SIS Journal of Projective Psychology & Mental Health

Use of Projective Techniques with the Elderly: An Historical Analysis of Key Research Studies

Chris Piotrowski

A review of the mental health literature clearly indicates that both clinicians and researchers have considered various projective measures as suitable and pragmatic assessment instruments in the mental health evaluation of the elderly. The aim of the current study is to present a brief overview of this body of scholarship, based on a bibliographic analysis. To that end, a comprehensive search of the database PsycINFO identified 35 peer-reviewed articles with a focus on projective tests and aged populations. Of these, the author determined that 23 references were either select reviews or empirical studies. Based on an aggregated analysis of this dataset (1954-2016), the author contends that projective techniques have the ability to reveal latent psychodynamics, identify cognitive deficits, and differentiate select diagnostic groups. These attributes of projective measures are a key feature in the assessment of the elderly, where issues such as depression, declining health, and deficits in verbal expression are critical clinical challenges. A select bibliography of key studies is provided.

Introduction:

From an historical perspective, projective techniques were in the limelight in the mid-20th century, evident by exponential levels of both research and clinical attention (Gilbert & Hall, 1962; Lemov, 2011; Murstein, 1965; Piotrowski, 2015a). And much of this scholarly attention has had a focus on the elderly (see Hayslip & Lowman, 1986; Lawton et al., 1980; Oberleder, 1967; Overall & Gorham, 1972). Moreover, Panek (2006), in a classic commentary, argued that projective techniques are a clinically viable aid in forming reliable assessments of pathology and differential diagnostic decision-making in the mental health evaluation of aged patients. However, Piotrowski (2019) concluded that, based on bibliometric analyses, personality testing is rather neglected in assessment practices of the elderly. Hence, it would be worthwhile to review scholarly work regarding the issue of the status of projective techniques reflected in the research literature. To that end, the aim of current study is to provide an overview of key studies with a focus on projective tests, from a historical perspective. Thus, this review should support the position that clinical work with the elderly indeed has a central role in both geriatrics and in gerontological psychology (Karpf, 1978).

With regard to Rorschach testing with the elderly, prior research concluded that constriction, stereotypy, and problems with perceptual clarity contributes to fewer responses, higher W%, fewer M and C, and more card rejections (e.g., Ames, 1966). Weiner et al. (2019) provides a contemporary overview on Rorschach assessment with elderly individuals.

With regard to ‘thematic’ measures, researchers have used up to 12 cards from the TAT when testing older adults and relied on specially selected cards not from the original TAT set. Due to the lack of specialized measures for the assessment of aged individuals, clinicians developed the Gerontological Apperception Test (GAT; Wolk & Wolk, 1971)and the Senior Apperception Test (SAT; Bellak, 1975). Both these instruments have a moderate level of visibility in the literature, in addition traditional projective techniques. The GAT purports to allow easier identification with aged peers than the TAT. A central critique of both the GAT and SAT is the negatively stereotyped depiction of the elderly. Thus, this raises serious validity concerns (see Swensen, 1972).

Table 1 presents the 23 studies identified via a search of PsycINFO, where the Boolean online search had a focus on projective techniques with elderly populations. Several key references were obtained by scanning the bibliography of these articles.

Table 1. Key Studies with a Focus on the Use of Projective Techniques with Elderly Samples

*Study*	*Projective Measures*	*Major Finding*
Caldwell (1954)	Rorschach	Author cautioned regarding visual impairment of the aged.
Lorge et al. (1954)	Human Figure Drawings	Drawings showed lack of integration & proportion, and bizarreness.
Lakin (1958)	Human Figure Drawings	Drawings of institutionalized elderly were rather negative in affective tone.
Ames (1960)	Rorschach	Based on test-retest data, with increasing old age, participants showed decreased N, fewer color responses, increased F%, and higher A%; author concludes that the mental life of the elderly person tends to be extremely static, stereotyped, and restricted.
Eisdorfer (1963)	Rorschach	Findings indicated that cognitive decline was a key moderator to consider in Rorschach testing with the elderly.
Ames (1966)	Rorschach	Found that elderly participants easily responded to Rorschach testing.
Carp (1967)	Sentence Completion Test	Connotations of self-referent responses were related to other assessment findings.
Overall & Gorham (1972)	Holtzman Inkblot Technique	Responses to inkblots differed between younger and older age groups.
Andrew (1973)	Sentence Completion Test	Results on the SCT indicated diminished coping ability and verbal skills.
Fitzgerald et al. (1974)	Both the Gerontological Apperception Test (GAT) and TAT	Study found no significant differences for TAT or GAT to elicit selected themes in a sample of the elderly.
Panek et al. (1976)	Hand Test	Studied potential changes in personality due to aging; corroborating prior research with other projective measures, depletion and constriction of personality were noted.
Pasewark (1976)	Both the GAT and TAT	Theme content did not differ among adolescents, middle- aged, or elderly participants.
Foote & Kahn (1979)	Senior Apperception Test	Provides a method analysis to differentiate psychological impaired vs. normal elderly; the best predictor dimension was ‘interpersonal relationships’, the poorest was ‘mood’.
Stock & Kantner (1980)	Senior Apperception Test	In a sample of 40 elders, no significant sex differences on SAT scores were found; Major content themes were: affiliation, physical limitations, and dependency.
Hayslip (1982)	Holtzman Inkblot Technique	Reported normative and factor structure data (7 factors) on the HIT with an elderly sample; substantial variation for several HIT scores was found.
Hayslip & Panek (1982)	Hand Test	In a sample of institutionalized elderly, the authors studied organic dysfunction; HT scores of Withdrawal and Pathology were valid indicators of cognitive loss.

Kornfeld & Marshall (1987)	Both the SAT and TAT	Findings showed that institutionalized and nursing home elders had a narrow, present-oriented time perspective on both tests.
Rajagopalan & Prakash (1990)	Senior Apperception Test	In a sample of 60 elders, the authors reported several main themes (authority, nurturance, submissiveness); older individuals expressed unsympathetic and indifferent attitudes toward younger figures in the stories.
Knapp (1994)	Human Figure Drawings	Drawing features (e.g., use of space, size of drawings) proved to discriminate between normal and Alzheimer’s patients.
Singh et al. (1999)	Somatic Inkblot Series (SIS-II)	Elderly sample failed to show a significant sex difference with regard to total number of responses.
Hayslip et al. (2002)	GAT	Developed a novel scoring model for the GAT that reflects salient issues of the elderly, such as interpersonal, health concerns, and intrapsychic aspects of aging; findings support the clinical utility of the GAT, particularly regarding cognitive functioning.
Panek (2015)	Figure Drawing Techniques	Based on a literature review of published research over 3 decades, the authors argue that Human-Figure-Drawings (HFDs) are suitable assessment tools in addressing referral questions directed about older adults; HFDs can differentiate dementia vs. normal elderly patients.
Fernandez et al. (2016)	SAT and Tree Drawing	Authors claim that these projective techniques are particularly useful tools in the study of Alzheimer’s patients with communication deficits.

Conclusion:

Over the past 30 years, there has been extensive research and clinical attention devoted specifically to the psychological assessment of the elderly (Hunt & Lindley, 1989; Lengenfelder et al., 2019; Segal et al., 1998).The aim of the current analysis is to provide empirical support for the utility on the use of projective techniques with older adults and seniors in both research and practice. Admittedly, in the current clinical milieu, the predominant focus on assessment of the elderly is on neuropsychological evaluation (e.g., Piotrowski, 2014), yet the current review points to the importance of salient factors in gero-psychological testing, such as issues of depression and deficits in verbal expression (Fiske & O’Riley, 2008; Panek et al., 2013; Piotrowski, 2019).Hence, projective measures can serve as key assessment tools in the evaluation of the mental health status of older individuals, including insights into the nature of personality characteristics. Indeed, projective techniques have been and continue to be relied upon by mental health professionals across various disciplines (see Dubey et al., 2019; Frauenhoffer et al., 1998; Piotrowski, 2015a). However, their continued usage will largely depend on their status in professional training programs (see Piotrowski, 2015b, for a review).

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