AZIMA BATTERY

PROPONENT

DR. FERN J. CRAMER-AZIMA

● Canadian psychologist from Kingston Ontorio, Canada
● She took her doctorate degree at University of Montreal (Quebec, Canada) and made a lot of remarkable fellowships and
academic titles mainly at McGil University.
● She is also the former president of The International Association of Group of Psychotherapy (IAGP) from 1989-1992.
● In the 1950s, Dr. Azima was involved in an assessment of psychiatric occupational therapy in Canada that caused a
published finding of dismay and criticisms all the way to the United States.
● With this published finding, she was immediately invited by the American Task Force to report on a new test procedure and
a new philosophy/dynamic orientation for the field.
● The motivation for the battery was the simultaneous involvement of the department in Projected group therapy (formerly
known as Analytic group therapy) and studies related to schizophrenia.
● The concerns revolved around understanding and clarifying distorted object relations, the regressive phenomena that occur
in severe psychopathological, drug, or marked states of stress.
● During this time, psychiatric occupational therapy was concerned exclusively with traditional occupational and recreational
functions and minimally with evaluation and therapeutic functions.
● Dr. Azima believed that the occupational therapists are the primary therapists that can evoke the client’s meaningful
relationship to reality.
● “The presence of objects (ready-made, offered, or created) and dynamics of the object relations as referable to an available
external medium is and should be taken as the distinguishing mark of occupational therapy from individual or group
psychotherapies.”
● The presence of non-structured objects which can be structured according to the emergence of internal happenings marks
the point of emphasis and distinction of on-going processes in OT
● Occupational therapy which allows both verbalization and doing was distinguished from psychotherapy which only requires
verbalization from the individual.

PURPOSE

● The Azima battery is a projective assessment used by occupational therapists in order to phenomenologically elicit and describe
the activity performance and narratives of individuals at risk of, or on, the psychotic-spectrum. They do this by means of using
expressive media in a standard setup (Zafran et.al, 2016).
● In addition therapists administer Azima Battery with aims of:
○ Helping hospitalized persons with psychiatric conditions to uncover their attitudes, motivations and defense and coping
mechanisms
○ Assessing behavior to know how they are in contact with reality
○ Monitoring the degree of their ego, their relation to others, and the clarity of communication that they can manifest
compared to their defensiveness
● Uses:
○ For evaluation, diagnostic aid of the battery itself, for change detection, prognosis, therapy, and rehabilitation
○ Tracks behavioral modules, such as desensitization, conditioning, implosion, and feedback
○ To assess the client’s ability to comply with the test procedure and to show sufficient spontaneity, creativity and easy
association
○ One of the projective batteries that render the person’s hidden past into a visual identifiable form which gradually the
ego recognizes and codes into language.
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ADMINISTRATION

FREE DRAWING
DESCRIPTION MATERIALS PROCEDURE
This subtest reflects the client’s the extent of 1. Pencil 1. The therapist instructs the client to draw anything using a pencil on a piece of paper.
detailing within the object and/or the surroundings. 2. Eraser a. Script: “Name of client, draw anything using a pencil and a paper.”
3. Drawing paper 2. The client gathers needed materials and follows the instruction of the therapist.

DRAW A PERSON AND A PERSON OF THE OPPOSITE SEX

DESCRIPTION MATERIALS PROCEDURE
This subtest reflects the presence of perceptual 1. Pencil 1. The therapist instructs the client to draw a whole person and a person of the
incoherencies with the human figure drawing e.g. 2. Eraser opposite sex using a pencil on a piece of paper.
flatness, perspectival distortions, problems with 3. Drawing paper a. Script: “Name of client, draw a person with a whole body, then draw a
spatial relations or figure ground.
man/woman.”
2. The client gathers needed materials and follows the instruction of the therapist.

CLAY TASK
DESCRIPTION MATERIALS PROCEDURE
This subtest reflects the client’s concept formation, 1. Clay 1. The therapist instructs the client to mold the clay to make anything.
anticipation, ability to initiate, logic of sequencing 2. The client gathers needed materials and follows the instruction of the therapist.
of performance regardless of quality of final a. Script: “Name of client, mold the clay to make anything.”
product.

FINGER PAINTING
DESCRIPTION MATERIALS PROCEDURE
This subtest reflects the client’s efficiency and 1. Finger paints (yellow, 1. The therapist instructs the client to do a finger painting using the finger paints on a
quality of performance and created object. red, green, blue, brown finger painting paper.
and black) a. Script: “Name of client, using your fingers, paint anything.”
2. Finger painting paper 2. The client gathers needed materials and follows the instruction of the therapist.
3. Small bowl with water
4. Paper towel

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According to Hemphill (1982) the administration of the battery is usually performed in a:
● one on one social setting between the client and the therapist.
● The occupational therapist and client sit side-by-side at a table (rather than face-to-face).
● After the instructions are given, the therapist moves slightly behind the client to be out of the client’s line of vision.
● The Azima Battery test requires a specific layout of the materials on top of the table, on the centre is where the 16 by 22-inch
finger painting paper is located, on top is the location of the 2 pieces of 8 by 11-inch white paper. Above that is the placement
of the finger painting colors where a specific spectrum of color is also required, ranging from left to right are the colors yellow,
red, green, blue, brown, and black. On the most left is where the clay contained within the plastic container is placed and
next to that is the paper towels. On the right portion of the table is where the small bowl for dipping is placed.

1. The therapist will ask for the client’s age, education, marital, and occupational status.
2. After gaining some rapport, the therapist will give orienting instructions such as:

“ As part of the evaluation routine of our hospital, I would like to carry out a battery of tests with you. I am going to ask
you to make some different things with the various materials on this table. This is another investigation to help assess
your mode of functioning and some of the problem areas that are not always visible on the surface, or even that you
may be aware of. I may repeat the procedure at various intervals and at discharge to assess your progress.”

3. The therapist will move slightly behind client to be out of line of vision and begins to record time for each of the productions as
well as total test time
4. The therapist must take note of the following:
a. client’s behavior of the drawing
b. clay & finger painting sequence
c. Verbalizations
d. total technique employed
5. The occupational therapist refrains from talking and responds minimally to allow maximum concentration and externalization of
the client during the creation phase. The inquiry stage is preferred to be conducted when all tasks are completed. However, for
certain active children, organics, or memory damaged individuals, inquiries can be conducted after each task is completed.
6. The occupational therapist proceeds to the association phase by asking the client the following when all the tasks are completed
(but not limited to):
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 a. “Please tell me what you have made.” (Hemphill, 1982) / “Maari mo bang sabihin sa akin kung ano ang iyo nagawa?”
b. “Describe to me what you see, had in mind, and what comes to you now.” (Hemphill, 1982) / “Maari mo bang ilarawan
sa akin kung ano ang iyo nakita, ano ang inisip mo noong bago ka gumawa, at kung ano na ang iniisip mo ngayon?”
7. The therapist must be careful not to influence in any way the client during the association phase. Specifically, the therapist must
“not directly suggest meanings, but, rather, show positive interest, a need for elaboration, and understanding of the tasks”
(Hemphill, 1982).

PHASES OF AZIMA

CREATION PHASE ASSOCIATION PHASE

● The therapist must refrain from talking and respond
minimally to allow the client’s maximum concentration and
externalization.
● It is preferable to commence the inquiry stage after all the
productions are finished.
● Exceptions to this rule are:
o certain active children
o organics or memory damaged individuals where the
inquiry for association phase is made as each product
is finished.
• As with other projective techniques, associations are
gained by such statements as:
o “Please tell me now what you have made.”
o “Please describe to me what you see.”
o “Why did you choose to use this color?”
(applicable for clay and finger painting)
o “What did you have in mind while making this?”
o “Now that you’re done and looking at your
output, what do you have in mind?”
o “Which part of the battery test did you enjoy the
most?”
“Which part of the battery test did you have
difficulty with?”

● The therapist must be cautious not to project his own

associations or directly suggest meanings, but to show
positive interest, a need for elaboration and understanding
of the productions.
● The client’s motivation, behavior and rapport to the test
situation and examiner should be noted.
● For each part of the battery, the phases reaction and total
time of: Preparation, Production, and Completion are
recorded
● For the interpretation of the battery an evaluation scale
has been published and the scale is divided into:
a. organization of mood
b. organization of drives
c. organization of ego
d. organization of object relations

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SCORING

Azima diagnostic rating scale includes organization of mood, organization of drives, organization of ego and organization of object relations. This is observed from the client's
behaviour and content of speech while doing the activity. This is used to interpret the result of the activity (Azima 1982).

D – Drawing
F - Finger Paint
C – Clay or P – Plasticine

ORGANIZATION OF MOOD ORGANIZATION OF DRIVE ORGANIZATION OF EGO

Elation-Depression
1. Use and Handling of Color (F,C,P)
● Degree of control - very controlled to no control
● Intensity of color - very intense to no intensity
● Extensity of color - mixed to small
● Range and purity of color - mixed to no color
● Texture of color - very thick to none
2. The Use and Handling of Form (D,F,P,C)
● Control of form - controlled to symbolic
● Form-movement - very mobile to immobile
● Extensity of form - whole to part
● Purity of form - mixed to impure
3. Speed of Response - very fast to slow
4. Tone of Content - very happy to very sad
● Animate to inanimate
● Human to non-human
● Symbolic to comprehensible
5. Number of Responses
● Many to unique
Nature of drives 1. Organization of thought:
1. Libidinal Drives: overt or covert manifestation ● Dissociation (complete-occasional)
(action-inferred) ● Confusion (complete-occasional)
● Content overt libidinal content; covert libidinal ● Delusion (elaborate-feeling of reference)
content (symbolic) ● Emergence of memories (many-some)
● Degree of form control ● Increased rate of speech (logorrhea-no silence)
● Degree of intensity of color, texture, movement ● Decreased rate of speech (mutism-few silences)
● Mode of object handling (stroking, rubbing, 2. Organization of perception:
messing, soiling, smearing, licking) ● Hallucination (very elaborate- occasional)
● The behavior toward the therapist and object ● Hallucinosis (very elaborate-occasional)
2. Aggression: overt or covert manifestation (action- ● Body image change (elaborate- one organ)
inferred) 3. Organization of defenses:
● Projection (elaborate delusion-feeling of
Content of drives reference)
1. Oral (action -inferred) ● Withdrawal (immobility-slight mobility)
2. Anal (action-inferred) ● Splitting (complete-some dissociation)
3. Phallic (action - inferred)

Anxiety
1. Use and Handling of Color
● Color shock - marked to none
● Clarity - very clear to chaotic
2. Use and Handling of Form
● Distinct-shading-indistinct
● Continuity -discontinuity
● Controlled-uncontrolled
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 ● Smooth-shaky
3. Movement
● Blocking-rapid movement
● Smooth flow- choppy
4. Tone of Content
● Overt anxiety
● Covert anxiety
5. Texture
● Degree of shading
● Degree of smoothness
● Degree of fuzziness

IMPORTANT THINGS TO TAKE NOTE AND SHOULD BE DOCUMENTED

● Hemphill (1982) listed the following that should be noted during the assessment:
○ The motivation, behavior, and rapport to the test situation and examiner;
○ The phases reaction and the total time of the following for each part of the battery are recorded:
■ Preparation
■ Production
■ Completion
● Ikiugu (2007) mentioned the following information that should be obtained from the observations of the client:
○ Orientation to reality;
○ Relationship with other people;
○ Ego control;
○ Ability to cope;
○ Expression of mood;
○ Clarity of communication; and
○ Interpretations of the symbolism in the creation used to determine the intrapsychic content of the client.
● Paper towels are provided but rulers or other tools used in ceramics are NOT allowed.
● There is a preferred presentation of pencil, clay, and finger painting, since the latter medium usually requires the hands to be washed before continuing
with the association phase.
● It is important for the therapist to build some rapport towards the client
● The occupational therapist must keep note of the client’s behavior, of the drawing, clay, and finger painting sequence, the verbalizations, and the total
technique employed.
● The occupational therapist must refrain from talking, and should respond minimally to all the client's maximum concentration and externalization.
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 ● The therapist must be cautious not to project his own associations or directly suggest meanings, but to show positive interest, a need for elaboration
and understanding of the productions.
● The client’s motivation, behavior, and rapports to the test situation and examiner should be noted.
● For each part of the battery that must be recorded, the phases reaction and total time of:
1. Preparation
2. production
3. Completion
● For the interpretation of the battery an evaluation scale (Azima Diagnostic rating scale) is used.

REFERENCE

• AZIMA Battery. (n.d.). Retrieved from https://www.scribd.com/document/433945739/AZIMA-Battery?fbclid=IwAR2wtznInzj103-_AykbS_j982EMuLDpl17BNQy2Pp9P3aWHmMF0T3dRcfo

• Hemphill, B. J. (1982). The Evaluative Process in Psychiatric Occupational Therapy. West Deptford Township, NJ: Slack.
• Zafran, H. (2016).A mixed methods inquiry into the clinical utility of an expressive projective assessment with individuals experiencing early psychosis. (Doctoral Thesis). McGill University,
Montreal, Canada. http://digitool.library.mcgill.ca/R/?func=dbin-jump-full&object_id=141261
• Creek, J., & Lougher, L. (2011). Occupational Therapy and Mental Health. Churchill Livingston Elsevier.
• Hemphill, B. (Ed.). (1982). The evaluative process in psychiatric occupational therapy. Thorofare, NJ: Slack, Inc.
• Ikiugu, M.N. (2007). Psychosocial conceptual practice models in OT. Building Adaptive Capability. Mosby Elsevier.
• Hiba Zafran, Beverlea Tallant, Isabelle Gelinas & Steven Jordan (2018) The Phenomenology of Early Psychosis Elicited in an Occupational Therapy Expressive Evaluation, Occupational Therapy in
Mental Health, 34:1, 3-31, DOI: 10.1080/0164212X.2017.1338982
• Zafran, H., Mazer, B., Tallant, B., Chilingaryan, G., & Gelinas, I. (2017). Detecting incipient schizophrenia: a validation of the Azima battery in first episode psychosis. Psychiatric Quarterly, 88(3),
585-602.

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