The Rorschach test has permeated the collective imagination perhaps more than any other psychological tool. The image of the impassive doctor, holding aloft a series of inkblots and asking, “What do you see?” is an emblem of all that is considered wishy-washy about the therapeutic process.

But the test is still used; in fact, many mental-health specialists say there are few better methods of gauging personality or identifying thought disorders. And the Rorschach is particularly beloved in Japan, which is home to the world’s largest Rorschach society.

But why do the Japanese so embrace this near-century-old assessment?

The test was first introduced to the Japanese in 1925 by a psychologist named Yuzaburo Uchida, after he stumbled upon a copy of Hermann Rorschach’s Psychodiagnostik in a Tokyo bookshop. According to The Development of the Rorschach in Japan, Uchida had already devised his own psychological assessment tool, an arithmetic-based test that measures performance speed and accuracy. And as a test designer, Uchida recognized the potential of the Rorschach immediately.

The Rorschach is a projective test, which means that it is unstructured and ambiguous, provoking unrehearsed responses. As a boy, the Swiss-born Rorschach, the son of an art teacher, toyed with klecksography, a parlor game of creating inkblots and making up stories about them. As an adult, he became a Freudian psychologist, and came to believe that patients’ perceptions of these indefinite images could reveal their unconscious preoccupations and desires.

In the years leading up to World War II, the Rorschach approach blossomed in Japan; many Japanese researchers and intellectuals at the time spoke German, Rorschach’s native tongue. In the 1940s and 1950s, American researchers published extensively on techniques for using the Rorschach, and the Japanese psychological community, heavily influenced then by Western clinical psychology, devoured these texts. In 1958, the Rorschachiana Japonica, a journal that presented case studies and methodologies, was launched. Today, the membership of the International Rorschach Society is 52 percent Japanese, according to Noriko Nakamura, director of the Nakamura Psychotherapy Institute and president of the society.

In the United States, meanwhile, the test was hit hard by the 2003 publication of What’s Wrong With the Rorschach?, a blistering critique that equated the methods for scoring the Rorschach to wizardry. The authors, four clinical psychologists, found the Rorschach unreliable, and its interpretation vulnerable to the administering therapist’s subjectivity. Wikipedia’s publication in 2009 of widely used ink blots further imperiled the Rorschach’s credibility, as patients who had seen the images ahead of time could not then provide truly spontaneous responses to them. But already many psychologists had abandoned Rorschach.

“A lot of times when people are coming into therapy, they already have a sense of what they want to work on,” said Kevin Meehan, an associate professor of psychology at Long Island University. “The reason patients would be given the Rorschach, as part of a larger assessment battery, is if it’s not clear why they’re struggling.”

More often, first-time patients in the United States fill out a questionnaire in which they self-report their emotional state. “A questionnaire assumes you’re aware of your feelings and that you're willing to share that,” Meehan said, which could be unpleasant for those from a culture that does not embrace direct expression. “With the Rorschach, you have no idea if you’re giving a ‘good’ or a ‘bad’ response. I could imagine that that test would be more appealing in a culture where there’s a greater need for social desirability.”

However, in Japan, the Rorschach still ranks among the most frequently administered projective tests, and is used particularly often in hospitals and psychiatric settings, Toshiki Ogawa, a clinical psychologist with the Japanese Society for the Rorschach and Projective Methods, told me. While the test is often associated with psychoanalysis in the United States, in Japan, “the Rorschach is widely used in practice, independently of doctors’ theoretical orientation,” Ogawa said. “Students who major in clinical psychology in Japan inevitably study the Rorschach—it is an obligatory subject.”

The test has broader applications in Japan, too. “The way I use the Rorschach is more behavior-based,” said Nakamura. “My job is to translate Japanese into the Rorschach language. The benefit is I can then access that patient’s psychological map.”

After giving the test, Nakamura conducts feedback sessions in which she discusses the results with her clients. She has found the test particularly helpful in couples’ counseling. By seeing themselves through the lens of their test results, she said, patients come to objectively understand their problems. “Talking about the data is so safe—I can tell the truth without harming them directly,” Nakamura said. “It's much easier for us to find out where we should go.”

The test also complements some of Japan’s cultural values, according to those who use it. Ogawa compared it with the Thematic Apperception Test—an assessment that is popular in the United States but seldom used in Japan—which asks subjects to tell a story and therefore requires a greater degree of assertive expression. “The Rorschach interpretation needs a holistic view,” Ogawa said. “I think the Japanese way of thinking agrees with this. The Japanese respect relationships, context, and incorporation.” Indeed, Japan is said to be one of the world’s highest context cultures, meaning that its citizens eschew explicit communication, leaving much unsaid. Rorschach, then, is perhaps the ultimate example of reading between the lines.

Nakamura sees another source of the Rorschach’s appeal in the challenge of mastering it. At first glance, the test is deceptively simple, but in fact the process of interpreting and coding a client’s responses is painstaking. Doctors must weigh how patients respond to shading and negative space; whether they observe texture, movement, and distance; if they see human or animal figures, and what they say the figures are doing; and how exactly they verbalize their perceptions. From there, a psychologist extrapolates what patients’ answers indicate about their information processing, reactivity, self-image, and interpersonal relationships, among other characteristics. “It’s hugely labor-intensive to learn the coding system," said Meehan.

But for those who still use the test, the time investment is worth it. Nakamura said that the test is easily administered to patients of all ages and backgrounds. “The simple question of ‘What might this be?’ makes them call upon their memories and learning and experiences, revealing patterns of how they cope with everyday life,” she said.

Meehan noted that while there is variation across cultures in what people see—one card, for instance, resembles to many Japanese subjects a stringed instrument known as the koto, which Americans rarely see—the objects people name are not very important in the coding of the test. “It’s not really what they say; it’s more about how they pull together the image,” Meehan said. “And the how is very cross-culturally stable.”

In understanding the results of their Rorschach tests, then, patients learn what this how means about their inner mechanisms, which they ordinarily cannot see or explain. The beauty of the Rorschach lies in its psychoeducational potential, Nakamura said: “It makes the invisible visible.”