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Occupational Therapy in Mental Health
ISSN: 0164-212X (Print) 1541-3101 (Online) Journal homepage: http://www.tandfonline.com/loi/womh20
“It Would Be a Shame to Lose Them”: A Critical
Historical, Scoping, and Expert Review on the
Use of Projective Assessments in Occupational
Therapy, Part I
Hiba Zafran & Beverlea Tallant
To cite this article: Hiba Zafran & Beverlea Tallant (2015) “It Would Be a Shame to Lose Them”:
A Critical Historical, Scoping, and Expert Review on the Use of Projective Assessments in
Occupational Therapy, Part I, Occupational Therapy in Mental Health, 31:3, 187-210, DOI:
10.1080/0164212X.2015.1065538
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‘‘It Would Be a Shame to Lose Them’’: A
Critical Historical, Scoping, and Expert
Review on the Use of Projective Assessments
in Occupational Therapy, Part I
HIBA ZAFRAN
School of Physical and Occupational Therapy, McGill University, Montreal, Canada
BEVERLEA TALLANT
Occupational Therapy Program, School of Physical and Occupational Therapy, McGill
University, Montreal, Canada
Projective assessments have a long history in occupational therapy,
yet their relevance may be questioned. This first article reviews the
clinical utility of projective assessments by providing a critical
history of their development, followed by a scoping review of the
current evidence. The second article outlines the opinions of nine
experts in this field. Through this comprehensive process, concep-
tual and methodological issues are articulated in order to suggest
educational and clinical guidelines, and future research avenues.
The place of projective assessments in occupational therapy is
demonstrated as a salient specialty area of practice in the current
evolving landscape of mental health.
KEYWORDS epistemology, evidence-based, expressive assessment,
psychiatric discourse, therapeutic evaluation
INTRODUCTION
There are vast changes currently occurring in mental health practice across
Canada (Mental Health Commission of Canada, 2012), and the world (World
Health Organization, 2012), which call for a mental health practice that is
recovery-oriented, accessible, and empowering (Leamy, Bird, Le Boutillier,
Address correspondence to Hiba Zafran, BSc, (OT), MSc, School of Physical and
Occupational Therapy, McGill University, 3654 Promenade Sir Wiliam Osler, Montreal, QC
H3G 1Y5, Canada. E-mail: hiba.zafran@mcgill.ca
Occupational Therapy in Mental Health, 31:187–210, 2015
Copyright #Taylor & Francis Group, LLC
ISSN: 0164-212X print=1541-3101 online
DOI: 10.1080/0164212X.2015.1065538
187
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Williams, & Slade, 2011). In this context, priority is given to approaches that
value the individual’s experience, culture, and voice, the quality of thera-
peutic relationships, the nature of engagement, and non-technological
approaches to foster these (Bracken et al., 2012). Therefore, all disciplines
are called to appraise their procedural tools in light of the evidence base
for these practice philosophies and values (Kirby & Keon, 2006; Petrova,
Dale, & Fulford, 2006).
Projective assessments are the earliest theoretically informed and forma-
lized therapeutic evaluation tools for occupational therapy in mental health.
Occupational therapy evaluation tools using creative media were called ‘‘pro-
jective’’ based on the underlying belief that the person ‘‘project[s] his or her
personality into task performance’’ (Bruce & Borg, 2002, p. 95). The potential
space for projective assessments in the current landscape of mental health
may lie in their non-threatening, activity-based approach to evaluation and
therapeutic engagement. ‘‘Creative or expressive arts assessments ...enable
therapists to enter the patient’s subjective world more successfully and,
above all, to communicate in greater depth with the patient and thereby
build an empathic alliance’’ (Reynolds, 2008, p. 82). Such an approach elicits
biographical information, as well as an understanding of the client’s personal
meaning, which are both emphasized in recovery (Slade, 2009). The use of a
projective assessment is particularly salient in the provision of recovery-
oriented care to people whose expressive or communicative ability is
compromised by illness, stigmatizing or traumatic experiences, or power
differentials inherent in health care.
Although projective assessments have been in circulation for a long
time, and hold useful possibilities in clinical practice, the use of formalized
expressive media in evaluative activities is no longer as present in North
American occupational therapy clinical practice (Schmid, 2004). Further,
there is very little current research on these types of projective assessments
and=or their clinical use (Reynolds, 2008). The aim of this two-part article
is to critically examine the historical, scientific, and clinical basis for projec-
tive assessments. This is done with the clinician, researcher, and student in
mind in order to contextualize and make contemporary how projective
assessments are clinically used, appraised, studied, and taught in occu-
pational therapy.
This review is composed of four sections. This first article (1) provides
an overview of projective assessments and theory, a critical summative
history of their entry into the domain of occupational therapy, and their
perceived current status in clinical practice; followed by (2) a description
of a formal scoping review of the evidence base for occupational therapy
projective assessments, where the results are interpreted in light of the
broader field of research on projective tests as well as methodological issues
in the research. The second article (3) outlines and reflects on the opinions of
nine experts who were interviewed on the clinical use of, and educational
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requirements for, projective assessments in occupational therapy.
Philosophical, clinical, and methodological issues that have remained tacit
over time are identified and clarified throughout these three review sections.
(4) Finally, the reader is offered a comprehensive and critical synthesis in a
discussion of future challenges and applications. Guidelines are suggested
for psychosocial occupational therapy curricula, clinical practice, and
research avenues for the ongoing development and use of expressive projec-
tive assessments in occupational therapy.
Projective Assessments in Occupational Therapy
ABRIEF INTRODUCTION TO PROJECTIVE ASSESSMENTS
The use of projective techniques in the human sciences can be traced back to
1895(Rabin, 1981), 1879 (Lilienfeld, Wood, & Garb, 2000) or even 1876 (Kramer
&Iager,1984). Projective techniques were initially based on perceptual the-
ories of cognition, and then on psychodynamic formulations of personality
development. The term was first used in 1938 (Murray & Morgan, 1938), at
which point the Rorschach Inkblot Test had already been in academic circu-
lation for 17 years (Rorschach, 1921). For the purposes of reader clarification,
a glossary of terms used in this domain is provided (see Table 1).
Projection is the process of attributing qualities, feelings, attitudes, and
inspirations of one’s own onto objects in the environment. Also, it includes
the interpretation of situations and=or events by reading into them one’s
own experiences and feelings, particularly when they are ambiguous, lacking
in social referents, or a right or wrong answer or behavior (Mosey, 1986).
Projection is based on the assumption that people tend to view the world
in an anthropomorphic manner. In so far as this view is colored by personal
and cultural history, personality, and defensive or pathological traits or states,
their projections will give clues into their intra-psychic functioning (Hammer,
1981) and what matters to them.
The creation and use of various projective tests and therapeutic
approaches in psychiatry increased exponentially in the 1940s and 1950s,
including in occupational therapy (Beran, 1955; Friedman, 1952; Vogel,
Hanke, Miller, & Smith, 1950). This was accompanied by the attempt to forma-
lize projective techniques in occupational therapy (e.g., Friedman, 1953; West,
1959). The first published standardized projective assessment in occupational
therapy was the Azima Battery in Canada (Azima & Azima, 1959). This was
reported in parallel with publications in the United States by Gail and Jay
Fidler on occupational therapy as a diagnostic and evaluative process (Fidler,
1963; Fidler & Fidler, 1954). The Fidlers created a Diagnostic Battery (Fidler,
1968) and later the Activity Laboratory (Fidler, 1982). A multitude of projective
assessments now exist in psychology, art therapy, and occupational therapy.
Review of Projective Assessments I 189
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‘‘The essential feature of a projective technique is that it evokes from the
subject what is in various ways expressive of his private world and person-
ality process’’ (Frank, 1948, p. 47). The characteristics of a projective tool that
elicit this rich insight into a person’s world are: the ambiguity of the pre-
sented stimulus (e.g., inkblot, clay), the interviewee’s freedom of responses,
and holistic-ideographic interpretation, that is, an analysis of the ‘‘whole’’
projective protocol (content, structure and process) that is individualized
(Hammer, 1958; Lindzey, 1961; Rapaport, Gill, & Schafer, 1968). Projective
assessments vary in the type of stimulus (visual, media, instruction) and
response (verbal, graphic, artistic) that they require of the participant, as well
as the manner of test interpretation (numeric scoring vs. content-qualitative
TABLE 1 Glossary of Terms for Projective Assessments
Term Description
Projective techniques Global term used for assessment and treatment approaches
that involve the use of vague or ambiguous unstructured
tasks
Projective test A personality test based on projective theory with extensive
psychometrics and norms
Projective assessment An instrument or battery (series) of standardized tasks based
on projective theory without norms or psychometrics
Expressive assessment Projective assessment used in occupational therapy involving
the standardized administration of creative tasks with
various media
Projective evaluation The unfolding session as a whole process, which includes the
quality of therapeutic rapport and the client’s ability to
integrate feedback
Object or production What the client makes as part of the occupational therapy
projective assessment, e.g., drawings, finger paintings,
collage, etc.
Object structure Composition and arrangement of component parts of the
object and the manner of organization and construction of a
complex whole
Object content Theme and significance of the object to the client. It represents
the meaning of a particular object
Associations or narrative What the client spontaneously says and is elicited to elaborate
about the object that they created during the projective
assessment
Structure of associations Pertains to the tempo and characteristics of expressed
thoughts, concerned with the composition and organization
of thought process
Content of associations Attributed meaning of what the client expresses about him=
herself and his=her world
Projective material Holistic consideration of structure and content of both objects
and associations
Projective profile Synthesized interpretation that the therapist renders about the
evaluation session as a whole, including analysis of
projective material and the intersubjective process
Sources: Anastasi (1982), Anderson and Anderson (1951), Asher (1996), Azima and Azima (1959), Hammer
(1958), Hemphill (1982a), Lezak (1983), Rabin (1981), Rapaport et al. (1968), Stein and Cutler (1998), and
Tallant (2002).
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analysis). The following are the five types of projective assessments
(Lindzey, 1961):
1. Association techniques, where the participant verbally associates to a
visual stimulus, e.g., Rorschach Inkblot Test (Rorschach, 1921). This is
reported to be the only projective tool which meets the full projective test
criteria (Rapaport et al., 1968).
2. Construction techniques, where the participant is requested to either
construct a narrative in response to a pictorial vignette, e.g., a thematic
apperception test (TAT)(Murray & Morgan, 1938), or construct a specific
drawing such as a human figure drawing (HFD) (Machover, 1949).
3. Completion techniques are usually based on the participant verbally
completing the start of a sentence or story, e.g., sentence completion test
(SCT) (Loevinger & Wessler, 1970).
4. Choice=ordering techniques require the arrangement of themed pictures,
e.g., the Szondi test (Szondi, Moser, & Webb, 1959).
5. Expressive techniques, such as painting, psychodrama and free drawings,
that stimulate creative expression and emotional reactions, e.g., finger
painting (Alleyne, 1980) or magazine picture collage (Lerner, 1979).
Types 1 and 3 require exclusively verbal responses from the participant;
types 2, 4, and 5 require motoric involvement and some construction, free
creation and open-ended discussion. From an occupational therapist’s
perspective type 5 assessments have an obvious advantage because of the
client’s involvement in an activity and the opportunity to observe their
performance process. Expressive assessments are the predominant type of
projective tool that were selected and developed in occupational therapy.
Projective materials have been used as evaluations in psychiatric occu-
pational therapy to aid in psychiatric diagnoses and case formulation as well
as change detection (Azima & Azima, 1959; Buck & Provancher, 1972; Fidler,
1963), to uncover mental processes (Llorens, 1967), to determine the appro-
priate therapeutic activity (Androes, Dreyfus, & Bloesch, 1965), to formulate
treatment objectives (Goodman Evaskus, 1982), and to engage the client in a
therapeutic rapport (Reynolds, 2008).
The therapeutic value of projective assessments was recognized very
early on (Azima & Azima, 1959). The process that arises in an expressive
projective evaluation elicits the projection of the client’s internal states in
terms of their performance and final object creation. This initiates a thera-
peutic awareness in the client as he=she is confronted with the real objects
that they have created (Saint-Jean & Desrosiers, 1993). Projective assessments
may be used individually or in a group format to facilitate clients’ under-
standing of themselves, and to communicate with the occupational therapist
and others (Eklund, 2002; Fidler & Velde, 1999; Lloyd & Papas, 1999;
Reynolds, 2008).
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THE EMERGENCE OF PROJECTIVE ASSESSMENTS IN OCCUPATIONAL THERAPY: A
MULTIPLICITY OF REASONS
Much has been written about the psychodynamic roots of projective
techniques in occupational therapy, which primarily emerged during the
ascendancy of both Freudian and object relation theories and practices in
psychiatry (Thompson & Blair, 1998). The clinical reasoning underpinning
expressive projective techniques in the 1950s is best expressed by leaders
in the field: ‘‘Categorical diagnosis and prognosis should be known but are
not necessarily of great importance within themselves. Diagnosis in terms
of psychodynamics is of far greater importance’’ (Fidler & Fidler, 1954,
p. 25). Bruce and Borg (2002) explained that this is an understanding of the
client’s attachment or relational style, emotional functioning, sense of self,
layers of motivation, and ego functioning, which all enable and affect occu-
pational performance.
Expressive media combined with projective theory afforded a psycho-
logical window into a client’s internal world that would not be accessible
otherwise. This led to the premise that one of the key roles of occupational
therapy in mental health is to provide activity-based approaches to aid in
diagnostic and functional evaluation (Fidler, 1963; Fidler & Fidler, 1954). In
addition, the interpretive lens provided by projective theory for the analysis
of activity performance took on implications for non-expressive activities
and other occupations as well (Fidler, 1957; Fidler & Velde, 1999; Rhe
´aume,
2006).
Certainly, object relations theory is now a viable conceptual model for
occupational therapy practice, and has been developed across time into an
occupation-specific clinical and research base (Cole, 2005,2011; Eklund,
2000; Mosey, 1970). It is also useful, however, to take a more critical stance
toward this history, especially in the context of a female-dominated pro-
fession trying to validate its existence while experiencing sociopolitical tugs
from various directions (Friedland, 2011; Peters, 2011). Published historical
data reveals that during the 1950s the role of occupational therapy in mental
health was simultaneously being both questioned and articulated in Canada
(Azima & Wittkower, 1957) and the United States (Fidler, 1957). This was
occurring because of the impetus for occupational therapy to align itself with
medicine and its focus on disease and impairments (Friedland, 2011).
A Canadian government funded partial field survey of mental health pro-
fessionals highlighted the lack of theory and educational knowledge of occu-
pational therapy in psychodynamics and object relations theory, as well as
their poorly perceived inter-professional standing with psychiatrists (Azima
& Wittkower, 1957). In the United States, the results of a national survey of
128 hospitals and expert consensus led by the American Occupational Ther-
apy Association (AOTA) were published examining the roles and methods of
practicing occupational therapists in their contribution to psychodynamic
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case formulation (West, 1959). As with the Canadian survey, the AOTA also
noted that occupational therapists were spending much time observing and
interacting with their patients yet this information was not being elicited by
psychiatrists or framed in a useful manner. Of note was the ongoing caveat
that occupational therapy’s focus is not on diagnosis of psychiatric illness
but rather on understanding the ‘‘patient’s needs ...[and] the degree of
health’’ (West, 1959, p. 132).
Gail Fidler advocated for occupational therapy to develop training and
language to ‘‘increase one’s ability to state more specifically what can be
achieved in occupational therapy and thus increase the potential for com-
munication with other disciplines’’ (Fidler, 1957, p. 9). In an interview with
Dr. Fern Cramer-Azima, co-author of some of these early Canadian studies
and publications, she explained that among the mental health disciplines at
that time occupational therapists were lowest in terms of interdisciplinary pro-
fessional regard, and that the aim was to find ways of including occupational
therapists’ perspectives and clinical observations within the psychiatric team:
Object-relations was the name of the game ...and they [occupational
therapists] were spending many more hours with patients than anyone
else so therefore they must have knowledge that must be tapped.
(Cramer-Azima, 2012)
A specific first step identified By Dr. Hassan Azima (a psychiatrist and
psychoanalyst) and his wife Dr. Fern J. Cramer-Azima (a psychologist) was
the lack of standardized, occupational therapy-specific evaluation tools in
order to provide useful data about a patient’s functioning.
There was no standardized way of OT interviewing from the emotional
point of view, they [occupational therapists] were using ‘‘physical
approaches’’ for evaluating daily functioning ...Projective media were
used to ‘‘establish rapport,’’ or to facilitate translation into action. It was
an available way to tackle what was going on in the schizophrenic mind.
(Cramer-Azima, 2012).
Clinical observations made by the research group at the Allan Memorial
Institute in Montreal, Canada, led to the development of both a dynamic
theory for occupational therapy (Azima, 1961; Wittkower & Azima, 1958)as
well as the development of the Azima Battery (Cramer-Azima, 1982). The
aim of the Azima Battery is both diagnostic (in terms of psychodynamics) as
well as to provide a therapeutic function. The Diagnostic Battery developed
in 1964 (Fidler, 1968) used similar tasks to the Azima Battery, however,
the attendant Outline of Evaluation was less psychoanalytical in orientation,
placing more emphasis on the production process and psychosocial
communication. In 1965, Gail Fidler developed the Activity Laboratory for
teaching and diagnostic purposes. The purpose was to elicit personality styles
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of performance as well as to promote the individual’s self-awareness of how
their responses are associated with daily performance of activities (Fidler,
1982; Fidler & Velde, 1999). Both the Azima Battery and the Activity Labora-
tory consist of five tasks in multiple media yet with different evaluative aims:
the Azima Battery is intended to evaluate psychodynamic functioning while
the Activity Laboratory is designed to assess domains such as motor, cognitive
and social behaviors (Hemphill, 1982a).
Thus, the emergence of expressive projective assessments in occu-
pational therapy occurred based on naturalistic evidence of what occu-
pational therapists were actually doing and achieving, an activity-specific
clinical rationale, as well as a professional-political context in which using
the theories and terminologies of psychiatrists and psychologists legitimized
this approach. An additional issue worthy of note was the potential for
activity-based projective assessments steeped in psychodynamic theory to
bring occupational therapy in mental health beyond a uniquely recreational
focus and to place it on a par with occupational therapy in physical medicine
and rehabilitation. This led to expanding curricula, clinical, and research foci
to include the interpersonal and emotional dimensions of occupational and
vocational functioning (Fidler, 1957). Guiding the education and research
of occupational therapists toward the predominant psychodynamic paradigm
in psychiatry was both a theoretical as well as a strategic choice.
CONTEMPORARY PRACTICE
As biological and cognitive psychiatry have firmly taken over North American
practice, the past two decades have seen a loss of expressive projective evalua-
tions as an expertise integral to occupational therapy (Steward, 1996). This has
occurred both in evidence-based occupational therapy curricula that streamline
into entry-level MSc. programs, and in clinical practice. Another influence has
been the devaluation of psychodynamic theories, with the rise of cognitive-
behavioral therapy in psychiatry and its focus on the verbal, conscious and
rational in adaptation (Thompson & Blair, 1998; Yakobina, Yakobina, & Tallant,
1998); and on clinical methods that are more amenable to quantifiable scientific
research (Han Men, 2004; Lloyd & Papas, 1999). A poignant depiction of this
loss can be seen between the first and second editions of Assessments in Occu-
pational Therapy Mental Health: An Integrative Approach (Hemphill, 1982a;
Hemphill-Pearson, 2008), a key teaching text. In the 25 years between both
editions, eight chapters and 15 appendices on projective assessments, including
rich case material and images, were diminished to one summative chapter
entitled ‘‘Expressive Media’’ (Reynolds, 2008). This is particularly notable as
the editor herself had created a self-named projective evaluation process for
occupational therapy, the Barbara Hemphill Battery (Hemphill, 1982b).
Further, a similar de-emphasis can be seen between the first (Asher, 1989)
and second edition of Asher’s Occupational Therapy Evaluation Tools: An
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Annotated Index (Asher, 1996). The section on psychosocial evaluations in
the first edition includes three projective assessments, the BH Battery,
Goodenough-Harris Drawing Test (Harris, 1963), and the House–Tree–Person
Technique (Buck, 1970). The second edition does not have a psychosocial
section and only includes one projective assessment, the Goodenough-Harris
Drawing Test, reclassified as a cognitive assessment. Overall, the assessments
selected for the 1996 edition reflect the then current theoretical frameworks of
practice, which include behavioral and cognitive behavioral therapy, and the
Model of Human Occupation (Kielhofner, 2008). The majority of the tests
mentioned use standardized checklists to note observed behaviors and perfor-
mance and self-ratings of self-esteem.
Certainly the practices and tools in psychiatric rehabilitation have
expanded enormously with the shift toward community-based psychiatry,
quantifiable evaluation tools, and evidence-based practice. In such a land-
scape concerned with outcomes, advocacy, and policy (Mental Health
Commission of Canada, 2012), the use of expressive media may seem frivol-
ous and archaic. In occupational therapy, however, regret has been expressed
about the loss of expressive approaches (C. Harris, 1997; in Thompson &
Blair, 1998). More broadly speaking, the importance of subjective experience
in the shaping of performance, satisfaction, and therapeutic outcomes,
and even more so, the primacy of experience in meaningful occupation
(Hammell, 2013), has taken an increasingly explicit place in articulating
conceptual models for practice (e.g., Kielhofner, 2008) and occupational
research methodologies (e.g., Cook, 2001; Hammell, 2007; Park, 2012). In
fact, in contemporary practice and terminology, expressive projective assess-
ments offer a ‘‘window’’ into the person’s lived experience, values, and occu-
pational identity, ‘‘a sense of who one is and wishes to become’’ (Kielhofner,
2008, p. 106). They also offer a window for therapeutic engagement and clini-
cal utility in the rehabilitation process (e.g., Zafran, Tallant, & Gelinas, 2012).
Published Evidence for Projective Assessments in Occupational
Therapy
Given the rich historical roots, and potential clinical utility of occupational
therapy projective assessments in recovery-oriented and occupation-focused
approaches, a formal scoping review was conducted. Scoping reviews are
used to explore and summarize the nature of research activity in a given
domain of inquiry, as well as to identify gaps in existing knowledge (Arksey
& O’Malley, 2005).
SEARCH QUESTION
What is the published evidence to date on the use of projective assessments
as an evaluation process in psychosocial occupational therapy? Of interest in
this scoping review was the level of evidence, client populations, and how
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projective assessments were, and are currently, used in occupational therapy.
For a listing of specific occupational therapy projective assessments, the
reader is referred to the first edition of The Evaluative Process in Psychiatric
Occupational Therapy (Hemphill, 1982a).
SEARCH STRATEGY
The following databases were searched on June 3–5, 2012, and May 29, 2015.
These databases were searched both individually and in composite form:
PubMed, PsycInfo, MedLine, HAPI, CINAHL, Web of Science, EBSCO, ASAP,
SCOPUS, FRANCIS, ARTStor, ERIC, and BIOSIS. No restrictions were placed
on publication dates. The following keywords were used individually and in
a combined manner: occupational therapy combined with each of projective,
projective techniques=tests=assessments, expressive media=art=activity, and
arts-based assessment. The addition of qualifiers to ‘‘expressive’’ and the term
‘‘arts-based assessment’’ did not yield further results in the first six databases
(less than eight per database) and were duplicates. Hence these were subse-
quently dropped from the ongoing search strategy which focused exclusively
on ‘‘occupational therapy and projective,’’ and ‘‘occupational therapy and
expressive’’ as keyword combinations in any field.
The total number of articles found in this manner was 1493, with an
estimated 60%duplication rate across databases. An additional 47 articles
were added to the results via a hand search of the reference lists in the book
chapters and articles cited in the first section of this article. As well, a specific
search by name of researchers known to have worked and=or published in this
domain (projective techniques or psychodynamic approaches to evaluation in
occupational therapy) was conducted in the first six databases listed above,
with an addition of a further pertinent four articles for a total of 1,544.
These 1,544 articles were deleted for duplications (n¼985), and the
resultant 559 articles were searched by title and abstract and sorted by the
first author based on the following criteria:
Inclusion criteria: Articles were kept if they were research studies or
conceptual papers on the use of projective media as
an evaluation approach in occupational therapy with
clients of any age or diagnosis. Both English and
French papers were included.
Exclusion criteria: Articles on projective tests or assessments in psy-
chology or art therapy were not included. Occu-
pational therapy studies examining the use of
projective or expressive therapy, or art as therapy
or rehabilitation were also excluded from the final
count (n¼41). These two sets of excluded articles
were maintained in two separate bibliographies to
further contextualize the findings.
196 H. Zafran and B. Tallant
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A final count of 28 English-language empirical articles on projective
assessments in occupational therapy published between 1950 and 2015 were
identified, of which 24 relate to the development of projective assessments
and four use a projective assessment as an outcome measure (see Figure 1).
These 28 were retained for critical appraisal and qualitative review. Figure 1
further outlines the number of conceptual or theoretical papers found and
retained on the topic (n¼13). Four literature reviews on projective techni-
ques in occupational therapy were obtained. These four broad reviews on
the use of expressive media in occupational therapy have been referenced
in Part I of this article and are re-summarized here as follows: (1) an unpub-
lished thesis dissertation reviewing the use of arts in occupational therapy
groups in mental health (Kavanagh, 1994); (2) a research project conducted
for a graduate-level evidence-based practice symposium at the University of
Puget Sound, openly available online (Han Men, 2004); (3) a historical
and conceptual review contextualizing the shifts in paradigms and clinical
psychiatric practice which have influenced the use of arts in occupational
therapy (Thompson & Blair, 1998); and, finally, (4) an evidence-based critical
appraisal of the use of expressive media by occupational therapists in mental
health settings that used a convenience sample of 16 articles published
between 1984 and 1994. These articles were found through a hand search
of occupational therapy journals available at the authors’ university library
(Lloyd & Papas, 1999).
An overview of the results of the scoping review is also provided in a
chronological graph (see Figure 2). This graph illustrates the historical rise
and fall of projective assessments as described above. Empirical research on
expressive assessments peaks in the 1970s with a steady decline as paradigm
FIGURE 1 Flowchart of results of scoping review: 1950–2015.
Review of Projective Assessments I 197
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shifts occur toward biological and cognitive psychiatry. Expressive therapies
follow behind projective assessments and peak in the 1990s just prior to
the legitimate creation of art therapy as a formal profession (see Edwards,
2004). The relative lack of conceptual work and theoretical advancement
on the administration, utility, and interpretation of occupational therapy
projective assessments after the 1950s is highlighted.
SCOPING REVIEW FINDINGS: SUMMARY AND CRITICAL APPRAISAL
To our knowledge, this is the first methodologically rigorous scoping review
(as per Levac, Colquhoun, & O’Brien, 2010) conducted on the evidence for
the use of projective assessments in occupational therapy. It is unfortunate
that in spite of several calls for the use of expressive assessments and the
first-person perspective in occupational therapy this scoping review cannot
add much further to the four literature reviews on the topic, hence only a
brief summary will be given here. This will be followed by a critical analysis
and outline of the issues relevant to the scientific status of occupational
therapy projective assessments.
Earlier text and journal publications between 1950 and 1980 were
focused on establishing a theoretical foundation for the use of projective tech-
niques from the psychodynamic perspective of the client relating to both the
media and the occupational therapist (Fidler, 1963; Lawn & O’Kane, 1973;
Llorens, 1967; Malcolm, 1975; Miller, 1970; Weinroth, 1955). Research from
this time period examined the development of assessments such as the Azima
Battery (Azima & Azima, 1959) and other Diagnostic Batteries (Androes et al.,
1965; Fidler, 1968). Researchers attempted to demonstrate the diagnostic and
therapeutic use of projective assessments with a neuropsychiatric population
FIGURE 2 Publication trends, by decade, about projective assessments and expressive
therapies in occupational therapy (N¼86).
198 H. Zafran and B. Tallant
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across the lifespan (Llorens, 1963; West, 1959). These studies were based
on naturalistic clinical reasoning and small sample case-based clinical
observations. They were conducted in the domain of psychiatry, in the era
of institutional and daycare programs, with amorphous distinctions between
medical diagnostic, occupational evaluative, and therapeutic aims.
A wide variety of media were used in evaluations, ranging from single to
multiple media approaches. Common examples include magazine picture
collage (Buck & Provancher, 1972), drawings (Sheffer & Harlock, 1980),
finger paint (Alleyne, 1980; Vogel et al., 1950), clay, and sculpture (Azima &
Azima, 1959; Shoemyen, 1970). These studies are almost exclusively pre-
sented within an object relations frame of reference. Only a handful of studies
attempted to examine the psychometric properties of projective assessments.
These studies used simple pre-post or correlational test designs, or straightfor-
ward expert judgment-based discriminant validity. Sample sizes ranged from
10–150, with or without matched controls (Bendroth & Southam, 1973;
Lerner, 1979; Lerner & Ross, 1977; Menks, 1973). A small number of attempts
in the 1980s and 1990s were made to increase scientific rigor by shifting away
from psychodynamic to more cognitive-perceptual or activity-based check-
lists and positivist measurement (e.g., Polatajko & Kaiserman, 1986). Clear
summaries and critical appraisal of these can be found in Lloyd and Papas
(1999) as well as Han Men (2004). No studies were found prior to 2004 that
were not identified by these two reviews, and only a further three were found
for the years 2004–2015.
While the historical bias in occupational therapy practice has been to use
projective assessments in mental health settings, none of the three most recent
studies are in the domain of psychiatry. One is a qualitative study (N¼7)
exploring typical children’s understanding of time in relation to daily occupa-
tions through the use of drawings, interviews and rating scales (Minkoff & Riley,
2011). This study found that children preferred to represent their daily occupa-
tions through drawing rather than talking. The drawings were then elaborated
upon with interviews. This data was corroborated by standardized rating scales,
yet the qualitative drawing and interview approach gave richer, more in-depth,
data about the children’s temporal experience of daily occupations.
The other two studies are larger scale quantitative designs aimed at test
validation. One study provides discriminant validity for the use of the HFD as
a screen for unilateral neglect in a neurological setting with 161 participants
(51 participants with a stroke and 110 age-matched controls). The study cor-
relates the classification scheme of the drawings with performance in activi-
ties of daily living (Chen-Sea, 2000). The final study developed and validated
a scoring system for anxiety and depression also for a figure-drawing test,
and demonstrated convergent validity with gold standard measures in a sam-
ple of 323 college students (Li, Chen, Helfrich, & Pan, 2011).
Overall, in terms of the quality of the evidence to date, the articles were
graded along the convention that a level 1 study is of the highest quality in
Review of Projective Assessments I 199
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terms of study rigor and generalizability, down to a level 5, which is based on
expert opinion with critical appraisal (Centre for Evidence Based Medicine,
2009). The current level of evidence for projective assessments in occu-
pational therapy is at a level 2b, with the majority of research falling between
levels 3–5. It is worth mentioning that the latter two most recent health
measurement studies using figure drawings are at a level 1 of quantitative
research evidence. At this point in time, while it may be superficially stated
that there is an overall Grade B recommendation for the use of projective
assessments (there is fair scientific evidence), it may be more accurate to sug-
gest a Grade C recommendation, that is, to consider their use dependent on
individual considerations. This is because, in addition to the small number of
studies, the research is particularly difficult to generalize because of a wide
heterogeneity in study populations, the specific occupational therapy projec-
tive assessment used, variability in study design and quality, and particularly
methodological orientations.
DISCUSSION: REVIEWING THE LITERATURE THROUGH A BROADER LENS
Very early on leaders in occupational therapy advocated for multi-
disciplinary practice and on sharing and building knowledge with others
who use projective techniques (Fidler, 1957), such as art therapists and
clinical psychologists. In clinical psychology, the use of projective
techniques is almost exclusively in the area of formal testing rather than
therapy. The projective tests used and studied in psychology are of the
verbal association and construction (pencil drawings) varieties. There is an
impressive body of rigorous research and journals dedicated to the topic,
such as the Journal of Personality and Projective Techniques. In spite of
the initial excitement over projective tests, and their current continued clini-
cal use internationally (Piotrowski, 1984; Piotrowski, Keller, & Ogawa,
1993), empirical findings to date demonstrate highly mixed results for associ-
ation and construction techniques (Garb, 2003; Singer, 1981). This positivist
research was aimed at improving the standardization of test design, the
development of theory-driven scoring manuals, empirical hypothesis-testing,
and the establishment of norms with large sample sizes early on. The best
known is the study on the Rorschach Inkblot Test (N¼600) and was
reported by Exner (1974).
Rather than delve into the details of this large body of research, greater
interest is placed here on the methodological and philosophical controversies
that are better articulated within psychology as compared to occupational
therapy about projective assessments. The main issues are (a) general ques-
tions around diagnostic validity in psychiatric practice and (b) the question
of the relationship and rapport between the examiner and the interviewee.
These two issues pertain to a critical understanding of the scoping review
findings, and are summarized as follows.
200 H. Zafran and B. Tallant
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If the primary clinical purpose is diagnosis, then this ties into critical
questions about the nature of mental illness, diagnostic categories and clas-
sifications, their etiology, cross-cultural validity, and debates across time
about the methods and psychometrics of diagnostic methods (Meehl, 1986;
Phillips et al., 2012). This also begs the question, not just about the quality
of studies prior to the mid-1980s, but also to their comparability to studies
after 1984. A primary consideration is that the Diagnostic and Statistical
Manual (DSM) underwent a radical shift in orientation from a psychodynamic
theory to a purportedly atheoretical observable, behavioral approach during
that time (American Psychiatric Association, 1984). With the publication of
DSM 5 in 2013, debates over what actually constitutes mental illness continue
to be heated (Phillips et al., 2012).
Art therapists, similar to occupational therapists, use a mix of construc-
tion and expressive projective tests. A meta-analytic review of assessments in
art therapy was published recently (Cristina, & Aneta, 2012). Their conclu-
sions reference occupational therapy work (Heine & Steiner, 1986) and find
that in art therapy, as in occupational therapy, the variety of assessments
across 93 studies is wide ranging and, therefore, it is difficult to aggregate
the findings. As well, 41 of these studies are based on clinical observations
and reflections rather than rigorous research designs. This is similar to the
situation in occupational therapy during the period 1950–1980, as art therapy
has only, in this century, established a scientific orientation (Edwards, 2004).
What is especially significant in this particular reviewed body of
research is that the theoretical focus in art therapy is an objectifying psycho-
dynamic one. That is, the interpretation process in art therapy assessments
seeks out signs and symbols that can be reliably and validly read for their
unconscious or diagnostic meaning. This is a divergence from the occu-
pational therapy approach to projective assessments which very early on fol-
lowed the premise that ‘‘[p]henomenological evaluations are preferred over
symbolic interpretations, unless clear associations are given by the client’’
(Cramer-Azima, 1982, p. 59). When asked in an interview what she meant
by this, Dr. Cramer-Azima explained that:
It is better for the patient to describe the experience they had, otherwise
you shortcut the process ...you have to let their narrative develop. ...
Symbols are just a shortcut’’ which may not necessarily represent
the client’s world or experience, and result in misinterpretation.
(Cramer-Azima, 2012)
The authors of the literature reviews in this domain of occupational ther-
apy have all pointed out the discrepancy between (a) an exclusively quanti-
tative research design that uses a scoring system based on symbolic content
and quantification of behavioral performance and (b) a clinical approach
that relies on therapeutic rapport and the qualitative interpretation of an
Review of Projective Assessments I 201
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individual’s lived experience as elicited and shared during a projective
evaluation (Han Men, 2004; Reynolds, 2008; Thompson & Blair, 1998).
In projective assessments used by occupational therapists, the content,
structure, and process of creating objects and associations are all deemed
meaningful and are interpreted qualitatively. Communication and under-
standing are enhanced because the participant verbalizes his own symbols
and projections. Expressive projective assessments are
distinct from other projective techniques in that the temporal sequence of
the process involves therapeutic as well as diagnostic values....The
effectiveness on which it [self-expression by the participant] is so
depends to a very great extent on the skill of the therapist. (Napoli,
1951, p. 387)
Anastasi stated that projective assessments ‘‘serve as supplemental quali-
tative interviewing aids in the hands of a skilled clinician’’ (1982, p. 590).
In terms of the relationship between the examiner=therapist and
interviewee=client, ‘‘[i]t would be an injustice to our patients to pretend that
our clinical observations are completely objective’’ (Miller, 1970, p. 201). The
interpretation of projective material is necessarily a subjective and qualitative
process, which is the reason why quantitative approaches flourished in
both psychology and to a lesser extent occupational therapy, to ‘‘safeguard’’
the objectivity of projective tests (Rapaport et al., 1968, p. 227; see also
Ritzler, 1995).
This positivist approach is not consistent with the original theories upon
which projective tests, especially expressive techniques, were based
(Frank, 1948). ‘‘The primary legitimate use [of projective techniques] is non-
psychometric; an interview focused on growth in various contexts’’ (Dana,
1975, p. 563). When these assessments are interpreted in a qualitative manner
rather than being quantitatively scored, they offer special value to the clinical
process (Anastasi, 1982). The therapist-interviewer was conceptualized as
having to be qualified, with an expertise based on clinical experience, to inter-
pret what patients made and said (Hammer, 1958; Llorens, 1967; Machover,
1949). Furthermore, it was necessary to be able to understand how the thera-
pist’s own projections and reactions might affect the assessment and interpret-
ation process (Alleyne, 1980; Azima & Azima, 1959).
In an early attempt to understand contradictory results in determining
the diagnostic discriminant validity of projective drawings, Schmidt and
McGowan studied the clinician-judges as opposed to the participants and
their productions (1959). They found clinician-judges used different reason-
ing processes in interpreting the drawings: one group was labeled ‘‘cognitive’’
and used specific isolated signs to interpret drawings in a ‘‘scientific’’ and
‘‘intellectualized’’ manner. The second group was labeled ‘‘affective’’ and
used an impressionistic, overall meaning and feeling approach to drawing
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and overall evaluation interpretation. It was the ‘‘intuitive’’ group that was
able to successfully diagnostically sort the drawings, not the cognitive group,
leading the authors to conclude that the type of clinical reasoning style signifi-
cantly changes study results (Schmidt & McGowan, 1959). This echoes distinc-
tions in procedural-deductive and narrative-interpretive clinical reasoning
processes of occupational therapists (Mattingly, 1998). With the exception
of one study in occupational therapy (Tallant, 1966), the question of the rela-
tional process between the occupational therapist and the client has not yet
been addressed in the research.
In terms of the limitations of this scoping review, it is likely that there
may be further publications of interest that were not captured by this search.
For example, if studies were published in non-occupational therapy journals
without the use of ‘‘occupational therapy’’ in the title, abstract or keywords,
or if a projective assessment was used as an outcome measure for a study but
once again was not identified in the title, abstract or keywords (e.g., Bell &
Stein, 1991; Levine, O’Connor, & Stacey, 1977). Conference proceedings
were referenced in articles but did not come up in the online search (e.g.,
Beran, 1955; Tallant, 1966). In addition, expressive media with standard
administration that are defined for use as an intervention modality, such as
the Tree Theme Method (TTM) (Gunnarsson, Jansson, & Eklund, 2006) did
not meet inclusion criteria. However, the first opening session of the TTM
is described as an expressive evaluation. Another example of an evaluation
not captured by this literature search would be the Kawa Model (Iwama,
2006). The Kawa Model was not developed as a projective evaluation, nor
does it offer an observation of performance with unstructured expressive
media, yet it certainly facilitates communication through symbolic and visual
representation. Finally, discussions about projective evaluations embedded
in occupational therapy studies focusing on object relations or psychody-
namic theory may not have been identified (for examples see Eklund,
2002; Eklund & Nilsson, 1999).
CONCLUDING ON THE EVIDENCE TO DATE
Through a critical tracing of the history of projective assessments and a rigor-
ous scoping review of their scientific status, the epistemological and methodo-
logical challenges of studying projective assessments across shifting discourse
in psychiatric practice have been highlighted. In part II of this article, the
findings of a qualitative study exploring the opinions of occupational thera-
pists deemed to be experts in the use of projective assessments are presented.
This is because a key element of the challenges identified herein is the focus
on the notion of being an ‘‘intuitive’’ or ‘‘skilled’’ evaluator, and the relational
dimension inherent in conducting and interpreting projective assessments.
The use of projective assessments in occupational therapy has remained
a minor yet consistent presence in occupational therapy literature across
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decades and domains of clinical and research practice. This may be attributed
to the romance of the arts, the nostalgia for an era of practice, a healthy
respect for a rich history, and to the experienced clinical utility of projective
techniques for both assessment and treatment. The literature reveals that
although small, the conceptual base for the clinical use of projective assess-
ments in occupational therapy has evolved from an exclusively top–down
application of object relations theories in the 1950s to a more eclectic,
client-centered, humanistic and relational approach. Further research is
needed to explore the educational preparation, clinical reasoning and skills
required to enact this approach, and to validate the ongoing clinical utility
of projective assessments in occupational therapy.
FUNDING
This research was funded by McGill University’s School of Physical and
Occupational Therapy graduate awards. No conflicts of interest are noted.
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