Schafer’s (1954) “Constants in the Patient’s Psychological Position” in Rorschach Testing: Implied Consent & Case Illustration
Jed Yalof
Securing a patient‘s informed consent (American Psychological Association Practice Directorate, 2024) to a psychological evaluation includes, under most conditions, clarifying the client‘s understanding of the reason for the referral and goals of the evaluation; record keeping and storage; fees and payment; confidentiality, HIPAA, and legal parameters; contact policy; report recipients; feedback procedure; voluntary participation; and freedom to withdraw from the evaluation without penalty. Informed consent is a legal term and differs from implied consent (Nosak et al., 2011), which includes psychological processes outside of conscious awareness or control. Roy Schafer‘s (1954) description of ―constants in the patient‘s psychological position‖ appears consistent with the notion of implied consent as applied to a psychodynamic understanding of Rorschach test administration. Schafer‘s constants are represented by: (a) self-exposure in the absence of trust, (b) loss of control in the interpersonal relationship, (c) the danger of self-confrontation, (d) regressive temptations, and (e) the danger of freedom. In this study, I apply these constants in an integrative way, following test administration stages used by the Rorschach Performance Assessment System (R-PAS; Meyer et al., 2011) and the Comprehensive Systemrevised (CS-R; Exner et al., 2022).
Psychological assessment requires the psychologist to strive to obtain client consent ―where appropriate‖ (American Psychological Association; APA, 2020) prior to participating in an evaluation. The Ethical Principles and Code of Conduct (American Psychological Association, 2002), APA Guidelines for Psychological Assessment and Evaluation (2020), and Informed Consent Guidance and Templates for Psychologists (APA, 2024) provide assessors with informed consent guidelines for psychological assessment. Guidelines include clarification and ensuring the client‘s understanding of the reason for the evaluation, goals of the evaluation, record keeping and storage, fees and payment, confidentiality and legal parameters, contact policy, HIPAA information, who receives the report, and the client‘s voluntary participation and freedom to withdraw from an evaluation without penalty.
What the client consents to either verbally or on a standard consent form does not, however, encompass implied consent. Informed consent is a legal term and differs from implied consent, which includes the engagement of psychological processes outside of the client‘s conscious awareness or control as part of a procedure (Nosek et al., 2011). Clinical implications of implied consent are prominent in personality assessment, where test responses are integrated through algorithms of true-false, ordinal, and coded variables, qualitative interpretation of response content, and clinical observations of the client‘s test-taking behavior and relationship with the assessor. In projective personality testing, which Piotrowski‘s (2015) survey identified as having strong worldwide utility amongst practitioners, the concept of implied consent has particular saliency. This is especially the case with the Rorschach test, which, along with the Thematic Apperception Test (TAT; Murray, 1943) are the most frequently taught measures in clinical psychology doctoral programs (Mihura et. al., 2017) accredited by the American Psychological Association. Villanueva van den Hurk and colleagues (2023) reported on the increased popularity of the Rorschach-Performance Assessment System (R-PAS; Meyer et al., 2011) which, with the Comprehensive System (CS; Exner 2003), remain the two most popular Rorschach systems taught in doctoral clinical psychology programs accredited by the American Psychological Association. The Comprehensive System-Revised (CS-R; Exner et al., 2022) upgrades the original CS with respect to administrative and interpretive strategies. Both tests, however, are foundational to understanding how the concept of implied consent imposes psychological risks to the client that are not obvious until testing is underway, a point which I elaborate as follows.
Considered within the category of performance-based personality assessment measures (Meyer & Kurtz, 2006), the Rorschach has administration procedures that impose unique psychological demands on the client. In Rorschach testing, the client is required to scan and respond to inkblots, identify percepts, and decide what to say and how to say it. In other words, there is a silent process of sifting, associating, sorting, and settling on a percept that becomes the verbalized response. For example, a client might have a series of private reactions when scanning Card I that include the popular ―bat‖ response such as ―It could be a bat, a strange looking bat, a morbidly dark bat, the Batman symbol, and a bat with wings that need to be clipped.‖ How the client responds, however, will differ, depending on character style.
Roy Schafer, in his classic book, Psychoanalytic Interpretation in Rorschach Testing (1954), identified a series of constants in the client‘s psychological position when taking the Rorschach test that have implications for implied consent. Schafer address this point directly: ―In what follows, attention will be centered on the irrational, primitive, usually implicit attitudes and conceptions in the patient being tested‖ (p. 33). Constants in the patient‘s psychological position were described as: (a) self-exposure in the absence of trust, (b) loss of control in the interpersonal relationship, (c) the danger of self-confrontation, (d) regressive temptations, and (e) the danger of freedom, each of which poses an implied risk that could lead to unpleasant experiences associated with the Rorschach task. Schafer described how the client ―takes on faith its helpfulness and the tester‘s helpful intent‖ (p. 33) but then qualified this more benign disposition by stating that even ―ostensibly positive and cooperative conscious attitudes toward the testing —as well as adequate test behavior itself— may be disrupted‖ (p. 33). Schafer (1956) elaborates these points when discussing transference reactions to the tester in Rorschach testing.
Although Schafer (1954) presented the five constants as discrete categories for descriptive purposes, his intent was to highlight their integration across the administration of the Rorschach test, a point which I explain as follows. Rorschach test administration procedures are thought of as distinctive phases in the assessment process and less so as dynamically tinged experiences organized around unconscious psychological processes, as Schafer suggests, that help define the client‘s experience of a Rorschach administration. There are aspects of Rorschach administration, including implications of pre-response scanning of the inkblots (Dauphin et al., 2024), modification in number of cards utilized (Kleiger, 1997), audio-taping versus writing responses (Meyeret al., 2011), seating (Exner et al., 2022; Meyeret al., 2011)and psychoanalytic implications of readministration procedures (Yalof & Rosenstein, 2014) that have been addressed in the Rorschach literature; however, no literature applies Schafer‘s psychodynamic model across all aspects of administration. In what follows, I summarize each of Schafer‘s five constants and then discuss each in relation to four aspects of the Rorschach test procedure: (a) seating arrangements, (b) introducing the Rorschach, (c) response and inquiry, and (d) record length and re-administration procedures as outlined in Rorschach Performance Assessment System (R-PAS; Meyer et al., 2011) and The Rorschach: A Comprehensive System-Revised (CS-R; Exneret al., 2022). Bram and Yalof (2018) discussed strengths and limitations of the R-PAS and the original CS (Exner, 2003) systems.
The current paper further builds on these comparisons by integrating Schafer‘s psychological constants across administration procedures of R-PAS and CS-R.I use a narrative format to illustrate how Schafer‘s ideas can be integrated within each stage of Rorschach test administration. Since Schafer‘s clinical examples involved young adults and adults, I apply my ideas only to these populations. An illustration highlights the integration of each of Schafer‘s constants in relation to a Rorschach response, with cross-measure support for this response provided by a TAT (Murray, 1943) response.
Schafer’s Constants
Self-exposure in the Absence of Trust; Violated Privacy
Schafer recognizes the client‘s conflict between the desire to disclose and inhibit disclosures when presented with the Rorschach stimuli. He states, ―It is generally true that the testing situation is not spontaneously sought out by the patient and that the process of self-exposure is not relished‖ (p. 34). He describes how the patient confides ―innermost matters‖ (p. 34) to a stranger whose trust is not earned over time, and whose professional boundaries define the relationship. With respect to boundaries in the relationship, Schafer states, ―On his side, the tester reveals next to nothing of his inner self‖ (p. 35). On other hand, Schafer also describes how the transience of the relationship and the client‘s not being aware of ―much of what he is communicating and exposing‖ (p. 35) are protective factors that reduce anxiety over what can be experienced as violation of privacy.
Loss of Control in the Interpersonal Relationship
Schafer states that the ―balance of power seems very much to be on the tester‘s side‖ (p. 36). Elements of the client‘s submission are shaped by what Schafer described as the autocratic and oracular aspects of the Rorschach assessor‘s role, which engages the client‘s ―realistic and transference modes of coping‖ (p. 36) in relation to authority. Further, the colors, shadings, shapes, and other inkblot features make the client confront what they might otherwise choose to avoid or approach at their own discretion. Not having the freedom to do so, however, leads to a disruption in typical ways of interacting with the environment and a reduction in control over preferred response options.
Danger of Self-Confrontation
The danger of self-confrontation can be summed up as, ―You can run but you can‘t hide.‖ Conflicts and their associated defenses are portable. Unconscious danger lurks when a flurry of images passes across the client‘s mind when handed an inkblot. At the beginning of this section, Schafer states, ―It is becoming increasingly clear that testing represents and is felt by the patient as an assault on his defenses‖ (p.38). Fears of being confronted with disowned self-representations and ―the risk of becoming prematurely aware of angry, dependent, sexual, or shameful feelings, for example, which can result in ―painful external blows to selfesteem‖ (p. 39).
Regressive Temptations
Early in his discussion of regressive temptations, Schafer states, ―Filled with feelings of futility, he is tempted to give up the struggle, regress to an overly passive and helpless position, and demand that some real or fantasized figure in the environment ―nurture‖ and ―save‖ him‖ (p.38). Schafer frames the regressive temptations imposed by the demand characteristics of the Rorschach test as a tension between two competing alternatives: passivity in the face of needing help and a fear of relinquishing autonomy. Examples of adapting to this tension might include counter-dependency, confusion about expectations, and blaming the assessor for the vagueness of test instructions.
The Danger of Freedom
Schafer describes the risks and rewards of being free to respond without rules. Depending on character styles and preferred modes of adapting, clients might react by asking questions about the test, testing process, and response process (Meyer et al., 2011, pp. 10-11). Other comments might be associated with attempts to create a social encounter (e.g., talking sports after each response), taking advantage of newly found autonomy by making dismissive remarks about the test or assessor, or by becoming overly concerned about who has the authority to review the report and requiring the assessor to assume responsibility for managing client anxiety or suspicion during the evaluation.
Application Rorschach Procedure Seating Position
R-PAS introduces the seating arrangement by stating, “To do the Rorschach (or the inkblot test), we need to sit side- by-side, so that I can see the cards as you hold them” (italics in original, p. 7). For clients who experience the requested seating arrangement as awkward, the assessor might add, “Also I do not want to interfere as you look at the card, so I am going to sit off the side here” (italics in original, p. 7). R-PAS assessors are encouraged to be aware of diverse cultural meanings attached to the intimacy associated with side-by-side seating and to address questions that emerge in response to cultural differences in a sensitive manner while maintaining fidelity to the seating requirement. CS-R highlights the importance of assessor neutrality supported by the side by-side position and notes that the side-by-side seating arrangement reduces the ―natural feelings of being judged‖ if seating position is face-to-face and ―induces the desire to give the best possible performance
(p. 6). CS-R recommends that all testing be administered side-by-side to reduce the unexpected and sudden shifting of seating positions during an evaluation, exceptions (e.g., forensic assessment) notwithstanding, but this type of seating arrangement is not widespread practice.
The interaction between Schafer‘s constants and the Rorschach seating arrangement is applicable in the following manner. Whatever degree of assessor-client alliance and trust developed prior to Rorschach administration is placed at risk by the decision to modify the usual seating arrangement from face-to-face to side-by-side. This shift in seating position is more relevant to R-PAS than CS-R, which states that side-to-side is preferred for all tests, though test manuals have different preferences for seating position depending on the types of tests administered as part of an integrated, multi-method assessment battery. Moreover, the transition request is loaded with language that can leave the client uncertain about expectations despite the assessor‘s wellintentioned efforts to provide a rationale for the change in seating positions. R-PAS instructions include the assessor ―not wanting to interfere‖ with the client by sitting off to the side, whereas CS-R aims to reduce the client‘s sensitivity to being judged with the goal of supporting the client‘s ―best possible performance.‖ Questions arise about the uniqueness of the Rorschach test: What, for example, do― not wanting to interfere‖ and ―best possible performance‖ imply and why would the client feel ―less judged‖ if eye contact with the assessor was reduced or lost?
Client compliance with seating is expected at the expense of agency and control. The client has no recourse and, depending on character, might comply without feeling empowered to ask questions, or ask the assessor pointed questions (e.g., ―Can you say more about why I have to sit this way?‖), show discontent through anxious commentary (e.g., ―This feels weird, makes me uncomfortable,‖), express feelings nonverbally (e.g., obsessing about aligning the chairs to exacting side-by-side coordinates), or complain verbally (e.g., ―How long is this test going to take?‖) in an effort to irritate the assessor as a counter to a reduction in personal agency. Both R-PAS and CS-R recommend that the assessor respond neutrally to client questions about other parts of the Rorschach test and provide examples on how to respond to client queries but offer no examples for addressing reactions to the seating arrangement. In fact, R-PAS states, ―The respondent typically experiences it as a standard, insignificant procedure‖ (p. 7). This might indeed be the case assuming manifest rapport has been established but Schafer‘s psychological constants operate under the radar, influencing clients in ways that might manifest through behavioral observations of the client‘s test-taking behavior that speak to an underlying sense of confusion or discontent. Freedom to question authority is reduced as both seating arrangement and minimally elaborated responses to queries are under the assessor‘s full control. Moreover, typical verbal cues from the assessor present in other tests are diminished, forcing the client to rely less on direct visual contact and previously established rapport and more on recollections of the assessor‘s tone of voice, facial expressions, or even visual representations of the testing room itself based on a prior face-to-face seating orientation that likely characterized the administration of other tests. While nonverbal face-to-face cues may be reduced significantly, it is plausible that the client‘s responses are affected by visual and auditory memory residuals based on prior interactions or even by illicit ―sneak peeks‖ at the examiner during the evaluation, which provides a measure of reality-based anchoring. The danger of self-confrontation arises when the inkblots evoke more primitive feelings than anticipated without the usual options of avoidance; here, images persist even when discarded as possible responses, whereas regressive temptations take the form of balking at a shift in seating arrangements, devaluing the assessor, and feeling confused or free to indulge responses that would otherwise be inhibited in everyday exchange governed by a higher level of structure and psychological distance created by the side-byside seating arrangement. In sum, we can see how the dangers of self-exposure, reduced agency, selfconfrontation, regression, and loss of freedom emerge during what on the surface might appear to be a minor request designed to strengthen the client‘s ability to perform well.
Introducing the Rorschach
When introducing the Rorschach, the assessor asks if the client has taken the test before and proceeds with instructions that differ depending on the assessor‘s preferred Rorschach method. The R-PAS assessor informs the client that they will be handed the inkblots with the task of responding to the question, ―What might this be?‖ Once reassured that the client understands the requirement, the assessor states, ―Good, we can get started then. Try to give two responses, or maybe three to each card‖ (p. 9). The assessor pauses after stating the word ―two‖ and places less emphasis on the word ―three‖ (p. 9). The CS-R assessor introduces the test as follows: ―We will now proceed with the Rorschach test. Have you heard about it? Were you administered this test before?‖ (p. 8). For clients unfamiliar with the Rorschach, the assessor states, ―It‘s just a series of inkblots that I‘ll show you and I want you to tell me what they look like to you.‖ (p. 8). The only directive upon handing the client the first inkblot is, ―What might this be?‖ (p. 9).
Questions arise about how clients might perceive these instructions; for example, how is the client to understand the implications of ―two responses or maybe three responses‖ with a brief pause after ―two‖ as provided by the R-PAS assessor? The client might question whether three responses are better than two responses, the meaning of the pause, and the possibility that there could be consequences if only one or more than three responses are offered? The way in which Schafer‘s psychological constants might emerge are as follows. With respect to trust, can they take the assessor‘s word that three responses are acceptable, or, for example, hear the assessor‘s setting a boundary with ―or may be three‖ as a tempering of ambition in the face of a challenge, a competitive dare to challenge the limits, an invitation to regress passively and give only one response or actively tempt fate and offer four or more responses. How much freedom and control does the client have? CS-R provides even less direction by only asking the client to state what the inkblot might be; however, as noted below in the discussion of record length, both procedures have more in store for the client with respect to managing record length that were not part of the initial directions and interface with Schafer‘s constants.
Response and Inquiry
The embeddedness of Schafer‘s psychological constants throughout distinct phases of the Rorschach test is highlighted by the complex and interrelated processes of what R-PAS designates as response and clarification phases and CS-R identifies as the phases of free association and inquiry. I have opted to use ―response‖ for the phase where responses are offered and ―inquiry‖ for the phases where responses are queried to clarify various coding categories for the assessor while acknowledging the distinctive terms used by each method. Within the response phase, there are directions for managing brief and lengthy records. For the R-PAS method, the client does not know that one response to a card or a card rejection will result in the assessor prompting for more responses or that the card will be pulled after a fourth response to any card during the administration. These procedures are intended to optimize performance by securing the ideal of 27-32 responses for interpretive application in relation to the R-PAS norm base. The CS-R assessor prefers 14-50 responses per record but less specific about the requested number of responses per card compared to the R-PAS assessor and has a different approach to managing the response phase when there is a concern about either underreporting or over reporting of responses. If the CS-R client offers only one response to each of the first four cards and these responses are ―simple or if they are based on a single detail, the assessor does not accept the card…‖ (p.15), and states, ―Wait, don‘t try to hurry through these. Please take your time and look some more‖ (p. 14). Card rejections on the CS-R are met with an encourager: ―Take your time. We‘re in no hurry. ―I‘m sure you‘ll find something there‖ (p. 13).The R-PAS assessor responds to a card rejection by encouraging the client to take their time and try to provide more responses by stating, for example, ―You can do it.‖ (p. 15). The CS-R assessor addresses lengthy records by determining if ―the flow of responses becomes evident on card 1, the recommended procedure is to take back the card after the fifth response, thanking the person and saying, ―Now I‘m going to show you the next one‘‖ (p. 15). The procedure is continued on each subsequent card as long as five responses are given; once the response number falls below five, the assessor does not take the card back even if there are more than five responses to the follow-up card(s).
Following the completion of the response phase, the assessor poses a series of queries to each response with the goal of clarifying location, determinants, form quality, and other coding categories specific to each method. Queries are neutral (e.g., ―You said ‗darkish‘ when mentioning the cloud. Help me see it like you do.‖) but can be experienced in diverse ways depending on client character style and different dynamics that are operable during the evaluation (c.f., Schafer 1954, pp. 6-32).Assessor uncertainty about Rorschach coding for a particular response can render a client confused and wondering, either during or after the test administration is completed, about how to respond to nagging question related to the assessor‘s inquiry (e.g., ―Why did he ask a question when I said, ‗the lighter and darker tones‘ when I saw a vagina, but no question when I said ‗lightish‘ after I saw a cloud on another card?‖). A decision not to ask a question provides an example of how Schafer‘s psychological constants are expressed when responses are queried. Client agency can be affected by uncertainty about whether to ask the question, whereas the danger of regression is potentiated by confusion about expectations. Compliance and trust might lead to curiosity but no further entertainment of the issue. Selfconfrontation and feelings about privacy become riskier, for example, in the context of whether to ask a question because the client might not want to draw further attention to a sex response or, in contrast, might wonder if ambiguity of external direction and authority might signal a further loss of control under these conditions, whereas the chance to respond freely without rules in challenged by the wish to comply with the idea that questions cannot be asked and the danger of regressing.
Re-administration
In cases where the client does not provide the preferred minimum number of total responses, R-PAS assessors recommend ―an additional response phase‖ (p. 15) ―if 15 or fewer responses emerge during the RP‖ (p. 15). The original responses are not queried; instead, the assessor states, “That was fine. However, we need a few more responses for the test to be helpful. So let’s go through the cards again. Take your time when looking at them and see what other things you can come up with.‖ (Italics in original, p. 25). Clients are then provided with an opportunity to view each card to which fewer than four responses were administered and add responses (returning cards if the four-response ceiling is met), which are then combined into a single, complete record following which the responses are subjected to inquiry. The CS-R does not advocate for re-administration when fewer than 14 responses are given but states, ―Sometimes it is possible to propose the Rorschach anew in another session.‖ Conditions for making this type of recommendation are not specified but appear to be at the assessor‘s discretion. Schafer‘s psychological constants are easily identifiable through the R-PAS readministration procedures. Yalof and Rosenstein (2014) discussed superego pressures related to asking a client to retake the Rorschach. The R-PAS client is unaware that the assessor will merge responses from both records into a single record. Re-administration exposes the client to a sense of ―not good-enough,‖ or ―good, but you can do better; I still need more from you.‖ There is pressure to produce, but there is also a potential for breach of trust, of having to offer responses that might have been screened, fantasies about whether the assessor wants a certain type of response, self-questioning about the impression generated by low productivity, a challenge to turn passive into active, and a loss of freedom to control output.
Illustration
The following hypothetical case highlights Schafer‘s psychological constants in relation to the client‘s presenting problems. An adult male physician was referred, begrudgingly, by his therapist because of disinhibition and dismissive behavior toward colleagues resulting in two complaints filed with the Human Resources department, including a recent situation in a bar where he made sexually provocative remarks to a coworker. Using the R-PAS coding method, painful self-exposure in the absence of trust was suggested by his first response to Card 1 (―Brain split with white myelin showing‖). Myelin sheath coats the neuron and serves as a conduit for efficient neuronal communication between cells in the nervous system. The response of exposed myelin in a split brain suggested a disconnect with impairment in easy communication. For coding purposes, the response included the whole blot (W), white space integration (SI), dysphoric affect (C‘), an unusual form quality (Fqu), a morbid theme (―split open‖) and was accompanied by a pointed question about trust in the relationship (―I‘m saying this to you but don‘t feel comfortable with what you might do with it.‖). The assessor tries to reassure the client by stating that he just needs to say what he sees and reminding him that he will have an opportunity to read the report. The client‘s discomfort persists. The response ends with the client stating, ―That‘s all I got for you today.‖ With palpable relationship pressure mounting, the assessor prompts for a second response, to which the client replies with a nonverbal show of annoyance, a thirty second delay, and then with the popular ―bat‖ response. Even though the client could have said something else, he withholds, feels a loss of freedom, and reacts by regressing, demonstrating frustration, and heightened uncertainty about the wisdom of agreeing to an evaluation. He then gave four responses to Card II and was on the verge of providing a fifth response when the assessor pulled the card. The client stated, ―What are you looking for? I thought you wanted more than one response.‖ The assessor replied, ―at least two, maybe three.‖
In this brief illustration, performance-based manifestations of Schafer‘s five constants emerge quickly.
The client displays discomfort around trust and privacy, the danger of self-confrontation, regressive temptations, diminished agency in the relationship, and the danger of freedom. These constants are neither encompassing nor empirically derived but instead reflect a psycho analytically informed theoretical base and serve as descriptors for understanding the embedded and less conscious psychological risks that clients tacitly accept when agreeing to a personality evaluation. The client‘s response to TAT Card 13MF provides additional information related to Schafer‘s constants. In this story, the male figure is preoccupied with the woman‘s exposed breasts. The man in the card feels shame with his hand over his eyes, but the client then states, ―This is too much. Makes me think of HR. Hard for me to control my thoughts here. I hope he feels some guilt, but who knows? Take this card away.‖
He then laughs but with a sense of embarrassment. The dangers here are related to self-exposure, shame and guilt when confronting his behavior, yielding to a regressive temptation both in the narrative and after the story, and indulging freedom while also questioning if it comes at the cost of painful embarrassment.
Discussion: The Rorschach test, because of its uniquely structured ambiguity, places considerable emphasis on the client‘s intra psychic adaptation to test stimuli which, in turn, illuminates the client‘s character and transference engagements. The concept of implied consent has particular relevance to the Rorschach since there are subjective risks when test administration procedures are presented without much direction about process and expectation. Under these conditions of test administration, the Rorschach client is exposed to character logical vulnerabilities that can be framed conceptually, as suggested by Schafer (1954), around a group of psychological constants, each of which exists on a dynamic continuum that can manifest in response variables, content, sequence, and in the client-assessor relationship. One might consider the possibility that Schafer‘s five constants might be integrated under different report headers as freedom of self-expression, capacity to regress and resilience, agency, frustration tolerance and affect expression, and capacity for healthy relationships, or find integration within a psychodynamically informed report. The case analysis provides an example regarding how these constants are operable during Rorschach administration and transference sensitivities that can arise in response to these considerations (Schafer, 1956).
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