Am I Going Crazy

Journal of Personality Assessment, 90(5), 421434, 2008
C Taylor & Francis Group, LLC

Copyright
ISSN: 0022-3891 print / 1532-7752 online
DOI: 10.1080/00223890802248679
CLINICAL CASE APPLICATIONS
Am I Going Crazy, Doc?: A Self Psychology Approach to

Therapeutic Assessment
ERIC J. PETERS,1 LEONARD HANDLER,2 KATHRYN G. WHITE,2 AND JUSTIN D. WINKEL3
1
The Erik H. Erikson Institute of the Austen Riggs Center, Stockbridge, Massachusetts
2
Psychology Department, University of Tennessee at Knoxville
3
Connecticut Valley Hospital, Whiting, Forensic Division, Middletown, Connecticut
In this case study, we explore the effectiveness of Therapeutic Assessment with a severely disturbed 25-year-old man, referred by his therapist,
following Finns (2007; Finn & Tonsager, 1992, 1997) model. This patienttherapist pair had been working together for approximately 2 months,
but the therapy had ceased to progress. The therapist requested a clearer picture of his patients affective functioning, interpersonal functioning, and
self-functioning that might facilitate more effective treatment. Through a collaborative assessment process informed by the principles of Kohutian
self psychology, the evaluator and patient slowly formed a working alliance that proved useful for the eventual communication to the patient of his
psychologically tenuous reality. This case illustrates the utility of a collaborative, multimethod Therapeutic Assessment with a severely ill patient
and the use of Therapeutic Assessment by a less experienced clinician.
Fowler (1998) offered a sensitive portrayal of the challenges encountered by clinicians in training who are attempting to master
the complexities of psychological assessment. Fowler advised
trainees and their supervisors alike to pay close attention to
subtle interpersonal and intrapsychic dynamics that often mobilize defenses in the clinician, which, in turn, may threaten the
integrity of the process and outcome. Fowler urged thoughtful
use of the assessors own personality resources in developing a
deeper understanding of patients experiences. Berant proposes
a perspective similar to that of psychotherapy and favor a
dual process within which the traditional goals of psychological assessment coincide with a sophisticated analysis of
the complex relationship between assessor and patient (Berant,
Saroff, Reicher-Atir, & Zim, 2005, p. 207). Fortunately, with the
advent of collaboratively based, therapeutically oriented assessment principles (Finn, 1996a, 1996b, 2007; Finn & Tonsager,
1992, 1997; Fischer, 1994), the field of personality assessment
has opened new possibilities for the integration of psychotherapy with assessment.
The case presented here represents E. J. Peters (hereafter
I, me, and my) first attempt at a therapeutically oriented
evaluation. During this assessment, I attended a semester-long
class taught by the second author (L. Handler), which focused
on the theory and practice of a variety of therapeutic assessment
models guided by the principles and techniques developed by
Finn and colleagues (Finn, 1996a, 1996b, 2007; Finn & Tonsager, 1992, 1997), as well as the works of other contributors
to collaboratively based assessment (Fischer, 1994; Handler &
Hilsenroth, 1998). Additionally, I attended a 2-day seminar led
Received June 6, 2007; Revised August 27, 2007.
Address correspondence to Eric J. Peters, The Erik H. Erikson Institute
of the Austen Riggs Center, 25 Main Street, Stockbridge, MA 01262; Email:
epeters4@utk.edu
by Stephen Finn during which the theory and practice of Therapeutic Assessment (TA) was presented.
OVERVIEW OF TA
TA is a clinical technique in which the assessment process
itself is considered to be a therapy-like intervention that is transformative for the patient. That is, the TA process provides experiences that allow patients to alter their self-view. In a sense,
TA is a treatment experience in microcosm, one that enhances
self-awareness and often leads to life changes (Finn, 2007; Finn
& Tonsager, 1992, 1997; Handler, 2007, 2008).
In a landmark article, Finn and Tonsager (1997) contrasted TA
with traditional information-gathering assessment. The goa of
traditional assessment is primarily to diagnose, plan treatment,
evaluate treatment, understand a patient better, or to monitor the
progress of treatment. The focus is on communication about the
patient. The major goal of a TA, according to Finn and Tonsager
(1997)
is for patients to leave their assessments having had new experiences
or gained new information about themselves that subsequently helps
them make changes in their lives. The assessors primary task is to
be sensitive, attentive, and responsive to patients needs and to foster
opportunities for self-discovery and growth throughout the assessment
process. (p. 378)
Finn and Tonsager (1997) noted that in the traditional assessment approach, tests are usually seen as methods used to
provide standardized scores that are useful for describing patient behavior to a third party. These scores are used to make
nomothetic comparisons that reflect or predict behavior outside
of the assessment setting. In TA, a test is considered useful if
it also provides an opportunity for the patient and the assessor to have a dialogue concerning characteristic ways of responding to usual problem situations and tools for enhancing
421
422
assessors empathy about [patients] subjective experiences
(Finn & Tonsager, 1997, p. 378). Notice that the emphasis here
is on mutual learning by the assessor and patient.
Finn and Tonsager (1997) also discussed what defines success
in TA as compared with traditional assessment. In the traditional
approach, success is determined by how cooperative a patient is
in following instructions and generating responses to the tests in
an uneventful manner. Emphasis is placed on whether the diagnoses and recommendations are clearly supported by nomothetic findings and on assuring that the referring agent is satisfied
and puts the report to good use. Success in TA is defined by
whether the assessor understands the patient and whether the
patient has had experiences in the assessment process that are
transformative. In other words, a successful assessment in TA
is determined by whether the patient felt that he or she was understood, valued, and respected by the assessor and whether the
answers to the patients questions produced some meaningful
change for the better. Success is also determined by whether the
patient feels more empowered and capable of maintaining the
positive changes in the future.
Finn (2003) published the first comprehensive TA case study
of an assessment involving a referral from a therapistpatient
dyad whose therapy had recently lost a clear focus and had begun
to stagnate. Finn (2003) described his use of TA in the service
of getting the therapy back-on-track by obtaining diagnostic clarification and helping his patient develop new personal
insights. Finn (2003) also emphasized the in vivo empathic responsiveness experienced over the course of the assessment as
a helpful tool for facilitating greater understanding.
This case, also a referral from a therapistpatient dyad, differs in two important respects. First, the level of symptomatic,
intrapsychic, and interpersonal distress of the patient to be presented far exceeds that of Finns (2003) patient. The second
defining feature of this case study is our explicit discussion of
self psychology theory and technique when applied during a
TA.
SELF PSYCHOLOGY THEORY INFORMING

THIS CASE STUDY
TA, by virtue of its particular emphasis on collaboration and
curiosity rather than procedures defined primarily by information gathering, offers evaluators flexibility to adapt their theoretical inclinations in the service of understanding another human
being. In this assessment, due to the evaluators theoretical interests, self psychology (Kohut, 1959, 1966, 1968, 1971, 1977,
1984) was the major orienting framework guiding interventions,
case conceptualization, and ultimately treatment recommendations.
Kohuts (1966, 1968) seminal contributions have concentrated around his concept of the self as the moderator of subjectively experienced tension states and fluctuating self-esteem. An
internal self-structure that is insufficiently developed is far more
prone to falling apart in the face of lifes usual frustrations and
disappointments (Kohut, 1968). An individual with this type of
structural or narcissistic deficit is at risk for impoverished selfesteem, symptomatic suffering, disturbed object relations, and
occupational underachievement. These sources of distress often
leave one unable to harness realistic internal resources (e.g., talents, compassion) that normally lead to achieving satisfaction
and success in important areas of life in addition to promoting
PETERS, HANDLER, WHITE, WINKEL

self-esteem. Rather, individuals struggling to feel whole attempt to endure lifes frustrations and symptomatic fallout
through increased reliance on external compensatory structures
when attainable (e.g., excessive seeking of affirmation and idealizeable others), or more regressive self-protective measures
(e.g., grandiosity, devaluation, substance abuse, promiscuity)
that serve as alternative methods of achieving a sense of selfcohesion and vitality (Kohut, 1977; Silverstein, 1999).
Kohut (1959) emphasized the importance of empathy or listening in on the inner experiences of a patients self with vicarious introspection. Kohut (1959) believed empathy was the
most essential tool for experiencing the private workings of another human beings inner life. As we illustrate, empathy was
used to track the ebbs and flows of this patients inner experiences as indicated by test data; the test-taking experience;
and explicit, in-the-room, dyadic interactions. Beyond empathy, applying Kohuts (1959) unique listening perspective in TA
requires additional understanding of developmental selfobject
experiences and the selfobject transferences that are more likely
to manifest in psychotherapy/assessment if the patient suffers
structural deficits of the self.
A healthy, vibrant, and cohesive self forms in response to
adequate mirroring and idealizing functions provided by early
caregivers (Kohut, 1968, 1971). These two fundamental developmental experiences provide the necessary external functions
for an individual to develop the healthy internal building blocks
of the self. These early interpersonal interactions are known as
selfobject experiences (Kohut, 1971). A selfobject is best defined as the function provided by a person, idea, or aesthetic
(e.g., music, paintings) that helps another person maintain an
inner sense of cohesion and vibrancy (Silverstein, 1999). The
term selfobject is also commonly used to identify the actual
person, idea, or aesthetic providing the function.
Kohut (1971) believed that parents who are capable of titrating lifes inevitable frustrations by providing phase-appropriate
mirroring, in addition to serving as reliable idealizeable others
when needed, foster healthy development. For example, such
parents help their children come to understand that they have
limitations and strengths, the capacity to have control and tolerate aspects of reality out of control, soothe themselves instead
of excessively relying on others for a sense of internal calm,
and know that they are still loveable and valued even if they
do not continually achieve vocational, moral, and interpersonal
perfection.
When children experience nonoptimal frustration during
early mirroring or idealizing selfobject experiences, their
healthy development is impeded, typically sensitizing them
to experience early selfobjects as disappointing. These inadequate early experiences often lead people to seek others with
the aim of correcting this disappointment and reinvigorating
their short-circuited developmental process (Silverstein, 1999,
p. 43).
When these vulnerabilities to feel disappointment in the face
of selfobject empathic failures become mobilized in the clinical
transference, self psychology considers patients mirroring or
idealizing selfobject transferences to represent an opportunity
to bolster their fragile sense of self that otherwise is regularly
prone to distressing anxiety, fragmentation, poor self-esteem,
and a sense of inner deadness.
Importantly, Kohut (1984) maintained that there is a normative, lifelong need for selfobject functions. For example, it is
SELF PSYCHOLOGY AND TA
423
natural for healthier personalities to seek out older and wiser

mentors, music, literature, and/or philosophical ideas as ways
of further constructing and maintaining a healthy, vibrant self.
This theoretical position itself provided an important selfobject
function for me, as I often made use of my theoretical knowledge and relationships with my supervisor (K. G. White) and
mentor (L. Handler) to remain calm amidst a variety of difficult
therapeutic encounters with this patient.
I hope to accomplish two main goals by sharing this clinical
experience: to illustrate that TA can be used quite effectively
by less experienced clinicians and to demonstrate the utility
of integrating TA and self psychology for optimal use of an
assessors affective, cognitive, and intuitive responses with a
severely disturbed patient.
CASE STUDY
Referral
A 5th-year, doctoral-level, psychodynamically oriented therapist (J. D. Winkel) referred his 25-year-old patient, Mr. G, to a
community-based, university clinic for a psychological assessment. The therapist had been working with Mr. G for approximately 2 months at a nearby community mental health center.
The therapist was increasingly concerned about factors contributing to Mr. Gs aggression and his propensity to experience
intense and fluctuating mood states within and between sessions. The therapist had discerned Mr. Gs narcissistic character
defenses but was uncertain as to the severity of an underlying
mood or thought disorder, his level of self-cohesion, or his ability to discern how others function psychologically. The therapist
expressed specific interest in ruling out a psychotic disorder so
that he might be assisted in appropriately balancing his use of
supportive/expressive therapeutic interventions. According to
the therapist, Mr. G was open to participating in the evaluation
but was not optimistic that it would be of any use, considering
that he had a prior negative assessment experience.
Intake session. As part of clinic policy, Mr. G was interviewed to collect information about his reasons for seeking
an evaluation; treatment history; and social, occupational, and
developmental history. He also completed the Minnesota Multiphasic Personality Inventory2 (MMPI2; Butcher, Dahlstrom,
Graham, Tellegen, & Kaemmer, 1989) and the Symptom
Checklist90Revised (SCL90R; Derogatis, 1994). The intake was completed by a 3rd-year, doctoral-level student and
not the 2nd-year, doctoral-level student ultimately assigned to
complete the assessment (E. J. Peters).
Mr. Gs MMPI2 and SCL90R indicated significant
distress in multiple areas of functioning. In regard to his
MMPI2 clinical scores (Figure 1), Mr. Gs distress was so
all-encompassing that his profile defied nuanced interpretation
of particular areas of concern. The F (110) and F-back (116)
Validity scores suggested the need for a cautious interpretive
approach, especially in regard to Content scales, which were
likely invalid. In contrast, his TRIN (50) and VRIN (68) suggested a generally honest attempt at responding in a consistent
manner. Thus, validity indexes do not indicate beyond a doubt
that this protocol was invalid. Based on these initial measures,
E. J. Peters tentatively began to view Mr. G as a young man
with a potentially psychotic-level character who was experiencing a level of distress so subjectively overwhelming and
FIGURE 1.Minnesota Multiphasic Personality Inventory2 (MMPI2) basic

Validity and Clinical scales.
all-encompassing that he was no longer able to discern areas of

great trouble from areas of lesser concern.
Session 1. When I met Mr. G in the waiting room, I was

struck by his strained and vigilant expression. Mr. G had a
thin face with sunken eyes, suggestive of a man who had not
slept well in weeks. Mr. Gs casual clothing was disheveled and
slightly worn. He shook my hand with accentuated firmness, as
he vigilantly scanned me from head to toe.
Mr. G reported a variety of problems and concerns that led him
to seek treatment. These included disturbed sleep, poor work
history, lack of responsibility for his children, poly-substance
abuse (currently in remission for the past 3 years), poor impulse
control, and difficulty in establishing and maintaining relationships; he added, specifically, sloughing personal responsibility
in favor of feeling comfortable; strong feelings of hate towards
others, excessive blame-laying; and feeling compelled to seek
inner peace in religion and philosophy that usually borders on
fundamentalism.
During the initial meeting, as is indicated in the TA model,
Mr. G and I set out to develop a list of questions he wanted
to explore during the assessment. In response, he immediately
expressed concern about my credentials and the value of the
process, stating, I need Freud. I experienced this comment
as a not-so-subtle attack and, in truth, felt realistically exposed
for my lack of experience. I feared he was indeed right about
my lack of skill and that he was seeing straight through my
attempt to appear professional. Feeling chipped at slowly, I
wondered silently how he might be feeling chipped at with my
questions, or the reality of having to request help from someone
of comparable age. Despite the potential insight I gained from
my countertransference reaction, at this point in the assessment,
I was not clear as to its specific meaning for Mr. G, nor did
I feel well equipped to respond. I could not garner a wellformulated response and simply asked with as much equilibrium
as I could muster, Freud? He began to backtrack and stated
that he meant no offense but that his life was, in his words,
really complicated. Strikingly, I witnessed him begin to shrink
as he transitioned to an explicitly obsequious position. After
424
about 30 seconds of silence, perhaps having assumed enough
submission, he employed a sarcastic and grandiose tone and
began to question the validity and effectiveness of psychological
testing in general. He said he would be able to see through the
tests and that they would be unable to help him.
When asked about the origin of these concerns, Mr. G spoke of
a prior assessment experience during which he felt the examiner
was condescending and dismissive of his perspective. He stated,
Im disturbed by the notion that someone cant be emotionally
unwell and also know he is sick. He felt the prior assessment
didnt help at all and that he was left with the sense that he
was too complex and therefore need[ed] Freud if there was to
be any hope of figuring out his problems. I responded
I can understand why youd be guarded about the prospects of this
evaluation. Part of you feels itll be worthless and you wouldnt want
to get your hopes up, but part of you wants to take a chance with this
because youre here. Until this point no ones been able to help you
understand what might be going on. To make it worse, you were left
out of your last evaluation, as if your perspective didnt matter, because
youre supposedly sick and incapable.
I suggested that if he and I set out to use a variety of different

tests, we might, together, be able to learn important things. More
specifically, I explained to him that his reactions to the different
tests, as well as his experience of our interactions, were just
as important as actual test data. I added that all these aspects
combined might provide us with important clues about what
is bothering him and holding him back in life. Following my
remarks, Mr. G seemed less guarded and I took the opportunity to ask him if he would like to work together to develop a
list of questions to explore throughout the assessment process.
We decided on three core areas of concern: (a) Why am I a
chronic asshole?; (b) Am I as sick as I think, or, am I frauding
everyone?; and (c) Am I going crazy, doc?
Session 2. The second session included an interview

to better clarify Mr. Gs developmental background, academic/vocational history, and past and current social relationships. Although born in New England to a working-class family,
Mr. G spent the majority of his child and adult life in the Pacific Northwest. He reported significant levels of physical and
emotional abuse at the hands of his father. The abuse continued
after he moved in with his father and his fathers new wife,
following the divorce of his biological parents when Mr. G was
in elementary school. Since leaving home at the age of 16, in
his words, to live on the streets and find myself, Mr. G has
had very limited contact with his father, stepmother, or any of
his five siblings. At the time of the assessment, he lived in a
low-income apartment with his girlfriend in the same town as
his biological mother.
Mr. Gs childhood was, to use his word, terrifying. His earliest memories, occurring around the age of 5 years, tell of sadistic
paternal intimidation and violence. His father beat him with callous indifference, and he was forced to endure a near constant
state of terror due to his fathers emotionally and physically
predatory behavior. Mr. G reported that although the physical
violence was terrible in and of itself, it was nothing compared
to the immobilizing fear associated with waiting around for the
next, entirely unpredictable explosion. The absence of Mr. Gs
mother from any of his earliest memories was conspicuous, and
his present relationship with his mother was strained at best. He

stated he has little respect for her because she was weak and
silent in response to his fathers violence toward both of them.
Mr. G reported his early school experiences as being a source
of pain, due in large part to his poor academic performance and
the abusive responses his father had to his difficulties. At the
same time, Mr. G reported that he also experienced school as
a refuge from his hostile home environment. In his words, he
remembered being amazed at the spontaneity and liveliness of
the other children. It was almost like looking at aliens, looking at other people who were normal and laughed and werent
inhibited, werent always holding their tongue, werent always
careful of the image they were projecting. Feeling different
from his peers, Mr. G generally stayed on the sidelines of social
interactions and reported having very few friends growing up.
This social alienation was exacerbated by his fathers inclination
to keep the family isolated to maintain his authoritarian control.
Mr. G is estranged from his three young children as well as
their mother (his ex-wife). He and his current girlfriend have
a tumultuous relationship. In fact, prior to one session, he was
overheard screaming obscenities at her in the clinic hallway.
He reported that this incident is representative not only of his
current romantic relationship but those of his past as well.
What stood out during the interview session with Mr. G were
his attempts to appear strong, confident, and emotionally contained despite what appeared to be significant anxiety and general uncertainty regarding his psychological sturdiness. During
difficult discussions of his past, a storm of emotion would swell
into observable tension or a deeply depressive reaction that appeared to leave Mr. G feeling profoundly depleted and morose.
He appeared to regain his equilibrium and mask his negative
affectivity by defensively touting his superior intellect and honesty, devaluing others, explicitly minimizing the severity of his
abuse history, becoming polemical about his political or religious ideals, and/or expressing his disillusionment with the
assessment process.
These fluctuations were most explicit when discussing the
nagging sense of falseness that enveloped his sense of self. For
example, he stated, I dont even really know who I am. . . . In
adulthood I almost immediately erected a persona. I think the
persona is me, but I dont want him to be me because the persona
cant function. But, on the other hand, I like the persona. On
the heels of this deeply confused self-description, I watched Mr.
G pick himself up with grandiosity. He stated, Im the most
honest person I know, and I cant stand it when others lie to me or
themselves. Throughout, he appeared to be straining very hard
to manage his emotional upheaval with little insight into why
he was upset or the interpersonal impact of his self-protective
narcissistic strategies.
Standardized Testing
Session 3. Although most patient experiences and behaviors during the administration of the Wechsler Adult Intelligence
ScaleIII (WAISIII; Psychological Corporation, 1997) are uneventful, this was not the case for Mr. G, as his insecurities and
narcissistic defenses manifested themselves clearly. For example, during the WAISIII Picture Arrangement subtest, he stated,
Im sexually aroused by this story. His level of anxiety filled
the room, despite his better than average performance (Verbal
IQ = 131, Performance IQ = 97, Full Scale IQ = 116). His petulant behavior, although unsettling due to its intensity, was quite

clearly a defensive attempt to protect his shaky self-esteem. That
is, my experience of Mr. Gs approach to the WAISIII was of
a man desperate to display a clear strength, as if his intellectual
competence was one of the few things he felt he could rely on
in his generally distressing life.
Similar to interactions in earlier sessions, I began to feel provoked to respond in a negative and defensive manner due to his
continued provocative behavior. Because TA encourages exploration of the patients experiences of tests, I attempted to reflect
what I believed to be Mr. Gs experience of the WAISIII. I
stated, Seems to me youre really smart and it makes sense that
youd want to do well on an IQ test. In this manner, I was able
to contact something beneath the sarcastic smokescreen and resonate with Mr. Gs more authentic experience of guarding and
taking pride in a realistic inner strength. Subsequently, he was
able to articulate how frustrated he was with his vocational failures. He stated, I know Im smart, so why cant I hold down
a job? Based on his negative behavior in this session, I took a
chance and asked him if he ever became frustrated at work and
became a wise guy when he couldnt finish something on time
or understand an aspect of his job. He responded that he does
not become a wise guy per se, but rather he becomes overly
detailed and vigilant about not making mistakes when he begins
to question his abilities. He added that he would subsequently
begin to fall further and further behind and get even more frustrated and hopeless about why he could not complete a task that
should be second nature. Mr. G wondered aloud if this is why
he underperforms at jobs and why, after workdays, he depressively collapses and, in the past, relied on illicit substances to
relieve the pressure. This discussion also helps clarify the significant differences between his Verbal (131) and Performance (97)
IQ scores, the latter, of course, containing substantially more
timed subtests that seemed to have mimicked work pressures
that regularly trip up Mr. G. Indeed, during the timed subtests,
he appeared frantic, noticeably agitated, and less verbally fluent. In retrospect, it seemed that my mirroring response helped
Mr. G feel affirmed as intellectually gifted and motivated to do
well despite difficulties on certain aspects of the WAISIII. This
empathic approach steadied the interpersonal and intrapsychic
space for Mr. G to safely explore his vocational difficulties.
Following the end of the session, Mr. G completed the
self-report Inventory of Interpersonal Problems32 (IIP32;
Horowitz, Rosenberg, Baer, Ureno, & Villasenor, 1988). Results
on the IIP32 helped me begin to contextualize my anxious and
somewhat intimidated countertransference reactions during our
first few sessions. Mr. Gs IIP32 results were very instructive
for understanding his tendency to present himself to the world
as aggressive and aloof. His highest score fell in the pathological range of the vindictive/self-centered octant. People who
score in the pathological range of this octant readily fight, experience irritability, exhibit a preoccupation with vengeance, are
suspicious of other peoples intentions, and experience others
as uncaring and unsupportive of their general welfare. Particularly instructive of Mr. Gs very rigid and aggressive interpersonal style was the total lack of any distress associated with
submissive behaviors as measured by the IIP32. That is, on
the IIP32 circumplex, all of Mr. Gs interpersonal problems reflected pronounced difficulties in regard to issues of accentuated
dominance, control, and lack of interpersonal warmth.
Despite this session ending with an apparent increase in
rapport, I felt anxious and confused and looked forward to
425
supervision. Beyond his manifest aggressive and controlling
behaviors, my supervisor (K. G. White) helped me understand
how emotionally disorienting and uncomfortable it is when a
patient needs you to provide a selfobject function rather than
being seen as a whole, complex person in your own right. In
fact, Kohut (1968) hinted at the potential for the clinicians
edgy experience due to being used to fulfill something urgently needed within an idealizing or mirroring transference
when he wrote, These objects are not loved for their attributes,
and their actions are only dimly recognized; they are needed in
order to replace the functions of a segment of the mental apparatus that had not been established in childhood (p. 481). Based
on the patients traumatic familial and subsequent interpersonal
history, in-session fluctuations of barely manageable affect, and
my own strong internal responses, my supervisor began to suspect a deeper level of psychopathology than simply a narcissistic
character disorder. My supervisor advised that my postsession
reactions might be useful and felt that we should wait and see,
with the Rorschach and other tests, what else might lie beneath
Mr. Gs manifest narcissistic defenses. My supervisors positive
contextualization of my internal responses provided me with a
stabilizing and calming selfobject experience that undoubtedly
allowed me to function more empathically as the evaluation
progressed.
Session 4. In our next meeting, we continued the assessment with relatively unstructured tests (the Draw-a-Person test
[DAP]; Handler, 1996) and Bender Visual-Motor Gestalt Test;
Bender, 1938). This phase of the evaluation was defined by a
clear increase in Mr. Gs use of exhibitionistic, arrogant, and
aggressive behaviors as observed during our interactions and in
the test data. A few notable experiences are worth discussion.
Mr. Gs DAP drawing was meant to represent me (E. J.
Peters). He did not take his eyes off me as he sketched my
whole upper body in detail. When asked to tell a story about
the man in his picture, he began, This is a big university hot
shot. . . . I was acutely aware of a tension creeping into my
body as he was now assessing me. I felt frozen in place; there
was aggression in the air.
The parallel process in this moment was striking in that as the
video camera recorded our interaction, Mr. G and I would both
be evaluated and exposed in supervision. I remember distinctly
feeling subpar and inarticulate. It slowly began to occur to me
that this experience might be akin to Mr. Gs experience in a
potentially important way. After all, we both rely heavily on
our intellect, and when it is not available to us, we are both
less armed for dealing with whatever life throws at us. In this
particular moment, my intellectual resources were eluding me,
and my level of anxiety shot up accordingly. I knew it was
important not to let our mutual anxieties collapse the space
between us that needed to remain open if we were to mutually
explore what was occurring in the room.
To rediscover a sense of calm, I mobilized a selfobject function of my own by summoning Kohuts (1984) theoretical
premise that it is essential for the integrity of the clinical process
that the therapist remains steady and not react with thinly veiled
aggression, withdrawal, or submission to the patients experiences. As I grew calmer, I was able to reflect on how disorienting
it could be to be evaluated and intuited that Mr. G might be angrily responding to feeling like a guinea pig and feeling the
threat of exposure of supposed weaknesses. I also realized that
426
FIGURE 2.Mr. Gs Assessment intervention Bender Visual-Motor Gestalt Test

drawing. The hat and curb is the original Bender stimulus item.
although I had sufficient internal resources to regain a sense

of equanimity, Mr. G was not as fortunate and thus relied on
defensive aggression. Recalling his last evaluation experience
during which he felt unresponded to and judged, I humorously
remarked of his DAP drawing, Well, now were really both a
part of this evaluation! Quietly, I affirmed the shared humanness between us by suggesting that anyone can feel exposed and
defenseless at times. Use of my internal responses, including
accessing an important selfobject function (i.e., Kohuts theoretical principle), allowed me to connect with Mr. Gs yearning
for equality and acceptance without counterproductive passivity
that might be interpreted as weak and silent (the phrase used
to describe his mothers response to his fathers brutality).
In one component of the Bender Visual-Motor Gestalt Test
administration, which asks the patient to change the shapes in
any way he or she chooses, Mr. G worked with a self-approving
smile as he produced very creative drawings (Figure 2). When
asked about his experience of the test, he remarked that he was
set on devaluing the assessment process. Despite his defensive
sarcasm and aggression seen in his drawings and behavior, I
couldnt help but be impressed with his creativity. After working
through the prior DAP experience, I felt better equipped to
less anxiously observe his sense of self-satisfaction and was
therefore able to free associate to his experience. I imagined him
enjoying his creativity and fantasizing as a child might while at
play. Citing this as a healthy trend in his personality, I mirrored
his creativity and made a comment to him about his enjoyment
of the task rather than focusing on the drawings hostile content
or his relatively obnoxious behavior. His petulance seemed to
be a way of deflecting potential criticism about his performance,
and it was clear that this was an approach used to avoid feeling
wounded or unseen in ways he likely had felt countless times
in the past. Mr. G ended this session with humor and a sense
of spontaneity not seen until this point in the assessment. By
remaining available for much needed selfobject functions, I was
not only surviving Mr. Gs provocations, but he and I were also
steadily improving our rapport.
Session 5. In our next meeting, the evaluation continued

with the administration of the Rorschach (Exner, 2003). For
reasons explained below, there is no structural summary for

Mr. G because his protocol did not contain the required number
of responses necessary for this computation.
The Rorschach (Table 1) illuminated Mr. Gs underlying cognitive confusion, affective instability, and overall sense of inner
fragmentation. His body language, pained facial expressions,
and the progressively disorganized content of his responses indicated the intensity of his struggle to manage powerful feelings stirred up by the test. His 11 responses demonstrated his
extensive difficulties with maintaining orderly thinking while
experiencing unsettling emotions. There were a variety of Special Scores, dysregulated use of Color, and poor Form Quality
throughout the brief protocol.
Unlike psychotherapy, during which a therapist can attempt
and often achieve optimal empathy with a patients experience,
the increased abstinence inherent in the Rorschach testing situation provides an opportunity to observe how a patient responds
to less than optimal empathy. That is, as in the selfobject transferences [in therapy], the testing situation provides an environment which mobilizes the unmet needs for mirroring of the self,
or for merger with an idealized selfobject (Arnow & Cooper,
1988, p. 54). In this framework, we present a few of Mr. Gs
responses and test behaviors, in addition to my countertransference responses, following.
Card III provides straightforward evidence of Mr. Gs intense
need for an idealized other:
Mr. G (Card III): This looks like some sort of mythic . . . Titans. (Inquiry): These are two, theyre conjoined twins. Theyre facing each
other, but theyre tearing, you know pulling away [with hands makes
a tearing motion] . . . they obviously share something which is being rended as they pull apart from each other [pulled apart, rended?]
Theyre obviously an entity, obviously theyre intimate, but the lines,
theyre faint lines, their position looks like pulling apart . . . split half
way up.
As he continued, Mr. G. began anxiously looking around

the room with sudden, choppy movements. His seeming intense need to merge (i.e., conjoined) or stay connected with
a powerful other is colored by a painful history of difficult-toidealize, unsatisfactory selfobjects. Thus, it appears his healthy
impulse to receive in the present that which was once withheld
is inhibited by his deep fear that the powerful other will prove
disappointing or is not even a possibility in the real world (i.e.,
mythic); indeed, the connection between the powerful and
intimate Titans is ultimately split. Beyond this tenuous connection to an unreliable idealized selfobject, this split may also
be instructive of the two identifiable poles of Mr. Gs personality. At one end of the split, he revitalizes his need to idealize
others (i.e., Titans) and often seeks religious gurus and powerful
political rhetoricians. On the other, more grandiose end of the
split, he disavows any human need for others and stands apart
from the world of interpersonal relating. Such a process had
been clearly observed with his self-protective approach to me
throughout most of the assessment. After all, if one expects that
only the easily idealizeable Freud will do, then my own empathic missteps and professional weaknesses are more bearable
and less disappointing.
Clearly shaken by the experience evoked by Card III, Mr. G
gave another clue to what might regularly happen to his perception of others when his needs for idealization are thwarted.
His subsequent response to Card IV suggests strongly that
427
TABLE 1.Mr. Gs Rorschach responses.
Card
Response
1. It looks like a demonic apparition. The face of a

monster laughing.
2. It also looks like an angelic apparition with no head.
II
3. Oh gee. What do you think it is? Its obvious to me

that this is the insides of a woman. This is a woman
during her cycle because here are two ovaries [traces
red]. And heres the discharge. Im not sure what
these organs are [points to black on sides]. This is the
lower inside of the lower abdomen. I guess these are
kidneys. You see when I look at it I know what
theyre [i.e., creators of the test] looking for. I wonder
if this tests my sexuality.
4. This looks like some sort of mythic, it looks like uhh
two entities trying to separate though they share the
same vital essence. Reminds me of a Salvador Dali
painting. Titans. These are titans. Am I barking up the
right tree, am I doing these right? [There are no right
or wrong answers; patient beginning to sweat and tap
his fingers quickly on table.]
III
IV
VI
5. This is a, this looks to me like a large forest creature

that is looking down on me as Im lying. [brings card
towards and away from face three times]. Its caught
me in the forest. I could throw something in about
this, Im not sure whether this is a tree up his ass or
his dick, but well just say its a tree behind him to get
away from the salaciousness. Hey all these look like
effeminate sex organs, just by whatever mechanism
they were made by. Im seeing fallopian tubes [patient
slams card face down on table then picks it up, looks
at it briefly and then places face down again].
6. It looks like a . . . I just dont know how to do the test,
just dont know how. Looks like a freaking butterfly.
But you know I wanna find something for you so I
keep looking. Sometimes a rose is just a rose, a cigar
a cigar.
7. Skinned cat. The pelt of a cat [20 s] or one thats been
run over.
VII
8. Seeing female sex organs again [pushes card away

annoyed]. Reproductive organs.
VIII
9. It looks like and I dont know if this is a valid answer

obviously. It looks like a stylized or idealized forest
scene. It almost looks like, Ill pull some shit out of
here for you, like a creation myth. These are two
wolves climbing a tree to make contact with some
sort of powerful being, and a vagina, just kidding.
Inquiry
Well its monochromatic, black, so it lends not much life to this blot. It lends itself to a kind of
sinister interpretation and its just . . . horns kinda put demonic into it, eyes, mouth. Reason I
say demonic apparition is because you see the mouth open here and you can see the back of
the apparitions skull. [Laughing?] Yes, the mouth is here, its turned up and his eyes seem,
as I understand it, slanted in a sinister way. After I saw the face I saw a second one which is
better I think.
These are his hands. The way he has his wings and hands, hes kinda supplicating to God
maybe [patient motions hands upwards] a higher power. I say angelic because he has a high
collar, it appears to be some sort of official uniform, also a belt. Do you see what I see?
[Yes, I see it]. The student has become the master [patient motions with hands wildly above
his head].
What makes this a vagina is the discharge down here, the red down here. The red towards the
bottom looks like discharge, coupled with inflamed ovaries, and their position makes it
look like ovaries. [Inflamed?]. Color, and the fact that I know, well you asked me how it
looked, I know inflamed because discharge is happening. Theyre starkly red compared to
the kidneys which have a diminished color compared to reproductive organs. [Kidney?]
Looks like kidneys because of their position in relation to what I recognize as sexual
organs. [Patient appears upset as he is holding his head with a strained expression on his
face.] They do not in fact look like kidneys, maybe this person should see a doctor because
they may have some kidney problems.
Reminds me of a Dali painting in which, because these heads, these broad shoulders are
disproportionate to the heads which is why I say titans, almost in that Raphaelesque look,
like a painting back in the days when they made the men look super huge and with tiny
heads. Arm, hip bones. These are two, theyre conjoined twins. Theyre facing each other,
but theyre tearing, you know pulling away [with hands makes a tearing motion]. These two
heads looking askew and these are the two people. This is this guys left shoulder, this
guys right shoulder [points to the card and his own body numerous times]. Two arms
coming down and this is the heart. I guess I couldve said heart; thats what I meant by vital
essence. It could be a heart, maybe not, but they obviously share something which is being
rended as they pull apart from each other [pulled apart, rended?] Theyre obviously an
entity, obviously theyre intimate, but the lines, theyre faint lines, their position looks like
pulling apart, but their lines give perspective, motion to their lower halves as if theyve been
split half-way up [patient is becoming increasingly distressed as he is anxiously looking
around the room with sudden movements].
Again, a large forest creature because its black, dark so thats where that evil intent comes
from. I kinda pulled that one out of my ass. These are the undersides of his feet as if were
looking at him from under a glass. These are his legs. I say creature because really his face
is unidentifiable from anyone I know, let alone one that would be attacking me in the
woods. [Caught me?] He is in a very high position. Im in a very low position. Hes very
tall and Im very close to him as I see it in my minds eye. [Do you see another person?]
No, its narrative. [Tree/Dick?] Theres something the overwhelming sense is, dont write
this down, Im working through this. [Transcribed after session from videotape]: This does
not fit so I cant make it a part of the blot. Since Im a funny guy I postulated a few theories.
These are wings. We are looking at it from top-down, as if it were lying on its belly on a table.
These are antennae. Im not intimately familiar with the biology of butterflies, but looks
like some sort of appendage. Funny enough color didnt factor otherwise Id see it as
demonic like the other ones. Well I do see it demonically, theres a little face but I didnt
want to see a demon in every one.
This is obvious. I doubt this is an inkblot. I think this is an actual skinned cat because this was
the easiest one for me. It looks exactly like a pelt! [Pelt?] Because its been prepared as if a
hunter or tracker has stretched the skin. It reminds me of, like if you go to a lodge and see
hides of buffalo. Its stretched out. Im not sure what the practicality is of that, I dont know
why they stretch out the skins, probably to dry it. But, it looks like a dried out, intentionally
prepared pelt because of its symmetry and uhh because it looks like a pelt thats why!
Its just the, well because it looks like pictures Ive seen in medical books of female
reproductive organs. Its got some plumbing, two objects that look like ovaries, more
plumbing down here, this is a vagina, a vaginal cavity. There are so many body parts, why
am I seeing body parts? Because they look like that!
Looks like an artists rendering because heres the two wolves. These are hands climbing up
rock or some sort of summit and its stylized because real world physics wouldnt allow for
this. This seems to be rocky. They almost symbolically . . . what seems to be some sort of
forest. Are you familiar with Viking mythology [recites stories about mythology and
warriors for approximately 3 min]. Its like theyre passing a symbolic forest or a tree.
Theyre gonna pass through all this [points to center of card]. Looks like some sort of skull
sitting atop a tree so hes, he looks powerful, all-knowing, not even looking at the wolves.
Knelt on tree, not even looking at them. Hes passing something to them, transmitting
something.
(Continued on next page)
428

TABLE 1.Mr. Gs Rorschach responses. (continued)
Card
Response
IX
10. I see an alien peering from behind some strange

plasma-like material. An armored alien, the alien is
armored, armor on for battle. I was very abstract on
that. I invested so much of my imagination that Im
not sure I can see anything else.
11. This is a shaman. A prehistoric shaman dressed in

animal pelts. Hes supplicating to the gods. Thats it.
Inquiry
Its not an alienjust a joke. Armor because this looks like plate-metal. Two shoulder plates.
This is an alien looking at us. These are the breast plates. Shoulder plates are rounded, red
makes it look shiny, the red and theres light glinting, thats what makes me think of armor.
Thats the first part I put together. [plasma?] I cant fit the plasma because it looks chaotic,
free-forming, billowing. [Billowing?] Flowing. Dont see much face because of plasma.
Green evoked thoughts of little green men. There are his two eyes right there looking at us
from behind whatever this crap is. I couldnt assimilate it to my satisfaction.
I like this one because it didnt look, its not obvious. I could get something out of it. First
thing I noticed were the animals. Hes holding crabs. This looks like a big pincher because
a lot of crab species have one long and differently colored pincher. Red looks like some sort
of animal, dyed animal pelt. When I say shaman I guess that has to do with that fact that I
see robes and skins, but then theres not much behind it, like in a modern scene someone
wouldnt be wearing one garment, hes got this slung over his shoulders and hes like naked
underneath, so Im seeing the vestiges of the first clothing. These are pelts flung over his
shoulders, this is his face. Hes got some sort of mask made from animal parts, bone or
leather mask with a horn. Arms outstretched with crabs in hands. The rest of blot, painting,
is the other part where I got shaman because hes got animals, hes praying, and all these
strange colored magical parts like a spell is being woven.
Mr. G not only fears disappointment from idealized others but

also malevolence:
Mr. G (Card IV): This is a, this looks to me like a large forest creature
thats looking down on me as Im lying. Its caught me in the forest.
. . . Im not sure whether this is a tree up his ass or his dick . . . [patient
slams card face down on table then picks it up, looks at it briefly and
then places face down again]. (Inquiry): Again, a large forest creature
because its black, dark so thats where that evil intent comes from. . . .
I say creature because really his face is unidentifiable from anyone I
know, let alone one that would be attacking me in the woods. Hes in a
very high position. Im in a very low position.
On this card, Mr. G presents himself as dominated by an

intimidating, unrecognizable creature with a large phallus. By
stating that he does not recognize the monster as someone familiar to him (i.e., his face is unidentifiable from anyone I
know), Mr. G, unconsciously perhaps, distances himself from
the horrifying memories of his malevolent and abusive father as
an attempt to modulate his intense state of terror about being
harmed, which was evoked by his experience of Card IV.
Card VIII provides further evidence of Mr. Gs archaic need
for idealized others and how others in his past experiences and
future expectations disregard him (i.e., not even looking at the
wolves) and prove to be quite unsatisfactory for helping him
get his maturation process back on track. The poor Form Quality
in this response further illustrates his cognitive confusion when
pressured by these very powerful needs:
Mr. G (Card VIII): These are two wolves climbing a tree to make contact
with some sort of powerful being. . . . (Inquiry): Its like theyre passing
a symbolic forest. . . . Theyre gonna pass through all this [points to
center of card]. Looks like some sort of skull sitting atop a tree so
hes . . . powerful, all-knowing, not even looking at the wolves. Knelt
on tree, not even looking at them. Hes passing something to them,
transmitting something.
During administration of the Rorschach, I empathized with

Mr. Gs experience of falling apart: The room became hot, I
felt suddenly dizzy, and an odd glare settled into the room. It
was difficult for me to sit with his dramatic regression. On one
hand, I felt devalued, as I suspected Mr. Gs overcomplicated,
intricate responses were a way of making a mockery of the test

and me. On the other hand, I felt an intense pressure to help
Mr. G, as he seemed to be drifting away into a despondent state
of anxious helplessness.
As had been my tendency throughout this assessment, I began
actively wondering how my mentor (L. Handler) might respond
in this situation. By evoking visual images of us sitting together
in class, where collaboration was the standard, I began to reorient
myself with a renewed sense of compassion, minus any feelings
of being taunted or belittled by Mr. G. By calling on a person
whose skill and integrity I idealize, I gained access to a greatly
needed, calming, selfobject function. In this way, I was able
to avoid a regressive preoccupation with messing up the test
administration by not getting the correct number of responses
and as a result, I was able to stay open to Mr. Gs own need for
a calming idealized selfobject function.
Given his degree of fragmentation, I felt it inappropriate to
shame Mr. G by asking him to do the Rorschach over again,
thereby suggesting he failed the task. As Silverstein (1999)
wrote, test responses reveal not only how the patient undoubtedly feels, but also what he urgently needs (p. 129); and, as
contended here, this may also be true for patients experiences
of the test process and assessor. It was clear that Mr. G made
a tremendous effort to manage difficult feelings stirred up by
the testing situation. To not recognize and respect his efforts in
this regard could easily have been experienced as belittling and
potentially communicate to him the sense that he had failed.
With these considerations in mind, I decided not to seek additional responses but rather respond to Mr. Gs implicit need for
a soothing, holding response by proceeding directly with the
Inquiry phase.
Following the Inquiry phase, I used what Finn (2007) called
an assessment intervention (AI) to illustrate to Mr. G an underlying issue that was out of consciousness. AIs are devoted to
elicit patterns of test behavior that clearly illustrate the patients
problems. Concrete and obvious test findings in this phase are
often quite convincing, whereas mere discussion, without examples, might not make the interpretation clear or meaningful
to the patient (Handler, 2008). Finn (2007) described this process as [bringing] into the room those problems-in-living of
a [patient] that are the focus of the assessment, where they

may be observed, explored, and addressed with various therapeutic interventions (p. 14). By utilizing an AI, I aimed to
help Mr. G regain his balance, diminish his anxiety, and potentially provide him with insight that might be used in a future
situation.
When I asked Mr. G how he experienced the Rorschach, he
explained that he was dubious of the tests value for him
because he is idiosyncratic and special. His attempt to bolster
himself with grandiosity was again evident in this moment.
As his responses got away from him as the test progressed, I
suspected that his effort to provide idiosyncratic and special
responses was a reaction to significant feelings of incompetence
and vulnerability. In striving for complex and ideal responses,
he strained the limits of his thinking and paradoxically provided
himself with fertile ground for falling short and exacerbating
already powerful feelings of inadequacy. His effort to provide
overly complex responses was a nonreflective reaction to his
faltering self-esteem, as well as powerfully intrusive affects,
much in the same way that his petulance and arrogance was
used during earlier tests.
I proceeded with the AI as follows:
E. J. Peters: Okay, well lets try something different. I want you to not
be so idiosyncratic. Tell me what you think most people see in each
card.
Mr. Gs original response to Card I: It looks like an angelic apparition
with no head.
AI response to Card I: Now see, this is cool . . . a woman looking up
and crying, screaming for help. This is probably more true to life.
During the original response phase, it did seem to me that

Mr. G was screaming for help for somebody to help him
understand his often powerful and frightening inner experiences. However, the headless, damaged, semihuman angel could
not feel, let alone remember or speak. Indeed, decapitation in
dream or projective material often relates to a disconnection between mind and body brought on by a patients protective urge
not to feel or remember anguished past or present experiences
(Kalsched, 1996). Now relieved of the pressure to perform and
be impressive in the AI phase, Mr. G regained the ability to
speak and feel as did his perception of the woman on Card 1.
Feeling more coherent, Mr. G felt freer to acknowledge sadness
and, despite a regular tendency for grandiose defensiveness,
even asked/scream[ed] for help.
Mr. Gs original response to Card II: Its obvious to me that this is the
insides of a woman. This is a woman during her cycle because here are
two ovaries [traces red]. And heres the discharge. Im not sure what
these organs are [points to black on sides]. This is the lower inside
of the lower abdomen. I guess these are kidneys. . . . (Inquiry): What
makes this a vagina is the discharge down here, the red down here. The
red towards the bottom looks like discharge, coupled with inflamed
ovaries.
AI response to Card II: A clowns face. Two eyes, nose painted red,
the ridge of the nose, some orange hair coming down and this is the
big smile. Its shadowed in. These faint lines are the lips, the shading
of the lips.
Mr. Gs original response to Card VII: Seeing female sex organs
again [pushes card away annoyed]. (Inquiry): . . . well because it looks
like pictures Ive seen in medical books. . . . Its got some plumbing,
two objects that look like ovaries, more plumbing down here, this is
429
a vagina, a vaginal cavity. There are so many body parts, why am I
seeing body parts?
AI response to Card VII: Two women looking at each other. . . .
Theyre older women with fancy hats on, churchgoing hats.
Blood and bodily deterioration in the two original responses

to Cards II and VII indicate a strong preoccupation with a
fragmented and debilitated sense of self (Silverstein, 1999). In
the AI phase, the morbid preoccupation with falling apart inherent in the original responses was replaced by far less dreadful
images such as a smiling clown and accurate human percepts.
As a result, Mr. G was able to more realistically respond to the
Rorschach stimuli, even conveying a healthy sense of buoyancy
suggested by his appropriate use of Color.
Mr. Gs original response to Card IX: I see an alien peering from
behind some strange plasma-like material. An armored alien, the alien
is armored, armor on for battle. . . .
AI response to Card IX: Now Im seeing like a whole facial structure,
this is the guys face . . . there is a lot of movement, color.
With idealized, soothing, selfobject function in hand to assist

in steadying the ship, rather than a heavily armored alien warrior
preparing for battle, Mr. G was now less defensively engaged in
what I believed was a task mutually experienced as enjoyable
and creative. The original, semihuman alien peering from behind some strange plasma-like material is not only dressed for
battle but distinctly lacks the human facial features recognized
in the improved AI response. Mr. Gs more accurate percept, and
the use of movement and color, suggested he was beginning to
feel more alive and was able to see and be seen by a benevolent
other (i.e., the guys face and/or evaluator).
Mr. Gs original response to Card X: This is a shaman. A pre-historic
shaman dressed in animal pelts. Hes supplicating to the gods. (Inquiry):
. . . hes like naked underneath. . . . Hes got some sort of mask made
from animal parts, bone or leather mask with a horn.
AI response to Card X: If someone were as genius as me, but different, and looking at it [patient laughing enthusiastically]? . . . my second
interpretation, after shaman, would be lots of organic plant life, lots of
green, yellow, browns, flowers, fruits, stalks.
Similar to the futuristic alien of Card IX, a shaman is also

temporally and culturally distant, indicating a profound difficulty in relating to others in the here and now. Also, similar
to the alien, the shaman is masked and is clothed in a manner that protects and hides ones vulnerability (i.e., hes like
naked underneath). His AI response is far more realistic, less
defensively grandiose, and is laden with organic life and color
rather than a sense of desperation (i.e., Hes supplicating to the
gods.).
Overall, as the AI phase progressed, Mr. G appeared to calm
down and respond with a greatly diminished sense of urgency
compared to the response/Inquiry phases. Using AI as a way of
attuning to Mr. Gs plea for help, I noted that he began to joke
playfully and recognized me as a coparticipant by asking me
what I saw in the cards. As can be seen, Form Quality, use of
Color, and Content (e.g., human figures/features in particular) of
his responses generally improved as his affect began to modulate
with the empathic hold provided.
430
Case Conceptualization
Mr. Gs above average intellect helps him contain an embattled inner life that is burdened by considerable uncertainty
about his own identity and capacity to relate to others. Yet, his
intellect is not available to be used effectively in vocational or
academic pursuits because it is almost wholly enveloped by his
overwhelming need to shield himself from a world that he perceives as hostile, alien, and unreachable. Due in large part
to his abusive past, Mr. G has had to employ an inordinate
degree of his intellectual resources for the sake of navigating
a world that has offered him little in the way of security or
joy.
Mr. G is often internally pressured to put on what he refers
to as his stronger, more confident alter ego. Rorschach responses filled with powerful semihuman responses, in addition
to provocative behavior toward the assessor, clearly attest to his
fear of being shamed and exposed as impotent. After all, he
learned from a very young age that any sign of weakness would
be met with brutality. Thus, he often overcompensates, and his
defensiveness becomes interpersonally vitriolic and ultimately
an impediment to deep relationships. His use of narcissistic defenses such as grandiosity, rageful devaluation, and undiscriminating idealization of radical cult-like leaders all serve to keep
him at a distance from reciprocal, intimate relationships. It is as
if he feels continuously under siege, and with preemptive verbal
barrages, he attempts to ward off potential threats. His pressured
need to create a dramatic and impressive but also bizarre and
off-putting self-image when he senses himself to be under the
scrutiny of other people can be seen in his interactions with the
assessor as well as his approach to a variety of tests, including his
extreme MMPI2 and his aggressive and exhibitionistic DAP,
Rorschach, and Bender. As a consequence of these defensive
maneuvers, he does not get close enough to others to experience
the more benign ebbs and flows of interpersonal closeness. Because relationships are necessary for developing and sustaining
a stable sense of self, Mr. Gs interpersonal conflicts seem to
maintain and exacerbate his identity confusion. However, as can
be seen from the AI phase of the Rorschach, appropriate attunement to his need for soothing, idealizing, selfobject functions
goes a long way in diminishing his narcissistic defenses as well
as his dysphoric and anxiety symptoms.
Mr. G is distressingly uncertain of who he is (e.g., The
worlds very existence, and that of my own is what lies at the
bottom of my puzzlement.) and is deeply torn in two contradictory directions. On one hand, he experiences himself as one
of the rare few individuals who sees things the way they truly
are. In this mode, he holds firmly to radical neo-fascistic political beliefs, intellectual grandiosity, and a pose of total lack
of dependence on others. Clearly illuminated by the content
and his approach to the Rorschach, Mr. G holds himself to the
prophetic ideal of being emperor-like and, as he stated, special.
This ideal, as one could imagine, is quite difficult to realize day
in and day out and often leaves him gravely vulnerable to affective slides if his grandiosity is not aptly mirrored. When chinks
in the armor begin to appear, he spirals into deep depressions,
experiences himself as falling apart, and thus becomes unable to
maintain his sense of invulnerability. At these points, he looks at
his interpersonal decisions and radical beliefs and feels wholly
different, or, in his words, alien, pathetic, and ashamed.
These experiences, laden with intense anxiety, are so radically
dissociated from his alternative sense of grandiosity that he feels

wildly thrown from one pole of self-experience to the other. It
appears that with each intensifying experience of dysphoria,
obliterated self-esteem, and massive anxiety, he is compelled
to protect his fragmenting self with even greater narcissistic
bolstering. Unfortunately, from these increasing heights the fall
is inevitably greater and more painful, leading to growing fears
of madness.
Due to not having caregivers who mirrored Mr. Gs positive traits or modeled/helped with self-soothing in any reliable
manner, he is deeply prone to sliding into states of marked
worthlessness and disintegrative anxiety when his narcissistic
defenses falter. Indeed, he struggles consistently with his fear
that he is dangerously close to, as he put it, totally falling apart.
Poignantly, he asked, Am I going crazy, doc? Although he is
intermittently aware of painful feelings of neglect and grief related to his childhood, he is unable to emotionally integrate these
experiences into a self-concept that would help rather than harm
him. Testing indicated that these painful experiences arouse intensely negative affect and can result in significantly disordered
thinking. Beside the backdrop of his abusive childhood, Mr. G
also has limited insight into situations that trigger fluctuations
in his mood and sense of self. As a result, he deeply fears that
he has no ability to put the brakes on this emotional and cognitive confusion, leading to a profound fear that he is, in his own
words, on a slippery slope to institutionalization.
Feedback Session
In line with the case conceptualization and his questions developed at the beginning of the assessment, the feedback session
was aimed at providing Mr. G with insight to help him better
understand his aggressive and devaluing behaviors, the impact
of his childhood on his capacity to manage his emotions, and
a sense that understanding of his difficulties is possible. Due
to his potential for disorganized thinking, it was conceptualized that his narcissistic defenses, for now at least, were his
best defense against psychosis. The feedback was designed to
empathize with the need for these protective defenses without
colluding with them.
The question was how to share these insights with Mr. G.
I was concerned that informing a patient that he was precariously close to a psychotic break would increase his fears and
make the situation worse. Both my supervisor (K. G. White)
and mentor (L. Handler) explained that conveying accurate understanding would likely impact him positively because it was
likely that he already had a sense that his thinking was, at times,
disordered. They indicated that avoiding such essential feedback was akin to not seeing and not understanding Mr. G
and therefore potentially invalidating the assessment process
in his eyes. Instead, by honestly attuning to his increasingly
frightening experiences of cognitive confusion, narcissistic behaviors, and poorly integrated childhood memories, his fear that
nobody could understand him other than Sigmund Freud might
be ameliorated. Further, empathically and mutually discussing
the findings of the assessment process might provide him with
a sense that human relations based on compassion and understanding, rather than shame and misunderstanding, are indeed
possible. To alleviate my own fears about flooding Mr. G, it was
helpful to role-play with my mentor (L. Handler) to practice
sharing, as empathically as possible, difficult issues illuminated

during the testing process. The following is a partial transcript
of my feedback to Mr. G:
E. J. Peters (EJP): On one hand, theres the exceptionally intelligent
Mr. G, with unflappable confidence in his intellect and integrity. On
the other hand, theres a scared man in terrible despair over his lack of
success in terms of love, work, and fatherhood. What do you think of
this split?
Mr. G: It resonates. I feel like Im two different people. Ive had
to live a double lifethe person I am at work is not the same person
at home. The person sitting here talking to you isnt the same person
thats gonna go home and rail at my mom. I beat myself up over this.
EJP: It must be tiring going back and forth, back and forth.
Mr. G: That really resonates, it sounds right.
EJP: You know, I think we experienced this during a few tests and
I think going over this might help you understand how it impacts your
life. Do you remember the IQ test we did together? You were killing
the Vocabulary section on which you made a perfect score. Then you got
to a subtest that was a little more challenging and you didnt do as well
as you probably couldve. It seemed to me that once you perceived an
error you began to shuttle between the super confident guy who nailed
the Vocabulary section and the very anxious person who all of a sudden
stagnated and looked gloomy.
Mr. G: Yeah, I give up. Stagnant, like lead. I think this really affects
me at work. If Im not doing it right, I begin to fall apart and cant
finish stuff. I just give up.
EJP: Yeah, so when you sense youre not getting everything perfect, it breeds the anxiety and depression youve described, and things
then spiral deeper and deeper. I think that learning more about these
fluctuationswhat triggers them, what they feel like, what memories
are associated with themwill be useful for getting them under control.
I think therapy can help with this.
Mr. G: Do you think the emotional outbursts that make me a chronic
asshole are related to these fluctuations? My interactions with others
dont allow me to be warm, show regret, be sensitive. Deep inside I
know these things are there, but the rigors of my normal life dont allow
me to be those things.
EJP: Yeah, weve spoken a little about how troubling it is to you that
your relationships become caustic and ruined by your hostility. I agree
with you, I think your outbursts help you maintain some equilibrium
when youre feeling bad. For example, during discussions of your dads
violence you would become stagnant in here and cry and shake. Then,
as if you had felt enough pain, you picked your head up, stood up
above me, hit your chest [assessor stands and pounds chest as the
patient did previously] and said, Fuck it, I am right. You used anger
and aggression to shake off these feelings. In that sense it has a positive
edge but . . .
Interrupting mid-sentence, Mr. G finished the thought:

Mr. G: . . . but theres also a lot that I cant negate, like my temper and
being so unforgiving of others faults.
EJP: Yes, exactly! Thats true too. This tendency is also destructive,
especially in relationships. Feeling superior and then totally incapable
leaves youas weve been talking aboutfeeling anxious and tired.
When youre feeling these things you seem to get very defensive and
protect yourself with anger and puffing out your chest.
Mr. G: . . . You know, this makes sense because as a kid I was so
vigilant for myself [because] I was always so afraid of my father.
Always trying to hide stuff and look out for myself. So, if I already
know whats coming after me in the adult world I can be prepared.
431
I was surprised to watch Mr. G make this deep connection
with his past. Wanting to give him an example of how hes not
an asshole, I responded:
EJP: Thats wonderful, you being able to do this, to sit here with such
difficult thoughts and feelings and stay open without getting stagnant
or puffing out your chest with me. This is why I think psychotherapy
will be so helpful for you over time.
In a small way, it appeared that we were, together, experiencing

the nascent development of middle ground between the allpowerful or all-weak split.
This now left the issue of Mr. Gs disordered thinking. I
wanted to convey to him that although he is not schizophrenic
or overtly psychotic, when under enough emotional pressure he
displays significant problems with his thinking. Further, without
help working through some of his most difficult emotions, I
wanted him to understand that his thinking and reality testing
could deteriorate further.
EJP: This brings me to the issue of your thinking and how your intense
emotions at times affect your capacity to not just control your temper,
but to stay cognitively clear. Do you remember the Rorschach we did?
Mr. G: Oh-h-h yeah, uh-huh.
EJP: This test has few boundaries, meaning people can take it wherever they like. It seemed that this test dredged up a lot of strong feelings
in you. It suggested that you often perceive the world as dark and threatening. On top of this, I noticed that just like with the IQ test, when you
started to feel like you werent doing the task well enough, you began
to feel even more anxious and gloomy.
Mr. G: Yup, I got really confused and kept trying so hard to make
sense of it.
EJP: And when this happened, you tried and tried to use your intellect
to correct for it and give really big, complex responses to get away from
those feelings. . . . As you said earlier today, not being up to par in
your childhood meant . . . there would be abusive consequences, so it
makes sense youd try to be big and strong to feel protected when you
get anxious or scared.
Mr. G: Yeah this makes a lot of sense.
EJP: Right, but, it seems to go too far and you have a hard time shutting it off, and then your intellect turns against you eventually. People
can only make sense of so much, no matter how smart they are. Throw
in the old experiences being dredged up when you feel sad, anxious or
incapable and it leaves your thoughts disordered and illogical. What Im
saying is that under enough emotional pressure you display significant
problems with your thinking. Youve mentioned that your confusion
lately surrounding your fear of someday not being able to tell right
from wrong makes you feel crazy. Let me tell you: youre not overtly
psychotic or schizophrenic. But without help working through some
of your most difficult emotional problemsespecially those related to
your youthyour thinking may deteriorate further.
Mr. G: In terms of my disordered thinking, I think thats right on. The
emotions just become so overwhelming. I think I need to be allowed to
stew in some of that and work it out. But, I need help. I need someone
there like you or someone else to put down rails to keep me on track,
someone there to help me solve my own problems. I always want to
dismiss my past, maybe to stay away from these kinds of emotions, but
I know its very real to me.
I wanted to give Mr. G an example of how he got back on

track during the Rorschach by way of the AI. By reminding him
of this aspect of the testing, I aimed to affirm for him that he was
432
indeed capable of responding more clearly and with a greater
degree of reality testing.
EJP: Right, I agree. You do need to sit with these things and work them
through. And, youre right that it would be good to have someone to
help keep you on track. It was like when I asked you after the Rorschach
was over to just tell me what everybody else sees. I sensed the emotions
in you were getting too hot and I wanted to take some pressure off.
Mr. G began to weep quietly and continued slowly:

Mr. G: Yes, it was much easier, I remember. I need to stop telling
myself that Im just feeling sorry for myself. Stuff from my past has
really affected me, it really affects me. These are things I didnt expect
from the evaluation, especially about the thoughts. This is really helpful.
Im very, very happy to have something to take forward and act on.
. . . Also Ill show this to people in my family; its important for them
to know that Im not just a bad fruit, a horrible black sheep. Its not
to justify myself; Im not saying its an excuse for my bad behavior,
but [to] show them so they know theyve had an effect. Im not just a
bad person. This testing has given me something to go on and I will
continue my therapy.
He sat a few moments choking back tears. Twisting the report

into a tight scroll, he continued:
Before this testing with you, it was just about showing up in front of
whatever doctor and only being able to say, Im depressed. This kind
of brings all my problems and history together much better. I know its
probably not perfect, there might be other things wrong, there might
be things to be changed here and there, and I recognize that, but it feels
very good to finally know that someone has listened to me and looked
at me and paid attention to me for more than five minutes and taken the
time to put some thought into it.
The evaluators fears that discussion of Mr. Gs potentially

emerging thought disorder would be damaging proved to be
unfounded. Quite the contrary, Mr. G, in fact, cited this as a
particularly new way of looking at his fears of going crazy.
Conclusion
The results of this assessment indicate that TA can be mastered by less experienced clinicians with little to no experience with traditional information-gathering procedures. A few
months after the evaluation, Mr. Gs therapist reported an increase in rapport as well as commitment to therapy. In particular,
the therapist expressed gratitude for highlighting the usefulness
of empathy as a way of tempering Mr. Gs stormy and vacillating self-experiences. The following was reported by the therapist
following the assessment process:
Just prior to the evaluation, Mr. G screamed at the top of his lungs
in a tearful rage, Nobody understands me! Nobody knows what I go
through! After the testing was completed, Mr. G stated that the results
were very representative of his struggles. He engaged therapy with more
vigor and a greater sense of hopefulness. He declared specifically that
he wanted to show his mother the report so she might better understand
him. Mr. G did show his mother the assessment report and reported
afterwards how he became enraged when she attempted to explain her
view of portions of the social history. Unfortunately, Mr. G interpreted
this as an indication that his mother was too ignorant and egocentric to
understand his pain and his problems. At least initially, Mr. Gs wish to
be better understood by his mother was dashed. However, using some

of the reports findings, we were able to keep open the possibility that
a different kind of relationship might be had with his mother.
For example, the report clarified Mr. Gs tendency to become enraged
when he feels people do not understand him, a reaction potentially stemming from impoverished early experiences that left him feeling empty,
hungry, and shamed. This information opened up space for us to discuss
how his enraged reactions, although understandable in light of what he
has not always adequately received, might preclude a connection to
his mother that, although not perfect, might also prove enriching and
supportive in some respects. It is, of course, unclear if the assessment
helped Mr. Gs mother better understand him, but it did provide a starting point for him to reflect on the dynamics of the relationship with less
shame and rage. In fact, before concluding our therapy relationship, his
mother invited Mr. G to move into her residence, perhaps attesting
to a certain degree of amelioration in their interactions. Although his
postassessment conversations with his mother were not void of disagreement, they signified improvement considering that, in the past,
Mr. G would consistently become enraged with the limitations of his
mothers support and understanding.
Overall, the assessment report seemed to serve as a moderator of Mr.
Gs intense internal experiences, as well as an arbiter of a potentially
different relationship with his mother. It seemed to me that his experience of being attuned to and included in the assessment process helped
our own therapeutic alliance, as it allowed us to explore, with greater
equanimity, the complexities of his relationships (especially with his
mother) without him feeling criticized or judged. As a result, Mr. G
was able to reflect more completely on his experiences without relying
as heavily on defensive rage or grandiosity.
Unfortunately, the therapist was leaving on internship and

the therapy came to an end soon thereafter. However, a few
months following termination, Mr. G completed an intake interview at our clinic, during which he requested to have me as
a therapistanother indication of his positive assessment experience. Overall, the success of this casea case that would
be deemed challenging by even the most seasoned clinicians
suggests that TA can be effective, even with less experienced
clinicians.
The flexibility TA provides for exploring in-the-room interactions and patient responses to the tests allowed me to capture Mr.
Gs rapidly fluctuating affect states and identity themes over the
course of multiple sessions. Information gathering alone would
likely have precluded the in vivo emergence of Mr. Gs core
relational, affective, and cognitive difficulties. Thus, TAs emphasis on collaboration (e.g., formulating therapeutic questions
together), eliciting patterns of test behavior that clearly illustrate the patients problems (e.g., using AIs), and providing a
therapeutic milieu fostered an environment of deepening trust
in the evaluator and the assessment process.
Of course, it is debatable how much cooperation in the ordinary sense of the word occurred during the clinical process
with Mr. G. Thus, one might presume that a higher functioning
individual would be more appropriate for a process such as TA
that requires collaboration; but, as this assessment illustrates,
this is only if we consider all forms of collaboration conscious
and affiliative. In the context of TA, collaboration may be better defined by meeting the patient where he or she is. Indeed,
I felt that Mr. G and I were collaborating in an interpersonal
drama driven largely by his core developmental experiences
and relational dynamics. That is, in this type of collaboration,
therapist and patient may be less likely to walk side by side in a

cooperative manner with the shared goal of getting to the bottom of something alien and distressing to the patient (i.e., ego
dystonic). Rather, the ego-syntonic nature of the psychopathology suggests a need for the therapist to recurrently enter into
and mindfully detach from the core interpersonal dynamics of
the patient.
Is TA effective with more severely disturbed patients, especially when integrated with a self psychology approach focusing
on the use of transference/countertransference? As illustrated
extensively by Silverstein (1999), self psychology is capable
of providing a powerful theoretical frame for conceptualizing
actual test responses and quantitative test data. Building on Silversteins ideas, in the following discussion, we focus more
heavily on the effectiveness of a self psychology approach for
making use of the in-the-room dynamicssomething that has
traditionally been in the domain of psychotherapy rather than
assessment.
As this case study demonstrates, the use of self psychology
conceptualizations can greatly enhance TAs effectiveness in regard to what can be learned from complex dyadic engagements
and disengagements. In this sense, it is essential to remember
that more severely ill patients have increased difficulty maintaining their affective equilibrium in a conscious manner and
often communicate important information in nonverbal, affective ways to a greater extent than healthier patients (Hedges,
1983). Therefore, self psychologys emphasis on empathic immersion may be particularly useful for accompanying more regressed patients through difficult moments in testing.
In this case, the use of my internal reactions to Mr. G helped
both of us remain more simply human than otherwise for each
other and, I believe, avoid premature ruptures or flight from the
process. Therefore, the powerful in-the-room experiences common to clinical work with more severely disturbed individuals,
rather than being a barrier, seem to be particularly amenable to
the collaborative and interpersonal nature of a self psychologyinformed TA. In this sense, the core principles of self psychology
may enhance the TA model for navigating clinical encounters
with patients who exert intense pressure for selfobject responsiveness and who exhibit heavy reliance on less mature defenses.
By the end of the assessment, it became clear to me that both
the principles of TA and the additional psychoanalytic elements
were instrumental for reaching, holding, and ultimately understanding Mr. G. Minus these important elements, it is perhaps
easier to understand why he felt that he did not benefit as much
from his previous, more traditional, information-gathering assessment.
As the experience with Mr. G illustrates, self psychology
may not only be useful for understanding the patients inner
world but can be especially helpful for contextualizing and
making appropriate and effective use of an assessors countertransference responses. On more than one occasion, I accessed
the buoying selfobject functions provided by my supervisor
and self psychology ideals to contain my own difficult emotional experiences and regain my perspective. By doing so, I
was generally freer to explore the therapeutic dyad for important clues to the sources of Mr. Gs distress. If I had fallen
prey to my own narcissistic deficits, I would have missed valuable opportunities to engage this man and get a feel for his
private self experiences and the experiences of others who
spend time in his presence. Thus, self psychology principles
may be a means of managing and learning from the assessors
433
emotional responsiveness in a therapeutically oriented assessment. As this difficult case makes clear, there is potential
for significant benefit for patient and clinician alike when
the internal worlds of both are considered essential resources,
rather than impediments, for a deeper understanding of human
personality.
Finally, because one of the core motivations of self psychology is to help a patient feel heard, seen, and understood, it is particularly amenable to TA. The optimal attunement experienced
by a patient in a well-organized, self psychology-informed TA
might make it more likely that he or she will proactively consider
treatment recommendations, as did Mr. G.
ACKNOWLEDGMENTS
A brief version of this manuscript was presented as a paper at
the 2006 Society for Personality Assessment Annual Meeting in
San Diego, CA. We thank the two reviewers for their thoughtful
and constructive reviews that greatly enhanced this manuscript.
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Am I Going Crazy

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Journal of Personality Assessment, 90(5), 421434, 2008

C Taylor & Francis Group, LLC

CLINICAL CASE APPLICATIONS

Am I Going Crazy, Doc?: A Self Psychology Approach to

SELF PSYCHOLOGY THEORY INFORMING

PETERS, HANDLER, WHITE, WINKEL

SELF PSYCHOLOGY AND TA

natural for healthier personalities to seek out older and wiser

FIGURE 1.Minnesota Multiphasic Personality Inventory2 (MMPI2) basic

all-encompassing that he was no longer able to discern areas of

Session 1. When I met Mr. G in the waiting room, I was

I suggested that if he and I set out to use a variety of different

Session 2. The second session included an interview

PETERS, HANDLER, WHITE, WINKEL

SELF PSYCHOLOGY AND TA

FIGURE 2.Mr. Gs Assessment intervention Bender Visual-Motor Gestalt Test

although I had sufficient internal resources to regain a sense

Session 5. In our next meeting, the evaluation continued

PETERS, HANDLER, WHITE, WINKEL

As he continued, Mr. G. began anxiously looking around

SELF PSYCHOLOGY AND TA

1. It looks like a demonic apparition. The face of a

2. It also looks like an angelic apparition with no head.

3. Oh gee. What do you think it is? Its obvious to me

5. This is a, this looks to me like a large forest creature

8. Seeing female sex organs again [pushes card away

9. It looks like and I dont know if this is a valid answer

(Continued on next page)

PETERS, HANDLER, WHITE, WINKEL

10. I see an alien peering from behind some strange

11. This is a shaman. A prehistoric shaman dressed in

Mr. G not only fears disappointment from idealized others but

On this card, Mr. G presents himself as dominated by an

During administration of the Rorschach, I empathized with

intricate responses were a way of making a mockery of the test

SELF PSYCHOLOGY AND TA

During the original response phase, it did seem to me that

Blood and bodily deterioration in the two original responses

With idealized, soothing, selfobject function in hand to assist

Similar to the futuristic alien of Card IX, a shaman is also

PETERS, HANDLER, WHITE, WINKEL

SELF PSYCHOLOGY AND TA

Interrupting mid-sentence, Mr. G finished the thought:

In a small way, it appeared that we were, together, experiencing

I wanted to give Mr. G an example of how he got back on

Mr. G began to weep quietly and continued slowly:

He sat a few moments choking back tears. Twisting the report

The evaluators fears that discussion of Mr. Gs potentially

PETERS, HANDLER, WHITE, WINKEL

Unfortunately, the therapist was leaving on internship and

SELF PSYCHOLOGY AND TA

PETERS, HANDLER, WHITE, WINKEL

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