuming, pains-
taking strategies she used to get through elementary and high school to her
undergraduate and graduate studies. Moreover, she approached every occu-
pation she held in essentially the same way, expending probably two to three
times the amount of time and effort to complete her work responsibilities. This
patient’s entire life was given over to work in the same way that her childhood
and adolescence were nearly totally devoted to schoolwork and studying.
Upon completing a masters degree, Ms. C. took a chance working as a speech
pathologist, but she sensed that she might not be able to meet the demands of
the work environment using the same strategies she had developed for studying
and overpreparing herself throughout her school career. Within six weeks, she
realized that her intuition was correct, and she quit the job before she imagined
she surely would have been fired once her employer realized that something
was seriously amiss about her impaired processing and cognitive capacities.
What she did next was to find work in the only kind of environment in which
she really ever felt comfortable: Ms. C. became an assistant to the head of the
graduate program she attended and from which she earned her masters degree.
She had earned a reputation as a serious, well-prepared student and she was
known to the faculty for her work habits and for always being on top of things.
By working in the same way that she had as a student ever since first grade,
Ms. C. managed to do her work without being detected as having a learning
disability. She eventually left for other administrative positions, often changing
jobs every seven to ten years as she kept receiving promotions, which because
of the greater demands on her cognitive functions mainly threatened to expose
her longstanding problem.
As time went on, of course, computers and word processing had become de
rigueur in nearly all office environments. She simply could not learn the basic
fundamentals of computer use, and she painstakingly did her work either in
longhand or using a typewriter, often at home or before or after regular work
hours. She managed to dismiss her failure to learn computer skills as a personal
eccentricity, deftly enlisting others to transcribe her work to help her out. Over
many years, she had become quite skillful in getting people to help her and
thus managed to circumvent her cognitive problems. She managed to use one
reason or excuse after another throughout her work and school life as a means
of concealing the severity of her cognitive difficulties, always in a way, however,
that elicited concern and a willingness from others to help her compensate for
her “peculiar idiosyncrasy.” Ms. C. believed that no one in her life—including
her parents as a young child—had any inkling of her cognitive problems. She
was always seen as industrious and hard working, and by being thoughtful and
pleasant to others she managed to recruit people willing to indulge her unusual-
seeming needs and thus cover for her problems.
Having now undergone a neuropsychological evaluation, Ms. C. recognized
that she could not conceal her cognitive deficits from me, and for the first time
in her life she felt there was now a person—myself—with whom she could
talk about her lifelong struggle in this area. She believed that I had in this way
become the only person in the world who knew her secret. I would hasten to
add that the primary motivation underlying this transference position came
about only because she now recognized that “the jig was up” and she might as
well try to understand more about this disability she secretly devoted her entire
childhood and adulthood to overcompensating for and concealing. That is,
never having been offered or having sought treatment or remediation, Ms. C.
now felt that since I knew her secret she could talk with me about her problems.
She was mildly interested in seeing whether I might be able to help her remedi-
ate her learning problems—an area I told her I could not help her with because
it was not my field—but she actually was more interested in talking with me
to see if I could help her find more successful strategies to better disguise her
problems and thus continue her lifelong strategy of overcompensation and con-
cealment. Thus there began a 13-month period of psychotherapy focused on
this goal—from Ms. C.’s point of view—although I became particularly inter-
ested in understanding why her problem might have gone unrecognized by her
parents and why she could not talk with them or sympathetic teachers about
her difficulties.
I will first briefly summarize the neuropsychological findings to provide this
relevant context, but I will primarily emphasize the personality assessment
findings to focus on the central question of my interest in this case and why I
selected it to present in this chapter—the characterologic dispositions defining
this woman’s personality and how these fostered the development of her adap-
tation to a longstanding neuropsychological deficit that was either congenital
or acquired early in childhood development. I also will describe briefly the 13-
month course of psychotherapy.
Neuropsychological Findings
Ms. C. obtained a WAIS-III full scale IQ of 106 (66th percentile level), with
marginally better verbal comprehension (index score 112) than perceptual
organization (index score 101) abilities. Although verbal concept formation was
normal, Ms. C.’s verbal reasoning and problem-solving abilities were appreci-
ably better. Visual-spatial abilities also were variable, ranging from average to
low average spatial analysis to above average visual-spatial reasoning and prob-
lem-solving abilities. Speed or efficiency of information processing (processing
speed index score 103) was comparable to verbal and perceptual ability levels;
however, working memory (index score 84, 14th percentile level) was inferior to
all three WAIS indices. Other tests of processing efficiency and speed revealed
greater deficits, however, particularly when more effortful demands on capac-
ity were required.
Memory functions were mainly within normal limits; however, retention for
selective material—mainly delayed recall of visual-spatial stimuli—fell below a
level that would have been expected given this patient’s intellectual capacity.
Verbal memory remained well preserved, as did verbal fluency, and motor
functions were within normal limits bilaterally. Higher level cognitive functions
involved in conceptualizing sequences of steps appeared to be compromised,
particularly when novel strategies for problem solving were called for. Conse-
quently, Ms. C. was able to learn basic concepts but she had difficulty shifting
to other concepts or cognitive structures when such shifts would have been
more adaptive to particular tasks at hand. At such times, she approached new
problem-solving situations haphazardly, characterized mainly by random and
consequently unresourceful thinking which was particularly problematic when
she could not easily apply verbal strategies to talk or think her way through
novel problem-solving situations. It seemed that relatively greater impair-
ment was revealed when familiar cues or prompts were not readily available
to be used. Ms. C. seemed aware of but oddly indifferent to her frequent failed
attempts at such moments, despite otherwise adequate levels of motivation and
concentration.
The principal findings indicated that while verbal and visuospatial neu-
ropsychological functions were generally well preserved, compromised working
memory and executive functions undermined efficient performance, including
implementing resourceful or adaptive strategies for problem solving or concept
learning.
Minnesota Multiphasic Personality Inventory (MMPI-2)
Ms. C.’s MMPI-2 profile yielded a valid (T < 65 L, F, K, VRIN, and TRIN) 3-1
profile in which Scale 3 (hysteria) was elevated at T = 73 and Scale 1 (hypochon-
driasis) was elevated at T = 67. This 3-1 code type is typically seen in patients with
prominent or persistent somatic complaints and in individuals exhibiting a per-
sonality pattern prone to somatization of psychological states. That being said, it
deserves note that Scale 2 (depression) was not much lower than Scale 1 (with a
T score of 64), and all other clinical scales fell well below these levels. Examina-
tion of the restructured clinical scales (RC) correcting for demoralization as an
influence on the major clinical scales indicated that somatic complaints and low
positive emotions emerged as the highest elevations. However, both of these RC
scales fell below T 65, particularly low positive emotionality, and RCd (demorali-
zation) was also low. For this reason and because of the level of Scale 2 in respect
to Scales 3 and 1, a conversion pattern of somatic reactivity was not especially
indicated, nor was pronounced anxiety or depression prominent either. This
pattern suggested that Ms. C. was unlikely to be troubled by marked psychiatric
symptoms; rather, she more characteristically functioned at a diminished level of
efficiency despite a generally asymptomatic psychiatric presentation.
Apart from the possibility that the scale elevations seen here might reflect
somatic complaints attributable to this patient’s recent medical problems, Ms.
C.’s characteristic personality organization suggested that she viewed herself as
well functioning and responsible. If there were somatic symptoms of particular
note, she was not generally inclined to show the kind of concern about such
symptoms that normally would be indicated. Such patients usually are not par-
ticularly given to psychological insights concerning physical symptoms, nor as a
rule are they responsive to this way of thinking. Being instead more likely to rely
on denial and projection as prominent defenses and externalization of blame,
Ms. C. was inclined to experience indifference about problems, probably acting
defensively unconcerned and optimistic instead. A somewhat self-focused nature
coupled with needs for attention or affection also seemed to dispose her to show
heightened dependency, while simultaneously feeling uncomfortable about
dependency needs. Although generally outgoing, interpersonal relationships
nevertheless appeared rather superficial and lacking in genuine involvement
because other people were perceived mainly for their need-fulfilling functions.
She was prone to feeling resentful when people would not respond attentively to
her, or when they were not sufficiently supportive or did not serve her needs. This
patient generally controlled hostility in such circumstances, although it could
emerge through passive-aggressive actions or less frequently as temper outbursts.
Ms. C. was more likely to act in socially acceptable ways so that others would see
her as a conventional and conforming person who behaved reasonably.

Ms. L. began by drawing a stick figure (Figure 5.1). When I asked her to draw
a whole human figure, she first drew a male (Figure 5.2)—an unusual initial
Figure 5.1 Human Figure Drawing (initial drawing)
drawing of the opposite sex—which, unlike her second drawing, looked

unclothed except for possibly having shoes. The right-side extremities were
notable for having extra lines and erasures, particularly the hand, which
appeared misshapen and distorted. The face and head had some detail, and
she also had a faintly drawn circular shape enclosing the human figure. When
asked to describe the person she drew, Ms. C. said:
A hardy person, healthy, ready to do a job. A happy person, but determined. I have it as a
male, not a weak person. It’s a strong structure, everything’s in proportion—the arms, the
legs, someone who comes across as a confident person and eager and motivated.
(What’s he like on the inside?) He has a good head on his shoulders. His thinking
is rational. He’s responsive, and responsible. A warm person, a feeling person. He would
be a helping person.
(A helping person?) I just came from Target and there was this person who helped
two women get something down off a shelf. He didn’t say, “It’s not my department.” He
assumed the responsibility and said, “Sure, I’ll help.” It measures their values, how they
were raised. That’s what makes or breaks a person.
(How do you mean?) When I had this disability with my eyes, I felt awkward asking
for help. I felt I was intrusive, and it was so important how people offered to help me. I
didn’t even have to ask for it, they just knew.
I next asked in turn about the person’s fears or worries, what made him
depressed, and what made him angry. Ms. C. responded as follows:
(Fears?) He’s pretty confident, but maybe a fear of getting ill, getting sick. Hurting him-
self. I drew him as being coordinated—there’s strength—and it’s scary to lose that.
(Depressed?) Maybe the feeling of losing that confidence or the stick-to-it-iveness. But
I think it would be situational. I think he’d have the fortitude to work it through. The
strength is there.
(Angry?) Disrespectful people, who don’t respect other people or who are abusive. Abu-
sive behavior or language.
(Abusive?) People who don’t see how their actions affect other people. They’re just
encased in themselves. He’s the opposite of it—he must be strong. He’s I-oriented but
he’s we-oriented as well.
(What about that makes him feel angry?) It pollutes the world—people who don’t
see how their actions affect the world.
Finally, I asked what the person was doing as she drew him. Ms. C. replied:
He’s standing up straight. He’s not hunched over, he’s not bending.
Everything about this patient’s verbalization emphasized the man’s strength,

confidence, and stability. Her comment about drawing the figure as a male
and “not a weak person” seemed to imply that she had in mind a contrast, pos-
sibly suggesting that she regarded women as weak. Further, Ms. C. noted the
psychological qualities of warmth and sensitivity alongside the figure’s fortitude
and hardy nature, creating an impression of an idealization of manliness, integ-
rity, and kindness—or as Ms. C. stated it, “he’s responsive and responsible.”
She associated to an event she witnessed earlier that day, describing how a
male employee helped two women at a store. She emphasized that the man was
helpful in a situation in which it was not incumbent on him to act that way. Still
more telling, Ms. C. then associated to her own difficulty asking for help when
she was ill recently. She was concerned that her requests for help would be
perceived as intrusive and she felt grateful when other people intuitively sensed
what she could not easily express. Ms. C. seemed to be signaling being able to
or wishing to turn to men for sensitive understanding at times of need.
Still, the figure she drew did not particularly create an impression of strength,
vigor, or even a strong sense of character. Indeed, while the figure appeared
to resemble more a male than a female, the drawing at first looked to me as
much like an adolescent boy as a grown man. Furthermore, the absence of
any features of the clothing made the figure appear nondescript or perhaps
vulnerable and exposed. Note also the asymmetry between the right and left
arms with erasures in the area of the right hand or arm, the meaning of which
was unclear.1
As a result, despite Ms. C.’s emphasizing strength and hardiness about the
male she drew, there may have been more to it than meets the eye, which
should raise an examiner’s index of suspicion regardless of the way she ver-
bally described the figure. As she spoke about being in need of assistance, being
hesitant to show or express this need, and appreciating when others intuitively
sensed a state of need and responded accordingly, I kept wondering about her
attribution of such empathic or sensitive qualities to a man. Moreover, I was
particularly curious to hear what she would have to say about the female figure
I would ask her to draw next.
I realized after the fact that I had neglected to ask Ms. C. about the circu-
lar line she drew around the figure; however, her verbalization about people
“encased in themselves” might offer a clue. It was of more than passing inter-
est that when she spoke about what made the man angry, her use of the word
abusive prompted me to inquire further, probably because it seemed like a some-
what strong word to use here. My asking her to elaborate led to her clarifica-
tion about people not seeing the effect of their disrespectful or abusive actions,
which was not however the question I asked. She then proceeded to go further
off the point when she referred to abusive people as “encased in themselves,” by
which she seemed to mean egocentric. At this juncture she seemed to be talk-
ing about a quality that sounded still further removed from abusive, and Ms. C.
added in this context that the person she drew was the opposite of “encased” (or
egocentric). However, she returned to the idea of his being strong—which also
did not seem related to the idea of being “encased” let alone “abusive”—and
she ended up referring back to egocentricism and how that was balanced with
concern about others. Her response to my question about anger seemed to
reiterate her distaste or anger about people acting in a self-centered way (“it
pollutes the world”); however, it also was not an obvious response to the ques-
tion I asked.
I have analyzed this sequence of questions and replies for several reasons.
First, it was the earliest point in the assessment that Ms. C. became emotion-
ally moved about something—possibly anger—at which point she seemed to
wander off the point while also sounding elusive. Second, while her somewhat
circumlocutory thoughts lacked coherence and thus were difficult to follow, she
did not go astray to the extent that I had trouble understanding her meaning.
What became especially difficult to follow was her way of seeming to slip in
other ideas or connotations that also were not well explained. Thus, the more I
asked, the more elusive she became. She seemed to steer me in different direc-
tions, ultimately going around in circles and leaving me to give up trying to get
a clear enough understanding about what she meant. Further, I suspected that
this manner of confusing people was unwittingly a part of how Ms. C. managed
anxiety, remaining close enough to what a conversation concerned for others
to feel she was on the same wavelength as they were, while by the time people
might realize they did not know what she was saying they probably would give
up and leave the conversation alone. (Recall how Ms. A., described in Chap-
ter 2, showed a similar elusive pattern. However, in that case the motivation
behind Ms. A.’s defensive evasiveness served a different purpose.) This particu-
lar style of expression occurred at many points throughout the evaluation, and
I comment later about the defensive purpose it appeared to serve. At this junc-
ture, however, I am mainly calling attention to this patient’s unusual stylistic
way of expressing herself, noting that its fuller meaning will become clearer as
the test material continues to unfold.
Ms. C.’s description of the female figure (Figure 5.3) surprised me:

It looks like Olive Oyl! Determined, athletic, friendly. Smart. She’s an achiever, an
empathetic person—to people as well as animals, without regard to age, to people of all
ages. She’s a goal-oriented person, a mover and shaker, not happy with the status quo.
She wants to change things and will fight for it.
I also asked about the person’s fears, and what made her depressed and angry.
(Fears?) She’s an athletic person, so she worries about anything that would happen to
her body. She’s very conscious about her health and always wants to have that mobility.
(Mobility?) To accomplish what she wants to. She doesn’t want to waste time. She
wants to do a lot of things.
(Depressed?) Death, losses. But she’ll spring back. But a loss like a family member,
she’ll recoup. She’s viewed as being a strong person.
(Angry?) Rudeness, abuse. Theft. (Theft?) If someone stole a car or something, or
someone took advantage of someone else, or who does things that will hurt someone. She
knows right from wrong and who does the wrong thing.
The character of Olive Oyl from the popular cartoon Popeye was generally
portrayed as gangly, awkward, and clumsy—a decidedly unflattering sight to
behold with her toothpick-thin figure and large feet. Still, Olive Oyl was Pop-
eye’s girlfriend, and he was steadfast in his devotion to her despite her some-
times grating ways. Nevertheless, hardly any young girl of Ms. C.’s generation
would have aspired to be anything like Olive Oyl. What could Ms. C. possi-
bly have been thinking here! As the evaluation proceeded, I continually asked
myself what kind of self-representation or identificatory figure was Ms. C. char-
acterizing through this odd, highly idiosyncratic choice.
This patient did emphasize several prominent characteristics about the fig-
ure she drew, one of which—her determination and achievement-oriented atti-
tude—could well describe Ms. C. from the brief historical sketch I provided
about her. She emphasized as well that the person subscribed to strong senti-
ments about her beliefs and that she was intent on righting situations she con-
sidered needing correction. Ms. C. also emphasized the figure’s good-hearted,
empathic nature, particularly stressing how these attributes extended broadly
and without discrimination.
When I asked Ms. C. about fears or anxiety, her associations predominantly
concerned incursions on physical or athletic robustness and a concern about
health or that there might be something the matter with the woman’s body. For
her to use the word mobility was, I thought, a curious choice, prompting me to
inquire further. The patient’s explanation reemphasized the theme of accom-
plishment, particularly her mention of not wanting to waste time. I wondered
whether wasting time or not being mobile might have been connected with
Ms. C.’s own worries about falling behind, which she could ill afford to let happen
in her everyday work life. Even as she imagined what might cause the figure she
drew to feel depressed, Ms. C. emphasized its aftermath when she immediately
followed the mention of death and loss by saying, “she’ll spring back . . . she’ll
recoup.” Although this patient commented that the figure was “viewed as being
a strong person,” I wondered whether her stating that the figure was viewed as
strong might belie recognizing or at least doubting how she actually felt, mindful
of the importance of being seen as strong and resilient by other people.
In the same way that the word viewed crept subtly into her verbalization,
causing me to wonder what she was implying, her reference to theft in relation
to feeling angry also was a curious choice. When I asked Ms. C. to clarify what
she meant, her response took her somewhat far afield from what she initially
said, much as also happened when she was asked to clarify what she meant
by a connection between anger and abusiveness in relation to the male draw-
ing. Thus, her association between a theft of a car and taking advantage of
or hurting someone and knowing right from wrong was not intuitively clear.
Rather, the idea of abuse actually seemed to be the starting point for her appar-
ent digression—just as that same word was the starting point for her circum-
locutory digression during the inquiry about the male figure she drew. Why the
idea of abuse was as disorganizing for her as it appeared to be, and why its link
with anger was as poorly articulated as it was remained to be determined.
Ms. C. also mentioned a concern about anything that might go wrong about
the person’s body and the importance of mobility in her description of the female
drawing. It made me wonder whether the ideas about something being wrong
with the body, mobility (now in the sense of being able to free herself from
something going wrong), and righting of wrongs were all connected with either
an actual or attempted episode of abuse in her history. Perhaps representing a
dissociated experience, it nonetheless seemed quite evident that an associative
link between abuse and anger gave rise to this patient’s intermittent drifting into
an incoherent manner of communicating her thoughts. I was not sure whether
the lack of coherence of her cognitive processes was specific to something con-
cerning abuse or whether it was a broader ego deficit, though in either case it
pointed to a somewhat brittle, compromised ego function.
What by now had been two wandering digressions, both provoked by the
idea of abuse which she herself spontaneously introduced, led me to return to
Ms. C.’s comment about her drawing of a man when she talked about abusive
people being “encased in themselves.” She may have meant egocentric in the
sense of wanting what they want regardless of how it might affect others, and
this quality may have provided the link to anger, a link she could not herself
explicate clearly. But I also wondered whether being “encased” might have
represented getting lost in thoughts others could not follow, something closer to
feeling lost in space and accordingly experiencing a feeling of being insulated
or isolated. True, the context for being “encased in themselves” belonged with
the male drawing and it emerged in the specific context of people who were
abusive. She probably was referring to men although I was not entirely certain
of that. When I originally thought of her meaning egocentric when she said
encased, I had in mind a reference to men; however, Ms. C.’s circumlocutionary
language did not make it any clearer. In any event, her particular meaning
would remain to be determined as the evaluation proceeds.
It often is unclear what to make of a person drawing an opposite sex figure
before drawing a figure of the same sex as themselves. Typically, people of both
genders draw their own gender first, particularly men. Ms. C. began, however,
by drawing a male first, which was preceded by drawing a stick figure. Although
her drawing of the male figure lacked much detail, one of the hands was mis-
shapen and distorted, and there were no apparent details of clothing. Ms. C.
nevertheless described the figure as strong and confident. In contrast, her draw-
ing of the female figure appeared to be a more defined figure (although the nose
was omitted from the face), it was clearly clothed unlike the drawing of the male,
and the person was described as sure of herself and determined. However, her
description of the male figure as being strong when it looked exposed or possibly
defenseless seemed somewhat incongruous. Moreover, that Ms. C. described
the female figure as recovering well from setbacks and being “viewed” as strong
suggested the possibility that Ms. C. wanted to be perceived as strong but that
she felt uncertain about how strong or resilient she really was.
Influenced in part by these curious and possibly contradictory representa-
tions, together with her initially drawing a person of the opposite sex, I very
tentatively speculated that qualities of the male she drew might have described
the female she drew more accurately, and also that the female she described
was simultaneously strong and bold—like Olive Oyl—but also dissociated and
thus weakened. Further, depending also on what she meant by “encased in
themselves,” she could have been talking about both men and women.
I continued to be intrigued by Ms. C.’s reference to Olive Oyl, and I now regret
not asking her more about her association to that character from the well-known
cartoon she undoubtedly would have known as a child. Certainly, weak would
hardly be a way anyone familiar with the Popeye cartoon would have described
the brash, outspoken Olive Oyl, who was someone to reckon with and hardly a
pushover. Although earlier I wondered what kind of identificatory figure Olive
Oyl might have represented, it was possible that her no-nonsense, strong nature
might well have served as a basis for an identification; after all, there were very
few bold, outspoken female identification figures among the popular cultural fig-
ures of the time when Ms. C. was growing up. Perhaps struggling with anger trig-
gered by feeling abused or taken advantage of, and because certain experiences
or memories may have been dissociated, Ms. C. appeared to vacillate between
walling off or insulating her emotional life and presenting a resilient image of her-
self to others. I could imagine why Ms. C. might be drawn to a representation of
a self-assured woman, regardless of her rather unfeminine physical appearance,
who could stand up to and hold her own with a man, even one like Popeye—a
somewhat diminutive figure but nonetheless a gruff sailor man symbolized by
deriving his strength and assurance from eating spinach. Indeed, Ms. C.’s male
drawing and verbalization reminded me of this incongruity about Popeye: he did
not look powerful but once fortified he was indeed a powerhouse. Moreover, he
remained devoted to Olive Oyl through thick and through thin.
No doubt, I am stretching beyond the imagery Ms. C. presented in these
drawings and the verbalizations associated with them. However, Figure
Drawings by their nature can allow for a broad palette of hypothesis-generating
ideas; they are a good basis for forming hypotheses and raising questions, but
on their own merit drawings do not provide a satisfactory basis for answering
the questions they raise. That being said, having previously discussed Ms. C.’s
MMPI-2 findings, I next proceed to discuss her Rorschach.
Rorschach

Presented below is Ms. C.’s Structural Summary followed by a summary of
the CS-and R-PAS-derived clinical interpretations, after which I consider
the responses proper and their implications for interpretation. It will become
evident that Ms. C. produced highly idiosyncratic response content, largely
impacted by freely wandering elaborations and associations.
Figure 5.4 shows the Rorschach location sheet for Ms. C., and her CS
Sequence of Scores and Structural Summary are shown in Figures 5.5 and 5.6.
I 1 WSo 1 FC’o (A) 3.5
2 Wv 1 C’F.YFu Art
II 3 D+ 6 FMpo 2 Ad,Id P 3.0
4 Do 3 CF.YF.mp- An,Bl DV, DR,
MOR
5 Dd+ 99 F- 2 A 3.0 DR
III 6 D+ 1 Mp.FC’o 2 H,Cg,Fi P 3.0 GHR
7 D+ 3 Mp.FC.FYu 2 An 3.0 FAB, PHR
IV 8 Wo 1 FT- A 2.0 INC
V 9 Ddo 99 Fo A
VI 10 Wo 1 F- A 2.5 INC
11 Do 1 C’F.YFo Ad P
VII 12 Do 4 FTu Fd
VIII 13 Wo 1 FCo 2 A,Art P 4.5 INC
14 Do 2 Fu Cg
IX 15 Wv 1 CFo Ls
16 Ddo 28 FC’- 2 Ad
X 17 Wo 1 FC.FMao A P 5.5 DV
18 Do 3 Fo An
In this interpretively valid profile with an elevated Coping Deficit Index (CDI
= 4) and D < Adj D, the cluster strategy for interpretation began with capac-
ity for control/stress tolerance, followed sequentially by the situation-related
stress, interpersonal perception, self perception, affect, processing, mediation,
and ideation clusters.
The first notable findings were thus derived from the variables compris-
ing controls and stress tolerance, such as the EB ratio of 2:3.5, elevated CDI,
D = –3 and Adj D = –2, and EA = 5.5. Such a pattern would suggest that Ms.
C. did not appear to show a consistent style of coping, fluctuating between
thoughtfully considering and emotionally responding to events and experiences
R = 18 L = 0.38 FC:CF+C = 3:2 COP = 0 AG = 0

-------------------------------------------------------------- GHR:PHR = 1:1
Pure C = 0
EB = 2 : 3.5 EA = 5.5 EBPer = N/A a:p = 1:4
eb = 3 : 11 es = 14 D = −3
Adj es = 11 Adj D = −2 Afr = 0.50 SumT = 2
-------------------------------------------------------------- S = 1 Human Content = 1
Pure H = 1
PER = 0
m = 1 SumV = 0 SumY = 4
a:p = 1 :4 Sum6 = 8 XA% = 0.72 Zf =9 3r+(2)/R = 0.33

MOR = 1 M- =0 S- =0 Zd = +2.5 FD =0
M none = 0
X+% = 0.50 DQ+ =4 MOR =1
Xu% = 0.22 DQv =2 H:(H)+Hd+(Hd) = 1 : 0
impacting her life. Accordingly, she sometimes showed a measured or even-

tempered approach to problems, but Ms. C. also was capable of responding
unpredictably with impulsive or uncontrolled outbursts, mainly when feeling
emotionally overwhelmed. She characteristically appeared to experience con-
siderable distress, which also represented a longstanding feature compromising
adjustment. Because she struggled with and at many times lacked adequate
resources to manage the degree of stress she experienced in much of her every-
day functioning, Ms. C. was vulnerable to feeling disorganized or preoccupied
with managing stressful situations.
Presently, and probably characteristically as well, Ms. C. appeared sensitive
to marked situational demands with prolonged or intensified periods of needi-
ness. As a result, she often would experience compromised self-control, prob-
ably accompanied by anxious-dysphoric affect. Although generally affectively
constrained, Ms. C. also displayed complex thinking and emotional reactions
which, rather than fostering adaptability, instead appeared to make her appear
fairly complicated and unpredictable to the people around her.
Examining CS interpersonal relations and self perception variables unsur-
prisingly revealed how this patient might act sociably albeit in a self-protec-
tively superficial and guarded way, which probably stemmed from her internal
discomfort about people’s expectations. Prone to being passive and also some-
what dependent in her relationships with other people, Ms. C. was inclined
to subjugate her needs to others. Thus, acting deferentially and in a passive-
dependent but also guarded manner only served to intensify her neediness
and feelings of deprivation. Ms. C. was probably not strongly inclined to show
interest in or derive satisfaction from interpersonal relationships, contributing
to her relative isolation. Although being somewhat withdrawn in this way did
not appear to lead to self-absorption, neither did it promote self-awareness.
Echoing one of the key MMPI-2 findings, Ms. C. seemed particularly preoccu-
pied with somatic functions, which might impact how she felt about herself.
Ms. C.’s affective experience seemed to be dominated by a diffuse feeling
of tension or unease, which because of her defensive style typically operated
outside of her awareness. Although some stressors may have been of relatively
recent onset, she also was vulnerable to chronic loneliness and feeling deprived.
Because this patient showed considerable emotional constriction, her affect life
could appear stilted or tight as she was inclined to back away from affective
experience. By preferring to favor dealing with emotional reactions somewhat
distantly or intellectually, Ms. C. could be at some risk for developing somati-
zation reactions. Limited though they might be, the affect states she did allow
herself to feel were probably experienced deeply, accompanied by moments of
unmodulated intense affect, though usually fleeting.
CS variables concerned with information processing and cognitive mediation
and ideation also provided indications about how Ms. C. perceived and reacted
to emotional and interpersonal situations. Her characteristic emotional reserve
served an adaptive function insofar as it disposed her to confront difficult situ-
ations dispassionately. Though not without emotional concern or engagement
when necessary, this patient more characteristically appeared even-tempered
and she was inclined to contain the intensity of emotional involvements or
responsiveness. As a result, she was prone to approach many situations in a
vague or imprecise manner that could at times lead to inaccurate perceptions
of people’s intentions and actions. At such moments, Ms. C. probably initially
would appear confused about what to do in situations that were not clearly
defined. Sometimes, transient disruptions of orderly thought processes typi-
cally reflecting unmet needs might lead to lapses of judgment; however, this
patient generally recovered quickly from such brief disruptions. While intrusive
thoughts stimulated by need states did not typically interfere with relationships
with other people, Ms. C.’s thinking could nevertheless become rigid, which
also limited realistic, adaptive problem solving.
On balance, Ms. C. showed several areas of vulnerability. However, these
were mitigated by adaptive strengths serving to create an outward appearance
of mostly adequate functioning. More internally but also more outside of her
awareness, Ms. C. was susceptible to feeling deprived or lonely, thus disposing
her to anxious-depressive mood, an inconsistent pattern of responding effec-
tively to stressors, and as a result moments of confused thinking.

Figures 5.7 and 5.8 show the Sequence of Scores and Page 1 variables for
Ms. C. Ms. C.’s protocol was somewhat brief but still interpretable, despite a
potential for false negatives that was partially offset by a more than adequate
ODL R-
(RP) Opt
I 1 W SI (A) o C’ AGC
2 @ W Art Vg u C’,Y
II 3 @ D 6 Ad,NC Sy 2 o P FMp
4 D 3 An,BI - mp,CF,Y DV1,DR1 MOR
5 Dd 99 A Sy 2 - F DR1
III 6 D 1 H,Cg Sy 2 o P Mp,C’ GH
7 D 3 An Sy 2 u Mp,FC,Y FAB1 PH
IV 8 W A - T INC1 AGC
V 9 Dd 99 A o F
VI 10 @ W A - F INC1 AGC
11 D 1 Ad o P C’,Y
VII 12 @ D 4 NC u T ODL
VIII 13 W A,Art 2 o P FC INC1
14 V D 2 Cg u F
IX 15 W NC Vg o CF
16 > Dd 28 Ad 2 - C’
X 17 W A o P FMa,FC DV1
18 D 3 An o F ODL

number of blends in her record. Her functioning could be compromised by

periods of destabilization as she became overwhelmed by anxiety and helpless-
ness she probably had trouble managing. At such moments, Ms. C. could easily
feel a diminished sense of control over important aspects of her life. While the
CS interpretation emphasized her ambitent style of back-and-forth fluctuations
between measured and impulsive responsivity, R-PAS emphasized more this
patient’s emotionally deadened or dysphoric manner that very likely encum-
bered her ability to function adequately.
Ms. C.’s coping capacities were marginal, contributing to her difficulty
in thinking through problems that probably faltered when the considerable
stressors she seemed to face much of the time got the better of her. However,
she could usually manage to regain her composure and redeploy her customar-
ily adaptive resources, typically by reining in perturbing affect states. In gen-
eral, Ms. C. tended not to be aware of or concerned about subtleties of her own
or other people’s actions, and she undoubtedly had problems interpreting peo-
ple’s motivations accurately. Nevertheless, interpersonal relationships seemed
mainly congenial. Characteristically more inclined toward an avoidant rather
than a detached orientation to people in her surround, Ms. C. appeared to
keep involvements with people at arm’s length largely as a result of her marked
shyness and passivity. Thus, although on the surface she related well enough
to other people and relationships remained generally stable and comfortable,
intimate relationships were probably rather controlled and as a result fairly
remote.
g
Pr 0 Pr
Pu 0 Pu
R (Responses) 18 39 96 49 99 R
Blend 6 80 113 83 115 Bln
Sy 4 29 92 42 97 Sy
MC 5.5 44 98 56 103 MC
MC - PPD –8.5 8 79 8 78 MC-PPD
M 2 32 93 39 95 M
M/MC [2/5.5] 36% 24 89 25 90 M Prp
(CF+C)/SumC [2/5] 40% 39 96 39 96 CFC Prp
EII-3 0.9 86 116 88 118 EII
WSumCog 18 90 119 90 119 WCog
SevCog 0 35 94 35 94 Sev
FQ-% CS FQ 28% 80 113 84 115 FQ-%
WD-% CS FQ 20% 68 107 70 108 WD-%
FQ-% CS FQ 50% 45 98 41 97 FQo%
P 5 44 98 42 97 P
YTVC’ 11 95 125 96 125 m
m 1 48 99 52 101 m
Y 4 93 122 94 124 Y
MOR 1 53 101 56 102 MOR
ODL% 11% 57 103 66 106 ODL%
MAP/MAHP [0/0] NA MAP Prp
PHR/GPHR [1/2] NA PHR Prp
M- 0 32 93 32 93 M-
AGC 3 52 101 60 104 AGC
H 1 24 89 30 92 H
COP 0 22 88 40 96 COP
MAH 0 26 90 26 90 MAH

The R-PAS, like the CS, recognized Ms. C.’s sensitivity to stress provoked by
neediness and her vulnerability to anxious-dysphoric affect. Ms. C.’s shy, dis-
tant manner and her passivity disposed her to find interpersonal relationships
generally unrewarding. Although dependency was not a prominent finding,
relationships with people were important to her, even though she appeared
to have largely given up on expecting emotional relationships to be satisfying.
However, Ms. C. seemed not to recognize how she probably came across to
people, thus accentuating her shyness and a tendency to keep to herself. Nev-
ertheless, despite difficulties with thinking and reasoning, reality appraisal and
judgment were generally adequately preserved.
In what follows, I examine the response-by-response content and sequence
of percepts for a more detailed, fleshed out picture of Ms. C.’s vulnerabili-
ties and personality adaptations. I focus on gaining an understanding of this
patient’s unique way of adapting to a long history of learning difficulties and
her unusual, secretive manner of compensating for the cognitive deficits she
experienced throughout her life.
Card I
1. I see a butterfly, a mixture of a butter- The claws, the eye here, the wingspan.
fly and a spider. It has claws, a tail, and It’s a combination because a butterfly
the wingspan. It has eyes. How detailed doesn’t usually have these claws and they
do you want me to be? don’t have this indentation.
(That’s up to you) (Mixture of a butterfly and a spi-
der?) In a butterfly, you don’t have the
(Take your time; look some more) break in here— these indentations and
∧>∨ where this white is here. I don’t see a pure
butterfly. It reminds me of a butterfly.
Can I move it in any direction? Usually butterflies are very pretty. This
∨ is drab, it’s not colorful. So this thing
No, that’s it. is—it’s not horrendous—but it doesn’t
remind me of anything too great. Like a
blotchy item—the coloration in the black
and gray. A hybrid of different things. It’s
not a real butterfly, not a real insect. A
hybrid of things.
(Spider?) Where the claws are. It
reminded me of a spider. I don’t think a
butterfly has claws.
Ms. C. began conventionally enough with a percept of a butterfly. However,

she quickly revealed that she also seemed to see a spider. Rather than keeping
these percepts separate, she delivered them together without bothering to indi-
cate that they were separate images—hence, her unusual-sounding “mixture of
a butterfly and a spider.” She did not fuse these images to produce a contami-
nation response, however, nor did this patient’s solution unequivocally merit
any other cognitive special score. Although it may have come close to being
an incongruous combination (INC )—and indeed to some it might have been
coded as such—the main point to emphasize is that regardless of this coding
decision, there can be little doubt that any examiner would have thought long
and hard about the unusualness of this verbalization. Struggling over how to
code this response surely must parallel the puzzlement casual observers must
experience concerning the oddness of Ms. C.’s thinking. I had little doubt that
Ms. C. knew that her “mixture” was not real; however, I was not as confident
that her misguided choice about creating such a “mixture” took into account
how odd this integration would sound to others.
Perhaps there was a clue behind her question about how detailed she should
be about this response. She reported discrete features of the insect, even though
certain features such as a claw and a tail might not make sense together. I
wondered whether her question about detailing what she saw had to do with
describing discrete features without regard to how they might be integrated.
Apart from the matter of asking me for direction or what I wanted or expected
from her—not unlike how one might ask a teacher what kind or level of depth
was expected in an answer to an examination question, a not irrelevant factor
given this patient’s history—Ms. C. seemed to be wondering about whether
she should take a relatively concrete approach to the Rorschach situation or
whether I was looking for a more integrative or conceptual approach.
My noncommittal response led to no further verbalization. This being Card I,
I prompted her in a nonleading fashion to look further on the card. Ms. C. then
turned the card on all sides, after which she asked for permission to do what she
had in fact just done. It seemed to me that Ms. C. was attempting to clarify the
parameters of the vague Rorschach situation, on the one hand trying different
ways of working around the problem and on the other hand needing to establish
ground rules about how much flexibility she actually was permitted.
Later, during the inquiry phase, Ms. C. herself attempted to clarify the
incongruity she left unexplained previously. Without retracting or modifying
the combination of the butterfly and spider, Ms. C. took pains to note that such
a combination did not exist. Her combination of a butterfly and a spider did,
however, account for there being no POP code assigned.
Perhaps even more importantly than the question of thought disturbance,
this patient’s repeated comments about the diffuse shading seemed to explain
how hard it was for her not to be able to see it unequivocally as a “pure” but-
terfly. That is, the drabness of the card seemed to overshadow an expectation
(or perhaps a need) to see something “colorful,” suggesting how potently an
affective dimension potentially compromised reality-oriented thinking. Moreo-
ver, the way she repeated several times how the shading threw her off track led
me to wonder whether, more than the incongruity she mentioned, she also may
have been troubled by the affective quality represented by the drabness which
got the better of her. It therefore may have been the affective disharmony she
sensed in the card that threw her off balance, causing her to be unable to let
go of the idea of a combination or mixture of a butterfly and a spider. Despite
her protest to the contrary (“it’s not horrendous”), one could not escape believ-
ing that this patient really perceived some kind of “horrendous” quality in this
percept. Apart from the fact that the word horrendous implies a quality of affect
that is more intensely distressing than that which drabness connotes, I won-
dered as well whether Ms. C. wanted to rid the card of the drab colors, as if by
talking over and over about it she could talk her way out from seeing the drab
quality—and the affect giving rise to the confusion she experienced, a state of
confusion that was also “not horrendous.”
I later realized that I should not have let her comment “blotchy” go unex-
amined. True, it immediately preceded her saying that the “coloring is
black and gray,” which I took to mean at the time that Ms. C. was clarifying
what she meant by “blotchy.” Although there was no other implication that
shading was used as a determinant, it remained possible that she might have
seen a blend of shading and achromatic color (FC'.FY), as she did on R2. The
rarity of more than one shading-shading blend and its distinctive interpretive
significance was not mitigated however by the potential loss of still another such
blend, because there already was more than one such blend in the full record.
As is usually the case with the start of a thematic content analysis, specula-
tive impressions such as these are best registered by examiners as worthwhile
hypotheses, albeit tentative and subject to modification or rejection as the anal-
ysis proceeds. Certainly, such hypotheses should not be dismissed as being too
unsubstantiated to deserve serious consideration; whether they are affirmed or
ultimately discarded or modified becomes the work of the rest of the content
analysis in the context of the Structural Summary/R-PAS findings.
2. An ink stain, an inkblot. If you spilled The inkwells they used to have, or if you
ink on a piece of paper and folded it, you’d spilled ink on a piece of white paper.
get that kind of pattern. It’s black and (Ink?) Just the color. It’s a mixture of the
gray, just more depressed. Or it can be black and gray.
more distinctive—black and white. (Depressed?) The features, the color.
They’re not strong colors. There’s a lighter
gray here than over here. Some areas are
darker than others.
(Depressed?) The colors are depressing
colors. They’re not vibrant colors.
What probably was most striking about this response was that having struggled
to defend against a potentially distressing affect state on her opening response
to Card I, here the transparency of Ms. C.’s affective experience was laid wide
open—it was “more depressed.” Note also that despite her reference in the
response phase to “depressed” and two inquiry questions attempting to clarify
what she saw, Ms. C.’s verbalization remained at a descriptive level without
attribution of an affective experience. As a result, neither Hx nor MOR codes
were assigned. Although the depressive tone emerged transparently, Ms. C.
seemed to pick herself up more easily than she did in her previous response.
Thus, she began the present response with the vague image of an inkblot and
she seemed content to remain with that amorphous percept, referring to the
black and gray coloration but never returning to the depressing quality it gave
rise to. Unlike Ms. C.’s “mixture” on R1, here she was less ambiguous about
clearly articulating what was coded as a shading-shading blend.
As I tried several times to probe her comment about depression during the
inquiry, my two questions about what made the card look depressed to her led
nowhere. Ms. C. reiterated her use of the card’s achromatic coloration and
shading, revealing nothing more about how this suggested depression beyond
saying “they’re not strong colors . . . some areas are darker than others.” She
gave a bit more of a clue when I asked her a second time what made the ink-
blot look “just more depressed,” commenting that “the colors are depressing
colors . . . they’re not vibrant colors.” Although saying that the colors were
depressing added nothing to what she said previously, adding that the colors
lacked vibrancy clarified to some degree what she might have meant by say-
ing “they’re not strong colors”—enlivening, vitalizing affective experience
may have been lacking in her life. Whether she was expressing what might be
regarded as a form of empty or anaclitic depression (Blatt, 2004) or the sense of
ennui or lack of zest associated with a depleted, devitalized self (Kohut, 1977),
very likely at least some of Ms. C.’s experience of herself reflected a substantial
degree of diminished vitality.
Regarding her shading-shading blends, the occurrence of even one such
blend is generally very rare in a protocol; that Ms. C. produced two was partic-
ularly noteworthy because it would suggest that the intensity of the kind of pain-
ful psychological experience giving rise to this unusual combination of determi-
nants was indeed pronounced. Exner (2003, p. 329) regarded shading-shading
blends as an indication of “a more tormented experience that creates a very
disruptive impact on most all affective functioning.” Considered together with
this patient’s emphasis on the “depressing” quality of the achromatic colors
that were “not vibrant” and the fact that Ms. C. seemed to be announcing
this particular combination of affective qualities fairly early on, she may have
been signaling the importance of a rather deeply embedded diminished sense
of her emotional life and internal experience. It appeared to represent a form
of experience that registered as being important but it also was an experience
reflecting an aspect of her psychological life she could not get too close to and
thus articulate clearly—hence her response of an inkblot that was apprehended
with only the most vague, formless anchor in external reality. This form of
unanchored, empty, and tormented psychological experience seemed to por-
tend a vulnerability to easily feeling lost or confused, not unlike the way some
patients talk about their inner life as if it were an abyss from which there is little
hope of an escape.
It was still premature to conclude much about Ms. C.’s awareness of her
emotional life and how she experienced affects. Several indications pointed
to an appreciable degree of dysphoric affect, yet she did not present with
overt depression nor did she express much more than fleeting concerns about
depression. Neither was the DEPI constellation particularly elevated, nor did
the MMPI-2 suggest prominent depression. Although shading-shading blends
occur with marginally greater frequency in depressed patients relative to non-
patients and schizophrenics, a muted, subclinical depression seemed plausible.
In view of the elevations on MMPI-2 scales Hy (3) and Hs (1), and MMPI-2-RF
scale RC1, a personality pattern consistent with experiencing distress primarily
in the form of somatic complaints could account for the presence of several
shading-shading blends.
Considering the two responses to Card I together, this patient’s opening
response was mainly characterized by the drabness that appeared to color her
internal experience, which she perhaps tried to avoid feeling. Seemingly unsuc-
cessful at that, R1 led to a questionable cognitive lapse, giving way in her sec-
ond response to a vague, amorphous image that conveyed more rather than
less of the quality of empty, devitalized internal experience she may have tried
to deny. Some might question whether R2 should be considered as a legitimate
response without there being greater clarification about what she saw or what
made the card look like an inkblot. I chose however to retain it as a discrete
response because of the way Ms. C. described a pattern resulting from spilling
ink on paper and folding it. Naturally, there can be little doubt that also cap-
turing a verbalization about a percept looking depressed was psychologically
important and should not be ignored.
Card II
3. Two puppies. Same type of dogs, fac- The head, muzzle, ears, paws, collar or
ing each other. They’re muzzle to muz- neck area. There’s some object between
zle. Between them is a toy. ∨ ∧ them, a solid object—a triangle with an
extension down.
4. Here I see bleeding hearts. One side of the heart, it’s like cherry
red. It’s not completely attached because
there’s a lighter shade here.
(Show me how you see the bleed-
ing hearts?) There’s two parts but I
don’t see it as complete yet. There’s open-
ings in it, it’s not completely formed.
(Bleeding?) The way it’s scattered here.
(Scattered?) It’s more like it’s drip-
ping—it’s going downward.
(Lighter shade?) It’s a heart, not
completely together. It’s not a solid color
red—that’s the openings—it’s not com-
pletely together yet.
——————
It could be a birth defect—biological or
emotional [laughs].(Q) Crybabies. A
Bleeding Hearts Club where people just
commiserate. It’s not necessarily a nega-
tive thing.
(Crybabies?) Someone is a mush, a
pushover. For the underdog.
Ms. C. began Card II with a well-formed popular percept with no unusual
features. This good form quality response (R3) suggested that when affect was
not prominently triggered, she managed to reconstitute herself quickly enough
to produce a well-integrated response, in spite of the apparent difficulty she
showed on Card I.
However, Ms. C.’s stabilization did not last long, because the following
response (R4), which was of poor form quality, involved inanimate movement
together with two different affective experience determinants (chromatic color
and diffuse shading). R4 therefore represented a color-shading blend—the first
of two such blends on the entire Rorschach protocol. Further, as was the case
with this patient’s shading-shading blend on R2, this color-shading blend on R4
also was not form-dominant, indicating the potential for the affective valence
to take precedence in the response process (and by inference presumably in
life, too) when confusing or ambivalent affective experience was triggered.
Moreover, this response revealed just how compromised this patient’s cognitive
organization could become when affective engagement was prominent—an
indication I suspected even as she began the Rorschach but which was by now
more evident and unequivocal. The content of this response (bleeding hearts,
which she later clarified as one heart with its two halves shown) also graphically
revealed an aspect of ego destabilization in Ms. C.’s description of this incom-
pletely formed and disconnected heart. The color-shading blend response has
an important history in Rorschach psychology, including the CS. Like shading-
shading blends, color-shading blends are more prevalent in depressed patients,
particularly among suicidal depressives (Applebaum & Holzman, 1962). The
occurrence of even a single color-shading blend is one potential variable com-
prising the Suicide Constellation.
Interpretively, Exner (2003) and Weiner (2003) regarded this type of blend
as an indication of confused or ambivalent affect, creating problems in knowing
how one feels at different moments. Weiner also regarded color-shading blends
as a form of anhedonia in which a capacity to experience pleasure was notably
diminished, particularly when the number of such blends was greater than one,
as in Ms. C.’s record. Elevated color-shading and shading-shading blends, both
of which were apparent in this patient’s record, left little doubt that Ms. C.
experienced considerable difficulty managing affective experience. Her prob-
lem did not appear to be affective dyscontrol; rather, the problem appeared to
center around how difficult it was for Ms. C. to absorb and recognize affective
arousal in herself. As a result, feeling states were short-circuited or filtered out
of her ongoing experience.
She thus appeared to react as if affects did not exist, in spite of verbali-
zations that would suggest heightened emotional arousal to most observers.
People might feel somewhat relieved that they did not have to contend with
potent feeling states in Ms. C., but they still might be confused by the way she
appeared to them. Thus, her words could sound as if strong emotions were
not far from the surface; however, such emotions probably rarely if ever actu-
ally emerged. It must have been something like the reaction people would
have following a weather forecast about a severe storm coming, bracing for it
but then seeing nothing much at all as the storm arrived and blew out to sea,
leaving little more than a mild whimper. Stated another way, and perhaps
more to the point, her affect resembled what a person might anticipate if a
robot delivered an ominous warning about an impending disaster that did
not arrive because the robot’s computer mechanism reported it incorrectly.
Indeed, Ms. C. resembled such a robot, one whose batteries might need to
be changed! In fact, whether to change her batteries or leave well enough
alone constituted precisely a kind of therapeutic decision a clinician would
need to consider, taking into account the underlying psychological structure
or degree of deficit.
I neglected to inquire about the heart not being completely attached; how-
ever, the idea of a heart being disconnected and dripping blood, while not
entirely comprehensible, nonetheless suggested an aberration. On a testing-
the-limits inquiry, Ms. C.’s association concerned a congenital abnormality—a
chronic, longstanding condition that was not unlike her own persistent strug-
gle against all odds to compensate for an appreciable learning disability. This
response might thus be understood as a metaphor for seeing herself as dam-
aged—biologically and emotionally, as she spontaneously added—which then
provoked discomfort, as reflected in her nervous laugh after she mentioned a
birth defect. Interestingly, Ms. C. then emphasized the psychological dimension
in focusing on the idea of a bleeding heart as a metaphor for disparaging weak-
ness, feeling sorry for oneself, or appearing weak-willed. Thus, she derisively
made light of “crybabies” by trivializing emotional damage or vulnerability (“a
Bleeding Hearts Club where people just commiserate”), adding for good meas-
ure the view that feeling sorry for oneself or parading around one’s emotional
damaged goods was for psychological weaklings (“a mush, a pushover . . . the
underdog”).
This kind of toughing it out and dismissively trivializing psychological
life seemed quite consistent with the way Ms. C. had lived her life with a
chronic learning disability, forging full steam ahead in spite of roadblocks
threatening to undermine her efforts at every turn. It also suggested that she
had internalized a rather puritanical attitude toward defects or weaknesses, a
way of life that pushes on without reflecting about or indulging in adversity
(“mush”).
I inquired about her seeing the blood as “scattered,” not certain whether
she meant to say splattered but used the wrong word. Although she clarified
that she meant “dripping down,” I could not entirely dismiss what crossed my
mind at this point—the mater dolorosa, a reference to a Latin hymn describing
the profound sadness of the weeping Mary at the cross as Jesus was crucified.
My association was not totally unfounded because the images of a broken heart
and blood dripping down as a veiled symbol connoting tears were plausible
referents for such a cultural-religious association. I think the association to mater
dolorosa (or at least that of the profound sadness and tears associated with a
broken heart) may have occurred to me because of the subtle, muted tone of
melancholy that was increasingly taking shape as I sat with this patient, a tone
that was not at all evident in her behavior or affect but which seemed to emerge
from the content of her responses.2 Particularly notable in this regard were
two of Ms. C.’s three previous responses—the drabness of the butterfly/spider
lacking bright colors and the “depressing colors . . . not vibrant” of the inkblot
stain. My association to mater dolorosa, of course, is another example of a specu-
lative hypothesis too far removed from a sufficiently compelling rationale for
interpretation in Schafer’s (1953) sense, but neither is it the kind of association
that should be discarded prima facie. Just as a clinician would undoubtedly
keep thinking about and possibly return to such an association in a context
of psychotherapy, so too should a personality assessment examiner keep such
thoughts viable in a sector of his or her awareness that considers their import
and potential meanings, subject to confirmation by the cumulative evidence
from a complete assessment evaluation.
In addition to the dripping blood reflecting inanimate movement as a third
determinant, it also was seen as “cherry red.” This verbalization seemed to con-
vey a particular quality of vividness about the blood in which the brightness of
the cherry red color stood in sharp contrast against the “not horrendous” drab-
ness that prevented her from seeing a “pure . . . pretty . . . colorful” butterfly on
Card I or the “vibrant . . . strong colors” she seemed to miss when reporting the
“depressing colors” on her second response to that same card. Interestingly as
well, when Ms. C. described the lighter shade in her bleeding heart response,
she used it to convey that the parts of the heart were “not completely attached
. . . not completely together”—once again, a veiled but nonetheless suggestive
reference to loss or separation, perhaps tinged with sadness. The confluence of
the lighter color referring to a disconnection and the bright cherry red color
referring to dripping blood in this color-shading blend added to the implica-
tion that Ms. C.’s awareness or tolerance of her internal affective life was either
ambivalent or confused—a rather deeply distanced sense of her emotional life
she seemed to struggle with in order to keep increasingly intense, burgeon-
ing affect states suppressed and in their place, affect states this woman seemed
not to know what to do with or how to feel or comprehend what they meant
to her.
And what of the kinds of affect states she managed not to register, which
were in effect blown out to sea like the metaphorical storm I suggested above?
The prevalence of two shading-shading blends suggested that her style of man-
aging painfully disruptive emotions was to short-circuit them. In one respect,
Ms. C.’s way of deflecting affects reflected a defensive accomplishment; how-
ever, it came at a cost of a dampened, emotionally diminished existence, one
that depleted a sense of a deeper inner psychological life. In addition, the
prevalence of two color-shading blends indicated how she apprehended her
emotional life—a perplexing mélange of affects, alternating between satisfy-
ing emotions and fearfully and sometimes painfully unsatisfying emotions. She
seemed not to imagine that anything good would come her way or last for long.
Considering these two kinds of blends alongside each other, the question could
legitimately be posed thus: Was it better for this patient to experience a full
range of emotions—including emotions of deep or intense psychological pain
(Exner’s “tormented” psychological experience; Exner, 2003)—or not to feel
much of anything at all?
Perhaps an answer might be discerned from this patient’s frequent associa-
tions to using color, for example her complaint on R2 that “the colors are
depressing . . . they’re not vibrant colors.” Or perhaps the “cherry red” color
on R4 alongside a lighter shade of red signifying something not completely
attached or formed; or how on R7 “the coloring changes to something more
lively, it seems happier . . . two hearts coming together” alternating with “a
lighter shade, so they’re not completely merged yet,” to which she associated
how “the merging of the colors” represented “as you get older and experience
different things and it gets stronger or weaker, or you get wiser . . . the growth
process of the heart.” Then there was her penultimate response on Card X
where she said about the different colors that “they’re vibrant, lively and warm.
The ocean is very alive with all different kinds of life,” which interestingly was
followed by her final response of the protocol—a wishbone.
Unquestionably, Ms. C. showed a lively, stimulated awareness concerning
chromatic color throughout her Rorschach, but notably the level of arousal
it represented was nearly always qualified or neutralized. For example, bright
colors suggesting happiness or merging were followed by lighter shades sug-
gesting incompleteness. Often when color was mentioned, presumably refer-
encing something affectively vital being opened up, it was quickly followed
by its being shut back down again. The missing vibrant colors she mentioned
also were closely linked to a lack of vibrancy—which impressed me most
about the way Ms. C. seemed to have lived her life, devoting untold hours
to the effort required to camouflage the shame of her pronounced learning
deficiency and neuropsychological impairment. I was reminded here of the
poignant final line from Chekhov’s The Cherry Orchard, in which the 87-year-
old manservant Fiers reflects on his lifetime of service entirely devoted to one
family. As the family members disperse from their estate forever, Chekhov
gives these words to this character who has known no other life: “They’ve gone
away . . . forgotten about me . . . never mind . . . life’s gone on as if I’d never
lived.”
In this regard, note also what Ms. C. said as she added spontaneously after
her dismissive, derisive comment about crybabies and a Bleeding Hearts Club
on the testing-the-limits inquiry: “it’s not necessarily a negative thing.” Here—
not unlike the comment of Chekhov’s character, “never mind,”—after already
having minimized the psychological significance of everything she opened up
about the bleeding heart, dripping blood, and cherry red color, Ms. C. pro-
ceeded to demonstrate how I would suppose she picked up the pieces of power-
ful affective fragments and went on to reconstitute a psychological equilibrium
for herself. It is quite possibly how she had found a way to manage the unhap-
piness and profound cognitive difficulties she encountered nearly daily as she
made her way through life.
5. Two things coming together, but the Two objects, they’re together. They’re
noses are together. But down here, it’s attached up here, but here on the bot-
separated. They’re joined, but they’re not tom they’re not completely independently
going to remain. They’re going to walk whole. The outline of two images.
away, or they’ll be separated due to some (Coming together?) They’re together
reason. on top, but not completely connected on
the bottom.
(Walk away?) They’ll walk away and
be able to function.
(What do you see?) Some type of living
things. Two animals. They can’t func-
tion down here, they can’t live their full-
est. So after some repair, they’ll be able to
live independently and function.
——————
They can’t function the way they are
because they’re conjoined. They’ll be
physically two separate things but will be
working together.
In this response, Ms. C. continued the theme of disconnected objects she intro-
duced in her previous response of the bleeding heart. This response, however,
not only contained the reference to animals’ body parts not being connected
but it also revealed how this patient’s attention centered on trying to make sense
of animals functioning with partially connected and partially separated parts.
She initially saw “two things coming together” but soon noticed that actually
only the noses were together. Ms. C. was then preoccupied by the fate of these
separated parts (“they’re joined, but they’re not going to remain”). Admittedly,
“they’re not going to remain” is an odd-sounding idea or phrase, not that dis-
similar from her odd-sounding mixture of a butterfly and a spider (R1) when
she became perturbed about how the coloration prevented her from seeing just
a butterfly. Here on R5 this patient may have become similarly perturbed when
something she expected to see did not materialize, generating anxiety when her
experience of a stable, familiar world seemed to fail her. Thus, when Ms. C.
becomes anxious, her thinking can falter, giving way to peculiar or odd ideas or
ways of expressing herself. However, examiners need to be judicial about such
cognitive slippage so as not to assume that it automatically represents genuine
thought disorder. Rather, it is important to exercise care to distinguish between
disordered thinking consistent with acute psychosis and a momentary faltering
or brittle ego function.
That being said, this patient’s idiosyncratic thinking appeared in this context
to reflect anxiety when her expectations about reality let her down. Here on
R5, as in her previous response, Ms. C. mentioned early in the response that
something was the matter—something that concerned cohesion or connection
of parts of objects. In R4 the heart was not completely attached, and on R5 only
the noses were together while “down here, it’s separated . . . they’re not going
to remain, they’re going to walk away.” She proceeded to express ambivalence
about the prospect of the disparate parts becoming connected in order for the
animals to remain intact.3
Ms. C. seemed to indicate that the two animals were coming together as if
it were natural for them to be joined. She then noticed that the animals were
not fully joined, conveying anxiety that the connection was fragile and also her
pessimism about the connection being sustained (“they’re joined, but they’re
not going to remain”). Following this, she then added that “they’ll be sepa-
rated,” which to my ear seemed to convey anxiety about separation rather than
a psychological achievement of autonomy. Moreover, during the inquiry, Ms.
C. began to consider how this form of life could be “completely independently
whole.” When I asked what she meant when she said “they’re going to walk
away,” I was not convinced that she genuinely believed what she said in her
reply about the animals being able to function. I asked again what she meant by
walking away, framing my question around what she saw, and she replied not
about what she saw on the card but rather with a verbalization that seemed to
negate what she had just said about being able to function: “they can’t function
down here, they can’t live their fullest. So after some repair, they’ll be able to
live independently and function.”
Further, on a testing-the-limits inquiry, Ms. C. confirmed an unsatisfactory
outcome (“they can’t function the way they are”) to which she added “because
they’re conjoined . . . they’ll be physically two separate things but will be work-
ing together.” She seemed to be expressing the idea that ideally the animals
should remain connected, but their separation was inevitable because a secure
connection could not be sustained. She did not seem to imply that the tenu-
ous connection was necessary for their survival, but she did seem to imply that
their separation was premature and accordingly that it compromised optimal
development. Stated another way, Ms. C. did not appear to be describing the
phenomenon of hanging by a thread; rather, she seemed to be conveying the
idea that the thread was weak and insecure. The animals could function in their
disconnected state, albeit not optimally. Consequently, “walking away” repre-
sented the best they could do to ensure some degree of functional independ-
ence. It sounded more like a necessary evil than it conveyed a psychological
achievement such as a satisfactory resolution of Mahler’s (1968) separation-
individuation subphases.4 As a result, the animals “can’t live their fullest . . .
after some repair” is the functional equivalent of making the best of a less than
ideal solution. It is also a good psychological assessment illustration (Silverstein,
2001) of what Kohut (1971, 1977) and Tolpin (1993) meant by a compensatory
structure.
It was of more than passing interest that there was barely any, if any verbali-
zation or outward indication of anxiety considering the nature of this response,
even more so when considering the conventional nature of Ms. C.’s initial
response to Card II. I had already commented on the matter-of-fact delivery
of her responses to Card I, particularly R2, which also sounded as if affect had
been engaged in a way that might have indicated greater perturbation than that
which was apparent. Taken together, these observations suggested the possibil-
ity that anxiety was sufficiently walled off from Ms. C.’s ongoing experience,
representing a degree of emotional distance which left her unaware of what she
felt from moment to moment.
Already by this point at the end of Card II, it was becoming clearer how
certain of the Structural Summary, MMPI-2, and Human Figure Drawings
indications about Ms. C.’s personality functioning emerged in relation to the
people in her life. Her way of vacillating between a measured, affectively con-
strained approach to problems and an unpredictable yet still controlled way of
talking about complex feeling states seemed to represent her way of keeping
affect states in check and outside her awareness. It was a way of existing, there-
fore, that was simultaneously defensive and adaptive, but such fluctuations in
the way she processed ongoing experience must have been perplexing to oth-
ers. People probably could not be sure from one moment to the next what was
going on within Ms. C. As suggested by the MMPI-2, managing to behave in a
socially agreeable way served the purpose of fostering an appearance of being
reasonable and conventional; however, it only partially masked how compli-
cated this patient must seem to other people despite her surface appearance of
conventionality.
Both Ms. C. and the people around her thus did not have much of a sense
of the troubling psychological states she probably managed to obscure when
she seemed to effortlessly slip into expressing oddly complicated thought
processes. She seemed oblivious that people might have difficulty in compre-
hending her thoughts. Consequently, this patient created a veneer of appear-
ing complicated at best and strangely confusing at worst; moreover, not only
were her circumlocutory thoughts at times difficult to follow, but in addition
they would not necessarily become much clearer even after she was asked to
explain herself. Recall, for example, how on the Figure Drawings the more I
asked her to clarify what she meant, the more elusive she became, steering me
this way and that and going around in circles such that I ultimately gave up
trying to understand her—which, I suspect, is what happens to many others
in her everyday life. I imagine this way of defensively wearing down people
has been one of the ways Ms. C. has managed anxiety, and I would not rule
out the possibility that it might actually reflect a dissociative mechanism or
defense. Nevertheless, this patient could create an impression of being on the
same wavelength as other people, who might think they were following her;
however, the effort to continue filling in the gaps in what they thought she was
saying might easily become too much of a strain, leading people to withdraw
from her.
Card III
6. Two abstract dancers. They’re over The color schemes going from the black
a fire or a basket—something round. and white to the introduction of more
They’re in costume. color. The head, neck, torso, arm, leg.
(Abstract dancers?) The contour—it’s
not a typical body. They’re bent over so it
looks like an abstract.
(Dancers?) The way they’re bent over
and the contour, they look very sleek.
(In costume?) Maybe a mask because
it’s not a typical head. The fluffiness—
like feathers or fur or something.
(Fluffiness?) The gray—lighter and
darker; here it’s solid gray.
(Fire or a basket?) Something round,
like a campfire that’s not burning. Just
something circular.
As she did after her butterfly/spider “mixture” and “depressing colors”

responses on Card I, Ms. C. here also demonstrated a good capacity to recover
her psychological composure after in effect spilling her guts, albeit in her con-
trolled, distanced manner. Thus, Card III began with a generally conventional,
popular response which contained for the most part no particularly troubling
codes or special scores, much as Card II also began with a similar kind of well-
balanced response and verbalization. Ms. C. could often seem to be the kind
of person who approached new situations with at least the appearance of there
being a clean slate with relatively few signs of emotional baggage from recent
experience.
However, her cool, detached manner could only preserve this veneer for a
short while, as she again succumbed fairly quickly to the pull of psychologically
conflictual themes. But even at that, her considerable affective reserve kicked
in to protect her from succumbing too deeply under the influence of pressing
needs. She seemed to stand apart and watch herself react to emotionally pro-
voking content, almost as if she were acting a character’s role in a play rather
than experiencing anxiety resulting from the intensity of affects in the moment.
It was not for nothing that Ms. C. had four C' responses in her total protocol,
one of which occurred in this response. Note also that this was a response of
people who were dancers but they were not described as dancing. Dancing, of
course, is driven by music—itself an experience connoting emotional arousal—
and the motivation to move in synchrony with the emotional sway of music.
Thus, although a connotation of emotionality was suggested, the act—and by
inference participating in or experiencing the emotionality—was left out of her
response.
Consistent with this impression, note how deliberately and cautiously Ms.
C. spoke about how she perceived the achromatic colors, commenting about
“the color schemes going from the black and white to the introduction of more
color.” That was about as close as Ms. C. would allow herself to get to the
darker recesses of her internal experience, as if the tentativeness suggested by
“the introduction” of more color was her way of standing outside and looking
in, so to speak—something akin to a person dipping a toe in cold water and
then saying he or she had gone swimming. Moreover, perceiving the dancers
as abstract added to the impression of emotional distance, which notably was
her first—and only—response containing human content. Being “in costume”
also carried a connotation of removing herself from a deeper layer of affective
experience, in the sense that an actor wears a costume when stepping into the
psychological states of a character being enacted.5
Until it was called to my attention, I did not pay sufficient attention to the
area this patient used to indicate the R6 location. Without looking carefully, at
first I assumed that Ms. C. included the D7 area in this response. Wondering
why I thought so, I now believe that my error occurred because she referred
plausibly to the D3 area as a fire/campfire or a basket. Assuming that where
there’s smoke, there’s fire, as the saying goes, I mistakenly thought that the red
area of D7 represented smoke, that being the reason the patient saw fire. I also
believe that I was misled by Ms. C.’s reference to “the color schemes going from
the black and white to the introduction of more color,” mistakenly thinking that
she meant achromatic color leading to chromatic color. But chromatic color
was not included in the D1 area she used for location. In my mind, I translated
the D7 area as smoke coming from the fire Ms. C. mentioned and also that its
red color was the reason she saw fire in the first place.
However, although Ms. C. did see a fire (a reference, incidentally, to which
she did not commit because she alternated between seeing the D3 area as a fire
and a basket), she did not include the red D7 area. Moreover, she gave form as
the sole determinant for the fire, volunteering that the fire was “not burning.”
Thus, not only was the fire under control, it also was finished—she had in effect
put out the fire. Also, the fire became an innocuous campfire, an image more
likely associated with something pleasurable or generally safe. What I am sug-
gesting is that seeing how Ms. C. could so easily toss out teasers about material
with emotional overtones, and also seeing how masterful she was about throwing
a cover over such innuendos, I wonder whether I—probably like many people
in her surround—assumed, so to speak, a fact not in evidence. Given the pow-
erful connotation so strongly associated with the idea of fire, I thus wondered
whether I somehow wanted to capture the chromatic color determinant under-
lying the relatively intense affect I suspected was there yet well concealed.
Although I did not get what I was going after (in my mind at least), in think-
ing through my error and taking into account the equivocation over the fire
or basket, the fire becoming a campfire, and then the campfire that was not
burning, I may actually have gotten more than I thought I needed. Thus, it
became possible to see just how Ms. C. managed to have it both ways: she
could talk about a potent affective image represented by the fire, but because
the fire was tamed (a campfire) and controlled (not burning) she could psycho-
logically remove herself from experiencing affective arousal. Stated differently,
“losing” chromatic color as a determinant may not have been that important;
rather, seeing in the verbalization how step by step she weakened the affective
valence of the fire actually may have revealed more than the chromatic color
determinant might have. Its absence actually was the more telling observation,
which also could be discerned by the combination of a Fi content without there
being a chromatic color determinant. The verbalization actually revealed a
more graphic look at this patient’s way of putting out the fire—a fire she herself
started in the first place—leaving nothing in its wake as she weakened its force
by systematically removing everything emotionally salient about it.
Ms. C. similarly seemed to imply texture as another determinant, thus seeming
to flit around the edges of this determinant as she also may have done with chro-
matic color, without committing to either. It was late in the inquiry that Ms. C.
introduced the textural reference; however, although she subsequently clarified
it as being determined by the achromatic color, it was not coded as T because of
its late appearance during the inquiry. Consequently, this patient actually may
have implicitly perceived texture, in a sense toying with the affect so implied but
falling short of genuinely taking the plunge (to recapitulate my swimming meta-
phor) and having to expose the vulnerability of a state of need often associated
with affectional cravings and deprivation. Together with injecting a layer of
defensive distancing by describing the dancers as abstract and in costume, Ms.
C.’s cautious, defensively layered explication of this percept appeared to insu-
late her from exposing the emotional longing that texture responses frequently
connote, or failing that to prepare her for the fallout she might experience were
she unsuccessful at keeping this kind of uncomfortable affect at bay.6 Perhaps
her capacity for affective constraint at just the right moments helped Ms. C. to
maintain a protective balance, represented here by the FC' determinant in this
response—in addition to the three others she produced.
It was of particular interest that this same response contained Ms. C.’s only
human movement response, which also was coded for passive movement. Never-
theless, R6 was coded as Popular, it was of good form quality, and it also received
a good human representation (GHR) code. These saving graces did not go unno-
ticed; however, they mainly served to demonstrate how Ms. C. could maintain
at least an outward appearance of normal, reality-oriented contact with the
external world, fostering her capacity to keep a constricted, tightly controlled lid
on potentially painful or disruptive affect states. Such a defensive operation kept
Ms. C. insulated from her internal affective experience—although it went far-
ther than that to the extent that it left her disconnected from her emotional life.
Ms. C. saw the people “over a fire”—which she quickly qualified somewhat
by offering the possibility that the people might be over a basket, a neutral and
far less affectively potent image. She did not clarify what she meant by seeing
them dancing over a fire or a basket, and I neglected to ask her about that. None-
theless, seeing people over a fire sounded like they were in or perilously close
to the fire—indeed, a dangerous predicament. Although this patient probably
did not intend to convey such a quality of danger, saying that she saw people
positioned above an object—even a basket—nevertheless was at least a mod-
erately odd verbalization, but still one that fell short of a DV code. (It might be
construed as a concrete description because the card area referring to the peo-
ple (D1) is perhaps above the card area referring to the fire or the basket (D3);
however, the people would probably more likely be seen literally to the side of
rather than above the card area representing the fire or basket.)
In clarifying what she meant by seeing the dancers in costume, Ms. C.
described them as wearing masks, which immediately preceded her reference
to a fluffy textural quality. Although a mask might be part of a costume, it also
signifies concealment, which may have been a way to create further distance
before referring to texture—much as she did earlier while referring to achro-
matic colors as an “introduction” to more color. That is, she may have had
to interject a layer of distance in effect by putting on a mask before she could
consider entertaining the possibility of a textural quality, which still is a relevant
consideration in spite of the fact that texture was actually not coded.
7. The dancers are in black—that’s Shaped as a heart. This piece right here is
more depressed. Here, the coloring attached by this, but it doesn’t look like it’s
changes to something more lively, it seems really flush. Two individual hearts and
happier—coming together, it could be they’re separated, but this piece—I don’t
two hearts coming together. It’s a lighter know what it is—maybe an appendage.
shade so they’re not completely merged yet, (A lighter shade?) A lighter shade of
or they’re in the process. red—darker red and like a pink.
(Not completely merged yet?) If this
shade or color was merged, it would make
it darker. The color is merging, not the
hearts.
——————
They’re functioning, each one is formed.
(Different shades/colors?) Possibly
as you get older and experience different
things and it gets stronger or weaker, or
you get wiser. The merging of the colors
has to do with as you get older, the heart
gets larger—it could be part of the growth
process of the heart.
This response began with a reference to the previous response; evidently, Ms. C.
was still not ready to let go of that response (R6) in spite of all she had already
expressed about it. Although the first sentence of R7 referred directly to R6,
I included it with R7 mainly because there was a pause of sufficient length to
suggest that the patient was considering the possibility of another response to
Card III. It appears that R6 and R7 were clearly interwoven. In fact, one could
easily infer that Ms. C.’s opening statement described an affect state (“the danc-
ers are in black—that’s more depressed”) that she probably could not bring her-
self to say in such an undisguised way on R6. She may have needed the pause
between these responses to gain still greater distance. She then launched into
the main part of R7, which was fundamentally a negation of the feeling tone she
expressed in R6 (“here the coloring changes to something more lively, it seems
happier”). Ms. C. did something similar on Card I when she seemed to complain
about the drab, depressing colors. There, when she said “they’re not vibrant
colors,” she seemed to want to turn the card into something colorful and thus
reverse experiencing what I imagined represented a drab, depressing existence.
Here, on R7, she managed to do something more than register a complaint.
She actually attempted to undo or reverse the depressive affect. Her attempt to
somehow turn the affect she described almost upside down on itself probably
misfired—except possibly to herself—because there was very little about this
response or the way it was elaborated on inquiry to substantiate a convincingly
lively or happy quality. At least, I was not convinced that she managed to pull
that off.
That this response and R4 on Card II were both color-shading responses
adds to the impression that this patient lacked a clear perception of her mood
states. Consequently, ambivalently felt emotions coupled with dysphoric mood
may have left her confused about what she felt at different moments, including
how she felt about the people in her life, harboring a pessimistic sense that good
things would not last (Weiner, 2003). Given that Ms. C. expressed no observ-
able dysphoria or overt depression, her characteristic defensive way of walling
off affect protected her from becoming aware of internal affect states.
However, it also seemed to prevent her from clearly comprehending emo-
tions she felt and what they signified about ongoing affective experience. This
patient’s shut-down awareness about herself consequently may have limited
her ability to differentiate affect states—like the present response, which she
described as a lively or happy mood state (in order to get away from intrusively
encroaching dysphoria, I suspect). Her response not only had nothing to do
with lively, vibrant mood, but instead it concerned something unsettling associ-
ated with disconnection, separation, and possibly loss. Ms. C.’s odd-sounding
comment that “the color is merging, not the hearts,” like her similarly odd-
sounding comment on R1 about a mixture of a butterfly and a spider, also may
have reflected how her thinking could become compromised when intrusive
affect states destabilized her functioning.
It is also of more than passing interest that the content associated with the lively,
happy color she emphasized represented the identical theme Ms. C. described
on R4 (the cherry red hearts that were not yet together). The present response,
like R4—two hearts “in the process” of coming together—also was influenced
by the gradation in shading of the color, which accounted for the hearts being
seen as “not completely merged yet.” R7 was the second of her two color-shading
blends, which like R4 contained nearly identical color and shading determinants.
The metaphorical connotation of “two individual hearts and they’re separated”
was all the more compelling because of its poignancy.7 Being separated, trying to
forge a connection but not quite getting there, the idea of a merger with its rich
if somewhat uncertain implications concerning object relations or self-cohesion,
and the yearning quality suggested by this imagery of disconnection and prob-
able loss were all psychologically compelling qualities that practically jumped off
the page. No examiner could fail to be drawn to the unmistakable undertones
expressed in responses such as this and R4, and yet it was remarkably striking
to me how straightforwardly she delivered these responses. Indeed, her matter-
of-fact manner was indistinguishable from that of most people who deliver a
response to this card as commonplace as two people standing over a pot.
Perhaps for this reason, being so disconnected from realizing how peculiar a
percept of hearts in the process of coming together would sound to others, Ms.
C. apparently was not concerned enough to either inhibit it or to rationalize
what she meant (or did not mean) to express. On this response, she seemed to
suffer a loss of distance from which she did not recover, probably more because
she did not seem to recognize that her response was idiosyncratic than because
she truly could not recover from it. Although it was coded as FAB, one of the
more serious of the cognitive special scores and the one that would probably
represent the greatest loss of distance among all of this patient’s special scores,
I was less concerned about its reflecting disordered thinking than I was about
its reflecting the extent to which lapses of judgment might occur. Indeed, such
lapses were not rare for her in consideration of the entire protocol, as seen
for example by this patient’s WSum6 of 18 on the CS, and WSumCog scaled
score of 119 and EII-3 scaled score of 116 on R-PAS. Moreover, 7 of her 18
responses—nearly 40 percent—contained at least one cognitive special score,
half being incongruous combinations (INC) or fabulized combinations (FAB).
Such responses indicated the extent of Ms. C.’s impaired capacity to modulate
or inhibit her thinking as she attempted to insulate herself from experiencing
distressing affect states—reflecting more the psychological cost of walling off
painful emotionality than they reflected genuinely disordered thinking.
Ms. C.’s reference to an appendage was a curious one. Although the word
appendage typically refers to an attachment, it also may have a connotation
meaning subsidiary or subordinate. In the context of this response of separate
hearts not quite coming together or merging and in respect to note 7 above,
I tentatively wondered whether her perception of an appendage had a mean-
ing representing something more than an attachment or addition. I wondered
whether Ms. C. might have had in mind herself as an appendage in the sense
of subordinate or less important in relation to the important people in her life.
I am calling particular attention to this response because of the unique psy-
chological content it appeared to contain for Ms. C., all the more so because it
practically was a repetition of an earlier response—thus implying special sali-
ence—and because the anticipated loss of several of this patient’s friends and
her own thought about relocating to remain close with them constituted one of
the very few emotionally salient topics she spoke about in her psychotherapy.
The testing-the-limits inquiry represented my attempt to understand what
Ms. C. was trying to convey about herself through this peculiar yet highly evoc-
ative percept, a percept that was all the more important to understand because
it reprised a similar theme expressed previously on another card. By way of
explaining the merging of hearts/merging of colors, she seemed to step outside
the response per se, reflecting almost philosophically about her experience of
life: “possibly as you get older and experience different things . . . it gets stronger
or weaker, or you get wiser. The merging of the colors has to do with as you get
older, the heart gets larger—it could be part of the growth process of the heart.”
But I felt no closer to understanding what she meant, either about the idea of
hearts merging or about growing stronger, weaker, or wiser; or the heart get-
ting larger; or what Ms. C. called the “growth process of the heart.”
Just as it happened earlier while inquiring about the mixture of a butterfly
and a spider on Card I, the more I asked (or the closer I tried to get to under-
standing what she meant) the more confusing or disorganized her thinking
became. Again, she seemed to be keeping me and my line of probing from get-
ting anywhere beyond what I sensed to be a wall of confused communication.
I left the matter alone at this point. However, there can be little doubt that an
orderly, logical continuity of thoughts seemed to elude her. Her thinking may
not have been inherently confused but I did think that it sounded confusing
because she intended it to be so. I actually am rather impressed how deftly she
managed to camouflage what seemed to lie behind this response to my question
about how she saw shading and color. At the moment I recorded and inquired
about this meandering verbalization, however, I very much doubt I saw it that
way at all, probably feeling anxious and concerned about the severity or depth
of psychopathology I thought I might be seeing.
8. Some type of a bug or insect, with Claws, eyes, the head. Part of a foot here
claws or fur or a hard shell. Some type of or some type of appendage. Two feet.
reptilian thing. (Fur or a hard shell?) It’s multicolored:
light to dark gray to black, it makes it look
crusty. Little striations—I don’t know if
it’s fur or part of a shell. Here it looks
crusty, but here I see striations, almost
like a petal, like a flower petal.
(How do you see it—striations,
almost like a flower petal, on a bug?)
Yeah. It could be a bug eating a petal.
(Crusty . . . fur or part of a shell?) It
looks harder or like little hardened holes.
Here it looks softer like fur.
Card IV
This was Ms. C.’s first of what were to be two texture responses on the Ror-
schach, which here combined texture—connoting a state of affectional need
or craving—with an incongruous combination (INC) and poor form quality.
This response, following immediately after one that was coded for a FAB, was
consistent with the by now rather firmly established impression that Ms. C.
fared poorly when emotionality and need states were triggered, unless she could
manage to wall off her affective reactions even if that came at a cost of strained,
peculiar or off-putting thinking. Indeed, it was quite strange to imagine how she
could see a bug or insect having fur, claws, or a hard shell. None of these tex-
tural qualities made any kind of sense for a bug or an insect, nor did seeing an
insect with feet for that matter. It seemed that no matter how she tried to avoid
perceiving a textural quality, presumably she could not manage to extricate
herself from the forceful pull of the particular kind of emotional longing that is
often associated with perceiving texture. Moreover, of the three textural quali-
ties this patient mentioned—claws; a hard-textured quality suggesting attack-
ing; and a hard shell, another hard-textured quality suggesting insulation from
potential attack—two of them (claws and the hard shell) appeared to represent
body structures important for self-protection. By contrast, her possibly seeing
fur (or a flower petal, as she added during the inquiry) also indicated perceiv-
ing a quality of softness alongside the hard-textured quality just noted. I can-
not infer very much about what this might mean, but it deserves mention that
rarely do patients’ references to textural qualities contain as broad an array of
soft-hard qualities as Ms. C. verbalized in this response.
To complicate matters further, Ms. C. also described the gradations of shad-
ing as denoting crustiness. Upon inquiring further, she stated (but did not clar-
ify) that she perceived both hardness and softness—and for good measure she
also threw in another curve ball when she referred to the crustiness as “hard-
ened holes”—an image I could barely understand but yet I think I was myself
too emotionally exhausted by this point to ask her what she meant. Indeed, I
felt by this point that I had been put through the ringer!
That being said, note also that Ms. C. referred to an appendage on two
consecutive responses (R7 and R8), and that I neglected both times to inquire
about what she meant by an appendage. If it may serve in any way to excuse
my lapse over not inquiring about both of these responses, I can only believe
that the strain of trying to follow her thought processes must have gotten the
better of me, considering that by this point practically every one of her Rorsch-
ach responses was difficult to hear and absorb, and thus to figure out how best
to conduct an inquiry. Consequently, I think I must have let pass some of this
patient’s more innocuous-sounding imagery and verbalizations. For example,
I cannot at all be sure what Ms. C. might have meant by seeing two feet on
this bug or insect with claws, fur, or a shell. I cannot know with certainty what
might have been sacrificed by these and probably other omissions from the
inquiry, although no doubt the richness of the verbalizations I did carefully
inquire about yielded otherwise important information for interpreting this
Rorschach protocol. Nonetheless, I recall vividly feeling drained after finish-
ing this Rorschach. I could only imagine how draining Ms. C. must seem to
the people she interacts with in her life. Yet I must add that I did not find this
patient to be as frustrating or emotionally draining during our regular psycho-
therapy sessions, perhaps because she hardly ever brought her emotional life
into the psychotherapy.
This poor form quality response, apart from suggesting how judgment or
reality appraisal may suffer when a state of neediness or deprivation is pro-
voked, also indicated that Ms. C. could go to great lengths to minimize the
potentially destabilizing consequences triggered by yearning or deprivation.
Thus, her percept of a bug or an insect was unusual for this card, which typi-
cally pulls for percepts of large and sometimes looming or overpowering fig-
ures. By seeing a small and typically harmless animal she may have attempted
to minimize the potential for feeling overwhelmed; however, this attempt led
to an ominous distortion of form accompanying this particular shading deter-
minant (T). Accordingly, although apparently unable to prevent herself from
perceiving a textural quality, Ms. C. was able to at least limit the influence of
the psychological salience texture implied by rendering something often seen
as potentially overpowering into the quite harmless, diminutive bug/insect she
reported. It may also bear pointing out that while it is by no means unusual
for examiners to expend considerable effort deciding whether a bug or insect
realistically could have fur, claws, or a shell, for example—and consequently
whether such a response would receive a special cognitive score such as INC as
this particular response did—it surely is important for examiners to give equal if
not actually greater attention to peculiar imagery such as a bug with fur, claws,
or a hard shell for what this portends about regulating the intrapsychic balance
between drives and defenses. After all, having mentioned fur, claws, and a hard
shell as metaphors expressing the threat of being exposed, just how much pro-
tection could such a little bug really need! For Ms. C., the strain of insulating
herself from being reexposed to the deprivation associated with thwarted or
suppressed affectional yearnings was increasingly showing signs of fraying at
the edges. Consequently, the effort to sustain the kinds of defenses she required
to effectively wall off affect states must have been faltering. One manifestation
of this vulnerability was detectable in her compromised reality-anchored think-
ing, which seemed to occur more frequently than just occasional lapses.
9. It’s almost like a bat, with the excep- The wingspan, legs, top of the head.
tion of these two extremities.
Card V
I can imagine that most examiners would by now feel as relieved after read-
ing this response as I undoubtedly did by this point in Ms. C.’s Rorschach.
Although a bat is a very common response to this card, it fell short of being
coded as a popular (POP) response because it was seen in a Dd99 area of the
card—a fact I could almost be persuaded to overlook, in part because most of
the area she used for the bat remained intact and also because form quality was
satisfactory. However, it also felt reassuring to have heard a familiar-enough
sounding response from this patient after so many of the preceding strained
responses stretching the bounds of conventional percepts and verbalizations.
Why, I thought, did she have to spoil it all by making it a point to omit a fairly
minor part of the card! Granted, her spoiling the response was indeed a minor
point, and spoiling in this context only cost her a POP code. Nonetheless, she
still could not produce an unfettered response even here on a card that is easily
seen as a bat but which Ms. C. had to qualify as being “almost like a bat.”
I recognize that my petulant-sounding complaint may come across as petty,
but I also think my complaining and frustration here serves to illustrate another
important point about a person such as Ms. C., who easily could be seen as
idiosyncratic if not actually strangely different—the proverbial peculiar duck.
Accordingly, when people are accustomed to expect oddness from someone
and then at certain moments such a person behaves less oddly, there is a ten-
dency to benignly excuse relatively less oddness by adjusting one’s expectations
about what passes for conventional and what would be considered odd. It is
as insidious as the creeping grade inflation that teachers barely perceive to be
happening, which only becomes perceptible when one steps back and observes
their perceptions from a more critical distance.
I was not certain what to infer from this patient’s focus on there being some-
thing the matter with the way the extremities looked to her. It made me think
of her two previous responses in which she noted but could not fully integrate
areas she ended up calling “appendages”—attached parts that were not very
different from extremities. Thus, on R7 Ms. C. did not know how to integrate
the appendage which remained unspecified with the main part of the response
of hearts coming together, and on R8 she said the appendage was two feet but
she did not indicate how these feet were related to the bug or insect. Here on
R9, because Ms. C. saw something wrong about the extremities she eliminated
them from her percept of the bat. I could not conclude that she was being more
discerning here by not finding a way these extremities could form a part of
the bat. Certainly, there appeared to be something quite perplexing (and also
strange) about how Ms. C. perceived attached parts, even when she said they
represented appendages or extremities.
10. ∧ ∨ ∧ ∨ [long hesitation] Some Claws, the head, it’s equal on both sides.
type of insect. But I’m not getting any real But the claws aren’t terribly defined.
feeling for what it is.
Card VI
Hesitations before generating responses and lengthy pauses between responses
continue to be intriguing observations, notwithstanding Exner’s (2003) deci-
sion not to record latencies because he found that the reaction time difference
between chromatic and achromatic cards (color shock) was not an important
discriminating variable in the CS. Nonetheless, it deserves some note that Ms.
C.’s latency at the start of Card VI was noticeably longer than her latencies
to other cards; in addition, there was appreciable card turning. When she did
deliver her first response to this card—an insect—she immediately commented
that the percept was not well defined, which she repeated during the inquiry.
This patient mentioned claws as the first body part of the insect—which
accounted for the INC code and also contributed to this response being coded
for poor form quality—but she shortly attempted to negate seeing the claws.
Considered together, the long hesitation, the claws, and the poor form qual-
ity suggested that Ms. C. may have been uncomfortable with this card, possibly
though only speculatively because its form features sometimes suggest genitalia.
Claws could suggest several possible meanings, including gripping or grabbing
onto objects, or in reference to people clawing it could suggest aggressive or
malicious intent. Claws also could represent metaphorically arming the insect
for the purpose of self-protection. Claws are not typically on insects, although
the analogous body part, pincers, is sometimes mistakenly confused with claws.
This patient’s reference to claws followed by an attempt to disclaim that ref-
erence raised the possibility that a defensive function might be operating to
distance herself from a connotation of hostile or malevolent intent or that it
might have belonged in a context of self-protection. Recall that R8 contained
a similar reference to claws on an insect or bug, although on that response Ms.
C. mentioned a hard shell and fur in addition to claws, in a context I thought
of in connection with insulating herself against potential attack. If there was a
particular implication behind Ms. C.’s reference to claws on R10 followed by a
disclaimer, her self-protective defenses apparently were robust enough to man-
age to keep it well hidden.
11. Something you’d find on an Indian It was alive and was used to keep people
reservation—a tanned skin. Something alive.
from nature, like a buffalo hide. It’s not (Used to keep people alive?) To keep
necessarily depressing, it’s something that themselves warm. It was kind of recycled
was alive. [laughs]. The tone of it, the shading.
(Tone of it, the shading?) It’s not
heavily darkened like in the other cards.
Here there’s grays and then lighter grays
and then a solid black. And also how it’s
formed, I just saw it as part of a skin or
hide of an animal.
This patient’s affective association (“it’s not necessarily depressing”) to this
response of a commonly seen, popular animal hide arrived almost simul-
taneously with the response itself. Rarely do people perceive this popular
animal hide or skin with any particular affective valence. Moreover, her ref-
erence to its not being necessarily depressing appeared to both recognize and
then negate its effect on her—thus, it was at one and the same moment a
projection followed by a denial. That the skin or hide came from an animal
that was now dead does not usually evoke feelings of depression any more
than does eating a meal despite knowing that an animal was killed as the
source of the food. Ms. C.’s attribution of depression here also suggested that
she may have assumed that other people would have the same association to
an animal skin, perhaps another aspect of being out of touch with or prone to
misread others’ motivations. Thus, here again was a response of good form
quality, including a POP code, but that still contained a subtle but definite
distortion.
In Ms. C.’s elaboration during the inquiry, she explained how an animal skin
came from a formerly living animal and that it now was “recycled” to sustain
another’s life. Her emphasis on the achromatic colors and the gradation of the
colors that superseded form—thus making this response another shading-shad-
ing blend—yet again pointed to the complex quality of her affective experi-
ence. This response suggested emotional distress including dysphoria, as noted
previously in connection with another shading-shading blend (R2) and one of
her color-shading blends (R4). Moreover, the dominance of shading over form
indicated that she seemed to apprehend the affective component as the more
gripping psychological quality capturing her attention.
By this point in the Rorschach protocol, it was compelling that intense albeit
confused, ambivalent, or powerfully conflicted manifestations of affect apparently
could coexist in tandem with disavowed, detached experiences of affect. The dis-
tinction I am drawing here is one that seems counterintuitive insofar as potent
affect states that might be expected to result in immobilizing, intense displays
of affect unpredictably did not actually occur. That is, Ms. C. showed sev-
eral indications of affective arousal in the scoring codes that were not matched
however by a corresponding affective experience one would expect to see in
the verbalizations. This represented a curious kind of disconnection between
what she would say and what observers might expect to see as a reaction, and
how Ms. C. actually behaved—a disparity that probably confused people with
whom she interacted. Yet, this apparent disconnection or disavowal was prob-
ably comfortable for Ms. C.
The affective experience I have been emphasizing was derived primarily
from the formal codes, particularly the significance of this patient’s shading-
shading and color-shading blends. However, the psychological qualities these
blends represented were not particularly well reflected in her verbalizations.
Thus, for example, an “animal skin . . . not necessarily depressing . . . recy-
cled . . . to keep people alive” sounded mainly like an odd or idiosyncratic
chain of thoughts. Similarly, her previous shading-shading blend of an “ink
blot . . . black and gray, just more depressed” also could pass by without very
much notice. So too with the outset of Ms. C.’s color-shading responses, which
began by sounding at most unusual or idiosyncratic (“bleeding hearts” and
“dancers in black . . . that’s more depressed . . . here the coloring changes to
something more lively”). However, in contrast to her shading-shading responses,
by the time Ms. C. finished elaborating on these color-shading responses, the
highly evocative though bizarre shape her elaborations took was unmistakable.
Consequently, Ms. C.’s shading-shading blends may have indicated subtle
though not particularly disorganizing qualities of emotional experience, but
which nevertheless conveyed what I called above a disconnected or disavowed
experience of emotionality. They reflected the presence of intense affective
manifestations coexisting perhaps oddly but comfortably with bland affective
experience that did not match the potent quality of affective arousal (Exner’s
“tormented experience”) associated with such responses.
That being said, the response content was noteworthy for the animal hide
being described as something that was once alive but now was recycled to con-
tinue promoting life. Based on her explanation, it seemed that she may have
conflated ideas containing the rather uncommon association of sustaining life
and keeping warm. A more dominant association to keeping warm more likely
would pertain to warmth as a comfort or need state, possibly a textural quality.
Certainly, the quasi-tactile quality associated with an image of warmth could
represent in a disguised fashion feeling comfortable or soothed, or even pos-
sibly being protected against uncomfortable coldness such as an animal skin
might provide through touch or bodily contact. But Ms. C. neither mentioned
nor intimated a tactile quality; consequently, it would be far too speculative to
assume she had that in mind, even though she had already produced one tex-
ture response and there was one more to come—in fact, in her next response.
With appropriate caution, however, there is no reason for an examiner not to
keep in mind and continue to reflect on this patient’s curious link between the
ideas of staying alive and keeping warm.
Card VII
12. ∧ ∨ ∧ McNuggets. [smiles/laughs] The shape and texture. It’s tan, or gray-
ish. It just looks like something that’s
fried.
(Looks like something that’s fried?)
The texture, that crustiness. The shading
here. It looks sandy or crusty.
The combination of a reference to food and the use of texture suggested that
a need state was stimulated. (I also would not rule out the possibility that
this T determinant was in part stimulated by her previous response; note my
comment above regarding R11.) However, from Ms. C.’s characterization
of the food content (McNuggets) and even more so from the way she smiled
as she delivered this response, I wondered whether an affect state other than
neediness or craving was triggered, one that might have reflected there being
something lighthearted or cute about seeing McNuggets on a psychological
test. Had she not emphasized the textural quality—a characteristic of shading
that examiners take quite seriously when interpreting patients’ affective dispo-
sitions in relation to psychological need states—I might not have called much
attention to this patient’s smiling. However, from earlier material it appeared
that making light of serious matters and affective distancing from deeper layers
of needs formed an important part of Ms. C.’s modus operandi for getting by in
life. I previously noted this disparity in relation to this patient’s offhand, some-
what dismissive comments about psychologically loaded verbalizations such as
a Bleeding Hearts Club of crybabies as an association to a disconnected, bleed-
ing heart (R4). Even her “recycled” animal skin to keep people alive (R11) had
a bit of this same flippant quality about it.
Note as well how she perceived the textural quality—“grayish . . . sandy . . .
crusty.” Except possibly for “crusty,” this was hardly an appetizing description
of the texture of food! And it also was nothing to smile about. The combination
of her amused smile and a response of McNuggets, possibly an indirect refer-
ence to a kind of comfort food perhaps associated with fun or a treat, together
implied a pleasurable quality of affect. But then adding “grayish . . . sandy”
spoiled any sense of something either appetizing or enjoyable. (Interestingly,
though I suspect improbably, the word crusty could have been a reference to
a crust of bread to indicate a small, insufficient amount of food. Crusty also
might connote disagreeableness, such as a rough or uncivil quality of behavior.)
Ms. C. seemed to be equating food and pleasurable enjoyment with something
unappetizing or disagreeable. Moreover, she appeared to keep these affective
connotations isolated from one another, as if one quality was entirely removed
and apart from the other. Her defenses of isolation of affect and thought, and
disavowal were operating once again.
Furthermore, for a patient who had not rotated the cards during the
response phase on the first five cards, it was somewhat surprising that she
would have begun doing so in the middle, first on Card VI and now again on
Card VII, and several times. I speculated that on Card VI, the long hesitation
before starting her response coupled with several card rotations and a vaguely
articulated response suggested her discomfort about the card, possibly avoid-
ing seeing genitalia, which is uncomfortable for some people . Here on Card
VII, considering that the popular D1/D2 area is readily seen as a head or
human figure by many people, and one more commonly seen as female, I
wondered whether the card turning might have reflected a defensive attempt
to avoid seeing a female figure. If a female figure stood for nurturance and her
food response with a texture determinant but described in a distinctly unap-
petizing way were linked together, then her defensive disavowal noted above
and the card turning possibly to avoid seeing the popular human figure might
connote being stimulated by needs or cravings experienced as frustrating or
unsatisfying. It tentatively raises the possibility that Ms. C. had blocked an
awareness of this kind of need in relation to a maternal function or figure, a
hypothesis perhaps better considered with the benefit of incorporating find-
ings from the Figure Drawings and TAT. I recognize that I am stretching
fairly far out on a limb in raising such a hypothesis, however as long as it
remains hypothetical until confirmed or disconfirmed, it is not a bad work-
ing hypothesis to keep in the background as the interpretation continues to
unfold.
What was becoming increasingly clear as the Rorschach proceeded was the
impression that Ms. C. appeared considerably removed from internal need
states and the affects these typically stimulate. She might be able to speak a
language that acknowledges needs and affects but in a genuinely felt sense her
actual experience of such needs and emotion states remained miles away from
the words she might use to talk about them. This patient also seemed to man-
age to conceal a perhaps deeper feeling that might even be at odds with the
words she used to express herself. The content of Ms. C.’s response concerned
food, which coupled with texture as a determinant implied emotion states pos-
sibly reflecting feeling deprived or craving nurturance. The mostly disagreeable
depiction of the texture of this food only added to this impression concerning
dissatisfaction or unhappiness about what might have passed for such nurtur-
ance as was available to her. Certainly “McNuggets” is an idiosyncratic choice
to represent nurturance or nourishment. Moreover, her McNuggets were not
moist, firm, tasty or otherwise inviting; instead, her “grayish . . . sandy . . .
crusty” McNuggets were mainly unappetizing. Small wonder, therefore, that
she might experience her existence as unsatisfying and unappetizing—not
unlike the way an infant might make a disapproving face and turn away from
sour milk. It also makes it less of a mystery why Ms. C. might turn away from
feeling stimulated by the promise of nurturance, expecting to find what came
her way to be mainly disagreeable, all the while driving her needs and desires
underground in the process.
Card VIII
13. It’s almost like a collage—two ani- The legs, arm, head, ear. Same on both
mals, one here and one here, perhaps a sides. The bears are part of the collage
bear. because their colors go in with the rest
of it.
(Collage?) The different shapes, sizes,
and colors. I don’t know what the other
parts are. A grouping.
14. ∨ Like a jacket on one side. A sleeve, One side is one sleeve, and one sleeve’s on
a zipper. the other side.
(Zipper?) Something has to keep it
open, not closed, so I’m just going on the
assumption that it’s a zipper.
——————
Like they’re hunting. Two eyes, they’re
hiding and blending in with the color
scheme in here.
Ms. C.’s first response to Card VIII, unlike most of her responses, was one of
the few that did not strike any note of oddness. Like R3 and possibly R9, this
response merits little comment. Even the INC code was a minor lapse, one that
would not call any particular attention to itself. The patient’s description of the
bears as part of a collage was mildly unusual but it was not especially deviant,
and there was nothing about her explanation of the collage during the inquiry
that raised any question. That she described R13 as a collage—a grouping of
objects in an art work—at most might indicate some distancing or possibly
intellectualization, but probably of greater interest was the good integration
of color with the form features, suggesting that a capacity to experience affect
adaptively was possible at least at some times.
In contrast, with R14 Ms. C. returned to an idiosyncratic, somewhat odd-
sounding description of what otherwise would have been a moderately well-
conceived response. True, form quality was less than optimal (although a jacket
does appear in the form quality tables as Fu); however, it was Ms. C.’s ver-
balization about the zipper (“something has to keep it open, not closed”) that
injected the odd quality into this response. Still, it fell short of receiving a special
cognitive score. Conceivably, however, other examiners might be inclined to
code a special score here. Nevertheless, whether or not this verbalization fell
just within or just outside earning a special cognitive score—a determination
that often can be a difficult boundary to decide—a more useful way of think-
ing about a zipper as something to keep something open but not closed would
inevitably surround inferring what Ms. C. might have been thinking as she
offered this comment. Thus, I asked myself, what could she have meant by
a zipper intended to keep a jacket open when typically a zipper’s main pur-
pose is to close something? Compounding my curiosity was the comment she
spontaneously added after referring to the zipper for opening but not for clos-
ing something: “I’m just going on the assumption that it’s a zipper.” Here,
Ms. C. may perhaps have sensed from my asking her about the zipper that
what she said might have been amiss, and seemed to allow herself a way out
should she need it, thus building in a way to self-protectively take back what she
had said.
On a testing-the-limits inquiry, Ms. C. commented about hunting and hid-
ing. Ms. C. may first have thought of a hunting jacket; however, she soon spoke
about hunters in hiding, presumably lying in wait for their prey. Her reference
to hiding was influenced by seeing eyes—probably a figure-ground reversal and
using achromatic color—although she also commented how the eyes blended
in with the other colors, which added to an impression of hiding.
She did not comment further on the zipper or the comment that prompted
my asking her to elaborate further on this response in the first place. Perhaps
she thought there was nothing further to explain about why a zipper might keep
something open but not closed; or perhaps she did not want to say anything
more about it. I probably could have pressed the issue further; however, I had
already seen how Ms. C. could deftly avoid subjects she did not wish to talk
about. By introducing the idea of hiding, Ms. C. may have tried to hide from
what she said, but it was not clear exactly why she might hide from or avoid
explaining what she meant about the zipper. As I commented earlier concern-
ing R10, Ms. C. was accomplished at self-protectively concealing things she
said but may have sensed she was better off not saying. She was perhaps alerted
to a deft clamming up in this way by inquiry questions and further testing-the-
limits probing intended to call attention to idiosyncratic ideas she may not have
noticed. On the Rorschach and in life, this acquired, hypertrophied skill may
have been one of her greatest assets.
Card IX
15. Some type of floral. Things you’d The color schemes are very soft, very gen-
find in a coral reef or Mediterranean tle. But I don’t see figures I can identify
waters, because of the colors. with. So, something in coral reefs in very
warm water, very indistinct. It’s equal on
both sides.
16. > I see a face here. An eye, the long The eye, the long nose.
nose. One here, too. (Eye?) It’s round and it’s black. Like
something like a moose or a reindeer, with
a long snout.
(It’s black, the eye?) It’s like an oval,
and the eye is black. The other colors are
red, orange, and this is like a black.
Ms. C. began Card IX with a response nearly totally given over to color as a
determinant. Unable to come up with any definable shape beyond the general
indication of a coral reef and with little more than the symmetrical appearance
of the area as an indication of form use, this response suggested a substantial
degree of openness to affective experience. Yet, despite the rather open and
undisguised affective valence indicated by this response and the nearly textural-
sounding description of the “soft . . . gentle . . . warm” colors, this patient was
barely able to provide an articulated form to go along with and thus support
an affective experience. Hence, it was not surprising when she commented that
“I don’t see figures I can identify with.” She experienced, therefore, a pleas-
ing, almost luxuriant affect state in consideration of her emphasis on the soft,
gentle qualities about the color, but she could not bring it into alignment with
words or thoughts having meaningful associations or memories for her. In this
percept’s vagueness, it operated like an affective fragment—something “indis-
tinct,” and as such difficult to grasp, remember, or otherwise bring to life in
respect to her ongoing experience. It was a pleasing affect, but one that seemed
to feel intangible and unrelated—somehow just out there, lost in space.
After delivering this response, Ms. C. proceeded to see a more definable
form, an animal face, which also used the achromatic color features of the card.
She could comment that the chromatic colors on Card IX were present, but
these were not integrated into her response, where she several times referred
to blackness. Thus, R16 implied a quite different experience of affect, one that
was more muted, limited, and probably constricted. The distinctiveness of the
animal face, in contrast to the undefined forms of R15, implied that the dimin-
ished affective quality was familiar and knowable to her. It was an experience of
emotionality that she lived with most of the time, while the affective quality of
R15 was unfamiliar and not anything “I can identify with,” as she herself put it.
In R15’s emphasis on the card’s prominent pastel colors, she may have enjoyed
a brief respite from what I imagined to be her typically diminished, constricted
experience of her life. Thus, by R16 it was back to business as usual for Ms. C.
in the one-dimensional monocolored, disconnected, disengaged way she went
through her life.
Card X
17. Crabs, of different colors. Something All different types of life in the coral
that’s crawling. sea. Shrimp look like this, crabs. All the
shapes.
(Of different colors?) They’re vibrant.
Lively and warm. The ocean is very alive
with all different kinds of life.
18. A wishbone. The shape.

In her opening response on Card X, Ms. C. seemed to come to life once again,
as she did briefly on the preceding card. When I asked her specifically about the
colors she referred to during the response phase, without hesitation she spon-
taneously commented about their invigorating quality (“vibrant . . . lively and
warm” sea life).8 Though it is not uncommon for people to see crabs in several
locations on Card X, it is however rare for people to describe them as vibrant.
True, although Ms. C. never specifically said that she saw anything other than
crabs perceived as crawling, she seemed to strongly imply that she actually may
have seen various types of sea life. For many people, although crabs that are
crawling may not necessarily be regarded with disgust or revulsion, neither are
they associated with being lively and warm. Thus, it seemed incongruous to
imagine the idea of crabs and warm, vibrant colors in the same context.
Ms. C., however, was a person who was nothing if not idiosyncratic or capable
of apprehending unusual images simultaneously. Consequently, for the same
reason that imagery such as a mixture of a butterfly and a spider (R1), bleeding
hearts not completely attached (R4) or hearts merging to come together (R7),
or a bug or insect with claws or fur (R8) and the like arrived trippingly off the
tongue for this patient—at the expense of a code for minor cognitive slippage
(the “coral sea”)9—so too would the image of vibrant and warm crabs not seem
particularly incongruous for Ms. C., knowing what seemed rather clear by now
about her internal life. Indeed, an image of crabs with lively or warm colors
was not all that dissimilar from the image of a bug or insect with fur that she
reported previously. It suggested now as it did then that soft, warm affect states
could easily coexist with images or qualities that were hardly associated with
softness or rich, vivid emotions—such as bugs, insects, and now crawling crabs.
It conjured up an impression about this woman as someone expecting to find
warmth in cold or repulsive places. It led me to wonder what it might be like
for someone made to feel repulsed who then seeks affection or enlivenment. I
imagined a mother who barely tends to if not actually rejects the runt of the
litter.
Following this rather innocent-sounding albeit nonetheless psychologically
complex response of crabs and vibrantly colorful forms of sea life, Ms. C. deliv-
ered a deceptively simple response of a wishbone, which was her final Rorsch-
ach response. She had the least to say about this response in the inquiry, and she
offered no extraneous verbalization as she had done previously with many of
her responses. Besides being a moderately common response of ordinary form
quality to the D3 area in which it was seen, the idea of a wishbone probably
should not be overlooked, in part because its significance often stems from what
precedes such a response. For Ms. C., the immediately preceding response was
crabs and the vivid, lively colors on the card—an incongruity, as I discussed
above, that may have sparked something related to the idea of wishful hoping or
anticipation. Although I was interpreting this patient’s reference to a wishbone
as representing wishing for good luck, I could not of course be certain that this
symbolic connotation was the one Ms. C. had in mind.10 That being said, it was
tempting to cautiously speculate that the interesting choice of words she used to
describe the colors on Card X (“vibrant . . . lively . . . warm”), notwithstanding
the fact that the basic percept was that of crabs seen as crawling, might stand
for a wished-for quality of an emotional experience she could only imagine, an
experience that nonetheless might elude her a great deal of the time.
I had no doubt that Ms. C. could comprehend what the concepts of vibrant
or lively signified and that she knew that other people might at times have such
experiences. However, I doubt that such words felt in any meaningful way
tangible for her or that she could readily summon up memories of such states,
because they were too alien. Nevertheless, I suspected that she could have been
thinking in her whimsical-sounding closing response of a wishbone, wouldn’t it be
nice to experience what vibrant and lively might feel like!Thus, when she said, “the ocean
is very alive with all different kinds of life,” I could almost imagine a sense of a
child’s wondrous discovery of something new and exciting, which also might
include a world of affective experience that might well have seemed remote to
her.
Recapitulation
Although Ms. C. could appear unaware of feeling anxious, her anxiety appeared
to lead to odd or circumlocutory thoughts obscuring what she meant to say
and as a result making it difficult to follow her train of thought. This would
constitute both a defensive position and an adaptive mechanism to keep peo-
ple at some distance. She herself seemed unaware of what she does to create
emotional distance, so Ms. C. probably would be less perturbed than others
concerning the continuity of her thinking. Thus, as people might feel puzzled
by what she could say, Ms. C. was relatively undisturbed. Although sometimes
fraying at the edges, her capacity to usually maintain a generally normal if per-
haps idiosyncratic outward appearance came at the expense of keeping a tight
rein on experiencing painful affect states. In this way, she was largely insulated
from her internal affective experience.
Indeed, this patient’s experience of and estrangement from emotionality
was very likely the most telling characteristic of her psychological function-
ing, certainly as revealed on the Rorschach. Not only did she produce five
responses using chromatic color—some of which were color-shading blends—
but in addition she had five C' responses—and several of these were shading-
shading blends. Moreover, on four of her five chromatic color responses there
appeared a verbalization referring to aliveness or vividness (on R4, the “cherry
red” bleeding hearts; on R7, “the coloring changes to something more lively
. . . happier”; on R15, “the color schemes are very soft, very gentle”; and the
vibrant colors she described on R17).
On two other responses in which color was not formally coded, it was men-
tioned and in particularly interesting but quite different ways. First, on R6 Ms.
C. referred to the “introduction of more color,” a comment I previously called
attention to for its halting, tentative implication of color rather than a definitive
commitment to its use. Secondly, on R16 she referred to two of the brighter
colors on Card IX (red and orange), but she did not actually use them as a
determinant, favoring instead the black achromatic color. Nonetheless, the red
and orange clearly registered with her despite these colors not being used in a
way to reflect there being a color determinant. Mentioning the red and orange
here sounded somewhat impulsive as if it strongly captured her attention but
was not integrated with the response proper. Ms. C. seemed almost to blurt it
out with no real context in mind, much as a disconnected non sequitur might
sound, contrasting noticeably with the more contained, held back “introduc-
tion” of color on R6. Even on an achromatic card, Ms. C. referred to color, or
more accurately to its absence, when on R2 at the end of the inquiry she men-
tioned how the colors were “depressing . . . they’re not vibrant colors.”
Clearly, Ms. C. had considerable difficulty coming to grips with her emo-
tional life, including how affects were apprehended or expressed. Because
affects were so deftly tucked away and isolated from ongoing experience, she
probably had little overt difficulty with or even much awareness about what she
felt at many times. Ms. C.’s affect life was fraught with confusion and conflict;
thus at some moments lively and vivid affect emerged only to include alongside
it odd or twisted verbalizations, while at other times she experienced affects that
appeared to be in conflict with one another. At still other times, disquieting or
tortured affect states appeared to surface surprisingly freely. This patient mostly
appeared to expend much effort constraining the appearance of affect states.
Emotionality was never a simple matter for Ms. C. With what served as both a
defensive and at the same time an adaptive function, she managed to remain
at a considerable distance from most affect states, hardly ever thrown by them
and in this way coasting along blithely insulated from their intrusive impact on
her functioning.
Card 1
This is a young boy, maybe 8 years old. The violin here, he’s contemplating how to fix
it if it was broken, or this is something he really wants to do. I know parents want their
children to have lessons to learn an instrument, and someone suggested violin, so this kid is
supposed to be practicing. But he’d rather be somewhere else, because he does look sad.
(Outcome?) He doesn’t continue violin lessons and his parents say they lost all this
money.
(How does the boy feel about that?) Happy, because he didn’t want to continue.
Maybe his parents were saying, “if you don’t want to do it, don’t do it, we’re not going
to waste the money.”
(How do his parents feel about it?) One parent probably wanted it more than the
other, to round out a person. Maybe they also played an instrument at one time, so maybe
they pushed it on him.
(How does that parent feel about the way it turned out?) I think disappointed
but then reality set in. The boy has other interests and maybe one parent will talk to the
other parent and so maybe one parent will be disappointed and the other parent will be
more understanding. But it’s a dilemma for him.
(Dilemma?) Disappointing the parent. (Q) He’s sad but he knows this is not going to
work. I don’t think any child wants to disappoint a parent and they try their best, but then
say this is not what I want to do. He doesn’t seem like an acting out kid, he’s not going
to act out and say I don’t want to do it because I don’t like it. He’s more like the kind of
kid who’d say to the parent I don’t want to do this rather than acting out. I mean, it’s I
don’t feel comfortable with it and I don’t know how to do this.
Ms. C.’s story may have reflected her own childhood experience of having a
problem, how she attempted to engage her parents in the problem, and how
the parents responded. She vacillated concerning the nature of the boy’s prob-
lem on Card 1, initially saying that he was trying to repair the violin but then
shifted to the boy’s learning to play violin. She also vacillated about the boy’s
motivation, at first saying “he really wants to” play the instrument but she then
switched gears to indicate that the boy was disinterested and sad because he
wanted to do something else. Her story seemed to communicate what happened
to an enthusiastic desire (“he really wants to” learn the violin) that decisively and
possibly irrevocably was transformed into sadness and disinterest. She described
parents who seemed to lack genuine interest in the boy’s learning an instrument,
appearing instead to be going along for the ride (“parents want their children to
have lessons”) without matching or fostering the boy’s enthusiasm.
Ms. C.’s story never returned to what she initially mentioned—learning to
play or fixing the violin. Her subtly slipping in the comment about “something
he [the boy] really wants to do” may have represented how the boy’s eventual
loss of interest and sadness was the aftermath of the parents’ dispassionate, dis-
engaged reaction. Not only did the parents fail to match the boy’s enthusiasm
but they also seemed to overlook his desire to play the violin, misinterpreting
what looked like the boy’s turning elsewhere as being flighty or showing dimin-
ished interest. The parents appeared to react to the boy’s shifting interest as
normal (“reality set in”); however, it did not seem to register with them that at
one point it was “something he really wants” and that he was also left feeling
sad. Thus, what at first looked like vacillation or ambivalence on the boy’s part
more likely concealed deeper and submerged feelings of diminished self-worth.
Feeling so diminished could easily give way to sadness representing the resi-
due of having lost a sense of wonder or enthusiasm and consequently feeling
devalued.
In addition to the parents’ disengagement with the boy’s seemingly genuine
interest and their unawareness of his mood state, they appeared to rub salt in
the wound by indicating concern only for the money they “wasted,” in this way
trivializing what mattered most to the boy and also conveying that nurturing an
interest of his was at best grudgingly tolerated. The parents in this story barely
concealed that they would be glad to be done with what seemed to be little
more than a wasted effort. There was no sense of joyful pride or pleasure in the
boy’s interest or curiosity as Ms. C. depicted their relationship with the boy in
her story; rather, she described parents who appeared to feel imposed upon and
not wanting to be burdened. It was as if she felt that when the parents said to
the boy, “if you don’t want to do it, don’t do it,” they really meant “do whatever
you want, just leave me alone.” If this reconstruction of the family dynamics
was reasonably close to Ms. C.’s actual experience of her early life, it would
not be difficult at all to imagine that her parents might have readily missed the
struggles she went through with learning and cognitive functions, and equally
importantly that she would have done her best to conceal her problems—as
well as her hopes and aspirations—from as unsympathetic and unknowing a
home environment as she portrayed here on Card 1.
It also deserves note that in spite of the above depiction of the boy’s parents
as unsupportive or indifferent, Ms. C.’s story also suggested how one parent
may have failed to show an awareness of the boy’s preference in favor of
wanting something from him and then reacting with disappointment. The
other parent, however, comprehended the boy’s dilemma more empathically
(“one parent probably wanted it more than the other, to round out a person .
. . . maybe they pushed it on him . . . one parent will be disappointed and the
other parent will be more understanding”). This dynamic illustrated that it
might be possible to appeal to one parent for a more responsive, understand-
ing recognition of a child’s developmental need if the other parent shows a
pronounced, unrelenting empathic breach. The germ of such empathically
involved understanding, whether from another parent, a grandparent, an
interested teacher, or someone else capable of providing that kind of self-
object function might be sufficiently enlivening to permit thwarted devel-
opment to continue despite a child’s originally healthy striving falling on
deaf ears. Awakening or stimulating stalled development through another’s
psychological engagement with a child may potentially restart a normal
developmental process that was interrupted, thus leading the way to depres-
sive disillusionment or chronic boredom.
This description represents a good example of what Kohut (1971, 1977)
and Tolpin (1993) meant by a compensatory structure, an idea I previously
described in relation to diagnostic assessment (Silverstein, 2001). A related
concept from psychoanalytic self psychology is the concept of a leading edge,
which Kohut (1971) briefly mentioned only as a footnote to refer to an aspect
of interpretation that recognizes such thwarted needs and strivings along
with defenses and conflicts in the hope that submerged longings essentially
forgotten or driven underground might be remobilized in the transference.
Tolpin (2002) developed this idea further, describing what she called a
forward edge transference, to represent the possibility that thwarted developmen-
tal longings may be revivable in treatment with the hope that securing self-
object responsiveness might reinvigorate and thus foster repair of a so-injured
self.
In Ms. C.’s story, she implied that one parent might have been able to
serve a somewhat felicitous selfobject function—a tendril of a compensatory
structure—while the other parent only fostered the boy’s feeling that he was a
disappointment. Her story thus expressed what might happen when, instead
of recognizing what a child needs to restart a stifled developmental longing,
a parent to whom the child might have turned has failed to recognize what
the child needed and unwittingly responded in a way that only made matters
worse.
I suspect that the real dilemma for Ms. C. was partially captured by the differ-
ence in the parents’ responsiveness, the one failing to comprehend and the other
providing some kernel of understanding but possibly not enough to promote an
involved engagement with restarting thwarted developmental strivings. Thus
regarded, this patient’s dilemma might be understood as that between giving
in to the demoralization of defeat or attempting to turn elsewhere to secure a
recognition of what she needed to find a viable route to succeeding in life. I did
not know how much good was achieved when “maybe one parent will talk to
the other parent” and I also could not be sure that the “dilemma” for the boy
did not concern whether to follow one parent’s wishes or follow his own. How-
ever, I hypothesized that instead of succumbing to the school failures that so
often ensue when children experience severe learning deficiencies, living their
lives as though they were failures and thinking of themselves as dummies, Ms.
C. was buoyed on by the kernel of “understanding” from a parent who seemed
to have at least some implicit idea about her struggling, and she was enabled to
find a way to mask her deficits and egg herself on to successfully achieve some
semblance of a professional career, albeit with great difficulty.
I did not at first understand what she meant by a dilemma; however, upon
inquiring further Ms. C. explained that the boy was “sad but he knows this
is not going to work. I don’t think any child wants to disappoint a parent.”
Thus, worried about being seen as disappointing rather than being difficult or
ungrateful (“an acting out kid”), Ms. C. ended her story by expressing how the
boy accepted the blame for his failed interest, saying how uncomfortable he
was and that he could not successfully navigate learning the instrument. Lost
in all of this was the initial desire or interest—the “something he really wants
to do”—which was replaced by self-blame and the boy’s not wanting to be a
disappointment in the eyes of his parents. Ms. C.’s story conveyed nothing of
what one might reasonably expect to see, namely requesting help or trying to
make the parents comprehend how much of a struggle learning the violin had
become. Rather, in her story she seemed to emphasize the importance of stay-
ing out of the parents’ way, not becoming a burden or a disappointment, and
in the process assuming the blame for the problems the child had rather than
expecting that anyone should be there to help—a child’s version of the adage,
keep your problems to yourself.
The original enthusiasm was lost in the shuffle, dampened down as I imagined
she herself felt. Ms. C. soldiered on by herself to make the best of things, there
being no support for and no time to feel the desire of “something [s]he really
wants to do,” much like the “lively . . . vibrant” colors she noted at several points
during the Rorschach. I suspect that Ms. C. submerged what was lost behind a
stoic, affectively diminished existence that left no room to indulge in a “Bleed-
ing Hearts Club . . . for crybabies,” as she described earlier on Card II of her
Rorschach. Further, what may have been left of the initial desire probably never
left her, surviving in the tremendous perseverance she showed throughout her
academic and work life when it could have been very possible to secure an easier
route to getting by, one that did not involve the degree of struggle she continu-
ously experienced. This was not therefore simply overcompensating; instead, it
could be thought of as trying to keep an original desire or enthusiasm alive in
herself, as she tentatively seemed to peek out at certain points, as for example her
comment about the “introduction of more color” on the Rorschach.
Card 2
Looks like a father or a brother, he has one horse to do all the plowing. This looks like a
mother, it looks like she’s pregnant. And this is the daughter, she has books and has very mixed
feelings about wanting to change her life and going on to school and leaving the farm. And
especially leaving her mom, it looks like she’s pregnant. She’s making a decision. Her parents
want her to get an education. I think she leaves, because I think that’s what her parents want
her to do. She’s not a child, she looks like a teenager. Her parents are saying, “it’s okay.”
(How does she feel about leaving?) Mixed. She needs reassurance from the mother.
(Q) The mother’s life is set. The girl feels that maybe by getting an education she can send
money back to the farm and help out that way.
(Mixed?) I’m not sure she knows. The mother’s attire—she’s been a farmer’s wife
her whole life. The daughter looks like she’s been going to school, she’s chosen what she
wants. She’s the one who’s being chosen to go and get an education.
(Being chosen?) It’s an awesome responsibility. She’s probably the oldest one. So this
one’s leaving, but there’s another one coming.
(How does the mother feel?) She has a look of peace. A decision was made, and
she’s okay with it.
At first glance the girl appeared to be ambivalent about leaving for school,
but on closer analysis her story portrayed the girl struggling more with her
relationship with her mother than with the conflict between leaving for school
and staying at home. The emotional tone of the story suggested that the daugh-
ter was not so much deciding as she seemed to be churning around unarticu-
lated feelings. Her thinking was repetitive and scattered, sounding very little
like a struggle to reach a decision. As Ms. C. developed her story, it reflected
how unfocused the daughter’s thinking appeared, starting with ambivalence
about “wanting to change her life and going on to school” vs. remaining at
home (while commenting at two points in between that the mother was preg-
nant, without commenting about what this meant for the girl). Most tellingly,
Ms. C.’s story related that the girl had “chosen what she wants” but in the very
next breath, without seeming to recognize that she contradicted herself, this
patient said that the daughter was “the one who’s being chosen.” Ms. C.’s story
proceeded to jump around as she spoke about leaving the home and being
replaced, the responsibility that being chosen entailed, that the daughter was
no longer a child and thus the time was right to go off to school, and the daugh-
ter’s needing or hoping for the mother’s reassurance that leaving home was the
right developmental step.
The story continued in its unfocused, scattered trajectory as Ms. C. spoke
about the mother’s life being set and how the daughter could help the family. I
inferred that the sometimes contradictory or unfocused directions that emerged
as her story unfolded reflected the daughter’s feeling lost and confused about
what was happening and what she felt. When she expressed needing “reassur-
ance” from the mother, I wondered whether she mainly meant that she sought
a mother who could clarify or help her make sense of the confused, uncertain
emotions the daughter experienced. However, what the girl hoped the mother
would provide was not forthcoming, and thus she was left in a confused state, in
a sense fumbling around in the dark. Interestingly, the daughter seemed to keep
as great a distance from the mother as the mother kept from her. That is, nei-
ther of them tried to engage the other and the girl expressed no clear emotional
reaction to her dilemma other than what might have been concealed behind
her unfocused thinking. For the most part, her story recapitulated the story she
told to Card 1, which also concerned the relationship between a child and an
indifferent, disengaged parent.
The daughter offered at most a rather weak statement about what she wanted
for herself. It was the parents who wanted her to leave for an education or she
was designated to assume that responsibility—in a sense, the sacrificial lamb.
There was much talk about making a decision in this story, but the only decision
that seemed up for discussion concerned the parents’ deciding whether or not
the daughter should be cast out of the nest, so to speak. It was not at all clear
that the daughter really had any say in the matter, and although she seemed to
express some interest in leaving home for an education, that desire was not espe-
cially strong or compelling. Her main feeling appeared to be that an education
was a good commodity to have or a responsibility to bear. Even when Ms. C.
said the daughter chose what she wanted, she immediately followed that state-
ment by saying that the daughter was chosen to pursue further education that
would allow her to send money back home and thus preserve some tie to the
home front. She did not appear unable to separate nor did she seem to prefer
remaining at home; however, it did seem that part of the daughter’s motivation
to stay at home concerned preserving a connection with her pregnant mother.
This might express the idea that in spite of the mother’s disengagement—which
the daughter may have defensively been unable to see—any connection was bet-
ter than no connection at all, no matter how remote or uninvolved it might be.
However, from the mother’s point of view, it appeared that the daughter was
designated to leave, but not necessarily because the daughter was chosen for a
special honor. The daughter might wish to believe that to be the case, so as not
to feel the rejection and abandonment that mainly underlay the mother’s deci-
sion. However, the story seemed to imply that the daughter was being pushed
out not necessarily for her own development but perhaps more for the mother’s
convenience or because the mother was no longer interested in her. When Ms.
C. said, “so this one’s leaving, but there’s another one coming,” she appeared to
express the idea that the mother saw the daughter as easily replaceable, perhaps
because she did not need or enjoy the daughter. There was no consideration
from the mother’s side—at least as Ms. C. seemed to perceive the situation—
about the daughter’s ambivalence, insecurity, or concerns about separation. It
was all matter of fact: a decision was made, so off she goes.
The mother appeared to represent an unresponsive maternal object whose
life was “set” as “this one’s leaving but there’s another one coming.” This was a
mother who had “a look of peace” while the daughter was lost and struggling,
right in front of the mother’s eyes but outside of her awareness. A picture thus
emerged of an aloof, unseeing, self-absorbed mother unable to recognize the
daughter’s distress that did not simply represent a conflict surrounding separa-
tion and loss. Rather, the picture Ms. C. painted more compellingly depicted a
mother–daughter relationship characterized by a neglectful, narcissistic mother
whose presumably chronic affective unresponsiveness disposed the daughter to
an anxious sense of distress surrounding feeling forgotten about and ignored.
It is also worth noting here that although the girl spoke about what her parents
“want her to do,” the father was a peripheral figure in the story. He was men-
tioned only once and it seemed clear that he was not a part of the main psycho-
logical action of the story about the girl’s dilemma, which transpired entirely
between the girl and the mother. Consequently, the daughter was left having
to fend for herself not only with an apparently uninvolved, remote mother but
also with an equally unavailable father who might otherwise have served in a
compensatory capacity to buffer the mother’s unresponsiveness.
In consideration of the above, I suspect that the daughter’s “very mixed feel-
ings” had more to do with her relationship with the mother and very little to do
with the ambivalence involved in the decision being made on the surface. Thus,
there really was no decision the girl had to make. What passed for her strug-
gling to decide whether to leave or stay was never about a decision at all; rather,
the struggle reflected little more than the girl’s unrecognized distress, camou-
flaged behind what she oddly called her “awesome responsibility.” The girl’s
struggle—her “awesome responsibility”—was hardly one about ambivalence
or the problem of a naturally occurring developmental step; it was instead the
anxiety over feeling psychologically dropped and the ensuing distress surround-
ing feeling lost and alone. The anxiety also was reflected in the girl’s unfocused
and scattered thoughts.
Although in certain respects it may constitute an inferential leap to go from
the specifics of this story to a reconstruction of a profoundly distant and unin-
volved mother–daughter relationship, this story also goes a long way toward
explaining a dynamic pattern seen repeatedly throughout Ms. C.’s Rorschach
and Figure Drawings. I came to regard Ms. C.’s story to Card 2 as particularly
telling as it compellingly revealed what I suspect was the psychological reality
of her relationship with her own mother.
Card 3BM
Obviously it’s a middle-aged woman, something’s obviously upsetting her, I don’t
know—this is a set of car keys down here. I believe she’s just heard something that’s
happened that’s very upsetting to her. She’s reacting to it.
(What led up to this?) Could have been illness, death, some type of disappointment.
Just having her fill of frustration. I think perhaps the woman received a phone call, some-
thing unexpected and she’s reacting to it. Maybe a death.
(Reacting to it?) Sadness. [long hesitation] I’ll go with she’s distraught. [hesita-
tion] Either she just finished crying or she just started to cry. It looks like she’s somewhat
composed, so either she’s just been crying or she’s just now reacting to it.
(Make up a story) I would go with an older person: a mother, father, aunt, not a child,
but an older person.
(Outcome?) She gets up and goes to where she has to go. She’ll either call someone to be
with her or have someone accompany her. Or she’ll just get in the car and go.
(What does this death represent for her?) The end of a milestone. I don’t see her
as a young woman, I see her as a middle-aged woman, so maybe the loss of a parent.
Everyone becomes an orphan at some point.
(What does it mean to her?) Sadness. It was more of a shock, because she’s not sit-
ting, she’s down on the floor and she dropped the keys. Like a fait accompli—something
happened, and the person is gone.
Contrary to most of her psychological test responses and her customary nature,
Ms. C. here openly described an affectively charged situation right from the
start. Interestingly, however, it took her quite a while to settle on a definite
story, focusing for quite some time on vague, noncommittal details such as
“something’s obviously upsetting her, I don’t know . . . just heard something
that’s happened . . . something unexpected . . . could have been illness, death,
disappointment, frustration.” After a number of inquiry questions, I realized
that she still had not told me what exactly the “something” was, and I asked
her again to make up a story—which she still did not do (“I would go with an
older person: a mother, father, aunt, not a child, but an older person”)! When
I asked her for an outcome, it may not yet have registered with me that Ms.
C. still had not told me exactly what was happening in her story. Assuming
that she probably had in mind that someone died by some unexpected (and
unexplained) means, I asked her specifically about the meaning of the death,
at which point she finally was able to indicate that the protagonist experienced
the death of a parent—still not saying whether it was a mother or a father.
Ms. C. was unquestionably perturbed by what she was experiencing affectively,
costing her more effort to easily sustain a nonchalant, matter-of-fact psycho-
logical state concerning an “obviously” innocent event in which she could “just
get in the car and go.”
Considering how often patients have trouble identifying whether a person
in the picture is male or female, curiously Ms. C. had no difficulty with that
at all: the person “obviously” was a woman, and like herself, middle-aged. Of
course, it is by no means obvious whether the person is male or female. Ms.
C.’s certainty may have reflected a powerful identification with the traumatic
event to the extent that she initially may have lost some distance from the card
by nearly placing herself squarely in the psychological action she described—as
if it were her and the traumatic event was happening to her right there in the
moment. Caught off guard and unable to defensively create some insulation
to protect her normally intellectualized, distanced affective experience, this
patient seemed to be struggling to maintain her composure, and by inference
ego control, about what she was experiencing. If there was anything “obvious”
about her story—which actually was more of a fragment describing a reac-
tion than a complete story with a beginning, middle, and end—it was Ms. C’s
attempting to dilute the experienced affect and thereby maintain emotional
control to “just get in the car and go.” That she twice said “she’s reacting to
it” before saying the person was sad might well reflect her way of feeling over-
whelmed by an affect state she might not have been able to even identify—not
unlike the distressed affect I assumed to be triggered previously on Card 2.
After several evident hesitations during which time she modified feeling sad
to a more disorganized emotional state (“distraught”), Ms. C. then struggled to
determine whether the figure in the story had finished crying or was about to start
crying—yet another indication of her estrangement from affect states she was
feeling or perhaps trying to forestall. She evidently decided that the person had
stopped crying, and thus it looked as if “she’s somewhat composed”; however, she
seemed to misjudge the affective intensity of the moment because she shortly again
became disorganized and thrown by overpowering emotionality such that she
still could not identify whether the person had been crying or whether “she’s just
now reacting to it.” Thus, for Ms. C. composure or regaining ego control seemed
to mean creating distance from affects by waiting for their potency to diminish
and therefore removing herself from the emotionality of moment. Repeatedly,
Ms. C.’s story emphasized that the figure in the story was an older woman rather
than a younger woman, which seemed important for her to stress.
Ms. C. here seemed mainly to be depicting her vulnerability to affective
overstimulation, particularly when it caught her off guard and without an effec-
tive defense to insulate herself from the intensity of what she was feeling. The
preceding card (Card 2) reflected a contained emotional reaction to a story
about an indifferent or unresponsive mother. However, on Card 3BM Ms. C.’s
story conveyed just how emotionally overwhelmed she sometimes could feel
and how difficult reconstituting an affective equilibrium could be when caught
off guard. Her intense but immobilizing emotional response to this story about
the traumatic death of a parent appeared to suggest that it required all she
could muster to reconstitute herself. It was only toward the end of the story that
Ms. C. could say that the traumatic death was that of a parent, adding the curi-
ous comment that “everyone becomes an orphan at some point.” It suggested
possibly a greater degree of attachment to a parent than her earlier stories indi-
cated, albeit perhaps a dismissive or disorganized style of attachment, masking
a far stronger emotional valence than she dared allow herself to experience and
which her earlier stories deftly managed to conceal.
Card 7GF
A mother and a young girl, and it looks like she’s holding a baby, a toy baby. The moth-
er’s reading from the book to the daughter who’s holding the baby—her play baby—and
she’s looking away from the mother or out the window and thinking about what the
mother’s reading. It’s very peaceful, as if the baby was real, and it’s almost like three
generations of women. They’re on a couch. The mother looks like she put the table closer
to her so she can talk with the daughter and spend time with the daughter.
(Mother holding a book?) She’s reading from a book. It looks like the daughter would
pretend she’s a mother and this is her child. The daughter’s listening to her mother read-
ing, it’s a very calming scene. She seems relaxed and peaceful.
(What’s the daughter thinking about?) [long hesitation] She’s just staring out.
The voice is a soothing voice, like her mother in the background, like soft music.
Card 7BM
An older man and a younger man and it’s his father or a relative. I see there’s wisdom in
the father’s eyes, the son has told him something and he feels more perplexed. The father’s
given him some advice and now the younger man is coming up with a decision. It’s very
calm, I don’t see it in any way depressing.
(Decision) Something the young man does not want to do. The older man is telling him
what’s the right thing to do, and his eyes are much more soothing because it’s as if “I’ve
been there,” whereas this is the first time this younger man has been in this situation and
is facing the reality.
Apart from the patient’s unusual phrases referring to the baby (“a toy baby . . .
her play baby”), Ms. C.’s stories to Cards 7GF and 7BM were coherent and
nonconflictual. Particularly on Card 7GF, the mother–daughter relationship
was depicted as calm and intimate, contrasting sharply with the unavailable,
remote portrayal of the mother on Cards 1 and 2. In particular, the mother
was represented as being attentive to the daughter, responsively maternal, and
there was no indication that the girl in the story showed discomfort or distanc-
ing from the mother. The same emotional tone was present on Card 7BM.
Also unlike Cards 1 and 2, in which there was only the faintest indication
of an interaction between a child and a parent, the way the girl was described
on Card 7GF indicated that she was in emotional contact with the mother
throughout the story, as she listened to and thought about what the mother
was reading, and as she felt calmed by the mother’s ministrations and soothed
by her voice—“like soft music.” So, too, was the younger man on Card 7BM
soothed by the father’s calming advice. The mother was also attuned to the
daughter, as she leaned in closer to “talk with . . . and spend time with the
daughter”—although I was not entirely sure how the mother’s pulling the
table close to herself reflected intimacy rather than possibly creating a bar-
rier instead. Another indication of an enduring bond was reflected in Ms. C.’s
statement about “three generations of women” as the daughter comfortably
contemplated the idea of the play baby as her own in the future.
There was only one indication that there might be a dark cloud in the midst of
these two successive cards with an affective tone dominated by soothing respon-
siveness to a child’s needs: on Card 7BM, Ms. C. interjected the comment, “I
don’t see it in any way depressing”—very nearly a non sequitur considering that
this comment seemed unrelated to anything in her story and thus seemed to come
out of nowhere. Not seeming to recognize that the comment did not follow from
the context of her story, Ms. C. may have been conveying misgivings about the
comforting paternal advice or the reassurance the young man felt from his father.
Thus, talking about calming while simultaneously communicating unconsciously
a sense of a depressive pall suggested that despite a benevolent quality, she might
harbor some doubt or uncertainty about an intimate or trusting relationship.
In the context of her Rorschach and the previous TAT cards, what might
account for such a vastly different picture of these parental representations?
Although seeming incompatible with the personality formulation thus far
emerging, ambivalence or vacillating between the psychological positions sug-
gested by these TAT stories could offer one potential explanation for such
marked disparity. Other possible explanations also come to mind. For exam-
ple, as is frequently the case, patients’ conflicted object relationships are not
necessarily problematic all of the time. Consequently, ambivalence arising
out of conflict or pre-Oedipal (pre-ambivalent) deficit states such as alternat-
ing all-good/all-bad object representations is not an unexpected clinical find-
ing, either on interview or on psychological assessment. Moreover, from an
attachment theory perspective, a fearful-avoidant pattern would characterize a
desire for attachment intimacy that could be impeded simultaneously by feeling
undeserving but also distrustful, in which steps toward closeness alternate with
backing away from or suppressing intimacy longings entirely. This patient’s let-
ting slip an out of context comment (“I don’t see it in any way depressing”) on
Card 7BM could reflect such a process occurring in the middle of an otherwise
benevolent-sounding verbalization.
Card 4
Oh, this is like something out of—like Clark Gable. Well, it looks like the man’s saying
something like “I’ve got to go do something,” whether it’s a dangerous act or it’s that he’s
made a decision and he has to go through with it. She is— [hesitation] I don’t think it’s
fear, it looks like it’s more temptation—like “Stay” and not “Don’t go.” I don’t know if
it’s “I’ve got to go back to my wife.” She’s more seductive than wifely.
(What is their relationship?) His is more “I don’t want to go but I have to” and hers
is “Don’t go.” So it’s more of a turbulent relationship. In the past they’ve been together
but now he’s made a decision to leave.
(Outcome?) He goes.
(How does he feel about that?) He’s not terribly happy but [laughs] he knows it’s
the best to do. She’s saying “Stay,” maybe. It’s something I’ve seen in the movies because
it looks like that, an old World War II movie. But the way she’s made up, she doesn’t
look like a wife, but more a mistress.
(How does she feel?) She invested time but I think she knew at some point it would go
this way. She’s not gripping into him with her hands, like “Don’t go, I’m going to die.”
(How does she feel about his leaving?) I think she’ll accept it, she’s unhappy, but
he’s going to go—the inevitable.
Ms. C.’s story to Card 4 was one of the usual variants of a loss and separation
theme, concerning a man leaving a woman who tries to keep him from leaving
her. What was atypical about Ms. C.’s story was that the woman did not show
a strong attachment to the man, and consequently the woman did not care that
much about his remaining with her. Ms. C. emphasized that the woman was
at most ambivalent and certainly not acting out of desperation (the woman first
said, “‘stay,’ and not ‘don’t go’” but just a few moments later she was saying
“don’t go”; then later, “stay, maybe . . . she’s not gripping into him with her
hands”). The woman was not indifferent or unconcerned but neither was she
particularly invested in his staying.
She seemed prepared, in a cynical and almost world-weary way, that “he’s
going to go—the inevitable.” Portrayed as a seductive mistress, there was no
hint that the woman was about to collapse after the man left, notwithstanding
the fact that “she invested time . . . [and] she’s unhappy.” Ms. C.’s mention
of the story as temporally distant (referring to Clark Gable and World War
II) and her comment that “it’s something I’ve seen in the movies” further
suggested emotionally distancing. Her hesitation and cynical laughing as she
related the story added to the impression that Ms. C. appeared unmoved and
emotionally detached in the face of abandonment. Even her manner of telling
the story in the kind of shorthand she used for words the man and woman said
to each other (“stay,” “I’ve got to go back to my wife,” “don’t go”) conveyed
insulating herself from the protagonists’ emotions because it represented a
way of having the examiner infer affect states rather than Ms. C.’s communi-
cating them more directly, and thus injected still further distancing. Her story
seemed to be a TAT analogue of her Bleeding Hearts Club response on the
Rorschach.
Card 18GF
This looks like two women, one has fainted and has fallen back on the rail of the steps.
And the other one almost looks like a daughter. The other one looks like an older woman.
There’s concern on the part of the younger woman, it’s a look of finality, that the person
was sick and it’s a look of sorrow. It’s happened, and the sadness in the eyes, so I don’t
think it’s something that was coming as a surprise or an emergency. It’s the end.
(Outcome?) I think the woman dies.
(What does she feel?) Sadness, but I think it was not unexpected. I think she’s
resolved.
(What’s their relationship?) A mother and daughter, or two sisters.
Card 13MF
Okay, this is another death scene. It looks like a younger woman. [hesitation] I want
to go with either a sudden death or a suicide.
(What led up to this?) I don’t know, it looks like a younger woman so I’m presuming
something happened during her life, or an illness. Although usually when you commit suicide
[laughs] you’re not laying in a bed. And I’m not sure if the man has white hair, gray hair,
or whether he’s her father, but I’m tending to think it’s more of a husband and wife scenario.
And also, the person’s in a single bed, so he may have walked into this, into the room.
(What did he walk into?) The person who’s now deceased either committed suicide or
died of an illness. But I don’t think it’s an illness, I think she committed suicide.
(Led up to suicide?) I’m going with either being ill, she took her own life, or a breakup
or a doomed marriage, or whatever. I don’t see this as a house, and it’s certainly not their
bedroom, and it’s a single bed so maybe even another room in the house. Usually people
that suicide don’t do it in another room.
(Outcome?) She’s dead [laughs] and he’s sorry. Maybe he knew and came to her
rescue, or maybe he got a phone call or something like that. Because it almost looks like, I
was going to say a motel or maybe a dorm room or something. I think it’s a rented room,
because that’s the kind of picture you’d find in a rented room—it’s a barn, a traditional
barn, and it looks like a night stand with two books, each going in different ways.
(What does that suggest to you?) I think she went there to commit suicide. I don’t
think it’s a natural death.
(What happens with the man?) Well, he’ll have to come to terms with what hap-
pened. Apparently he thought something may have been taking place, and it looks like he
came in, and there’s no coat or anything like that, so apparently it was warm out and he
doesn’t have a coat on. And also he’s dressed in office attire, so I think he either got a call
or he surmised something.
These last two stories, echoing Ms. C.’s story to Card 3BM, also were concerned
with death. Her story to Card 18GF was about a daughter’s sadness following
her mother’s death. The main difference between this story and that of Card
3BM was that here the death was anticipated, and thus it did not come with
the traumatic shock that nearly immobilized the protagonist on Card 3BM.
Indeed, on the earlier card Ms. C. appeared so taken aback that she could
barely imagine who had died. The woman on Card 18GF—who “almost looks
like a daughter,” thus injecting a degree of distance—was calm and resolved to
expect the outcome. Considering the stories to these two cards (3BM and 18GF)
alongside each other, it appeared that the main differentiating characteristic
was the sudden traumatic rupture in one story vs. the anticipated loss that was
not a shock in the other. Being “resolved” to the “finality” of the mother’s death
allowed for preserving emotional composure as the daughter tolerated sadness
and reconstituted herself. In contrast, “reacting” to the traumatic news on the
earlier card promoted exactly the kind of affective dysregulation that clearly
unnerved Ms. C. It led to her trying to tamp down all but the most controlled,
manageable affect states to preserve a level of emotionality she could tolerate
more comfortably with some distance.
Ms. C.’s story to Card 13MF was more complex. Although it began as
“another death scene,” her story turned into another sudden death, in this case
suicide. Trying to make light of what must have impressed her as a grave situa-
tion, Ms. C.’s laughter at the thought of a person not committing suicide while
lying in a bed missed its intended mark. Her thoughts continued to focus away
from the young woman’s motivation to the color of the man’s hair and noticing
that the woman was lying on a single bed. As I tried to redirect Ms. C. to her
story about the suicide, she backed away from that idea to briefly entertain the
possibility that the woman was ill. Although she reaffirmed her original thought
concerning suicide, she may have been trying momentarily to divert me from
pursuing the matter. I again asked Ms. C. about the suicide and she briefly
mentioned a “doomed marriage,” but then she immediately was off and run-
ning in an unrelated direction—to distract me once again, so I thought—this
time by wondering in which room in the house the action was taking place if the
woman was lying on a single bed.
By this point I thought that asking her repeatedly to talk about the suicide
was fast turning into a cat-and-mouse chase—much as I felt at several points
when I inquired about her Figure Drawings. I decided to switch gears to ask her
about the outcome, either hoping I might be able to backtrack or that I could
try in this way to reconstruct the reason for the suicide or the woman’s mental
state. She again tried to joke her way out by responding to my question about
the outcome by saying, “she’s dead.” Ms. C. then changed the subject and pro-
ceeded to speak about the man on Card 13MF, but before long she launched
into another diverting tangent, this time about whether the suicide occurred
in a motel room or a dormitory room, whether a picture of a barn on the
wall indicated whether it was a motel or a dorm room, and the fact that there
were two books on a night stand “each going in different ways”—just as at this
moment she and I were going in different directions. Even as I asked about the
man—still not knowing exactly how he was related to the woman—she quickly
dispensed with the question with a simple platitude before digressing in a par-
ticularly confusing, illogical aside about a coat not being there which implied
that the weather was warm “and he doesn’t have a coat on . . . and also he’s
dressed in office attire.” Almost as if she could read my mind, when she spoke
about the books facing in different ways and I asked, incredulously, “What does
that suggest?” she answered, “she went there to commit suicide!” We were right
back to playing a game of a they went that-a-way chase!
Unquestionably, Ms. C. could not speak at all about the woman and her
mental state, or what happened and why, and her digressions to unrelated
and largely irrelevant material became increasingly prominent as I repeat-
edly tried to move her in a different direction to talk about the woman’s sui-
cide. She also could not speak about the man in the picture as well, not even
to say how he was related to the woman or how he figured in the scenario of
her suicide. What it mostly indicated was the degree of this patient’s vulner-
ability when emotionally provocative thoughts or affects threatened to over-
whelm her defenses. Looked at in one way, her tenacity in being able to hold
me at bay as I repeatedly attempted to get closer to her thoughts and emotion
states revealed a resiliency of ego control as she maintained these stubbornly
impenetrable defenses. But it also revealed a potential for momentary frag-
mentation as she implemented defenses that may well have been close to the
limit of their capacity to ward off thoughts and affects that potentially under-
mined adaptive functioning.
There is nothing really new about this conclusion because I had already
commented on this theme previously in the analysis of both the Human Figure
Drawings and the Rorschach. Also, as I noted previously on other tests, her
periodic lapses into circumlocutory thinking again indicated what probably was
apparent to others but not to herself. Thus, for example, she could respond to
my questions about the woman’s suicide by repeatedly digressing on irrelevan-
cies such as whether this was a motel room or a dorm room, the type of art work
on the room’s wall, and the placement of books on a night table. I did not know
what it was about themes of suicide, traumatic death of a mother, or abuse that
particularly affected her in this way. Nevertheless, these themes appeared to
provoke marked avoidance of these subjects as she became entangled in a web
of sometimes odd, sometimes tangential, and sometimes markedly loose and
disconnected thoughts, all of which served to insulate her from and therefore
rein in experiencing the kind of affective destabilization these psychological hot
buttons undoubtedly triggered.
Summary of Treatment
It will probably come as little surprise that Ms. C. brought all of her affective
reserve into the psychotherapy as she spoke about her life and earlier history.
And because, as I have already noted, the majority of her life was centered
around the adaptations she had developed to manage her work, most of what
she spoke about in a weekly psychotherapy over a period of 13 months was
related to her work. She experienced problems writing reports on patients she
evaluated, keeping track of patients she worked with as a speech pathologist,
and documenting progress notes. As I also mentioned earlier, although it felt
like a relief to Ms. C. to be able to talk frankly for the first time in her life about
her cognitive processing problems, after the neuropsychological evaluation was
completed it became clearly apparent to her that I was fully aware of the extent
of the difficulties she had tried her whole life to keep hidden. What she was
looking for in the therapy was not an opportunity to talk about how she had
managed throughout her life or at what emotional cost or sacrifice; rather, she
mainly wanted to try to find possibly more effective ways to conceal her prob-
lems from her coworkers. She was not opposed to trying to see whether she
could develop better cognitive strategies to manage her considerable organiza-
tional and writing problems, but it was clear that what she perceived as being
most important was strengthening her concealment strategies. It did not seem
to matter to her that the amount of time she spent doing her work, both in the
office and at home, was nearly equivalent to holding down three jobs. When I
asked her about the emotional component of living her life as she did, Ms. C.
looked at me with a surprised look that seemed to say that she did not compre-
hend what I was talking about.
She told me more about her ways of organizing her work and how she had
done that throughout grade school, high school, and later on at university level.
She would recite her rituals in a matter-of-fact, affectless tone that did not seem
as necessarily compulsive as I may be making it sound but actually was more
like going through the motions of an intensive regimen of physical therapy
stretches and exercises she had to make her way through, as if she were a person
with a chronic back or arthritic problem. It did not sound particularly joyless,
nor did it sound enjoyable, and even though there was a prominent obsessive,
mechanistic quality about her repetitive drills, routines, and constant copying
of notes over and over, her ways had more of a quality of reflecting what her
life was about that was not unlike the way someone might describe driving the
same route to their work day in and day out. What was unusual, therefore, was
not the repetitive nature of how she led her life; what in fact was unusual was
that there did not seem to be much of anything else in her life. Surprisingly, I
was not left with the impression of Ms. C. as a dull, obsessional, dry or affect-
less person. Instead, I found myself feeling impressed with her dedication and
her purposive drive to be successful, and the intensity of how she struggled was
quite palpable. I particularly found it poignant when she described how she
became intently focused on trying hard to learn how to operate and retain the
sequence of steps for using a cell phone.
When I would ask her about her life apart from her preparations for work,
what Ms. C. told me was not especially surprising. She lived by herself, spent
untold hours in the evenings and weekends writing and rewriting reports,
organizing her records, and preparing for work assignments she anticipated in
coming weeks. She spent some time with friends and saw family periodically.
There were no overt family tensions, at least by her report; however, she said
very little about her activities with family members. She apparently did not
date, which was a subject like discussing her family that she never brought up
and said very little about when asked. The focus of her interest remained sol-
idly on trying to find ways to disguise her problems at work, and on how better
to engage coworkers to assist her with problems. She devoted much thought
to ways she could learn more about her coworkers to give them thoughtful
presents or do thoughtful deeds she thought they would appreciate, so they
would thus be inclined to sympathize with Ms. C.’s difficulty navigating the
computer age and how that impacted modern offices. She looked for ways to
lightheartedly have the secretarial and clerical staff look upon her plight as a
sign of being an old fuddy-duddy, accustomed to her ways and content to keep
up her idiosyncratic ways of doing things that might seem amusing, especially
to younger staff members who had not grown up when the basic office machine
was a typewriter.
Once, and only once, did Ms. C. come in wanting to talk about how anxious
she was beginning to feel about a number of her friends who all were planning
to retire to Florida within the following six months. Ms. C. had planned to visit
these friends—some of whom were married and some single—several times a
year and she also knew that they would return to the area for periodic visits with
their families. However, she anticipated feeling more lonely and isolated and
she expressed concern about how she would get by. She started to think that
it would be advantageous for her to consider retiring within the next few years
and moving to be close with her friends in Florida. Although she actually did not
see many of these friends very regularly or frequently, she talked about wanting
to see more of them over the following months before they were scheduled to
move away. Ms. C. had no particular hobbies or interests, and it sounded as if
she passively went along with activities her circle of friends were interested in,
such as movies, playing cards or board games, and occasional trips.
Ms. C. mentioned anticipating her friends’ moves mostly in passing over the
next few sessions, and it always came up parenthetically after discussing what
had transpired during the previous week at work and in relation to her struggles
writing reports. She was becoming increasingly anxious and sad as she spoke
about her friends’ moving. However, although she seemed to want to bring up
the subject, she also was obviously uncomfortable talking about her reactions
and anticipating feeling lonely. I felt I needed to be very careful how much I
asked about what she felt and that it was more important to listen sympatheti-
cally than to probe too deeply beyond what she was willing to mention.
The more she spoke about the impending losses as the weeks went by—
always mentioning it toward the end of a session and after having talked about
her more customary topics related to adapting to her work environment—I
began to get the impression that Ms. C. was becoming anxious over the fact
that she kept bringing up the subject, almost against her will. I suspected that
at this point it was starting to sink in for her in a deeper way. She seemed par-
ticularly uncomfortable during one session as she talked about her fear of losing
her friends and it appeared that she was fighting against becoming tearful. I
had little doubt that she would have wanted to return to her customary state
of assuming a dispassionate, emotionally distant perspective to preserve her
level of adaptive functioning and to keep her thought processes in check. At
the very end of the session, she announced that she would need to miss several
weeks’ appointments because a larger than usual number of reports would be
coming due and she needed to focus all of her efforts on those projects. She said
that she would contact me to resume sessions once the pressure began to ease,
but I somehow thought she would not return. And she did not. After all, if a
“Bleeding Hearts Club . . . for crybabies” was not her style, neither I am sure
was psychotherapy if it was about to take that kind of a turn.
Discussion
Empirically Based Scales (MMPI-2, and Rorschach CS

and R-PAS)
Underlying an outward appearance of mostly adequate functioning, Ms. C.
showed considerable vulnerability which she managed to mitigate by devel-
oping adaptive strengths that served her moderately well. More internally,
though outside of her awareness, Ms. C. was susceptible to feeling deprived
or lonely, thus disposing her to anxious-depressive mood, an inconsistent pat-
tern of responding effectively to stressors, and as a result moments of confused
thinking. While appearing to most observers as mainly adjusting well to life
demands, on closer inspection her functioning might better be described as
unresourceful rather than conforming to a pattern suggestive of a recognizable
syndrome.
Ms. C. may have found herself feeling more emotionally at loose ends and
distracted at present than was customarily her nature. She was inclined to vacil-
late between a measured approach to problem solving and a more unpredict-
able, possibly impulsive approach, usually resolving to a position in which her
affective restraint operated to cover over complex emotional reactions. This
patient was more inclined to appear distraught when neediness was triggered;
however, her typically subdued, flattened out internal affective experience gen-
erally prevailed, often accompanied by rigid thinking. Although it produced
a rather dispassionate orientation to situations and people in her midst, at the
same time her affective reserve usually shielded Ms. C. from emotional experi-
ences she would prefer to avoid, despite momentary lapses.
Ms. C. could appear oblivious to problems that others might notice and
wonder about, and thus in her rather indifferent way go about her business
relatively unconcerned about how she might come across to others. She could
still behave in a compliant way that would not lead to people turning away
from her. This patient’s relationships with people were cordial but neverthe-
less remained close to the surface. She was not particularly close with people
and her relationships appeared to be defined largely according to their need-
fulfilling functions. Ms. C. was, however, inclined to feel resentful when she felt
ignored or unsupported, and she may have struggled with dependency while at
the same time attempting to deny such needs.
Ms. C.’s affective experience seemed to be dominated by a diffuse feeling
of tension or unease, which because of her defensive style typically operated
without her recognizing what she could be feeling. Because this patient showed
considerable emotional constriction, her affect life appeared stilted or tight as
she was inclined to back away from affective experience, preferring to take a
distanced, intellectualized perspective concerning her emotional life. There also
were indications suggestive of somatization; however, it could be equally likely
that rather than expressing somatic concerns per se, her functioning reflected
externalization or a lowered capacity for psychological-mindedness. Partly as
a result, Ms. C.’s vague, unarticulated way of regarding situations and people
left her open to inaccurate perceptions of people’s intentions and actions and
transient disruptions of orderly thinking or compromised judgment.

Expanding on the above observations, Ms. C.’s ability to act in ways that could
seem normal enough alternated with ways that would undoubtedly seem idi-
osyncratic in the eyes of other people. She could maintain such an outward
appearance, largely insulating herself from her internal affective experience,
to keep a tight rein on experiencing painful affect states. Thus she could pro-
tect herself from becoming aware of anxiety, although this seemed to come at
the expense of odd or circumlocutory thoughts that often made it difficult to
understand what she thought about situations and feeling states in her midst. It
appeared that keeping herself estranged from her affect life was the predominant
mechanism she cultivated and integrated into a well-oiled, ingrained way of life,
one that represented both a defensive position and an adaptive achievement. By
managing to remain affectively insulated and keeping people at arm’s length,
Ms. C. usually was able to appear oblivious even as people in her surround
probably felt puzzled by her odd ways. I easily could imagine how thoughts or
events might capture her attention, leading Ms. C. to impulsively blurt out what
she might be thinking, all the while not realizing that she was not understood or
unable to organize her thoughts so people could follow her train of thought.
Certainly, Ms. C. had considerable difficulty coming to grips with her emo-
tional life, including how affects were apprehended or expressed. Because
affects were so deftly tucked away, she probably had little awareness about
what she felt at many times. Ms. C.’s affect life was fraught with confusion and
conflict. Thus at some moments lively and vivid affect emerged only to include
alongside it odd or twisted verbalizations, while at other times she could experi-
ence affects that appeared to be in conflict with one another. At still other times,
disquieting or tortured affect states seemed to surface surprisingly freely. This
patient mostly appeared to expend much effort constraining the appearance of
affect states. Clearly, emotionality was never a simple matter for Ms. C. Defen-
sively distant, this patient was, I suspect, rarely thrown by affect states beyond
her capacity to comprehend and synthesize, which thus insulated her from their
potentially destabilizing impact on her functioning. However, at least of late,
Ms. C.’s defensive adaptation seemed to be fraying at the edges.
While estranged from her inner depths in this way, Ms. C. also seemed dimly
aware of something off or diminished about her emotional life. She seemed
to recognize that there was something potent about what was lacking in her
inner psychological life, a quality she perhaps could apprehend but not articu-
late. This form of empty and sometimes tormented psychological experience
probably confused her, leaving her feeling unanchored but not realizing how
empty or deprived she also might feel, and not knowing how to express such
sentiments or why they affected her so. Ms. C. could be simultaneously aversive
to and overstimulated by cravings for nurturance that had become associated
with deeply frustrating or unsatisfying gratification. Affection appeared to feel
unappetizing to her, and consequently unfamiliar.
However, despite appearing affectively removed, her emotional distancing
did not prevent her from sounding otherwise. Ms. C. could sometimes confuse
people around her who might expect to see more potent feeling states than
she expressed; indeed, sometimes she could sound as if strong emotions were
not far from the surface. However, emotionality frequently dissipated before
it ever really emerged, which also might explain why she might show what I
would call a rather hard-boiled intolerance leading her to disparage weakness
or vulnerability. Sounding tough or unsympathetic seemed to reflect her way of
managing burgeoning affect states—keeping them on a slow simmer and thus
suppressed, in their place, and tucked away outside of her awareness—mainly
because Ms. C. seemed not to know what to do with or how to comprehend
what strong affect states meant for her.
Nevertheless, this patient had not entirely written off an awareness that
there was a form of emotional experience extending beyond the dampened-
down affective life dominating her own existence. Ms. C. showed some sense
that there was more to life than what she mainly experienced; however, there
was little sense of desire or yearning for anything more. Nor did she appear
to express regret or disappointment, or even resentment over what she had
missed. If anything, there was more of a sense of curiosity—a curiosity resem-
bling looking in with wonder about a kind of emotional experience that prob-
ably seemed unfamiliar or mystifying. In the end, she either seemed to accept
her lot in life or dismissively mocked what other people seemed to experience
but which she did not, as she went about picking up the pieces of her life and
moving along as best she might. It was an adaptation she evidently had come
to make peace with in spite of the profound cognitive difficulties that precipi-
tated the kinds of compromises that consumed much of her life and practically
defined her existence.
From Ms. C.’s TAT story to Card 13MF and references to men on other
TAT cards, and her verbalization concerning the man she drew on the Figure
Drawings, it appeared that men represented complicated, incongruous figures
for her. Her drawing of a man—which somewhat atypically she drew first, the
opposite sex than her own—depicted a person described as strong and sensitive
but also “encased” in himself. There were few details drawn, the man’s cloth-
ing was indistinct, and a hand looked misshapen. She represented the man
as helpful to women, whom she seemed to imply were weaker or dependent.
However, the drawing did not look much as if it matched the psychological
qualities she attributed to the male figure, and once her association to abuse
emerged her verbalization became increasingly confused and elusive. Recall
also her description of the two men on TAT Card 7BM, described as an older
man comforting or benevolently advising a younger man. However, coming
out of nowhere it was followed by a comment that made little sense in the con-
text of her story (“I don’t see it in any way depressing”). Her other TAT stories
also described men’s motivations in perplexing ways.
I had no knowledge of whether Ms. C. might have experienced abuse at the
hands of a man earlier in her life or childhood, and I hesitate to go any further
than raising that as a possibility in relation to her confused representations of
male figures and her reference to abuse followed by a digression into confused,
circumlocutory thinking. I also tentatively considered in discussing TAT Card
1 how a possible compensatory structure in relation to one parent experienced
as understanding and the other as disappointed might reflect this patient’s turn-
ing away from an uninvolved, unresponsive mother. She perhaps attempted
to turn instead to a father perhaps seen as more attentive to her needs, though
probably not without some ambivalence or possibly trepidation. I stop short
of speculating much beyond this point about these interpretive possibilities
and about Ms. C.’s representations of men; however, I will conclude that she
appeared rather clearly to harbor incongruous and confused sentiments about
what men were like and what kind of mental representations they signified in
her internal psychological life.
All that being said, it should not go unnoticed that Ms. C.’s representations
of women were no less confusing and probably equally troubled. She drew
an opposite sexed figure before drawing a woman—a somewhat unusual
response, although what that meant was of uncertain clinical significance. It
might have indicated turning with greater interest toward a male or turning
away from a female; however, such an inference could only be regarded as
speculative. But what surely was a more productive direction to pursue about
this patient’s drawing of the woman and her verbalization was attempting
to understand her curious reference to Olive Oyl. I discussed above many
potential interpretive implications concerning this familiar cartoon charac-
ter, and I note here in summary mainly how that character was boldly and
confidently depicted: Olive Oyl was free-spirited, resilient, capable of holding
her own, and equally capable of putting a man in his place when necessary—
spinach or no spinach! There was another side, too: Olive Oyl was gangly
and unattractive, and there was a certain brashness about her free-spirited
manner that certainly would not have been considered feminine or lady-like.
She would not easily have been a figure idealized by most girls of the period
in which Ms. C. grew up.
However, it might not be hard to see why Ms. C. might be drawn to a rep-
resentation of a self-assured woman such as Olive Oyl, regardless of her rather
unfeminine physical appearance—a woman who, like Ms. C., could easily have
said about a Rorschach response of bleeding hearts that it suggested “cryba-
bies, a Bleeding Hearts Club . . . a mush, a pushover.” To face her world as a
developing child and adolescent with the extensive and pronounced cognitive
difficulties she showed, Ms. C. indeed would have needed every bit of Olive
Oyl’s spunk and determination to have survived in a parental atmosphere that
may have been compromised. I suspect her parents either failed to comprehend
the depth of her cognitive and academic difficulties or possibly comprehended
but disregarded them, or were otherwise unable to assist her more effectively.
In such an environment, this patient was largely left to her own devices to
develop the compensations and adaptations she would need to get through
school and cultivate for her working life.
One byproduct of adapting to Ms. C.’s profound cognitive deficits also
entailed an adaptation that included walling off her affective life at great per-
sonal cost to sustain a resilient external presentation. Greatly distanced as she
was from needs for affection or comfort, which were concealed behind an exte-
rior picture of no-nonsense toughness and determination—Olive Oyl-style—
Ms. C. managed to fashion a life that more or less succeeded, in her way. She
was doubly hindered by having to stave off whatever memories or destabilizing
affective reactions these represented in relation to abuse—and for that matter
theft, possibly of a life, as I wondered about from another comment she made
during her Olive Oyl drawing and verbalization. At the cost of reserved and
strained relationships with both men and women, and odd or idiosyncratic
thought processes that seemed to emerge when neediness or anxiety-provoking
situations intruded on the way of adapting she had crafted for herself, Ms. C.
thus managed to make her way in a life that many people with the kind of cog-
nitive deficits she showed would have shunned. Ms. C. could peep out once in
a great while, as her concluding Rorschach response of a wishbone suggested,
together with the imagery she seemed to allow herself to luxuriate in for a brief
moment in her immediately preceding response about a form of life that was
“vibrant, lively and warm . . . alive with all different kinds of life.” She could
thus imagine a different, emotionally richer life than the drudgery permeating
much of her existence.
6 Continuity and Change
from Adolescence to
Young Adulthood
This chapter contains a follow-up assessment of Carl, who was presented in

Chapter 3 at age 15. The assessment was conducted when Carl contacted me
ten years after I saw him in psychotherapy and when the original psychological
assessment was conducted. I saw him briefly at age 25 to talk about a current
problem he wanted to discuss and to gather a history of the course of his life
during the intervening ten years. Shortly afterwards, I asked Carl if he would
agree to repeat the testing, and thus I conducted a personality assessment over
two visits six to eight weeks after he consulted with me.
Although there is a productive literature concerning longitudinal or follow-
up assessments of personality, most of the research and clinical reports on this
topic examine a single test and most such studies have relied on self report.
There exists very little literature examining longitudinal outcome and person-
ality assessment using a psychological test battery in part because personality
assessment is frequently a cross-sectional method of studying the personality
dynamics and psychopathology of individuals. Test batteries comprised of
self report and performance instruments offer potentially important infor-
mation for examining the stability of characterologic or trait-like aspects of
personality. They also are useful for distinguishing state from trait charac-
teristics and ingrained, chronic personality features from either acute or
temporary adaptational features that may not necessarily form part of an
enduring, stable personality structure. Follow-up assessments, though they
undoubtedly occur for a variety of clinical reasons, have infrequently entered
the literature, particularly in relation to a comprehensive analysis of clinical
outcome. The relationship between personality assessment and ongoing psy-
chotherapy has been studied very infrequently. Several years ago, I reported
a case of Rorschach findings at the initiation and midpoint of a four-year
period of psychotherapy, accompanied by a 30-year follow-up (Silverstein,
2007b).
The case of Carl’s second assessment reported below considers the changes
from the original to the second assessment using a battery of performance and self
report tests, both in relation to the ongoing psychotherapy from ten years before
and in relation to the history I obtained concerning Carl’s life in the intervening
ten years. Naturally as well, the important developmental shift from middle ado-
From Adolescence to Young Adulthood 269
lescence (age 15) to young adulthood (age 25) will be considered in the report of
findings and the ensuing discussion. Differentiating clinical change from normal
maturation is always difficult to achieve in a naturalistic context, and thus such
factors are sometimes inextricably intertwined. In considering aspects of the find-
ings and comparisons across the two time periods, I keep in mind the impact of
development (maturation) and issues related to clinically distinguishing between
immutable and potentially malleable personality changes, while recognizing that
disentangling such factors is often speculative and usually not verifiable.
At the time of the follow-up, Carl was a young man of 25, a college graduate
from an Ivy League college who had been awarded a prestigious postgradu-
ate fellowship to study and work on a research project in political science at a
major university in England. After returning from his year abroad, Carl was
uncertain and somewhat unenthusiastic about a career direction and he was
disinclined to continue into graduate school, despite his successful accomplish-
ments. Although he did well in coursework, he was mainly interested in politi-
cal satire. Carl secured an internship with a magazine known for its satirical
bent. He enjoyed that experience and the people he worked with. However, he
continued to feel uncertain about what he was interested in doing in that field
and what he wanted to do with his life. As the internship was nearing its end
and recognizing that it was doubtful he might be hired by the magazine as a
staff writer, Carl realized that he needed a job but was unsure about the kind of
position he should seek. He was living at home and consulted me to talk about
these concerns, although he was not sure what he would talk about or whether
he really was in need of psychotherapeutic help. Moreover, without insurance
and a work prospect in hand, Carl felt he could not see me for more than two
appointments. I told him that I would be glad to see him after that point if he
would like to continue. He said that he would think about that once he had
secured a job that provided health insurance.
I noted that it had been ten years since I had seen Carl in psychotherapy and
had conducted the psychological assessment. I was interested in repeating the
assessment for several reasons. First, ten years had elapsed and given the nature
of the findings and the therapeutic work when he was 15 years old, I was curious
to see what the test findings would indicate, particularly because Carl’s chief com-
plaint at age 15 was that he despised school and had no interest in his studies or
attending college. Secondly, then as now, Carl was concerned about what kind of
work lay in store for him. Third, during the ten years that had elapsed since I last
saw Carl he had not felt a need for continuing psychotherapy; thus the follow-up
test findings would not have been influenced by intervening treatment.
I learned from him that after first attending a well-regarded state university,
Carl did well academically and was motivated to do even better. He applied to
transfer to a prestigious university where he had some friends, and was thrilled
that he was accepted. Carl’s interest and motivation was further stimulated by
his successfully pursuing a prestigious award for postgraduate study abroad—
all this from a young man who at age 15 could not wait to get out of school!
Carl, anticipating being out of work after his internship finished, agreed to
come in for the testing, which I conducted in two visits and for no fee. What
follows are the complete assessment findings from age 25, using the same tests
(except that the MMPI-A was replaced by the MMPI-2). My discussion empha-
sizes comparison of the two time periods (designated as 15yo and 25yo below),
with a particular focus on a response-by-response content analysis comparison.
I conclude with a detailed history of Carl’s life covering the past ten years.
Minnesota Multiphasic Personality Inventory (MMPI-2)

Carl showed an elevated F scale (T = 70), which also was elevated at 15yo,
accompanied now at 25yo by an elevated F B scale (T = 79) suggesting endorse-
ment of a wide range of symptoms. Although these elevations and an elevated
PK scale value (T = 87) indicated marked stress and self-depreciation, they also
pointed to a heightened sense of vulnerability. Similar to the 15yo profile, his
25yo MMPI contained normal VRIN, TRIN, L, and K validity scales. This rep-
resented at both time periods essentially valid records but with some possibility
of symptom exaggeration.
As at 15yo, most of the main clinical scales at 25yo were elevated (T > 65),
perhaps signifying an exaggerated clinical presentation superimposed on a pre-
dominant pattern reflecting chronic disturbance more than situational distress.
At 25yo, a 2–7 pattern was the predominant configuration (D, T = 91; Pt, T =
85). Carl displayed an atypical 1–7 configural pattern at 15yo; however, now as
a young adult his 2–7 pattern conformed to a more common one (however, a
peak on D is relatively uncommon among males). Thus, anxiety and depression
were most prominent, and although somatic reactivity (Hs, T = 75) was also
notable it may not have been as marked as it was at 15yo. Although the MMPI-
A and MMPI-2 are not directly comparable, it appeared that the 25yo profile
for the most part reflected similar and persisting personality characteristics.
Immaturity or impulsive acting out (Hy, T = 74; Pd, T = 84) appeared to
accompany the predominant anxious-dysphoric personality features at 25yo, and
although signs of guilt and unworthiness were apparent Carl probably took little
responsibility for his actions and he seemed to show mainly superficial indica-
tions of remorse. Disinclined to be confrontational and tending to deny personal
problems, Carl’s feelings of guilt and regret often would leave him unhappy and
worried about the future. He could feel rather hopeless or alienated, and he also
might be prone to concentration problems, obsessional thinking, and difficulty
making decisions. Carl could seem withdrawn, and limited energy or enthusiasm
for life added to his anxiety and also might give rise to suicidal thoughts.
The PSY-5 negative emotionality/neuroticism (NEGE, T = 70) and introver-
sion (INTR, T = 71) scales added to this picture by revealing an anhedonic, pes-
simistic side of Carl’s personality structure, characterized by marked worrying,
magnifying problems, and self-criticism. The INTR scale was also moderately
elevated at the 15yo assessment; however, psychoticism which was elevated at
15yo was not elevated at 25yo. As he showed ten years before in respect to school-
related discomfort affecting self-esteem and aspirations, Carl’s psychological
difficulties seemed once again concentrated in areas related to work functioning
or adjustment. Except for a possibly greater level of severity at present, the inter-
pretive inferences from the 15yo MMPI generally remained constant at 25yo.

Carl drew a male figure first (Figure 6.1), which he described as follows:
Describing this person, like giving him a personality, or just describing him physically? I
was just taking an anatomical approach in drawing a whole person. I don’t know, he’s
kind of a blank slate of a person. I don’t know anything about the person.
(What would you imagine him to be like?) Well, I sort of inadvertently gave him
kind of a scaley face, it wasn’t really intentional, actually it looks more like a monster
than a person. Sort of a zombie quality. I gave him a more muscular frame but that’s sort
of a standard comic-booky thing. A bizarre version of humanity, like a buxom female.
Stranger than life characteristics. I imagine he’s confident, he has good posture.

(What’s he like on the inside?) I don’t know, it’s impossible to say. Probably incred-
ibly insecure because anyone looking like that—that weight lifter look—is probably try-
ing to compensate for something. A very superficial thing—that tough guy look, this idea
of success, insecurity with females, or defenses or something. They do that to attract
females, the hypersexualized kind of dude.
(What does he think and feel about things?) There’s a tendency to constantly
evaluate yourself so he’s constantly comparing himself to other people. All that shallow-
ness, he’s probably not thinking and feeling too much.
(Anxious?) That alpha male status thing, money and looks and sexual partners, all
those things. I guess he worries about falling on the social ladder.
(Sad or depressed?) Maybe that you’re never going to be at the top of the hill. It’s a
fake game but people keep playing it anyway. There’s this ideal out there of where you’re
supposed to be, like this super-rich business dude. I don’t subscribe to that because I
realize it’s dumb.
(Angry?) Frustration and challenging this alpha male status, so I guess a direct chal-
lenge to his rank.
(Doing now?) I just drew this anatomically, he’s just standing there, not doing any-
thing, just sort of removed from reality completely, just a representation of a person.
Carl’s male figure looked and sounded like a toned-down version of the “warrior
type dude” he imagined and drew at 15yo. At 25yo, Carl had more difficulty
describing this hypothetical person than he did at 15yo, but the difference may
well have lain with producing a more nuanced characterization of the figure’s
inner life compared with the more outward, stereotypically brutish image he
depicted ten years before. True, the “muscular frame . . . weight lifter look . . .
alpha male” aspect of masculinity persisted alongside many of the hedonistic,
mindless features of Carl’s 15yo characterization. But Carl also sensed and was
trying to integrate a more vulnerable, uncertain representation of men and
masculinity. Thus, despite being seen as confident, his 25yo male drawing also
conveyed the insecurity of compensating for something lacking.
Carl’s idealization of brutish fighting and strength was mainly emphasized
in his drawing of a male figure at 15yo, although it also contained references
to deeper layers conveying concerns about a purpose in his life. Now at 25yo,
self-doubt representing uncertainty about goals to guide his life or to provide a
center of initiative was more predominant. Masculinity was still idealized as a
reflection of vigor and robust strength; however, Carl spoke more unambigu-
ously than at 15yo about the “alpha male” image that captured his imagination
as being a shallow one. It nonetheless represented a quality he seemed to desire,
though he also may have sensed that it eluded him. Carl might have defensively
diminished its importance (“a fake game . . . comic-booky . . . bizarre version
of humanity”) but he also needed to secure a place for himself on the “social
ladder.” From a point of some distance from this ambivalently felt standard of
success, Carl expressed in a somewhat veiled way what I considered to reflect
concern about winding up standing on the sidelines “removed from reality . . .
not doing anything”—a euphemism, I suspect, for not going anywhere. He con-
sequently depicted a self-image of a young man who seemed to understand and
in some sense admire how things worked in life, simultaneously feeling apart
from what he sought to achieve, perhaps because he did not know how to carry
it off and succeed in a social or interpersonal way. The depressive ennui of his
adolescence concealed behind an idealized image of a brutish “warrior dude”
had largely been replaced as a young adult by an aggressive “alpha male” ide-
alized jock effortlessly pursuing money and girls. I did not yet know what had
happened to the depressive ennui but what did seem to emerge was a persisting
concern about what he was capable of becoming and whether he would be able
to make the cut to succeed in life, “shallow” and “fake” though that might be.
Much as it appeared at 15yo, Carl at 25yo showed little understanding of or
differentiation among affect states.
Carl’s verbalization following the drawing of a female (Figure 6.2) was as
follows:

It’s always so damn hard to draw females. We’ll just hint at it, I’ve got the full picture in
my mind. I don’t know if this is the complement to that guy, so this is a vague representa-
tion of a female, I guess. It’s really just the same picture, but with boobs and long hair.
Is she shallow? I don’t know.
(What’s she like on the inside?) I don’t know, confrontational or assertive, but not
necessarily in a bad sense. Aggressive in a good way, like career-wise. I can’t draw too
many conclusions, I don’t know what more to say.
(Anxious?) I feel like I’d be misogynous to say relationship concerns or other generic
female concerns. I don’t know, I wish I was more able to elaborate on this stuff for you.
It’s hard to say. I need something like a Likert scale here—you’re killing me.
(Depressed?) Betrayal by friends or sexual partners.
(Doing now?) Sort of standing on display.
Despite representing the female figure as a “complement” to the male just

drawn, Carl seemed to attribute somewhat greater self-assurance or a sense
of direction to this person compared to his verbalization about the male figure
he drew and described. Although neither figure was richly fleshed out in his
verbalizations about them, Carl seemed to show more understanding about
the inner workings of the male figure. His depth of understanding of women
indeed seemed “vague” as he said, save for some greater sense of purpose or
motivation than that which he attributed to the male figure. Carl at 25yo was
no less tentative about imagining the figure’s inner life than he was at 15yo. His
verbalization was brief relative to that of the male figure and he said “I don’t
know” or “I guess” about the female far more than he did when describing the
male figure. His 15yo drawing of a female was peppered with comments such
as “she isn’t as deep as him . . . he analyzes everything, she won’t.” Thus, not
much had changed ten years later. Carl did appear however to apprehend a
greater capacity for self-assertion in women and perhaps a drive to make their
way in the world, which stood in contrast to a view of men as psychologically
stuck in the same place and going nowhere.
Contrasting with his idealizing “alpha male” qualities about men, Carl
repeatedly expressed devaluing views about women. Concealed behind his
depreciating comments about “boobs” and shallowness, and notwithstanding
his protest about not wanting to sound “misogynous,” Carl more than any-
thing created the impression that he may not yet have developed much in-
depth experience or intimacy in his relationships with women. His trivializing
though simultaneously defensive-sounding use of the royal we (“we’ll just hint
at it”) made it seem that he thought that only a hint was necessary to express
the essence of the woman’s life. It seemed to cover over a lack of familiarity,
conveying discomfort or thinly veiled hostility, perhaps underlying his remark
implying that the female drawing was little more than a “counterpart” to that
of the male, differing largely in respect to having “boobs and long hair.” It also
sounded condescending when he said “I’ve got the full picture in my mind,”
as if to say that there was not that much to draw or represent about a woman.
Carl’s presumption that the woman represented in the drawing was shallow
appeared to reflect his not knowing how to approach or relate to a person of the
opposite sex to be able to come to know what she might be like. When he began
the drawing by saying, “it’s always so damn hard to draw females,” it sounded
like an imposition he could barely be bothered with.
Indeed, at one point during the verbalization, he said he needed a “Lik-
ert scale” as a guide to knowing a person in a way that ordinarily would not
require a measuring stick! He followed this comment by expressing how hard
it was for him to get inside the personality of the female figure he was having
trouble describing when he jokingly said “you’re killing me!” Sounding on the
surface like an innocent enough remark, it also conveyed an attempt to forge a
connection with another man about a troubled, confusing area of Carl’s expe-
rience. He also expressed what I thought reflected letting me down or being a
disappointment when he said, “I wish I was more able to elaborate on this stuff
for you.”
These two comments that followed each other sequentially suggested that
when he felt psychologically adrift it seemed important for him to be able to
turn somewhere for an assuring, guiding hand on his shoulder as he charted
unfamiliar waters. That is, letting me down or feeling as if he had failed me
represented a way of thinking about this young man’s need to feel that some-
one understood the anxiety he could not quite grasp himself. Recalling Carl’s
Figure Drawings and TAT from 15yo, I noted his concern over not feeling up
to facing expectations or challenges and that his parents seemed unable to com-
prehend how he felt. He seemed alone with his fears as he tried to get through
what was expected of him.
I thus could picture Carl at 25yo still facing developmental expectations that
were fraught with anxiety, not recognizing how he felt and also anticipating
that no one would understand his concerns. He seemed to need to feel compe-
tent and appreciated rather than feeling like a disappointing failure. Without
asking for help in so many words—which he was neither accustomed to doing
nor would he have expected help to come his way—Carl’s way of bantering
with me provided a means of understanding what he probably meant behind
the words he spoke. Possibly recalling from his psychotherapy ten years ear-
lier that he might not need to submerge and conceal feeling distressed with
me, Carl could risk conveying that he felt vulnerable, although I doubt that he
understood how he could easily feel psychologically lost and adrift without an
anchor—his metaphorical Likert scale.
Rorschach
In this section, I examine Carl’s Structural Summary and a summary of R-PAS
findings, followed by a discussion of the findings in comparison with his 15yo
protocol. His Rorschach location sheet appears in Figure 6.3.
Carl’s CS Sequence of Scores and Structural Summary are shown in Figures
6.4 and 6.5. None of the constellations were positive, including PTI which had
been an area of concern at 15yo. However, as will soon become evident, the
verbalizations in the 25yo record were no less problematic than they were ten
I 1 WSo 1 Fo Cg 3.5 DR
2 W+ 1 Ma.mp.FC’u 2 (H),Cg 4.0 COP, DV,

GHR
II 3 W+ 1 Ma.FCo 2 (H),Cg,Id 4.5 COP, DV,

GHR
III 4 D+ 1 Mp.FMpo 2 (H),A,Hh,Sx P 3.0 GHR

5 Do 2 mp.CFu 2 An,Bl DR
6 Do 3 Fo An DV
IV 7 Wo 1 FMa.FDo (A) 2.0
V 8 W+ 1 Mau 2 H,A 2.5 INC, PHR
VI 9 Wo 1 FTo Ad P 2.5 MOR
VII 10 W+ 1 Mao 2 H,Cg,Id P 2.5 COP, GHR
VIII 11 D+ 1 FMao 2 A,Ls P 3.0 DV
IX 12 D+ 2 Mau 2 A,Na 2.5 FAB, PHR
13 Do 6 CFo 2 An
X 14 Dd+ 21 Ma.FCu (H),Cg 4.5 GHR
15 D+ 1 Mao 2 (A),Bt P 4.0 GHR
16 Dd+ 99 FMa.CF- 2 A,Fi 4.0 FAB
R = 16 L = 0.14 FC:CF+C = 2:3 COP = 3 AG = 0

-------------------------------------------------------------- GHR:PHR = 6:2
Pure C = 0
EB = 8 : 4.0 EA = 12.0 EBPer = 2.0 a:p = 10 : 4
eb = 6 : 2 es = 8 D = +1
Adj es = 7 Adj D = +1 Afr = 0.60 SumT = 1
-------------------------------------------------------------- S = 1 Human Content = 6
Pure H = 2
m = 2 SumV = 0 SumY = 0 PER = 0
--------------------------------------------------------------
a:p = 10 : 4 Sum6 = 9 XA% = 0.94 Zf = 13 3r+(2)/R = 0.69

MOR = 1 M- =0 S- =0 Zd = +1.0 FD =1
M none = 0
X+% = 0.63 DQ+ = 10 MOR =1
Xu% = 0.31 DQv =0 H:(H)+Hd+(Hd) =2:4
years previously. Accordingly, W Sum 6 was essentially unchanged, falling at

a notably high level at both time periods. Perhaps what was different at 25yo
was that Carl was better able to contain how his idiosyncratic and at times
troubling thoughts were expressed. However, as will be seen later, his responses
sounded no less bizarre or uncontrolled than they had when he was an adoles-
cent, despite his XA% of 94% being markedly better than the value of XA%
(61%) at 15yo. Similarly, his X–% at 25yo (6%) was considerably lower than
the comparable percentage at 15yo, which was 33%.
There also were other general indications of more stabilized adjustment. For
example, half of Carl’s six M responses at 15yo were of poor form quality,
whereas as a young adult at 25yo none of the eight human movement responses
he produced were FQ–. Furthermore, at 25yo there were no pure color
responses (compared with one at 15yo), he had three COP responses compared
with one at 15yo, he had two m determinants compared with five at 15yo, and
his sole MOR code at 25yo contrasted sharply with seven such codes at 15yo.
Moreover, Carl’s GHR:PHR ratio of 6:2 was decisively improved compared
to the comparable ratio of 2:6 at 15yo. Consistent with these shifts in inter-
personal and object relations capacities suggested by GHR:PHR, MOR, and
COP, Carl also showed appreciably more favorable a:p and Ma:M p ratios rela-
tive to the 15yo values of 4:9 and 2:4, respectively. His single texture response
was more optimal than the absence of texture at 15yo; however, egocentrism
was more pronounced at 25yo and Carl also may have been somewhat more
isolated compared to his 15yo record. The predominant clinical picture sug-
gested mainly adequate functioning and adaptation uncompromised by signifi-
cant anxiety.
Carl produced about the same number of responses at 25yo as he did at
15yo, and these responses also were as complex and richly imaginative as they
were at 15yo. As a result, Carl’s low lambda ratio of 0.14 was not appreciably
different than the comparable value of 0.20 at 15yo. Carl’s EB at 15yo shifted
from 6:6—an ambitent style—to 8:4 at 25yo—an introversive style. A shift
away from an ambitent style might not necessarily be surprising in the transi-
tion from adolescence to adulthood. Being for the most part at 25yo less likely
to be experiencing intrusive thinking, which was troubling to him as an ado-
lescent and which precipitated his seeking psychotherapy at his own request,
the recent protocol suggested that Carl may have settled into more of an idea-
tional approach to life situations, a pattern that dominated decision making
more than feeling states or intuitive or emotion-based impressions. He neither
avoided nor had difficulty with modulating affective experience. Carl might
display momentary fluctuations in regulating intense emotion states, but he
could readily regain his composure and show restraint as situations warranted.
Although he displayed a preferential style of problem solving favoring think-
ing through problems, Carl’s affect life was not inaccessible. Moreover, despite
less incapacitation by troubling and intrusive thoughts than he had had at 15yo,
Carl still showed problems thinking clearly and coherently, sometimes drawing
conclusions arbitrarily that reflected irrational or unconventional thinking, par-
ticularly surrounding unmet needs or when feeling limited control over situa-
tions he might face. He was inclined to favor overly accurate and precise views
of reality, though at times rigidly so, because he could not easily relax a way of
being exacting in his thinking. Carl also was inclined to overlook subtle signals
in interpersonal situations that might sometimes interfere with relationships with
people; however, his capacity to bounce back from momentary stresses coupled
with good impulse control fostered generally good adjustment most of the time.
Openness to new experiences and a preference for ambiguity were compara-
ble at both time periods, but so too was Carl’s inclination to see situations in life
and relationships with people as more complicated than necessary. As a result,
his overly complex way of apprehending events around him, while advanta-
geous in some situations, could create problems in interpersonal relationships
such that people could tire of his pedantic ways. Coupled with more than an
average degree of self-absorption and the appearance of being less attuned
to other people’s motivations, Carl was prone to experiencing dissatisfaction
concerning relationships with people. While he showed a good capacity to be
reflective, his self-awareness seemed compromised by an equally prominent
disinclination to become intimately involved with people. He appeared to favor
instead rather limited and less mature ways of relating to people, which also
could interfere with identity development.
Although Carl appeared to demonstrate an interest in relationships, he also
tended to feel inadequate and consequently vulnerable around people, which
left him somewhat socially isolated. He probably was not avoidant or fear-
ful in social situations, but neither was he adept at engaging others in a way
that would lead to greater intimacy or establishing deep rather than reserved
relationships.
ODL R-
(RP) Opt
I 1 W SI Cg o F DR1
2 W (H),Cg Sy 2 u Ma,mp,C’ DV1 COP,AGM,AGC PH
II 3 @ W (H),Cg,NC Sy 2 o Ma,FC DV1 COP,AGM PH
III 4 D 1 A,Sx,NC Sy 2 o P Mp,FMp GH ODL
5 D 2 An,BI 2 u mp,CF DR1
6 D 3 An o F DV1
IV 7 W (A) FMa,FD AGC
V 8 W H,A Sy 2 u Ma INC1 PH
VI 9 W Ad o P T MOR,MAP
VII 10 W H,Cg,NC Sy 2 o P Ma COP,AGM,AGC GH
VIII 11 D 1 A,NC Sy 2 o P FMa DV1
IX 12 D 2 A,NC Sy 2 u Ma FAB1 PH
13 D 6 An 2 o CF ODL
X 14 Dd 21 (H),Cg Sy u Ma,FC AGC GH
15 D 1 (H),NC Sy 2 o P Ma GH
16 Dd 99 A,Fi Sy 2 - FMa,CF FAB1

Copyright © 2011–2012 by the Rorschach Performance Assessment System, LLC (R-PAS). Repro-
duced by permission. All rights reserved.

Pr 0 Pr
Pu 0 Pu
R (Responses) 16 23 89 5 75 R
Blend 7 87 117 75 111 Bln
Sy 10 85 115 73 109 Sy
MC 12.0 91 120 83 114 MC
MC - PPD 4.0 93 122 93 122 MC-PPD
M 8 94 123 89 119 M
M/MC [8/12.0] 67% 72 109 76 111 M Prp
(CF+C)/SumC [3/5] 60% 59 104 59 104 CFC Prp
EII-3 0.7 82 114 79 112 EII
TP-Comp (Thought & Percept.Com...) –0.1 25 90 22 88 TP-C
WSumCog 20 92 121 90 119 WCog
SevCog 0 35 94 35 94 Sev
FQ-% CS FQ 6% 9 80 9 80 FQ-%
WD-% CS FQ 0% 4 74 4 74 WD-%
FQ-% CS FQ 62% 76 110 79 118 FQo%
P 5 44 98 35 94 P
m 2 72 109 67 103 m
Y 0 19 87 19 87 Y
MOR 1 53 101 47 99 MOR
ODL% 19% 85 115 85 115 ODL%
MAP/MAHP [1/1] NA MAP Prp
PHR/GPHR [4/8] 50% 64 105 60 104 PHR Prp
M- 0 32 93 32 98 M-
AGC 4 71 108 65 106 AGC
H 2 49 100 34 93 H
COP 3 93 122 93 122 COP
MAH 0 26 90 26 90 MAH

Copyright © 2011–2012 by the Rorschach Performance Assessment System, LLC (R-PAS). Repro-
duced by permission. All rights reserved.
The Sequence of Scores is represented in Figure 6.6, followed by the Page

1 variables in Figure 6.7. The below average number of responses (R) was
just barely sufficient for interpreting R-PAS; however, it was consistent with
the CS impression of largely more stable functioning compared to the earlier
15yo record. Although Carl showed a greater than average level of engage-
ment and awareness of psychological processes, adaptive resources could
appeared relatively immature and not as well developed as they might seem
on the surface. Stated another way, it could be said that while he talked a good
game, the psychological substance underlying how he came across was not
always secure. Thus, whereas the potential problematic determinants variable
(PPD) was not elevated relative to M and C, the quality of a number of Carl’s
responses seemed to compromise the effectiveness of thinking before acting and
exercising good judgment. He seemed emotionally overresponsive to many
situations, as he also did at 15yo, while at the same time revealing that it could
be difficult for him to filter affective reactions to be able to experience many
ongoing events in a neutral way. Carl often appeared to experience emotion
states and react to situations he encountered as being more complicated than
necessary.
Carl showed distortions in thinking; however, these were generally modest
in intensity or severity. The elevated EII-3 suggested that problems in this
area, when present, might be influenced by interpersonal difficulties. Although
this patient’s elevated CritCont% (Critical Contents) suggested appreciable
concerns related to bodily functions or aggression, these areas of functioning
did not seem particularly troubling, particularly in a context of there being
no notable stressors impacting overall functioning. The quality of self and
other representations indicated heightened dependency (ODL%), which
might be experienced in an overly dramatized manner, and a tendency to
present himself to others as appealing and deserving of others’ caring concern
(elevated COP, no MAH codes). In other respects, Carl’s interpersonal rela-
tionships appeared mainly congenial and unremarkable, although the poten-
tial for harboring hostile ideation (AGM, AGC) should not be discounted.
Nevertheless, there was no appreciable concern about potential aggressive
dyscontrol.
Comparison of CS and R-PAS Findings at 15yo and 25yo

With the caveat about interpreting the adolescent normative reference points
in mind, it was still mostly possible to compare the two Rorschachs conducted
ten years apart. It appeared that in many respects Carl was generally less dis-
tressed and functioning better at 25yo relative to the earlier record. This would
not be surprising because Carl was depressed and anxious as an adolescent
and he sought treatment on his own. At 25yo, although there seemed to be a
vague sense of discomfort, it was not nearly as destabilizing as it had been at
age 15. Although Carl displayed a stable level of psychological functioning and
more mature adaptive capacities at 25yo, there persisted problems that, while
subtle and not overtly expressed or even perceived as problematic, nonetheless
compromised Carl’s establishment of closer and more satisfying relationships
with people.
None of the CS constellations were positive, including PTI which had been
an area of concern at 15yo. A similar finding also was noted in the R-PAS
interpretation, mindful however that some variables were not unequivocally
interpretable. Nonetheless, this patient’s verbalizations in the 25yo record were
no less problematic than they had been ten years previously. Both the CS and
R-PAS showed evidence for improved reality testing and fewer or less prob-
lematic thought distortions at 25yo. Although the two interpretive approaches
identified less incapacitation by troubling and intrusive thoughts at 25yo com-
pared to the 15yo record, Carl potentially could still show problems thinking
clearly and coherently, sometimes drawing conclusions arbitrarily that reflected
irrational or unconventional thinking. He was characteristically inclined to
overlook subtle signals in interpersonal situations. However, in both the 15yo
and 25yo protocols Carl’s capacity to bounce back from momentary stresses
coupled with good impulse control fostered generally effective adjustment in
most situations.
This patient’s EB at 15yo shifted from an ambitent style to an introversive
style at 25yo and he neither avoided nor had appreciable difficulty with modu-
lating affective experience. He might have displayed momentary fluctuations
in regulating intense emotion states, but he could readily regain his composure
and show restraint as situations warranted. These impressions also were gener-
ally consistent with interpretive inferences based on R-PAS.
Both the CS and R-PAS approaches suggested that Carl’s involvements
with people might be limited or superficial, and thus less mature. The R-PAS
and CS indicated a normal capacity for and interest in relationships, although
the CS also indicated that he tended to remain somewhat socially isolated.
Carl’s tentativeness, insecurity, and possible fearfulness in developing inti-
mate attachments also may have contributed to compromised self-esteem and
hindered the development of a more mature pattern of identifications. This
aspect of his immaturity seemed largely unchanged and as a result remained
underdeveloped as Carl moved from adolescence to young adulthood. Fur-
ther, affective experience, although well regulated, was probably experienced
with some degree of distance, more than likely representing his premorbid
level of emotionality which was disrupted in adolescence as he became over-
whelmed by trying to contain an upsurge of distress about school and his
future.
Card I
1. [long hesitation] It’s weird. Two Four ventilation holes. Just the shape.
things. One, the bottom half of a face This would pull around to be like a
mask, like a ski mask. Like a swat team buckle in the back.
face mask. Something that would be worn (Lower half of the head?) Those
to cover the lower half of your head. There generic dime-a-dozen bad guys coming
would be goggles with it. at you. They can never shoot. Like storm
troopers. The running joke with them is
why can’t they seem to aim, they never hit
anyone. Every video game has those guys.
The generic foot soldier, it was okay to shoot
right through them and have blood and guts
everywhere. They don’t count, really.
Carl began Card I with a mask percept, albeit an unusual mask from his descrip-
tion. A swat team usually signifies a superior level of uniquely trained police
specializing in high risk missions. Although perhaps signifying little more than a
longstanding interest in science fiction adventure movies and video games—an
interest he had shown ten years earlier and which appeared in many of his 15yo
Rorschach responses—its persistence ten years later together with an adoles-
cent-sounding reference to bad guys would raise a question about this young
man’s maturity level. Interestingly, however, Carl quickly belittled the swat
team figures he saw, emphasizing their ineptness and how de-idealized they
had become in his eyes (“they don’t count”), which also was a theme in some of
his 15yo Rorschach responses.
Carl seemed to emphasize the mask in his verbalization, raising the possibility
that its connotation as a symbol of concealment or disguise was a crucial element
in this percept. He seemed to relish the idea of exposing this figure, typically seen
as powerful or highly skilled, as an incompetent laughing stock. In this sense,
Carl appeared to be removing a mask to reveal weakness rather than vigor, a
Wizard of Oz-like theme that was very much at the interpretive center of his
15yo protocol. Thus, beginning in some sense where he left off at that time,
Carl seemed to announce that disparaging and de-idealizing powerful figures
remained important for him. Behind Carl’s observation that these “generic . . .
dime-a-dozen . . . storm troopers” were a “joke,” he may have been expressing a
veiled wish for strong or competent figures in his life who did count.
2. Two angels, but definitely a malevo- Like evil angels, there’s something demonic
lent edge to them. But they’re kissing. about them. Heads here, they’re holding
Maybe demons, but at the same time they their hands away. Their garments, some-
seem flowy and evanescent. Hands are off thing like a priest would wear, like flow-
to the side. The more I look at it, the more ing robes, a skirt-like thing. Their feet are
I’m going with the scary angel thing. pointing down almost like they’re floating
in a mid-air embrace thing. But it’s totally
malevolent, there’s nothing good about these
guys. There’s giant wings in the back.
(Malevolent?) The shading, the fact
that they have wings and they’re black.
And those priestly vestments gives them
sort of a malevolent edge.
(Shading?) It’s black, it gives it that
look.
(Flowy and evanescent?) An ethereal
kind of incorporeal sort of thing. Espe-
cially the wing part, like your hand would
go right through the wing.
(What do you see that makes it

look evanescent?) Parts of the wings
are sort of floating away. The wings are
just there for show.
(Wings floating away?) Not like
actual physical wings like birds. They’re
just there to look scary. Something about
the shape of the wings—they suggest
wings, it gives it that evanescent kind of
flow to it.
(Kissing?) Not a romantic gesture. It’s
something they’re doing that’s spooky or
crazy.
(Evanescent?) Like with everything,
comic books and video games, they’re bad
guys, some kind of malevolent demonic
bad guys. They’re not the final bosses
of the game. They’re evil parodies of an
angel—like an evil version of that. Like
mocking that—the antithesis of an angel.
Carl struggled with considerable ambivalence every bit as much as he did

on a similar response to Card I at 15yo. Whether the hugging monsters or
attacking demons of the earlier protocol—which was part of his “civil war of
the monsters” response—or the kissing angels or malevolent demons of the
current record, Carl continued to have trouble resolving the ambivalence such
images so compellingly stimulated for him. Even when he seemed to reach
what he thought was an attempted resolution (“the scary angel thing”), Carl
did not seem to recognize that what he thought was a resolution was nothing
of the kind. Although perhaps no longer a civil war of monsters, the analogous
response at 25yo was only somewhat better modulated. The warring, hate-
filled “showdown” of 15yo thus seemed to become “mocking . . . evil parodies .
. . the antithesis of an angel” at 25yo, implying that it might be difficult for Carl
to believe that benevolent-appearing objects could be in his corner and that he
had to be careful not to become too trusting and thus be deceived by an appear-
ance of good intentions.
Carl thus seemed to struggle with integrating introjections of good and bad
objects, not very differently than he had ten years previously. Need states were
still fraught with potential danger, humiliation, or deceitfulness, causing him to
keep a cautious distance from others, although not to a degree that included
paranoid ideation. Like the preceding response containing the idea of mock-
ing a powerful image, here too Carl commented about mockery in reference
to “demonic bad guys” as “parodies of evil . . . the antithesis of an angel.” He
seemed to be saying that goodness was a cruel “joke” being played to disguise
truer malevolent intentions—and possibly also, from R1, to disguise ineptness
masquerading as strength or stupidity masquerading as boldness.
As much as he might have wished to see the angels not only as benevolent
but also as kissing—which I am regarding as an intimation of closeness more
than an intimation of eroticism—Carl seemed to be saying here that intimacy
portended danger or deceitfulness. Moreover, using the word mocking carried
a connotation of concern about being laughed at for being taken in by a false
appearance of intimacy. Considered together, I wondered whether Carl might
have felt that intimacy was a pretense, a dangerous lure that led to deceit,
mockery, and potential danger. Consequently, “kissing” in any sense of the
word was something to be avoided or undertaken with some distance or with
great care, and needs for intimacy or closeness were fraught with danger. As I
speculated concerning Carl’s female drawing, my hypothesis about his discom-
fort with women or sexuality seemed increasingly likely from his description
of the figures kissing as “spooky or crazy.” This comment added a connota-
tion of anxiety extending beyond mere discomfort arising from inexperience
or unfamiliarity.
The inquiry was more protracted than usual because this response contained
several verbalizations suggesting potential determinants or imagery requiring
clarification, some of which seemed to defy my attempts to do so. Thus, refer-
ences to malevolence, evanescence, “flowy,” and wings floating away reflected
the complex nature of this response. It was difficult to be certain exactly what
he saw or to what extent some of these verbalizations were secondary elabora-
tions. “Wings floating away” was a particularly odd verbalization.
This response was also the first of four with a content code of (H), which rep-
resented 25 percent of his responses overall. By contrast, Carl produced only
two H responses, yielding a 1:2 ratio of H: (H) responses. In his 15yo protocol,
Carl had four H or Hd responses (two of each type) and two (H) or (Hd) responses
(one of each), yielding a 2:1 ratio of H: (H) responses. Consequently, although
at 25yo Carl produced no Hd or (Hd) responses, he had proportionately more
responses involving human figures of an unrealistic or fantasized nature com-
pared to his 15yo protocol. Carl’s Isolation Index also increased slightly from
15yo to 25yo. These patterns suggested the possibility of greater distance from
apprehending other people in a mature, fully fleshed out, or realized manner as
he moved from adolescence to young adulthood.
The words Carl used to describe the angels (“evanescent . . . incorporeal . . .
ethereal”) suggested imagery connoting their being insubstantial and not dura-
ble or fading away. Though it may be so that angels commonly are perceived
as not of this world and thus are transitory or fleeting figures, the idea of things
not being long-lasting or durable clearly seemed to dominate much of Carl’s
verbalization. Similarly, his comment about the demonic bad guys as “not the
final bosses of the game” was curious and its psychological significance was not
entirely clear at this point. As a tentative working hypothesis, Carl may have
been experiencing benevolent and malevolent objects as fluid mental images
in conflict with one another. Thus, his comment about “not the final bosses”
might suggest in addition to experiencing contradictory mental states in flux
that a resolution of such mental states might be possible.
Card II
3. Two faceless gnomes pressing their Sitting on benches. Big gnome overcoats.
hands together. Seated in front of each Wearing orange gnome boots.
other. Silly gnome hats, pressing their (Gnomes?) That hat especially. Those
hands together, wearing big oversized funny little gnome jackets with a hood-
coats. ∧ ∨ [long hesitation] type thing. Your iconic garden gnome. I
remember from ten years ago, what I’m
now seeing as gnome hats was the entirety
of the heads. Now I’m seeing two chil-
dren—this is their hair and the outline
of their face, yelling at each other. And
a severe underbite. It looks like two kids
engaged in arguing, dressed in giant
smocks for some reason.
——————
(Gnomes?) A hobbit-like mischievous
kind of character, but good. A dwarf,
fantasy kind of character. Playfulness. I
can’t see the gnomes any more. The kids
are like those Dutch figures with bonnets.
They’re arguing, pushing each other. It’s
the same hands, maybe it’s because there’s
spittle coming out of their mouths, because
they’re arguing really intensely.
(Underbite?) They’re just kids, it’s just
something I notice, I’d attribute it to a
less intelligent character. I just picture
that lower jaw jutting out like that, like
they’re less sophisticated.
(Can’t see the gnomes anymore
. . . two kids arguing?) I’m just see-
ing more for some reason. The gnomes are
missing faces here—not normally—so
maybe when I saw the faces more, the
children became clearer. Now that’s all I
see—just the children and their faces and
not really the gnomes.
This response of faceless gnomes wearing silly hats and overcoats appeared
at first glance as a playful, whimsical image. Carl seemed to think he saw
something similar at 15yo; however, what he actually did see was a crying
dragon that was accompanied by a verbalization about imagining he had to
overpower threatening figures so they were “reduced to tears.” After recalling
what he thought he saw at 15yo, Carl immediately observed that he could no
longer see gnomes and he proceeded to transform the image of gnomes into
children yelling or arguing. When I asked him about gnomes on a testing-
the-limits inquiry, Carl’s association was that they represented playful and
diminutive albeit benevolent fantasy figures—which could be understood as
harmless and underpowered. Once he perceived the image of children, how-
ever, that image so dominated his imagination that he could barely see the
gnomes any longer. The children seemed to represent an ambivalently appre-
hended image, described as innocent-looking Dutch children with bonnets
arguing “really intensely.”
I could not be sure whether Carl may have had in mind a connotation of
gnomes from common folklore as deformed or troll-like, diminutive old men
who were subterranean dwellers usually functioning as guardians of treasure
mines. His association concerned mainly a silly or funny-looking, dwarfed
appearance, and thus no further conclusions about what they signified could be
justified beyond their being benign or diminutive figures. (An image of Carl’s
one-armed father crossed my mind at this point, although I could not of course
infer whether Carl might have had the same association.) That the gnomes
were practically erased from his perceptual awareness after he saw the figures of
children might reflect having repressed the imagery of gnomes or associations
to these mythical figures, perhaps even more so because Carl saw the gnomes
as faceless. Clearly, the children represented ambivalent motivations, and his
commenting on the prominent underbite followed by his association to unintel-
ligent or unsophisticated figures suggested an element of primitiveness about
this image.
Card III
4. [long hesitation] I guess it looks It’s breast-like in the chest, but it also
like humanish figures with something very looks like an erection. More like a bassi-
phallic but with breasts. Standing around nette, two babies in a crib or something.
some kind of cauldron. And a butterfly The head, a protruding kind of mouth.
floating in the middle—maybe a bowtie. They’re tilted back. And legs.
It could be a bassinette, or a cauldron. (Butterfly floating in the middle,
maybe a bowtie?) It’s just sort of sus-
pended there. Those wing-like projections
attached in the middle.
(Something very phallic with

breasts?) I don’t know, I see both. Seems
more feminine because it seems like it’s
over a baby. But it also has a penis. The
more I look at it, it looks more ape-like,
like an intermediate stage between apes
and humans.
——————
It could be either or. More than a man
with breasts, it seems like a woman with
a penis.
(Woman with a penis?) Transgen-
dered people. What is it really, then? It’s
rocking a cradle, both of them are.
(Butterfly in the middle?) I don’t
know, it seems extraneous, like it has
nothing to do with it.
5. Two stomachs with an esophagus This is the stomach and this thing trailing
hung on the wall. off from it. Definitely the color, it looks
like blood. I can’t decide on anything,
maybe in the context of this sexual iden-
tification thing, these could be testicles,
suspended organs.
(Hung on the wall?) They’re not just
magically floating, so maybe they’re on
the wall.
6. Spread-out lungs. The description The shape of them, they’re connected in

makes it sound darker than it is. It’s kind the middle.
of odd, these body parts in different places (Description makes it sound darker
and these figures with breasts and penises. than it is?) It’s like where did these lungs
come from! I pictured blood and guts, but
I don’t see it as violent or anything in this
context.
(Spread out?) Like if you were going to
post them to the wall. Like they were nailed
to the wall, that’s how they would look.
Although Carl was productive on Card III, there was a noticeably long hesi-
tation before delivering his first response. Although this initial response was
the relatively uncommon hermaphroditic human-like figures, Carl’s further
description was more problematic. He could not decide whether the D3 area
was a butterfly or a bowtie and whether the D7 area was intended as a caul-
dron or a bassinette. Even when I asked about the butterfly/bowtie during the
inquiry, Carl commented about its form but seemed to totally miss the incon-
gruity I was going after in trying to clarify exactly what he saw, thus seeming
to evade the issue. In both instances, neither area was well integrated with the
human-like figure. Moreover, Carl also noted that the penis was erect, sug-
gesting that erotic stimulation was at least as important as the reference to the
anatomical anomaly influencing how he saw this percept.
Carl began by noting the incongruity about a breast and a penis belonging to
the same figure, but he seemed to retreat quickly from the topic by making ref-
erence to the bassinette. This comment at first sounded as though he intended
to continue elaborating about the breast and penis images, but when he pro-
ceeded to talk about an unrelated image—the bassinette—it actually sounded
more like a non sequitur. His direct reference to eroticism or sexuality (the erect
penis) may have provoked his rapid retreat from the subject. Carl proceeded to
mention that the bassinette contained two babies—perhaps a safer, not sexually
tinged image.
When I drew Carl’s attention back to the hermaphroditic image, he com-
mented on its ape-like appearance, perhaps to emphasize that it was unreal-
istic but possibly also to create distance from a potentially threatening image
having connotations either of discomfort about sexuality or sexual identity
confusion. His odd-sounding comment on a testing-the-limits inquiry (“more
than a man with breasts, it seems like a woman with a penis” and later, “what
is it really, then? It’s rocking a cradle, both of them are”) only added to this
impression.
Carl’s next response (R5) struck me at first as deliberately playful or provoca-
tive rather than bizarre. I thought that he perceived the shape of a stomach and
the shape of something resembling an esophagus, but rather than searching
for a plausible connection between them or editing what he saw, Carl instead
chose to blurt out just what he saw—perhaps to be daring or unusual, or to
get my attention, or to show off how creative he could be. I did not however
regard this odd-sounding response as psychotic or thought disordered ideation.
It reminded me of Carl’s frequent over-the-top style of bravado responding on
his 15yo Rorschach.
That being said, when Carl later spontaneously referred back to “the context
of this sexual identification thing,” however defensively provocative or cavalier
he may have been trying to act it appeared that he could not easily break away
from a concern this card seemed to stimulate for him. Consequently, when he
said “I can’t decide on anything,” I would add to that how he also was indeci-
sive about his esophagus/testicles response and the unresolved cauldron/bassi-
nette and butterfly/bowtie images of his previous response.
Carl’s third response to Card III (R6) once again made reference to R4,
making it abundantly clear that the ambiguous sexual imagery and connota-
tions of this card were evidently stressful for this young man. I did not know
what he was thinking when he said “I pictured blood and guts, but I don’t
see it as violent,” or what he meant during the response phase when he said
“the description makes it sound darker than it is.” Figuratively, Carl seemed to
be whistling in the dark, as the saying goes, and it reminded me of Freud’s
comment that “the benighted traveler may sing aloud in the dark to deny his
own fears, but, for all that, he will not see an inch further beyond his nose”
(1959, p. 96).
Card IV
7. I remember this from ten years ago and Like that first big reveal in those movies,
I still think it looks like a giant monster when you see how big Godzilla is.
from underneath. Like you’re looking at (Plant-like tendril arms?) It’s very
it almost standing on glass. You’re look- loose and viny or something. Where his
ing up at it, seeing the bottom of its feet. hands should be there’s all these plant-
There’s a tail in the background, curl- like things.
ing up in the back, holding its plant-like (Menacing?) The position it’s in.
tendril arms, holding them up in a kind There’s no context but maybe because it’s
of menacing way. A plant-like snakish like a hundred feet tall, and also those
head. Like a dramatic swooping shot like arms in a scary position.
in a movie when you’d first see Godzilla. (Scary position?) Like Boris Karloff
the mummy, like hanging its hands out.
(Snakish head?) Like a king cobra
snake.
——————
Like a giant B-movie monster, like
impending destruction.
Carl correctly remembered that he did indeed report seeing a “big Godzilla-
like monster . . . looking up from below, like he’s standing over you” ten years
before. That monster from ten years ago also had “droopy” tentacles and
“he’s really goofy . . . stupid-looking . . . not very threatening . . . I wouldn’t be
scared of him.” Now, ten years later Carl’s monster still had weakened arms
(“plant-like tendril arms . . . loose and viny”) and was perceived as menac-
ing, and it also was perceived as large because of a perspective relationship
(although at 25yo the determinant was FD rather than shading (V) as was the
case at 15yo). Although Carl did not supply a verbalization consistent with
the “goofy . . . not threatening” verbalization of his 15yo Rorschach, at 25yo
he suggested that the monster resembled an image from a “B movie . . . like
Boris Karloff the mummy.” Accordingly, perhaps indicating a threat now
experienced more distantly though similarly diminished as it appeared to him
on the 15yo Rorschach, Carl still seemed alert to looming figures portending
danger. However, once he got past “that first big reveal” when the potential
threat first became apparent, what I referred to as his whistling in the dark
defense on the previous response and his immobilizing the monster (its “viny
. . . tendril arms”) seemed to kick in, signaling diffuse anxiety.
That Carl’s anxiety and defensive disavowal were apparent in this response
was not particularly unusual, but what was noteworthy was that his anxiety
did not seem to dissipate. Although it might be possible to regard a shift from
the vista determinant at 15yo to form dimension at 25yo as a potentially more
favorable indicator of managing anxiety, I think the recurring and unrelenting
theme of danger both at 15yo and 25yo across these first six or seven responses
was not a sign to be ignored regardless of the defensive overlay surrounding the
theme of threat that seemed so much a part of the psychological world Carl
inhabited.
Card V
8. Like a moth creature thing. It’s very Some kind of bat creature because of the
large. Its arms outstretched, antennae, it’s antennae. Like a giant moth. For some
covering up two nude females. The females reason he’s using his wings to cover up
are like one of those mud flaps you see on two nude females, doing it intentionally.
trucks behind the wheels—sometimes they (Nude females?) The top of their heads,
have a silhouette, like of women, or team sitting on their side.
logo ones. (Females?) Something slender about the
legs, like females.
(Nude?) An unclothed leg. The part I do
see isn’t clothed and the fact that some-
one’s trying to cover them up.
(Doing it intentionally?) Like it’s not
letting you see even though you want to.
(Connection between the moth
and the two females?) I can’t imag-
ine where the connection would be. But
it’s like censoring them for some reason.
It’s obstructing your view and it knows
it is.
This was the second of Carl’s responses that was similar or nearly identical to
one he produced on the 15yo Rorschach. Indeed, for several such responses
Carl himself noted that he saw the same or highly similar percepts. There was
one obvious difference on R8 between the two responses ten years apart: at
25yo the large moth-like figure was covering up nude female figures. Carl made
no attempt to withhold—or possibly he could not stop himself from comment-
ing about—the nude females he saw. Although he referred to thwarted or frus-
trated desire, he also expressed the idea that something was “censoring . . .
obstructing your view . . . not letting you see even though you want to . . . doing
it intentionally.”
Alongside these references to thwarting or censoring he also commented
about concealment (moths covering up the nude women and images of nude
women behind a truck’s mud flaps where they might not be especially promi-
nent). His turning the nude female images into a possibly less threatening or
possibly denigrating team logo insignia also was pertinent to understanding
Carl’s response. I could not be certain about the meaning underlying his asso-
ciations to truckers and sports teams, particularly in this context of an image of
nude women, but it was not easy to believe that he had in mind something well
intentioned. Carl’s reference to the women’s “unclothed leg” also sounded odd
or stilted, suggesting possibly inexperience, inhibition, or discomfort. Certainly,
from his earlier responses it seemed clear that Carl was uncomfortable with or
anxious about sexuality.
The idea of something or someone getting in his way or censoring his desires
was curious, possibly suggesting a conflict model interpretive view pitting drives
against superego prohibitions. However, I decided to reserve judgment until
a clearer picture emerged concerning maturity and stability of object relations.
I noted in regard to Carl’s 15yo protocol on this card that he had appeared
to find a way to transform feeling dominated into feeling that he had overpow-
ered a source of threat. Adolescent boys sometimes need to buck up against
authority or prohibitions on a path toward stabilizing greater autonomy. How-
ever, as the 15yo evaluation proceeded, I expressed reservations that what
might have appeared to be an adaptational accomplishment was really not
very well secured.
Now as a young adult, Carl faced adaptational demands that included
managing sexuality and the development of mature sexual-emotional rela-
tionships. I was skeptical that he showed adequately fortified psychological
strengths to successfully navigate such demands as an adult. I doubted that
ego functions were sufficiently secure and autonomous to meet mature adult
demands, largely because malevolent object relations and unneutralized
aggression undoubtedly interfered far too readily. While fantasies of over-
powering, fighting and defeating, and omnipotent control may be compre-
hensible in a context of normal adolescent development, they do not bode
well for most situations of adulthood. Carl seemed to be showing in R8 at
25yo a precarious balance between desire and inhibition or prohibition that
so far suggested a picture of being stuck or frozen more than it suggested
being on a clear enough path to resolution.
Card VI
9. I remember this one, too. An animal The front legs, and hind legs. The color-
skin. It’s been gutted and cut out, and this ing and texture, it looks like a leather look
is what’s left over from the skin. Like a to it. Like someone tried to dry out the
deer, the hide of the animal’s just kind of skin. Someone cut the head off.
splayed out. (Coloring . . . leather look?) It
looks like untreated leather. Lighter here
and it’s changing. It’s that coupled with
the shape that seems very animal-like
to me.
——————
Not bad things, like a tribal decoration.
There’s something very natural about it.
Card VII
10. I remember this one, too. I remember The nose, chubby little kid faces, the
I saw two kids—I still see it. Wear- feather sticks up in the back, the torso, a
ing Indian hats, playing cowboys and little tuft of curly hair.
Indians. They’re holding two very large (Hair?) The positioning of it relative to
cleavers. The iconic feather headband hat, the face.
looking at each other. (Cleavers?) The shape and the fact
they’re holding it. It implies violence, like
they’re out to attack each other with the
cleavers.
(Headband?) I don’t really see it. It’s
implied, because it’s holding the feathers.
It’s a silhouette, just the outline of it. I’m
doing my darndest to see something else in
this one, but I can’t. I can’t imagine what
other people would see. I remember this
one and I went right to it and couldn’t
see anything else because I remember it
so vividly.
Carl was correct about remembering that he saw a splayed out animal skin
at 15yo on Card VI, although now at 25yo (R9) the addition of the texture
determinant suggested at least the possibility of an emerging awareness of
need states he probably rarely experienced, let alone was able to articulate.
Carl mentioned on the 25yo Rorschach that the animal’s head was cut off,
which he did not mention on the 15yo Rorschach, although he did comment
at the earlier time period that the animal skin was “messed up.” Overall, the
response seemed relatively benign, which I confirmed on a testing-the-limits
inquiry in which Carl observed that the animal skin looked decorative and
“natural.”
On Card VII (R10), Carl also recalled a response from his 15yo Rorschach
(“I still see it . . . I remember it so vividly”); however, the dramatic-sound-
ing verbalization on his protocol at 15yo and the clinical concern it gener-
ated about violence or disinhibition (“let’s go kill someone”) appeared better
controlled at the point of the 25yo Rorschach. Nevertheless, some concern
remained, as Carl showed considerable difficulty in trying to get away from
the imagery that captured his attention as compellingly now as it had ten years
earlier (“I’m doing my darndest to see something else in this one, but I can’t”).
Note that his mention of violence came at the very end of the inquiry on the
15yo protocol, whereas now at 25yo Carl mentioned seeing cleavers during
the response phase. Furthermore, his reference to the boys using the cleavers
to attack each other, mentioned during the inquiry, was at least a more direct
explanation of the boys’ motivation, albeit not a particularly comforting assur-
ance of Carl’s capacity for control when he was stimulated by aggression. Also,
as before, the human figures were baby-faced boys with tufts of curly hair (at
15yo, Carl also mentioned baby fat), suggesting innocent play. Still and all,
struggling to do “my darndest to see something else” also suggested that anger
continued to be problematic for this young man and that he might not always
feel himself to be sufficiently in control of his affect states and impulses. His
comment that “I can’t imagine what other people would see” also indicated
some degree of concern about his thoughts or urges as he worried, I suspect,
how normal he was.
Considering these two responses on Cards VI and VII both sequentially
and in respect to his responses to these cards at age 15, I would infer that
Carl continued to convey concern about many thoughts that could at times
come over him, worrying whether the affects and thoughts he experienced
were like those of other people and whether there was something wrong with
him. Possibly less troubled or distressed at 25yo than at 15yo, Carl still strug-
gled with impulses that frightened him but which he mostly managed to keep
under wraps. I never felt Carl to be on the verge of aggressive acting out as an
adolescent, and my impression of him at age 25 as well as his clinical history
during the intervening ten years was consistent with that impression.
In this context, I will introduce at this point a spontaneous side comment
Carl made later on (Card X), saying with an unmistakable look and sound
of fearfulness and concern, “My answers here are so lame, why do I go back
to these childish things?” I will address this comment later, but I refer to it
now in relation to the concerns I have raised thus far about this young man’s
shame about his inner life as he struggled to deny or disavow disturbing mental
contents.
Card VIII
11. They look like bears on the side. Nor- The bears I saw first and I can’t really
mal sized bears climbing up a teeny, tiny make anything out of the rest. I don’t
miniature of a mountain. A mountain and really see the mountains and trees that
trees scene, a tiny miniature version of it. much, it’s really the bears mostly.
(Miniature of a mountain?) I don’t
really know anything about the middle,
it’s mainly the bears. You’ve definitely got
bears. I guess it’s rock colored-ish or true
colored-ish but I don’t really see anything
about it. If I keep staring at it, that’s mostly
what I see—these scary monster things.
(Mountains and trees scene?) I guess
the coloring. (Q) Greenish and the other
has sort of a rocky look to it.
Gone at 25yo was the morbid quality of a dead, decaying carcass on Card VIII
that Carl saw at 15yo, giving way to a percept of bears alongside a mountain,
albeit a “teeny, tiny miniature of a mountain.” Carl’s diminutive mountain,
stripped of any sense of imposing majesty, also was a vague form that seemed to
function mainly as a backdrop, scaled back in size, against which the more promi-
nent image of normal-sized bears took precedence. Perhaps because of the way he
saw the perspective relationship, the bears seemed to tower over the mountain—
both literally and figuratively—and as a result the bears carried the psychological
connotation of appearing as “scary monster things.” Certainly, it appeared that
Carl’s description of a fairly conventional wildlife or mountain scene probably
was not as benign a representation of his internal psychological life as it initially
may have seemed. Try as he might, Carl could not find much respite from the
“scary monster things” that seemed to give him little peace. A somewhat serene,
naturalistic environment—a metaphor, I suspect, for a sense of well-being or
equilibrium—soon became small in size as it became dominated by anxiety.
Card IX
12. Two moose or antlered type creatures. The heads upturned, antlers, the general
Like riding a wave. shape, the hind area. Water or a wave
they’re on, almost like they’re surfing.
(Moose riding a wave?) Not literally
like a surfing moose. Almost like a moose
is landing with a crash of water.
——————
Something powerful, majestic.
13. And that wave happens to be on top Because it’s pink and something with the
of two fetuses on the bottom. shape is like little pink digits. A chubby
fetal look to it.
Carl’s initial response to Card IX—a moose riding a wave—was just as oddly
incongruous as his response to this card had been on the 15yo Rorschach—a
deer head growing out of the back of a person’s head. I did not have the same
concern about the 25yo Rorschach as I had about Carl’s seemingly outrageous
manner of responding as an adolescent, at which time I concluded that his
over-the-top responses represented an attempt to call attention to a sense of
urgency that may not have been attended to or recognized. But I did have a
different kind of reservation about this more recent Rorschach, based not only
on this response but also on the tenor of the entire Rorschach thus far: I thought
Carl was living with a quiet but persistent undercurrent of tense discomfort
that seemed to permeate his entire existence, a quality of discomfort he actually
may not have known he felt, perhaps because it did not connote the same sense
of distress he felt as an adolescent. Even the imagery Carl conveyed—surfing
a wave—suggesting an affect state of relative calm or pleasurable excitement
gave way in the inquiry to “landing with a crash,” which suggested either a
sensation of an intense thrill or of the bottom dropping out. Although on a test-
ing-the-limits inquiry Carl’s comment about something “powerful, majestic”
conveyed an impression of the former, in the context of the entire record I
thought there was good reason to doubt that Carl really could feel that sanguine
deep down.
The general content of the response that followed (R13) also was similar to
that of Carl’s 15yo Rorschach; however, the “chubby” pink fetus did not con-
tain the possibly troubling associative elements accompanying this response
at age 15. Thus, references to an aborted fetus or undeveloped extremities
were now absent and accordingly this response was less provocative than its
counterpart on the 15yo Rorschach. Moreover, it was less striking in respect
to how it followed the preceding response (R12) compared to the same
sequence of responses on Carl’s 15yo Rorschach. It was possible and not at all
unlikely that the same degree of confusion or distress that permeated Carl’s
15yo Rorschach persisted into young adulthood, the difference being largely
that at 25yo he was less aware of or troubled by thoughts or affects that as an
adolescent overwhelmed his capacity to keep such distressing mental contents
in abeyance.
Card X
14. [long hesitation] A helmet of some Like a Darth Vader helmet. My answers
scary monster guy. He has a very large red here are so lame—why do I go back to
cloak over his shoulders. He’s holding his these childish things? Here’s his shoul-
hands together like he’s going to tell you ders, so I feel this is where the helmet
what he’s up to, like a super villain going would be. Like a metallic thing.
to explain his plans. (Metallic?) The coloring. Silver tones
with charcoal in it, the darker colors.
(Hands?) The position relative to the
person.
15. Two aliens and they have palm A multi-legged type of spider, crab things.
leaves they use to fan the alien overlord (Palm leaves?) They just look like that.
guy. Something crustacean. ——————
They’re senile to him. He’s running the
show.
16. Two deer-like creatures jumping The position they’re in. Tilting their head
away from him, with their heads on fire. back, the front and hind legs.
(Heads on fire?) Just looks like fire.
(Q) The coloring, the shape of it.
——————
They’re victims of him—this evil
character.
It was difficult to decide whether this sequence of responses represented a single

response or three discrete responses, about which knowledgeable expert con-
sultants disagreed. I decided to consider Card X as being comprised of three
separate responses. Regardless of one’s personal predilection on the matter
there would be little doubt that the overinclusive, broadly encompassing chain
of thoughts and imaginative ideas Carl demonstrated on this card richly dem-
onstrated the degree to which an unfiltered and diffuse flow of ideas could arise
and so dominate his thinking. This response or series of responses was in part
drive-dominated, and as such signified drives or urges overriding an expectable
level of ego function capacity to bind or contain the flow of thoughts or ideas.
I largely came to the same conclusion in my discussion of Carl’s responses to
Card X on the 15yo Rorschach.
On R14, Carl’s “super villain . . . explain[ing] his plans” replaced the “freaky
evil doctor . . . super villain” with a trail of blood and wires coming from its brain,
from the 15yo Rorschach. To some degree, explaining intentions conveyed a
sense of control that spilled blood and mysterious wires did not, just as in R10
on the 25yo Rorschach, Carl’s indicating that the cleavers were intended for
attacking was at least some attempt to explain what they represented compared
to Carl’s rather shocking-sounding comment coming at the very end of a simi-
lar response to the same card at 15yo (“let’s go kill someone”). Nevertheless,
it was not easy to take too much comfort about an image of a “scary monster
guy,” notwithstanding the fact that Carl actually said that he saw the helmet—
potentially connoting a reference to protecting the head—and that he devoted
a good deal of his verbalization to describing features of the helmet. Carl may
have felt some degree of better self-control or being better insulated from his
inner demons than he did at age 15; however, he himself seemed concerned
that his “lame” responses were “childish”—which I took to represent that he
really meant naïve or immature.
The following response (R15) of aliens with palm leaves fanning an “alien
overlord guy” (the same super villain of R14) was Carl’s 25yo version of his
comparable response from the 15yo Rorschach of “little evil minions” that
were “not really scary, it’s more goofy.” Although Carl said very little about the
aliens during the response and inquiry phases, on a testing-the-limits inquiry he
observed that they were “senile,” by which he seemed to mean without a mind
or intentions of their own and being entirely subservient to the wishes of the
central super villain figure described in R15, like the “minions” he described on
his 15yo Rorschach. Rendered mindless and unknowing, here Carl may have
been speaking metaphorically about damping down emotional states that could
come over him and overtake self-control, leaving him uncomprehending about
perturbing feeling states that seemed to come out of the blue.
Carl’s final response on Card X appeared to wed a heightened state of affec-
tive arousal as expressed by the fiery colors, the incongruity and perplexing
nature of the experienced affect that ensued, and ultimately a feeling of being
overcome and passively subjected to the consequences of the emotional fallout
he could barely comprehend let alone master.
Recapitulation
In many ways, this last response neatly summed up the major psychological
dynamics of this young man’s emotional experience. Whereas the 15yo Ror-
schach seemed to be dominated by an exaggerated, over-the-top attempt to
convey the emotional distress he experienced and which seemed to overwhelm
him, now ten years later Carl appeared to be living somewhat more comfort-
ably but with many of the same perturbing psychological concerns. They had
not subsided appreciably, although they may not have been pressing in on him
quite as much as they did when he was an adolescent. But neither was Carl able
to gain better control of aspects of his internal life that either were momentar-
ily disturbing or that lurked in the background as vaguely distressing emotion
states he might sometimes apprehend and then try to put out of mind and in so
doing forget. He was prone to disparage people he thought should be stronger,
whom he thus de-idealized—a theme that would be more apparent and better
fleshed out on the TAT—and Carl’s distancing from people probably repre-
sented a defense operation serving to minimize close, intimate involvements
with others to thus protect himself from exposing the immature, aggressive,
and otherwise pathological object relations that seemed to dominate much of
his inner life.
The similarity of themes across the two Rorschach records, the degree of
idiosyncratic thinking or imagination still present in the 25yo Rorschach, and
the troubling flashes of intermittent discomfort or distress Carl sometimes expe-
rienced were consistent with an impression of Carl as a young man continuing
to struggle with immature object relations, aggressive impulses, and probably
compromised or underdeveloped psychosexual adjustment despite his experi-
encing less overt distress at the moment. The fusion of aggressive and libidinal
drives very likely interfered with managing to develop or maintain both inter-
personal friendships and intimate sexual relationships. In this context, I again
cite the side comment Carl proffered on Card X when he said, with visible
discomfort, “My answers here are so lame—why do I go back to these child-
ish things?” in which lame and childish really, I believe, meant primitive and
immature.
Card 1
This kid is being forced by his parents to take violin lessons and he really doesn’t want to,
so now he’s locked up in his room. He’s supposed to be studying but he’s just going to end
up falling asleep because he doesn’t have any interest in studying violin.
(What led up to this?) The parents wanted him to do it but he doesn’t want to.
(Outcome?) He eventually falls asleep and the parents will come up and find him
sleeping, and probably scold him. And he’ll explain to them that he doesn’t actually want
to play.
(How do they react to that?) They’re displeased, they expected him to play the
violin.
(How does he feel about that?) He thinks he disappointed them. There might be a
little friction immediately but they’ll all get over it pretty quickly, so it’s probably not that
big of a deal.
Carl’s story to Card 1, one of the commonly told stories to this card, was similar
to the story he told at age 15. He did not dwell as much at 25yo about the theme
of boredom and meaninglessness as he did at 15yo, but he clearly indicated just
as much displeasure about having to do something he did not enjoy. Although
Carl’s story did emphasize being forced to play the violin, adding that the boy
was “locked up” in his room, as in his story at age 15 the boy was able to get
through to the parents that he did not want to practice. He conveyed a greater
sense of friction between the boy and his parents, and Carl also referred to the
parents as feeling displeased and disappointed about the boy’s disinterest, an
attribution he had not expressed ten years before. Moreover, as he did at age
15, Carl seemed to feel conflicted that his solution still was to literally and figu-
ratively fall asleep.
I emphasized in the earlier assessment how the boy’s parents seemed unable
to provide motivation or interest that would feel invigorating to the boy. Rather,
they seemed to feel as little intrinsic interest as the boy himself felt, and although
the same dynamic fundamentally still held true in the present, Carl depicted
the parents as acceding to the boy’s wishes to discontinue studying violin. This
shift, of course, might simply reflect Carl’s having more choices open to him
compared to his adolescence, when he felt pushed or forced in directions about
which he had little interest or control. Perhaps the more important dimen-
sion of the story concerned the boy’s perception of his parents. The friction
may have indicated that he more easily stood up for what he wanted, but the
parents’ unknowing sense about the boy’s interests or desires seemed undimin-
ished. On the 15yo TAT, the parents understood that the boy did not enjoy the
violin but they and the boy passively went along and played the game. On the
25yo TAT, although the boy got his way and was relieved not to have to play
the instrument any longer, he initially felt his parents’ displeasure and that he
was letting them down. Carl thus expressed a sense of not living up to parental
expectations, and even though in the story the parents reluctantly went along
with the boy’s wish, I did not have the impression that he or they felt proud
about the outcome.
Carl also conveyed the idea that perhaps the parents felt that the only way
to make the boy do what they thought was good for him was for him to be
“forced . . . locked up.” Expecting or hoping for something to take hold, the
parents may have assumed that all that had to be done was to enforce disci-
pline, perhaps not comprehending that they themselves might need to provide
a source of interest or motivation, or otherwise become involved with the boy’s
studying. Like being made to eat one’s spinach, compelling often does not bring
satisfaction.
My point here is to emphasize how Carl characterized what such a state of
affairs probably felt like for him. He felt internally unhappy and not readily
able to express his unhappiness. His solution seemed to lie in his comments
about falling asleep—which he mentioned no fewer than three times in his
story. Thus, much as he did as an adolescent, Carl shut down what he felt
and attempted to submerge his unhappiness in emotional withdrawal or joyless
compliance. True, he might have been able to risk greater “friction” and, as a
young adult, voice more autonomy than he had felt he could as an adolescent.
But he was no better able to understand what he felt beyond vague displeas-
ure, and he could not manage to engage his parents in his psychological life.
Moreover, I suspect that this also set the stage for Carl’s diminished awareness
of his own affect life and disengaged involvement with other people.
Card 2
[long hesitation] I don’t know what to make of this scene. For some reason, I picture
these two as a mother and daughter. The other guy looks too young to be her father, so
there’s some kind of sexual relationship with the mother and this male, and the daughter
is aware of it. She’s slightly jealous of it, but I think nothing will come of it, she won’t
actually confront the mother and it will go on for a while. The mother actually looks like
she might be pregnant, so eventually she gives birth to that guy’s kid. This will be her new
little sibling and she’ll resent the sibling. The end.
(What led up to this?) They always owned the farm and he was some new guy who’d
come to work on the farm.
(Outcome?) They just go on resenting each other quietly. The mother seems to be some-
what oblivious to the fact that the daughter’s not happy about it, and it goes on forever.
Carl’s story to Card 2 at age 15 was more commonplace than his story at age
25, the former emphasizing a “regular relationship” among the family mem-
bers whereas the latter story emphasized a story dominated by resentment and
rivalry. Carl took a long time before initiating his story, and his opening state-
ment (“I don’t know what to make of this scene”) also suggested blocking. His
comment that “for some reason, I picture these two as a mother and daughter”
sounded odd because of his “for some reason” qualification. Surely, there was
a good reason why Carl saw a mother and daughter; what I suspect was hap-
pening was that he was avoiding talking about something else he saw. Further,
uncharacteristically saying “the end” as he concluded his description of the
story before the inquiry began also suggested that Carl likely wanted to be done
with this card as soon as possible.
As he developed his story, the obvious themes of secrecy, jealousy, and not
talking about what was going on under cover emerged clearly and directly.
I also suspect that Carl’s description of the girl as feeling “slightly jealous” is
hardly what she really would have felt; probably very little is slightly anything
in Carl’s family regardless of how buttoned up or swept under the rug events
may seem on the outside, which is why Carl may have had trouble initiating
a story to Card 2 in the first place. Why his emotionally loaded story slipped
by his more typical guardedness surprised me. His rich characterization of
this family’s life, in contrast with his earlier “regular” depiction, revealed a
deeper layer of psychological tension than Carl characteristically experienced
or engaged.
True, there were indications from his other TAT stories ten years earlier
that he probably harbored anger related to his parents’ insensitivity that may
have been targeted more directly toward his mother. However, I would not be
inclined to regard Carl’s story on Card 2 at 25yo as a reflection of an emerg-
ing awareness of his own emotional life. Indeed, Carl was if anything more
distanced from his emotional life than he had been as an adolescent, when an
upsurge of anxious depression broke through in relation to his unhappiness
about school and what his future would be like.
I have no knowledge of an antagonistic or conflicted home environment
in Carl’s history. Indeed, the main impression about his parents that had
emerged during the period of psychotherapy ten years previously was one of a
mother and father who were reasonably available for their children and who
tried to do their best, while being somewhat insensitive to subtleties about
need states or emotional nuances. There was no overt indication of paren-
tal problems or disharmony that led me to wonder about appreciable con-
flict or tension between Carl’s parents, or whether either parent might have
been having an affair. Furthermore, Carl rarely spoke about his brother, yet
I never had reason to question that there was anything of the ordinary about
their relationship.
Consequently, while Carl’s story to Card 2 on the 15yo TAT was unreflec-
tive but otherwise ordinary, I was surprised by the degree of overtly expressed
hostility that emerged in his story on the 25yo TAT. What was not surpris-
ing, however, was that the anger was experienced as a more muted affect—
resentment—rather than as hostility, that the mother was “oblivious” to what
the child understood and felt about the situation, and that “nothing will come
of it . . . it will go on forever,” with neither one confronting or acknowledging a
highly charged situation.
Card 3BM
I can’t seem to tell what’s on the floor next to her. I don’t know, it almost looks like a
victim, like someone killed themselves. I can’t tell if that’s a gun. It looks like a waiting
room. I don’t know what to make of this picture. It looks like maybe there’s blood around
her, but I can’t tell, maybe it’s just a shadow. It looks like some kind of violent scene, I
wish I could think of some kind of narrative here. Something led up to her maybe killing
herself, maybe with a gun. Now she’s laying down, curling over maybe a couch like you’d
have in your dentist’s office, not something you’d have in your living room. So maybe she
came to the doctor’s office and attempted to kill herself there. But I can’t tell what that
thing is next to her.
(Led up?) I don’t know, maybe she’s super depressed or something, or doing it for atten-
tion there at the doctor’s office. She thought the doctor could help her, she didn’t really
want to kill herself, but she might survive if she did it there.
(Outcome?) Maybe she shot herself, she will live, someone will find her.
In his story to this card on the 15yo TAT, Carl saw a girl devastated by the
death of someone close to her, and she then collapsed in tears and fell asleep.
Now, at 25yo, although Carl depicted a suicide attempt in his story it seemed
that his main intent was to convey seeking attention or help. The suicide
attempt occurred in a doctor’s office, and probably because it took place there
the attempt was averted. Although I did not push him enough to develop a
story about what led up to the girl’s depression or why she thought suicide was
a solution, Carl nevertheless communicated in much the same way as he did
as an adolescent that appreciable distress would not be recognized unless emo-
tional upheaval sounded dramatic.
Following the story he told on the immediately preceding card, this story
continued to capture how Carl dealt with affect states that were fleetingly rec-
ognized. It was not Carl’s nature to tune into what he felt for very long. He thus
typically appeared to ignore distress or wait for it to pass. His story to Card
3BM at 15yo ended with Carl saying that the girl in the picture “eventually
. . . gets so sick of crying that she just falls asleep and goes on with her life,”
which is exactly how I suppose Carl himself was inclined to react by ignoring
as much of his inner life as he could. Even when matters became sufficiently
distressing—as the significance of making a suicide attempt would imply—Carl
probably would let matters build until he would have to exaggerate a level of
emotional distress he could not otherwise express in order to make others take
notice. Thus, Carl’s story was not one unequivocally concerning suicidal idea-
tion or concern; rather, it was a story revealing the extent of his psychologically
buttoned-up, constricted life.
Carl was thrown by this card, momentarily losing equilibrium until he could
settle down to be sufficiently composed to organize a coherent story. Even more
so than he did with the same card at age 15, Carl was initially flustered (“I can’t
seem to tell what’s on the floor . . . I can’t tell if that’s a gun . . . I don’t know
what to make of this picture . . . maybe there’s blood around her, but I can’t
tell, maybe it’s just a shadow . . . I wish I could think of some kind of narrative
here”), and as all of these verbalizations implied, it took quite some time before
he could settle into a story. In my discussion of Card 3BM on the 15yo TAT, I
again wondered whether the emotional floodgates had opened on this particu-
lar card for some reason.
I speculated that Carl’s stories to the two preceding TAT cards concerning
themes of resignation or the beginning tendrils of imagining a more felicitous
direction for his life gave way on Card 3BM to a sense of floundering, possibly
provoked by the theme of loss or death. On the 25yo TAT, Carl seemed to
trade feeling resigned to meaningless compliance for relief that he need not
be forced into doing things he did not enjoy; however, the empty or depleted
and meaningless existence that permeated the 15yo TAT, while possibly less
prominent at age 25, surely no less dominated his internal life as I attempted to
probe more deeply into how the person felt and what lay ahead in the future.
The kernel of beginning to consider that a better life might await him—a theme
on Card 2 of the 15yo TAT—did not continue on the same card in Carl’s 25yo
TAT, however. Carl’s story suggested remaining stuck in an existence where
strong sentiments could not be given voice and had to be reined in and toler-
ated in silence—“forever.” Card 2 actually revived the emotional resignation
Carl expressed on Card 1 at 15yo.
Starting with Card 3BM at 25yo, which at both time periods concerned a
theme of death, Carl’s characteristically joyless, dampened down emotional
life emerged in a more undisguised way, a way that triggered an affective
reaction beyond his normally restrained, reserved experience of emotionality.
I do not particularly think the theme of death was the crucial trigger at either
time period, in part because at 15yo the person “gets so sick of crying that
she just falls asleep” and at 25yo the person survived the suicide attempt at
the doctor’s office, thinking that “the doctor could help her.” It was possible
that the real trigger was the heightened affect stimulated by the imagery on
Card 3BM, a degree of affect that Carl could not seem to defensively ignore
very easily.
Card 6BM
This looks like an overbearing mother. The son is telling her that he’s going to leave and
the mother just looks to the side, trying to deny the fact of what he just said. He feels guilty
that he just said that, maybe she’s alone and doesn’t like the idea of her son leaving, but
he’s going to.
(What led up to this?) He’s been living with his mother for a while and now he feels
guilty about having to leave. But it could be that maybe he met a girl, or maybe he’s leav-
ing to go to school, for some reason he’s got to leave. I think the mother is in denial of that,
looking off to the side trying to make him feel guilty. She lays on the theatrics but he tries
to maintain his resolve and leave.
(How does he feel?) Really guilty but he does what he has to do. He seems nervous like
he’s fidgeting with his hat in his hand. Seems like the father is gone and it’s just the son
and the mother now, and she’s dependent on him. Sort of hampering him from growing
up a little bit.
The mother of Carl’s 15yo TAT was “crazy or sick,” the son felt intimidated
and thus could not feel comfortable around her, and he struggled between insti-
tutionalizing the mother and leaving her unprotected on her own. The mother
of the 25yo TAT was still difficult to be with or to relate to, he perceived her as
“overbearing,” and although his story continued to reflect struggling between
staying at home to care for her and being on his own Carl seemed to remain
conflicted about how to resolve the matter. At both time periods, Carl’s stories
described a quality of separation that sounded rather close to the son’s need
to wrench himself away from the mother’s grip, afterwards feeling guilty, but
still having to act decisively to insulate himself against a mother who seemed
oblivious to or unconcerned about the son’s need for autonomy. Evidently,
what I took to represent Carl’s characterization of his mother had not changed
substantially as he moved from adolescence to early adulthood. He seemed
to regard his mother as thinking mainly of her own needs, “hampering him
from growing up,” and although unable to block his psychological develop-
ment she made a difficult step no easier for him. Nervous and unsure of his next
developmental steps, Carl appeared to feel that it would have to require all of
his resolve to move forward.
Card 7GF
I can’t tell if that’s a doll or not. Is it a real baby or a doll? I can’t tell. I have no idea
what’s going on here. Some type of hyper-feminized conversation that wouldn’t be had in
front of any male. Maybe that’s the mother and she’s with her 9-year-old daughter and
the mother just had another child, and the mother’s encouraging the daughter to play with
the new baby. But the daughter doesn’t want anything to do with the new baby. That’s
why she’s looking off to the side because she’s completely disinterested. The mother’s trying
to say good things like you’ll love the baby, play with the baby, but the daughter has no
interest in the baby. So the mother will keep pushing her to love her, a new sibling, but the
daughter’s disinterested and not happy about having another sibling.
(Outcome?) She doesn’t like this new sibling getting all the attention, she resents that.
(What happens next?) The mother takes the baby back and the daughter angrily
storms out of the room and goes about her business.
(What’s their relationship like?) I feel it was better before because the mother was
paying more attention to the baby and the daughter doesn’t like that.
Here was another representation of a mother–child relationship reflecting no less

a state of tense discomfort than had Carl’s stories to Cards 7BM and 2. It also
continued the same general theme that was present on Carl’s 15yo TAT. While
at 15yo his story revealed the mother’s obliviousness to the daughter’s indiffer-
ence and disinterest, now at 25yo Carl’s story revealed—as his story on Card 2
also showed—far greater anger about the mother’s obliviousness concerning the
daughter’s psychological state. Thus, for example, the daughter in the story from
ten years ago was “just sitting there listening even though she doesn’t care . . . she
doesn’t want to be rude”; in Carl’s story at 25yo the daughter “angrily storms
out of the room and goes about her business.” Similarly, on Card 2 ten years ago
Carl’s story about a girl whose relationship with her parents was “regular” had
changed such that at 25yo the girl and her mother “resented each other quietly.”
In both of Carl’s stories on the 25yo TAT, the girl was angry about being
pushed aside as the mother showed greater attention toward another child and
appeared indifferent to the girl’s feelings about being displaced. When I dis-
cussed Carl’s 15yo TAT stories in Chapter 3, I suggested that disengagement
or ennui underlay his understated depression, giving rise to compliantly toler-
ating what I assumed represented his mother’s insensitive unawareness of the
impact of her possibly neglectful actions. Now at 25yo Carl’s passive compli-
ance may have shifted to become a bolder expression of what had been swept
below the surface as he seemed to more directly articulate anger and resent-
ment when feeling shoved to the side. Previously having kept his own counsel
behind a veneer of bored but silent compliance, Carl at 25yo may simply have
traded that quiet tolerance of a situation he felt helpless to change for walking
away from it and wanting no part of it. Note also that his story to Card 6BM
described a son needing to keep his resolve to leave a mother who seemed to
express more interest in cajoling the son to stay with her. The mother appar-
ently was thinking only of her own needs as she seemed unconcerned about
what the son needed for himself.
Nevertheless, I was not sure that Carl could fully recognize what he felt
enough of the time or why angry or injured feelings could surge up within him
at different moments. Carl might thus “look off to the side” or walk away (or
even sometimes “storm[s] out of the room”), as he said about the girl in his story
who “go[es] about her business.” Although Carl’s possibly greater access to
knowing when he might feel angry or resentful could be viewed as a favorable
indicator suggesting recognizing or articulating affect states, I had no reason
to believe that he comprehended the link between feeling angry and feeling
responded to in an indifferent, oblivious manner. Nor did I think he could
begin to understand how feeling resentful originated in what I considered his
experience of his mother’s neglectful lack of awareness.
An important reason why I came to this conclusion, in spite of the content of
his stories and the way such psychological connections seemed to come to him
fairly readily, resulted from Carl’s apparent surprise at what was coming out of
his mouth, seen in the anxious wariness that seemed to surround his storytelling
and through his comments about struggling to come up with stories. For exam-
ple, at the beginning of the present card, Carl conveyed the difficulty of making
up a story in this way: “I can’t tell if that’s a doll or not. Is it a real baby or a doll?
I can’t tell. I have no idea what’s going on here.” He sounded more than con-
fused; he actually sounded somewhat distressed. On other cards, Carl struggled
in a similar manner. Thus, for example, he said on one card (Card 16, below),
“That’s pretty impossible. I don’t know if I can just come up with things . . . I’ll
be floundering for 40 minutes here, I have no clue . . . maybe a continuation of
the scene from the last card. I can’t answer this . . . I don’t know how to come up
with something”; and earlier on Card 3BM, “I can’t seem to tell what’s on the
floor . . . I don’t know . . . I don’t know what to make of this picture . . . I wish I
could think of some kind of narrative here.” In this context, recall again Carl’s
agitated comment as he struggled with Card X on the Rorschach: “My answers
here are so lame—why do I go back to these childish things?”
Card 7BM
This is a guy out with his boss, some work-related activity. They’re drinking or whatever,
and maybe the boss is commenting that the guy doesn’t look too happy being out and
maybe the guy doesn’t enjoy a party-type atmosphere. The boss is trying to cheer him up
and the boss fails to do that.
(What led up to this?) He’s the quiet guy at work and the boss is pretty outgoing, and
he tries to get the guy come out of his shell a little bit when he’s out.
(Outcome?) The guy does his best to give the boss what he wants and seem happy, but
the guy’s not actually going to be happy.
(Why isn’t he happy?) I don’t know, maybe it’s just his disposition, he’s not an outgo-
ing kind of person.
Carl’s story was in one respect a story characterizing an unhappy, morose state
and in another respect it depicted a benevolent attempt by an older man to
assist a young man to recover from that mental state. As he did on the 15yo
TAT, Carl began by describing a casual, relatively nonconflictual relationship
with an older man that was quite different from the tense, troubled relationship
he depicted on the previous cards of the 25yo TAT representing a mother–child
relationship. The 25yo story also did not reflect the shift seen in Carl’s story at
age 15 in which the relationship changed from one representing friendliness
to a story about an older man tripping up a younger man. Thus, Carl’s story
might represent a more uncomplicated and unambivalent image of an older
male than he imagined as an adolescent, perhaps indicating a degree of comfort
with a paternal figure that was less conflictual than the persisting hostile mater-
nal introject originating from the mother’s distance and insensitivity. Carl saw
paternal figures as interested and potentially helpful, but he was not hopeful
that a benevolent male figure could remedy what appeared to be a pessimistic,
morose sense about himself or his life.
Card 18GF
I think it’s a middle-aged woman, she came home to find her mother laying at the bottom
of the stairs, presumably dead. She lifts her head up and she realized that the mother just
died and she looks grief-stricken about it.
(What led up to this?) The mother just died of old age. The daughter was out and she
wasn’t able to take care of the mother, and maybe the mother slipped down the stairs. She
was old, and it was natural causes. But now the daughter feels extremely guilty because
she wasn’t around to take care of her.
(Outcome?) She’ll feel guilty for a long time after because she wasn’t around even
though she couldn’t have been.
This story emphasized an adult child’s guilt surrounding insufficient atten-

tion to her mother. It echoed a theme of guilt Carl expressed earlier on Card
6BM, in relation to his story about an adult child trying to forge a life that was
independent of an overbearing mother’s needs. The present card stressed the
degree of unrelenting guilt the daughter experienced, despite circumstances
beyond her control. Carl seemed to express the sentiment that the daughter
should have watched after the mother more diligently even though she could
not have been around at all times. Juxtaposing her autonomy with a sense of
responsibility to the mother left the daughter feeling perpetually conflicted, so
it seemed, and although at some times she could recognize anger and resent-
ment toward the mother, there seemed to be times when guilt overshadowed
resentful anger.
Comparing Carl’s story at 25yo to Card 18GF with his story at age 15, a
theme of murderous rage without guilt predominated in the earlier story of a
woman who discovered her husband cheating on her, “so she killed him . . .
and she was right in doing it.” Granted, Carl’s highly dramatized responses at
age 15 spoke to a need to gain attention to his distress, and thus in his story to
Card 18GF he may have exaggerated the intensity of his anger. Nonetheless,
his more measured story at 25yo conveyed none of the anger of the earlier
story—only the guilt. In like manner, Carl’s relatively tame story on the preced-
ing card (Card 7BM) about a benevolent boss was quite different than his story
to the same card at 15yo when a cordial camaraderie between two men was
transformed into the older man tricking or deceiving the younger man.
The overall pattern suggested that Carl’s generally moderated presenta-
tion at 25yo reflected a more stabilized adjustment than he showed at age 15.
Although the dramatic intensity of affect had diminished for the most part,
Carl’s quieter and somewhat more subtly expressed manner of conveying his
concerns did not indicate that the disquietude of his adolescent years had disap-
peared. Of course, there was no compelling reason to expect otherwise, but it
also should come as little surprise to see that what replaced the loud distress of
ten years earlier might resemble an emergence of a complacent, resigned adap-
tation. Consequently, themes of unrelenting guilt or unhappiness (“she’ll feel
guilty for a long time”; “the guy’s not actually going to be happy . . . it’s just his
disposition,” Card 7BM; “it will go on for a while . . . the daughter’s not happy
and it goes on forever,” Card 2) ran throughout several of Carl’s stories. I did
not have the impression that Carl overtly felt resigned or unhappy much of the
time; however, the affective tone accompanying several of his stories suggested
resigned acceptance or feeling chronically disaffected whether he was aware of
this affect state or not.
Card 13MF
Part of me thinks it’s just a post-coital scene, but something about it just seems very dark
and menacing. Like he might have just murdered her for some reason, maybe they were
having rough sex or something and he choked her too hard [nervous laugh]. He’s
sweating and he looks guilty. The way her arm is hanging off the bed seems unnatural
for a sleeping person, and also people don’t just go to bed with their breasts exposed like
that. She’d pull a blanket up over her, so I feel like she’s dead. He just killed her and he’s
realizing what he’s done. He’s trying to formulate a plan for what he’s going to do. So
he’s going to call his best friend and make that dead hooker call that everyone wonders
they might have to make one day.
(Dead hooker call?) No, I don’t think it was a hooker, it was just some tryst he was
having on the side and he’s going to try to hide the body.
(How does he feel?) He feels terrible, he didn’t mean to do it, but he doesn’t want to
accept responsibility for what he did. He knows there’s no way he can explain it to the
police. So he’s got to take care of it himself, and try to hide the body.
(Outcome?) The friend comes over and they try to hide the body, but there’ll always
be some piece of evidence that they forget. I don’t know, just something about this, it’s
got that Hitchcock style, it sure looks like that to me. There’s no way the police are going
to understand. In the end, his own mind will play tricks on him and he’ll end up giving
himself away.
Although not without some degree of remorse, what seemed most striking in
Carl’s story was his lack of interest or concern about the fate of the woman.
He expressed regret not that the woman had died but rather that he regret-
ted what had happened, and the focus of the action in the story was directed
toward covering up what transpired “so he’s got to take care of himself.”
His dispassionate description of a “dead hooker call” sounded more like the
immaturity of a fraternity-brother ritualistic bond of mutual self-help than it
reflected a psychopathic or disinterested attitude toward women or the way
men relate to women. This was at least the second reference to Hitchcock’s
film noir style of conveying intrigue and suspense. Despite some apparent
interest in Hitchcock’s classic method of portraying tension, Carl’s under-
standing of that style was not well developed; thus his story to Card 13MF
appeared to reflect far more a sensibility closer to Animal House than it resem-
bled Spellbound or Vertigo.
Carl’s story to Card 13MF on the 15yo TAT also reflected an immature ado-
lescent’s view of male–female relationships with its references to “smacking her
around . . . he was probably drunk . . . he just went nuts and knocked her out.”
The degree of hostility he expressed seemed both extreme and out of character
for Carl. However, as I commented in Chapter 3, I did not think it necessarily
compelled inferring disinhibition or loss of control of anger, nor did it seem to
reflect psychopathic lack of remorse or emotional disregard. At 15yo, Carl’s
exaggerated stories which I thought reflected a need for others to pay attention
may not have been as pronounced at the time of the 25yo assessment, which
seemed to reflect mainly his deficient understanding of and manner of relating
to women. At the very least, he showed marked inexperience and discomfort
about how to behave with women. Surely it was not difficult to see that he
undoubtedly would have considerable problems forging mature relationships
with the opposite sex, with his hostility creating a sufficiently potent impedi-
ment to developing intimacy or trust. Though I could mainly just speculate, I
wondered whether a growing recognition of his mother as unaware or insensi-
tive was beginning to surface in his adult relationships with women, possibly
triggering an intensity of hostility that took him by surprise and perhaps fright-
ened him when he could not simply disparage or make light of close relation-
ships or involvements.
Card 5
I feel like she’s secretly doing some kind of drug in her room. She’s up to no good. It’s the
forties or something, something bad she’s up to, maybe that meth they gave the housewives,
I don’t know, whatever drug a fifties or forties housewife would have been doing. She
heard a sound and she’s opening the door real cautiously, she’s nervous, someone might
have come home and interrupted her. It’s the husband, and he starts saying “what are you
doing!” like he knows she’s up to something she’s trying to avoid. She’s trying to stop him
from going in that room, but he finds whatever drug she was using.
(Outcome?) A fight ensues and she ends up sobbing on the floor.
(How’s their relationship?) It’s strained. He’ll try to get her help, but was there actu-
ally rehab in the fifties? He’ll slap her around or something.
Here was yet another “strained” male–female relationship at a time when in

Carl’s view “he’ll slap her around” took the place of enlightened understanding
of emotional problems. Once again, although not without an undercurrent of
rage toward women, Carl’s approach to a relationship with a woman was based
on hostile control or domination rather than a capacity to see another person
as unhappy or distressed. I did not explore further his reference to the 1940s or
1950s and a drug “they gave the housewives,” although later on it reminded me
of a film (The Stepford Wives) in which men systematically drugged their wives to
turn them into robot-like machines completely in the husband’s control. Carl’s
story, however, reflected some capacity, albeit limited, to recognize a woman’s
distress.
Card 16
That’s pretty impossible. I don’t know if I can just come up with things, I’m terrible at
stuff like that. I’ll be floundering for 40 minutes here, I have no clue. It seems silly, but
what’s floating through my mind is the script for every Hitchcock movie I’ve ever seen.
I don’t know why, I just picture some fighting couple for some reason, I don’t know
why they’re fighting. Maybe a continuation of the scene from the last card. I can’t
answer this.
(Make up a story) I don’t know how to come up with something. Some couple that’s
been married for a while, they’re arguing about finances. Something generic but still it
gets to be an ugly spousal fight.
(What do you imagine the picture would be?) Just the two of them walking away
from each other, going to separate rooms, but I’m sure they’ll resolve and get back together
in the end. A normal married couple. I’m sorry it’s so generic.
Not much that was new unfolded in Carl’s story to the blank card. His marked
difficulty coming up with a story was surprising, but perhaps not so much after
all considering Carl’s apparent antagonism toward women and his difficulty
apprehending close male–female relationships much beyond adversarial or
hostile interchanges. Given free rein to imagine any picture on the card he
might wish to see, Carl chose to continue the theme that predominated in most
of his TAT stories. His apologetic excuse for yet another depiction of an antag-
onistic male–female relationship suggested that it was something that mattered
to him, whether or not he would have thought so or mentioned having prob-
lems developing relationships with women.
Carl’s solution to the antagonistic interaction represented in his story,
although different than his resolutions on other cards (“he’ll slap her around,”
“he just killed her,” “he leaves the mother,” “she resents that . . . it will go on
forever”), was not any better: “the two of them walking away from each other,
going to separate rooms.” Carl followed this comment by saying “I’m sure
they’ll resolve and get back together in the end,” however there was good rea-
son to believe that his depiction of “a normal married couple . . . it’s so generic”
was no more mature or any less colored by hostility than his other characteri-
zations about how mature relationships develop or relationship problems are
resolved.
Carl’s History during the Ten-Year Period between

the 15yo and 25yo Assessments
It was initially gratifying to learn how much Carl had accomplished in the inter-
vening ten years, particularly given his chief complaint as an adolescent that he
despised school, saw no direction that compelled his interest, and was depressed
over the prospect he imagined to be a long and tedious work life. However, after
listening to Carl describe what he had achieved and then how he felt about a
career, it did not take very long at all for me to realize that his impressive-sound-
ing credentials seemed rather empty and aimless. It was saddening to see myself
come to the conclusion that his progress, maturity and insight actually turned
out to lack much depth and that in some ways the person who was sitting before
me as I talked with Carl about his life was not substantially different than the
person I had seen as an adolescent ten years previously.
Carl began treatment at age 15 depressed and profoundly disinterested in
school and with little interest in developing a career direction. He also felt
socially awkward and worried about losing a support system of friends. At the
end of a period of weekly psychotherapy lasting for nine months of a school
year, his depression was in remission, he had had a good summer as a camp
counselor, he had started to date a girl he met at the end of the previous school
year, and although still disinterested in school he was comfortable approaching
the new term rather than dreading school restarting. He had had no further
therapeutic contact with anyone since that time.
Carl started college at a state university campus where he did well academi-
cally, earned straight As, and chose philosophy as a major. He felt enthusias-
tic about the subject, especially the problem of free will and determinism. His
freshman year was partially spent socializing as was expected and he had friends
and a social and dating life, while also maintaining his excellent grades. Carl
told me that he did not know he was intelligent until that point in his life. In his
sophomore year, he spent less time socializing frivolously, studied more, and
managed to keep his friends even though they commented negatively about his
studiousness and the nerdy reputation he was acquiring. But he enjoyed phi-
losophy and seemed to manage these two sides of college life.
He started to think about what it would be like to attend an even better, more
prestigious school, given that he was doing so well. Carl applied to a prestigious
Ivy League university as a transfer student, and was accepted. He worried about
being able to hold his own academically, not feeling certain about his abilities,
and ultimately he decided to remain at the state university. After spending a
semester abroad in his junior year at a prestigious college in Germany, Carl
reapplied to the Ivy League college, was again accepted, and this time made
the transfer. Although he attended the new college only for his senior year,
Carl continued doing very well academically. He began to realize, however,
that philosophy did not seem to be a practical major, so he double majored
in philosophy and political science, gravitating toward studying government.
Approaching graduation but with no particular plans and disinclined to attend
graduate school, Carl considered applying for a prestigious fellowship to study
abroad. He was successful at earning this fellowship, spending one year at a
university in England continuing a project he had begun as an undergraduate.
He found himself bored with the work he was doing, but he enjoyed the oppor-
tunity to spend a year there, enjoying mainly the prestige of being a scholar in
the program that supported him.
When Carl returned home after the fellowship year, he obtained work as
a research assistant at a magazine. He disliked the work because it bored
him and he also was unhappy with his supervisor, whom he thought did not
appreciate Carl’s ideas about sophisticated research methodology, wanting
Carl to mostly do the work she set out for him and not to question her. He
left after 18 months and then secured a part-time unpaid internship at the
news magazine where he was currently working and enjoying his job. He was
involved with the editorial staff, working mostly on layouts rather than writ-
ing, but he enjoyed the people he worked with, particularly the sophisticated
edge about the dry wit or sarcasm of the people and the type of image the
magazine represented. He had hoped the internship would have turned into
a salaried position, but he did not think that was likely as the internship was
approaching an end. Carl lived at home with his parents and brother, spend-
ing his off time reading (mostly books about political satire and economics).
He told me that he no longer had the interest he once had in philosophy,
reading very little in that area. Carl felt satisfied with his life, enjoying his
work and spending most of his time alone; however, he was not disconnected
from his friends and he occasionally dated.
Carl had only one sustained relationship of about two years, with a girl
he described as staid but dependable, whom he met during his final year
at college. He grew tired of this former girlfriend, not because she was
living at some distance while attending graduate school, but rather because
he found her increasingly conventional in her values and beliefs, especially
about monogamy while they had a long-distance relationship. He thought
the relationship was not working out well, and they seemed to mutually feel
they should not continue together. Carl did not say much about breaking up;
however, I did not get the impression that he cared about losing the relation-
ship as he continued having casual sexual relationships and maintaining his
male friendships.
I mentioned the two movies that had meant so much to Carl at age 15, and
he responded enthusiastically that they still did. As he spoke about the discon-
tented worker in Office Space and the group of men whose friendship was built
up around brute force fighting in Fight Club, Carl sounded to me as if he were
frozen in time—thinking in much the same way as he did when he was an ado-
lescent. I was rather surprised that these films still appealed to him as much as
they did when he was an adolescent. I asked whether there were any other films
that had captured his attention in recent years, and he said there were not. Carl
also had no other cultural interests; he had enjoyed reading during college, but
that did not continue after graduating. After some thought, he did mention a
movie that interested him quite a bit. This was a film about a young man who
left his existing life and went into the wilderness, Thoreau-like, but ran into
trouble and realized he was about to die either from starvation or exposure.
The film was about the man’s ill-fated attempt at survival, in which he may
have eaten poisonous leaves because there was nothing else to eat, and he drew
his own blood to scratch out a note to leave behind. What Carl liked about the
story was that it was a psychological thriller, which was largely the appeal he
said the other movies held for him.
Here then was this young man, discontented as an adolescent and worried
that he would not be enthusiastic about working in a dead-end job for the rest
of his life, who somehow found the drive from within to pursue and open up
important doors for himself. Feeling intelligent and accomplished perhaps for
the first time, Carl seemed to come to life and his pride in his abilities and the
energy that seemed to stir in him must have been intensely stimulating. That
a young person coming from a working-class background with little exposure
to or interest in understanding the world around him should become excited
about philosophy must have taken him by as much surprise as I found myself
feeling as I listened to him talk about this interest. Carl saw himself continuing
to achieve excellent grades and a world seemed to open up for him as he read
and expanded his horizons and interests.
Although Carl did not say as much, I wondered whether he might have felt
ignored or dropped when it came to a point of securing a mentor or advisor to
guide him through independent scholarship, his excellent grades notwithstand-
ing. This was not unlike the way I thought he felt at the hands of his unsuspect-
ing parents and possibly also about high school teachers who may not have
recognized a need for direction or stimulation. I thus wondered whether he
had not been able to interest a professor in working with him or in advising him
concerning the postgraduate fellowship he managed to secure. Carl thus was
perhaps left to his own devices, turning to a project he worked on earlier in col-
lege but which may not have interested his mentor at the university where he
studied in England. Interestingly, he studied the personality makeup of political
figures held in high esteem. I thought that Carl felt ignored and on the sidelines
in England, going through the motions of working on his project but largely
unaided. I had the impression that the sum and substance of Carl’s achieve-
ment was a high grade point average, but that there was not very much heft
beyond his straight As.
When Carl returned home, everything seemed imperceptibly to have fallen
apart—his enthusiasm was dampened, he had no one apparently to guide a
career path, and he worked in a setting where his supervisor spurned his efforts
to show what he could do, possibly dismissing his eagerness or even arrogance
as youthful hubris that needed to be tamed. I suspected that the combination
of these factors led his bubble of self-esteem to burst, puncturing the degree
of nascent pride he attempted to sustain. Thus, no longer feeling capable and
accomplished, the energy that fueled his interests dissipated as if the wind
had been knocked out of his sails, and I imagine Carl started floundering all
over again. He stopped reading philosophy, lost his interest in political science
and government, and his scope of interests and energy about a broader world
seemed to empty out. All that was left was an interest in political satire and his
enjoyment of dry wit and sophisticated sarcasm—the vestiges of a dampened
vitality replaced by unrecognized bitterness and disappointment. Without the
trappings of prestige all around him, Carl found himself again depleted, empty,
and uninvigorated as his moment in prime time seemed to fade away without
him comprehending what was happening or how to stop the downward spiral.
I kept thinking that one day he would wake up and find himself an empty
shell of a person—lacking in deep motivations or compelling concerns, extend-
ing perhaps to a relationship with a woman as well—and experience a psycho-
logical crisis again, not unlike the depression he presented ten years ago that led
him on his own initiative back then to seek treatment. Probably that was why he
sought me out again after ten years, unknowingly feeling that his options were
running out for holding onto something to revitalize his life.
Carl was not someone who could go it alone by providing the invigoration
from within; I always thought he needed a supportive, enthusiastic figure in
the background to egg him on and thus, serving an idealizing self object func-
tion, help to keep him afloat—much as his TAT stories to Cards 1 and 2 from
the 15yo assessment compellingly suggested. As the outcomes of those stories
foreshadowed, and like the direction his life seemed to take following college,
I think it became too difficult for Carl to sustain on his own the psychological
oxygen that resulted from pride in his achievements and a fortified sense of self-
esteem. No longer an Ivy League man with a prestigious postgraduate award
to his credit and the stimulation that internationally recognized universities
afforded, Carl folded up and resorted to the depleted existence he could not
break away from, as represented by his enduring, compelling interest in Office
Space and Fight Club. Truly, like the newer movie that captured his attention,
Carl was slowly dying from within.
Young adulthood is for many still a time of relative immaturity or superficial-
ity, but I did not see too many signs that Carl was moving in a psychologically
deeper direction. I thought that the shine of his “credentials” was already start-
ing to wear off and would prove disappointing to him if he continued going
nowhere fast. His disinterest in reading, which for a brief time had been an avid
interest representing a passageway to stimulation, seemed to evaporate because
the interest was sustainable only as long as the structure his credentials provided
was still standing. Without that calling card, Carl apparently could not sustain
the enthusiasm to chart a clear direction for himself; and without someone by
his side to assist him as he struggled, he seemed to flounder in ennui and not be
able to sustain the momentum to preserve feeling vitalized.
Carl expressed very little mature insight about himself or his life, using
words like “weird,” “cool,” and “dickhead” (to disparage others) quite a bit.
He had an air of slightly snooty Ivy League smugness, even in his manner of
speech, but he was not overtly arrogant or off-putting. He felt his best ability
was a sense of detecting pretentiousness in others and keeping a distance from
people until he felt they were more genuine or well-intentioned. His relation-
ship with his parents was much as it had been before: he felt closer with his
mother—but not in a substantially deeper way—and he felt more forgiving
about his father than my notes from ten years ago indicated. He saw his father
as depressed and self-conscious about his lost arm. Carl seemed surprised
when I suggested that he might have felt some distance on his father’s part
toward Carl as a young boy and adolescent. He insisted that his relationship
was good with his father and not very different than it ever was. However,
there was more overt antagonism toward Carl from his brother, who resented
Carl’s accomplishments while he himself was still struggling hard to finish an
associate’s degree.
Carl did not remember much about his psychotherapy, and when I reminded
him of some significant interpretive observations, they seemed to go over his
head and gave him no real pause for thought or reflection. However, he lis-
tened attentively to what I had to say, and I thought he felt gratified that I
remembered much about the events and feeling states we had talked about ten
years before. Carl generally appeared to show hardly any curiosity about his
motivations or about his past. He thought that he probably did not need the
antidepressant I recommended for him, thinking that his depression mainly
was alleviated when he lost weight on his own and thus became more desirable
to his friends and to girls. He remembered calling me once, apologetic about
disturbing me late on a weekend night, concerning a fight his friends were hav-
ing and how frightened he had felt, not knowing what to do. At the time he
seemed to appreciate my calling him back soon after receiving his phone call;
however, he now said as he recalled the situation that there was no need for
him to have called. He apologized again for having disturbed me, but I was
not sure he really felt apologetic. When I referred to it, he also seemed to miss
the point of what it meant to feel he had someone who understood his need at
that time.
Overall, Carl was initially engaging as a solid-appearing young man, more
poised and good-looking than I remembered him as a 15-year-old adolescent.
However, there was little insight or depth, and although he held on to the trap-
pings of some very real and important accomplishments at a young age, I won-
dered whether the narcissistic gratification of earning excellent grades, attend-
ing prestigious schools, and winning an important fellowship mattered more as
external markers of achievements. I did not have the impression that the sub-
stance of what he had learned or accomplished had changed him very much. In
short, I did not feel that he was moved or deeply affected by the experience of
this period of time in his life beyond being able to tell others what he had done.
Carl was not keen on attending graduate school and he was not sure of an area
he might pursue even if he were to pursue an advanced degree. As I spoke with
him, I kept thinking that in a fundamental way Carl was not appreciably differ-
ent or even more mature than the 15-year-old boy I had seen ten years ago.
Curiously, I found myself feeling insignificant in his presence, in the way cer-
tain narcissistic personalities leave clinicians feeling when it seems that the thera-
pist does not register for them as being important other than as an accessory. It
is of course flattering when a former patient, seeming to think favorably enough
about the work in the therapy, returns for additional help, particularly after the
passage of many years. Imagine that same therapist feeling injured when the
patient then proceeds to disparage their work! Thus did I feel as I listened to
Carl talk about his memory of the beneficial effect of an antidepressant and his
trivialization of feeling frightened enough to call me at a moment he had con-
sidered an emergency. But I was mainly left wondering why the meanings about
Carl’s life that I thought were so important seemed to mean so little to him.
I mostly found Carl to be shallow and rather uninteresting by the midpoint of
the interviews we had, mainly feeling shut out and disconnected. I asked myself
whether Carl’s narcissism was crystallizing into a predominant personality style
now that he was a young adult, and I also wondered why I did not seem to
notice it very much when Carl was a 15-year-old adolescent. From my notes,
I saw that I had commented about it, more indirectly however as I talked with
Carl about his need for admiration from a depressed, withdrawn father and the
transference significance of a responsive selfobject. He now appeared in adult-
hood as not particularly interested in other people, generally content about his
life although it sounded rather solitary and superficial to me, and mainly dis-
tantly aloof as he seemed to go through the motions of intimacy but not really
feeling it very much.
Carl’s reason for seeking me out again was because he was uncertain about
his next career or job move, which as I thought about it may have reflected a
veiled sense of deeper concern that he was progressively resting on his laurels
and worrying about what that could do for him. Although I doubt that Carl
would have recognized it, it seemed that the emptiness of his inner and external
life had set him back to where he had been before he started college and began
collecting his impressive credentials. I could only speculate that the diminishing
effect of his accomplishments continued as time went on; however, I have not
had any further contact from Carl since the visits I have described.
Discussion and Summary of 15yo and 25yo Protocols

While not overwhelmed at age 25 about a direction for his future, Carl’s lack
of a career path was no less pressing than it was for him as an adolescent. My
impression about his recent history suggested that the aimlessness and lack of
purpose persisted, notwithstanding his academic accomplishments that took
me by surprise. His rudderless goals on the Figure Drawings, coupled with an
impression of immature identifications and a shallow understanding of himself
and others, particularly women, stood in contrast with some of the more favo-
rable indications from the CS and R-PAS pointing to better adaptive capacities
and ego functioning, at least in comparison with Carl’s 15yo protocol. Carl
did show problems with thinking clearly or coherently at many times, per-
turbed further by intrusive ideas; however, he mainly seemed untroubled by
his thoughts.
As noted on the MMPI, appearing alienated or withdrawn may have insu-
lated him from an awareness of unmet needs and anxious-dysphoric features
or negative emotionality, contributing to his tendency to minimize problems.
Carl’s upsurge of anxiety surrounding uncertainty about his future at age 25—
probably catching him off guard and precipitating the contact he made with
me—seemed to dissipate just as quickly as it had emerged as he reconstituted
his defenses and retreated back to a position of sealing over anxious perturba-
tion and thus not pursuing further treatment. Evidently, many of the prob-
lems noted at 15yo seemed to largely remain unresolved as Carl entered young
adulthood.
Behind a thin veneer of presenting himself as a relatively confident young
man, he also conveyed a sense of there being something lacking internally. Carl’s
idealization of brutish fighting and strength was a thin overlay, barely obscuring
a desire to fortify an image of vigorous masculinity that he sensed was underde-
veloped. Notwithstanding all of his talk about idealizing an “alpha male” image,
I did not think that he really believed the words coming out of his mouth. For
example, it did not take long before he went from admiring the images of robust
strength he spoke about to devaluing its importance (“a fake game . . . comic-
booky . . . bizarre version of humanity”). I thought that he went along with the
image and the talk to try to hold his own on what he euphemistically called the
“social ladder,” but what I thought he really meant was that a disturbing feeling
of not going anywhere covered over a sense that he did not know how to carry
off making it in the world and that he felt psychologically adrift.
What was even more disguised and I suspect elusive for him was feeling
shame about needing a robust, secure man for a guiding or assuring hand on
his shoulder as he navigated unfamiliar waters. He seemed to need to feel the
secure understanding that another man might be able to provide in order to
become more robust or assured within himself. I think Carl mistook idealiza-
tion of an exaggerated “alpha male” image for the kind of paternal idealization
he did not manage to secure with his father, either because his father was too
uninvolved or disinterested to provide the kind of idealizing selfobject function
Carl needed or because Carl saw his father as too diminished or uninvigorated
to turn to in seeking idealization.
In a certain respect, Carl was continuing a struggle that preoccupied him
at 15yo, as he seemed to defensively disparage or de-idealize the very thing he
needed most. Stated another way, by trading the “crying dragon” of 15yo for
the “generic . . . dime-a-dozen . . . storm troopers . . . [who] were a joke” of
25yo, he may only have changed the imagery he used to express a need for a
strong or competent person who would count for something he could depend
on. He needed to recover from feeling hesitant or ashamed of turning to a man
for an involved, enlivening selfobject experience—the psychological oxygen
Kohut (1977, 1984) frequently described—that Carl could metabolize and thus
internalize to strengthen self-cohesion.
I was not certain what to infer about Carl’s apparent lack of experience
of in-depth intimacy in his relationships with women. His trivialization and
depreciation of women appeared to reflect a rather deeply seated hostility
about which I did not think he showed any awareness at all. Struggling to inte-
grate introjections of good and bad objects was problematic for him, and his
detached condescension regarding women belied a strong underlying concern
surrounding potential danger, humiliation, or distrust. This might explain why
he kept a cautious, fearful distance from women, whom he readily mocked and
defensively denigrated. It was not difficult to see how this dynamic concerning
denigration and depreciation was expressed through Carl’s enduring interest in
a world of science fiction adventure stories and movies centered on aggression
and overpowering others. It was more unclear in explaining why this dynamic
was as potent as it appeared to be and how it developed in respect to Carl’s
relationship with his mother. Nonetheless, Carl’s preoccupation with imagery
concerning good and bad objects locked in adversarial, overpowering positions
was strong and persistent. His continuing fascination with a film such as Fight
Club and a mainly sublimated adult version of that dynamic expressed in the
form of political satire and biting wit pointed to a problem that Carl did not at
present seem to recognize but which was likely to impede development of inti-
mate relationships in the future and might well also interfere with his capacity
to develop a work or career path.
Carl seemed caught in a position at the moment that fell somewhere in
between the existence he led growing up as a youngster trying to find a place
to fit in, and the existence he now found himself in as he again struggled to find
a place. He grew up in a psychological world of supportive but unempathic
parents who could not read his needs very well or offer him a model to generate
stimulation or foster self-esteem. Carl managed to secure a more steady place in
the world of college life, which stimulated him and showed him how intelligent
he was for the first time in his life. He took hold of feeling proud and successful,
and he assertively created opportunities for himself that offered the promise of a
life he could not have imagined for himself even five years previously. Ten years
ago I suspected that Carl needed a buoyant selfobject environment in order
to thrive and come into his own, and I had the impression that apart from the
satisfactions he derived through his own reading and working hard to get good
grades, he may not have known how to seek out a mentor or even have realized
his need for such a selfobject function. He managed to acquire the outward
signs of success, but I think Carl ultimately floundered in the absence of a guid-
ing hand to point him in a direction he could not manage on his own.
Probably feeling somewhat unanchored as he did at age 15 but not as acutely
distressed as he did back then, at age 25 Carl may have sensed he was heading
for difficulties in his life but was uncertain what he needed. Seeking treatment
once again, or perhaps toying with the possibility, probably represented a grow-
ing sense of impending psychological difficulty, but without a sufficient level of
distress he was not yet about to open up a can of worms he largely preferred to
ignore. Insulating himself from his emotional life and keeping a reserved dis-
tance from people probably protected Carl from having to face the impact of
the aggression he harbored and how that probably interfered with developing
or maintaining intimate relationships. However, unless Carl could manage to
continue functioning in the cocoon he may have created for himself, it would be
difficult to imagine that he might not need further help down the road.
Notes
2 Personality Problems Associated with Affect Dysregulation

1 In this context, I note that I experienced great difficulty setting up appointments with
Ms. A. She was firm about times of the day she could not make and I felt frustrated
trying to find a give and take in making appointments, particularly when she would
arrive late. She seemed unconcerned that the reasons for her lateness, however
reasonable they might be, threw off my schedule and necessitated making more
appointments than I would have thought necessary to complete this evaluation. I
was unable to feel much beyond anger and annoyance at her willful or irresponsible
disregard until I came to understand more clearly the dynamic underlying her
behavior.
2 In this regard, I have always been fond of Schachtel’s (1966) example of a vignette
from Freud’s “Introductory lectures on psycho-analysis” (1963, p. 407) about a small
boy who was frightened in a dark room and asked his aunt to speak to him. The aunt
asked the boy why speaking to him would alleviate his fear, to which the boy replied,
“If someone speaks, it gets lighter.” How telling that Ms. A.’s response of a festive
event followed and may have been provoked by the shading or achromatic color she
seemed to go to such great lengths to dispel in her previous responses.
3 It is also tempting to consider how the somewhat unusual phrase she used repeatedly
(pressed down) was elaborated in this response (“so the wings wouldn’t almost be
there”), alluding to the possibility that the insect might not be able to fly. In this
sense, it would be immobilized or trapped, which could be consistent with the
finding that this patient had seven diffuse shading responses in the entire record,
potentially signifying helplessness. However, note also that Ms. A. did not leave
her insect totally defenseless, for it had its “stinger”—both here and in the previous
response.
4 Because the butterfly and heart images seemed separate and the butterfly heart
was thus not apparently a condensation, this response was not considered to be a
contamination.
5 This concern might have reflected the attentional problem the referring clinician
wondered about, which was one of the main reasons for the consultation in the first
place. However, although the Rorschach may have its own unique ways of revealing
attentional problems, it is not an optimal method for assessing disorders of attention.
I would note, however, another possibility about this patient’s distraction: it might just
as easily represent a difficulty maintaining boundaries among responses. I will return
to this point to consider the possibility that such distractions or attentional lapses
may also indicate a problem found in bipolar spectrum disturbances. In such cases,
a gross loss of distance or marked perceptual fluidity might be consistent with a more
severe presentation such as acute mania. In contrast, more subtle or intermittent
lapses might be compatible with a milder form of bipolar affective dysregulation
Notes to Pages 46–110 321
such as hypomania. In the latter instance, such lapses would not be unnoticed but
neither would they be as prominent or severely tangential as genuine lapses of
attention from which patients cannot recover or return to the task at hand.
6 Note also that this quasi-response on Card II was followed by her first response
with a vista determinant. The following card (Card III), despite there being four
responses, had no color determinants even though areas of two responses that used
chromatic color were prominently used. Furthermore, Ms. A.’s second response on
Card IX was preceded by her other response containing a vista determinant.
3 Personality Problems in Adolescence

1 I note parenthetically in this context a vignette that emerged during Carl’s
psychotherapy. He once related to me how an alcoholic aunt’s caustic comments
to him provoked him to go to his room in tears. His parents thought little of the
situation because they were accustomed to the aunt’s sarcasm when she drank, and
they apparently did not feel a need to comfort Carl in his distress. I could not know
at the time of the assessment how alone he could feel when he wanted to lash out but
might have been confused by his emotions and unsure how far he could go to express
his anger. However, as I came to understand more about Carl’s relationship with his
parents, I thought about this and other Rorschach responses in relation to feeling
hurt and weakened when his parents failed to grasp how injured he could appear
when he felt belittled.
2 It could be easy to overlook such additions or overelaborated comments, falling
as some do just below a threshold of qualifying as a cognitive special score. This
may happen particularly when an examiner’s attention is focused on scoring
determinants and special scores for intricate or complex responses where such
elaborations could easily fall off an examiner’s internal radar screen. Consequently,
attending to subtle criteria for special scores could draw attention away from other
subtle aspect of responses, such as Carl’s adding these few additional words (“like
when you kill a deer or something”) to his response. Indeed, many such subthreshold
verbalizations as well as some genuine deviant responses (DR) are of a type that
examiners devote considerable effort deliberating how much verbiage is redundant
or tangential while sometimes becoming distracted from listening to what is actually
being communicated.
3 One of the more remarkable aspects of the Rorschach is just such a phenomenon.
As in psychotherapy, the meanings of much of behavior are not always clear in the
moment, but they emerge in a broader context that considers what both precedes
and follows particular responses.
4 What he needed therapeutically could be readily formulated along the line of Tolpin’s
(2002) forward edge transference, a concept she developed based on Kohut’s self
psychological perspective. Forward edge interpretations emphasize underdeveloped
aspects of normal development that were insufficiently responded to or were thwarted
by a selfobject surround that failed to recognize their importance for fostering
healthy self-cohesion. I will return to this concept at a later point; I introduce it here
mainly to illustrate how a conceptual framework may unfold as discrete Rorschach
and Figure Drawings findings become established. Inferences derived from the TAT
add an important context in an evaluation to ground theoretical understanding of
patients’ self-cohesion, their relationships with the object world, and the purpose or
directions they either wish for or find blocked or diminished in their lives. As Jenkins
wrote recently, “Storytelling is a quintessentially integrative function . . . stories
bring people, ideas, and feelings together . . . folktales build cultures; bedtime stories
raise children . . . understanding stories helps us understand these things, which
makes them useful for clinical work with clients who have trouble understanding
322 Notes to Pages 110–171
themselves” (2008, p. xi). TAT findings, superimposed on hypotheses from early and
middle points of an evaluation, help to make sense of assessment material obtained
from Rorschach and Figure Drawings interpretive inferences.
5 Previously, on Card 1, Carl also spoke of feeling bored followed by feeling sleepy;
that seemed to be his way of dealing with affect states he did not understand and felt
uncomfortable about. Thus, boredom (which was also his chief presenting complaint)
is a euphemism for submerged or diluted affects that Carl neither understood nor
recognized; he wished mainly to rid himself of these uncomfortable states, but the
price he paid was the listless existence he appeared to lead. The solution—that is,
the therapeutic objective—would seem to be finding a way to open up his emotional
life without causing him to run from it or feel too anxious.
6 The distinguished pioneer of descriptive psychiatry Emil Kraepelin once described
a patient’s explanation of the onset of her recurrent depressions as having been
precipitated by “the death first of her husband, next of her dog, and then of her
dove” (1921, p. 179). Kraepelin’s example referred to lower thresholds for stressors
to potentiate susceptibility to depressive episodes, which is a different but not
unrelated context from Carl’s comment on Card 3BM. Kraepelin’s patient was
mainly describing a vulnerability factor in this illustration; Carl was describing
becoming increasingly removed from a potentially destabilizing source of conflict.
4 Personality Problems in Later Life

1 Although I did not ignore the possibility that kissing, like eating, connotes orality
(including dependency, needs for or concerns about nurturance, and oral aggression),
I emphasize here the conflictual, confused or ambivalent, and destabilized affective
regulation implications of this and several of this patient’s eating/feeding responses
throughout this Rorschach protocol. I thus considered his use of contents concerning
oral activities much as I considered most other content references, more for their
indications of defenses, ego functioning, self-cohesion, and more generally the
structural aspects of psychopathology than as specific manifestations of libidinal
drives or psychosexual developmental stages as conventionally represented in
classical drive theory or ego psychology.
2 Differential reaction time between chromatic and achromatic Rorschach cards
was formerly a variable of clinical interest, typically seen as reflecting blocking due
to perceived threat or differential level of card difficulty (long reaction times), or
impulsivity or disinhibition (short reaction times). Exner (2003) retained this variable
when he initially introduced the CS; however, he later discarded reaction time as
there appeared to be insufficient empirical support for retaining it beyond the first
edition of Exner’s text.
3 I have speculated elsewhere (Silverstein, 1999, 2001) that some codes for DR contain
potentially important meanings extending beyond their tangential or off-task
nature. Thus, what may seem to be task-unrelated verbalizations also may represent
patients’ ill-fated attempts to find a way to convey something important about their
life or experience. Consequently, such apparently off-task verbalizations are in a
more important sense not primarily off task at all. Indeed, such verbalizations are
precisely what is most important about the task in the first place. Mr. B.’s response
here represents a good example of this phenomenon.
4 Not unlike the adolescent boy Carl, whose assessment findings I reported in
Chapter 3, Mr. B. also struggled with an unresponsive selfobject milieu. Without
understanding what they were feeling, Carl and Mr. B. both tried to make their
needs heard and recognized. Carl unwittingly resorted to over-the-top alarms he
used to signal his distress, in the hope that his parents would perk up and listen to
what was going on within him. Mr. B. similarly experienced the people in his life
to be unresponsive, misinterpreting his needs and deriding him for being willful or
disobedient when he tried to animate an existence he found uninvigorating. Both
felt trapped, each in his own way. Carl at age 15 tried to recover from his distress
by dramatizing the turmoil he felt in a way that could easily have been dismissed as
adolescent excess. Mr. B. at age 84 tried to lean on others to respond to his neediness
but probably in a way that drove people away at moments he most needed them.
5 As on Card 1 and the Figure Drawings, when Mr. B. did elaborate on the relationships
he was describing, what he said was particularly revealing and important: feeling
“helpless” (Card 1), worrying “that his wife would get tired of him and run away
with somebody else” (Figure Drawings), and now on Card 2, “the girl’s hungry . . .
wondering what’s to eat.” I should also point out that at least two of these three
comments seemed to come out of the blue because there was no particular context
leading up to these statements. And yet they were all provoked at the point or soon
afterwards that I asked Mr. B. to describe something about the depicted relationships
or what he felt about what was happening in his stories.
6 Note also that only very remotely does Card 7BM depict either man with his head on
the other’s shoulder. I had never heard that comment before, and I had to look on the
card to check whether seeing that was even possible, notwithstanding the inherent
ambiguity built into TAT cards. It appeared possible that Mr. B.’s strong need to
see a father as comforting may have led him to see one man’s head on the other’s
shoulder—not necessarily a distortion of the drawing, but still an extremely rare
observation, even after taking into account that the neuropsychological examination
revealed this patient to have no more than minor visuospatial problems.
7 Recent research on mother–infant interactions has observed and recorded infants’
common response of turning toward their mothers when the mothers appeared
to responsively and accurately engage their infants. However, when the mothers’
attempts to engage their infants were asynchronous or apparently disrupted an
ongoing interaction pattern, the infants turned their gaze away from their mothers
(Beebe & Lachmann, 2002).
5 Personality Problems Associated with Cerebral Dysfunction

1 Note also how her stick figure drawing emphasized the arms and hand areas.
Moreover, she initially drew the arms outstretched at shoulder level but then erased
the arms and redrew them alongside the torso. The hands on the stick figure were
disproportionately large, particularly the right hand, and the fingers resembled
something like prongs. Further, the position of the arms looked slightly unusual,
perhaps raised for some reason as the figure possibly was looking warily leftward.
As I tried to imagine what a person might be feeling or was about to do with arms
so positioned, my initial impression was that of being braced for something and
being self-protectively vigilant or prepared to act. However, the more I looked at
the drawing the less I thought so, but I continued to wonder why I had the initial
impression that I did. I also wondered why the male figure at first looked like an
adolescent, although as I looked further I became less convinced of that. I think that
I was having trouble matching up an impression about the drawing with Ms. C.’s
verbal description. I also wondered whether the incongruity I felt reflected something
about Ms. C. looking in the wrong place for the kind of sensitive understanding or
strength she may have wished to locate in men.
2 This may be another albeit unintended benefit of side-by-side seating during
Rorschach administration: when a response containing vivid, evocative imagery
is expressed with a matter-of-fact or bland delivery, by looking away examiners
may register such a disparity more keenly as they endeavor to attend to the more
important clinical function of listening to the melody and not the words.
324 Notes to Pages 224–228
3 Although this patient clearly indicated seeing two animals, I remained uncertain
whether she was really describing one organism with disconnected parts—implying
potentially an internal experience of fragmentation—or two animals in some state of
disconnection from one another—implying a separation-individuation or attachment
conflict. Although I favored the latter, I continued to wonder what it might mean that
this patient seemed to have difficulty articulating convincingly enough—in spite of
her frequent reference to two animals—that she was predominantly characterizing
a perturbing experience of separation failure. Certainly, a separation-individuation
difficulty could also be associated with some degree of fragmenting internal experience,
depending on the severity and chronicity of the disturbance of separation.
4 Although the interpretive basis for this statement followed most explicitly from
Mahler’s (1968) seminal work, her thinking clearly influenced related theoretical
formulations by many psychoanalytic theorists, among which those of Bowlby,
Winnicott, Kohut, Anna Freud, and Fonagy are only a few that immediately come
to mind. The burgeoning field of attachment theory and research is currently the
main theoretical heir to Mahler’s ideas. I have tried to express the formulation I
suggested above in a general theoretical way, emphasizing Mahler’s work in
part for its coherent position. Naturally, there are related interpretive viewpoints
representing psychoanalytic positions (such as those of Winnicott, Kohut, and Anna
Freud). Moreover, attachment theory itself is a complex area of inquiry that consists
of several interdependent propositions. Without becoming sidetracked by the variety
of theoretical positions, I have focused on Mahler’s mainly to demonstrate how the
content of Ms. C.’s responses may be conceptualized from this vantage point. Her
responses may of course be conceptualized in other ways as well. For this reason,
I have tried to favor the more theoretically neutral term disconnection rather than
attachment.
5 One function of a costume in the theater or in an opera is to disguise the fact that an
actor is someone other than the character being portrayed and to allow an audience
to “forget” that fact and lose themselves in the work being performed. A relatively
recent trend is for some theater and opera directors to recast a setting or time period
of a theatrical work in contemporary times, accordingly costuming actors as they
might dress themselves in today’s times. This serves the purpose of bringing the
emotional meaning or impact of the work closer to an audience’s current experience,
as if to suggest, for example, that the conflicts and vulnerabilities of Shakespeare’s
King Lear or Verdi’s Rigoletto are not unique to those of fathers from a different era
in the remote past but rather that they represent the conflicts and vulnerabilities of
fathers of all times, including those sitting in the audiences of today. Ms. C.’s abstract
dancers in costume, however, seemed miles away from the person inside.
6 Had she articulated a texture determinant earlier or more unequivocally during
the inquiry, Ms. C. might have come close to producing another shading-shading
blend. Moreover, had she included the D7 area—as I mistakenly thought she had
at first (and who knows, maybe in fact she did in her mind, managing however to
exclude this area from her actual delivered, verbalized response)—this patient might
have produced a color-shading blend in addition to a shading-shading blend. In the
final analysis, I am not convinced that it mattered very much that she did neither
because by this point I could see how effectively her deft, defensive concealment
seemed to work for her. It also would not be that difficult for an examiner to relax
the practice of holding fast to what is in the first place a somewhat arbitrary rule
about something being said and at what point it was said, and accordingly allow into
their internal calculus what I think is a more important psychological consideration
that the real spirit of this response favored Ms. C. having seen texture and chromatic
color, regardless of what she said she saw and when she said it.
Of course, these impressions still must remain speculative at this point in the
analysis, although they do point to a problem with Rorschach administration that
has never been satisfactorily resolved: By scrupulously avoiding potentially leading
inquiry questions lest we artifactually induce a determinant a patient may not have
had in mind, we run the risk of missing determinants that may actually have been
perceived but not articulated. We really do need to develop a way to resolve this
problem because sometimes we lose more than we gain by adhering to the strict
abstinence policy of a spare, unobtrusive inquiry. I do not personally believe that
examiners need to consider the thought of putting ideas into people’s minds as
heresy by taking a few judicious, carefully phrased risks. Many times, we may lose
more by constraining ourselves in an effort to avoid leading questions than we might
gain by asking carefully phrased nonleading questions. A testing-the-limits inquiry
following a conventional inquiry may be one potential solution. For example, when I
first learned the Rorschach in 1970, it was considered acceptable to ask the question
“if it were another color, would it still look that way?” when a somewhat obvious
potential color determinant was not mentioned during the inquiry. How I do miss
not being able to pose that question anymore, probably more times than I would
care to admit!
7 In spite of my having seen Ms. C. in weekly psychotherapy for 13 months, she never
mentioned a word about either a current or past romantic history. I was always
curious about this important omission about her life; however, I did not suspect
that there had been any serious romantic interest. Based on nothing in particular,
I tended to think that Ms. C. was a lesbian, but that did not alter my overriding
impression that the main motivation in her life was her frantic effort to complete
her work against all odds and keeping this difficulty entirely to herself. She did
speak about close friendships, and during the time I saw her in treatment she was
struggling with anticipating the loss of friends planning to move away. Interestingly,
this was one of the very few rather personal areas of her life that Ms. C. spoke
about. It was practically the only area of her life that she spoke about in a way
that left me appreciating in a deeper psychological sense the extent to which she
could experience longing or loss. Its significance for understanding R7 and R4 was
of course clear, and the compellingly poignant quality of R7 in particular made
it possible to imagine just how strongly she might have felt about the impending
separation from her friends. This was not, however, an area she wished to talk about
very much.
8 Ms. C. appeared to reemphasize this vibrant quality as she followed this comment
with another, explaining how “the ocean is very alive with different kinds of life.”
In the way she spoke of these vibrant colors, if one listened to this response with
eyes closed, I do not think it would be all that difficult to discern a quality of her
luxuriating in the colors—as if she could see or even touch what she was seeing and
describing. It is indeed intriguing how strongly expressed or perceived colors can
“sound” nearly palpable, which in the vocabulary of Rorschach psychology presents
a novel opportunity for thinking about interrelationships among determinants and
the affect states they represent (Schachtel, 1966).
9 It was pointed out to me that there is a body of water named the Coral Sea off the
northeast coast of Australia. Although I did not believe that Ms. C. had this specific
reference in mind when she referred to a coral sea, I could not however be certain
that she did not.
10 I was surprised to learn, however, that apparently there are several other cultural
references to a wishbone, such as a football position, the commercial name of a
salad dressing, and the name of a dog on a television program of the same name
who could imagine himself as well-known literary characters while being dressed to
resemble such characters.
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Personality Assessment

Comprised of five unique and extended case studies, Personality Assessment in

Marshall L. Silverstein, PhD, is Professor of Psychology at Long Island

This series of books is intended to provide information about personality proc-

ISBN: 978–0–415–80042–6 (hbk)

1 Empirically Based and Content-Based Clinical Interpretation 1

2 Personality Problems Associated with Affect Dysregulation 13

3 Personality Problems in Adolescence 76

4 Personality Problems in Later Life 138

5 Personality Problems Associated with Cerebral Dysfunction 193

6 Continuity and Change from Adolescence to Young Adulthood 268

One of my favorite descriptions of personality assessment is Schafer’s comment

The interpretation of psychological tests of personality has long been a thorny

Influenced by the growth of psychoanalysis, as the above example begins to

Percepts derive their meaning from the associative processes in which

Consequently, Exner described two approaches to examining projection, the

Differentiating among affective disorders is a complex matter because subtle

Millon Clinical Multiaxial Inventory (MCMI-III)

Human Figure Drawings

Figure 2.1 Human Figure Drawing (female)

I asked her about the person’s fears, and Ms. A. commented:

Figure 2.2 Human Figure Drawing (male)

Asked about his fears, Ms. A. said:

Figure 2.3 Rorschach location sheet

Figure 2.4 CS Sequence of Scores

RATIOS, PERCENTAGES, AND DERIVATIONS

R = 36 L = 0.57 FC:CF+C = 2:4 COP = 1 AG = 0

a:p = 6 :1 Sum6 = 12 XA% = 0.61 Zf = 16 3r+(2)/R = 0.14

PTI = 3 DEPI = 6 CDI = 1 S-CON = 7 HVI = Yes OBS = No

Figure 2.5 CS Structural Summary

record of 36 responses occurred in a context of neither an overstimulated nor

R-PAS Interpretive Findings

Figure 2.6 R-PAS Code Sequence

Figure 2.7 R-PAS Summary Scores and Profiles—Page 1

The Sequence of Scores is represented in Figure 2.6, followed by the Page 1

Thematic Content Interpretive Findings

In this second response to Card I, Ms. A. continued the theme of a smashed

(Pressed down?) Because the colors

(Rough?) That’s not really the word I’d

(Greenery?) That same area.

Here Ms. A. perceived a scene in perspective, making use of shading features to

(Reflection of the people?) No, it’s

∨17. Two peacocks. The head of a flamingo, large wings.

I frequently regard Card V as one that provides an opportunity for patients

21. Whiskers. This thin line, the way it’s protruding.

an outfit just laid out, sort of in disarray.

∨29. A pair of panties. The shape of it.

(Space?) Just the figure, where it is.

Inexplicably, Ms. A. no longer continued what seemed to be emerging as her

∨32. A boomerang. Or a sling shot. The shape—partially tri-

34. Lobsters. The large middle, and the legs.

The five responses to Card X were in several respects unusual—one response

Thematic Apperception Test

Once again here was a story of unhappiness, and as conveyed on Card 2, a

Both of these stories, as did Card 1 previously, emphasized a theme of wrong-

Empirically Based Scales (MCMI-III, and Rorschach CS and

Content Analysis (Figure Drawings/TAT/Rorschach)

Many psychological perspectives on adolescent development regard this often

Minnesota Multiphasic Personality Inventory (MMPI-A)