Self Psychology and Diagnostic Assessment (Book Review)

Author:  Silverstein, Marshall
Publisher: Mahwah, NJ: Lawrence Earlbaum Associates, 1999
Reviewed By: Shira Tibon, Winter 2003, pp. 35-37

In this most intriguing text, Marshall L. Silverstein offers a comprehensive analysis of the application of self psychology to personality assessment. The book addresses the question of what patients say through their responses to the Rorschach, their TAT stories, and their drawings of human figures, about the self state, its vitality, injuries, feelings of competence, buoyancy, and vulnerability.

The first part of the book begins with analyzing the shift from classical drive theory to self psychology, exploring major concepts that even Kohut acknowledged difficulty in clearly defining what he meant by them. These concepts, clinically most important nonetheless conceptually elusive and hard to grasp, are presented in a clear, non-ambiguous, straightforward language. Especially illuminating is the author’s discussion of compensatory structures, a concept that is less familiar than other concepts of self psychology and one that may hold particular interest for those concerned with personality assessment.

In the second part of the book, Silverstein provides clinical illustrations of projective test content indicating self states and their associated selfobject functions. This part begins with a detailed review of the principal approaches to content analysis in clinical interpretation of projective tests. Chapter four provides an excellent, thorough and systematic discussion about the integration of psychoanalytically oriented theory and personality assessment, including convincing examples drawn from the tests. Discussing the importance of the diagnostic context in interpreting test responses, the author states that similar responses can capture different subjective meaning in different psychopathological states. Thus, for example, the same response might indicate fear of fragmentation in a decompensated borderline state, and reflect an injured self in a disturbance conceptualized as a self disorder (p. 107). This suggestion that the specific meaning of the content should follow from the clinical developmental diagnosis seems to have most important implications for practitioners. The chapter is strongly recommended to both practitioners and graduate students of personality assessment in any clinical program irrespective of the program orientation.

In the following chapters the author demonstrates the conceptual and clinical characteristics of mirroring, idealization and twinship by providing illustrations of projective test responses. The concluding chapters present complete projective test protocols of two patients for further understanding the application of a self psychological perspective to test interpretation.

One might describe the author’s work as demonstrating responsiveness of a particular kind. This work involves the engagement of the clinician in a process, where interpretation is not only a version of the truth but also a derivation of an intersubjective “play” conducted between the assessor and the patient. The diagnostic work thus approaches becoming therapeutic in itself. For patients who lack responsiveness in their past or present experience this approach can point to frequently submerged areas of a devalued self-experience that could be used for exploration in subsequent treatment. Certainly, the full message of the assessor/therapist in this “play” requires not simply the knowledge of content and metaphor, but also the immediate contextual framework. Without the situation-dependent cue (e.g., the Rorschach card, the place of the response in the sequential order), clinical interpretations might degenerate into cliches.

Particularly intriguing is the author’s unique style of using self psychology concepts. By bringing a rich array of raw material quoted from test protocols, Rorschach responses or TAT stories are being revealed as much more than merely solutions to a perceptual-cognitive task but also as communications in this intersubjective “play.” In this sense, Silverstein focuses his attention on the communicative aspects of the projective tests. The tests are thus seen foremost as a means of communication and as such might serve as a stimulus to a semi-structured free association assessment enterprise. It is the clinician’s task to listen to this communication, and clearly the author is doing that with an extraordinary sensitivity to patients’ needs. This kind of work notably enriches our understanding of patients and might further be creatively used in the therapeutic process. It should be noted that many of the responses Silverstein uses are frequently given percepts. However, his attentiveness, colored by a self psychological conceptualization, to what patients are trying to convey is undoubtedly the assessment analogue of optimal responsiveness. The importance of the assessor’s responsiveness, which might make the assessment process therapeutic itself, belongs also to Kohut’s thought that the need for responsive, available selfobjects is not confined only to early periods of development, but might also appear at any stage when necessary selfobject functions are interrupted.

The author stresses that this type of interpretive work should be theoretically based on a self psychological perspective, using content analysis primarily. At this point, despite my general view of the book as a remarkable and outstanding achievement, I do have some reservations. Concerning the theoretical perspective, Silverstein presents interpretations using both self psychology and the more familiar ego psychology and argues that a self psychological view may offer a more phenomenologically accurate picture of the personality than does ego psychology.

This claim might reveal some reservations concerning the belief that there is one voice within the complexity of the patient’s experience that represents the patient’s true subjectivity. The assessor, according to this belief, searches for the core subjectivity through the test responses, interpreted in terms of self psychology, and this might constitute the key for a fruitful therapeutic process. The cutting edge of self psychology in terms of providing a more accurate picture is not self evident, at least not in all cases. I think that psychoanalytically oriented diagnostic assessment should not be a field susceptible to explanation in terms of any single theory. Rather, it must be open to the assessor’s engagement with many theoretical perspectives, with the aim of finding those that work best in given cases and in a specific analytic relationship.

Moreover, although this approach might help shift the focus to the patient’s personal subjectivity, it still uses the clinician’s own conceptual categories into which the patient’s experiences are detected and entered by the assessor. While the essence of good analytic work is not imposing the clinician’s perspective on the patient, capturing the patient’s subjective experience unmediated through the clinician’s theory is an impossible ideal. Within these limits, however, Silverstein’s work might be viewed as approaching the subject’s experience as much as it is possible, being fundamentally concerned with searching for what the patient really needs. The two case studies clearly demonstrate this point. In both cases one can be impressed by the author’s interpretations that do not remain experience-distant as many test interpretations do. Silverstein captures, in a congenial and erudite manner, the extraordinary complexities involved in discerning these patients’ genuine experiences and the two cases show the power and utility of interpreting projective test material from a self psychological perspective. However, this perspective should by no means be considered as more accurate than any other theoretical conceptualization used for interpretation.

Concerning the methodological point of view, although one cannot overestimate the valuable array of material that might be derived from content analysis, I do not think, as the author claims he does, that we should abandon the standardized scoring of the Rorschach and use test responses primarily as a stimulus revealing internal representations and experiences. The author’s main approach in analyzing the data represents Freud’s belief that the analytic method itself might be seen as an empirical method, with the analyst as observer cataloging data. Consequently he claims that he would not use Exner’s Comprehensive System by itself for interpreting the Rorschach. However, paradoxically, one might see that he does use, though infrequently, the scoring system, to stress some points in the discussion (e.g., p. 80).

While historically, Rorschach work was fundamentally divided into two fractious groups of those adamant proponents of the empirical atheoretical approach of Exner’s Comprehensive System, and the psychoanalytically oriented approach, today both groups can see the potential power of integrating the two approaches. Consequently, integrative work began to emerge, yielding analyses of a given case study from the two perspectives and exploration of measures addressed to operationalize psychoanalytically oriented concepts in terms of the Comprehensive System’s variables (e.g., the Ego Impairment Index). These developments brought contemporary test interpretation to a more balanced point where the Rorschach is seen both as a test from which various empirical findings can be obtained and a means of communication through which the patient tells us something about his or her internal world. This integration might be applied to some revisions in the Comprehensive System’s guidelines of scoring (e.g., distinguishing between different levels of perceptual distortions or different types of morbid responses, as well as for examining psychoanalytically oriented concepts and diagnostic categories (e.g., narcissistic personality disorder) in terms of Rorschach variables. Analytic ideas might thus be studied in research producing statistically significant results without damaging their intrinsic quality.

The relatively few clinicians who work empirically with psychodynamic theories may know that the Rorschach, when used with the Comprehensive System approach, reveals a well-constructed test for exploring different measures of personality. Nonetheless, these measures are employed almost exclusively by researchers and are not used to answer questions arising from daily clinical practice. With some exceptions, psychoanalysis still tends to rely exclusively on clinical data, as has been the approach of the present book. It would thus be most challenging to look for operational definitions of the wonderful ideas and insights of this volume in terms of the Comprehensive System’s variables.

To the psychologist-psychoanalyst, one of the most exciting features of the Rorschach is its ability to be used in a manner that accentuates process variables. Schafer’s process orientation and Schachtel’s experiential approach to the interpretation of the Rorschach have affected many psychoanalytic clinicians, including the present author, who tend to be skeptical of a score-based approach to the test. However, in further exploring his fruitful ideas the author might be interested in considering starting a new round of creative dialogue about the integration of self psychological concepts with the Comprehensive System’s variables and aggregate scores. It seems that a combined analysis of structural features, and sequence and content of a given Rorschach protocol, can help to provide a clearer and more experience-near interpretation of an individual’s test results, as well as empirically-based findings that might help in bridging the gap between research and practice in psychoanalysis. The results of such a psychoanalytically oriented empirical work would probably be read by many members of Division 39 rather than by the relatively few of those emphasizing both method and content in exploring psychoanalytical concepts.

To sum up, the cutting edge contribution of this book to contemporary psychoanalytic thought and personality assessment is undoubtedly clear. The book adds sophistication and intellectual challenge to the assessment enterprise and a strong claim to examine psychoanalytic theory through projective tests. The test of any psychoanalytic theory is in the clinical situation and Silverstein provides extended examples throughout, all of them showing an admirable clinical sensitivity. The present review has touched on only some selected highlights mainly concerning the use of the Rorschach. Nonetheless, readers for whom the question of what the patient really needs resonates, and readers who may want to search for answers through projective tests, should consider Silverstein’s book a “must read.” It is one of the most absorbing and articulate statements of the current status of personality assessment to date. This superb new volume deserves a wide readership, and I strongly recommend the book to experienced clinicians and to students. Psychoanalytically oriented clinicians who are engaged in both therapeutic and assessment work would find this book particularly useful, providing a substantial response to the need for exploring a self psychological conceptualization not only for understanding the therapeutic process but also for interpreting projective tests.

Reviewer Note

Shira Tibon is a psychologist at the Department of Psychology, Tel-Aviv University. She is on the American Board of Assessment Psychology and the American Academy of Assessment Psychology, and is a Fellow of the Society of Personality Assessment. Correspondence concerning this review should be addressed to Shira Tibon, at the Department of Psychology, Tel-Aviv University, Israel. E-mail: tibon@post.tau.ac.il

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