SIS Journal of Projective Psychology & Mental Health

The Case for Projective Measures in Bariatric Psychological Evaluations: A Review of the Scientific Literature

Chris Piotrowski

Bariatric psychological evaluation, over the past 20 years, has emerged as a clinical specialty, and recommended revisions to the standard assessment protocol have been recently published (Rutledge et al., 2020). Yet despite reliance on a host of clinical assessment measures across several mental health domains, projective techniques are rather shunned by professionals in this specialty area. Based on an extensive review of the extant literature, this article: a) provides supporting evidence that based on a myriad of clinical features central to the evaluation of bariatric surgery candidates (i.e., body image, self-esteem, self-representation, motivation, emotion regulation, interpersonal functioning, psychopathology), projective tests are ideally suited to tap these psychological domains; b) cites studies that make the case for the utility of projective assessment in the treatment of eating disorders, and for bariatrics specifically; and c) presents key findings, based on clinical data derived from projective tests, on studies of bariatric patients. Overall, this review supports the clinical utility of projective measures (i.e., the Draw-A-Person test, the Baum Test, Rorschach, Thematic Apperception Test, Sentence Completion tests, Somatic Inkblot Series), as part of a comprehensive evaluation of both candidates and patients facing bariatric surgery, in addition to assessment of post-surgery outcomes. Interestingly, the vast majority of the studies cited in this review were conducted by researchers outside the U.S.A., mainly Europe and Japan. Perhaps, the disuse of projective techniques by clinicians is more an artifact on lack of professional training in these methods (see Piotrowski, 2015), as opposed to the lack of applied utility of these assessment measures per se.

Introduction:

Psychological evaluation, both in pre and post bariatric surgery, is a burgeoning clinical specialty (Marek et al., 2016; Mitchell & de Zwaan, 2012). Indeed, a recent text on assessment in clinical health psychology devotes a key chapter on psychological evaluation of bariatric surgery candidates (Andrasik et al., 2015, pp. 405-426). This chapter outlines the critical assessment domains involved in bariatric evaluations (i.e, eating behaviors/attitudes, health maintenance, substance abuse, and personality/psychopathology). Moreover, the authors provide a rather extensive list of mental health tests/measures in support of tapping these clinical domains (e.g., AUDIT, Olbrisch Bariatric Eating Scale, Eating Disorders Examination, Millon Behavioral Health Inventory, MMPI-2, Personality Assessment Inventory, SCL-90, Beck Depression Scale). Recently, Rutledge et al. (2020) published a ‘revised’ model for improved clinical and research utility in bariatric evaluations. This applied framework includes the use of a myriad of assessment tools such as the AUDIT, SF-6, the Millon Behavioral Medicine Diagnostic, Pittsburgh Sleep Quality Index, and the Beck Depression Inventory II. Interestingly, neither of these highly visible references in the bariatric surgery field mention the potential for the application of projective techniques in the mental health assessment of patients. Moreover, in a recent review of prominent measures used in research on eating disorders, projective methods were found to be rarely emphasized (see Piotrowski, 2018), nor highly regarded by health psychologists (Piotrowski & Lubin, 1990).

The current study a) outlines the inherent clinical utility of projective measures for comprehensive bariatric evaluations, and b) presents findings from key studies in the psychological literature that lend support for the application of select projective techniques related to eating disorders in general and to bariatric assessment specifically.

Rationale on Use of Projective Methods in Bariatrics

From a conceptual standpoint, the lack of application of projective techniques in evaluation for bariatric surgery and patient outcomes is rather surprising given the clinical focus on obese individuals regarding body image, low self-esteem, distorted self-concept, and feelings of inferiority or inadequacy (Aguera et al., 2015; Calisir et al., 2020; Cella et al., 2019; Claudon et al., 2012; Hecht, 2020;

Kamitani, 1995; Karcher & Cherikh, 2015; Muller-Pinget et al., 2019; Yusufov et al., 2017), in addition to propensity for personality disorders and related mental health diagnoses noted in these patients (see Marek et al., 2016; Oltmanns et al., 2020). Thus, assessment for psychopathology is critical.

Indeed, drawing techniques such as the Draw-A-Person (DAP) task, the Baum Test, and House-Tree-Person (H-T-P) seem ideal tools that assess an individual’s self-representation, physical appearance, body image, and psychic life (Mizuta et al., 2002). Also, Sentence Completion measures can be effective in revealing latent aspects of an individual’s psychic life (Koga et al., 1992; Piotrowski, 2018). The projective nature of these techniques can reflect both conscious and unconscious views of oneself. Moreover, pre-post-surgery comparisons on these measures can provide valuable clinical insights on not only self-image and idealized self-concept, but also potential changes in self-perception, ‘body space’, and psychological health over time (Kindes 2006; Kubik et al., 2013; Wimmelmann et al., 2014).

Thematic tests such as the Thematic Apperception Test (TAT) can provide rich clinical material regarding the nature of interpersonal relationships, motivations, quality-of-life, and dealing with emotion and stress. These issues are central to the adaptation and ‘re-orientation’ of bariatric patients, post-surgery (Hachem & Brennan, 2016; Hsu et al., 1998; Marsden et al., 1999). Moreover, instruments such as the Kinetic-Family-Drawings (KFDs) could shed some light on life-long critical relationships in the lives of these patients.

Finally, the Rorschach seems ideal to tap on issues like ego-strength, dealing with reality, self-image, social interaction, and the emotional life of bariatric patients; in fact, several studies, investigating eating disorder, have found support for the clinical utility of the Rorschach in bariatric samples (La Gruta et al., 2018; Marsden et al., 1999).

Hypothetical Examples

I offer several potential areas of clinical application on the use of projective measures in bariatric evaluations: prior to surgery, the clinician could ask the bariatric candidate to offer 2 separate drawings (as they see themselves prior to surgery, and as they perceive themselves post-surgery). The key clinical signs/features would be comparative overall size of figures, placement of figures on sheet, and perhaps facial features such as the size of the eyes or smile. Indicators on the 2nd drawing, such as larger figure and larger eyes may reflect the patient’s expected increase in self-esteem, positive self-perception, and positive outlook on life.

TAT, KFDs, and Rorschach analyses, pre vs. post-surgery, could furnish key data on interpersonal relationships, emotional life, and motivational levels. Clinical data obtained on Sentence Completion measures could provide insights on all the issues noted above, in addition on the patient’s view and/or acceptance of their obesity. Finally, the Somatic Inkblot Series could serve as a prognostic indicator regarding the overall bariatric psychological evaluation (Brady, 1995; Dubey et al., 2018; Kumar, 2015).

Review of the Literature Research in Japan

Interestingly, over the past 30 years, much scholarly work on the use of projective techniques, in the study of eating disorders, has been conducted by Japanese investigators (see Kubo et al., 1997; Koga et al., 1992; Kamitani, 1995). Perhaps, one reason for this is that the Baum Test (i.e., Tree Drawing Test) has been shown to be the most popular clinical assessment measure reported by practicing Japanese psychologists (Ogawa et al., 2010; Piotrowski et al., 1993). In fact, Mizuta et al. (2002) utilized the Baum Test and a Sentence Completion test (SCT) in the study of subtypes of eating disorders in a sample of female patients. The findings showed that the ‘purging’ type of disorder patients drew smaller trees (skewed to the left side of drawing paper), and provided more negative (versus positive) responses on the SCT. Also, Ishii et al. (1994) applied Rorschach testing in the assessment of defense mechanisms in a sample of obese Japanese adolescents and adults.

Table 1. Research Studies Using Projective Tests in the Study of Eating Disorders/Bariatric Surgery

Study	Methodology	Major Findings
La Grutta et al.	Determined psychological profile of 10	Results showed difficulty in managing daily
(2018)	obese women in Italy; Rorschach	responsibilities, rigid control of emotions,
	method	sense of inadequacy, and affective turmoil;
		Authors contend that the Rorschach captures
		the psychic suffering of the obese person, an

		image of the self-concept, and emotional life.
Schwailbold & Cuynet (2015)	Investigated psychological dynamics of obese family members; utilized ‘House’ drawings to assess projective ‘spatiography’	Authors claim that such drawings illustrate the unconscious image of family dynamics.
**Venzon & Alchieri (2014)	Studied binge eating post-bariatric surgery; 40 patients, comparing those above vs. under 50% initial weight; Binge Eating Scale and Rorschach scores	The binge eating group expressed impulsivity and difficulty in perceptual integration
Schlitz & Brytek-Matera (2013)	Compared binge eating across 3 groups (N=46; obese, anorexic, bulimic); used Rotter’s Incomplete Sentences Blank	Findings indicated that the obese group had difficulties expressing negative feelings; the main clinical issues were interpersonal acceptance and deep-rooted shame.
**Claudon et al. (2012)	Studied 43 pre-surgery severely obese candidates on self-presentation and imagery of one’s body space; assessed anxiety & depression levels; Dutch Eating Behavior Questionnaire; Hospital Anxiety & Depression Scale; body image views via Rorschach protocol	On the Rorschach, ‘somato conflicts’ and body image concerns were evident; negative bariatric outcomes were linked to lack of positive psychological self-view; authors suggest the pre-surgery evaluations of somato-psychic conflict is a strong marker for bariatric surgery denial.
Sanahuja et al. (2012)	Used a novel approach in the treatment of obesity in adolescent girls, via meditation with a focus on representation of body image; Rorschach method	This procedure and intervention proved successful by re-defining a more lucid image of the body for this teen sample.
**De Almeida Ribeiro et al. (2011)	Investigated psychological profile of 16 women, pre & post bariatric surgery (3 - 7 months); the Rorschach test was the sole measure used	Based on the Rorschach data, anxiety levels decreased post-surgery, due to the implementation of defense mechanisms; Also, the patients showed gains in psychic maturity reflected in use of cognitive resources.
Daini (2009)	Examined self-evaluation in the study of eating disorders via projective methods	For males, issues about gender identification was paramount; Thematic tests highlighted clinical concerns regarding self-concept.
Gueniche et al. (2008)	Authors’ premise is the latency-age girls views of their parents plays a key role in psychic function and can lead to child obesity; N=10; Rorschach, TAT, and Coopersmith Self-Esteem Inventory were used	The main clinical issues identified were: narcissistic fragileness, depression, and separation-individuation dynamics.
Mitchell (2006)	Studied the unique characteristics of obese children; 41 male/54 female	Objective scales were weak indicators of identifying mental distress; the Drawing task

obese participants in the Loma Linda University Fit Clinic; measured depression, self-concept, and used the

‘Draw a Person in the Rain’ task

showed promise as marker for psychic distress in this clinical sample; authors support the utility of projective techniques.

**Marsden et al. (1999)

Evaluated self-image in overly obese gastroplasty patients, via the Rorschach; 21 female, 9 male

Rorschach analysis showed that the majority of these bariatric patients a) had difficulty in handling emotions, b) avoided emotional engagement, c) exhibited low self-esteem, d) tended to be isolated socially; 10 months post-surgery, many of these patients maintained poor body image and self-disparagement.

Waysfeld et al. (1977)

Studied alexithymia in 56 obese females from a psychodynamic framework; used the MMPI and

Rorschach

Findings showed that the psychosomatic patients were more prone to alexithymia versus those with neurotic characteristics.

Note. **References denote studies on Bariatric surgery samples.

Conclusion:

This study makes a vigorous argument for the clinical utility of projective tests in the bariatric surgery assessment model. This premise is supported by extensive research on the link between body image and overall self-concept in reference to positive outcomes regarding bariatric interventions (Castro et al., 2013; do Nascimento et al., 2013; Dube, 2008; Dykstra, 2013; Galvis-Aparicio et al., 2017; Geraci, 2016; Klassen et al., 2017; Lewinski, 2017; Rocha & Costa, 2012; Sarwer & Steffen, 2015; White, 2018). In fact, assessment of self-representation and ‘somatic’ perception are a classic clinical feature of most projective techniques (see Cassell & Dubey, 1996; Daini, 2009; Dubey, 2018; Porcelli, 2004) and, at the same time, a central focus of bariatric research (Bianciardi et al., 2019; Edward et al., 2018; Legenbauer et al., 2020; Peckmezian & Hay, 2017; Perdue & Neil, 2020; Perdue et al., 2018). This applies to bariatric studies involving obese adolescents as well (e.g., Jarvholm et al., 2012).

Undoubtedly, the implementation of projective measures into the bariatric evaluation protocol will be a challenge, considering the vast scholarly opposition to projective methods over the decades. Perhaps, by maintaining the visibility of projective techniques in graduate training programs (Piotrowski, 2015, 2017), these efficacious clinical tools may eventually be embraced by mental health professionals in the bariatric sub-specialty. The strong evidence, presented in this study, in support of projective techniques in this clinical area may contribute to that reality.

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