SIS Journal of Projective Psychology & Mental Health

JOURNAL OF PROJECTIVE PSYCHOLOGY & MENTAL HEALTH The Official Publication of the Somatic Inkblot Society Volume 2 Number 2 July 1995 SIS ISSN 0971 - 6610 Vol. 2, No. 2, Pgs. 93-162 SIS JOURNAL OF PROJECTIVE PSYCHOLOGY & MENTAL HEALTH 19945

SIS JOURNAL OF PROJECTIVE PSYCHOLOGY AND MENTAL HEALTH is published twice a year (January & July) by the SOMATIC INKBLOT SOCIETY and is devoted to the advancement of research in the areas of projective psychology, personality assessment, psychotherapy and mental health. The journal is broadly concerned with the development of inkblot tests and personality assessment in clinical, counselling, cross cultural, organizational and health psychology settings. It aims to reach clinical psychologists, psychotherapists, psychiatrists, social workers, medical professionals and professional managers interested in the understanding and modification of human behaviour. The journal includes (a) research articles (b) book reviews (c) brief reports (d) news about conferences etc. and letters to the editor. MANUSCRIPTS PREPARATION : Manuscripts should be typewritten (double spaced throughout) submitted in duplicate to B.L. Dubey, Ph.D. Editor- in - Chief SIS Journal, P.O.Box 1107, Sector-15 Post Office, Chandigarh 160015 (India). E-mail : sisdubey@hotmail.com Manuscript can also be submitted to Wilfred A. Cassell. M.D., Editor, 4501E, 104th Avenue, Anchorage, AK-99516 (USA). The Editors reserve the right to refuse manuscript submitted and to make minor additions/deletions. Authors should prepare their manuscripts according to the Journal of Personality Assessment. SUBSCRIPTION : The journal is free to members of the Society, Annual membership fees are US $50 for foreign members and Rs. 250, for Indian members, Institutional subscriptions are US $100 for Foreign institutions and Rs. 500 for Indian institutions. Life membership is US $300 for foreign members and Rs. 1500 for Indian members. Non-members may subscribe for $30 or Rs. 150/- per issue. Cheques should be made payable to 'SOMATIC INKBLOT SOCIETY’ Chandigarh and should reach Dr. B.L. Dubey, Editor- in -Chief, (Address given above). Please add $5./Rs. 30 if you are sending subscription through cheque. CHANGE OF ADDRESS : Society / journal members should inform Mrs Padma Dwivedi, Secretary, SIS Center, Post Box 1107, Sector-15 Post Office, Chandigarh-160015 (India), Tel/Fax 91-172-710986, E-Mail: sisdubey@hotmail.com and Foreign Members should inform, Anand Dubey, Joint Editor, SIS Journal, Post Box 244045, Anchorage, AK-99524 (USA), E-Mail : adubey@hotmail.com of any change of mailing address. Copyright @ 1994. SOMATIC INKBLOT SOCIETY

STATEMENT SHOWING OWNERSHIP AND OTHER PARTICULARS ABOUT SIS JOURNAL OF PROJECTIVE PSYCHOLOGY AND MENTAL HEALTH PLACE OF PUBLICATION : T-2/15, Sector-25 Chandigarh - 160014 PERIODICITY OF PUBLICATION : Half Yearly EDITOR'S PRINTER'S Name : Dr. B.L. Dubey PUBLISHER'S NATIONALITY : Indian ADDRESS : T-2/15, Sector 25, Chandigarh - 160015 OWNER : SOMATIC INKBLOT SOCIETY I, Dr. B.L. Dubey, hereby declare that the particulars given above are true to the best of my knowledge and belief. Sd/ Dr. B.L. Dubey, Editor-in-Chief SIS Journal of Projective Psychology and Mental Health Printed and Published by Dr. B.L. Dubey on behalf of Somatic Inkblot Society from T-2/15, Sector 25, Chandigarh - 160014 & Printed at Juneja Trading Agencies Pvt. Ltd. Printing Press, SCO 131-132, Sector 17-C, Chandigarh. Tel. : 702675, 704715. Editor : Dr. B.L. Dubey

SIS Journal of Projective Psychology & Mental Health Volume 2, Number 2, July 1995. Contents Page Nos. 1. Editorial : Wilfred A. Cassell 93-94 2. Corporal Perception in HIV Positive and Negative 96-110 Heorin-Addicts Assessed with Somatic Inkblot Series-I Giovanna Gaetani; Leder Fiorenzo, Lucchini Alfio, Strepparol Giovanni’ Vitali Rossano and Ferro Roderto 3. Inner Cry Through Somatic Inkblot Series 111-118 B.L. Dubey, W.A. Cassell, Padma Dwivedi & Mridula Mishra 4. A Study of Somatic Inkblot Series Application in 119-123 Medical Setting Deborah Brady 5. A New Combination of Therapies for the Treatment 124-127 of Schizophrenia of Less Than Five Years Duration N.L. Dosajh 6. Diagnostic Significance of Content Analysis of SIS-II 128-132 Dwarka Pershad and S.K. Verma 7. Projective Meanures of Alexithymia and the SIS 133-139 Rakesh Pandey 8. Human Figure Drawings of Prisoners and Vipassana 140-144 K.Chandiramiani, R. Jena and S.K. Verma 9. Basic Personality Structure of the Deprived Adolescents 145-149 Mahesh Bhargava and Anju Sexena 10. Diagnostic Significance of the Indices of the SIS-II and the 150-155 Rorschach Inkblot Tests. C.B. Dwivedi, Mridula Mishra and B.L. Dubey 11. Personality Profile of the Hemophiliacs in Comparison to 156-162 Normals; A Study using Self Report and Projective Measures S. Bhattacharyya, D. Biswas & J. Basu

Editorial There are a few special individual who challenge us to risk above the mediocrity of our lives. There ideal and accomplishment can serve to inspire us even long after their physical bodies have disintegrated. Hermann Rorschach has long been on inspirational figure for me. Body symbolism (1980) was “dedicated to the spirit of Klex’ (1984- 1992) and those who labor after him”. Roughly translated, “Klex” was a nickname assigned to him by his peers in school for his ability to produce artistic inkblot configurations. In later life, as an inquiring psychiatrist, he pursued the intellectual pathways created by artist of the 19th Century who paid ‘in determinant forms to stimulate creative imagination”. He described the rational for his approach to ink blot development as follows. “The projection of such accidental forms is very simple: a few large inkblots are thrown on a piece of paper, the paper is folded and the inkblot spread between the two halves of the sheet. Not all of the figures so objected can be used, for those use must fulfill certain conditions. First, the forms must be relatively simple; complicated pictures make the computations of the factors of the experiment too difficult. Second, the distribution of the blots on the plate must fulfil certain requirements of composition or they will not be “suggestive’ with the result that many subjects will rejects will reject them as simple inkblot without consideration of other possible interpretations’. In Switzerland, just after World War I, he conducted clinical trials with hospitalized psychiatric patients and eventually selected fifteen blots which met his criteria. Unfortunately, for economic reasons, the Swiss publisher refused to print all these cards and five blots were eliminated. Imagine how frustrating this must have been to him at the time. Perhaps this played a role in his untimely death at age 37. He died from what many modern physicians consider to be a stress-induced gastrointestinal illness. In spite of his medical training, he neglected his own life-threatening abdominal symptoms. He failed to seek appropriate treatment for several days after his appendix actually ruptured, even when he was in great pain. Surely he must have felt quite defeated at the time and perhaps even depressed. In any case, all subsequent work the remaining then blots must be considered to represent an incomplete series. If he had achieved some measure of professional published the complete series. Moreover, if he had lived a full life, no doubt he world have actively pursued their presentation on video and computer screen and Telemedicine transmission. In an attempt to follow in his intellectual leadership, in 1988, I developed a video version of the ten plates employing the same audio-visual technique as the SIS. Upon completion, I met with the representative of the Rorschach publisher who was shown the video and expressed considerable interest in this new technology. He graciously gave me permission for its research application provided it was not sold commercially. SIS J. Proj. Pst. & Ment Health (1995) 2:93-94

However, he wanted to check with certain Psychologists in the field before proceeding. Unfortunately it was turned down probably because of the author’s emphasis on content analysis. For many clinicians content analysis approach of interpretation is helpful. An video presentation of a Rorschach card or SIS image enables the therapist to elicit imagery which helps in the understanding of dreams, visual hallucinations, recall of repressed post-traumatic stress, real-life events, and abnormal perceptions projected onto the body, etc. Moreover, it facilitated the therapeutic processing of emotionally painful material in a way not possible in traditional therapy sessions. Additionally, it provides a learning experience of the viewer to understand how symbols may be employed to defend against threatening material coming into consciousness. At this time, I am pleased that the copyright on the incomplete Rorschach test is soon to expire. Consistent with what I’ve imagined to be Rorschach’s professional philosophy of methodological development and with the able leadership of authorities such as Dr. B. Lal Dubey in India, we are now actively working on video and computer presentation. Please join us in this endeavor. Hopefully, this journal will facilitate communication for investigators who employ the Somatic Inkblot Series, the Rorschach, and Holtzman tests, all other related procedures, which can enhance the exploration of consciousness. There is a type of mystique about certain existing tests with their standardized norms and methods, administration, and so on. For example, in regard to both the Rorschach and Holtzman tests in many instances when I use these procedures, I do not use the standard administration. In a clinical setting, when I want to learn as much as possible about a particular individual who is suffering and facilitate the relapse of his pain, I ask the individual to indicate which three blots are “most liked”. The detailed inquiry will then begin by requesting the subject to give associations to these cards. This serves to minimize test’s anxiety and reduce psychological defenses for the examination of more clinically relevant material which follows when responses to the three “least liked” are explored. In any case, the therapist needs to be flexible and not constrictive in the methodology when using a projective technique. Lastly, we plan to avoid the pitfalls experienced by both Hermann Rorschach and Wayne Holtzman in having to deal with cost-oriented publishers. Full copyrights for the SIS, in its various forms, are retained by SIS Corporation (W.A. Cassell). Eventually these will ‘be transferred to the Somatic Inkblot Society in each country where the work is being done. As a result, it will be researchers and clinicians in the behavioral sciences who will determine the direction of the future work. Please join us in this fascinating adventure. Wilfred A. Cassell 94 Cassell

SIS AWARDS Somatic Inkblot Society has great pleasure in announcing the SIS Research Awards to the following Scientists, to be presented in the next conference of the Society. 1. Dr. C.B. Dwivedi, Ph.D. Head and Miss Mridula Mishra, Research Scholar, Deptt. of Psychology BHU, Varanasi (India). 2. Dr.Roberto Ferro, Ph.D., Psychologist, Cernusco Sul Naviglio, Milano (Italy). 3. Dr. S. Ramachandra, Ph.D., Asociate Professor in Clinical Psychology, National Institute of Mental; Health and Neuro-Sciences, Bangalore (India). 4. Dr. Georage Savage, M.Sc., U.C.T., Psychotherapist, Cape Technikon, P.O. Box 652, Cape Town, 2000 (South (Africa). 5. Dr. S.K. Verma, Ph.D. Additional Professor, Division of Clinical Psychology, Deptt. of Psychiatry, Postgraduate Institute of Medical Education and Research, Chandigarh (Inndia). The Earlier Award Winners 1. Dr. B.L. Dubey, Ph.D. 2. Nrs. Padma Dwivedi, M.A. 3. Dr. D.S. Goel, M.D. 4. Mr. R.K. Joshi, D.M.S.P. 5. Miss. Mridula Mishra, M.A. 6. Dr. Dwarka Pershad, Ph.D. 7. Mr. S.P. Rathee, M.A. 8. Dr. D. Saldanha, M.D. Dr. Wilfred A. Cassell. M.D. (Director, SIS Center, USA) Patron Somatic Inkblot Society Email: siscassell@yahoo.com

Giovanna Gaetani, Psychotherapist; Lucchini Alfio, Psychologist, Psychotherapist, SERT coordinator; Vitali Rpssano, Assistant doctor, psucjotherapist, Sert, Ussl 58, Cernusco Sul Naviglio (M) Italy. Leder Fiorenzo, Neurologist, SERT Co.-ordinator, USSL 62, Meda (MI) Italy. Strepparola Giovanni, Psychologist, Psychotherapist, assistant doctor, SERT, Cemusco Sul Naviglio (MI). Italy. Ferro Roberto, Psychologist, Psychotherapist, Cernusco sul Naviglio (MI). Italy SIS J. Proj. Pst. & Ment Health (1995) 2: 96-110 Corporal Perception in HIV Positive and Negative Heroin-Addicts Assessed With Somatic Inkblot Series-I Giovanna Gaetani; Leder Fiorenzo, Lucchini, A; Giovanni, S. Vitali R. and Ferro Roberto Forty-five drug addicts were studied; of these 15 were HIV negative, 15 HIV positive and 15 HIV positive and undergoing AZT therapies. We used the SIS-I projective psychological test to assess emotional perception of the body. We observed emotional elements revealing unconscious underlying conflicts manifested clinically in the form of anxiety and distress. Evident anxiety appeared in the presence of the cards regarding the head, sexuality and the Gestalt. Anxiety regarding the organic illnesses the subjects was suffering of defense mechanisms of repression and denial in the presence of the cards stimulating the subject of death. There were significant differences in preoccupation and aggressiveness between HIV positive and negative subjects. In particular, in subjects on AZT therapy the fear of death was expressed as a distressing sense of expectation before a terrifying event seen as inevitable and accepted-sometimes with resignation, sometimes with resistance and sometimes as a liberation from suffering or as atonement for one’s misdeeds. This paper is based on the psychosomatic interpretation of positivity to AIDS Virus antibodies. The unusual application of SIS-I was adopted for a better understanding of the corporal perceptions of our patients in whom mind-body unity is achieved paradigmatically. The test will be presented with subsequent analysis of the most pertinent corporal results (Para’s 1:1 and 1:2). Last will Come a more general analysis of the symbols emerging and an attempt to identify unconscious problems with particular attention to those we believe most relevant to the perception of drug addiction and AIDS (1-3). This last section will be based on C.G. Jung’s teachings; we shall try to group the symbols to highlight the main myths expressed by and implicit in these symbols. We believe that the question C.G. Jung asked in 1961 at the start of his own long activity, after his separation from S. Freud (In what Myth am I living?”) Can also be applied to the subjects. In what myth does an HIV positive drug addict live?” is the question, which guided this part of the work. This interpretation cannot of course cover

the complexity of the subject; one of the characteristics of the symbol is the fact that it constantly lends itself to new meanings. Other interpreters could, of course, discover different meanings and contents not explored by us. Material and Method: The Somatic Inkblot Series-I (Cassell, 1976) consists in a collection of twenty cards; each one represents a partially ambiguous visual stimulus based on specific anatomical structures and designed to induce a somatic perception in the subject. The cards, in black, red and gray on a white background, show anatomical structures sufficiently clearly to evoke spontaneous comment, but not such to limit the responses merely to the perception of apart of the body or the naming of the colors. In this way, the material examined reveals a deeper meaning, more symbolical than a mere bodily perception. Each of the twenty cards is presented in numerical order and always in the same order. No card is omitted and the instructions should be given in the test. The instructions should include the following basic information. 1) This test has no time: take all the time you need to answer: 2) I am going to show you one card at a time; you can turn them as you please if this helps you to answer; 3) Different people see different things in these cards; there is not a right or a wrong answer. 4) Do you have any questions? 5) Are you ready to start? The reaction time must be recorded for every card; this is an important resistance indicator and significant for clinical data. The inability to respond to a card or a mere ‘I don’t know” are recorded as a rejection and interpreted as resistance to that specific body image. After a detailed examination is conducted showing all the cards and asking the subject to choose the three cards which stimulate the most pleasant sensations. This enables the examiner to positively assess the cathartic and libidinal centers, focusing them on a specific corporal image. The same procedure is then repeated for the most negative reactions. We shall not describe the theoretical basis of each of the twenty cards in the series, with specification of the somatic area stimulated by each of them. Card 1 : the face Card 2 : the human gestalt Card 3 : two people SIS in HIV 97

98 Gaetani et al Card 4 : a woman Card 5 : a person Card 6 : the heart and lungs Card 7 : the heart and female genitalia Card 8 : the thorax Card 9 : the urogential system Card 10 : the month and stomach Card 11 : the gastrointestinal tract Card 12 : the female reproductive organs Card 13 : the perineal area Card 14 : the female genitalia Card 15 : the spinal column Card 16 : the nose, eyes Card 17 : the male genitalia Card 18 : a threatening face Card 19 : the hands Card 20 : a threatening face As already mentioned each card is ambiguous. Each card is capable of stimulating images, feelings and emotions for the somatic area represented but may also stimulate broader perceptive contests going beyond the corporal perception and revealing more general unconscious contents. The test was applied to 45 former drug addicts who had not used drugs for periods ranging from a minimum of one month to a maximum of three years. Fifteen were HIV negative fifteen HIV positive and the remaining fifteen were HIV positive and undergoing AZT therapy. The latter situation is a practical declaration of AIDS. The mean age was twenty-sex (from a minimum of nineteen to a maximum of thirty-seven). There were thirty-four males and eleven females. Results: 1.1 The body schema and the “affections”: Before analyzing what emerged, we believe a little theory is required. We shall begin with that peculiar psychophysical ‘ structure” that is the body schema. This with that peculiar psychophysical “structures” that is the body schema. This term dates back to the last century when the physiologist Reli (see M. Callegari, 1989) introduced the term “cenestesi”, this word encompasses all the sensations transmitted from various pats of the body to the nervous centers (thalamus and cortical sensorial areas).

SIS in HIV 99 Concepts such as “sensory homunculus” and “motory homunculus” began to be used express the “whole” of the cortical tissue to which the corporal sensations were transmitted and from which the motor commands departed. Next came the concept of body schema, and many synonyms were found to better explain its meaning e.g. “spatial image of the body”, postural schema”, image of the corporal ego”, awareness of one’s body. The body schema was, however, considered the outcome of the “perceptive work” conducted by the brain of the sensorial afferents arriving to the specific cortical areas. It is important it note that the study and evolution of this study turned into a multiple concept-both physical and psychological. According to the latest views, factors not only of a physiological order (tactile, visual proprioceptive, muscular and particular sensations) but also psychological ones are present in the values learned from parents and educators and to our object-relations, especially those of very early infancy (although it should be pointed out that the concept of body schema is dynamic and susceptible to charge during one’s life). The body, as w perceives it, is not just a combination of organs and systems; it is an affective body, a sexual body; it bears the imprinting of our experiences, the events and emotions of our life. A test on corporal perception does not explore, clarify and highlight only a physical body, but also an emotional one, the “affections”. For a better understanding of the concept of “affective body” we can start from a concrete example observed in our tests. When one boy saw a card showing a thorax with a heart at the center he said: ‘I see a heart devoured by monsters”. This is not the expression of the fear that this could actually happen, but that his heart, in its familiar symbolic sense, the center of life and sentiments could no longer exist, vanish; he therefore fears the end, the loss the dissolution of his own sentiments and affections. This example also allows us to express another extremely important concept: the symbolic opening of our body, that “extra sense” to which it defers and which can be grasped if we seek it with proper tools – one of which may be a test, such as SIS-I, specifically studied for corporal perception. Our gestures of our actions, feelings, deem and the single parts, the single organs of our body all have symbolic contents. A hand is not that specific organ for grapping objects, it is also symbol of union and communication; a foot, in addition to the specific organ used for walking can be the symbol of how one ‘ lives in the clouds”. All the comments made by our subjects should be analyzed, without forgetting this “double register”, on the one hand the actual organ, system, and on the other that symbolical aperture that organ or system permits to our inner emotional world. The analysis and interpretation of the cards proposed herein will always be based on this possibility.

1.2 Analyses and Interpretation of the Cards: The first face, the first identification: The first card in the test shows an image generally describable as the “face of an animal”. More than 80% of the participants did indeed see the face of an animal. Those who specified the type of animal identified it as a wolf (one subject) a lynx (one), a moose (one), a spider (one) a dragon (one), a cow (one), a butterfly (one), a sheep (four) and a bull (six). Three saw a devilish face in the card. Six people found the image ugly, none attractive. Three participants saw some pliers in the drawing. One person saw little geese in the red spots at the sides. These images reveal a high degree of aggressiveness and anxiety. No substantial differences emerges between the three groups (HIV-; HIV+; HIV+ on AZT therapy) The Human Gestalt: Card 2 proposes a full-length figure loosely described as “a clown” on “as a smiling clown”. The smile can also be seen as a heart. Of our subjects, more than 60% did indeed recognize a happy clown and there were no essential differences between the three groups 9HIV-; HIV+; HIV+ on AZT). The most interesting fact is that the card was classified among the most pleasant cards by 9 HIV-subjects, 5 HIV + ones and by 2 on AZT. In contrast, the card was not liked by only 1 HIV-subject, by 3 HIV+ ones and by 3 on AZT. Those who did not like the card described the clown as “stupid”, deformed or “unattractive”. Our interpretation is that this smiling clown indicates an acceptance, an ability to see oneself in a situation of joy and of frivolity; we believe it significant that it was much less appreciated by HIV+ subjects than by HIV – ones. The comment made by R., given the test just six days after learning she was HIV + would seem significant. She saw “a deformed face, like those in a Picasso painting”, thus conveying how hard it was for her to be smiling and frivolous in this moment. Those who saw a heart in place of the smile described it mainly as “oppressed” “bleeding” or “exploding”, while no one descried this organ in a positive manner. The Head: Evident anxiety also emerged with card 2, again for the area corresponding to the head. Three subjects saw “a vulture”, one saw “a piece of wood”, another “a black cloud moving on high”, yet another “a bat”. What was recurrent in these images is that the head is seen as a heavy, oppressive and impending presence, which from above threatens to crush something alive and throbbing. These comments seem to indicate that the head is considered the center, the receptacle for persecutory, oppressive thoughts which threaten the more emotional, more vital areas, situated in the area of the thorax and the heart. 100 Gaetani et al

There were also more positive response: one subject saw, in the area of the head, “a free bird flying away” whereas another saw ‘a tree rising from the heart”. We highlight this unusual image because it is present in alchemic works and is pointed out by Jung (1994) in his book “Psychologies und Alchemies”, as symbols of regeneration. Movement and Affectivity: Card 3 shows two people dancing. Card 4 shows a female figure picking an apple. Both images refer to movement, eros, affectivity, and expression of our own drives. Card 3 was described in this way by almost all subjects, everyone saw “two people”; the intensity of the feelings binding these two people and the importance attributed to the movement varied among the participants’ some saw the figures as static, for others they were more active. The following differences emerged among the subjects who saw something other than the “two figures” one HIV-subject saw “two insects come out from a cocoon”, an image of rebirth, of renewal, and only another HIV-subject saw crab with tentacles. Among the HIV+ subjects, one boy saw “two cacti with two crows above them”, another “two lovers spied upon by a ghost”, another said he saw “nothing”, and a fourth saw “two numbers”. One subject on AZT saw “a gloomy war scene”. These last comments would appear to show that the control of the emotions and drives is more difficult and problematical among HIV+ subjects and those on AZT; inappropriate presence such as crows, arid cacti and ghost, scenes of war and destruction all impede the free and spontaneous expression of the subjects’ feelings. For the very importance of the themes brought to light no one found this card unpleasant, although there was a significant difference in approval: 9 HIV-, 7HIV+ 4 HIV+ on AZT. HIV+ subject therefore gave it a wide birth. This important question will be better examined in the chapter. “The Hero’s Sacrifice”. The responses to card 4 confirm the greater affective problems of HIV+ subjects. Analysis of the alternative responses to the standard: “a woman with an apple”, we observe that the HIV-subjects: three said they saw “nothing”, one saw “two dry branches” and two declared that “the woman is not interested in the apple”. Of the HIV+ subject, three said they saw “nothing”, one described “a cold, unnatural figure” and another two saw some “snakes”, another called the woman “Eve” (an image linked to the snake) another saw “a cobra” and another saw a person “oppressed by overwhelming thoughts”. As can be seen in some HIV+ subjects on AZT there are a felling of weight, of oppression before this image, something absent in HIV-subjects. Image of snakes appear and this is an extremely significant element explored later. Again, in partial confirmation of what was previously stated, this card was placed among the most unpleasant ones by two subjects, both HIV positive and on AZT; it pleases among the most pleasant by 9 HIV subjects, 6 HIV+ ones and only by 4 HIV+ positive on AZT. SIS in HIV 101

The Heart: Four cards (no. 5 to8) re-propose the image of the heart. On card 15 it is shown on the thorax of a person drawn in black. On card 6 it is associated with the lungs. On card 7 it is split in two parts. On card 18 it is the rib cage. The subjects described the heart in these cards as follows: “A heart” (with further details) 35 times “Devoured by animals” 2” “Suffering” 2” “Dismal” 2” “Broken” 4” Worn” 2” “Oppressed” 3” “Rent open” 5” Bleeding” 5” “Hanging from something” 2” “Pierced” 1” “Ill” 1” Dead” 1” “Alive” 2” “Victorious over evil” 1” “Throbbing” 1” “In love” 2” “Good” 1” Only one of the subjects had physical problems of a cardiac nature: and HIV+ boy suffering from dilative cardiopathy ; when faced with the cardiac image of the four cards, he repeatedly refused it and gave the following interpretations: “a bat jumping” (No. 5: “and x-ray with ribs, pelvis and spine” (no. 6) (he interpreted the heart as the spine); “a fire burring” (no 7 turning the card around); “ an underground cavity with something inside” (No. 8 turning the card around). There was no reason to believe that, apart from this in case, any other subjects had cardiac problems. Plainly, the symbolic meaning of the heart as the center of the emotional, affective and sentimental life, the hub of the joys and sorrows of life prevailed. Thus, what emerged also (empathically) from these responses regarding the heart is the expression the declaration of great suffering; as can be see, negative contents 102 Gaetani et al

clearly dominate. This is spite of the fact that one of these cards (cards7) shows the heart on objectively abnormal situations (i.e. split in two). No significant differences emerged between the tree groups although, if the 4 cards are considered as a whole, there were 7 rejections by HIV-subjects, 15 by HIV+ ones and 13 by HIV+ subjects on AZT. No hasty conclusions should, however, be drawn as in none of the cards was the heart the only stimulus present. One can presume that extreme suffering (and HIV+ subjects have, at least in theory, additional motives for concern) produced rejections instead of comments. The Lungs: Card 6 in the test shows the heart and two lungs. This card was of particular interest for us; we expected it to provoke extremely important reactions regarding problems linked to AIDS as the lungs are among the organs most affected by this illness and AIDS patients often die from incurable pneumonia. On the contrary, nothing of this kind emerged; only three subjects saw lungs “black from cigarette smoke” and nobody described them as sick or suffering from a physical illness. What we believe happened is that the symbolic meaning of the lungs and breath as first action in life prevailed, thus it was closely linked to inner matters of birth or rebirth. Indeed, almost all the reaction came within this scope. Besides the general comments “lungs” (without other details) or “two animals”, the following comments were made. 1) HIV-subjects: “something developing inside something else”. “Two animals mating”, “two unborn babies”, two little fish”, two seals kissing one is pregnant”, “a fetus” (two subjects). 2) HIV+ subjects: “two animals mating”, “two fish”, “two fetuses”. “two little birds mating”. “a flower opening”, two fetuses who are stillborn”. “two foetuses torn away by a cord”; “the evil surrounding the heart”. 3) HIV+ subjects on AZT; “an archeological relic”. “two capons”, “two little birds mating”, ‘two animals trying to keep something tighter”, two elephants with trunks”. As mentioned earlier, numerous images of birth are present, again with important differences between the three groups; for HIV-subjects the images are always positive; HIV+ subjects and those on AZT add images of death; the fetuses who are not born or stillborn or reduced to relics without life or lid ice energy (fossils or capons) or evoke fantasies or breaking (trying to keep something togther) It could be said that death appears among HIV+ subjects but it is our impression that what emerges is not only the fear of physical death, but that of an ‘inner” death i.e. that the fact of being HIV positive can wither the most vital inner parts, or not permit complete rebirth, the full expression of one’s potential and libidinal energy. This aspect will be explored later. SIS in HIV 103

The Excretory System: Card 9 shows two kidneys with the bladder and urethra. Thanks to the ambiguity of the stimulus very often two lungs and a heart are seen. This was one of the cards, which caused fewest problems: there were few rejections (3 in all). The subjects saw the kidneys (16 times), the lungs (13 times), the female genitals (3 times) and the male genitals (2 times), nearly always without providing further details. As this is one of the few entirely black cards (the first of this kind in the test), the lungs and kidneys were described as sick: 3 times the lungs, for smoke, and twice the kidneys without explanation. No substantial differences emerged between the three groups. The Gastroenteric System: Two cards (no. 10 & 11) show respectively the mouth and stomach and the small and large intestines. The main worries were expressed on the mouth: nearly all recognized it, but with queries (“I don’t know what it is connected to… It seems to be bleeding… I don’t know what is coming out… it seems to be smiling”). Many subjects expressed doubts on card, 9 describing it as abstract, incomprehensible. The stomach was very rarely recognized; it was mainly described as a piece of meat, a geographic terrain, a striped animal. The gastroenteric system was also recognized only a few times: the image of a man or a small, gentle, loving but lonely or sad animal was the main response. Unlike the other cards, the prevailing emotional associations regard tenderness or depression. These cards may unconsciously have aroused archaic oral problems, relating to the affective privations of very early infancy. The genital System and Sexuality: Card 13 and 14 show the perineal area and the female e genital system. Considered together, no great differences emerged between the three groups with regard to the approval or the hostility provoked. Three were 8 rejections among HIV- subjects, 7 among HIV+ ones and 5 among those on AZRT from the sum of the two cards for each of the three groups. This does not differ greatly from the percentage of rejections for the other cards. The impact with these cards was not particularly traumatic; only some subjects who had resigning the female genitalia said they slightly embarrassed, reticent to say so far fear of poking a negative judgment. It is, however interesting to examine the kind of comment made. HIV-subjects recognized the female (8 time in all) or made comments which, if interpreted symbolically come very close to sexual subjects; they saw “fruit” (4 times) or (3 time). Many subjects (7 times in all) saw “a cave” or “a cavity” (5 times) expressing the fear of losing themselves inside, not being able to come out and remaining imprisoned or the hope that “there is an exit” on the other side. 104 Gaetani et al

It will be seen later that these comments link the subject of sexuality with that of death. Moreover, two subjects saw “ an owl”, an animal symbolically linked to darkness, the night and death. Another human organ name was the “heart” (seen just once). The HIV+ subjects and those on AZT did not repress their answer any more than the HIV – ones although they did, if their responses are interpreted, reveal strong defense mechanisms of “escape from sexuality”, mainly of denial or sublimation. The female genitalia were recognized and named 7 times by HIV+ subjects and 4 times by HIV+ subjects on AZT. The definition “a cave” “a cavity”. (and similar) appeared only twice among HIV+ subjects and three times among those on AZT. One extremely significant example of these defense mechanisms came from an HIV+ subject in response to card 14: “a tube-with the shape of a heart”. The response “a heart” was indeed given by 5 HIV+ subjects and by 2 on AZT. The responses “a flower” and “fruit” (twice and once respectively by HIV subjects, 3 times and once by subjects on AZT) were fewer. The response “and owl” was given twice in all but other animals appeared e.g. “black widows” or “beetles” – closely linked to death. Some definitions, which appeared only once, are highly significant for our argument. Among HIV+ subjects: “a man with a shadow behind him” (sexuality has to be left behind) “a butterfly” (something flying away, climbing high). Among those on AZT: “advertising posters” (the characters are not alive but fictitious); “a tower, on a mountain” together with “a distant cliff” (escape to an alternative reality). These results will be explored later. One extremely important element should be stressed: 3 subjects on AZT saw in card 13 a mysterious ship moving forward. This important image will also be discussed later. Analysis of card 17 (showing the male genitalia) leads to similar conclusions, even though the entire symbolic framework evoked by the image of the uterus is lacking (cavity, cave, darkness, fear of not being able to come out, etc.). Although among the anatomical responses HIV-subjects named “the penis 6 times and “the thorax” once, HIV+ subjects named “the penis” only twice other answers were: “a thorax” (3 times); “a pelvis” (4 times): “the neck” (once), the oesophagus” (once); among those on AZT: “a penis” (twice): “a pelvis” (twice). Hence, this card also confirms the defensive mechanisms described above. Other parts of the body: Among the other cards one shows the spine (no. 15), one the hands (no. 19) and another the eyes and nose (no. 16). These will not be examined in detail, as they did not seem to provide particularly significant images and responses not any very different from the standard ones. SIS in HIV 105

The fear of death: Cards 18 and 20 shows two extremely threatening faces, capable, in our opinion, of arousing emotional contents linked to death. This proved true: in the majority of the subjects these cards provoked feelings of repulsion, fear and distress and were clearly more unpleasant to subjects on AZT (18 total indications of displeasure out of the total responses to the two cards) and to HIV+ subjects (17 indications in all) than to HIVsubjects (10 indications in all). Seven subjects (1 HIV-, 4HIV+, 2 on AZT) explicitly named death before these two cards. Other definitions conducted in a wide variety of monsters. These reactions will not be explored in detail as the figures on the two cards are objectively-speaking monstrous: quantification of a fully expected reply is not particular importance. Something will be said later on the kind of monsters seen (nearly all linked to a devilish symbology). It may instead be much more important to assess in groups the reactions to card 5 (a black man) as this should not in theory condition too greatly the appearance of contents regarding death, it being a much more neutral stimulus than cards 18 and 20. When presented this “black man” HIV-subjects said the following: “a preacher in a sect”, “a statue which gives me a sense of freedom”, “ a turtle” (3 times), “a turtle bleeding”, “a turtle with two babies” (“it seems dreadful but is good deep down”, “a man with two babies” (“I don’t know whether this person is good or bad”), “a scare crow”, “the devil”, “a volcano”, “a chasm”. The following emerged from the HIV+ subjects: “an eagle”, “an animal ripped open” (twice), “a man with a cloak” (twice), a turtle with two octopus” (twice), “death eating two red beings”, a bat” (twice) “evil encompassing the heart”, “the devil” HIV+ subjects on AZT saw the following: “a black mass priest”, “the devil”, a turtle” (twice), “a fish”, “a fearful alien”, a dark mysterious person with open hands, like death”, “death”. There is a clear qualitative difference between what HIV-subjects said and the responses of the two HIV=groups. While the former shows a certain ambivalence before the figure, with a relatively limited content of fear and distress, in HIV+ subjects, whether on AZT or not, images of death prevail. This appears a highly significant difference for the fact that a fairly neutral image was used. 1.3 Symbols and myths underlying the drug addict’s behavior and the conditions of HIV positivity: In the presentation of this paper it was said that every card was ambiguous, capable of provoking contents reaching beyond the somatic perception. In this part of the study, different from but complementary to the previous section, an attempt was made to understand these deeper unconscious aspects using the patients comments to identify the symbols and myths, the deep and unconscious drives regarding drug addiction and HIV positivity. The studies on the symbol made by Jung (1954) were the backup to this work. 106 Gaetani et al

Jung believed that our unconscious comprised not only contests deriving from our subjective experience, but also impersonal contents, which constituted what he, called “the collective unconscious” or “objective psyche”. These psychic contents common to all mankind are formed, so to say, by the “sedimentation” of the experience, which has always belonged to all mankind. According to Jung (1954) the objective psyche expresses itself through universal symbols and myths, the meanings of which remain relatively unchanged in the various cultures. Our effects, in this part of the work, were concentrate on the identification of the collective myths and symbols emerging in the responses, the expression of which could have been “activated” by the experience of drug addiction or HIV positivity in the subjects being studied. The hero’s sacrifice: In his book Symbole der Wandlung: Analyse der Vorspiels zu einer Schizophrenic, Jung (1950) reported a series of symbols and myths with which the libido, seen by him as psychic energy, a vital force not necessarily of a sexual nature (although of course sexuality did indeed constitute one of the most important forms of expression of the libido). Among the various myths and symbols which, according to Jung (1950), express the vicissitudes of the psychic energy during the span of our life, there is the myth of the “Hero’s sacrifice”. In short, this myth tells of a hero who, having reached his maximum potential, is suddenly bitten and killed by an animal (nearly always a snake) unexpectedly come out for the bowels of the earth. This myth expresses a profound existential meaning: the psychic energy cannot always and only expand: there are times of regression: once arrived at the peak of life, the descending parabola commences; everybody must accept decline. This type of animal appeared frequently in the responses of our subjects: cards, mice or snakes, seen by our patients much more frequently than in control data, with a significant predominance of HIV+ subjects over HIV- ones. Two responses wee regarded as highly significant: L. (26 years, HIV+) responded to card no. 6 as follows: “I see two little brids mating: then I see a mouse which wants to bite them and destroy them and their love”. Then thinking to himself, he said: “ I think this mouse is my HIV positivity which can ruin love between wife and I”. This is an extremely expressive comment which L. manages to interpret himself and which offers many analogies with the myth of the sacrifice: in this case the vital force, the libido, is seen in relation to his wife, because of the strong emotional and symbolic charge it had for L. Instead A. saw on card 12 “an evil little gnome, biting an arm”; the same “little gnome” also appeared in card 17, showing the male genitalia, on the penis. It is suggested to him that this small threatening being could be his HIV positivity acquired by injecting heroin into his arm with infected syringe and which he can transmit by sex, A. agreed. SIS in HIV 107

These were by no means isolated cases; images of cards, mice, snakes (all having in common aggressiveness, sudden appearance and parasitic behavior were vary frequent. In the myth analyzed by Jung (1950) the “hero’s sacrifice” is often accompanied by natural phenomena such as volcano eruptions or an earthquake. Similar images appear in the records; volcanic eruptions and atomic explosions (the modern analogy for the ancient earthquake once is tempted to think are often mentioned by patients, especially HIV+ ones. Our interpretation of these images is as follows: these HIV+ people find themselves in an extremely difficult inner situation: just when (both for age and their being cured of drug addiction, which had closed them in an autistic situation, strongly reducing their libidinal; interest) they regain a great interest in life, love and sexuality and find themselves in a situating in which they must ‘sacrifice” their drives, their emotions because of their HIV positivity. They find themselves having to precociously ‘freeze” their libido, their vitality. Although what is “sacrificed” is the “vital force”, because of the age of the patients, the sexual factor is often predominant. The most repressed images and cards i.e. those with the highest percentage of rejections or denials are explicitly sexual ones (nos. 13,14,17). Paradoxically, these denials (often in the same subjects who had rejected the explicitly sexual image) are accompanied by a strong “sexualization” of other cards, which should not, in theory, arouse associations of this kind. Parts of the individual figures showing protuberances are often interpreted as male genitalia; vice versa indentations are frequently interpreted as female genitalia. This too, in our view, expresses the drama of these young people. They must deny their sexuality just when it once again becomes a very important component in their life. The boat of the dead: No less than three subjects on AZT saw in card 13 a boat advancing threateningly towards them. G. said: “I see a war ship advancing towards me. Around it the sea is very angry and pushes the boat forward”. In many myths a ship represents the boat the dead, the last resting place that will return the dead person to the vast open sea on his last journey. A stormy sea is often a symbol or manifestation of the “wrath of the gods”. And the gods lose their temper when men offend the laws of life in some way. The arrival of the ship experienced by these young people with a resigned fatalistic attitude, as a manifestation of a fate, a destiny, which must be fulfilled. It is as if G. had said: “I have offended life and its laws with my behavior; it is right that now my fate be accomplished and the boat comes to fetch me”. Indeed, at the beginning of the test, when speaking of his AZT therapy, G. had said: “What do you expect? I went looking far it” It is our assumption that often death is perceived by these young people as an unconscious punishment for their behavior which, in the past, “offended life”. 108 Gaetani et al

As well as in this image of the boat, considered extremely significant by us since it was expressed only by those on AZT and in reference to a card which should not in theory stimulate this kind of image, the fear of death appears frequently. Cards 18 and 20, showing two black and extremely threatening faces, provoke strong feelings of distress; cards 20, in particular, was classified among the most unpleasant by 10 subjects on AZT, 9 HIV+ and only 5 HIV-; this again shows that, as expected, the fear of death is much stronger in HIV+ subjects. Other images regarding death also appear with other cards; often corpses, men with their heads chopped off, men bleeding, threatening beings advancing to snatch at them. We observed that the fear of AIDS is hardly ever manifested with fears projected onto a particular organ or system; only one subject expressed great fear for his lungs on seeing card 9 “two lungs ruined by the illness. What does appear is a fear for the ending of their sentimental and emotional life. It is in this sense that we interpreted the numerous images of “broken hearts”, “suffering hearts”, “hearts devoured by monsters” which often appeared, based on the complex affective and emotional symbology, which the heart bears. Aids was explicitly named only once: an HIV+ subject responded to card 12: “a man bleeding, increasing worse, with his torn; he frightens me a lot, he seems the image of a person with AIDS”. Again, the image referring to the skin is rich in symbolical references. The tearing of the skin, and organ containing the inner space and in relation to the others, may express a strong fear of no longer managing to contain inner distress and of losing every possibility of relations. A night journey - symbols of death and rebirth: The previous considerations referred mainly to HIV positivity, but what follows regards drug addiction in particular. Another myth recurring in many cultures is that of the night journey. The main character, the hero is swallowed by a whale, or by a sea monster, and makes a night journey of symbolic duration (often three days) towards the East and then re-emerges from the stomach, renewed and reborn. This is the oscillation in every human life between progression and regression between disintegration and integration. What comes to mind, to use one of W.R.Bion’s images (Neri, et al 1987) is an oscillation between Ps and D (between the schizo-paranoid position and the depressive position). Images of rebirth often appear in the images of our patients, mainly former drug addicts in rehabilitation communities. Card 6 was often interpreted as “two babies in the placenta getting ready to come out.” The heart is often seen as “life love-fondness which wants to-must be reborn”. Here and there images of small babies, little animals anxious to live appear. These would appear to be ways to affirm the desire for rebirth from an experience of strong regression such as that of drug addiction and to express the hope that one’s most emotional but still small parts, can be allowed to develop. SIS in HIV 109

The image closest to this myth is that expressed by some who in card 14 (showing the female genitalia) saw “a dark cavity to go into”, one expressed the hope that “perhaps there is an exit on the other side” while four other subjects expressed “the fear of not being able to emerge from that cavity cave”. Although we acknowledge the obvious references to fears of female sexuality, this image may also express the fear of not being reborn after an experience of dark regression and death such as that of their previous lives. Support for this interpretation comes in the fact that these births do not occur without risks and danger. These sweet little animals are often threatened by other much bigger and ferocious animals, the hearts throbbing with life risk being broken or overwhelmed by devouring monsters; one boy even saw the fetuses stimulated by card 6 as “stillborn”. These young people have a strong fear that their violent, aggressive and overwhelming inner parts may suffocate the softer and emotional ones preventing them from developing. This subject is so involving and significant that during the test two subjects built their own personal myth: the alternation of the colors red and black on the various cards was interpreted by them as a constant fight between good (red) and evil (black), between a life wanting to be reborn and a death trying to prevent this rebirth. Symbol of initiation - the “myth of the devil”: In his book Nascere non basta, L. Zoja (1985) sees the drug addict’s behavior as “a rite of initiation” to death. C. Olivienstein (1987) in his work “The life of the Drug Addict” sees in the behavior of some drug addicts the constant search for “ordeals”, driven by a need to sublimate themselves by constantly challenging death. During our study we found many confirmations of this idea. On many occasions our patients saw members of the ‘Ku Kulux Klan’, often various evil figures appeared: from nit better defined “devils” to “Satan” Lucifer” the king of Evil”. It is as if these young people were aware of having participated in a “rite of initiation to death” through their drug addiction. Although in the important moments of the various initiation rites their may be a sanction by a divinity, often aliens appear, all of them threatening and evil: like “angels of devil” they sanction the course of the death rite or the challenge to death. Apart from the obvious meaning of the devil as the symbol of evil, the analysis of the “myth of the devil” presents many elements relating of the concept of closing, the limit involution. The etymology derives from the Greek: diabolism; to separate, to divide to break what was joined together; it is the opposite of symbol, which is integration, conjunction of opposites. 110 Gaetani et al

The concept of the devil refers to all the forces which disturb, obscure, weaken the consciousness making it regress towards the undetermined and the ambivalent. The process of identification is a process of ascent, of integration of evolution; the reaching of a center but the “process of demonization” is a path to dissolution involution, disorder, and division. The strong attachment to this myth could thus represent the fear of these young people of no longer being able to achieve a balance, an inner maturity, for the excessive superiority of their inner, more aggressive and self destructive parts. Many analogies with the symbol of the devil show the symbols of the dragon and the snake, fairly often seen by our patients. These symbols too represent our dark and evolutional forces, which, however, must be recognized and integrated with the other parts of our personality, in a personal and creative synthesis. Two subjects, who did the test, after seeing “the devil” in some cards, said they were fans of rock groups which encourage satanic-like cult worship, and that they were probably conditioned by these musical preferences in seeing devilish images so often. Although on the one hand this justification can be taken as valid, on the other it also reveals how common among these young people is cult worship, identification with negative heroes, and how difficult it is for them at least for the moment, to express more positive and constructive identifications. One of these two subjects had a sense of pride of considerable self esteem for having in the past adhered closely to this “stereotype” of negative hero (perhaps for him the devil could be the negative hero part excellence). Only recently confrontation, dialogue with educators and companions in the rehabilitation community in which he was staying enabled him understand the insubstantiality of adhesion to such models and life-styles. Conclusion: It is hoped that this work may make a contribution to the understanding of the complex emotional problems which HIV positivity or AIDS can cause. We are fully aware of the limits of this work, mainly resulting from the limited number of patients assessed and the inevitable conditioning deriving from the subjectivity and the personality of the researchers. Nonetheless, we believe that the use of the Jungian interpretation, with its objective bases, may have partially compensated for this latter problem. Reference: Callegari, M. (1989). Psicoterapie di rilassamento. Lezioni tenute presso la Scuola Superiore di Formazione in Psicoterapia, Cremona. Cassell, W.A. (1976). Body Symbolism and the Somatic Inkblot Series. Anchorage: Aurora Publishing Co. Chevalier, J. and Gheerbrant, A. (1969). Dictionnaire des Symboles SIS in HIV 99

Gutheil, E.A., (1984). Manual per I’ analisi del sogno. Roma: Artrolabio. Jung, G.G. (1994). Psychologie und Alchemie. Jung, C.G., (1950).Symbole del Wandlung; Analyse der Vorspiels zu einer Schizophrenie. Jung, C.G. (1954). Uder die Archetypen und das kollektive Unbewu Bite. Jung, C.G. (1961). Erinnerungen, Traume, Gedanken von C.G. Jung. Neri, C., Correale, A. and Fadda, P. (1987). Letture bioniance. Roma: Borla. Neumann, E. (1956). Die Grobe Mutter. Olivienstein, C. (1987) La vita del tossicomance Roma: Libreria Lauretiana. Solardi, C. and Bimbi, A. (1990). L’ ascolto del corpo in psiciterapia. Milano: Unicopli Zoja, L. (1985) Nascere non basta; iniziazione e tossicodipendenza Milano: Cortina. 98 Gatani et al

BL. Dudey, Ph.D., D.M. S.P., FIACP, Director SIS Center, E-mail : sisdubey@rediffmail.com. W.A. Cassell, M.D., FAPS, Psychiatrist, SIS Center, E-mail : siscassell@yahoo.com. Padma Dwivedi, M.A., Social Worker, Sept. of Cardiology, Post Graduate Institute of Medical Education and Research, Chandigarh- 160 015 (INDIA). Mridula ,Mishra, M.A. Clinical Psychologist, E-mail : sismishra@rediffmail.com. SIS J. Proj. Pst. & Ment Health (1995) 2:111-118 Inner Cry Through Somatic Inkblot Series B.L. Dubey, W.A. Cassell, Padma Dwivedi and Mridula Mishra Somatic Inkblot Series-video (SIS) was administered to two female patients belonging to high strata of the society. They were feeling uneasy at home with severe conflict with their family. SIS was able to bring out inner cry of the individuals and after therapeutic intervention their condition improved. Content analysis of responses in SIS video is discussed in the paper. Psychosomatic disorders are a signal of some disturbances at conscious or subconscious level. Defense mechanisms are powerful to protect the man from a distressing situation but complete resolution is never possible. Unresolved problems may lead to distress in the personal and occupational life. It depends upon individual sufferer on how he resolves the conflict. Some individuals cry for help through their body with somato-form disorders. Disturbances of body images are the disturbances of the perception of the diseased mind. Descartes’ mind body dualism is helpful to understand the behavior of the suffering individuals. The mind and body are so interwined that disturbances in one causes disturbance in the other. Everyday conversations are replete with examples of the mind body connection, such as “broken heart” for depression or grief, “pain in the neck” for frustration. By developing a practical eye and ear for such imagery, therapists can more directly share the perceptual would of the suffering individuals. Such projection of inner cry is never possible thru Paper-Pencil Tests. The Somatic Inkblot Test is found to be reliable and valid (Verma, 1995) for such assessment. To understand such tender feelings, clinicians and therapists must have sufficient experience. Projective test, specially inkblot imagery, are more powerful in bringing out inner feelings (Dubey et. al. 1994). The Somatic Inkblot Test (Cassell, 1980, 1984) is the latest addition in the series of Inkblot test. SIS can help therapists more sensitively “hear” the “cry for help” of a suffering individual; the inner cry that is hidden, not only from other but often from one’s own conscious awareness as well. Since projective tests are not based on verbal communication, they more effectively penetrate the “outer shell” of defenses and surface behavior. The Somatic Inkblot test is based on the somatic imagery theory, which proposes that everyone has a unique and highly personalized system of attitudes, conscious and

112 Dubey et al unconscious, that are projected onto the body as a spatial entity. These interact with feedback sources and internal sensations. Relatively discrete mental representations exist for particular somatic regions, which constantly compete for full registration in consciousness (Cassell et. al. 1995). It becomes apparent that there were difficulties in using the Rorschach inkblots to assess body imagery and somatic symptoms. There is, in very little somatic structure in Rorschach inkblots and because of rigid scoring pattern and indices based interpretation, it fails interpreting the meaning behind the responses given by individuals. Exner (1989) has commented that Rorschach is party a projective instrument and feels that only about 20 percent of the responses involve “projecting” into or form stimulus properties of the inkblots. Exner’s criticism seems to have roots in his system of interpretation of Rorschach through indices, not through the analysis of contents, which are obviously more important. In fact Exner’s system had limited the scope of the Rorschach test. Somatic inkblot test has been found more powerful in understanding the problems of such patients. Two cases are described to understand the power of SIS Test. Case1: A 45 year old female, married at the age of 19 years, graduate, doing garment business at home, belonging to high status family, came to one of the authors (BLD) with complaints of disturbed sheep, poor self concept, feels deprived of family life including dissatisfied sex relationship for t last 15 years. She has consulted a number of physicians without any relief. In fact over the years her symptoms have worsened. SIS video was administered to her. Her response on a few images is given here. Image Response A1 Cancerous lungs A2 Female trying to pull herself away from men A6 A sad baby bear A27 A foot of a baby through the window which is painted B19 Broken heart with dark future with little hearts on each side B22 A dead man’s soul going up On enquiry of the least liked images her response was as follows: A1 Cancerous lungs B27 Half infected fetus A23 Caterpillar-insect

Inner Cry Thru SIS 113 In image A27 her response was “Foot of a baby through the window which is painted”. Where as on this image typical response should have been” breast”. She could not see breast even on suggestion during image processing. In fact, it was denial of problems. The clinician enquired from her if she had some problem related to breast. Hearing this, she started sobbing, kept mum for a few seconds and narrated her first contact with her husband immediately after marriage. Her husband after touching her breast remarked that it is very sagging/loose breast as if it has been used. Premarital sex is not encouraged in Indian culture and this remark of her husband tremendously disturbed her and made her very sad as she says her husband was the first man in her life. She is having dissatisfied sex life as they meet occasionally 3 to 4 times yearly. She is a mother of 2 children, and still she feels alone in the family. Seeing cancer on image A1 could be indicative of her fear and death of her father-inlaw, who died of cancer. On image A2 she perceived “A Female trying to pull herself away from men” is her own conflict of getting away from a few known male friends with whom she had post marital physical relations. “A sad baby bear” on image A6 is her own depressive mood and feelings. On image B19 she has seen ‘Broken heart with dark future with two little hearts on each side” once again indicated her depressive feelings. This may also indicate her dissatisfied conflicting relationship with her husband. Two little hearts in each side might be her two children. On image B22 “A dead man’s soul going up” might be her social thought and low spirits. After viewing the video, she was asked to select 3 images which she liked the least. She had selected A1 “ Cancerous Lungs”, B27 “Half infected fetus” and A23 “A Caterpillar. Image A1 once again indicated her face of cancer. A27 “Half infected fetus” may even indicate her fear of contacting infection because of physical contact with a man other than her husband. Fear from Caterpillar might be indicative of phallic disturbances that are obvious in her case. The SIS video was able to bring out her inner cry on the surface, which can now be treated. This clearly suggests the power of Somatic Inkblot Test. On account of her poor relationship with her husband, she has been misinterpreting the intention/interest of other male members towards her. She perceives that others appreciate her beauty and contour. She has difficulty in interpersonal relationship with her husband who never appreciates her, is very busy to find time for family life, domestic pursuits and also has relationship with other women. Other responses particularly of sexual connotation suggest her conflict in libidinal area. To correct perceptual disturbances, she is under psychotherapy, and showing good progress. Her husband could not be contacted for family therapy.

Case 2: Miss X, 27 years, unmarried, Law Graduate, practicing as attorney, belonging to high middle class family, had history of sex abuse at the age of 4 years by a 19 years boy, physical relationship with an aged family friend, history of feeling depressed, wish to leave the family and conflicting parental relationship was given Somatic Inkblot Series Video for understanding the personality and therapeutic intervention. Interpretation of a few responses found to be quite relevant has been given for understanding the psychology of the case. A few responses on SIS-video given by Miss X: A1 A man who looks healthy and majestic but pretty empty inside. A3 My soul –when will it become free. A5 A lady who is all heart celebrating alone (this might be her own mother’s projection). A6 A sad teddy bear. A10 Blind Woman. (I am tired of waiting). A11 A needle thru the heart-I want to weep but I won’t. A12 Can you hear me with your ears and listen with you heart? A13 A window hazy with fog with the center clear, a hand outstretched asking me to wait. May be I should give up. A14 A dry flower. A18 A man hanging upside down with smoke bellowing out of his head and waiting to fall thru the dark circle into a hole. A23 Looking like a deadly ardroid, resembles a creepy centipede (scary feeling) (had h/o injured tailbone). A31 A beautiful women looking at her hazy refection. She is not sad yet contemplative (Feeling confused). B3 Two people sitting inside a womb overlooking an alter of fire. Her fire signifies life (feeling of wonder). B6 A half statue girdle down wards with some infection around the girdle. (feeling of depression). B12 A parrot hanging upside down trying to fly away. B16 The centipede is back again. I hate centipedes. (feelings of filth and dread). B28 A person hugging a while colored pet. (child is missing from the scene). B30 Two ears (can you hear me)? (once again brings out her inner cry). 114 Dubey et al

On image A1 she saw “ A man who looks healthy and majestic but pretty empty inside” is a direct projection of how she feels empty inside although she looks normal and healthy on the outside. The fact is that she conjures up images if a man rather than of women may reflect her sexual identification partially identified with that of her perpetuator my. Many people in viewing A3 introduce spiritual connotation with this image. Here she directly projects her feeling of wanting to be free of her past traumatic memories and inner trauma be seeing “My soul when will it become free”. She viewed “A Lady who is all heart celebrating alone” on A5 is direct projection of same sex identification to the human form. She focuses on the heart because she is introspective and socially withdrawn as a result of her pain and depression. It may probably also represent a projection of her mother’s image that is critical and nonsupporting. Her depression is abnormally high and she has given lot many responses depicting depression. “A sad teddy bear” on A6 brings back the theme of sadness or depression almost in a perseveratory fashion. In addition the response has repressive features. She totally avoids reference to the human gestalt and focuses instead in a child like fashion in a teddy dear. On image A10 ‘ Blind Woman” is the projection of her psychological blindness associated with her repressing images of her past sexual abuse. She also comments that she is getting impatient and needs therapeutic resolution for her lone standing childhood conflict. She viewed ‘A needle through the heart-I want to weep but I won’t” on A11. This is a direct projection of an emotional pain and depression, the fact that she conjures up the image of a needle penetrating the heart symbolizes her past sexual penetration and body boundary violation. In commenting on this horrible response, she for the first time acknowledges to the examiner her depression and need for emotional catharsis as well as her inability to do so as without therapeutic assessment. She viewed “ can you hear me with your ears and listen with your heart” on A12. With this question she directly ask the interviewer if she will be heard with empathy and compassion. Previous attempt to share her pain as a child felt on the deaf ear of the parents. She saw “ A window hazy with fog with the center clear, a hand out stretched asking me to wait. May be I should give up on A13. Here she continues the theme of her own reluctance to weep and share her pain with the therapist. She has learned from the failure of past attempt to share, which were met with frustration, and further hurt that the process of attempting to communicate may itself lead to further hurt and rejection. Inner Cry Thru SIS 115

The hand symbolizes that part of herself that “I won’t on A11, will not allow her self to trust the therapy process. To remove this resistance in therapy it would be necessary to interpret the symbolic significant of this response in terms of transference. Lastly the reference to ‘ giving up” continues the depressive feelings of her helpless. She saw “A dry flower” on image A14. Here rather than recognizing the anatomical structure, she projects her self image as being dead inside. On A18 she viewed “A man hanging upside sown with smoke bellowing out of his head and waiting to fall through the dark circle into a hole”. Many individuals see anatomical contents here such as the heart or image of sexual intercourse. Because of her sexual trauma and resultant pelvic anxiety she totally avoided reference of somatic structure in the video image. The defensive material projected symbolizes of her severe depressive mood and latent death wishes. At times she fantasize running away from her home and escaping from her problems. She saw “Looking like a deadly ardroid, resembles a creepy centipede (scary feeling)” on A23. Here the response is remarkable because of her failure to correctly identify somatic structure, which is so clearly depicts spinal column. There are two possible determinants of somatic repression, one relates to her past medical history of having fallen 4 year earlier injuring her tail bone and causing considerable pain. The other relate to phallic connotation of this particular image. While both hypothesis can lead to heightened body anxiety, symbolic analysis of her defensive imagery suggests that the later determinant is more noticeable that she saw a deadly ardroid resembling a creepy centipedes which is highly threatening to her. Remember that previously in responding to image the needle had threatening phallic connotation. A little girl violated by penal penetration will always carry such negative association to phallic imagery. On image A31 she viewed “A beautiful women looking at her hazy reflection. She is not sad yet contemplative (feeling confused)”. Here she avoids reference to central content in A31, which pictorially depicts a man and woman is very close interaction, because this material is highly threatening to her due to her past experience with her male perpetuator. The normative content is totally repressed. She defenses against this structure by substituting image symbolizing her self in therapy looking at her psychological defense mechanism of denial. The introduction of the idea that the woman is confused symbolized her own confusion and cognitive disarray. “Two people sitting inside a womb overlooking an alter of fire. Here fire signifies life (feeling of wonder)” was her response on B31. In responding to B3 in seeing 2 people inside the womb continues the regressive theme previously noted on A6, the fire denotes her emotional pain. In this essence rather than associating depressive aspects she introduce the concept of life and wonder. This was positive prognostic implication 116 Dubey et al

to therapy, and needs to be interpreted to her context. There is hopeful recovery if she is willing to share her pain during therapy. She saw “A half statue girdle downwards with some infection around the girdle (feeling of depression)” on image B6. Here she partially picks up the correct anatomical structure referring to the lower abdomen and thigh. However, because of her trauma to related pelvic anxiety she defends against the specific somatic content by seeing a more abstract image “i.e. statue girdle”. Here it is noteworthy that she projects a pathological anatomical response. “Infection” symbolizes her own inhered genitalia. The facts that this image accentuates her feeling of depression in responding to the Image indicated that she is grieving the loss of her virginity and body boundary intactness. The assault on a child’s body id not just injurious in a sexual way but when a perpetuator is a close family friend, the overall ego becomes distorted and confused just like she indicated on A31. The other explanation could be her repeated infection in her pelvic region for which she has taken treatment. On B12 she viewed “A parrot hanging upside down trying to fly away”. Here again she totally represses the real structure of the image, which dents some man’s facial area and nose. Substituting image of a parrot neutralizes the threat in this image. The fact that the bird is seeing upside down trying to fly away directory symbolizes the childhood feeling of vulnerability and helplessness to avoid her perpetuator. She saw “The centipede is back again. I hate centipede (feeling of filth and dread”) on image B16. The significance of this response is previously reviewed with A23. On B23 She viewed “A person hugging a white colored pet”. Most individuals who have had experience of positive nurturing mother will see as a woman holding the child. Here she defends against by avoiding reference to the maternal and female connotation of the adult figures seeing only a “Person”. Similarly she avoids reference of the child introducing the image of a pet. In spite of this, it should be recognized that of an image which was loving and affectionate. Frequently when child has not received maternal love, they will turn to pets to meet the; need for aggression. Such individuals with other inkblot test such as the Rorschach test and the Holtzman Test give higher number of animal response than the human response. She saw once again “Two ears-can you here me?” on 30B, Here like in A12, she directly asks the therapist if her inner cry will be heard and responded to therapeutic alliance and that she is given reassurance that unlike the past when no one has heard her she will be heard with empathy and compassion now. In this sense her cry will be heard and she will have the helpful therapeutic relationship. Many male therapists because of trust issue prefer to refer such traumatized female patients to a female therapist. Inner Cry Thru SIS 117

Here we have presented two cases of clinical interest. Although the subject of both cases are females it is important to point out that the problem of inner cry is not only males or females but human beings in general. It is not limited to any particular part of the world, society or culture but is universal in nature. The responses to SIS have been successful in identifying the inner cry of the individual, which itself is the first step of therapeutic intervention. Conclusion: It is important to remember that the projective tests do not have so called objective procedure of interpretation. It is the clinician’s acumen, which is necessary to interpret a protocol. In the first case study, it was a denial of the problem initially, but through SIS images and on subsequent enquiry it revealed the roots of the problems, whereas in the second case study, it was the obvious percepts to unstructured stimuli. Rorschach test was tried in the first case but could not reveal much. It could be due to the fact that Somatic Inkblot Test is based on the theory of body imagery whereas; Rorschach is largely based on general perception. References: Cassell, W.A. (1980). Somatic Inkblot Series-II SIS Center Anchorage, Alaska. Cassell, W.A. (1984). SIS Video, SIS Center, Anchorage, Alaska. Cassell, W.A. (1990) Manual of Somatic Inkblot Series -II, SIS Center, Anchorage Alaska. Dubey, B.L., Mishra, M., Dwivedi, C.B. and Mishra, N. (1994) Diagnostic and Therapeutic utility of Somatic Inkblot Series II and Roschach. SIS J. Proj.Psy. & Mental Health 1, 19-26. Exner, J.E. Jr. (1969) Roschach Systems. Grune & Stratton Inc., New York. Verma, S.K. (1995) Reliability and validity of Somatic Inkblot Series Test. SIS J. of Projective Psychology and Mental Health 2, 67-71. 118 Dubey et al

Deborah Brady, Psychogist, 4001 Turngin Blvs, Anchorage, Alaska - 99517 (USA). SIS J. Proj. Pst. & Ment Health (1995) 2: 119-123 A Study of Somatic Inkblot Series: Application In Medical Setting Deborah Brady Somatic Inkblot Series –Video test was administered to 15 patients displaying somatic and 15 normal subjects. To demonstrate the clinical utility of the SIS Video a case along with responses of the patients on SIS Video is presented in the paper. DSM IV defines Somatic Disorder as delusions of having a physical defect of general medical condition. Since Somatization disorder usually involves the long-term treatment of a chronic disorder, it is helpful for the physician to have another professional confirmation of the diagnosis. Sometimes it is difficult for physicians to make a diagnosis of somatic disorder, in that the patient had come to their doctor seeking help for recurrent multiple somatic complaints for which medical attention is sought but which have no apparent physical cause. Some common complaints include headaches; fatigue, allergies, abdominal, back and chest pain, gastrointestinal symptoms, symptoms suggesting neurological disorder, and heart palpitations. Anxiety and depression are frequently reported, as are a host of behavioral and interpersonal problems, such as truancy, poor work records, and marital difficulties. The damage resulting from inappropriate diagnoses is sobering to contemplate. Such consultation with trained mental health professional tends to lower the physicians anxiety about missing some esoteric diagnosis, thereby enabling them to more closely adhere to appropriate management guidelines. Another behavioral viewpoint of this disorder states that the variety of aches, pain discomforts and dysfunction are unrealistic anxiety, which manifests itself in a particular bodily system. The idea is the extreme tension of an individual may localize itself in the stomach muscles causing the person to fee nauseous. This pattern may continue due to the attention it receives or the excuses or avoidance of everyday challenges it provides rather than facing them as an adult. Disability from work is a very problematic issue for people with somatic disorder. DAM- IV distinguishes malingering which the individual fakes an incapacity so as to avoid responsibility. To know with certainty whether behavior is consciously or unconsciously motivated is difficult to discern. The researcher noted that malingerers are likely to be more guarded and cautious when speaking of their symptoms, perhaps because they consider interviews a challenge to the success of the deception of their “illness”. There may also be a stress induced wish to regress to an infantile dependent position and be taken care of by parental figures (Cassell, 1987). Current findings in this study

120 Brady pose questions of those with this type of delusional disorder to be related to neglected childhood. This invariably causes enormous societal expense. Constant encouragement to continue working or simply functioning in society is important. When work is no longer optional rehabilitation and further extensive counseling is advised. Objective: The present study aims to compare the responses of medical patients with somatic disorder (multiple symptoms of pain and discomfort) and normal subjects (diagnosed without medical condition or disease) using the Somatic Inkblot Series. The study is being conducted to verify the possible use of the SIS in helping physician’s diagnoses and properly treat those with combined physical and emotional illness. It also aims to study the relationship between physical disturbances and projected anatomical responses as proposed by Cassell (1990). Material and Method: Fifteen patients displaying somatic disorder in the age range of 25-54 years of age, both males and females, formed the sample. All of them were fresh symptomatic cases and receiving active treatment. Fifteen normal subjects matched with the age, education and socio-cultural variables of the somatic disorder group were also taken for comparison. All 30 cases initially seen by a medical doctor and prepared for psychological assessment. Later on, they were administered the SIS test individually by the psychological research assistant. Normal subjects were also administered the SIS test individually buy the Psychological research assistant, after explaining its purpose and seeking their consent to take the test. About the Test: The Somatic Inkblot Series was administered by viewing a video - tape with the responses to the image recorded in a response form. The image provides enough obvious anatomical structure to evoke spontaneous verbalizations. The obvious anatomical structure provide a feeling of security to make deeper, more symbolic, repressed material more accessible to the person being tested. The SIS is used as a diagnostic aid for body perception assessment to make the individual’s most personal feelings audible and in the way it uses video media to assess the altered state of consciousness which we experience when watching television (Cassell, 1992). In this study the SIS is being used to assess the depth and the significance of somatic symptoms, somatic delusions. Psychoanalysis of responses can help in understanding somatic repression and anxiety (Cassell, 1980). Responses of body assault may further clarify the extent of aggressive impulses (Cassell, 1988). Procedure of Test:

Applicatoin of SIS 121 The Subjects were asked to read and sign consent form. Blood pressure and heart rate were taken and recorded for later comparison to normal BP and HR according to medical records. The SIS video was presented before the subject and responses were recorded on the Response Form Booklets. For qualitative interpretation of the test, the subject was then asked to select three images, which she identified with as “Most Liked” and an inquiry was conduced to find out the reason. The subject was then asked to identify the three images “Most Disliked or Threatening”. Some details about these images were asked for any association with his/her personal life. Such inquiry helped in assessing the depth and significance of somatic symptoms, somatic anxiety and somatic delusions or repressions of the subject. Analysis helped in understanding psychopathology of the case, which was reviewed by the subjects’ medical physician, psychiatrist and test administrator. Quantitative scoring was used by assigning a numerical score to the degree of pathology in pathological anatomy and Depressive responses. Five indices e,g. pathological anatomy, depression, rejection of images, most typical and atypical responses were scored in this study. Pathological anatomy responses are those in which the body is perceived as diseased usually related to specific body parts, organ systems, or functions and are evaluated qualitatively. Anatomical imagery is similar to that described in Rorschach Inkblot responses of “diseased anatomy” (De Vos, 1952). A certain degree of depression is common among medical patients suffering with disease. Multiple symptoms and varying degrees of pain, chronic recurring pain, cataloged and substantiated pain, non-substantiated pain were also noted. Bearing in mind that pain is not a tangible thing for purposes of measurement and recording responses datum were assigned a score of one for mild depressive content, typically associated with and marked with weeping or grieving, and a score of three for severe affect, response of a burdened body or sad face, directly associated with an anatomical image. It should also be noted that a high number of rejections may also signal depression (Cassell, 1977). For the purpose of quantifying these data, a single point is given for all depressed responses. Most typical responses were accounted to indicate that the subject tented to view the world as most others did. Atypical responses indicate vague quality in verbalization of perception. Consider the following example of patient Y referred for the testing by her regular physician: Case-1 : Female, 31 years, holding an associated degree in accounting and is working in a professional setting. She is suffering from Stomach acid, post nasal drip, extreme weight loss (30 lbs. in 3 months), abdominal and lower back pain. She suffers from severe menstrual cramping and is unable to conceive children. She believes that her

voice is changing and sounds like Donald Duck. Her regular physician could found no tangible evidence that she is suffering from any type of physiological disease. She is married and a stepmother of two preadolescent children. It should also be noted that she was 30 minutes late her appointment and her appearance was unkempt and disheveled. She seems to have a poor self-image and appears highly distracted and nervous. Patients Blood Pressure was taken before testing and registered slightly above normal. During pretest interview, she admitted to having a fear of breast cancer because her great grandmother died of the disease. When she viewed the SIS video she found the following images most threatening. 1. B22: prone woman with acute stomach pain, “It reminds me of someone dying, I think it is me lying there dying of pain, all alone”. 2. A17: reminds me of two dragons ripping apart a heart, a ripping pain. 3. A30: Reminds me of human skull or fossil with sinus pressure and extreme pain. It addition, several of her responses were very descriptive in nature and of sexual content as well as hostile or aggressive in origin. Typical response for image B1 is that of a campfire, she responded to the image as “A fist smashing something, and then eating it”. A Typical response to image A31 is that of two adults talking. She responded with, “Grandma whispering in my ear that she is not happy with me and that I am a nasty, dirty little child”. At this juncture patient began to cry while watching this image on the screen. When asked further why she was thought to be a” nasty, dirty child”. Patient responded with a scene her adolescence when an uncle sexually molested her. The uncle performed fellatio withy her and when she confided this information to her grandmother; this was her grandmothers’ response. After the test was completed the patient was asked how she felt. She responded with, when I first came here, I was very frightened and nervous about taking the test but I do feel better and my voice is not so small sounding, I don’t sound like a cartoon character anymore. “She left the office with a more relaxed affect. It seemed as though a catharsis of some very painful and threatening material occurred. The problem she complained of with her voice and the association with image A31 seems to be some sort of symbolic anatomy transference the image of a grandmother talking to her released a flood of emotion and the nature of the molestation is related. This is consistent with Rorschach’s suggestion that certain anatomical responses may be a projection of kinesthetic sensations in the musculature. This type of phenomenon occurred over again with several other patients interviewed after the SIS test was performed. 122 Brady

If it is the wish for professional to understand and empathize with more sensitivity to their patients who have come to them suffering with real or imagined pain, this type of video technique literates Freud’s so called defensive mental mechanisms which protect the individuals conscious awareness. Many of the subjects of this testing, after reviewing some of their responses seemed surprised at how much they had revealed. The researcher here found that patients with somatic complaints seek out physicians more often than psychiatric and psychological professional because physicians attempt to diagnose and give a name to the physical problems as well as medication. These patients are generally not very open to psychological explanations for their seemingly ailing bodies. Conclusion: The SIS test is a valuable tool in diagnosing and treating patients with multiple symptoms who are sometimes difficult to conform to such a diagnosis. It seems to allow the patient to see for themselves the nature of their symptoms the catharsis noted form this single case allowed the patient to liberate the repression and also allows the physician to put into effect and appropriate treatment plan for the medical patient suffering from more psychological symptomatology. References: Cassell, W.A. (1977) Aggressive Imagery and Clinical Symptoms. British Journal of Projective Technique, 16: 21-31. Cassell, W.A. (1980) Body Awareness and Somatic Delusions. American Journal of Psychoanalysis. 40: 125-135. Casse, W.A. (1987) The SIS Video Version. Paper Presented to Society for Personality Assessment New Orleans, Louisiana. Cassell, W.A. (1990) Inner World Reflections through Dreams and Art. Anchorage, Alaska. De Vos, G. (1952), A Quantitative Approach to Affective Symbolism in Rorschach Responses. Journal of Projective Technique and Personality Assessment, 36: 133-150. Rorschach, H. (1951), Psycho Diagnostics. Berne, Switzerland, Han’s Huber. Smith, M.L., Glass, G., & Miller, T. (1980). The Benefits of Psychotherapy. Baltimore: Johns Hopkins University Press. Applicatoin of SIS 123

N.L. Dosajh, Professor of Psychology,1121, Sector 15-B, Chandigarh-160 015 SIS J. Proj. Pst. & Ment Health (1995) 2: 124-127 A New Combination of Therapies for Treatment of Schizophrenia of Less than 5 Years Duration N.L. Dosajh A new Combination of Therapies, based on Western and Eastern Psychotherapies had been tries on 10 Schizophrenics of less than 5-year duration leading to satisfactory results. The various steps of the technique (e.g. Drug therapy, Psychotherapy, Yoga therapy) and evaluation of improvement through the Rorschach test are discussed in the paper. The etiology and pathogenesis of schizophrenia in various cultures are shrouded in mastery. Various attempts have been made to unravel this mystery. Genetic factors have been studies but still no specific genes have been earmarked which could be said to cause schizophrenia. Many twin studies and studies of adopted children have merely led to very conflicting results making the issue more complicated. The psychological studies have simply added to the number of symptoms and their classifications without throwing much light on the etiology of the disorder. The biochemical studies have been able to identify certain chemicals are the result of the disorder remains unexplained. The complete cure of schizophrenia is still not known because of its manifold complexities. Of course there are many psychopharmacological agents that have been tried but out of the many possible outcomes, a majority of schizophrenics emerge in the categories of social remission with frequent relapses. Even western Psychotherapies have not ensure complete cure. Combinations of Psychotherapy and Drug Therapy have proved more effective than either of two (Dosajh 1986). Even programs of after care combined with adequate dose of Fruphenazine Enanthate (Prolixin Enathate) have been found to be the treatment of choice, yet even this combination has not able to prevent the relapse of this disorder (Michael et al 1978). In an effort to have better management, the researcher tried the use of ‘Yoga’ Therapy in combination with other therapies (Dosajh, 1986) and evolved this new technique based on Eastern and Western Psychotherapies (Sinha, 1985, Dosajh, 1988) presented here, which has been tried on more than ten cases leading to better management. The steps of the techniques are: I) Drug Therapy: To manage violent patient by Psychiatrist. II) Psychotherapy: Here we use techniques like Psychoanalysis, Cognitive Therapy, Suggestion, etc. The nature of the technique employed will depend upon the nature of the patient.

Psychotherapy in Schizophrenia 125 III) Yoga Therapy: As soon as we find that the patient has sufficiently improved and accepts different therapies, he may be put on ‘Yoga Therapy’. Yoga prescribes total eradication of mental conflicts, unpleasant urges and tendencies. It claims improvement of neurotics and psychotics. IV) Evaluation: the evaluation of the progress of the patient is done from time to time by administering the Rorschach test, the process of evaluation is very well illustrated by the author (Dosajh, 1978, 1983). For illustration, one case is enumerated below: Case 1: It is the case of a woman, aged 32 years graduate, married and having one son, husband an officer in the Air-Force and father a retired officer of the Army. She had been diagnosed as a case of Schizophrenia. At the time of her contact with the researcher, she was full of fears and had lot of hatred for her father so much so that at times she felt like killing him. She lacked confidence in talking to others. She would not mix up with her neighbors. Her mother-in-law is a case of Depression. During her childhood and adolescence, she was nagged by her father and kept shut indoor many a time. She was not allowed to mix-up freely with people outside her house. She had to pass through a very submissive childhood. She was educated up to B.A. but in schools and colleges a strict supervision was kept on her. Parents did not give her unstinted love, father, instead of giving love, rebuked her. Especially when he was drunk. Her husband was posted away from home and so met her only on holidays; otherwise she stayed with her in-laws. Mother was of an irritable temperament and father and mother often used to quarrel over trifles. She hated sex life and this often irritated the husband. After the birth of one child, she had the problem of infertility. She liked to live alone and did not like to accompany her husband to his place of posting. In early life, she had a passionate attraction for one of her classmates. She used to sleep with her and the two would have lot of kissing each other and the relationship amounted to lesbianism. They would fondle each other’s breasts and then she would have erotic feelings. Then at times she would masturbate. She did not like to meet that classfellow now. During her college life she was very fond of novels depicting incidents of murders and ghosts stories. She often dreamt about her remarriage and her other dreams showed lot of anxiety about her only child. She would also often dream that she had another baby born to her. Also another dream that she often had was of having sexual intercourse with the elder brother of her husband. She was administered Rorschach Test in September 1984. The first administration showed the following characteristics: - 1) 10 W responses but vague, 2) 2) Human content – 1,

126 Dosajh 3) 3) No human movement, 4) 4) Anatomical responses - 4, 5) 5) There was complete vagueness of percept, 6) 6) There was lot of perseveration, 7) 7) Her protocol showed 4 bones, 8) 8) There were 4 pure color responses, 9) 9) There was one blood response, 10) 10) Total number of responses was twelve. Treatment: She was first under the treatment of a psychiatrist who administered her Eskazine and Calmpose. The patient was not happy with the psychiatrist hence changed the therapist and came to the author who administered psychotherapy to her. After about one month of Psychotherapy she was again administered the Rorschach test and results are shown below: 1) 10 W responses but vague, 2) Human content – (H) 3, 3) Human movement –1 4) Anatomical responses – 5, 5) Vagueness of percepts present, 6) Perseveration was there but less than last administration, 7) Bones - 4, 8) Color responses - 7 9) Blood response - 2, 10) Total number of responses - 39. She was trained in Yoga therapy. She learned Savasan, Padamasan, Pranayam, Cobra pose, Locust pose, Bow pose, Stretching pose, etc. After about 4 months she was again administered Rorschach test and the results are as under: 1) 7 W responses with good form level, 2) Human content – (H) - 1, 3) Human - movement – 1, 4) Anatomical response – 1, 5) Percepts on the whole - good, 6) Perseveration – once only, 7) Bones - 1, 8) Color responses - 4, 9) Blood response - 1, 10) Total responses – 31.

She was asked to continue Yogic exercises-Cobra pose, Locust pose, Bow pose, stretching pose, Corpse pose and Pranayam in routine. In May 1985, she informed the researcher that she was all right, thus she would like to terminate therapy, as she wanted to join her husband. Follow-up (One Year): She was staying with her husband happily. References: Dosaj N.L. (1978) ‘D’ Test and Rorschach Test. As Evaluation Tools. In the treatment of a Schizophrenic Patient, Journal of Rajasthan Psychiatric Society, 5 28-35. Dosajh N.L. (1983) Psychotherapy Including ‘Youga Therapy’, Kohli Publishers, 3 industrial Area Phase-II, Chandigarh-160 002. Dosajh N.L. (1986) “Treatment of a cast of Schizophrenia (undifferentiated with the Help of Western Psychotherapies and Youga, “Paper read at the XVI conference of India Association of Psychologists held at Dr. Hari Singh Gour, Vishwavidyalay,” Sagar (MP) Dosajh N.L. (1988) “Synthesis of Eastern & Western Psychotherapies” unpublished SP Easter Western Psychology National Award Lecture. Goldstein,M., Eliot H Rodnic, Jerome, R Erans, Philips R.A. May and Mark Steinberg (1978) Drug and family Therapy in the Aftercare. Treatment of Acute Schizophrenia, University of California Los Angeles. Perry, W.G. (1976) On the relation of Psychotherapy to counseling. In G.S.Balkin (Ed). Counselling, Directions in Theory and Practice. Dudugue lowar: Kenda/Hunt. Sinha A.K.P. (1985) ‘Eastern & Western Psychotherapies. Ind J. Psychology. 60, 1-22. Psychotherapy in Schizophrenia 127

Dwarka Parshad and S.K. Verma, Addl. Prof. of Clini. Psychology, Postgrad. Inst. Of Med Educ. And Res., Chandigarh-160 012. Partly based on the Research Scheme funded by the PGI, Chandigarh. SIS J. Proj. Pst. & Ment Health (1995) 2: 128-132 Diagnostic Significance of Content Analysis of SIS-II D. Pershad and S.K. Verma Twenty four case of Schizophrenia and depression were administered SIS-II to find out differences in their perception (a) of the images specific to elicit vita inner organs (b) in the anatomical content categories and (c) in the form level of responses. It was observed that the perceptual concordance for vital organs was 28.8 and 48.7 percent in schizophrenia and depression. Schizophrenic perceived more animal and less anatomical content of SIS image. Depressive group had relatively better form level as judged by the frequency of ‘most typical’ responses. Findings indicated that even the simplest content analysis of SIS had diagnostic significance. Somatic inkblot Series (SIS) is a relatively new test based on inkblot technique. It claims to have over-come a number of limitations of the earlier popular inkblot tests. In India the work on SIS started with the establishment of SIS center at Chandigarh. Unlike other tests of inkblot technique, SIS provides structured but vague inkblots called images, suitable for supervised self-administration. It required lesser training for its scoring and interpretation for clinical use. A few images are specifically structured to elicit vital organs. If perceptual theme is Concorde to the structured theme then it reflects healthy body imagery and reality contact. Omission or distortion of structural theme is indicative of poor body imagery. None-the-less, congruent never reaches to cent percent. It is only a matter of degree. It is therefore, likely that the perception on SIS images may very amongst two major psychotic conditions i.e. schizophrenia and depression on account of different psychopathology. Schizophrenic patients tends to regress and are known to have poor adaptability, therefore, they are likely to give less popular and poorer form responses. Depressive patients, on the other hand, more concerned with their body awareness and thus tend to perceive more anatomical structures to vague or semi vague stimuli. They are also likely to be more tense internally and may perceive movement in static blots. The SIS test (Cassell, 1990) employs the same principal of projection as that of the Rorschach or the Holtzman Inkblot Tests except that the SIS images are largely developed to elicit somatic awareness and to establish psychopathology for therapeutic intervention (Cassell, 1965, 1977, 1980). Because of the simplicity of the SIS test, clinicians in India had become interested to evaluate its psychometric properties and usability as a psycho diagnostic tool. (Pershad and Dubey, 1994; Cassell et al, 1995: Dubey et al, 1995, Dharamvir et al 1994: Rathee et al,1995; Saldanha and Dubey

1995, Verma et al 1995). Keeping this in mind, the present study was undertaken to find out differences in the perception of schizophrenic and depressive patients: (a) On the images specific to elicit vital inner organs. (b) In the animal and anatomical content categories and (c) The from level of responses on the SIS-II. Material and Methosd: Sample: Twenty-four adults, educated psychotic patients consisting of 12 schizophrenics and 12 depressive (using ICD-10 Criteria by the psychiatrist) were taken. These were among the cases referred to the division of clinical psychology from the department of psychiatry, Postgraduate Institute of Medical Education and Research, Chandigarh. Only those patients were taken who agreed to take the test and were amenable to testing. Tool: Somatic Inkblot Series –II consisting of 62 images was self administered under supervised instructions. Administration and scoring procedures adhered to were the same as mentioned in its manual (Cassell, 1990). Ten images with structured theme of vital organs (Heart, Kidney/Lungs, Spine/backbone, Skull/brain and stomach) and only two of human beings were identified to match with perceptual theme of two groups of patients. The other categories of indices wee also compared between schizophrenic and depressive patients, using t-test for mean differences and variance Ratio test with Bessel’s correction for significance of differences between two standard deviation (Moroney 1972) as a precursor for the former. Results: Education of the patients in the two groups ranged between 8 th Classes to Postgraduate level. Mean ago of the Schizophrenics was 29.33 years 9SD=11.47) and that of depressives was 39.25 years 9SD=10.86). The ratio of the male and female was 5:1 and 1:1 in schizophrenic and depressive groups respectively. Over all the concordance rate of depressive group was significantly higher than that of the schizophrenic group. Structured themes of kidney/lungs and Head/brain were more frequently perceived correctly than those of spine/back done, heart and stomach as shown in Table 1. ‘Animal content was perceived significantly more and ‘most typical’ less by the schizophrenic patients as compared to depressive patients. With regard to ‘anatomical content and ‘movement’ the variability was significantly higher in depressive group as compared to the schizophrenic group. The other scoring categories did not differ significantly in two groups as shown in Table 2. Significance Analysis of SIS-II 129

130 Pershad & Verma Table 1 Comparison of Concordance between Structured and Perceptual Themes of the Schizophrenic and Depressive Patients Serial Number of images Percept perceiving corresponding Structured to elicit theme (concordance) Schizophrenic Depressive Patients Patients Spine/Backbone A22 00.0 33.3 A23 08.3 66.7 B16 08.3 33.3 B18 00.0 08.3 Concordance 04.2 35.4 Head/Brain/Skull A30 66.7 58.3 B20 41.7 83.3 Concordance 54.2 70.8 Kidney /Lungs A20 58.3 83.3 B9 66.7 66.7 Concordance 62.5 75.0 Heart A18 00.0 08.3 B17 00.0 25.0 Concordance 00.0 16.7 Stomach A15 00.0 16.7 Concordance 00.0 16.7 Human beings A9 25.0 58.3 B5 100.0 91.7 Concordance 65.2 75.0 *Mean Concordance (MC) 28.85 48.71 MC=Number of S Conceded ___________________ x100 Number of Images X N *Chip Square = 12.97. p=.01

Table 2 Comparison of Schizophrenic and Depressive Patients of SIS-II Category of Schizophrenia Depression Responses M SD M SD Contents Human 17.25 5.28 17.75 4.92 Animal 8.66* 3.40 5.82 3.10 Anatomy 6.17 3.10* 10.67 8.91 Sex 0.67 0.85 0.67 9.06 Others 24.83 6.55 20.68 9.06 Form Level Most Typical 8.64* 1.93 10.58 2.96 Typical 19.69 5.44 18.83 6.11 Atypical 29.26 7.92 26.17 7.05 Others Total 57.58 5.65 55.58 5.69 Rejection 4.42 5.61 6.42 5.67 Movement 2.58 2.23* 3.08 5.27 p< .05 for Mean differences and p<.01 for differences in SD. Discussion: SIS-II known to consist of images specific to elicit anatomical concern of the subjects. A closer look, however, suggested that only 19 images depict anatomical theme (A14, 15, 17, 18, 19, 20, 22, 23, 30 and B 7, 9, 11, 13, 14, 16, 17, 18, 20, 24). Another 25 images are specifically developed to elicit human body parts (outer detail) or a complete human being (A 1, 5, 6, 7, 8, 9, 10, 11, 13, 14, 27, 28, 31, and B 3, 4, 5, 6, 8, 12, 22, 25, 28, 29, 30, 31). It helps in assessing interpersonal relationships and anxiety associated with body parts. Four images are structured to elicit animal responses (A 16, 21 and B 10, 23) and another four to elicit sex content (A 25, 26, B 26, 27). Perceiving other than the specified theme is suggestive of diversion from reality. This if demonstrated, any further confirm that schizophrenic patients have more disturbed reality orientation as compared to depressive patients. Response of depressive patients concorded more with structural theme of vital organs (Table 1). They also perceived more anatomical content (Table 2). The possible explanation of Significance Analysis of SIS-II 131

such findings in depressive patients could be offered as to better reality orientation or concern with self body image. Perhaps both conjectures are correct and thus cannot be separated. Never the less, there are a few other indicators to suggest different psychopathology on SIS response in two groups of psychotic Patients. Schizophrenic patients perceived more Aanimal content than depressive patients suggesting more regression and deviation in adaptability. Depressive patients were found to have more variability with regard to inner tension. These observations clearly suggested that the simplest procedure of content analysis as practiced in SIS has diagnostic significance. Thus it can be sumrised that SIS has promising future to replace earlier inkblot tests. References: Cassell, W.A. (1965) body perception and symptom localization. Psycho-somatic Medicine, 27, 171-176. Cassell, W.A. (1977) Desnisitization therapy for body image anxiety. Canadian Psychiatric Association Journal, 22, 239-242. Cassell, W.A. (1980) Body awarness and somatic delusions involving sexual organs. American Journal of Psychoanalysis, 40, 125-135. Cassell, W.A. (1990) Inner World Reflections Through Dreams and Art: Manual Somatic Inkblot Series. SIS Centre Anchorage, USA. Dharamvir, Parshad, D. Dubey, B.L. and Mann, S.B.S. (1995) Body imagery in vertigo patients. SIS Journal of Projective Psychology and Mental Health, 1, 65-72. Dubey, B.L., Cassell W.A. Pershad, D. and Dwivedi, P. (1995) Diagnostic Utility of Somatic Inkblot Series. SIS Journal of Projective Psychology and Mental Health, 2, 77-84. Moroney, M.J. (1971) Facts from Figures. Penguin Books, Middle Sex, England. Pershad, D. and Dubey, B.L. (1994). Reliability and Validity of Somatic Inkblot Series, SIS Journal of Projective Psychology and Mental Health, 1: 233-38. Rathee, S.P. Pandey, V. and Singh A. (1995) Diagnostic efficacy of Somatic Inkblot Series-II. Amongst psychiatric patients of Armed Forces: A preliminary study. SIS Journal of Projective Psychology and Mental Health2, 61-66. Saldanha, D. and Dubey, B.L. (1995) effect of sodium pentathlon of SIS-Video: A Inkblot images. SIS Journal of Projective Psychology and Mental Health, 2, 19-28. Verma, S.K. Pershad, D. Kaur, R. and Nehra, R. (1995) Diagnostic Significance of SIS-II. SIS Journal of Projective Psychology and Mental Health. 2, 72-76. 132 Pershad & Verma

Rakesh Pandey, Ph.D. Deptt of Psychology, Banaras, Hindy University Varanasi – 221 005 (India) SIS J. Proj. Pst. & Ment Health (1995) 2:133-139 Projective Measures of Alexithymia and the SIS Rakesh Pandey Alexithymia is a multidimensional construct, which refers to the deficits in the experience and expression of emotion. The present paper reviews the earlier attempts to measure the alexithymia construct with special reference to the projective techniques, and presents the potentiality of the Somatic Inkblot Series (SIS) for becoming a valid projective measure of alexithymia. The quantitatively scored SIS Alexithymia Indices such as decreased R, low R on chromatic images, increased Animal, Anatomical, Pathological Anatomy Scores, Sexual responses, and low Human and affect in Human responses are proposed in the paper. Since TAS-20 is the only scale, which has been adopted in Indian conditions, the proposed indices on SIS will be compared with TAS- 20 scale and the outcome will be reported in future. The term Alexithymia refers to the deficit in the experience and expression of emotions. Although the Alexithymia construct had proven to be difficult to operationalize (Taylor, 1984), now most of the researchers in this field agree upon four measurable features of alexithymia: (1) difficulty in identifying and describing feelings, (2) difficulty in distinguishing between feelings and bodily sensations accompanying various emotional states, (3) impaired symbolic activity as reflected by poverty of fantasies and other imaginative activities, such as dreaming and day-dreaming, and (4) a concrete, literal, and externally oriented thinking characterized by a preference for focusing on external events rather than inner emotional experiences (Taylor, 1984; Taylor and Bagby, 1988). Recent researches have identified certain other measurable features of alexithymia. For example, it has been empirically demonstrated by several researchers that alexithymics are prone to experience negative emotions and have a diminished capacity to experience positive emotions (e.g., Prince & Berenbaum 1993). Similarly, various other features, which have repeatedly been observed in alexithmics with considerable consistency, are (a) the tendency to focus on and amplify the somatic component of emotional arousal (Pandey, 1995; Taylor, Bagboy and Parker, 1991), and (b) the tendency to present physical complaints (Taylor et al., 1991). Several theorists have proposed that alexithymic features reflect deficits in the capacity to cognitively process and modulate emotional responses as well as deficit in the capacity for interpersonal regulation of emotions (Taylor, 1994). These theoretical speculations have now been empirically supported (Pandey, 1995; Parker, Taylor, and Bagby, 1993). These recent refinements of the alexithymia contracts puts the need for further refinement of the measurement instruments and to examine whether these features emerge as separate dimensions of the alexithymia construct.

134 Pandey Review of the measurement of alexithymia construct revealed that most of the instruments developed so far had failed to meet the contemporary psychometric standards (Taylor and Bagby, 1988). Further, the scales, which have shown adequate levels of reliability and validity, do not encompass certain important features (e.g., the impaired symbolic activity). For example, the twenty-item Toronto Alexithymia Scale (Tas-20, Bagby, Parker, and Taylor, 1994), the most recent and psychometrically most sound scale for measuring alexithymia, encompasses only three central features of alexithymia; (i) difficulty in identifying feelings, (ii) difficulty in describing feelings, and (iii) externally oriented thinking. Review of the projective assessment of the alexithymia construct revealed that very few attempts have been made to develop projective measures of alexithymia (Taylor and Bagby, 1988). A few researchers have utilized the Rorschach Inkblot Test (Acklin and Alexander, 1988, Acklin and Bernet, 1987) for assessing various alexithymic features. However, no further attempt had been made to validate these Rorschach alexithymia indices. Also, the normative data for these indices has not been presented. Thus these limitations make the use of Rorschach alexithymia indices impractical for clinical and research purposes. Some other researchers have utilized the quantitative content analytic techniques to assess alexithymic features. In this technique, generally the speech sample is analysed for the presence of affective content at various levels, such as lexical level, sentential level etc., and /or other types of contents related to the construct (Taylor and Doody, 1985; Ten Houten, Hoppe, Bogen, and Walter, 1985a 1985b 1985c 1985d, 1986). Findings of the content analytic technique indicated that certain content analytic indices such as, affect related word count (Taylor and Doody, 1985) might prove to be a valid measure of alexithymia. However there are several limitations with the use of content analytic techniques for measuring alexithymia. Firstly, it had been found that different types of speech samples (e.g., monadic versus dyadic speech sample) yielded different results (Von Ras and Lolas, 1982). Secondly, interrater reliability of various content indices had either been not determined or had failed to reach the acceptable level (Taylor and Bagby, 1988). Finally, these procedures are time consuming and have a complex scoring system. Recently, an attempt has also been made to develop an extra linguistic measure of alexithymia (Pandey, 1995). It has been found that individuals classified as alexithymic by a psychometrically sound scale (the TAS-20H, Pandey, et al 1995) took longer time to initiate emotional descriptions and utter for a significantly lesser duration with greater number of speech disruptions. The normative data for these extra linguistic measures of alexithymia, however, has not been obtained. Thus, the non-availability of normative data, and lack of or undemonstrated reliability and validity of various projective measures of alexithymia, limits their use for research and clinical practice. The only projective test of alexithymia, for which some normative

SIS in Alexithymia 135 data is available and has demonstrated acceptable levels of inter-rater reliability is the objectively Scored Archetypal Test with nine elements-SAT, (Cohan, Demers- Desrosiers and Catchlove, 1983). However, the SAT, measures only one feature of alexithymia i.e. the impaired symbolic activity. Moreover, few researchers have failed to demonstrate its validity (Norton, 1989). In the light of these limitations, the SIS seems a suitable projective instrument for measuring alexithymia. In the following sections the potentiality of the SIS for measuring alexithymia has been presented and the SIS Alexithymia Indices had been proposed. SIS: A potential instrument for the assessment of Alexithymia: The Somatic Inkblot series (SIS) is a newly developed structured projective instrument which consists of semi ambiguous stimuli based anatomical structures 9Cassell, 1980, 1990; Cassell et.al. 1995). SIS is now available in five forms: (1) SIS-I which consists of 20 cards depicting semi ambiguous pictures, (ii) SIS-II which consists of 62 semiambiguous images. This form of SIS has been designed for self administration, (iii) SIS-Video consist of the Video film of the 62 images of SIS-II, (iv) SIS-Video consist of the Video film of 20 cards of the SIS-I, and (v) SIS-Living Images consists of video film of 40 images and had been designed exclusively for women. The SIS can be scored quantitatively as well as qualitatively (Cassell, 1990, 1994; Cassell, Dubey and Pershad, 1995). The administration and scoring of the SIS is very simple. The development of the self-administered booklet form of SIS (the SIS-II) and the availability of normative data has made the SIS comparable with psychometric questionnaires in terms of the economy of administration and scoring. Due to its selfadministered nature, it also reduces the test-anxiety as well as the possibility of inhibiting responses due to the presence of the tester. However, the use of semi-ambiguous visual stimuli and individualized spontaneous response to it, provides all the advantages of projective test. The use of visual stimuli with moderate ambiguity provides an additional benefit of controlling the “levels effects”. The “levels effects” in projective assessment refers to the variation in responses due to variations in the degree of ambiguity present in given stimulus. It has been noted by a number of researchers that stimulus with a moderate level of ambiguity reveals the most meaningful response (Mustering, 1995). Further, attempts to develop computerized scoring system for the SIS have also been made (Cassell, 1984). Such attempts would make the SIS a potential projective instrument to address the problem of uneconomical administration and scoring in the projective assessment of alexithymia. Another advantage of the SIS over other projective measures of alexithymia is its capacity to measure body imagery and awareness. Since the tendency to present physical complaints and to focus on and amplify the somatic component of emotional arousal is an important alexithymic feature, the SIS would be the best option to examine

136 Pandey and measure it. The SIS would also make it possible to examine the disturbance of body imagery in alexithymics that has been the little studied aspect of alexithymia. In the following section, various quantitatively scored SIS indices theoretically congruent with various alexithymic features have been presented. For details of the scoring procedure see Cassell (1980, 1980a, 1990, Cassell et al 1995, Dubey et al 1995). SIS Alexithymia Indices: (1) The capacity to cognitively modulate emotional responses: This Alexithymic feature has earlier been studied by measuring the reaction time in naming the color of sex-related/emotion-arousing words printed in different colors (Pandey, 1995, Parker, Taylor and Bagby, 1993). Findings from, these studies indicated that alexithymics took more time to name color and sex-related words. Thus reaction time (RT) on cards of images designed to evoke affect and sex-related responses may be utilized as a measure of this alexithymis feature. Following SIS indices seem appropriate for measuring the capacity to cognitively modulate emotional responses: (i) Delayed /more reaction time on cards of images designed to evoke affect (e.g., card 18 and 20) and sex-related responses (e.g., card no. 7,13 and 14 on SIS-I, and image A8, 22, 25, 27, B18 and 25 on SIS-II/Video). (ii) Low R on chromatic cards/chromatic images on video. (iii) Repression and Rejection of sex-related responses. (iv) Increased sexual imagery. Alexithymics would score higher on all these measures. (2) Interpersonal regulation of emotion can be measured by scoring the following responses on selected images depicting interpersonal situations (e.g. cards 3 on SIS-I, and images A9, 21, 31, B4, 5, 28, 31, on SIS-II): (i) High RT on above images (ii) Repression of interpersonal responses and rejection of the images depicting interpersonal situations (Low Human Contents). (iii) Non-human responses: Scoring non-human responses on the images which are normally perceived as human gestalt (e.g., card 2 and 4 on SIS-I, and image A5, 6, 7, 9, 31, B4, 5, 22, 28, 31 on SIS-II). An alexithymic individual would have high RT and more repression and rejection on above images, and greater number of non-human responses.

SIS in Alexithymia 137 (3) Affective experience and expression: Alexithymics’ proneness to experience negative emotions would be reflected by a higher score on Depression Scale (D) of SIS. Anxiety-Threat rating scale may also be used for this purpose. The positive-affective contents can also be scored following the procedure of Depression scale. An alexithymic would score high on Depression Scale and low on positive emotion scale. The total number of affective responses (both positive and negative) may be used to index the affective expression. Inability to perceive affect on images designed to evoke affective responses may be another indicator of poor affective expression. For example, inability to see smiling face on card 3 SIS-I, motherchild on B28 of SIS-II, Happy man on card 2/A5 of video and sad child on A6 of SIS-II. (4) Impaired imaginative activity is a central feature of alexithymia, which has been excluded from various questionnaires of alexithymia due to its high correlation with social desirability. It can be measured by scoring the following SIS indices: (i) Low movement responses (both animal and human movement). (ii) Low number of total responses. (5) Concrete, literal and externally oriented thinking of alexithymic will be reflected in: Fewer gestalt responses. Due to the tendency to focus on minute details of external events, alexithymics are likely to give part responses on the images designed to evoke gestalt responses. (6) Somatic complaints and hypervigilance towards somatic arousal can be assessed by following SIS indices: (i) Increased Pathological Anatomy Score (PAS) (ii) Increased Anatomy responses. (iii) Increased Reaction time on image producing anatomical responses. (iv) Increased Anatomy responses. (v) High RT on cards or images designed to produce anatomical responses. Conclusion: It can be concluded that SIS have a potentiality to become a valid measure of alexithymia. However, further research is needed to demonstrate the validity of the SIS Alexithymia Indices. Some preliminary data collected by the author have indicated that individuals classified as alexithymic on the TAS 20-H scored in the predicted direction on these SIS Alexithymia Indices.

138 Pandey References: Ackin, R.W., and Alexander, G. (1988). Alwxithymia and somatization: A Roschach of ofur Psychosomatic groups. Journal of Nervous and Mental Disese, 176, 343-350. Acklin, R.W., and Bernat, E. (1987) Depression, alexthymia, and pain prone disorder: A Roschach study. Journal of Personality Assessment , 51, 462-479. Bagdy, R.M., Parker, J.D.A. and Taylor G.J. (1994). The twenty item Toronto Alexithymia Scale I: Item selection and cross-validation of the factor structure. Journal of Psychosomatic search, 38, 22-32. Cassell, W.A. (1980). Body Symbolism and Somatic Inkblot Series. Aurora Publishing Company Anchorage, Alaska. Cassell, W.A. (1980a.) Body awareness and Somatic delusions involving sexual organs. American Journal of Psychoanalysis, 40, 125-135. Cassell, W.A. (1984). Computerized projective testing as an aid in medical diagnisis. Alaska Medicine, 26, 1-9. Cassell, W.A. (1990). Manual Somatic Inkblot Series. Aurora Publishing Co.: Anchorage Alaska. Cassell, W.A., (1994). The SIS: Continuing Rosarch’s conceptualization. SIS Journal of Pprojective Psychology and Mental Health 1, 3-14. Cassell, W.A., Dubey, B.L. and Pershad, D. (1995). SIS video manual. SISCenter, Anchorage, Alasks (USA). Dubey, B.L., Cassell, W.A. Pershad, D. and Dwivedi, P (1985). Dianostic utility of Somatic Inkblot Series. SIS Journal of Projective Psychology and Mental Health 2, 77-84. Murstein, B.L. (1995). The relationship of stimulus projection and pathology in Projective techniques and the “Lovels effect”. SIS Journal of Projective Psychology and Mental Health 2, 41- 52. Norton, N.C. (1989). Three scales of alexithymia: Do they measure the same thing? Journal of Personality Assessment, 53, 621-637. Pandey, R. (1995). Stroop interference effect of emotion arousing words in alexthymia. Journal of Indian Academy of Applied Psychology (In Press). Pandey, R., Mandal, M.K. Taylor, G.J. and Parker, J.D.A. (1995). Cross cultural alexithymia: Evaluation of a Hindi translation of twenty-ten Toronto Alexthymia Scale Journal of Clinical Psychology. (In Press). Parker, J.D.A., Taylor, G.J. and Begby, R.M. (1993). Alexithymia and the processing if emotional stimuli: An experimental study. New Trends in Experimental and Clinical Psychiatry, 11-9-14.

SIS in Alexithymia 139 Prince, J.D. and Berenbaum, H. (1993). Alexithymia and hedonic capacity. Journal of Research in Personality, 27, 15-22. Sifneos, P.E., (1993). The prevalence of alexithymic characteristics in psychosomatic patients. Personality and Psychosomatic, 22, 255-262. Taylor G.J. (1994). The alexithymia: Concept: Conceptualization, validation, and relationship with basic dimensions of personality. New Trends in Experimental and Clinical Psychiatry, 10: 61-74. Taylor, G.J. and Bagby, R.M. (1988) The measurement of alexithymia: Recommendations for clinical practice and future research. In K.D. Hoppe (Ed.), Psychiatric Clinics and North America-Hemispheric Specialization: Afect and Creativity. Pp 351-366. Philadelphia Saunders. Taylor, G.J. Bagby, R.M. and Parker, J.D. (1991). The alexthymia construct: A potential paradigm for Psychotherapy and Psychosomatic, 43, 32-37. TenHouten, W.D. Hoppe, K.D., Bagen, J.E., and Walter, D.O. (1985a). Alexithymia and the split brain I.: Lexical level content analysis. Psychotherapy and Psychosomatics, 43, 202- 208. TenHouten, W.D. Hoppe, K.D., Bagen, J.E., and Walter, D.O. (1985b). Alexithmia and the split bring II: Sentential level content analysis. Psychotheraly and Psychosomatics, 45, 1-5. TenHouten, W.D. Hoppe, K.D., Bagen, J.E., and Walter, D.O. (1985c). Alexithymia and the split brain III: Global level content analysis of fantasy and symbolization. Psychotherapy and Psychosomatics, 44, 89-94. TenHouten, W.D. Hoppe, K.D., Bagen, J.E., and Walter, D.O. (1985d). Alexithymia and splitbrain IV: Gottschalk-Glaser content analysis. An overview. Psychotherapy and Psychosomatics, 44, 113-121. TenHouten, W.D. Hoppe, K.D., Bagen, J.E., and Walter, D.O. (1986). Alexithymia. An experimental study of cerebral commissurotomy patients and normal control cubjects. American Journal of Psychiatry, 143, 312-316. Von Rad, M., and Lolas, F. (1982). Empirical evidence of alexithymia. Psychotherapy and Psychosomatics, 38, 91-102.

K. Chandirmani, Assoc. Prof., R. Jena, Research Associate, Deptt. of Psychiatry, A, India Inst. of Med. Sciences, New Delhi – 110029 S.K. Verma : Additional Professor of Clinical Psychology, Deptt. of Psychiatry, Postgraduate Instate of Med. & Res., Chandigarh – 160 012. SIS J. Proj. Pst. & Ment Health (1995) 2: 140-144 Human Figure Drawings of Prisoners and Vipassana Kishore Chandiramiani, Renuka Jena and S.K. Verma Forty Tihar Jail Mail inmates were divided in two groups. One group received Vipassana training and the other did not. Twenty subjects were taken from each group. The study group as well as the control group with the same time interval made before and after Vipassana human figure drawing respectively. More positive changes e.g. more holistic, balanced picture of self (more complete and proportionate) with reduced dependence (buttons, pokers, mind-line emphasis) and aggression (eyes, teeth, gun) were observed in the study group as compared to the control group. The overall gains of Vipassana are discussed in the paper. There is increasing attention towards the use of Projective techniques, which are indirect methods of assessing human behavior. These methods are relatively fee from deliberate motivational distortions, as the subjects do not know in which way there responses would be scored and interpreted. Human figure drawing and their descriptions by the subjects fall in this group of techniques. This test is easy to administer, score and interpret. It requires only paper and pencil. Following Karen Machover’s work (1949) many people in India have worked on this test, with varied populations like students (Verma et al 1967), Psychiatric Patients (Verma 1971), impotence case (Kapur & Kapur 1967), patients awaiting surgery (Verma et al 1972) emotionally disturbed children (Solanki et. al 1975) etc. Although published work on this test been relatively less, but it has a lot of clinical utility. It is one of the 10 most frequently used tests in psychology (Sundberg 1961, Plotrowski and Keller 1978). Like any other test, it also has its limitations (Megargee 1966) and it is said that changes in human figure drawings over a period of time, with or without any intervention, can give a better and more reliable picture of one’s self personality. Experiments have been conducted using vipassana training on a few inmates of Tihar Jail, Delhi. Its beneficial effects on inmates of Tihar Jail have already been reported using subjective methods (Interviews) and psychological tests (like self-reporting questionnaires). In the present study an attempt has been made in this direction on a small sample of Jail inmates over a short period of time using the human figures drawings. The aim was to find out by this indirect method, where Vipassana technique shows definite and positive results not limited to subjective self-reports alone.

Material and Methods: Sample: Forty Tihar Jail inmates were randomly selected and divided into two groups the study group (n=20) and the control group (n-20). Vipassana meditation was given to the study group by an independent group of workers. Al the subjects were male, adult and volunteers. There was no refusal by any subjects to complete the test. Confidentiality was assured and they were told that they could discontinue if they desire so during the course of meditation. The Technique of Vipassana: Vipassana means “night”, seeing things as they really are. To learn this technique, a ten day course was given to the subjects by the vipassana International Academy (Nasik, Maharashtra). The prisoners took a vow of observing certain rules of moral conduct i.e. abstinence from killing, stealing, sexual misconduct, telling lies and taking any intoxicate ad the first step. The second component of tins training is known as ‘Anapana’ i.e. awareness of respiration. The trainees observed the natural flow of incoming and out going breath the third step is Vipassana i.e. purification of mind through enhanced awareness. The trains engaged themselves in conservation of body sensations and an attitude of non-judgment and non-reaction. This technique thus works as introspection. Tool: Draw a person test (Machover, 1949) was used Subjects were first asked to draw a human figure, then the opposite sex of the first figure drawn. Stander questions about drawn persons are, 3 desires and 3 fears in the order of importance followed this. A bond paper, soft pencil and eraser was provided to all subjects. The test was given only after establishing rapport with the subjects. Results: Changes observed in the human figure drawing, over a period of time, with of without Vipassana meditation, are compared in the two groups and shown in Table 1. There were more of positive charges in the study group, such as more holistic, balanced picture of self (in terms of more complete and proportionate figures), with receded dependence (lesser emphasis on button. Pockets, mind line) and reduced evidence of aggression (e.g. lesser emphasis on eyes, teeth, gun, etc.) as compared to he control group. Disproportionate figure, change of sex (male to female and female to male), incomplete second figure, missing of body parts was observed more in the control group (Table 1). Vipasamma & Human Fig Drawings 141

142 Chandiramani et al The positive trend was noted in the desires of inmates where positive changes were a little more in the study group compared with changes in the control group (Table-2). However in case of fears, no consistent pattern emerged in the short time follow up, between the two groups (Table3). Table 1 Chafes noticed in Draw-a-person test in the two groups (in Percentages) Change over time in Changes ion the group(Before Vs after) Study group Control Group N=20 N=20 1) Little or No change 2) More complete second figure 3) More proportionate figure/firmer Lines on second occasion 4) More incomplete figure/ Mouth missing /Details missing 5) Larger size now 6) Smaller Size now - 7) Change in sex Male to Female - Female to Male - 8) Lighter Lines - 9) Reduced dependence 55 to 5 increased by 5 (Buttons, pockets, midline emphasis) 10) Reduced aggression (Eyes, Teeth, Gun) 45 to 0 reduced by 5 11) Both female figures — — Overall impression More of Random (Changes) Positive or Changes Negative Changes

Table 2 Changes in desired in the two groups (in percentages Study Groups Control Groups 1. Little or no change 2. Love desired more 3. Family Life “ “ — 4. Health “ “ 5. Education “ “ 6. Work “ “ — 7. Wealth/Money “ “ — 8. Rest/Sleep “ “ — Also To eat drink, Take Drugs, Murder, run away (5 each) Table 3 Changes in feared in the two groups (in percentages) Study Groups Control Groups 1. No change 2. Poor health/illness 3. God — 4. Poor Education/illiteracy 5. Hatred 6. Being misunderstood — 7. Back biting — 8. Poverty — 9. Jail Staff — Conclusions The overall gains of Vipasssana meditation over the short follow up period were definite and positive through small. This justifies continuation of such work over a longer period of time and on a larger sample. Acknowledgement: The authors acknowledge the support of Vipassan International Academy. Nasik, Maharashtra and officials of the Tihar Jail, New Delhi. Vipasamma & Human Fig Drawings 143

References: Kapur. M. and Kapur R.L. (1967) Study of through projective tests Indian J. Psychiat. 9: 208-210. Machover K. (1949) Personality Projection in the Drawings of human figure: A method of Personality investigation. Springfield. IL, Thomas Megargee, E. (1966) Research in clinical assessment. Harper and Raw Pub. Piotrowski, Z.A. and Keller, J.W. (1978) Psychological test usage in South Eastern Outpatient metal health facilities in 1975. Professional Psychology 63-67. Solanki, PPS and Sen Mazumbar, D.P. (1975) A study of emotional indicators on Draw-A-Person Test with normal and emotionally disturbed female children of lower socio-economic group. India J. Clin. Psychology, 2: 13-17. Sundberg, N.D. (1961) The Practice of Psychological Testing in Clinical services in the United State. American Psychologies 16: 79-83. Verma, S.K. (1971) Disturbance of body image in Psychiatric patients. Manas 18: 111-116. Verma S.K., shah D.K. and Verma H.C. (1967) The concept of school going children in India. Manas 18: 59-64. Verma S.K., Wahi, P.L. and Wig N.N. (1972) Disturbance of body image in patients awaiting surgery. Indian J. Applied Psychology, 9, 44-46. 144 Chandiramani et al

Mahesh Bhargava, Ph.D., Secretary, India Psychological Association, New Delhi 1100049 and Director, National Psychological Corporation, 4/230, Kacheri Ghat, Agra 282004 Anju Sexena, C/o. Mr. Kuldeep Saxena, Allahabad Bank (U.P.) SIS J. Proj. Pst. & Ment Health (1995) 2:145-149 Basic Personality Structure of the Deprived Adolescents Mahesh Bhargava and Anju Sexena The present study aims at identifying the basic personality structure and evaluating 15 primary traits of personality on Rorschach Inkblot Test of the High and Low Deprived adolescents. Prolonged Deprivation scale was employed as the screening instrument for identifying the two extreme groups of deprived adolescents whereas Roschach Inkblot Tests was under as evaluating instrument. Data was collected on 80 HAD and 80 LDA studying at Xith Class and in comparison in the age group of 16+. The results indicated that in comparison to HAD, the LDA have developed better cover and overt control over their behavior as indicators of their better covert experiential balance in their personality. Consequently, there existed significant differences in their personality structures, particularly in F,M, Fc, FK, FC and Hd criteria of Rorschach Inkblot Test thereby accounting for the difference in their personality structure. Deprivation in a natural consequence in a land where a large section of the people live in poverty. Deprivation of any kind whether cultural, social, psychological, economic or even political hampers the natural growth and development of an individual; thereby adversely affecting his personality Chug (1979) reported that as deprivation increases the worrying, depressive and troubled tendencies showed a corresponding increase. A low deprived group is more critical, liberal, analytical, freethinking and radical as the compared to the high-deprived group. Bhargava and Aurora (1980) studied the dynamic structuring in the form of ergs and sentiments between high and low prolonged deprived female adolescents. Bhargava and Aurora (1981). Found that the severely deprived were more reserved, more emotionally unstable, serious, shy, depressive, conservative and frustrated as compared to their counterparts. Vashistha (1981) explored the differential personality traits among institution-Reared (IR) and Family-Reared (FR) boys and girl employing Rorschach criteria given b Carstaires, Payne and Whittaker (1960) and found that FRBG and IRCG significantly differ on the nine personality traits out of 13l namely emotional construction, abundance of creative impulses, marked inhibition o sexuality, dependence, high degree of empathy, relies for sexual expert emcees, more interested in practical concerns, and inhibition of association. The remaining four traits of personality which did not show any significant difference were inhibition of emotional expression, difficulty in establishing close personal relationship, level of general anxiety and given to introspection. In a study conducted by Kimble (1945) employing Roschach technique a significant difference was found in the M: Sum ratio, and in the direction of more colour in the associate situation.

146 Bhargava & Saxena Asthana (1963) and Dubey (1982) conducted a series of studies on personality structure employing Rorschach Technique and found that this technique was very useful assessing different aspects of personality. Carstaires (1956) demonstrated on the strength of his studies on Rorschach test employing Indians that the basic difference in personality structures of the Bhil tribes and the Hindus may not be only because of their basic personality factors, but also due to many cognitive elements. Lerner (1991) conducted a study on the analysis of the Rorschach content employing five dimensions of assessing Human Movement Responses (HMR) as identified by Mayman (1977) and recorded that three of these dimensions or components are the contribution to fantasy, Kineshesia and its relation to self-experience and object representation which provide organizational framework within which particular content indices are gleaned from the empirical work of several researchers. Bhargava and Singhla (1988) found that girls from advantaged group were found high in need variables of exhibition and change while the girls from disadvantages group were found high on difference and succourance. Saxena and Bhargava (1994) found that advantaged children were superior on most of the positive traits of personality as measured by Rorschach as compared to disadvantaged children. Significant sex differences were also noticed between advantaged and disdained groups of children. Objective: The present study, thus aims at two objectives namely” (j) To determine the ‘Model Personality Structure’ of the deprived adolescents employing Rorschach technique. And (k) To evaluate the derivational difference in the 15 personality dimensions of the HIDA and LDA. Method: Samples: 80 Highly deprived (HAD) and 80 low deprived adolescents (LDA) of class XIth and XIIth, in the age group of 16th+ evenly distributed between the two sexes were selected as normative ester me groups on PDS. Instruments: (a) Screening Tool-Prolonged Deprivation Scale (Mishra and Tripathi 1977) containing 15 dimensions was used for screening the highly deprived adolescents from the low deprived ones. An individual placed above 75th percentile was categorized as Highly Deprived Adolescent (HAD) whereas one who scored below 25th percentile was classified as low Deprived Adolescents (LDA). (b) Evaluating Technique-Rorschach Inkblot Test (Harmann Rorschach, 1921) was used for evaluating the personality variation of the HAD and LDA employing Klopfer et.al. (1954) analysis and interpretation of data.

Rorschach in adloscents 147 Table 1 Rorschach criteria yielding experiential balance of the HDA and LDA Partiality Rorschach Groups Dimensions Criteria HDA LDA t Mean SD Mean SD 1. Emotional M 2.88 2.49 3.23 2.39 2.47* Construction F 14.86 7.19 16.40 6.06 1.46 FC .77 1.05 1.48 1.03 5.07** 2. Absence of M 2.88 22.49 3.25 2.39 2.47* Creative Impulse FM 8.43 4.29 8.41 3.49 0.05 3. Marked H 3.59 2.59 3.83 2.65 0.59 In habitation of Hd 1.36 1.26 2.18 2.91 2.28* Sexuality 4. Dependency Cf 1.20 1.31 0.94 0.90 1.85 FM 8.43 4.29 8.40 3.94 0.05 M 2.88 2.49 3.25 2.39 2.47* 5. Higher Degree of Fc 0.99 1.05 1.66 1.42 4.18 Empathy 6. Inhibition of Sum C 1.44 2.75 2.05 2.07 1.16 Emotional C 0.33 0.54 0.46 0.59 1.14 Expression 7. Relish for cF 1.20 1.31 0.94 0.90 1.85 Sensual Expressionless 8. Difficulty in FC 0.77 1.05 1.48 1.03 5.07** Establishing Close Personal Relationship 9. More Interested M 2.88 2.49 3.25 2.39 2.47* In Practical Concern 10. Level of General FK 0.11 0.39 0.29 0.66 2.25* Anxiety 11. Amity Concerning At 1.31 1.36 1.33 0.96 0.39 Blood Function 12. Given to M 2.88 2.49 3.25 2.39 2.47* Introspection 13. Attempt at Strong M 2.88 2.49 3.25 2.39 2.47* Ego Function Fails 14. Inhibition of d 5.78 4.89 6.95 4.99 1.50 Aggression 15. Awe of Father H 3.59 2.59 3.83 2.654 0.59 Figure **Significant at .01 level*Significant at .05 level

148 Bhargava & Saxena Results: HDA and LDA were identified first on PDS from a large pupil population; and the two extreme groups so selected were given the Rorschach Inkblot Test employing standard procedures given in the manual. However, analysis treatment and interpretation of data were made following Klopfer’s technique. Personality traits were determined through from 9F) percentage Human Movement 9M) response and Chromatic responses popularly known as experiential balance as described by Rorchach. The results so obtains are presented in Table 1. Interpretation and Discussion: The results indicating Significant Personality differences between HAD and LDA reveal that the two groups differ significantly FC (t+5.07, p<. 01) and M (t=2.47, p<. 05) of ‘emotional construction’, in M (t+2.47, p<,05) of ‘abundance of creative impulses’, in Hd 9t=2.28, p< .05) of ‘marked inhibition of sexuality’, in M (t-2.28, p< .05) of marked inhibitor if sexuality’, in M (t=2.47, p< .05)of Dependency’, in Fc 9t-4.18, P, .01) of high degree of empathy’, in FC (t=5.07, p, .01) of difficulties in establishing close personal relationship’, in M (t=2.47, P,.05). More interested in practical concerns, in FK (t=2.23, P,.05) of level of general anxiety’, in M(t=2.47, P,.05of given to introspection’, and in M (t=2.47, P, .05) of ‘attempt at strong ego function failure’.” The high mean score on any of the given Rorschach criteria in the LDA group indicates superior personality structure and function of the individuals; and this superiority in the perception of forms or human movement or chromatic responses revealed their better experiential balance expressing stronger covert and over control of their behavior. Conclusion: The results presented above lead us to conclude that the LDA’s have developed better covert control over their behavior as indicators of better experiential balance in their personality in comparison to their counter-parts HDA’s. Consequently, significant differences exist in their personality structures; particularly in F, M, FC, FK, Fc, and Hd criteria of Rorschach Inkblot Test, accounting for their personality differences in various components of personality structures as discussed above. References: Asthana, H.S. (1963) A Rorschach study of Indian. Roschachiana, 45 (8): 283-286. Bhargava, M. and Aurora, S. (1980) Dynamic structure of prolonged disadvantaged girls. Paper presented at the 11th Convention of All India Association of Clinical Psychologists Nagpur. 26-28 Nov. Bhargava. M. and Aurora S, (1981) Personality traits as a function of prolonged deprivation. India Journal of Clinical Psychology, 8 (2): 167-171.

Rorschach in adloscents 149 Bhargava, M. and Singh, Uma (1988). Need patterns of social-economically disadvantaged female adolescents. Preachy Journal of Psycho-cultural Dimensions. 4 (1): 27-31. Carstaires, G.M. (1956). Research studies of twenty two Bhil men from Udaipur (India in B.Kaplon (Ed.) Primary Records in Culture and Personality Vol I. Modison. The Micro-Card Foundation. Carstaires. G.M., Payne, R.W. and Whittaker S. (1960) Rorschach responses of Hindy and Bhils. Journal of Social Psychology, 151: 217-227. Chug. R. (1979) a comparative study of personality characteristics of personality characteristics of deprived and provided female adolescents. Master’s Thesis in Home-Science, Agra University. Dubey. B.L. (1982) A pragmatic view of Rorschach Inkblot Technique. National Psychological Corporation, Agra. Kimble, G. (1945). Social influence on Rorschach records. Journal of Abnormal and Social Psychology, 20: 89-93. Klopfer, B. Ainsworth, M. and Holt, R. 91954). Developments in the Rorschach Technique. Vol. Techniques and Theory, New York, World Books. Lerner, Paul M. (1991). The analysis of consent revisited. Journal of Personality Assessment. 56 (1): 145-157. Mayman, M. (1977). A multidimensional view of the Rorschach Movement response. In M. Rickers Ovcanciha (Ed.) Rorschach Psychology. (pp. 229-250. Huntington, N.Y.: Krieger. Mishra, G. and Tripathi, L.B. (1977). Prolonged Deprivation Scale. Agra, National Psychological Corporation. Rorschach, H. (1921). Psychodiagnostik. Ernst Bircher Berg. Sexena, Anju and Bhargava, Rashmi (1994) Personality structure of advantaged school going children. India Journal of Psychometric and Education. Silver Jubilee Vol. 25 (1&2), 85- 90. Vashistha, K.C. (1981). Personality differences among family reared and institution reared boys and girl as indicated by Rorschach Inkblot Test. Doctoral Dissertation in Education Kurukeshtra University.

C.B. Dwivedi, Ph.D. Heas Deptt. of Psychology and Mridula Mishra M.A. (Psy.) Research Scholar, Banaras Hindu University, Varanasi – 221 005 (India) B.L. Dubey, Ph.D. Director SIS Center, E-mail : sisdubey@rediffmail.com SIS J. Proj. Pst. & Ment Health (1995) 2:150-155 Diagnostic Significance of the Indices of SIS-II and Rorschach Inkblot Tests C.B. Dwivedi, Mridula Mishra and B.L. Dubey The SIS-II and the Rorschach Inkblot Tests were administered to 50 normal 50 neuter and 50 schizophrenic subjects using the standard procedure to prepare profiles of the three groups of subjects and to find out the relationship between the common indices of the two tests. Out of 8 indices five indices could discriminate schizophrenics and 3 could discriminate neutrals from normal. Indices however, differed on the SIS and the Rorschach. The correlations of common indices on two tests were significant on one third of the indices. Only two correlations were found to be above 60 thus, it was concluded that the SIS is more suitable for understanding the psychopathology of the patients. Amongst the projective tests inkblot technique occupies a prominent position. There have been only two tests in this category –The Rorschach Test and the Holtzman. In India, the Holtzman inkblot tests is rarely used frequently, has certain limitation such as requirement of time, training and experience of the clinicians. The latest edition in this technique is the somatic Inkblot Series 9Cassell, 1980). It is a supervised selfadministered test. The patient can take the test which waiting for his/her turn. The scoring and interpretation does not require extensive training. It has psychometric properties. It is assumed that it has potential to replace the Rorschach in clinical practices. Somatic Inkblot Series is backed by the theories of Somatic Imagery’, ‘Body Symbolism- Body Perception’ and ‘Cry for help’ (Cassell et al. 1995). It emphasizes mainly on content analysis and psychoanalytical interpretation though it has indices for quantitative analysis. Review of Indian literature on the SIS test suggests that there is need for normative profile and clinical indices on different clinical samples. Since the two tests-the SIS and the Rorschach are based on the same theory of projection, using free association and verbalization through inkblot imagery, there had to be dome similarity. Relationship in the out comes of the two tests. Keeping this in mind, the present study was conducted with the following objectives: Objective: 1. To prepare profiles of normal neurotics and schizophrenic subjects on the SIS-II and the Rorschach. 2. To find out relationship between common indices of the SIS-II and Rorschach.

Material and Method: 150 subjects (50 each-normal neurotics and schizophrenics) in the age range of 20-50 years were taken for the study. The subjects belonged to similar social background and had education at least up to 8th standard. The SIS-II was administered by selfadministration following the standard procedure (cassell, 1990) and the Rorschach was administered individually following Klopfer’s procedure. He protocols of the subjects on both the test were scored on nine common indices such as total number of responses, Human, Animal, Anatomical and Sex contents, Human movement and Animal movement, Most-typical/Popular responses and Rejection of images/cards. Mean, SD, t-test and correlation were computed to find out the differences and relationship of indices between the two tests-the SIS-II nd the Rorschach. Results: Comparison of percentage of various indices on the SIS-II and the Rorschach in normal, neurotic and schizophrenic groups are shown in table 1 and 2. On the SIS-II, Anatomical responses, sex responses, Human movement responses and Animal movement responses did not discriminate amongst three groups. Most typical responses and rejection of images discriminated 3 groups with each other successfully. Total number of responses was significantly less in schizophrenics compared to both normal and neurotics. Human responses wee also significantly less in schizophrenics compared to both normal and neurotic groups. The mean number of Animal responses was significantly higher in two clinical groups compared to the subjects in normal groups. On the Rorschach Test two clinical groups differed significantly from normal group only on a few indices. The Human responses, Animal responses and sex responses did not discriminate amongst 3 groups. Mean Anatomical responses wee significantly higher in clinical groups and Human movement and Animal movement responses were significantly low in clinical groups compared to the normal groups. Popular responses were significantly low in schizophrenics (14.5%) compared to both normal (27.5%) and neurotic (26.6%) groups. The rejection of plates was more frequent in schizophrenic compared to both the normal and neurotic groups. The normal subjects gave more of R (total number of responses), Human responses, Most-typical/Popular responses followed by neurotics and schizophrenics on both the test-the SIS and the Rorschach. Anatomical responses and Rejection of image/cards were lowest in normal and highest in schizophrenics. Neurotics were found to be in between on both the tests. Animal and Animal movement responses gave mixed picture on both the test. Normal subjects gave lowest Animal responses and neurotics the highest on SIS but the same trend was not observed on the Rorschach. Indices of SIS & Rorschach 151

152 Dwivedi et al Table 1 Percentage of various indices on the SIS-II Normal, Neurotic and Schizophrenic Groups Normal Neurotic Schizophrenic SIS A B C t p Indices n=50 n=50 n=50 Human M 33.997 32.74 30.24 AB= 0.97 ns Responses SD 6.49 6.19 8.23 AC= 2.25 .05 BC= 1.17 ns Animal M 12.09 16.75 16.69 AB= 3.88 .01 Responses SD 4.94 6.88 7.84 AC= 3.51 .01 BC= 0.04 ns Anatomical M 19.09 21.93 23.17 AB= 1.79 ns Responses SD 6.20 9.31 7.84 AC= 2.14 .05 BC= 0.58 ns Sex M 2.05 1.82 2.81 AB= 0.14 ns Responses SD 3.19 2.39 3.68 AC= 1.10 ns BC= 1.60 ns Human M 5.37 4.68 4.34 AB= 0.85 ns Movement AC= 1.24 ns Responses SD 4.04 4.01 4.24 BC= 0.41 ns Animal M 1.78 2.00 1.50 AB= 0.556 ns Movement AC= 0.72 ns Responses SD 1.89 1.96 1.95 BC= 1.25 ns Most-Typical M 25.41 23.06 17.82 AB= 5.60 .01 Responses SD 2.33 1.96 2.23 AC= 16.50 .01 BC= 12.78 .01 Rejection M 1.05 2.44 3.76 AB= 2.73 .01 Of AC= 3.82 .01 Images SD 2.88 2.17 4.08 BC= 2.00 .05 M= Means, SD=Standard Deviation

Table 2 Percentage of various indices on the Rorschach in normal Neurotic and Schizophenic Groups Normal Neurotic Schizophrenic SIS A B C t p Indices n=50 n=50 n=50 Human M 16.35 15.03 13.09 AB= 0.77 ns Responses SD 8.86 8.30 10.87 AC= 1.81 ns BC= 1.11 ns Animal M 51.87 58.99 49.45 AB= 1.74 ns Responses SD 17.27 23.34 16.95 AC= 0.70 ns BC= 2.34 ns Anatomical M 8.93 14.23 16.30 AB= 2.60 ns Responses SD 9.30 10.97 17.73 AC= 2.60 .05 BC= 0.69 ns Sex M 1.60 2.11 3.58 AB= 0.54 ns Responses SD 3.62 5.32 6.46 AC= 1.88 ns BC= 1.25 ns Human M 11.33 7.59 4.77 AB= 2.01 .05 Movement AC= 3.81 .01 Responses SD 10.23 8.22 6.61 BC= 1.89 ns Animal M 24.00 2.00 1.50 AB= 0.556 ns Movement AC= 0.72 ns Responses SD 13.21 1.96 1.95 BC= 1.25 ns AB= .61 ns Most-Typical M 27.53 26.65 14.555 AC= 9.14 0.1 Responses SD 7.13 7.34 7.05 BC= 8.40 .01 Rejection M 0.31 1.24 5.59 AB= 1.82 ns Of AC= 3.77 .01 Images SD 1.52 3.34 9.79 BC= 2.98 .01 M=Mean. SD= Standard Deviation Indices of SIS & Rorschach 153

Table 3 Correlations of Common Indices of the SIS-II and the Rorschach in Three Groups Common Indices Normal n=50Neurotic=50Schizophrenic n=50 Total Number of Responses 0.16 0.13 0.17 Human Responses 0.27* 0.06 0.46 Animal Responses 0.29* 0.38** 0.35** Anatomical Responses 0.09 0.49** 0.70** Sex Responses 0.21 0.28* 0.65** Human Movement Responses 0.20 0.09 0.02 Animal Movement Responses 0.09 00.25 0.04 Most Typical/Popular Responses 0.07 0.10 0.32* Rejection 0.21 0.04 0.13 *0.5 **.01 The relationship of the common indices on the SIS-II and the Rorschach are presented in table 3. The table suggested that the relationship of indices on two tests (the SIS and the Rorschach) were different in three groups. In normal group, Human responses and Animal responses had low but significant correlations (.27 and .29 respectively). In neurotic group, three scoring indices that in Animal responses, Anatomical responses and sex responses had significant correlations (.38, .49, . 28 respectively). One of these three correlations was of moderate degree. In the Schizophrenic group four indices had significant correlations between the two tests. These indices were Animal responses, Anatomical responses, Sex responses and Most-Typical/Popular responses (.35, .70, .65, .32 respectively). Out of these four correlations, two were high (.70 and.65) and two were low. The pattern indicated that in normal group, correlations were generally low, in neurotic group more indices had significant and a little better correlations and in schizophrenic group still more indices turned to be significant, having better correlations. Discussion: The profiles to tests have been worked out. It has indicated that out of 8 common indices, the SIS could discriminate schizophrenics from normal subjects on 5 indices. The significant indices suggested that schizophrenics had poor interpersonal relationship, more regression, (Low H, High A) preoccupied with internal body parts (high Anatomical with low group conformity (Low Mt) and more rejection of images. On the other hand, the Rorschach Indices did not suggest poor human relationship and regression in schizophrenics. This difference is sufficient to indicate that the SIS is 154 Dwivedi et al

better test to uncover the basic psychopathology of the clinical groups. The movement responses (both Human and animal) were significantly low in schizophrenics. It may suggest that the schizophrenics are more passive and the Rorschach test evaluates activity-passivity dimension. It further supports the contention of Cassell that the SIS test is an improvised extension of the Rorschach. References: Cassell,W.A. (1980) body symbolism and the Somatic Inkblot Series. Aurora Publishing Co. 213 West Seventh Av. Anchorage, Alaska (USA) Cassell, W.A. (1990) Manual-SIS-II. Aurora Publishing Co. Anchorage, Alaska (USA) Indices of SIS & Rorschach 155

Somnath Bhattacharyya, Professor of Psychology and Debarata Biswas, Lecturer, Department of Psychology, Calcutta University. Dr. Jayanti Basu, Leacturer, Department of Psychology, Calcutta University, 92 A.P.C. Road, Calcutta 700009 (India). For further correspondence. SIS J. Proj. Pst. & Ment Health (1995) 2:156-162 Personality Profile of the Hemophiliacs in Comparison to Normal: A Study Using Self-Report and Projective Measures S. Bhattacharyya, D. Biswas and Jayanti Basu The present study examines the personality profile of adult Hemophiliacs of Calcutta in comparison to normal. The patients were in the age range of 20-38 yrs. And suffered form Factor VIII deficiency. The normal group was selected on the basis of a one to one matching (n=36). As India adaptation of the Eysenck Personality Questionnaire (PQ) was administered along with the Rorschach Inkblot Test. The two groups did not differ in any variable on the self-report inventory. But the Rorschach profile indicated neurotic constriction and difficulty. The term Hemophilia is applied to congenital blood coagulation disorder specifically in males, resulting from the genetic deficiencies of specific plasma factors within. Although the necessity of a detailed study of the psychological characteristics of the Hemophiliacs has been pointed out as early as 1949 by chosen and Herman, very few attempts have actually been undertaken. Recently, in connection with worldwide AIDS disaster, the interest in Hemophiliacs has been renewed. The physiological characteristics of Hemophilia render the patients some peculiar psychological effects. (Verhaareh and Conor, 1981). Unless a crippled condition is ensued due to lack of treatment, there are no external symptoms of the handicap. But whenever there is internal bleeding within the muscles and the joints, the patient has to taken bed rest, and often the deficient plasma factor has to be injected. Occasionally, blood transfusion also may be required. The frequency and the severity of the problem depend upon the deficiency level of the blood factor, which may be severe, moderate or mild. During the lucid phases however, the persons are capable of normal functioning and physical exercise. Thus, in the normal phase, the Hemophiliac is spared the stigmatization of the handicapped persons. But he himself and his family as well are under continuous anxiety as to the onset of his next bleeding episode. Keeping the above scenario in mind, the present study intends to investigate the impact of the Hemophiliac condition on the personality profile. As stated before, scanty literature is available in this regard, and whatever is available is laden with contradictions. While, Cohen and Herman (1949), and Poniard (1957) observed some differences in the overall personality profile of the Hemophiliacs, Streinhausen (1976) reported no such difference. One reason of this might be that the studies used different methodologies; the earlier two using clinical and person oriented evaluation approach, while the later study used inventory-based survey.

In order obtain a comprehensive view of the problem the present study employs both the descriptive and the dynamic approaches. Also the study is more of an exploratory nature, and therefore actively looks for sign and trends as well as for statistically substantiated differences. Method: Subjects: The Hemophiliac group: The Hemophiliac patients were identified with the help of the International Hemophiliac Society, Calcutta chapter. The selection criteria were as follows: All of them belonged to the adult age group (20-38 Years, residing in the metropolis of Calcutta and suffering from type A Hemophilia that is, Factor VIII deficiency. They were diagnosed as Hemophiliacs before the age of 2 Years and none of then was diagnosed as Hemophiliacs before the age of 2 Years and none of them was eminently crippled or severely disabled at the time of data collection. On the whole 18 such patients could be identified and all were included in the study. However, the patient group was divergent in thermos of severity level of Factor VIII deficiency (4 severe, 7 moderate and 9 mind), and in terms of a number of demographical variables. The Normal Group: To compensate for the large intra-group variable of the patient sample, one to one matching procedure was taken to select the normal group. 18 matched subjects were selected with comparable age, mother tongue, religion, socioeconomic status, locality, marital status, education, family type and family structure. The normal subjects were screened carefully to ensure that they were from psychiatric problem. Measure Used: 1) A detailed Information Schedule 2) The Socioeconomic Status Scale by Kuppuswami (1970) 3) The Multiphase Questionnaire by Murphy (1965) for screening 4) Personality questionnaire (PQ) by Eysenck and Eysenck (1976) adapted in India Chattopadhyay et al. (1990) to obtain the measure of three basic personality dimensions namely, Psychotics, Neuroticism and Extraversion. 5) The Rorschach Inkblot test: All 10 cards were used, scored and interpreted following Klopfer et al. (1954) system. Klopfer system was preferred over other system, because it’s deeply embedded clinical orientation between blind analysis and other supportive information. Klopfer et al. (1954) also pointed out that his method could reveal deeper conflicts or emotional strains existing within the personality but not manifested in over symptoms. Rorschach in Hemophiliacs 157

158 Bhattacharyya et al After collection of data, the Rorschach protocols were submitted to tower clinical psychologists trained in Klopfer system for blind scoring and analysis. Thereafter, interrater reliability for various measures was calculated which ranged from 0.71 to 0.95. Family inter-rater agreement was sought by mutual discussion between the raters. All the basic scorings plus the quantitative analyses were done. Result: The Kruskal Wallis One way Analysis of Variance by ranks among the patients with three severity levels indicated no significant difference in any of the variable used in this study. This suggested that the personality of the Hemophiliacs is not associated with the severity level of the disease. Henceforth, all 18 patients would be treated tighter as a group. The Means and the Standard Deviation of Psychoticism, Neuroticism and Extraversion scores were ejaculated. The life scale score was not included in the calculation as such., but was used to screen normal subjects for faking tendency. The mean life score for the within normal range. Wilcox on Matches between the hemophiliac and the normal groups in terms of the three personality dimensions and the normal groups in terms of the three personality dimensions were significant. The result are presented in the Table 1 indicated that none of the differences were significant. Table 1 Normal and Hemophiliacs on P.Q. (Wilcox on signed Rank Test) Variables Psychoticism Neuroticism Extraversion Groups M SD M SD M SD Normal 4.06 2.29 9.33 4.85 12.61 13.87 Hemophiliacs 3.56 2.97 9.72 5.50 13.72 3.37 T Values 34.5 39.3 N None of the T value is significant at 0.05 levels. Subsequently the mean percentage of the Rorschach variable wee calculated and the important ratios were computed. The results and presented in Table 2

Table 2 Normal and the Hemophiliacs on the Rorschach Test Variables Groups Normal Hemophiliacs Location in Percentage W 40.66 34.81 D 53.04 56.79 d 3.87 7.12 dd+S 2.10 1.26 Contents in Percentage H 11.55 9.49 A 32.8 35.08 Hd 5.23 4.48 Ad 4.60 5.96 At 9.99 8.43 Blood 1.70 1.19 Object 23.22 22.71 Determinants in Percentage F 45.59 57.06 M 11.65 8.18 FM+m 20.84 14.55 FC+CF+C 13.39 9.45 FC’+C’F 7.666 7.48 K+KF+FK 1.14 1.24 k+kF+Fk 0.62 0.77 c+cF+Fc 1.11 1.27 Reaction Time in Seconds Average 28.04 41.45 Chromatic 29.83 38.22 Achromatic 26.02 44.68 P 4.22 4.78 O 1.91 1.23 Ration VII+IX+X% 288.12 33.96 W : M 8 : 4 7 : 2 M : FM 4 : 2 3 : 1 M : FM+m 4 : 7 3 : 5 F : FK :Fc 9 : 2 13 : 2 Fc+c+C’ : FC+C+CF 4 : 2 3 : 2 FC : CF+C 2 : 2 2 : 2 C 2 : 42 1.92 M : C 4 : 2 3 : 2 H+A : Hd+Ad 10 : 2 9 : 3 H+Hd : A+D 8 : 4 8 : 3 Rorschach in Hemophiliacs 159

Then the Rorschach data was treated in terms of their deviation from the normal proportion of occurrence as suggested by Klopfer and Davidson (1962). That is the sign of pathology indicated from the percentages of each type of response and relationship were used to place the subjects in healthy vs. deviated categories. This was done for both the Hemophiliac and the normal groups, and a 2X2 contingency table was prepared for each response. Then the McNemar Test for change was computed for each. Most of the response percentages did not elicit significant differences between the Hemophiliacs and normal, in terms of relative inclusion in healthy vs. deviated category; but the few that showed such differences were quite significant in implication. These are presented in Table 3. Table 3 Distribution of Normal and Hemophiliacs into Healthy (H) and Deviated (D) Categories (Klopfer) W% F% M% Fc+cF+C M : FM Response H D H D H D H D H D Groups Normal Hemophiliacs MeNemars’s 4.0* 4.92* 3.61** 3.76* 4.0 Test Note : Only significant results are shown. *p<.05 **p<.10 It was observed that the Hemophiliacs had a low W% higher f%, lower movement and color response frequency and a deviated FM:M ration in comparison to normal. Discussion: The obtained results indicated that as far as the self report measures were concerned, the normal and the Hemophiliacs did not differ in any personality dimension. The secure for both the groups were within normal range. The Rorschach profiles yielded a few but quite significant differences. The low occurrences of whole response and high occurrence of form response supported the interpretation of a neurotic predisposition. Klopfer hypothesized that an underemphasize on whole responses with moderately good form level implied a low degree of interest in seeking relationships between the separate facts of experience and achieving an organized view of the world. The hypothesis of neurotic constriction states that although the subject is capable of a more differentiated response, at least intellectually, actually he fails to do so, repressing his acknowledgement of inner needs and denying his emotional reactions. His adjustment rests upon his stripping of the personal and individual components from experience. 160 Bhattacharyya et al

Both the movement and color responses were somewhat less in the Hemophiliacs. The movement response could be interpreted as an indication of bridging inner resources with external reality. That’s where the Hemophiliacs fell short of the normal; their personality rigidity refrains then from mobilizing inner resources meaningful towards the outer world. The paucity of color responses also indicated that the Hemophiliacs find difficult to come our easily to the world, with a free floe of emotion. There was apparently no difference in the shading, but the reaction time to the achromatic cards in the Hemophiliacs was much greater in relation to that of the chromatic cards. The shading responses indicate difficulty in handling need for aggression-often in could be related to the fear of being thwarted in love seeking. The FM or animal movement was excessively low in comparison to human movement or M among the Hemophiliacs. Klopfer interprets this as suppression of impulse life in the interest of conscious value. Thus, in the Hemophiliacs, there is an underlying tension and conflict resulting in excessive control and loss of spontaneity. Thus the overall Rorschach profile yielded considerable indication of personality difficulty. All the indications were consistent in the sense that none demonstrate gross pathology or disorientating; what we find was the appearance of a shall indications conjointly pointing toward an anxious, cornered, impoverished personality – not pathological, but also not free, full and fictional. The hemophiliac status did not grossly disport the reality perception of the afflicted, but degenerated their emotional well - being, and introduced a fear of embracing heartily the vivacious social outside. The questions still remains unanswered i.e. differences were not contained on the PQ scales but only on the Rorschach. Considering all the controversies regarding the efficacy and weakness of self-report vs. projective tests, it could be stated that the selfreport inventory like PQ unravels the consciously experienced and symptomatic manifestations of personality problems. To be captured within the framework of a self-report inventory. The problems must be prominent enough to be recognized by a person of average or even low insight. But the Rorschach is capable of reveling dynamic tendencies which might be some whir below threshold of recognition, yet nevertheless runs its own course. The basic projective hypothesis is viable on this ability to unready less than conscious tendencies. The findings about the psychological status of the Hemophiliacs are in line with their physical status. The hemophiliac patient is outwardly normal, but sick within. Psychologically also they are half way between health and sickness; consciously, they do not feel to be known as psychologically sick. This is in line with steinhausen’s (1976) finding reported earlier. Due to relatively easy availability of the Factor VIII now0a0day, the are even less fearful, but they do not behave as normal and express maladjustment (Poinsard, 1957). Rorschach in Hemophiliacs 161

Indeed this state of affairs has significant therapeutic and social implications Rehabilitating efforts should be directed toward integrating these two aspects and making the Hemophiliacs aware of as well as accepting of their difficulties. In this context, one remembers the labile self-esteem theory of depression. A number of depressives cannot be recognized as vulnerable under ordinary situations. But they are sensitive to environmental loss and break down under stress quicker than other 9Roberts and Monroe, 1992). The Hemophiliacs seem to demonstrate similar conditions. They are fearful and constricted within, but superficial testing does not reveal their vulnerability. References: Chattopandhay, P.K., Baiswas, P.K. Bhattachryya, A.K. and ttoraj, M. (1990) The Eysenck Personality Questionnaire (Q): Psychoticism, Neuroticsm and Extraversion in educated Bengalee adults. Manas, 37 (1-2) 41-44. Cohen, E and Herrman, R.L. (1949) Social adjustment of six patients with Hemophilia. Pediatrics III, 588-596. Eysenck, H.J. and Eysenck, S.B.G. 91976) Psychotics as a dimension of personality. London technique Vol. I, New Yord. World Book. Klopfer, B. and Davidson, H. (1962) The Rorschach Tenique. New York. Harciurt, Brace & World . Kuppuswami, B. (1965) Development of the Paranoid, depressive, manic and anxiety scales. Trans Journal of All India Institute of Mental Health 5,50-59. Poinsard, P. (1957) Psychiatric aspects of Hemophilia in J. Brinkhaus (ed.) Hemophilia and hemophilic discuses. Chapel Hill, Univ. of North Caroloin Press. Roberts, J.E. and Monroe, S.M. (1992) Valnerable self and depressive symptoms: prospective findings comparing three alternative conceptualizations. Journal of Personality & Social Psychology, 2 (5), 804-812. Rorschach, H. (1921) Psycholognostiks. Bern: Bricher. (Trans. Hans, Huber Verlage, 1942). Steinhausen, H.C. (1976) Hemphilia: A Psychological study in chronic disease in juveniles. Journal of Psychosomatic Research. 20 (5), 451-467. Verhaaren, P.R. and Conor, F.P. (1981) Physical Disnilities I J.M. Kauffman and D.P. Hallahan (eds.) Handbook of Special Education. New Jersey. Prentice Hall 248-290. 162 Bhattacharyya et al

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