SIS Journal of Projective Psychology & Mental Health

JOURNAL OF PROJECTIVE PSYCHOLOGY & MENTAL HEALTH The Official Publication of the Somatic Inkblot Society Volume 4 Number 1 January 1997 SIS ISSN 0971 - 6610 Vol. 4, No. 1, Pgs. 1-55 SIS JOURNAL OF PROJECTIVE PSYCHOLOGY & MENTAL HEALTH 1997

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 4, Number 1, Jan 1997 Contents Page Nos. 1. Editorial : S.K. Verma 1-2 2. Therpeutoc Dream Stimulation With the 3-14 Somatic Inkblot Series - Video Wilfred A. Cassell and B.L. Dubey 3. Some Experiences with Somatic Inkblot 15-20 Series-II N.L. Dosajh 4. Diagnostic Utility of Piotrowski’s Alpha Index 21-24 S. Chaudhary and S.G. Jyothi 5. Utility of Projective Tests in the 25-35 Psychological Assessment of Transsexual Patients: A Case Study Approach Jayanti Basu and Sonaili De 6. Sexual And Aggressive Contents in 36-43 Rorschach Card II Ana Herrers, J. Jacobo requiem, Frances Krivoy and Audrey Meza. 7. SIS – II Profile of Drug And alcohol Dependent 44-48 Cases Dependent Cases Amool R. Singh and B.L. Dubey 8. Bosy Image Disturbances In Psychiatric Cases 49-55 D. Pershad, S.k. Verma and Kusum Bhagat

SIS J. Proj. Pst. & Ment Health (1997) 4:1, 1-2 Editorial A Secret Message and a Challenge In the epic “Meghdootam”, the immortal poet Kalidas used clouds as a messenger to convey his feelings of love for humanity – through the usual medium of a love story. (A Yaksha sending his message of love to his beloved). In a way the inkblots can also be considered as a suitable, imaginative and effective means for a heart to heart dialogue between the sufferer (the patient) and the healer (the doctor). The message, in both cases, is written in an invisible ink and in a coded language, to be seen, heard, understood and appreciated by only an open, sensitive, receptive and imaginative mind. Clouds are as unstructured as ambiguous stimulus material as the inkblots. Still in the process of structuring it, a message is conveyed and received. The encoding of this message may be partial in the hands of an untrained less educated mind and improves with practice. The secret message once encoded is no longer a secret. It is shared by others. Hermann Rorschach developed this technique but unfortunately could not see it through due to his early and premature demise. Wilfred A. Cassell is attempting to complete this unfinished task the Somatic Inkblot Series that naturally has a series of versions – the card version, the booklet version and the Video versions. Some of these versions have parallel forms; others are still being developed and standardized. Through the formation of the Somatic Inkblot Society, B.L. Dubey is carrying this torch of light forward and giving it a well-derived momentum, in the true sense of a cavalier. He has taken it upon himself to take up this “Challenge”. This society and the official Journal of the Society are both having their teething problems. It is expected also. It is for us to help see that they succeed in their efforts. A great deal of skill is required in this process of encoding the message conveyed through the inkblots. To some, it may come as natural but for most of us it is an ongoing process of learning. Results are to be both qualitatively and quantitatively treated. Compete dependence on one method alone may not be sufficient for completely understanding and appreciating the full potential of this “messenger:” The process may require some refinements, which may take some time. Initial experiences may be rewarding at time but frustrating at other times – from the point of view of limited goals, but I am sure in the long run, the positive achievements would be far more rewarding and satisfying, while the negative findings would help us setting the limits for them as well as goading us to modify our approach to improve upon the

2 Verma existing methods of scoring and interpreting the results. Let us take up this challenge and share the bliss of decoding this special “message conveyed to us through this medium. S.K. Verma Addl. Prof. of Clin. Psychology Dept. of Psychiatry, Postgraduate Institute of Medical Education and Research, Chandigarh – 160 002. (India)

Wilfred A. Cassell, MD, FAPA, APC Director, Somatic Inkblot Center, E-mail : siscassell@yahoo.com B.L. Dubey, PH.D. DPM, FSIS, Director Somatic Inkblot Center India (INDIA) E-mail : sisdubey@rediffmail.com. SIS J. Proj. Pst. & Ment Health (1997) 4:1, 3-14 Therapeutic Dream Stimulation with the Somatic Inkblot Series - Video Wilfred A. Cassell and B.L. Dubey The Somatic Inkblot Series-II video (SIS-Video) was administered to a 41 years old woman who was suffering from depression. After viewing the SIS-Video she dreamt about an early life sled dog team. At the age of 3 years, she witnessed her 18 months old brother being killed by sled dog her limited verbal skill at the age of 3 years and the emotional unavailability of her parents, who themselves were grief stricken, she could never share this experience with anybody before the administration of this test. This suggests the power of somatic inkblot images not only as a diagnostic tool but also a therapeutic aid and a remarkable time machine. It is generally recognized that when individuals view television programs containing violence, this can have a profound mental effect. One involves the incorporation of violent images in their nighttime dreams. In a similar fashion, the viewing of SIS Video can give rise to threatening images, which stimulate dreams related to previously experienced trauma. A case example follows to show how this had a positive emotionally cathartic effect. In addition, it had important cognitive therapeutic effects since the person relived the trauma through the eyes of an adult and could come to understand, as a result, that the previously held childhood guilt was irrational. The person in question is a 41-yearold woman who was referred by her psychotherapist for anti-depressant medication. She had significant neurovegative symptoms of depression. Since she was relatively stable, she was sent home with the SIS-Video and answer sheet. The instructions were to view the video before going to sleep, then the following morning, to record nighttime dreams in the answer booklet. Her next appointment was scheduled a week later. Remarkably enough, the night after she viewed the video, she reported having a significant dream. She viewed an early life trauma that had been previously totally blocked from her memory. She recounted, at age three while looking out of her window, seeing her 18-month-old brother walking over to a neighbor’s sled dog team. She then witnessed the dogs viciously attack him. Because of her limited verbal skills at this age and emotional unavailability of her parents, who were grief stricken, she never had the opportunity to share this terrible experience with anyone. After viewing the SIS-Video, she, for the first time as an adult, remembered her horror. She experienced the repressed anger, guilt and grief about his tragic death. The dream imagery involved visualizing her brother’s head and facial features in consciousness, with the horribly wounded body obscured in clouds. This information was communicated to her therapist.

When the results of the video were reviewed, she labeled the following three as the “Least Liked”: A30: Was seen as the most threatening image. She saw “an evil skull in a cloud.” This response may be interpreted to directly reflect her dead brother. The fact that his body was not present in the initial dream reflected that the over all wounds were too painful for her to initially accept. It might be noted as time went on with therapy, a more complete image sequence of her brother’s death emerged. She was then able to grieve successfully and with cognitive therapy, correct her childhood erroneous belief of blaming herself. B28: Was seen as the second most threatening image. She saw this as “A ghostspooky.” It may be recalled that this image depicts a mother holding an infant. This was too threatening for her to accept in full conscious awareness. It may have reflected memories of seeing her mother holding her baby brother and childhood feelings experienced from also holding him. B1: This was the third most threatening image. She saw this as “A fist.” She said that this made her feel even angrier. Therapeutic exploration of this took her back to long forgotten angry feelings about his death. In an irrational fashion, she had blamed herself for the terrible tragedy. Frequently, when something tragic happens in a family, children irrationally blame themselves. Dr. C: We appreciate you coming here tonight, and giving our time and a little bit about yourself. We encourage facing the inner pain. We hope this will help others understand some of the processes of grieving and what is required. Do you feel okay? Patient: Yes I do. I feel good about it Dr. C: How did you feel about taking the Somatic Video Procedure? Can you share that? Patient: I feel good about it. I feel open about it. I didn’t know what to expect when I fell asleep last night. I saw my little Jimmy. Dr. C: Yes, yes. Let’s start with some of the images you found most favorable. B17 were the one you found as your favorite. You saw it as “a glowing heart.” Would you care to say more about this? Patient: It struck me as being something with “a lot of warmth and a lot of love”, and it really hit me that way when I saw it, and I really felt good about it. Dr. C: Yes, yes. Do you feel that you are now beginning to feel some grief and freeing up pain and allowing you to love with a lot more energy? Patient: Yes, a lot! Dr. C: Could you please tell us about that? Patient: Well, when I mentioned it before, I talked to you last; it is like I felt a lot of warmth and a lot of love for my husband. He probably feels a little overwhelmed by it all, but he’s handling it very well. He has been real supportive about it all, but as I get rid of the pain and grieve and understand, its just in everyday life you feel a lot of love for people and what’s going on around you, you just feel really good about it. 4 Cassell & Dubey

Therapeutic Dream Stimylation with the SIS-Video 5 Dr. C: Before you did not feel you had the energy to love the way as you do now since you’ve been in treatment? Patient: Not at all. Dr. C: And B31. Can you tell us what you see there and what it brings to mind? Patient: A family. It’s like togetherness. And I just see a lot of happiness and a lot of love there. It just struck me at that instant it just came to mind. Dr. C: What was your family like when you were a little girl and all, before the terrible loss of your brother? Patient: We had a lot of fun, from sledding to floating down rivers and looking at little baby ducks, everything you could possibly imagine, we did as a group, and it was really, really enjoyable. And after my little bother passed away, I sort of became my dad’s little girl. My sister became my mom’s little girl. And we kind of did things separate then. Dr. C: Do you wish, or did you ever wish while you were growing up for that nostalgic time that your family was complete and all? Patient: Yeah. Yes I did, and um —, I really, um —I really did want that. And I think I really felt it when I was showing horse and I did it on my own, where they wouldn’t come to shows to watch me. And I wish they had been there as a group. Dr. C: Yes, yes. There was one more image that I wanted you to look at. It is B29. What so you see there, please? Patient: Oh, a person jogging, that’s just, um — that’s just how it struck me right away anyway. It almost looks like the person has a smile on his face. And that they’re real happy about it. Dr. C: And what does that bring to mind? Patient: Um —, good health. Happiness. And probably getting out and doing something. Dr. C: So that we know that fun in Alaska and exercise is a part of the treatment of depression. Patient: Yes that is exactly correct. Dr. C: Now, the images that really bothered you. You mentioned that A30 were highly threatening for you. Could you please tell us what you saw in A30? Patient: In A30, to me, it was just a real, real evil skull in a cloud. And it represented death or the devil, and I didn’t like it at all. And it is something that we probably have to face. Dr. C: And when we talked about this earlier, you told me some other things that were brought to mind, the devil and the pain. Patient: With the experience I had been through before. Dr. C: Yes, could you tell us about that please?

6 Cassell & Dubey Patient: I had a friend who had died during childbirth, who was my closest friend. After she passed away, I felt like a separate entity was trying to take me over and where I lived and I went through a real battle in fighting this bad entity off and that I finally won. Dr. C: What was her name? Patient: Molly. Dr. C: What was she like? Patient: She was a real kind hearted and gentleperson. A very loving person. We were born three months apart and grew up together. Dr. C: So you were probably real close. Patient: Probably closer to her than my own sister. We moved in together when we were single, after high school. We were always together. Almost - a real bond between us. Dr. C: And what happened? Patient: She got something like a hemorrhage, I believe. Her blood pressure shot up real high and she started bleeding in the head and they couldn’t stop the bleeding and she passed away. Dr. C: Do you remember how you felt when you first heard about it? Patient: Um, devastated. When I first heard the news, it was like took an inflated balloon and filled it with air and someone took out all the air at once. It was terrible-just a horrible feeling. Then I could also remember laying in bed that night and thinking of Molly and at the same time I was crying and crying about her and all of a sudden my tears stopped and I really, really felt that God was there holding and comforting me for a while. And I never felt such peace or comfort in my whole life. It was wonderful. Dr. C: Did you have images of her in your dreams for a while during that period of time? Patient: A long time. Dr. C: What were they like? Patient: She would come to me and she was still on the pregnant side and she would say, “I’m okay! Not to worry, but I’m fine.” She did that several times. Dr. C: And how did you feel when you saw her in your dreams, were you sharing…? Patient: Happy that I saw her. But her death affected me so much that for years afterwards if I was driving down the road and I thought about Molly, tears would come to my eyes. But it wasn’t until when Maureen (her psychotherapist) had me write a goodbye letter to her I as able to… I felt then may be I could let go of her. Dr. C: So when you were in therapy with Maureen and wrote this, what were some of the feelings you wrote in the letter?

Therapeutic Dream Stimylation with the SIS-Video 7 Patient: I remembered all the fun times we had together, and how close we were together, and how we enjoyed and that I knew it was time for me to let go off her, but I would always love her. Dr. C: Did that affect your own feelings about pregnancy or having babies? Patient: Yes it did. At that time I didn’t understand it, but it made…having a tubular (where you have the tubes tied). I had that done and I thought I was having some problems — birth control pills that I’ve been on for quite a few years and the doctor thought I was having problems with them. So we decided to do this. But later, since I had it done about four months after she passed away and I had surgery to have the reversal done. And it wasn’t until this year that I actually realized that probably the real reason was because of Molly’s death. Dr. C: Can you share the real reason? Patient: Probably the fear of maybe because of Molly died in childbirth and that it was so sudden — maybe, — maybe it was my own fear of it happening to me or maybe it was — maybe because I didn’t think it was fair that she should die during childbirth. Dr. C: And you’ve been trying to have children since then? Patient: Yes. Dr. C: And what’s your emotional reaction, still not successful? Patient: I’ve decided, naturally, both my husband and I talked about it, and we have come to terms with that, should it happen, that if we were blessed with it, it was meant to be. Because as far being checked, everything is in working order. Dr. C: You should realize that as you process grief and so on, that it is not just a central thing, but that it could affect the reproductive functioning, that you might be more receptive now, and you might connect, who knows. It’s a wonderful thought because I think you would make a great mom! Patient: Yeah. Dr. C: The second image that you found quite frightening was B28. Would you tell us what you see there, please? Patient: A ghost. And it struck me as not being as being good. It struck me as being more on the bad side. Dr. C: Think of this ghost, what bad things of this ghost? Sherry: I think of Jimmy’s death and I think of Molly’s death. Dr. C: And what emotions are evoked? Patient: Depression, everything being more on the gray side. Dr. C: And the image B1, you rated as the third most threatening image. What do you see this as? Patient: Um — which one? Oh, anger. And I think I felt angry at Jimmy for leaving us like that. And maybe — and may be blaming myself.

8 Cassell & Dubey Dr. C: What sense of anger did you have as a little girl for Jimmy — for his leaving you - at wandering over to the dogs, and getting killed and all? Patient: I couldn’t understand why they had attacked him. I could never understand that. Dr. C: Could you tell us what you remember that day when you were three years old? Patient: I remember my mother finding Jimmy and he was still alive and she picked him up and put him in the car. And I went to the driver’s side of the door and I asked if I could go. She said “No!” She was frantic — I mean she was absolutely frantic! But I couldn’t — I couldn’t tell you what I saw on the seat. Even though Jimmy was lying there on the seat I couldn’t tell you what I saw. Dr. C: So that — you always blocked out those horrible images? Patient: Yeah. Yes, that’s for sure. And I definitely… but after my dream last night and actually seeing Jimmy with blonde hair and blue eyes — and actually seeing him, I feel relieved — real relieved about it. Dr. C: Perhaps you could tell us about the dream at this point? Patient: Well, I dreamt that, my dream started off with men and women in a kind of army/military type situation and then I, um, dreamed of a scalpel (which Jimmy did have surgery on him before he passed away — before he died they did perform surgery on him). And then it was kind of cloudy and foggy and then the clouds parted, and there was Jimmy and he was lying on his stomach. I wouldn’t say he was smiling, but he wasn’t sad. He just looked content. And he was just looking at me, and I felt very frightened if what I saw, I didn’t expect that to happen. It woke me up and I can remember looking at the clock and it was 2:05 A.M. and I was really, really startled by it. Um. Dr. C: What frightened you about this imagery in your dream? Patient: Because I actually saw him. It was seeing Jimmy. And maybe because I didn’t see beyond the head and shoulders, I didn’t see the rest of the body. Dr. C: And why do you suppose that was terrifying? Patient: Because that is the part of the body that was injured. I think that was what it was. I think that was why I probably woke myself up. Dr. C: Because you didn’t want to see the horror, which you saw as a little girl, and this represses that. Patient: Right, exactly. Dr. C: What were your emotions that followed then last night? Patient: I got up and I went to bed. And I felt really… I cried for a little bit, but I didn’t cry hard, but I did cry for a while about it and thinking about seeing Jimmy. And I felt the best thing for me to do is I sat down and I prayed to God. And I asked God, what do you want me to see or what do you want me to feel? I will leave it in your hands and then I will see it. And I left it up to Him. I then went back to sleep and I had two dreams after that. One was of a floatplane taking off a lake, but the floats fell off the plane and it was so it was no big deal to anybody and the other one was of … (interrupted).

Therapeutic Dream Stimylation with the SIS-Video 9 Dr. C: Um, can we talk about that one for a moment? What does that bring to mind, that the floats fell off? Patient: It brought back that the plane could not land; it could not land again when the floats fell off. Dr. C: What does that make you think of? Patient: That it could not come back to Earth. Dr. C: And what does that bring to mind? Patient: Jimmy. Dr. C: In what ways? Patient: That he cannot come back to Earth! That he is gone forever. Dr. C: That is in the physical way, but not in the spiritual way — um, what is your feeling? Patient: Um, that it is God’s way of telling me that he was probably fine. Dr. C: Do you feel that you will see him again? Patient: Yes I do. Dr. C: Could you share that thought? Patient: I really do feel that I will see Jimmy again, and my friend Molly. Dr. C: That is a very comforting thought, isn’t it? Patient: Yes. Dr. C: And there was a third dream? Patient: There was a little choo choo train with an old steam engine that came flying through the air over the lake after the plane. And — and it was a bright gold train, a little choo choo train, with a green trim. And I was looking, and nobody thought it was a big deal. It was okay that it was flying through the air. Dr. C: How did you feel when this train came zippin’ through the air? Patient: It was kind of funny. I thought it must not be a big deal if no one else thought it was a big deal, but it was just okay. Dr. C: Trains are neat. What do you think your dream is trying to do with this third dream? Patient: That again — that it was okay, and, um, no matter how odd something is, sometimes it is all right, or the circumstances — that we just have to realize that. So, it is hard. Dr. C: Yes, it is hard. Yes, it is hard. It has a wonderful that you are getting in touch with some of these feelings and freeing yourself up for love now. That it would be even more of a wonderful miracle if you and your husband could connect with a baby. Patient: Yes.

10 Cassell & Dubey Dr. C: I was wondering if we take a few moments now and go through the whole series of images. I do not want to tire you out, but if you could just look at each image and tell us what you see, starting with image A1 and go right through it, please. Patient: A1 hit me as two bunny rabbits. And they look like happy bunny rabbits. Dr. C: And does that bring anything to mind? Patient: Um — other than that we had little rabbits when I was growing up. We usually had rabbits running and they were just pets. And I really enjoyed them. Dr. C: So this goes back to a happy childhood theme. Patient: Yeah, oh yeah. Dr. C: Okay, A2. Patient: Is a squirrel with a tail which… when I looked at this image on paper it looked a little different than it did on film. It reminded me of a squirrel; then again, there were lots of squirrels running around. And there used to be lots of them and they were fun to watch. A3: Flowers floating on a pond. That reminded me of a lot of Lily pads and stuff floating around on the pond. I always thought that they were really pretty and I enjoyed them. Dr. C: Yes, Alaska is really beautiful. Patient: Oh yeah. And image A4. It was a person on the left with his hands up and on the right it looked like a bus: part of a bus. And, — um, I’m not sure why I saw that, but it was what came to mind when I saw this particular image. A5: I thought it was kind of comical. It was kind of cute. It had a Moose’s head at the top, a heart in the middle, and a person’s body at the bottom. And I thought that was some kind of comical thing. A6: Was a pumpkin that had two legs and a little teddy bear I saw — just sitting there. A7: Looked like a tomato and then a dancing person. Dr. C: And the sex of the person? Patient: Ah, I never really thought of it. I would have to say a boy! Dr. C: Okay. A9: Two people. To me it looked like they were dancing a square dance and then, when you look at it again it could be two duck heads. Dr. C: It’s interesting how we see images, isn’t it? Patient: Yes it is. A10: Reminded me of, when I first looked at it, like parts of two pansies of the flower petals. A11: I couldn’t come up with anything. Nothing came to my mind at all.

Therapeutic Dream Stimylation with the SIS-Video 11 A12: Clowns face with a hat on. And to me, the face was in the middle with the hat coming over the top. A13: A hand and then with people around it. It looked like little people to me — here. And there were people around the hand. A14: Was smoke coming out of a hole, is what it reminded me of. A15: Was a pelican in a dive. It looked like a pelican doing a dive. A16: Were two birds kissing. A17: Was a heart inside a rib cage, is what it looked like to me. Or it looked like it could be two horses’ heads and a heart. A18: Was a heart with a bunny rabbit and it looked like the back of a bunny rabbit with his ears up. A19: Was an intestine, is what it looked like. A20: Looked like two kidneys. A21: Looked like a bird. Because the colors in the picture it brought forms to, it looked like two little pigs with a bird. It was kind of cute. A22: That just hit me as a lobster because of the shape of it. A23: Was a candlestick holder. A24: That reminded me of people in the forest — probably because of the darkness of the image. A25: Was a mask. A26: Reminded me of a womb, of a baby in a womb. Dr. C: How do you feel seeing a baby in the womb? Patient: I felt good and I felt a little sad. Dr. C: What’s the good part? Patient: Birth. Um - something new happening inside a person. Dr. C: And the sad part? Patient: Is that I do not have one. Dr. C: Yet. Patient: Yet (laughs - anticipation, hope). A27: Reminded me of a little yellow chicken in the film. I’m not sure how I came up with that after looking at it here (laughs). A28: Reminded me of a person’s torso. A29: Looked like a volcano eruption to me. Dr. C: Well, we did have a volcano eruption going off here recently (laughs). Patient: Yeah, we sure did.

12 Cassell & Dubey Dr. C: Did that depress you? Patient: Yeah it did. Dr. C: What was your reaction to it? Patient: I was wondering if it was going to go really hard this time. You probably remembered when it erupted, in probably the fifties. And we were covered with dust and we had to stay in our houses. Dr. C: Gets your attention quick, doesn’t it? Patient: Yes, real quick (smiling). A30: Was a “Skull. An evil skull in a cloud.” I just didn’t feel good about this picture at all. Dr. C: Yes, we talked about that. A31: Was “two people faces with their brains –“ because in the film it looked to me like their face and brain were bright colors in the film. B1: Was a “fist” we talked about. B2: I could not come up with anything on that at all. B3: Reminded me of a “cow’s skull—” of the old skull as you would see in the desert. B4: “A side view and front view of a face—kind of together.” B5: Was “two people sitting down and they looked like they were throwing bottles between each other.” Which to me was that they were having fun? Dr. C: You’re going to have more fun as you process this grief. Patient: Oh yeah, a lot more fun (smiles). Dr. C: Yes. B6: Reminded me of a “flower or a sea anemone”, which I think were real pretty floating around. B7: “A sting ray fish.” That could be because when I was in Florida I got to pet one as it swam by (laughs). B8: Reminded me of a marble in the film and here it looks like part of a person’s face or nose. B9: It looked like two kidneys with a hand holding them at the top. B10: Reminded me of an owl. B11: Looked like flags waving in the wind. B12: Was a tree. B13: I could not come up with anything on that one at all. B14: It looked a face in a bottle, and it was very faint. B15: Was a child’s finger-painting?

Therapeutic Dream Stimylation with the SIS-Video 13 Dr. C: The face in the bottle, does that bring anything to mind? Patient: It was like something was trying to appear, but it was not quite clear. Which would bring to mind the image of Jimmy, but not quite clear? Dr. C: Yes, previously viewing the SIS, did you have many dreams about him? Patient: No, not that I could remember. B16 reminded me of an African with a mask on. B17: Which was my favorite, was the glowing heart? B18: Was the back of a person. Looked like a person just standing there. B19: A starfish with a couple of hearts in it, or a jellyfish. B20: A half moon with a cloud. B21: Reminded me of Mr. Potato Head, which was the game we used to play when we were kids (laughs). And you got to detach all the parts. Dr. C: It sounds like you had a lot of fun when you were a little girl. Patient: Oh yes, we did. B22: Reminded me of a person lying down with bubbles coming out of him. Dr. C: We had talked about that one a little bit ago. Would you like to expand on that image a little more? Patient: Yes, that one was like the life leaving a person I think. It’s… Dr. C: What does that bring to mind? Patient: Yes, of Jimmy dying is what it brings to mind. Dr. C: How does that make you feel when you think of that? Patient: Sad, very sad about it. Dr. C: It sounds like you had a good cry last night? Patient: I did (laughs). Dr. C: It helps, doesn’t it? Patient: I felt really relieved. Its — I don’t know, its funny how you feel healed, or start to heal. B23: That reminded me of ribs, of people’s ribs. B24: I couldn’t come up with anything on that. B25: Looked like hands holding a Christmas ornament. B26: Was like a shirt and a pair of pants. B27: Was two people dancing. B28: Was the Ghost. B29: Was a person jogging. B30: Looked like two people’s ears.

B31: The last one was a family, which… that imagery hit me really strong. Dr. C: What was the emotion? Patient: Togetherness and happiness. Dr. C: Yes. Patient: Yes, very, very much so. Dr. C: Thank you. Patient: (Smiles). Conclusion: It can be concluded that the SIS-Video took the patient back in time and stimulated her through dreams of her 18 months old brother being killed by a sled dog team. Processing her grief and anger helped her. SIS-Video has been found to be a powerful test helping in hearing the inner cry of the patient and relieving trauma. References: Cassel, W. A. (1990) Manual of Somatic Inkblot Series, SIS Center, Anchorage, Alaska 99508.

Some Experiences with Somatic Inkblot Series-II N.L. Dosajh During the author’s experience of about 50 years as a Clinical Psychologist, he used projective tests like Rorschach (RR), Holtzman Test (HH). Thematic Apperception Test (TAT), Dosajh Test (D) for psycho diagnosis. Recently he has started using Somatic Inkblot Series II (SIS-I) because he finds it more convenient, easier to administer and easier to interpret than other projective test. It elicits more projective material with a number of somatic responses. All this has been illustrated by taking a concrete case of an early schizophrenia. During the author’s practice of about 50 years as a clinical psychologist, for the psycho diagnosis of this patient, he was mostly making use of Rorschach Test (RR), Holtzman Test (HH), TAT and D projective test but recently SIS-II. The RR (1942), HH (1950), TAT (1943), and D (1992) test were quite cumbersome to work with. During the author’s younger days it was all right. He enjoyed putting labor to work with these tests. Now during his old age, when he cannot devote much time to testing, he mainly depends upon SIS-II (1990), since he finds it very convenient to work with. He just explains to his patients as to what they are expected to do and then leaves them to their own till they have finished the test. After interviewing the patients on their responses, he interprets watch responses for psycho diagnosis of the patients. Lastly he holds the therapy sessions. The somatic elements appear excellently well if the patients fall in the category of schematic aliments. The patients clearly projects on the images according to his somatic trouble. In case of an ailment like peptic ulcer, he mostly projects himself on images like 14A, 15B, and 12B. In case of a kidney trouble, he generally projects himself on images like 16A, 20A. In case of repressed aggression, he projects himself on images like 15B and 21B. In case of sex repression he rejects images like 6A, 7A, 9A, 17A, 18A, 19A, 21A, 22A, 23A, 25A, 12B, 13B, 17B, 18B, 19B, 25B, 26B. The elements of projection are more in SIS than in any other projective test. SIS images are very good at evoking repressed material. It is also because f the nature of images, which touch upon practically all aspects of personality structure disorders. To illustrate the above points of SIS, the author gives below the protocol on SIS-II of a case. The patient is a girl of age 14 years who has been showing early schizophrenic symptoms for the last about five years. Her performance in studies was going down from day to day. She was feeling depressed, showing depersonalization sometimes and altered consciousness also. She showed feelings of detachment from reality sometimes. Occasionally she would have pain in the stomach for about half an hour and after that she would go to sleep. She was mostly introversive and would talk to others far less than the girls of her age. She would show fits of anger and would brood very often. When she reported for treatment to the author her I.Q. was 110, but after the treatment lasting for about one month her I.Q. rose to 128. She was administered SIS- II to understand her psychopathology. Professor N.L. Dosajh Ph.D., 1121, Sector 15B, Chandigarh – 160 015 SIS J. Proj. Pst. & Ment Health (1997) 4:1, 15-20

Her performance on SIS-II Image 1A: Looks as if two similar dogs are standing and talking to each other. (Image stimulates pure projection of being together – a goods response.) Image 2A: A dog is sitting very sad as scared by some one. (Here she projects her feeling of sadness. It also suggests her helplessness with the situation and at the same time keeping herself away withdrawn). Image 3A: A person’s eyes show that he is tense of some pressure and is sad. (Once again the projection of sad feelings brought back. Emphasis on eyes may be indicative of her suspicious attitude.) Image 4A: On shoe is hanged and the other is a butterfly. (O.K. response). Image 5A: Middle part looks like a heart and end part looks as if some person is dancing without head. (Though ego strength is maintained but seeing headless person dancing may be hostility towards authority figure (father) and wishful thinking to see him powerless, as he is not able to protect the child from mother’s agony.) Image 6A: A mice is sitting and his eyes are closed as a spirit scares him. (Paranoid tendency is brought back and she feels threatened, scared) Image 7A: Upper part looks like an apple and lower part as a lady dancing. (Good response, suggests her ego strength and conformity of thinking with the group.) Image 8A: Looks like as if a man is trying to climb a tree. (It is a good response and suggests her efforts to manage the situation in her favor). Image 9A: Looks as if two ladies are talking to each other. (Ego strength is maintained). Image 10A: Somebody is seeing someone from a broken door to scare someone. (Once again paranoid tendency has come on the surface and scary feeling has become obvious.) Image 11A: Looks like an eye from the side face of woman and her hair. (Often eye responses suggest paranoid tendency.) Image 12A: It looks like ear of a human being. (It is good response with which strength still maintained.) Image 13A: Looks as if hands are coming 0ut from the frame of a photograph. (Tendency to flee away from her surroundings may be the reason to see such a response.) Image 14A: Looks like only one kidney of a human being. (She is aware of her body concept. It is a good response.) 16 Dosajh

Image 15A: It looks as if somebody is tied with a rope. (It suggests her inner cry and feeling of being kept as a slave in her own house. This may also suggest her uncomfortable home situation perceived by her.). Image 16A: Two birds are sitting and talking to each other. (God responses with good ego strength) Image 17A: It looks like lungs and the heart between it in human body. (Good responses with awareness of her healthy body concept.) Image 18A: It looks the face of a lion that is angry. (The may reflect her difficult relationship with father/father figure. Father or teacher can be instrumental in such difficult relationship). Image 19A: It looks like an ice-cream glass. (OK responses.) Image 20A: Looks as two kidneys of a human body. (Good response, suggests that her thinking is in conformity with the group.) Image 21A: Looks as if a bird is flying in the air. (She has avoided seeing small babies on either side of the big birds – suggests her feelings of separation from her parents – may be mother.) Image 22A: Upper part looks like hand of crab and lower parts like a heart. (OK response) Image 23A: Looks like a stylish leg of a table. (Avoids seeing spinal column, indicates her injury on leg, which caused discomfort and pain in her backbone region.) Image 24A: Looks as if a mother and her baby are wrapped in a blanket. (This may suggest her desire to be in close contact with her mother again as in the past. Her history suggests she feels separated emotionally from her mother.) Image 25A: Looks like frame of a photograph, which is empty, but eyes of cat are seen. (Once again paranoid tendency has come on the surface). Image 26A: Face of a small baby crying bitterly. (Inner cry is brought back and she has regressed to be a small baby to get attention of her mother.) Image 27A: Looks like a deer that is lying down. (Avoiding seeing breast again suggests her hostility towards her mother.) Image 28A: A hand of a person. (OK response.) Image 29A: It just looks like a mountain and a lot of fog is there. (Depressive content is brought back by this image.) Image 30A: Looks like a face of a skeleton. (OK response) SIS-II 17

Image 31A: Looks as if a girl is told something by her friend which frightens her. (Avoiding seeing parents on this image, suggests her poor interpersonal relationship with parents and even between both parents.) Image 1B: It looks like a fire burring. (It shows her hostility and aggression. She is probably unable to chanalize her aggression in more socially acceptable way.) Image 2B: It looks like a ghost who is trying to scare or kill someone. (Depressive feeling is brought back and she feels threatened. It may also suggest paranoid features of killing or being killed by someone.) Image 3B: Looks like the heart or inner part of the butterfly. (OK response). Image 4B: A boy who feels that a ghost is telling something in his ears. (Suggests her suspicious attitude and paranoid tendency.) Image 5B: As if two persons are talking and sharing their thoughts to each other. (Good response. It also suggests her desire to be together and share views with others.) Image 6B: It looks like the face of a wicked and scary cat. (Hostility and feeling of getting scared is brought back again.) Image 7B: Looks like a coat, which is hanged. (OK response) Image 8B: Shadow of a person’s shoes. (OK responses) Image 9B: Two inverted kidneys. (Good response with healthy body imagery) Image 10B: Looks as if ghost having head, ears etc are talking. (Hostility is brought back. Many such responses may lead to paranoid symptoms) Image 11B: It looks like a butterfly. (A good response) Image 12B: The dead body of an eaten animal. (Such pathological anatomy response may indicate her poor self-concept, insecurity and helplessness.) Image 13B: Looks like a lamp in the dark. (Still her ego strength is maintained and she wants to become all right once again.) Image 14B: It has a shape of an apple or heart (Good response Heart may be indicative of feeling of pleasure in life again.) Image 15 B: It looks like an area where tools are kept to clean the grass. (OK response) Image 16B: It looks like trachea, a pipe in our body. (OK response) Image 17B: It looks like a heart. (Good response. It suggests her ego strength and desire to be all right once again). 18 Dosajh

Image 18B: It looks like a lizard’s shadow. (This image generally brings lot of sexual connotation but keeping the culture of the patient in view; lizard may serve as a sexual symbol and does not suggest pathology in sex area.) Image 19B: A sun, which is having, cracks in it. (Once again depressive contents are brought on the surface. She has avoided seeing hart n either side suggesting her emotional problems with two hearts may be of parents.) Image 20B: Brains inner part (OK responses.) Image 21 B: It looks like a fallen flowerpot. (Feeling of helplessness is reflected again.) Image 22 B: A dead man and his spirit is going from the body. (This suggests depressive content, to some extent hostility and wishful thinking of seeing herself dead or someone else in her surroundings.) Image 23 B: Lungs of a human being. (OK response.) Image 24B: Kidney upturned of a child. (OK response) Image 25B: Looks like a flower pot whose leaves are dead. (It suggests depressive content and feelings as nothing are left in life, everything is dried like leaves.) Image 26B: It looks like a man standing. (It suggests her positive attitude towards life and desired to be all right again.) Image 27B: It looks like and ear and other a standing lizard. (OK response.) Image 28 B: A woman sitting who is sad thinking. (She has avoided seeing child with mother. Once again her confect with mother has come-on the surface.) Image 29 B: A man running. (Normal response.) Image 30 B: It looks like two ears. (A good response) Image 31 B: A family of two children, one father and a mother. Her projection of seeing a healthy family is still intact. She wanted to see a happy family. It further suggests her positive attitude towards life and such patients generally show good prognosis after psychotherapy. She has selected images 28B, 6A and 10 A, which she liked the least. Image 28B depicts her poor relationship with mother and images 6A and 10 A bring out her insecurity and fear on the surface. These images can be more helpful particularly at the time of therapeutic intervention. The three images, which she has liked, the most do not bring out any specific clues for psychotherapeutic work. SIS-II 19

20 Dosajh Conclusion: Somatic Inkblot – II images brought the patient’s inner cry at the surface, feelings of helplessness, need to get more affection from others, disturbed relationship with mother, passive father figure, depressive contents and suicidal thoughts, hostile attitude and feelings of separation. In spite of such a profile she has ego strength and optimistic attitude towards future. She was given supportive family therapy for about a month, which helped her tremendously. She has improved a lot and become symptom free. Her I.Q. has gone up by 18 points. The prognosis of the case looks good. She is likely to improve shortly. The case confirms the efficacy of the Inkblot Series in relieving pains and sufferings through Somatic Inkblot Images. References: Cassel, Wilfred A (1990) Manual of Somatic Inkblot Series, 4045 Lake Otis, Suite 101 Anchorage Alaska 99508. Dosajh, N.L. (1992), “D” (Dosajh) Test (Projective Test), Mahavir International, 1025, Sector 15-B, Chandigarh – 160 015. Hellerg Elizabeth (1950); The Individual’s Relation to Reality in our Culture, and Experimental Approach by Means of the Horn Hellenberg Test, Springfield, III, C.C. Thomas. Henery A, Murry (1943); Thematic Apperception Test Manual, Harvard University Press, Cambridge, Massachusetts Technique, World Book Company, Yonkers – on Hudson, New York. (The author is very thankful to Dr. B.L. Dubey, who assisted him in interpreting the SIS-II protocol.

Diagnostic Utility of Piotrowski’s Alpha Index Suprakash Chaudhary and S.G. Jyothi The Rorschach test by Klopfer’s method was administered to 100 consecutive Schizophrenic patients and 100 consecutive neurotic patients. The records of 54 Schizophrenics and 41 neurotics fulfilled the two requirements for application of Piotrowaski’s Alpha Index. The Alpha index correctly classified 46 Schizophrenics and 29 neurotics. The Alpha index had a sensitivity of 85.2% and a specificity of 70.7%, which compares favorably with other diagnostic tests in clinical medicine. In clinical practice one often faces the diagnostic dilemma of differentiating quickly and reliably an early psychotic from a patient with neurosis or less severe psychopathology due to overlapping symptoms. Psychological tests like Rorschach test are often utilized to resolve such diagnostic problems. However, even the Rorschach has its limitations as many early schizophrenia patients may not display variability, give bizarre responses or contamination, and make no unpredictable shifts in quality or trend of responses. The Alpha index (Piotrowski and Lewis, 1950, Piotrowski and Berg, 1955) was designed to combat such situations. The Alpha index was intended to identify early mild, incipient, and pseudoneurotic forms of schizophrenia in cases where clinical expression of the pathology was masked and indefinite. The index is based on the Rorschach indices of energy capacity and energy control, and it attempts to identify a disproportionate between these two variables. The Alpha pattern, when it emerges is presumed to reflect over control, under activity and under productivity. In view of the paucity of work utilizing the Alpha index, especially in India, the present study was undertaken to evaluate the diagnostic utility of Piotrowski’s Alpha index. Table 1 Piotrowski’s Alpha Score Weights Weighted W Sum-C Sum c-Sum C’ shock F+% Less than Score 3.5-4 0.5 2.5-3 3-4 1-1.5 1.5-2 Present Present 2-2.5 0-1 -1 3-4 -2 Suprakash Ch audhary, M.D., Ph.D. Psychiartist and S.G. Jyothi Nurse (Psychiatry), Miltary Hospital, Meerut 0 250 001 (Indai) SIS J. Proj. Pst. & Ment Health (1997) 4:1, 21-24

Material and Method: One hundred consecutive male inpatients with schizophrenia and an equal number of age and sex matched patients with neurosis (anxiety disorder, somatoform disorders, dysthymic disorder & depression disorder NOS) were included in the study with their consent. Psychiatric diagnosis was made as per DSM III R criteria (APA 1987). All subjects were of at least average intelligence on clinical examination (No formal intelligence testing was performed). All subjects were free from physical illness. The Rorschach test was administered individually to the patients and scored by Klopfer’s method (Klopfer et al. 1962). The Alpha index (Piotrowski & Lewis 1950; Piotrowski & Berg 1955) taken into account the number of W response given by the subject, the Sum C (scored in the usual way), Sum c (scored similarly to Sum C with 1.5 assigned to each c response, 1.0.for each Fc response and 0.5for each subordinate c response viz Fc, cF and c), the dark shock and the F+%. In order to arrive at the Alpha score weights are assigned to the various levels of W, Sum C, Sum c, minus Sum C, dark shock and F+% less than 70 which are given in table 1 (Piotrowski and Berg, 1955). The Alpha index is scored only when W is less than 7 and Sum c is more than or equal to Sum C. When these two conditions do not prevail the Alpha index is not applicable. It is intended for use only with subjects 16 years of age or older. In addition, the patient must be of average or above average intelligence, if the formula is to be useful, because it tends to give results of varying validity when used with people of differing intelligence. However, as the number of W responses, F+% and light shading responses on one hand and intellectual capacity on the other are correlated, it is doubtful whether individuals with less than average intelligence would produce many records that may fulfill the first two conditions (Prabhu, 1970). A score of three or more on the Alpha Index is taken as an indication that the subject is more severely disturbed than merely neurotic condition. The score went through the individual Rorschach protocols of both the groups and marked the presence or absence of each sign and recorded the total weighted score in each protocol. Statistical comparisons were performed using the Chi-square test. Results: The Rorschach records of 95 patients (54 Schizophrenia patients and 41 Neurosis patients) fulfilled the two requirements essential for application o the alpha formula. These patients were classified as Schizophrenia and Neurosis based on their Alpha score alone. The patients were followed up over a period of time ranging from 4 months to 2 years by which time a final diagnosis was arrived at. Table 2 shows the final clinical diagnose of the patients and the classification based on the Alpha index. It is obvious from table 2 that out of the 54 patients finally diagnosed as schizophrenia, 46 (85.2%) were correctly classified by the Alpha Index while out of the 41 neurosis 22 Chaudhury & Jyothi

patients, 29 (70.7% were correctly classified. Thus out of the 95 patients, 75 (79%) were correctly classified by the Alpha Index while the remaining 20 (21%) were wrongly classified. On applying the chi-square test the results were significant at 0.01 level (Chi-square = 30.6; df =1; p<0.01). In the present study the Alpha Index had a sensitivity of 85.2% a specificity of 70.7% and an overall positive predictive power of 79.3 percent. Table 2 Alpha Scores of Schizophrenia ns Neurotic Patients Final N Alpha Score Alpha Score Less Diagnosis 3 or more than 3 Schizophrenia 46 (85.2%) 8 (14.8%) Neurosis 12 (29.3%) 29 (70.7%) Total 58 (61.1%) 37 (38.9%) Discussion: In the present study the Alpha Index was shown to be a useful screening device as it differentiated the schizophrenia patients from the neurosis patients with a good degree of dependability. The results of our studies are in agreement with three earlier studies which have compared the incidence of the Alpha Index in schizophrenia and control groups (Piotrowski and Lewis (1950) reported that the Alpha Index successfully identified 28 of 30 schizophrenia patients and 19 of 20 neurosis patients. The Alpha Index in this study had a sensitivity of 93.3, specificity of 95% and a positive predictive power of 96.6 percent. In a follow up study, Piotrowski and Berg (1955) studied 100 schizophrenics and 45neurtocs. Of the patients meeting the criteria of the Alpha Index he found that 46 of 55 schizophrenics and 12 of the 15 neurotics were correctly diagnosed. Thus the Alpha Index had a lower sensitivity of 83.6% specificity of 80% and a positive predictive power of 93.9%. Prabhu (1970) reported that the Alpha Index correctly classified 49 of 58 schizophrenia patients and 30 of 42 neurosis patients, given the Alpha Index a sensitivity of 84.5%, specificity of 71.4% and positive predictive power of 80.3 percent. Mental health professional often wonder how the projective tests compare with diagnostic procedures or tests in other branches of medicine. The utility of a diagnostic test can be compared using the concepts of sensitivity and specificity. If the total of sensitivity and specificity is 100 this is a chance result and the test is virtually worthless, while if the sum is 200 the test is perfect. No available test is perfect. However, combing the data from the three earlier studies and the present study we find that the Alpha Index has a combined sensitivity of 85.8%. It is quite obvious from table 3 that the Alpha Index performs very satisfactorily compared to some established test in clinical medicine and psychiatry. Diagnostic Utility of Piotrowski's Alpha Index 23

Table 3 Sensitivity and Specificity of Various Diagnostic Test (Adapted from Galen, 1982) Tests Sensitivity Specificity Total Physical exam for Hepatomegaly Blood alcohol level for alcohol Liver disease Clinical exam and Dexamethasone Suppression test for major Depressive Disorder Clinical exam and Alpha Index for 85.8 76.3 162.1 Schizophrenia CPK, SGOT & LDH for myocardial Infraction in cardiac care unit In conclusion we may state that the requirements of the Alpha Index are met. It is easy and effective diagnostic sign to differentiate schizophrenia from neurosis patients. The Alpha Index for this purpose compares very favorably with other diagnostic tests in clinical medicine. References: American Psychiatric Association (1987) Diagnostic and Statistical Manual of Mental Disorder. Ed.3 revised. Washington: APA. Galen, R.S. (1987); Application of the Predictive Value Model in the Analysis of Tests of Effectiveness. Clinical Laboratory Medicine, 4: 4685. Klopfer, B. & Davidson, H.H. (1962) The Rorschach Technique: An Introductory Manual. New York: Harcourt, Brace & World. Piotrowski, Z.A. & Lewis,N.D.C.(1950)An Experimental Rorschach Diagnostic aid for Some Forms of Schizophrenia, American J. Psychiatry,107:360-366. Piotrowski, Z.A. & Berg, D.A. (1955); Verification of the Rorschach Alpha Diagnostic Formula for Underactive Schizophrenia. American Journal of Psychiatry, 112: 443- 450. Prebhu, G.G. (1970); Clinical Utility of Piatrowski’s Alpha Diagnostic Formula. Indian Psychological Review, 6 : 110-112. 24 Chaudhury & Jyothi

Utility of Projective Tests in the Psychological Assessment of Transsexual Patients: A Case Study Approach Jayanti Basu and Sonali De The Draw-a-person test the Rorschach Inkblot test was administered to three male transsexual patients. Analysis of the figures drawn by the subjects was done following Machover (1948) and the Rorschach responses were scored following Klopfer Davidson (1962). Results revealed that despite inter individual variability, the two tests brought out certain common factors which delineate the inner dynamics and conflict of the transsexual persons, particularly, their rejection of the male body, glorification of the female features and difficulty in adequate human relationships are highlighted. Transsexuals are a psychiatric disorder characterized by the conviction that one’s gender identity does not conform to one’s biological sex. It is characterized by (a) and insistent and overriding wish for sexual transformation into a person belonging to the other sex, (b) a delusional or semi-delusional belief that one really belongs to the opposite sex, (c) rejection of one’s own body, particularly the genitals and (d) concomitant behavior and attitude imitating those of the other sex. Although transsexuals have always resided within the society, systematic research in this field dates back only to an approximate quarter of a century; therefore a clear cut depiction of their intra-psychic life is yet to emerge. Etiological studies indicate that transsexuals are not directly inherited or organ disorder (Balen et. al., 1993), although occasionally chromosomal aberrations may be associated. Basically the psychological and psychodynamic factors play the most crucial role in the genesis of transsexuals. Psychodynamic literature suggests that the whole existence of the transsexuals is based on a perverse organization of sexuality Oppenheimer (1985) opined that the transsexuals are pervaded by an obsession, an invasive concern about their bodily transformation. It is fuelled by the hatred with their genitals. This hatred and disgust persuades them to search for novelty, which abolishes the past and generates a screen identity (Greenson, 1958). The inability to identify with the same sex parent and a defensive fixation on the opposite sex parent leads to splitting and disturbed person perception. The internal representation of this opposite sex parent is, however not benevolent and accepting, but often seductive, castrating and aggressive. On the basis of the characteristics, Oppenheimer (1991) stated than although no apparent psychosis is found in the transsexuals, the two characteristic phase of Jayanti Basu, ph.D. Senior Lecturer and Sonali De, M.A. Research Scholar, Dept. of Psychology, Calcutta University, 92 A.P.C. Road, Calcutta – 700009 (India). SIS J. Proj. Pst. & Ment Health (1997) 4:1, 25-35

psychosis can be discerned in them. These are withdrawn from reality and creation of a neo-reality. This neo reality in the form of a fantasized body acts as the idealized double and become the major source of narcissistic gratification. The above depiction of the transsexual’s psyche is based on clinical findings, usually obtained in the therapeutic settings. It is however expected that these descriptions would be corroborated by the various psychological tests administered under standard testing condition Projective test which unravel at least part of the unconscious ideation should be particularly useful in this regard. Unfortunately not many studies have been directed toward this end. A few available studies however, suggest a promising application of projective test material unearth the typical agony and confusion of the transsexuals. For example, Rebers et. al. (1990) studied adolescent transsexuals by using the IT scale, the Draw a person test and the Sheridan Make-a-picture test. The test results correlated adequately with each ether and provided a characteristic profile of these patients. In India, Sahay et. al. (1994) administered the Somatic Inkblot Test on two adult male transsexuals and studied their body image projection. In line with the above studies, the present paper reports the projective test profiles of 3 male transsexuals and in the context of their symptomatic expression, discusses their utility for depicting the intrapsychic state of these patients. Material: Subjects: The study was conducted in three male transsexuals. Surgeons and psychiatrists for psychological evaluation and therapy referred all of them. All of them were diagnosed as transsexuals fulfilling the DSM IV criteria by a psychiatrist and psychologist independently. A brief history of each case is presented below. All the names used here are fictitious, so that their real identity is kept concealed. Case-1 Ashok is a 28-year-old man coming from a middle class educated family. He is the younger of two siblings and presently employed in a private company. He is intelligent, educated and adept and interested in creative art. He remembers having a feminine identity since early childhood. He preferred girl’s attire and mixed more with girls, although childhood. He preferred girls’ attire and mixed more with girls, although he felt terrible when his classmates jeered at him. By adolescence he had been seduced by some local boys to engage in homosexual activity. Since then he had multiple affairs with men although none of them are steady and fills him with remorse. In his relationships he is clinging and jealous, and wants to be accepted as a ‘real wife’. Unhappy in his family relations he feels that only sex change can liberate him. 26 Basu & De

Case-2 Kamal is a 32-year-old man with average intelligence. He is the youngest of four siblings in an upper middle class family. He feels emotionally close to his mother, but dither, from his father who is presumably an addict. He is educated and has been in and out of jobs for a number of times. Since adolescence he has been approached any a number of men for homosexual relationship and responded to some of them. Presently he is engaged to a man with whom he intends to live as the legal wife after his sex reassignment surgery. At the moment he seems happy in his relationship, dresses and behaves like a women, and reports a comfortable feeling as long as he does not remember his disgusting genitals. Case-3 Reet is a 15-year-old boy from an educated middle class family. The younger of two siblings, he has discontinued his studies at high school level owing to the constant ridicule of the ears and complaints of his teachers. He recalls having a feminine identity, a habit of cross- dressing and comfort in the association of girls since early childhood. By the age of 12 he was seduced to homosexual activity by some boys - an experience that produced both fear and pleasure in him. Presently he is attached toward men, but his uncertainty about his sexual status makes him hesitate. He expresses a strong desire for a stable romantic relationship with a man who would love and accept him as his wife Therefore he plans a sex change so that he can become a “complete woman” and can also take up his desired profession of film acting. Procedure Each subject underwent a number of psycho diagnostic sessions including in-depth interview, intelligence tests, self-report inventories and projective test. In the present study the results of the two projective tests are discussed. These are: 1) Draw-a-person test: This was administered following the standard instruction of Machover (1948). After the first picture was drawn under neutral instruction, the subject was asked to draw the opposite sex picture. 2) Rorschach Inkblot test: All the 10 cards were administered and scored following Klopfer and Davidson (1962) technique. Two experts scored each protocol independently and a point of mutual agreement was reached through discussion. Utility of Projectiv Tests 27

Results Draw-a-person test” Levy (1952) suggested that the feature analysis of figure drawing should be preceded by a description of the drawing accordingly a brief of each figure follows: Ashok draw a female figure first. She was group’s girl sitting and looking sideways, with confident chins and glittering eyes. She had long flowing hair and her breasts were accentuated. Her lips were however, a bit overdrawn, and a tone of sternness was observed in her mouth, nose and eyes. The male figure drawn later was a half figure only, with some three quarter of the face toward the viewer. He had an aggressive expression characterized by stern look in the eyes and tight lips. He had a shaded shirt on his body. Hands were incomplete. Kamal drew a male figure first, a sorry Figure with dangling hands. He was standing and looking sidewise with a vague expression. The body outline was hesitant and flimsy. Neither clothing nor sexual anatomy was visible. The next drawn figure was a female with slightly more balanced posture, with her face towards viewer. Her arms were some what stretched away from the body, he had no pupil in her eyes, yet an expression of serene happiness was observed. She had two circles in the position of her breasts, and no clothing was indicated. She had on her head two locks of phallus shaped hair. Reet initially drew an adolescent boy standing in an unbalanced stance. He had trousers, shirt and chappals on, had a row of buttons in the middle of his chest and had hair parted in the center. His eyes were dots, nose was incomplete and lips were full. The connection between the head, neck and body was broken. There was anger in his eyes but helplessness in his posture. The female drawn later was girl of similar age; her position was also imbalanced and her hands were relatively more stretched away from the body. She wore two braids of hair dinging in the air, and had a tight blouse and skirt on, thus accentuating her breasts. She also had a row of button on her chest. The expression of the clumsily drawn eyes, raised and overdrawn brows and the parted lips give the impression of some agony; it seems she is trying to say something. The connection between the body and the legs is broken. After this general observation the specific feature analysis was done and the findings are summarized in the table-1. 28 Basu & De

Table-1 The Major Characteristics of the Figures Drawn by the Three Subjects. Ashok Kamal Reet Male Large Small Normal Size Female Large Normal Normal Male Balanced (sitting) Imbalanced Imbalanced Balance Female Balanced (sitting) Imbalanced Imbalanced First drawn Female Male Male Male Normal Low Low Detail Female High Normal Normal Male Normal Scanty Normal Hair Female Prom in net Prominent Prominent Male Normal Sketchy Dot Eyes Female Large Outline, no pupil Detailed Male Prominent Normal Omitted Ears Female Prominent Omitted Omitted Male Full Sketchy Full Lips Female Distorted Distorted Distorted Male Normal, a bit large Small, profile Incomplete Nose Female Normal, a bit large Norma, Full face Normal Male Aggressive Fearful, aggressive Confused Facial expression Female Aggressive Placid Helpless Utility of Projectiv Tests 29

Ashok Kamal Reet Male No Yes Yes Full figure Female No Yes Yes Mal Normal Normal Normal Sexual Features Female Breast emphasis transparent braes Breast emphasis Male Inadequate Inadequate Inadequate Fingers Female Absent Inadequate Inadequate Male Normal Distorted Distorted Hands Female Normal Distorted Distorted Male Absent Distorted Distorted Legs Female Absent Distorted Distorted Male None None None Phallic symbol Female Hair Hair Feet Male Moderate Slight None Shading Female Slight Slight Slight Male Sketchy Light & Sketchy Broken Line quality Female Sketchy Sketchy Broken Rorschach Inkblot Test: Subsequently the Rorschach responses were scored. The common features observed were high level of whole responses, although much of this was forced; high F%, low M responses and low shading and achromatic responses. Sex responses were abundant in the two older subjects, while the younger one gave plenty of animal responses. Human responses were less in all three of them. Popular responses, however was normal or near normal. 30 Basu & De

The Rorschach responses are summarized and presented in Table 2. Table 2 Rorschach Categories and their Normative Interpretation for the Three Subjects Following Klopfer & Davidson (1962). ‘H Indicated Higher than Normal, ‘N” Indicates Normal and ‘L’ Indicates Lower than Normal Responses Ashok Kamal Reet Total responses 26(N) 22(N) 11(L) Reaction time (Chrom.) 11.8”(N) 15.8”(N) 8.4”(N) Reaction time (Carom.) 8” (N) 18”(N) 9”(N) W% 50% (H 50% (H) 65.45% (H) D% 34.62% (N) 27.27% (L) 36.36% (N) d% 15.38% (N) 9.09% (N) 0% (L) dd+S% 0(L) 13.64% (N) 0% (L) F% 46.14% (H) 59.09 % (H) 65.45% (H) M (Human figure) % 3.84 % (L) 4.54 % (L) 9.09 % (L) M (Sexual parts) % 15.38 % (H) 0 (N) 0 (N) FM % 15.38% (N) 13.64 % (N) 18.18 % (N) Fm% 0% (L) 4.54 % (N) 0% (L) FC+C’F% 7.7% (L) 18.18% (N) 9.09 % (L) FC’+C’F% 0% (L) 0%(L) 0%(L) Crude c% 3.85 %(N) 0% (N) 0% (N) Fc+ cF% 7.69% (L) 0%(L) 9.09% (L) FK + KF % 0% (L) 0% (L) 0% (L) Utility of Projectiv Tests 31

Ashok Kamal Reet H% 3.85% (L) 4.54% (L) 9.09 % (L) Hd% 0% (L) 9.90% (N) 0% (L) A% 34.62 % (N) 22.73% (N) 65.45 % (H) Ad% 0% (N) 9.09% (N) 0% (N) Obi% 3.85% (L) 4.54 % (L) 9.09%(N) Anatomy % 7.77% (N) 0% (N) 18.18% (H) Sex% 38.46% (H) 36.36 % (H) 0% (N) Nature % 3.85% (N) 13.63% (H) 0% (N) Popular % 11.53% (n) 13.64 % (n) 36.35 % (n) Rough % 0% 0% 0% Discussion: The three qualitative description of the figure dawn by the subjects unravel the inner agony of the transsexuals. In all the representations the female had a relatively favorable expression. Ashok’s drawing demonstrates a very stern and aggressive masculine image of the male figure that he wants to supersede by the first drawn gorgeous female. Nevertheless the female figure has phallic hair on her head and her beautiful eyes and accentuated breasts coexist with a stern mouth and chin. This fits the dynamic hunch that the masculinity in the transsexuals is feared and avoided, and identification with an aggressive and seducing female is sought. Kamal first represented his masculine self – a timid, almost evaporating image looking sideways as if to evade reality. What he hopes for is a female with transparent body, round breasts, yet phallic hair and lack of pupil in the eyes. This idealized female thus seems to be guilt-laden, and as in the previous case, seducing yet phallic castrating. For Reet, the youngest of all, the inner agony is most prominent. His present self is a feminized male, striving for identity, with his inner female image trying to emerge but as yet is unstable. With accentuated breasts and dangling plants of hair, this imbalanced has an expression of seeking urgent help. 32 Basu & De

As we scrutinize the summary table we find that a few common points emerge. All three of our patients entailed the female more than the male implying greater identification with her. Figures were distorted and inadequate in all indicating difficulty in reality orientation. Line quality was disturbed in all the figures, thus highlighting the unstable body image. Legs were either distorted or omitted indicating confusion about sexuality. Breasts on the female were emphasized, which suggests these persons mainly in terms of physical features understand that feminity. The psychological aspects that differentiate feminity, for example softness, are not expressed in any female picture- two of them being phallic aggressive and the other being infantile and dependent. Here, it is interesting to observe that the first draw figure was not necessarily a female one in case of our subjects. While this inversion often characterizes homosexuals, our transsexual patients did not conform to this norm. Probably the typical transsexual is more uncertain in his identity than the confirmed homosexual who more readily accepts this sexual status. In the present case we find in essence, the two phases of the transsexual’s psychological condition outlined by Openhanded, namely, rejection of the present reality and seeking for a sexual identity. The results of the Rorschach Inkblot test also support the theoretical descriptions of the transsexuals. Presence of adequate popular responses point out that obvious psychosis is not present in them. But their distorted reality orientation, particularly in the area of object relationship is expressed through their forced organization and low human as well as human movement responses. It seems that the normal interpersonal relations based on empathy and identification is incomprehensible to them. The resulting instability is being constantly resisted with rationalization indicated by the forced whole responses. Low shading responses implying the inability to handle the tender, affectionate aspect of life corroborates the difficulty in human interaction. Indeed, their idea of human beings is in terms of sexuality only, as the older patients responded mostly in terms of sex content. Reet the younger one did not yield sex responses, but produced plenty of animal responses, which also deals with the impulsive side of the mind. Althought both Ashok and Kamal produced numerous sex responses, the nature of their preoccupation with sex was somewhat different. Ashok discovered and described vividly 9 female and 1 male sex organs, each of which he perceived as enlivened. For example he saw the “vagina of an old woman – withered and dry, presently inactive” in card V, or the “vagina of a teenager girl, blooming beautifully seen from below “ in card VIII. While the vaginas were of various connotations, he saw in the 10th card’ the insides of a man’s thigh, the fractured penis and the prostrate glands, degenerated by repeated use – a dirty thing. We can clearly see his detailed fantasy with the vagina and his ardent wish to get rid of the dirty fractured penis. Kamal also gave 8 sex responses – 7 vaginas and 1 penis. Like Ashok he also described the vagina in detail and the perspectives were mentioned carefully. The Utility of Projectiv Tests 33

peins seen by him was also inactive and flaccid; it was however inactive as such but had large opening pore. If seems that in his imagination he has already rendered his masculinity inactive and turned his organ to a fantasized open vagina. It is interesting to note in this context that Ashok had a series of turbulent and conflicting relationship and loathed his masculine self to a great extent. So he detests his degenerated penis and looks for emotionally charged vagina. On the other hand Kamal had a delusional quality about his body; he was already a female in feminine attire and gestures; - “I’m practically his wife, only a few modifications are to be made”, he says referring to his fiancée. So he has a nonfunctional male organ with an opening pore; thus he is already halfway his transformation. Thus the similarities as well as the individual differences in outlook are reflected through the Rorschach plates. The factor of these individual characteristics is further highlighted in the non-sexual responses as well. In such responses also Ashok has an evil overbearing. For example in Card I he sees “a vicious butterfly, evilness indicated by its black wings and the way it sits with its stings out”. In Card X he finds “many creatures, not real, like we see in nightmares and get frightened”. Devoid of any steady attachment, and confused in his daily life his fears and anxieties are clearly revealed. Kamal on the other hand sees in Card II: a colorful butterfly, in double color, beautiful red and black – coming out at the back”. In Card X he sees “splashes of jolly colors on the petals of a flower” thus showing his free emotions and even if defensive, his exuberance in relationships. In contrast, Reet did not give any sex response. He was the youngest and as yet a schoolboy from middle class family. He might have suppressed the sex responses due to cultural constraint. But a more probable explanation is that he is yet not certain about his impulsive wishes. Unable to embrace the world of human warmth, he visualizes a number of animals on the plates, thus revealing his isolation and confusion. Green and Blanchard 91995) in this context states that often the exact transsexual status is vague and conflicting in the adolescent, making diagnosis relatively. The full-blown transsexual identity is revealed in early adulthood. Probable this age factor rendered Reet’s data somewhat different from the others. Conclusion: The above discussion indicates that projective tests specially DAP and the Rorschach Inkblot test helps in unearthing the inner cry of the transsexuals. It revels the frail identity of these persons, as well as the transsexuals. It reveals the frail identity of these persons, as well as the idealized self with accentuated sex signs residing within their fantasized world. That these men are preoccupied with the debasement of their own sex organs and the glorification of the opposite sex characteristics are also apparent. Their inability to relate adequately to the social world and identification and empathy with fellow beings is also observed. Their Rorschach responses indicate a special type of reality distortion, - one that differs considerably from that of the psychotics. 34 Basu & De

Apart from this general feature, idiosyncratic personality traits also observed – thus leading the response pattern a range of variable directions. The limitations of the use of projective tests also emerges from this variability; indeed transsexualism is a feature that cuts across a number of personality disorders as well as psychotic and affective disorders. The projective tests reflect these personality features also, although for the fully expressed transsexualism, the typical signs of sexual inversion are prominent. We hope that with the accumulation of further data projective tests would be used in a more adept way to reveal the inner dynamics of the transsexual persons. References Balen, A.H., Schachter, M.E., Montogomery, D., Reid, R.W. & Jacobs, H.S. (1993) Polycystic Ovaries are a Common Finding in Untreated Female to Male Transsexuals. Clinical Endocrinology, 38: 325-329. Green, R. & Blanchard, R. (1995) Gender Identity Disorder in H.I. Kaplan and B.J. Sadock (Eds.) Comprehensive Textbook of Psychiatry, Sixth Edition, Vol. I, 1347-1360. Baltimore, Williams & Wilkins. Greenson, R.R. (1958) Onscreen Defenses, Screen Hunger and Screen Identity. Journal of America Psychoanalytical Association, 6: 242-262. Klopfer, B. & Davidson, H. (1962) The Rorschach Technique, New York, Harcourt, Brace and World. Levy, S. (1942) Figure Drawing as a Projective Test in L.E.Abt and L. Bellak (EDS.). Projective Psychology, New York, Alfred A Knopf, 252-297. Machover, K. (1948) Personality Projection in the Drawing of the Human Figure, Springfield, C.C. Thomas. Oppenheimer, A. (1985) La Sexualite Masculine, ou Comment s’en Debarsasser in Les Sexes de Home. Paris, Seuil, 125-138. Oppenheimer, A. (1991) The Wish for a Sexy Change: A Challenge to Psychoanalysis. The International Journal of Psychoanalysis, 72: 221-232/. Rebers, G.A., Rosen, A.C. & Morey, S.M. (1990) Projective Test Findings for Boys with Gender Disturbances: Draw a Person Test, IT Scale and Make a Picture Story Test. Perceptual and Motor Skill, 71: 771-779. Sahay, M. and Srivastava, P.K. (1994) Somatic Inkblot Series-I in Male Transsexuals, SIS J. Proj. Psy. And Mental Health, 1: 73-78. Utility of Projectiv Tests 35

Sexual and Aggressive Contents in Rorschach Card II Ana Herrers, J. Jacobo Requelme, Frances Krivoy and Audrey Meza. Within the normative and trams cultural research developed in Venezuela for Rorschach, responses to Card II given by a non-patients Caracas inhabitant’s sample was analyzed. Different authors present a coincidence pointing out Card II as a complex inkblot, which could easily stimulate responses with sexual and aggressive contents, as well as primitive and regressive fantasies. In order to assess sexual, aggressive and primitive object relations’ contents in responses in Caracas sample for the ten Rorschach Cards, with the aim of considering the specific weight of the aggressive and/or sexual contents provoked by Card II. Results are discussed regarding differences between males and females subjects as well as considering the shocking effects of Card II. In its structure, Card II is an intense stimulus, that is why perceptive distortions and/ or disturbing fantasies are usually found in the clinical work experience. This card presents a complex structure; the contrast of red and black, which are intermingled in some parts, and a wide white space in the center. From the point of view of color psychology, red and black are exciting stimuli. Red is a warm color and has a symbolic of passion and/or aggression. Black is related allegorically to fear, darkness, anxiety towards the unknown, depression and death. The white central space is associated to a hole (sexual connotation) or a vacuum (a feeling of revitalization disintegration or failure of holding.) Therefore this card provokes shocking reactions in subjects frequently. On the other side, this card incites two unequal contents; animals or persons interacting (whole objects), or also masculine and feminine sexual organs (partial objects), The integration of such images causes fantasies about erotic or sadistic relationships. When reviewing the meaning of Card II for different authors, it is observed a coincidence around this card as a stimulus able to generate sexual and aggressive contents in subject’s responses (Schafer, 1954;Bohm. 1954; Anzieu, 1960; Alcock, 1965; Campo, 1970; Klopfer & Kelly, 1972; Vasquez, 1980; Rausch de Traubenberg, 1993). Research Objectives: This research was made in order to prove at a statistical level the following hypothesis; the complex structure of Card II stimulates sexual and aggressive images and/ or fantasies, which could cause archaic and primitive anxieties. Ana Herrera. Rorschach Venezuelan Institute. Caracas Venezuela. J. Jacob Requiem. Rorschach Venezuelan institute, Central University of Venezuela, Caracas, Veneziela Francis Privy, , Central University of Venezuela, Caracas Venezuela. Audrey Meza. Clinical Psychologist. Caracas, Venezuela. Send any correspondence to Ana Herrea/J. Jacob Raquel to ; Apart ado 47581 Caracas Venezuela. SIS J. Proj. Pst. & Ment Health (1997) 4:1, 36-43

Based on our clinical experience, we have formulated a second hypothesis; women give responses of an aggressive content more often than men, while sexual contents are more frequently found among men. From the dynamic point of view, the theoretical reason for this hypothesis would be that the feminine archaic experiences are predominantly aggressive in relation to the maternal object and the masculine ones are predominantly erotic. Method: Responses to Card II given by 218 adults, non-patients, Caracas residents, were analyzed using different categories and scales to assess aggressive and sexual content. This sample is the one used in the normative and Tran cultural research which is being undertaken in Venezuela for the Rorschach. The sample was stratified on the basis of sex, three groups of different ages (20-31, 32-43, 44-45) and four social-economic levels (AB, C, D, E,) according to Graf far scale (modified ) and a zone and type of housing criteria, in order to make it proportional to the population of Caracas (capital of Venezuela). Criteria and categories for studying content were scored as it follows; 1. Comprehensive System (Exner, 1990). 1.1 Contents; Blood (BI), Fire (FI), Anatomy (AN) and Sex (SX) 1.2 Special Scores; Cooperative movement (COP), Aggressive movement (AG) and Morbid response (MOR). Aggression Scores (Gacono, 1990); Aggressive Past (Ag Past) and Aggressive Potential (Ag Pot). Primitive Object Relation (Kwawer, 1980); Categories of primitive object relation usually found among borderline patients. Affective Inferences Scoring System- Revised (AISS-R) (Boyer et. al. 1988); Hostility sub scale. Results for Card II were compared with the global results obtained in Caracas sample for the tem Rorschach Cards (Ephraim et. al, 1993), with the aim of considering the specific weight of the aggressive and / or sexual contents provoked by card II. Results: Primitive object relation categories show a high frequency for Card II. This is particularly significant for a non-patient sample. These categories are linked together to very primitive form of object relations, in which the subject is not able to integrate himself as an autonomous being. These responses are fusionable, symbiotic and indicate the separation experience is filth as destructive and violent. Nine of the ten categories proposed by Kwawer (1980) appear in the Card II responses, representing 23% of total frequency. Those, which stand out are: 1) Kpmal: Malignant internal processes (100%) 2) Ktras: Boundary disorders (45%) 3) Kmorf: Madam orphisms and transformation (40%) 4) Kesna: Narcissistic mirroring (31%) 5) Kintr: Intrauterine imagery (25%) Sexual & Aggressive Contants in Rorschach Card II37

For the Comprehensive System (Exner, 1990) content categories the following results were observed: Blood (BI): This content presented the highest presence in responses to Card II (63%.) In addition, the Formal Quality (FQ) for these 75% of these responses were unusual (u) or minus (-). Anatomy (An): Present for 34% of the responses to Card II. 80% of these responses were minus (47%) or unusual (33%). Sex (Sx): They comprise 32% of the responses, of which 41% has conventional formal quality, and 59% were codified as unusual or minus. Among Comprehensive System Special Score Cooperative Movement (COP) stands out (39%. For this kind of response, 80% has an ordinary (O) formal quality. Within the Hostility Sub-Scale excerpted from the Affective Inferences Scoring System (Boyer et. al, 1988), the total of hostility presented the highest percentage (36% in the subject’s responses to Card II. The following categories presented also and outstanding presence: 1) Explosion (Hexp): Score for 25% of the responses. 2) Phallic hostility (Hpha): Scored for 20% of the responses. Women comparing these responses regarding to sex, significant differences were found using Chi Square (p=.05). Women presented a higher frequency of this kind of content. 3) Vaginal hostility (Hvag): Only one response has been scored for this content category, and it was given by a masculine subject. 4) Hostility Other and Provisional (Hoth): This was the category with the highest percentage of presence (63%) among the hostility subscale. 5) No significant frequencies were found in responses to Card II for Aggression Scored developed by Gacono (1990). Discussion: When analyzing data, the high presence of responses codified for the Primitive Object Relation categories developed by Kwawer (1980) to assess disturbances linked to archaic anxieties and fantasies in borderline patients, could be considered as an amazing result, at least. This could e explained in terms of an Ego regression as consequence of Card II complex stimulation impact. As far as the sample was constituted by non-patients subjects. It can be deduced that Card II incites responses, which content refers to the inability of attaining the synthesis of contradictory pulsional images (libidinal and aggressive) of Self and/or objects linked to the Self. Then, subjects take refuge in regressive fantasies of primitive fusion. Malignant intern processes (Kpmal responses, as mentioned by Kwawer (1980) suggest the presence of parasitical and destructive early experiences regarding body 38 Herrera et.al.

and self. This could be related to the presence of Blood content (Exner, 1990) considering that this content implies body damage generally. This content is also liked with aggressive sexual and/or destructive impulses control disorders. Even though perception of blood in Card II presents and ordinary formal quality for Comprehensive System normative tables, Bl responses are mainly associated in this subjects, to unseal or minus formal quality. Clearly, this could be an effect of Card II simulative complexity, which provokes different kinds of shocking responses. Therefore, these responses are distorted and/or perceptually bad made. High percentage of minus responses with anatomical (An) content (Exner, 1990) are also interesting. These distortions are recognized as more severe because they are further always from the stimulus properties. Likewise, from the qualities analysis point of view, they refer again, to bossy damage and/or Self destruction feelings. The responses with Sexual (Sx) content (Exner, 1990) were observed in 32% with a smaller percentage e of distorted formal quality, went compared with Blood and Anatomy one. It is important to comfier that ordinary formal quality responses (41%) for this content is explained since the percept vagina is a common response for this Card. Equally, it is an outstanding result that responses with Phallic hostility (Hpha) from Hostility subscale (Boyer et. Al, 1988) were more frequent in women, and the unique response with Vagina hostility (Hvag) content was given by a man. A certain tendency to express fantasies of erotic hostility with sexual organs of the opposite gender could be observed here. About our second hypotheses: women give aggressive content responses more frequently and men sexual content ones, it was not confirmed. The contest expected in contents evoked by Card II, seems to appear In Cooperative Movement (COP) responses (Exner, 1990). Cop responses were mainly of ordinary formal quality, which are opposed to those mentioned above (Blood and Anatomy). This would point out to some kind of attempt for organizing perturbing effects stimulated by Card II through perception and fantasy activities. This could by demonstrating that for the same subject with pathological contents can become more linked with creativity. The low proportion of Aggressive Movement (AG=19%) responses for Comprehensive System criteria (Exner, 1990) and the Aggression Past (Ag Past – 17%) and Potential (AgPot+3%) responses (Gacono, 1990) when compared to Total score for AISS-R Hostility Sub-Scale (36%) could be interpreted considering that the evident aggressive behavior is inhibited, displaced or repressed among Caracas inhabitants, since it is not socially accepted. Because of that aggression is expressed by indirect and/or symbolic way. In turn, this could be corroborated looking at percentage found or others and Provisional category (Boyer et. al, 1988) which refers to nonspecific hostility aspects. We consider that this kind or research, using Comprehensive system criteria, content categories developed to assess specific elements of the responses and a welldesigned sample with statistical handling of data obtained, could be very successful Sexual & Aggressive Contants in Rorschach Card II 39

to study, and perhaps to confirm, hypothesis derived from psycho-analytical inferences made as resulting of considering symbolic and affective content of the responses given to Rorschach Inkblots. For future research, it would be important to study the frequency of appearance for the same content criteria and categories, in responses gives to the other nine Rorschach Cards, with the aim of assessing whether data obtained here are distributed in a significant form when compared to Card II contents. Likewise, it would be interesting to relate the statistical results obtained in this non-patients sample with other obtained from different clinical groups of Caracas (Vanezuala) for Rorschach Card II. In summary, it was demonstrated that the complex structure of Rorschach Card II stimulates, in a significant way, responses with aggressive, sexual and primitive fantasies contents among Caracas inhabitants. Nevertheless, non-patients, subjects attempted to reorganize themselves after been shocked by responses of cooperative activities and positive interpersonal mood. No evidence was found regarding a higher frequency of aggressive contents in women and higher frequency of erotic contents in men. It was also demonstrated that hypothesis from psycho-analytical approach could be studied through major samples using statistical strategies, when Comprehensive System criteria, by one hand, and symbolic content categories, by the other, are combined. References: Alcock, T. (1965): La Prueba de Rorschach en la Practica, Fondo de Cultura Economica Mejico. Anzieu, D. (1960): Los Metodos Proyectivos. De. Kapeluz. Buenos Aires. Bohm, E. (1954): Manual de Psicodiagnostico de Rorschach. De. Morata. Madrid. Boyer, L.B., Dithrich, C.W., Harned, H., Stone, J.S. & Walt, A. (1988): Rorschach Handbook for the Affective Inferences Scoring System (revised). (Available from Boyer Research Institute, 3021 Telegraph Avenue, Suite C. Berkeley, California 94705, U.S.A.). Campo, V. (1970): Rorschach, Pronostico y Tratameiento. EI Rorschach de Argentina. Ano 2 (2) Bueno Aires. Ephraim, D. Occupati, R, Riquelme, J.J. & Gonzalez, E.C. (1993): Gender, Age and Socioeconomic Differences in Rorschach Thematic Content Scales. Rorschachiana. 18, 68-81. Exner, J.E. (1990): a Rorschach Workbook for the Comprehensive System. (3rd. ed.) Asheville, N.C.; Rorschach Workshops Gacono, C. (1990): An Empirical Study of the Object Relations and Defensive Operations in Antisocial Personality Disorders. Journal of Personality Assessment, 54,589-600. Klopfer, B & Kelly, D. (1972): Tecnica del Psicodiagnostico de Rorschach. Paidos, Buenos Aires. Kwawer, J.S. (1980): Primitive Interpersonal Modes, Borderline Phenomena and Rorschach Content. In J.S. Kwawer, H.D. Lerner & P.M. Lerner (Eds.): Borderline Phenomena and the Rorschach Test. New York International University Press. Loosli-Usteri, M. (1965) Manual Practico del Test de Rorschach. Rialp, Madrid. Rausch de Traubenberg, N. (1993): The Rorschach; From Percept to Fantasm. Rorschachiana. 18, 7-25. Schafer, R. (1954): Psychoanalytic Interpretation in Rorschach Testing. Grune & Sttraton, New York. Vasquez, O. (1980): Rorschach Para Rorschachistas. Ed. Belgrano. Buenos Aires. 40 Herrera et.al.

Table 1. Descriptive Statistics for some variablesfor Comprehensive System on a non-pacient adults sample Caracas residents (N-218) Mean SD Min. Mx. Freq. Med. Mode Blood 0.09 0.31 0.00 2.00 0.00 0.00 Blood + 0.00 0.00 0.00 0.00 0.00 0.00 Blood o 0.02 0.15 0.00 1.00 0.00 0.00 Blood u 0.04 0.2 0.00 1.00 0.00 0.00 Blood - 0.03 0.16 0.00 1.00 0.00 0.00 Fire 0.05 0.23 0.00 1.00 0.00 0.00 Fire + 0.00 0.00 0.00 0.00 0.00 0.00 Fire o 0.05 0.22 0.00 1.00 0.00 0.00 Fire u 0.00 0.07 0.00 1.00 0.00 0.00 Fire +_ 0.00 0.00 0.00 0.00 0.00 0.00 Anatomy 0.22 0.43 0.00 2.00 0.00 0.00 Anatomy + 0.00 0.00 0.00 0.00 0.00 0.00 Anatomy o 0.04 0.19 0.00 1.00 0.00 0.00 Anatomy u 0.07 0.26 0.00 1.00 0.00 0.00 Anatomy - 0.11 0.32 0.00 2.00 0.00 0.00 Sex 0.13 0.36 0.00 2.00 0.00 0.00 Sex + 0.00 0.00 0.00 0.00 0.00 0.00 Sex o 0.05 0.22 0.00 1.00 0.00 0.00 Sex u 0.05 0.22 0.00 1.00 0.00 0.00 Sex - 0.03 0.2 0.00 2.00 0.0 0.00 Coperative Mvement 0.21 0.42 0.00 2.00 0.00 0.00 COP + 0.00 0.00 0.00 0.00 0.00 0.00 COP o 0.17 0.38 0.00 2.00 0.00 0.00 COP U 0.02 0.13 0.00 1.00 0.00 0.00 COP - 0.02 0.15 0.00 1.00 0.00 0.00 Cop Affective 0.03 0.17 0.00 1.00 0.00 0.00 COP Affective + 0.00 0.00 0.00 0.00 0.00 0.00 COP Affective o 0.01 0.12 0.00 1.00 0.00 0.00 COP Affective u 0.0 0.07 0.00 1.00 0.00 0.00 COP Affective - 0.01 0.12 0.00 1.00 0.00 0.00 Aggressive Movement 0.08 0.27 0.00 1.00 0.00 0.00 AG + 0.00 0.00 0.00 0.00 0.00 0.00 AG o 0.04 0.2 0.00 1.00 0.00 0.00 AG U 0.03 0.16 0.00 1.00 0.00 0.00 AG - 0.01 0.09 0.00 1.00 0.00 0.00 Mprbid Content 0.08 0.32 0.00 2.00 0.00 0.00 MOR + 0.00 0.00 0.00 0.00 0.00 0.00 MOR o 0.00 0.00 0.00 0.00 0.00 0.00 MOR u 0.03 0.17 0.00 1.00 0.00 0.00 MOR - 0.05 0.26 0.00 2.00 0.00 0.00 Fo Quality FQ + (Plus) 0.00 0.00 0.00 0.00 0.00 0.00 EQ o (Ordinary) 0.8 0.8 0.00 4.00 0.00 0.00 FQ u (unusal) 0.75 0.91 0.00 5.00 0.00 0.00 FQ - (minus) 0.42 0.63 0.00 3.00 0.00 0.00 Sexual & Aggressive Contants in Rorschach Card II 41

Table 2 Descriptive Statistics for some content categories on a non -pacient adults sample, Caracas residents (N+218) Mean SD Min. Mx. Freq. Med. Mode Kwawer Categories Ksuab (adsorbtion/engulfment) 0.00 0.00 0.00 0.00 0.00 0.00 0.00 Kviol (violent union/speartion) 0.01 0.09 0.00 1.00 0.00 0.00 Kintr (intrauterine images) 0.00 0.07 0.00 1.00 0.00 0.00 Kpmal (malignant internal process) 0.02 0.13 0.00 1.00 0.00 0.00 Knar (birth and re-birth) 0.00 0.07 0.00 1.00 0.00 0.00 Kesna (narcisistic mirroring) 0.02 0.13 0.00 1.00 0.00 0.00 Kusim (Symbotic union) 0.02 0.13 0.0 1.00 0.00 0.00 Kesdi (separation/division) 0.01 0.12 0.00 1.00 0.00 0.00 Kmorf (metamorphosis) 0.01 0.09 0.00 1.00 0.00 0.00 Ktras (Boundary disturbances) 0.02 0.15 0.00 1.00 0.00 0.00 Gacono Categories Aggressive Past 0.03 0.16 0.00 1.00 0.00 0.00 Aggressive Potential 0.00 0.07 0.00 1.00 0.00 0.00 Boyer Categories Hora (Oral Hostility 0.05 0.23 0.00 1.00 0.00 0.00 Hana (Annal Hotility) 0.03 0.17 0.00 1.00 0.00 0.00 Hexp (Explosion 0.04 0.19 0.00 1.00 0.00 0.00 Hsad (Sadistic) 0.03 0.17 0.00 1.00 0.00 0.00 Hvag (Vaginal) 0.00 0.07 0.00 1.00 0.00 0.00 Hpha (Phallic) 0.11 0.32 0.00 2.00 0.00 0.00 Hbir (Direct Hostility) 0.06 0.24 0.00 1.00 0.00 0.00 Hten (Tension) 0.02 0.13 0.00 1.00 0.00 0.00 Hdev (Devaluation) 0.02 0.15 0.0 1.00 0.00 0.00 Hpra (Pretetious) 0.01 0.09 0.00 1.00 0.00 0.00 Hcom (Competition) 0.01 0.12 0.00 1.00 0.00 0.00 Hoth (Hjud) (Judgement) 0.01 0.12 0.00 1.00 0.00 0.00 Hoth (Other and Provisional) 0.02 0.15 0.00 1.00 0.00 0.00 Total (Total Hostility Sub-Scale) 0.4 0.72 0.00 4.00 0.00 0.00 Responses 1.98 1.07 1.0 8.00 1.81 1.00 42 Herrera et.al.

Total Inkblot II % of Exper Freq. Freq. Total Sample Caracas Caracas Freq. Exer Blood 63% Fire 24% Anatomy 34% Sex 32% Cooperative Movement 39% Aggressive Movement 19% Morbid Content 14% Kwawer Ksuab (absorption/engulfment) 0% Kviol (violent union/spearation) 18% Knitr (intraterine images) 25% Kpml (malignant internal processes) 100% Knare (birth and re-birth) 5% Kesna (narcisitic mirroring) 31% Kusim (symbiotic union) 18% Ksedi (separation /division) 16% Kmort (metamorphosis) 40% Ktras (boundary disturbances) 45% Total 23% Gacono Aggressive Past 17% Aggressive Potential 3% Bouer Hora (Oral hostility 8% Hana (Anal hostility) 17% Hexp (Explosion) 25% Hsad (Sadistic) 13% Hvag (Vaqinal) 100% Hpha (Phallic) 20% Hdir (Direct hostility 18% Hten (Tension) 8% Hdev (Devaluation) 15% Hpre (Devaluation) 6% Hcom (Competition) 14% Hoth (Hjud) (Judgement) 13% Hoth (Other and Provisional) 63% Total (Total Hostility Sub-Scale) 36% Table 3 Sexual & Aggressive Contants in Rorschach Card II 43

SIS – II Profile of Drug And alcohol Dependent CasesDependent Cases Amool R. Singh and B.L. Dubey Fifty drug dependent and 50 alcohol dependent cases (matched on age, sex and education) were administered Somatic Inkblot Series – II (SIS-II). The SIS protocols were scored as per standard procedures (Cassell 1990) and were compared for the chosen variables selected for the study. The findings are discussed in the light of earlier work in the area. The SIS II can be used as a powerful psycho diagnostic tool for discriminating drug and alcohol dependent groups from normal subjects. The Somatic Inkblot Series-II is a structured projective diagnostic instrument and an adjunct to psychotherapy (Cassell, 1990). It employs the same basic principles of projection as that of the Rorschach. However, SIS images are largely developed to elicit somatic awareness to hear the inner cry of the patient and to establish psychopathology for appropriate therapeutic intervention (Cassell 1977, 1980, 1990, Ramachandra et. al. 1995, Savage, 1995). The efficacy of the SIS-II has already been established in discriminating various clinical groups and normal subjects (Bailey and Mustering, 1995, Bellamy, 1995; Cassell, 1980, 1990, 1994; Dubey et. al. 1993, 1994, 1995, 1996; Dwivedi et. al. 1994, 1995; Rathee et. al. 1995, Mukhapadhyay et. al. 1996, Verma et. al. 1994, 1995 and Singh & Banerjee 1996). Keeping this in mind, the present study was undertaken with the following objective. Objective: To prepare profile of drug and alcohol dependent cases on SIS-II indices and compare them with existing norms (Dubey et. al. 1995). Material and Method: (a) Sample: One hundred male patients (50 each drug dependent and alcohol dependant) from Dr. Vidya Sagar Hospital (now VIMHANS), New Delhi, diagnosed using I.C.D.-10 criteria, in the age range of 19-57 years, were taken for the study. It was a consecutive sampling. The two experimental groups were roughly matched on age, sex, and education). Most of the patients had urban background and except 5, rest of the patients had at least 8 years of schooling. Amool R. Singh, Ph.D., M.M. & SP., Consultant Clinical Psychologist, Samvedna Clinic, S-325, Greater Kailash-II, New Delhi – 110048 (India) B.L. Dubey, Ph.D, D.P.M., D.P.M., D.M.S.P., Director Somatic Inkblot 1671, Secto 49-B, Pushpac, Chandigarh – 160047. (India) SIS J. Proj. Pst. & Ment Health (1997) 4:1, 44-48

(b) Tool: The SIS-II was administered individually following the standard procedure (Cassell 1990). It consists of 62 images in two series, A & B, each with 31 images. It is selfadministered test under supervised instructions. (c) Procedure: SIS-II was administered only after establishing good rapport with subjects. All the patients were informed about the purpose of the study. (d) Analysis of the Data: The SIS protocols were analyzed on eight indices such as Total number of responses, Human, animal, Movement, anatomical, Sex, Rejection of images and Most-typical Responses. Mean and S.D. were computed for the indices of drug dependent and alcohol dependent cases and compared with normal subjects given by Dubey et al (1995). Results and Discussion: Psychodiagnosis is one of the important functions of a clinical psychologist. SIS-II is known for its efficacy and used as a diagnostic tool. The results are shown in Table 1 & 2 suggests that SIS-II is capable of discriminating normal subjects from alcohol dependent cases on some indices such as Movement, Human, Animal and Anatomical responses. The alcohol dependent cases gave higher number of movement human, animal and anatomical responses. When SIS-II protocols of Alcohol dependent and drug dependent cases were compared (Table-2), it was found both groups differed on some indices such as R (total responses), Movement, Sex and Most Typical responses. It is also evident (Table-1) that normal subjects and drug dependent cases differed on some variables such as total number of responses, Human Animal, Anatomical, Rejection of images and Most Typical responses. SIS-II in Alcohol Dependent 45

Table 1 Comparison of Normal Subjects, Drug Dependent and Alcohol Dependent Cases on SIS-II Indicter SIS Indices Normal Group Alcohol Group Drug Dependent Trend (N) (A) Group (D) (Highest (Dubey et. al.) Present Study Present Study to 1995 (n-100) (n-50) (n-50) Lowest) Total Number Mean 74.08 72.45 64.62 NAD S.D. 12.40 10.50 12.42 Movement Mean 9.60 12.32 9.56 AND S.D.. 5.33 2.74 4.32 Human Mean 14.66 16.50 16.31 ADN S.D. 5.46 3.60 3.22 ADN Animal Mean 8.65 11.62 12.669 DAN S.D. 4.69 3.85 4.03 Anatomical Mean 9.18 14.15 13.85 AND S.D. 2.58 3.05 2.30 Rejection Mean 0.82 1050 2.80 DAN S.D. 2.00 2.65 2.12 Most Typical Mean 13.68 13.22 11.65 NAD S.D. 1.98 3.12 1.25 Note : N= Normal, A= Alcohol Group & D= Drug Dependent Group Table 2 Comparison Between Alcohol And Drug Dependent Groups Variables Alcohol Drug Total Responses - Movement + + Human + + Animal + + Anatomical + + Sex - Rejection + ++ Most Typical - Note:- (+) Indicating Higher; (++) Indicating much higher; and (-) Indicating as lower compared to normal subjects. 46 Singh & Dubey

The two experimental groups also showed some differences like the Alcohol group was relatively low on sex responses whereas Drug groups was low on total and Most Typical responses. Conclusion: In comparison to normal group, I) Both Drug and Alcohol dependent groups are high on Projection, Anatomical, Animal and Human responses. II) Alcohol group is low on Total number (R) and Most Typical responses. It becomes clear from the present study that the SIS-II test can be used as a valuable psycho diagnostic tool for discriminating normal subjects from drug and alcohol dependent groups, thus confirming the utility of SIS II with psychiatric cases as reported in the earlier studies also (Dubey et. al. 1993; Dwivedi et. al. 1995; Rathee et. al. 1995; Vera et. al. 1994, 1995 etc.). References: Beiley C.J. and Murestein, B.L (1996): Paranoia Assessment with the SIS-II in a College Student Sample, SIS. J. Proj. & Ment. Health 3:109-122. Bellamy, E. (1995): Hospitalized Suicidal Patients and the Somatic Video Procedure, SIS J. Proj Psy. & Ment. Health 2: 85-91. Cassell, W.A. (1977): Aggressive Imagery and Clinical Symptom s in Schizophrenia, Brit. J. Proj, 22: 21-24. Cassell, W.A. (!980) Body Symbolism and Somatic Inkblot Series, Aurora Publishing, Anchorage, Alaska. Cassell, W.A. (1994): The Somatic Inkblot Series: Continuing Rorschach’s Conceptualization. SIS. J. Porj. Psy & Mental Health. 1:3-14. Cassell, W.A. (1990): Somatic Inkblot Series-II Video Manual. Somatic Inkblot Center, Anchorage, Alaska Cassell, W.A. and Fields Domain (1995): SIS-Video: Case Report and Discussion, SIS J. Proj. Psy and Ment. Health, 2: 3-18. Dubey, B.L. (1996): SIS as a Projective Psychotherapeutic Tool for the 21st Century, SIS J. Proj. Psy. & Ment. Health, 3: 95-108. Dubey, B.L. and Cassell, W.A. (1993) Some Experience with the Somatic Inkblot Series Brit. J. Proj. Technique, 38: 19-41. Dubey, B.L. Mishra and Cassell W.A. (1994) Diagnostic and Therapeutic Utility of SIS-II and Rorschach, SIS J. Proj Psy. & Ment. Health, 1: 19-26. Dubey, B.L. Cassell, W.A. Peshad, D. and Dwivedi, P. (1995): Diagnostic Utility of Somatic Inkblot Series. SIS J. Proj. Psy & Ment. Helath, 2: 77-84. Dwivedi,C.B., Mishra, M. and Dubey, B.L. (1995): Diagnostic Significance of the Indices of the SIS-II and the Rorschach Test, SIS J. Proh. Psy. & Ment. Health, 2:165-170. SIS-II in Alcohol Dependent 47

Dwivedi, P., Mishra, Mridula and Cassell, W.A. (1994): Somatic Inkblot Series Video in Adolescents, SIS J. Proj & Ment. Health, 1: 27-32. Mukhopadhyay,A., Banerjee, S. and Mitra, G. (1996): A Comprehensive Profile of Personality Characteristics of Male Drug Addicts, SIS J. Proj. & Ment. Health, 3:33-41. Ramachandra, S. and Chaturvedi, S.K. (1995): Body Imagery in SIS- Test, SIS J. Proj. Psy & Ment. Health, 2:53-60. Rathee, S.P. Pndey V. and Singh A. (1995): Diagnostic Efficacy of Somatic Inkblot Series-II among Psychiatric Patients of Armed Forces, SIS J. Proj & Ment. Health, 2: 61-66. Savage, G. (1995) Bereavement and Hypnosis: A Case Study, SIS J. Proj. Psy & Ment. Health 2: 29-40. Singh, A.R. and Bereavement K.R. and Hypnosis: A Case Study, SIS J. Proj. Psy & Ment. Health, 2: 29-40. Singh, A.R. and Banerjee, K.R. (1996): Efficacy of SIS-II in Discriminating OCD Patients and Normal Subjects. SIS. J. Proj Psy. & Ment Health, 3: 165-169. Verma, S.K. Pershad, D. and Nehra, R. (1994): Cross Validation of SIS-II in Psychiatric Population. SIS J. Proj. & Ment. Health, 1: 15-18. Verma, S.K., Pershad.D., Kaur R. and Nehra, R. (!995) Diagnostic Significance of SIS-II. SIS J. Proj. Psy. & Ment Health, 2: 72-76. 48 Singh & Dubey

Body Image Disturbances in Psychiatric Cases D. Pershad, S.K. Verma and Kusum Bhagat 50 Normal, 57 Neurotic and 70 psychotic patient were included in the study to find out the extent and type of body images disturbances in psychiatric patients and compare the body image disturbances in patients with different type of psychiatric illnesses. SIS-II test was administered individually. It was observed that Most Typical responses and Sex responses were minimum in the psychotic groups as compared to their normal healthy counter parts. This indicated that psychotics tended to deny anatomical structure and their perception was not in conformity with the typical responses. Movement responses and projection of images were high in pathological groups. In the normal group, 26 percent of the subjects gave their responses similar to structural theme of the image. In the neurotic group this number was reduced similar to structural theme of the image. In the neurotic group this number was reduced to 23 percent and in psychotics it was only 18 percent. However, a significantly high correlation was observed between Normal and Neurotics, Normal and Psychotics and Neurotics and Psychotics in their perceptual and structural theme on 16 images. The highest concordance was the thematic structure of kidney, spine and fetus. Disturbances of body images are the disturbances of the perception of the body, i.e. disease & mind. Descartes body mind dualism is important to understand a human being. As the saying goes, sound mind in a sound body similarly unsound mind in an unsound body or disturbances of body perception in a diseased person show that body and mind are so intertwined that disturbances in one cause disturbances in the other. As such it would be natural to expect that persons with psychological disorders will also have disturbances in their body images. The knowledge of such disturbances, and their relation to different type of mental disorder may help the clinician to understand perceptual processes of the patient for his better management and planning proper rehabilitation. Interest in the symbolic significance of the body can be traced back to the very dawn of civilization (Wentinck, 1972). Pectoral representations of the body have been a central theme of artistic expression and human research for identity throughout history. Philosophically, such representations are attempts to integrate mental and physical phenomena rather than isolating or reducing them (Cassell, 1980). Clinical interest in body perception dates back to the studies of phantom limb by Ambrose Pare in the sixteenth century. Subsequently, the term schema predating to body orientation was introduced (Bonnier, 1905). Additional terminology was employed to represent knowledge or consciousness or the body (Gerstman, 1927), body image (Lheimitte, 1939). Mental representation, pertaining to perceptual data from the body were included under the term schema in the preconscious state and referred to as images (Poek and Orgass, 1967; Cassell, 1980). SIS J. Proj. Pst. & Ment Health (1997) 4:1, 49-55 D. Parshad, Addl. Prof., S.K. Verma, Addl. Prof. and K. Bhagat Res. Asst. Department of Cl. Psychology, PGI MER, Chandigarh

50 Pershad et. al. Human figure drawings have been used to evaluate the subjective experiences of illness. Tai and Asher (1955) described their ‘Inside the Body Test to study body imagery in a variety of medical conditions. Wickelgren (1989) reported on how migraine patients perceived their headache in art. Verma et. al. (1972) used DAP test in the patients awaiting cardiac surgery. Rorschach test has also been used to show frequent anatomical responses in Schizophrenics (Brar 1970, Gold freed et. al. 1971). Cassell (1995) has described a number of limitations of these tests and has recommended the use of Somatic Inkblot Series for the study of body image disturbances. Using Somatic Inkblot Series (S.I.S.) It has been demonstrated in a number of studies that relationships existed between individuals physical disturbances and projected anatomical responses (Cassell, 1969, 1971, 1972, 1977, 1980; Dubey and Cassell, 1993). However in a current study from India on heart patients interim results suggested that somatic preoccupation was denied by the heart patients (Goel et. al. 1990) It might be of immense practical help to know whether SIS is a practicable tool to identify body image disturbances in psychiatric patients in India and to its relationship with socio-demographic and clinical variables Objectives: With this notion in mind the present study was planned to find out: 1. The extent of body image disturbances in psychiatric patients. 2. The socio-demographic correlates of these disturbances obeys images: and 3. Compare body image disturbances in patients with different type of psychiatric illnesses. Material and Method: One hindered and twenty-seven consecutive adult Psychiatry OPD patients formed he subject matter of the stud. Only educated (at lease 8th class) cases were included. A comparable group of 50 healthy subjects was also taken as control from amongst the attendants. Tools: Cassell’s Somatic Inkblot Series (Cassell, 1980, 1995) was administered. The subject is required to report what he sees in these unstructured inkblot images. The test required nearly 45 minutes for its administration. Procedure: Patients with psychiatric illness attending psychiatric OPD were requested to take the test. Those who volunteered were administered the test. The consultant in charge of the case made the diagnosis of the cases. Statistical Procedure: Homogenous group of different diagnostic categories of patients were formed. Their responses on each of the images were compared amongst the groups using parametric and non-parametric inferential statistics (like chi-square, t test, rho,).

Results and Discussion: Total numbers of psychiatric patients were 127 and normal healthy control subjects were 50. Amongst the patients 55 percent were diagnosed as psychotic and 45 percent were diagnosed as Neurotic. The three groups of subjects did not differ significantly on important demographic variables that are age, sex and education as shown in table 1. The various diagnoses of neurotic and psychotic cases of the sample are given in table 2. In the Psychotic group a large number of cases were found to be suffering from Schizophrenic illness. In preponderance Neurotic and Psychotic groups were not found to differ significantly from normal control on most of the variables of S.I.S. Nevertheless, normal subjects gave more number of responses, Most Typical Responses and Typical Responses. Anatomical responses were also high in normal group. Atypical responses were more in psychotic group. Psychotics also obtained low number of Most Typical, Typical and Anatomical responses. Pathological responses were more in Nerotics than both the groups as shown in table 3. It is evident that Psychiatric patients deny anatomical structure on S.I.S. images. Table 1 Sample Characteristics Background variable Normal Neurotic Psychotic t (No) (Ne) (P) No. No. vs vs Ne P N 1.23ns .28ns Age Mean 33.66 31.25 34.24 S.D. 10.39 9.67 11.69 Range 221.62 15.52 15.60 Sex Male 26 (52%) 33 (58%) 47 (67%) X2= 2.91 Female 24 *48%) 24 *42%) 23 (33%) df=2 P=n.s. Education Upto X 15 (30%) 19 (33%) 34 (49%) X2 = 8.50 XI-Graduate 25 (50%) 33 (58%) 30 (43%) df=4 Above 10 (20%) 5 (9%) 6 (8%) p=ns Graduate Body Image Disturbances in Psychiatric Cares 51

Table 2 Diagnostic Break up of Cases Neurosis Psychosis Depression Schizophrenic Hysteria Affective disorder Anxiety Delusion disorder Obsession Other Phobia Total Adjustment Other Total Low umber of Most Typical Responses in psychotic and Neurotic groups indicates that their perception was not in group conformity. The same trend is further indicated by high number of Atypical Responses by psychotics and Neurotics. 16 images of S.I.S. were purposefully structured to elicit anatomical themes. These images were 14A, 15A, 19A, 20A, 22A, 23A, 24A, and 26A. In B series of S.I.S. II these were 7B, 9B, 11B, 16B, 17B, 24B, 26B and 27B. The specific structures elicited by these images are given in table 4. The percentage of responses in concordance it structural theme in three group of cases is presented in table 4. It is surprising that 9 B and 20 A were concordant most frequently with structured theme in al the three groups of cases. The correlations between Normal and Neurotic, Normal and Psychotic, and Neurotic and Psychotic in concordance with their rating were .71, .83, and .85 respectively. Perception of Normal was more in concordance with structured them of S.I.S. images 14 A, 23A, 11B and 16B. These images are similar to stomach, spine, lungs spine. Neurotics and psychotics as compared to normal subjects most frequently perceived fetus on 27B. Some of the structural themes were perceived by only a few cases in the three groups. This is with regard to female pelvis on 24A, female sex organ on 26B. This may indicate that perception of sex is denied by patients group as well a by normal group because of traditional values and restriction imposed by society. The difference of perceiving of structural themes compared to normal subjects also suggests some sort of denial. This is further confirmed from table 3, as Normal subjects gave higher number of anatomical responses than Neurotic and Psychotic groups. 52 Pershad et. al.

Table 3 Comparison of SIS Variables Background variable Normal Neurotic Psychotic t (No) (Ne) (P) No. No. vs vs (50) (57) (70) Ne P Ps R M 58.96 54.56 55.35 ** ** Sd 5.89 7.67 6.06 3.36 3.28 Most M 13.28 10.98 8.45 ** ** Typical SD 3.53 4.32 3.73 3.03 7.21 Typical M 23.24 20.39 17.92 ** ** SD 7.09 6.99 6.6 2.08 4.16 Atypical M 22.44 23.19 28.98 ** SD 8.73 9.41 10.10 .43 3.78 Human M 20.23 16.50 21.48 ** SD 6.31 7.45 7.46 2.87 .92 Animal M 9.42 11.86 8.13 * SD 4.52 7.25 4.35 2.12 1.57 Anatomical M 10.94 8.22 7.40 * ** SD 4.99 5.98 6.12 2.57 3.47 Sex M 1.80 1.21 0.97 ** SD 2.42 1.78 1.42 1.40 2.13 Other M 16.48 16.77 17.37 SD 7.82 9.44 9.43 .17 .56 Pathology M 0.01 1.10 0.71 ** ** SD 0.70 1.79 1.54 4.54 4.12 Movement M 2.90 2.17 3.24 SD 3.49 2.42 3.90 1.26 .50 Rejection M 4.42 7.40 6.87 ** ** SD 5.28 8.90 7.17 2.13 2.15 **p<.01 * p<.05 Body Image Disturbances in Psychiatric Cares 53

Table 4 Percentage of Concordance of Perceptual Theme with Structured Theme in Three Groups of Cases. Image Structural Comparison of Number theme Perceptual Theme Normal Neurotic Psychotic A B C 14a stomach 20.0 (7) 3.5 (15) 4.3 (13.5) 15A Stomach & Fetus 16.0 (11) 19.3 (6) 17.1 (6.5) 19A Intestines 12.0 (13) 17.5(8) 7.1 (6.5) 20A (Kidey & Lungs 66 (1) 68.4 (1) 54.2 (2) 22 A Spine 16 (11) 26.3 (5) 7.4 (10.5) 23 A Spine 48 (3) 28.0 (4) 30 (4) 24A Female Pelvis 4 (155) 3.5 (15) 2.9 (15.5) 26A Embryo 18 (8.5) 17.5 (8) 14.3 (8) 7B Ribs 8 (14) 3.5 (15 4.3 (13.5) 9 B Kidney & Lungs 62 (2) 61.4 (2) 55.7 (1) 11 B Lungs 28 (5.5) 17.5 (8) 18.6 (5) 17 B Heart 18 (8.5) 15.8 (10.5) 8.8 (9) 24 B Kidney 16 (11) 7.0 (12.5) 17.1 (6.5) 26 B Female sex organ 30 (15.5) 7.0 (12.5) 2 (15.5) 27 B Fetus 32 (4) 61.4 (3) 38.6 (3) Mean of % 26.4% 23.3% 18.0 % A-B=.71 AD.83 B-C.85 Figures in parenthesis are rank orders. Conclusion: Looking at the results it can be summarized that the psychiatric patients usually deny Anatomical structured. This is also true with regard to female sex organs. Amongst all the scoring variables. “ Most Typical” response category is the most potent to differentiate psychotic cases. Since S.I.S. is backed by theoretical soundness, its use in individual situations to understand body image disturbance for therapeutic purpose is likely to be more rewarding. 54 Pershad et. al.

References: Bonnier, P (1905) L’ achematicc Review Neurology, 13, 604-609. Brar, H.S. (1970); Rorschach Content Responses East Indian Psychiatric Patients. J. of Projective Techniques and Personality Assessment, 34, 88-94 Cassell, W.A. (1969); Responses to Inkblot Configurations Resembling the Heart J. Projective Technique and Personality Assessment 3, 123-126. Cassell, W.A. (1971); Body Consciousness in Exhibitionism. British J. Projective Techniques, 16, 21-31. Cassell, W.A. (1972); Individual Differences in Somatic Perception. Advances in Psychosomatic Medicine, 8, 84-104. Cassell, W.A. (1977) Aggressive Imagery and Clinical Symptoms in Schizophrenia. British J. Projective Technique 22, 21-34. Cassell, W.A.(1955): SIS-II Manual. Somatic Inkblot Center, Anchorage, Alaska. Dubey, B.L. and Cassell, W.A. (1993); Some Experience with Somatic Inkblot Series. Brit J. Proj Technique, 38: 19-41. Gerstman, J (1927); Fingeragnosie and Islierte Agraphia. Neurological Psychiatry 180, 152-177. Goel, D.S., Rathee S.P., Sardhana M, and Chapel A.D. (1990); SIS-I in Coronary Heart Disease. Presented in the 1st National Workshop on SIS and Rorschach, Chandigarh . Goldfriend, M.P., Sticker G, Weiner IB (171); Rorschach Handbook of Clinical and Research Applications.. Englewood Cliffs. Prentice Hall. Lhernitte, J. (1939): Linage fe Notre Corps Paris: Nurvall Revue Critiques. Poek, L. and Orgass B (1967); The Concept of Body Schema; Proceedings of Annual Meeting of Academy ofAphesia, Michigan. Tait, C.D. and Ascher R.C. (1995); Inside the Body Test . Psychosomatic Medicine, 17: 139. Verma, S.K., Wahi P.L. and Wig N.N. (1972): Disturbances of Body Images in Patients Awaiting Surgery. Indian J. Psychology, 9, 44-46 Wickelgen, I (1989); Images of Pain. Science News, 136, 136-137. Wentinck, C (1972): The Human figure, Wynnewood, Pennsylvania: Livingston. Body Image Disturbances in Psychiatric Cares 55

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