Psychic changes: the rorschach, the psychoanalytical process and the analyst-analysand relationship

 

Cambios psíquicos: el rorschach, el proceso psicoanalítico y la relación analista-analizando

 

 

Norma Lottenberg Semer¹; Latife Yazigi; Maria Luiza de Mattos Fiore; Julieta Freitas Ramalho da Silva; Salvador Mario Bianco; Patrícia Gazire

Universidade Federal de São Paulo, Brasil

 

 

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ABSTRACT

The authors intend to articulate the clinical and theoretical frames of references in an empirical context of a psychoanalytical investigation. Four young women with borderline disorder were assisted in psychoanalytic psychotherapy at the outpatient psychotherapeutic public service of a Medical School. The Rorschach test, Comprehensive System, was administrated before the treatment and once a year. After one year of therapy it was possible to correlate the participants’ psychic changes detected by the Rorschach with the changes occurred in the psychoanalytic setting. In some situations, it was possible for the analyst to build together with the analysand new representations and elaborations. In other moments, due to the violence and intensity of the emotions lived in the experience with the analysand, acting outs were enacted by the therapist, what could be recognized and overcome latter.

Keywords: Psychic changes, Rorschach, Psychotherapy, Psychoanalytical process.

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RESUMEN

Las autoras intentan articular marcos de referencia clínicos y teóricos en el contexto empírico de una investigación psicoanalítica. Cuatro mujeres jóvenes con trastornos borderline fueron tratadas con psicoterapia psicoanalítica en el servicio público de consultorios externos de una facultad de medicina. El Rorschach, Sistema Comprehensivo, fue administrado antes del tratamiento y luego, una vez por año. Después de un año de terapia fue posible correlacionar los cambios psíquicos de las participantes detectados por el Rorschach con los cambios ocurridos en el encuadre psicoanalítico. En algunas situaciones, fue posible para el analista construir junto con la analizanda nuevas representaciones y elaboraciones. En otros momentos, debido a la violencia e intensidad de las emociones vividas en la experiencia con la analizanda, se desencadenaron actuaciones en el terapeuta que pudieron ser reconocidas y superadas posteriormente.

Palabras clave: Cambios psíquicos, Rorschach, psicoterapia, Proceso psicoanalítico.

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From our experience with the psychological evaluation of patients submitted to psychoanalytic psychotherapy, we intend to articulate the relations between the clinical and theoretical frames of references in an empirical context of a psychoanalytical investigation. Four young adult women diagnosed with borderline disorder, in accordance with the DSM-IV (American Psychiatric Association [APA], 1994) as well as with Kernberg’s (1968, 1992) and Gabbard’s (1994a, 1994b, 1994c) conceptions, are treated with psychoanalytic psychotherapy in an institutional context, that is, free of charge at the outpatient psychotherapeutic unit of a School of Medicine. The psychotherapy can last from three to four years depending on the patient’s needs. The Rorschach test, Comprehensive System, among other tests, is administrated before the treatment and each year. All of the women gave written informed consent.

After one year of therapy it was possible to correlate the participants’ psychic changes detected by the Rorschach indexes and content analysis with the changes or attitudes occurred in the psychoanalytic setting according to the sessions’ reports, mainly from the most striking moments of the sessions.

 

Psychoanalytic Concepts

Our approach is oriented by the changes depicted in the Rorschach and integrated to the psychoanalytical process that emphasizes the bonds in the analyst analysand relationship and the functioning of this duo. In this relationship, the projective identification defense mechanism plays an important role.

The projective identification concept was introduced by Klein (1946/1988) who describes the phantasies of the child of getting rid of good and bad parts of the self which are expelled and projected into the mother. “The processes of splitting off parts of the self and projecting them into object are thus of vital importance for normal development as well as for abnormal object-relations” (p. 9).

Given that the projective identification occurs in the interpersonal dimension, to Bion (1967), it is related to the paradigm container-contained. For instance, the baby wants to get rid of unbearable affects and intolerable mental state. The mother, in order to smooth the baby, will absorb and transform these emotions for her child. As a consequence, these projected states will be reintrojected by the baby after being metabolized by the mother’s ‘rêverie’. For Bion (1962), rêverie means:

. . . the state of mind which is open to the reception of any ‘objects’ from the loved object and is therefore capable of reception of infant’s projective identifications whether they are felt by the infant to be good or bad. (p. 36). The author stresses that besides the unconscious phantasy, an experienced interpersonal relationship always occurs between the baby and his mother. In transposition to the analytical relationship, the analyst is impelled to play a role in the analysand’s phantasy.

Ogden (1984) says:

Projective identification is a concept that addresses the way in which feeling-states corresponding to the unconscious fantasies of one person (the projector) engendered in and processed by another person (the recipient) . . . The projector has the primarily unconscious fantasy of getting rid of an unwanted or endangered part of himself (including internal objects) and of depositing that part in another person in a powerfully controlling way. The projected part of the self is felt to be partially lost and to inhabit the other person. In association with this unconscious projective fantasy there is an interpersonal interaction by means of which the recipient is pressured to think, feel, and behave in a manner congruent with the ejected feelings and the self- and object-representations embodied in the projective fantasy. (p. 1-2).

To Gabbard (1995) both projective identification (according to the British School of object relations) and countertransference enactment (according to classical or ego psychology) involve an understanding of the analyst’s countertransference as a joint creation by patient and analyst (Gabbard, 1994a, 1994b, 1994c). The analysand evokes certain responses in the analyst, while the analyst’s own conflicts and internal self-andobject representations determine the final shape of the countertransference response. Gabbard (1995) clarifies that projective identification is usually associated with more primitive patients with severe personality disorders and psychoses, and it reflects the analyst’s experience of being overcome by an ego-alien force that he feels is highly unfamiliar. Hence, projective identification generally connotes aspects of the patient being activated in a powerfully coercive way in the analyst. On the contrary, enactment implies greater contributions from the analyst’s unconscious conflicts that may be evoked by the patient’s behavior. Certainly the experience of the analyst is not an exact replica of the patient’s projected internal self- or object-representation.

 

The Participants’ Psychotherapy Excerpts and their Rorschach Thematic Imageries

We undertook a thorough comparative analysis of the four participants’ Rorschach protocols after one year of the psychotherapy. We were searching for common characteristics that could be correlated to the projective identification mechanisms of the psychotherapy process. This led us to Weiner’s thematic imagery (1998) related mainly to the associational aspects or the content themes of the Rorschach responses. Thus:

1. The number of human responses [H].
2. The ratio of whole human to human detail plus whole human fictional or mythological and human detail fictional or mythological [H: Hd + (H) + (Hd)].
3. The three indices based on content categories: Isolate [Botany, Clouds, Geography, Landscape, Nature], intellectualization [Art, Anthropology], and Hypervigilance [Clothing] provide information on the personality dynamics that constitute the subjects’ inner life.

Also, the responses charged with projected elements disclose the individual’s underlying needs, attitudes, conflicts, and concerns. According to Weiner, “selective attention and differential emphasis in Rorschach content interpretation has much in common with guidelines for interpretation in dynamic psychotherapy” (1998, p. 177). Projection occurs in Rorschach responses that involve form distortion [F-minus], movement [M-minus], or embellishments [Critical Special Scores].

Weiner and Exner (1991) developed measures of personality related to psychic changes in the Rorschach. These aspects are

1. Stress: D; Adj D; EA; CDI.
2. Difficulty dealing with experience: EB; Zd; Lambda; XA% X-%.
3. Problems with the experience of self: Fr+rF>0; 3r+(2)/R>.43 or <.33; FD>2.
4. Comfort in Interpersonal Relations: p>a+1;T=0;T>1; H<2; H<[(H) +Hd+ (Hd)].
5. Problems in Modulating Affect: Sum Sh>FM+m; DEPI=5; DEPI>5; Afr<.50; CF+C>FC+1.
6. Ideational Difficulties: Sum6SpSc>6; M->0; Mp>Ma; Intellect>5.

In Table 1 we present these variables of the two protocols of each patient related to their changes due to psychotherapy (Murray, 1993; Weiner & Exner, 1991).

 

 

As we can see, each participant shows their own singularity in the changes in their personality features. Aspects improved in some patients were impoverished in others. These changes occur in different directions, but there are some similarities.

Thus, as to the: (a) Stress variables there were 7 changes in the total (3,0, 2, 2); as to the (b) Difficulty dealing with experience there were 9 changes (5, 0, 2, 2); as to the (c) Problems with the experience of self there were 3 changes (0, 1, 1, 1); as to the (d) Comfort in Interpersonal Relations there were 11 changes (4, 2, 4, 1); as to the (e) Problems in Modulating Affect there were 6 changes (2, 3, 1, 0); as to the (f ) Ideational Difficulties there were 5 changes (1, 1, 1, 2).

Most of the changes occurred in the Interpersonal Relationship, followed by Difficulty dealing with Experience and Stress, and then by Affect, Ideation and Self Perception. These results are in accordance with Exner and Andronikof-Sanglade (1992) statement that thinking and self image are the areas of personality that need more time in psychotherapy in order to improve. Changes in Interpersonal Relationship are expected due to the therapeutic bond. Regarding the experience, there is a noticeable improvement in the reality test in three patients with less distortion in their perceptions. Also, two of them became more open to their experiences, manifesting feelings and emotional reactions, perhaps inaccessible before, displaying an increased contact with their inner emotional aspects at the expense of their affective responsiveness.

According to Smith (1993), responses to the cards often reflect key aspects of a patient’s self concept and points out that:

Projective identification differs from simple projection in that it involves the projection of a part of the selfrepresentation rather than simply an impulse. Typically, in projective identification, the object is treated in such a way that he or she behaves in a manner consistent with the projection . . . Lerner and Lerner (1980) suggested two indices of projective identification on the Rorschach (a) responses involving human content in which the formquality is pure and the response is overly embellished, usually with overtly sexual or aggressive material; or (b) human or human detail responses that are given to unusual details, use diffuse shading as a determinant, or use differences in shading to ‘carve out’ the response, and in which the figure is described either as aggressive or having been aggressed against. (p. 197-198).

Self and object representations are the building blocks of personality. Affect, self images, interpersonal relations and even thinking all derive from a child’s earliest relationships with significant objects. Thinking develops out of a mother’s capacity of rêverie (according to Bion, 1962) in the way that she accepts the baby’s projections, sensations, impressions and reactions of its inner world and transforms it into symbolic experiences. This is what happens in a psychotherapy context. Smith (1993) quotes Spitz (1957) who argued that the genesis of human communication as well as the earliest sense of the self lay in the opposition to the ‘yes’ of the caregiver.

We decided to compare the responses that each patient associated to the Rorschach in these two different moments. It is possible to verify whether the images have or have not changed in the first year of treatment and in which direction the changes would have occurred.

Alice

Card II First evaluation: “. . . A guy opened up, here’s the lung, all bloody . . . there are the marks of the ribs (points to shading inside), in the middle (space) the heart … dripping blood.”

Card II Second evaluation: “. . . A person on all fours, the head, part of his back, and here the sole of his feet (mimicking, feet behind).”

Observing the two evaluations through the thematic imageries, we can say that there is an evolution of the self and object representation; these representations seem less vulnerable and with more possibility of continence.

Card X First evaluation: “Lots of animals: a frog (D8), a cockroach (D1), because it has lots of paws, a little rat (D2) its little red eye, little paw, little tail, little ear.”

Card X Second evaluation: “. . . England, the island of Great Britain, because of the shape and because my brother is there and said that he wants to come home this weekend, I miss it.”

Through the images of the last card, we observe that there is an improvement, from a fragmented perception to a full image and the projection of feelings.

Iris

Card VI First evaluation:

. . . Two people strangling two other people, one weaker, more or less a child, that’s it. Here the feet of the weaker person, they are amalgamated, it is practically a fusion. Strangling because the head is hanging back. It’s like a mirror, a duplicate of the picture, so there are two people here and two people here.

Card VI Second evaluation: “A child sleeping on a cliff. The child is leaning over, this goes to the Oscar.” There is a growth, from a fusion image of two people she builds an image of a single person who expresses separation anxiety related to the risks and dangers within the process of individualization (Mahler, 1968).

Dora

Card I First evaluation: (the images are contaminated) “It looks like an animal, a bat. To me there is first a face of a guy who gets the face of an animal and looks like a bat too.”

Card I Second evaluation:

A face trying to frighten me and a somber image, terrifying. Because it is shadowy, the gloomy colors scare me a lot, the brown, the red, the black, the dark green; these colors appeared often to me when I was hallucinating. Gloomy because it looks like something that troubles me at the end of the day. Frightening.

Again, from a fused image Dora moves on to manifest consciously what frightens her: fears, disturbing memories from her hallucinations, anguish.

Agatha

Card II First evaluation:

This little red part here below looks like a little butterfly. These little red parts above looks a butterfly in profile. These little black parts look like a dog’s muzzle, when he is in profile and his ears are down.

Card II Second evaluation: “It looks like a sad person, with his mouth open and his tongue sticking out.”

From concrete, superficial and childish images, Agatha turns to a sad face, a human projection, even though of an odd quality & depicted in a grimace.

We saw through these Rorschach images the kind of self and object representations: partial objects, aggressive images, vulnerability and frailty, helplessness, despair. All these experiences were also present and lived in the interpersonal contact with the analyst. Therefore, in the therapeutic context, the analyst can receive, hold and metabolize these experiences.

 

The Participants’ Psychotherapy Excerpts and their Rorschach Thematic Imageries

We will present a few selected Rorschach responses of the two protocols of each participant related to their changes subsequent to some examples of analytical situations. In these situations, it has been possible for the analyst to stick to his analytic function, to realize what is going on during the session and thus to build together with the analysand new representations and elaborations. Thematic imagery analysis also provided subtler indicators of the changes in the participants’ protocols, while the psychotherapeutic sessions lent plausibility to the thematic interpretations that we will present.

 

 

Alice 2^nd Year

The first period of separation due to her analyst’s vacation coincided with Alice’s trip to London, where her brother was living. At her last session before the interruption, the emotional atmosphere was very tense, with suspense about the possibility that the trip could be a total disaster for Alice and her fear of an emotional rupture. Coincidently, that day, the analyst had with her a book, ‘Harry Potter and the Philosopher’s Stone’ and decided to give it to Alice. After the holidays, when the sessions resume, Alice brings the second volume of this series, ‘Harry Potter II’, Harry Potter and the Chamber of Secrets, and gives it as a gift to her analyst saying that during her trip when she felt very sad, she picked up the analyst’s book to read it.

Some examples of Alice’s responses:

Card IV first protocol:

. . . A rat opened up \/ because this reminds me of the rat’s little nose and the little head. It looks like a hamster, the whole body opened up. The rat’s skin divided in the middle, cut and opened.

Card IV second protocol:

. . . A rat opened up, this dark brown part reminds me of the rat’s little nose, and here it’s cut in the middle and opened up . . . A tree, all stripped of bark, here’s the trunk, it looks like loads of bark from the tree itself, it looks as if the tree’s bark has been removed, stripping. Like it’s peeling, at home there is a pine tree and sometimes it starts to peel (points at the card indicating texture).

Through the response of the 1st protocol, it is possible to see how Alice felt: splitted in two, exposed to the analyst in her vulnerability and frailty. In her 2^nd protocol, the same image remains, although less intense, especially concerning the details and description. She adds the image of the tree, that is, she was referring to the same phenomenon (peeling, taking out the skin) but no more as an aggression from the external world but as a natural process of renewal, renovation. Our hypothesis is that Alice seemed to have accepted separation not only as threaten but also as a growing process.

 

Iris 2^nd Year

Because she is extremely scared with a real situation of a rapist in the neighborhood of the clinic and in order to keep going with the therapy, Iris’ analyst started to accompany her to a point nearer her home out of danger after the session and in the same way he will meet her in this point before her session. Once, when they were walking the analyst hears Iris talking to herself: “If my father were alive, would he do this to me?”

Some examples of Iris’ responses:

Card IV first protocol:

A monster, monster in the form of a tree trunk. Two heads, empty like this, with no outline, two emptied heads, with no nose, eye, mouth. A head split open by an ax, a crack, a split. Behind the trunk there are two heads, too, but we can see the nose like this … yes … how can I explain… eaten by the ashes.

Card IV second protocol:

A monster, its head split in half, there is an incision, a surgery, here’s the cut, a fissure, the darker part, the lighter part. Look! There are two people. I think I had a nightmare, I’m not sure. I saw two people, their heads empty, an empty face, really there’s no shape, there’s hair, but no eye, nose, or mouth, it’s an empty face, and I think it’s me.

In her 1^st protocol the perception shows Iris fears, the danger, death and annihilation anguish. The same image remains on the second but now Iris describes a medical procedure and not only an attack. The other figures are named as a nightmare, that is, she can have some discrimination between external and internal world. She sees emptiness, danger and pain inside herself, the same process occurring in her therapy, where she can relate the external dangers, her need of protection and elaboration of her internal objects.

 

Dora 2^nd Year

During one session, Dora has an anxiety crisis. After suggesting that she lay down on the coach and holding her hand, the analyst brings her a glass of water. She doesn’t drink and remains sitting, moving her body and groaning. Because Dora’s mother refuses to come and pick up her daughter, the analyst, being afraid of an impulsive self-destructive act, takes Dora for a ride in her car. Slowly, Dora calms down and, recognizing her bus, says that she was feeling better and could be left alone. She thanks the analyst saying there’s nothing to worry about. The analyst waits until Dora takes the bus. Arriving home, Dora calls the analyst confirming she was better.

Some examples of Dora’ responses:

Card II first protocol: “Here, it looks like two animals fighting and this red part gives the impression of being blood… It looks like one is pushing the other… the fight and then it started to bleed.”

Card II second protocol:

Two animals sparring, bleeding. Sensation of impotence, blood, pain, sacrifices. A fight for a goal it seems will not be achieved. They are pushing each other by their paws. Because they have nails they are hurting each other, it is bleeding, there is blood, it is dripping, and blood is spurting upward and falling. Here, inside them, this red blot it is blood too. They are fighting, they are even, and they aren’t getting anything, as if they were one person only, they are in the same pattern, they are hurt and neither one will win the fight.

Dora reedits her perception in a less defensive and more vivid way in her 2^nd protocol, this time she expresses feelings pain and impotence about ‘her’ fight, showing that, little by little, she becomes aware of what happens inside herself, in her inner world. Probably what makes her feel so anxious is the perception of her loneliness and helplessness. The therapist is able to have empathy for these feelings and plays the role of an attentive mother. She doesn’t abandon Dora to her impulses and destructiveness. She can see this is an important moment of her therapeutic process, since Dora can have some insight of her mental functioning as well as her main difficulties.

 

Agatha 2^nd Year

When her psychiatrist asked to be replaced because she wasn’t feeling comfortable treating her, Agatha becomes despondent and started having crises of helplessness expressed through pains all over her body. When she came to the session she was in such a deplorable state that the analyst got the impression that she wouldn’t be able to get up from the armchair to leave. On two occasions, the therapist was compelled to hold Agate by her hand and take her to the ER have her hospitalized. Agatha was saying she needed to stay in observation, in bed, to be fed, medicated, and taken care of. However, the ER psychiatrics did not agree, saying she could stay home. These movements led Agatha to realize that she was missing her therapeutic sessions and she finally said to her analyst that she doesn’t want to be taken to the ER anymore because the doctors there didn’t do anything for her. From this point onwards she has been treated by a new psychiatrist.

Some examples of Agatha responses:

Card III first protocol:

This black part looks like an X-ray from here, the hip. This little red part looks like a butterfly. These two pieces look like kidney.

Card III second protocol:

These two little things look like a little human embryo with umbilical cord. First, the head develops, and then the spine and it remains a strange little thing. It is through the umbilical cord that it is fed. Very little, one month or one week.

Through her protocols, we can see that Agatha develops from an anatomy response to a human figure, although a regressed and primitive one, there is a possibility of developing. In her therapy, Agatha achieves an insight when she realizes that she needs a psychic ‘food’ in order to grow & the active relationship with her analyst and not only a passive position of being a patient to the physicians. She expresses a belief in her own development.

 

Comments

The comparative reading of the Rorschach thematic imagery contents of both protocols speaks for itself. These contents uncovered the patients’ intense and massive projection showing their state of high vulnerability and turbulence. They seemed scared when they realize the crude nature of their needs and their feelings. They looked frightened with the strength of their impulses. They express very primitive mental states with intense sensations and emotions as well as painful feelings where danger is very close and real to them.

As the Rorschach could show, the changes experienced at the intra-psychic level by each one of the participants, in their singularity, were also lived or acted at the interpersonal level, through the duo analystanalysand experiences. However, they can be used for a creative or a destructive purpose. Acting outs may take place aiming to disrupt the setting, to attack the bond or even to test the therapist’s coping capacity. These women are always seeking a more continent relationship that will allow them to change the archaic ways in their relationship with their internalized objects. We also look to focus on the repercussions of these patients’ significant moments for the psychoanalyst.

As we also could see, the four analysts were able to experience intuitively and empathically these mental states communicated through projective identification by the analysands. They understood that their analysands’ acting outs were their only possible way of communication at that moment. They realized that they have to find a way to keep this communication even if they need to expand the analytic setting outside the room in order to maintain their analytical function, their internal setting.

The participants’ unbearable and dreadful object- and self-representations projected into the analysts were recognized, contained and transformed by the analysts who did not feel threatened by these raw materials. The analysands were able to live a new and smooth relational experience once the analyst could bear their sensations, feelings, and discharges. This new experience opens a new door for the analysand: acceptance of his self with its dangerous and threatened contents.

 

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Received 29/10/2007
Accepted 23/05/2008

 

 

Norma Lottenberg Semer. Psicóloga pela Universidade de São Paulo (USP), Coordenadora do Setor de Psicodiagnóstico do Departamento de Psiquiatria da Universidade Federal de São Paulo (UNIFESP), Doutora em Saúde Mental pela UNIFESP, responsável pelo estudo: “Psicoterapia Psicanalítica de Pacientes Portadoras de Fibromialgia” do Projeto Temático: “Psicoterapia Psicanalítica de Pacientes Previdenciários” (Fundação de Amparo à Pesquisa o Estado de São Paulo & FAPESP), Membro Associado da Sociedade Brasileira de Psicanálise de São Paulo.
Latife Yazigi. Professora Titular da Disciplina de Psicoterapia do Departamento de Psiquiatria da UNIFESP. Vice-Presidente da International Rorschach Society. Pesquisadora responsável pelo Projeto Temático: “Psicoterapia Psicanalítica de Pacientes Previdenciários” (FAPESP).
Maria Luiza de Mattos Fiore. Psiquiatra Assistente da Disciplina de Psicoterapia do Departamento de Psiquiatria da UNIFESP, Doutora em Saúde Mental pela UNIFESP, responsável pelo estudo “Ensino de Psicoterapia para Residentes em Psiquiatria e Especializandos em Psicologia da Saúde”, do projeto temático supra citado. Membro Associado da Sociedade Brasileira de Psicanálise de São Paulo.
Julieta Freitas Ramalho da Silva. Professora Assistente e Chefe da Disciplina de Psicoterapia do Departamento de Psiquiatria da UNIFESP, Doutora em Saúde Mental pela UNIFESP, responsável pelo estudo “Psicoterapia Psicanalítica de Pacientes Borderline”, do projeto temático supra citado. Membro Associado da Sociedade Brasileira de Psicanálise de São Paulo.
Salvador Mario Bianco. Psiquiatra Assistente da Disciplina de Psicoterapia da UNIFESP, Mestre em Saúde Mental pela UNIFESP, participante como terapeuta do projeto “Borderline” e como supervisor do projeto “ensino”, ambos do projeto temático supra citado.
Patrícia Gazire. Psicóloga pela USP, Mestre em Saúde mental pela UNIFESP, participante como terapeuta do projeto “Borderline” do projeto temático supra citado.

¹ Universidade Federal de São Paulo, Rua Botucatu, 740, 3° andar, Vila Clementino, São Paulo, SP, CEP 04023-900, Brasil.
Telefone: (11) 55764160; Fax: (11) 55717254.
E-mail: norma.lsemer@terra.com.br