SIS Journal of Projective Psychology & Mental Health

ISSN 0971 - 6610 ISSN 0971 - 6610 ISSN 0971 - 6610 ISSN 0971 - 6610 ISSN 0971 - 6610 JOURNAL OF PROJECTIVE PSYCHOLOGY & MENTAL HEALTH The Official Publication of the Somatic Inkblot Society Volume 14 Number 2 July, 2007 SIS

SIS JOURNAL OF PROJECTIVE PSYCHOLOGY AND MENTAL HEALTH is a refereed journal and 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, counseling, 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 through E-mail or in CD to B.L. Dubey, Ph.D. Editor Emeritus, SIS Journal, E-mail:sisdubey@rediffmail.com. or sisdubey@yahoo.com with a copy to Amool Ranjan Singh, Ph.D. Editor In Chief and Head, Dept. of Clinical Psychology,RINPAS,Kanke,Ranchi-834006. E-mail:editor_sis@rediffmail.com & sisamool@yahoo.com, Mob 91-9431592734.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/ SIS Journal of Projective Psychology & Mental Health. SUBSCRIPTION: The journal is free to members of the Society, Annual membership fees are US $40 for foreign members and Rs. 300, for Indian members, Institutional subscriptions are US $60. for Foreign institutions and Rs. 600 for Indian institutions. Life membership is US $300. for foreign members and Rs. 2500/- for Indian members. Indian institutional life membership is Rs. 4000/-. Non-members may subscribe for $30 or Rs. 200 per issue. Cheques should be made payable to "SIS Journal of Projective Psychology and Mental Health" and should reach Amool Ranjan Singh, Ph.D. Editor In Chief. Members in foreign countries should send the cheque to B.L. Dubey, Ph.D. Editor Emeritus, 4406 Forest Road, Anchorage, AK-99517 (USA) Please add $5./Rs.60/- if you are sending subscription through cheque. CHANGE OF ADDRESS. Society / journal members should inform B.L. Dubey Ph.D, Director SIS Centre, Email : sisdubey@rediffmail.com Copyright @ 1994. SOMATIC INKBLOT CENTRE, India/Anchorage U.S.A. Website: http://www.somaticinkblots.com

SIS Journal of Projective Psychology & Mental Health Volume 14, Number 2, July 2007 Contents Page Nos. 1. Editorial : SIS : A Journey of Projective Technique from 85-86 Assessment to Treatment Amool R. Singh 2. SIS and Sand Tray Psychotherapy of Suicidal adolescents 87-97 Wilfred A. Cassell and Bankey L. Dubey 3. NEO and Hand Test Differences Between Chronic Pain Patients 98-109 and Non-pain Controls Paul E. Panek , John J. Skowronski, J. Michael George and Edwin E. Wagner 4. Gender Differences in Factor Structure of SIS-II Responses 110-116 Umed Singh 5. Projective Indices of Creativity: A Pilot Study 117-120 Dharmendra K. Singh, Gobinda Majhi and Amool R. Singh 6. Rorschach Profiles of Mentally Challenged and Severely 121-128 Hearing Impaired Children K. C. Vashistha and Shweta Bhardwaj 7. A Study of Potential Correlates of Reasons for Living in 129-134 College Students Atanu Kumar Dogra, Sujoy Kar and Saugata Basu 8. A Personality Perspective on Female Infertility: An Analysis 135-144 through Wartegg Test S. Daini, L. Bernardini and C. Panetta 9. SIS in Paranoid Ideation: A Case Study 145-149 Radhe Shyam 10. Rorschach Responses of Indian Children and Adolescents with 150-161 Psychiatric Disorders Suprakash Chaudhury, D. Saldanha, K. Srivastava, S.G.Jyothi, G.S.Sundari, and M. Augustine

SIS Research Award The editors and editorial consultants wish to express their sincere appreciation to Dr B.L.Dubey for his insightful and dedicated leadership. We wish to announce his selection for this year’s Research Award of one thousand dollars. Also to be praised are the behind the scenes supportive efforts of his wife Padma Dwivedi. Under their loving guidance, we have witnessed the birth of a new bodymind-spirit journal for SIS workers internationally. We also wish to acknowledge the impressive contributions of their son Anand Dubey. He has elevated the journal beyond traditional paper bound words to an electronic state of the art Internet communication vehicle. We anticipate many further years of their dedication to spreading information about the power of SIS technology for assessment and healing. Wilfred A. Cassell, M.D., FAPA. Director SIS Centre 4501 East, 104th Avenue, Anchorage, Alaska - 99516 (USA). Email: siscassell@yahoo.com

Editorial SIS : A Journey of Projective Technique from Assessment to Treatment Projective technique began its journey systematically in the year of 1921 by the publication of Rorschach Psycho-diagnotic test and occupied major position. The work of Herman Rorschach in the field of inkblot paved the way to many researchers to think seriously about the concept of formless stimuli that can stimulate an individual’s imagination and help to understand about the personality. Projective tests of personality assessment adapt a very different approach. Ambiguous stimuli that can generate a force into an individual to represent his/her own inner-offen unconscious feelings and needs. These stimuli are interpreted in different ways sponteneously as per psychic structure of the organisms. Since the stimuli themselves are ambiguous, it is assumed that the response given by the indivuduals will atutomatically reflect various aspects of their personality. Meaning there by, different individuals will perceive different things in these stimuli because individuals differ from one another in important ways. In 1959 germination of SIS took place into Dr. Wilfred A. Cassell’s mind while working with Seymour Fisher, who was an authortity on body perception. While initiating the idea of a newer test, the concept of body image got significant place as Cassell thought that projection carried through using an inkblot technique might yeild good results in the clinical practice of psychiatry. And then, the first series of Somatic Inkblots based on the concept of body image was developed in 1960. The Somatic Inkblot Series (SIS) provides images in three forms : on cards, in a booklet and on videotape. The Somatic Inkblot Series consists of inkblot images printed in black, red and gray colours on white cards. SIS images provide enough obvious anatomical structure to evoke spontaneous verbalization, but not enough to limit the responses solely to the naming of body parts or colours. In this way, obvious anatomical structure provides a feeling of secrutity, which makes deeper and symbolic repressed material more accessible to the person for evaluation and assessment (Cassell & Dubey, 1990). Cassell & Dubey (1990) concluded that “SIS is especially helpful in evaluating patients with limited language and verbal skills, the learning disabled or mentally subnormal as well as the normal population such as children, foreign born or new immigrants, native peoples. Those with limited language and verbal skills usually rely more on visualisation and adopt better to SIS than verbal interviews or testing that requires reading or language skills. SIS images generally use the language of dreams, visual imagery, and symbolic thought alongwith the most basic froms of thinking and expression. It is also the language of expression and brings whatever is buried in the mind”. The SIS provides a new diagnostic aid and can be used to assess in depth the significance of somatic symptoms, conversion reactions, somatic delusions and sexual dysfunctions. Psychodynamics of mutilated or distorted anatomy responses pave the ways to assess the possibility or level of castration anxiety (Cassell, 1980). Responses depicting themes of body assault may further clarify the extent of aggressive impulses (Cassell, 1977). Undeteacted affective disorders can be evaluated through somatic inkblot series (SIS). The responses to SIS inkblots might uncover body perceptual disturbances such as in catatonia, or the cognitive deficits of early schizophremia. Death annxiety in those going through major surgical operations or those suffering from terminal illness may give indication by excessive anatomical responses (Cassell, 1979). To make the procedure more interesting and dream-like, the video version of SIS was developed by Cassell in 1984. The SIS video begins with pictures of flowers and soft backgrond music, followed by

stimulus images, one at a time. Many of the images are coloured, and for some, impression of movement is also created. Many of the images are sharper on screen than they are in the booklet. The floral presentation, with soft background music, induces the subject to relax. Through the power of projection, it can reveal material from the inner self (Panek, 2001). Relatively unstructured and semi-structured images afford the trained examiner a wide range of oportunities for the comprehensive examinatin of the subject’s cognitive and emotional processes. The SIS has both diagnostic and therapeutic properties. Besides diagnostics it provides a useful aide to therapy which has been proved by a number of innovative clinicians and researchers. As more clinicians avail themselves of the SIS technology, they will be more effective at developing indepth and sophisticated treatment plans. One can envision and apply optimal blending of information from the medical and psychological aspects of human existence for the purpose of psychotherapy strategy. Refrences Cassell, W. A. Aggessive Imagery and Clinical Symptoms in Schizophrenia. British J. of Projective Techniques, 1977. 16: 21-31. Cassell, W. A. Anatomical Rorschach Responses and Death Symbolism. British J. of Projective Technique and Personality Study, 1979. 24: 7-16. Cassell, W. A. Body Awareness and Somatic Delusions Involving Sexual Organs. American Journal of Psychoanalysis, 1980. 40: 125-135. Cassell, W. A. & Dubey, B. L. Interpreting Inner World Through Somatic Imagery : Manual of the Somatic Inkblot Series. Somatic Inkblot Center, 4501E, 104th Ave, Anchorage, Alaska 99516 (USA), 1990. Panek, P. E., Editorial: Projective Psychology in the New Millennium: Issues and Challenges. SIS J. Proj, Psy. & Mental Health, 2001. 8:73-74. Rorschach, H. Psychodiagnostic. Ernst Bircher, Nern, 1921. Amool R. Singh, Ph.D. Editor-in-chief Prof. & Head, Dept. of Clinical Psychology, Ranchi Institute of Neuro Psychiatry & Allied Sciences (RINPAS) Ranchi-834006 (India) e-mail : sisamool@yahoo.com 86 Singh

SIS and Sand Tray Psychotherapy of Suicidal adolescents Wilfred A. Cassell and Bankey L. Dubey Many highly skilled psychotherapists are so immersed in practice that they rarely find time to publish their clinical findings. Yet they will gladly give of their time in case history training seminars. This article is based upon a transcript of an educational television interview with a practicing child psychiatrist and Jungian trained analyst experienced in Sand Tray technique. This is a widely used diagnostic/treatment approach which at this time of publication has 9,170 references in a Yahoo search engine. Like the Somatic Inkblot Series (SIS), this diagnostic/therapeutic approach is conceptually grounded in the body-mind-spirit principles of projection. When a child, adolescent or adult views ambiguous SIS “Inkblots” or figurines in a sand box, the responses can symbolically reflect disturbances otherwise hidden from traditional clinical interviews. The clinical application of these two projective approaches as clinical aides in the psychotherapy of two suicidal Alaskan native adolescents is discussed in the training tape. Before a transcript is presented, a brief review of current SIS theory will be reviewed. The video and computer monitor versions act as both a “Time Machine” and a modern day “Dream Catcher”. Each initially presents hypnotic like floral stimulation. This sensory input is received by the retina and then transmitted by the optic nerves to the visual centers in the brain. While no neuroscientist can explain the basic mechanisms by which the brain gives rise in consciousness to imagery, the hypnotic power of the SIS appears to work as follows: it transfers the viewer back in time to previous stressful periods. When the ambiguous SIS inkblots are presented following two minutes and fifteen seconds of the memory altering hypnotic flowers; this activate neural circuitry which previously recorded stressful situations, as well as their symbolic “nightmares”. This activation may be conceptualized as an illustration of SIS electronically based artificial intelligence. The latter stimulates the viewer to rethink and clarify confused memories, during low levels of autonomic nervous system arousal. When the visual activation of emotionally charged imagery is immediately followed by an image of a beautiful flower, this electronically reconditions the brain’s memory storage neurons. The nature scenes at the end of the 62 “Inkblot” series further facilitates the reconditioning. In terms of exploring the basic neurochemical mechanisms, there is now relevant research literature in the field of “Stress”. In laboratory animals, the administration of an anxiety blocking drug such as propranolol during experimental induced stress has been shown to block the recording of traumatic memories. Joseph Le Doux, a neuroscientist at New York University ( ledoux@cns.edu) has been conducting a clinical trial of propranolol in PTSD patients. This may now warrant clinical investigation with SIS stimulated stressful memories in the multidimensional treatment approach of such mental disorders. What is relevant to recovery is that sometimes solo SIS viewing enables a cognitively intact adult trauma victim to subjectively clarify the confused thoughts independently, without professional assistance. Yet especially with children and adolescents, a SIS trained psychotherapist can facilitate the recovery process by systematic projective response based cognitive behavioral psychotherapy. Transcript of Training Video Tape The following is a transcript of a somewhat loose and free flowing televised case conference discussing these approaches: Wilfred A. Cassell, MD, Director, SIS Center, 4501E, 104th Avenue, Anchorage, AK.99516 (USA). E-Mail: siscassell@yahoo.com and Bankey L. Dubey, Ph.D., President, Somatic Inkblot society, 4406 Forest Road, Anchorage, AK 99517 (USA) E-mail:sisdubey@rediffmail.com Key words: Sand Tray, Therapeutic Intervention thru SIS and Sand Tray

92 Cassell & Dubey Dr C.: “As one gets older, you appreciate the value of family and friends. Over the years, these are much more important than status or material things. One hears that said, but it truly is something that one can experience. It is a particularly traumatic if the stress involves the loss of loved ones. Today we are going to examine the effect of such a loss, in two Alaskan native youths. We are going to do this by reviewing their projective responses to Sand Tray and to the Somatic Inkblot Series (SIS). I am very pleased to have an authority on Sand Tray here - a senior child psychiatrist Dr. Patricia Patrick. Dr. Patrick could you fill us in a little bit on your experience with Sand Tray. Dr. Patrick: Thank you. Sand Tray or Sand Play therapy is a technique that was developed by a woman named Dora Koff. She was a Swiss woman, a friend of Emma and Carl Jung who went to England after World War II. Because of the numbers of children who had been displaced during the Blitz there was a virtual laboratory of children with problems. A woman by the name of Lowenfeld, who was a pediatrician from Poland tried very hard to find a way to help heal their wounded psyche from the affects of being separated from their families for such a long time. Dr. C.: When I was a youth back in Canada in World War II, one of my playmates was a boy from Britain. Dr. Patrick: Right. Many of those children went as far away as Canada. Often they were gone for as many as 5 years and had their youth away from their families. They then came back to London after the war and had to reunite with their families. Dr. C.: So their loss was real? Dr. Patrick: Their loss was real and then they needed to reintegrate. Dr. Lowenfeld developed a technique, which she called “Role play”, using a sand tray. Now Sand Tray… let me show you a picture here (Pointing to a photograph), is an actual visual field. It is about the size of a poster because you can look at the centre of the tray and see all parts of the tray at the same time. As you can see the depth of the tray is about 3” and it is usually about half filled with sand. Usually we work with a wet tray and a dry tray. Dr. C.: I like the notion of it also being analogous to a SIS “inkblot”. Dr. Patrick: Exactly…or a dream. A “Dreamscape” is the same idea. Dr. C.: And I think that is where our work comes together, the projection onto the SIS inkblot or onto the Sand Tray figurines. They both access the same stream of consciousness and dream imagery. Dr. Patrick: Exactly. It is the internal world of the psyche, the unconscious part of the psyche that now gets represented. What Dr. Koff did was she developed this technique. What we do is use miniatures, such as these which are on shelves and the patient or client selects from these the things that appeal to them. They then put them into the tray to make a picture. From that picture then, we believe that there is a representation of the internal psyche of the person. Dr. C.: Many of the figures are humanoid or human, but then a lot of the objects can be animal or inanimate objects as well. Dr. Patrick: And natural things such as rocks and sticks, leaves, flowers, anything that occurs in life, then can be represented in the sand. The collection can be very complicated; thousands and thousands of things, or it can be very simple. In the psychiatric hospital setting where we are working now, our collection is relatively simple. It probably is not more than maybe 200 items that we use. Either way it works well.

SIS and Sand Tray 93 Dr. C.: So the subject has to actively select figurines and in that motor process, the symbolism can get projected onto the objects. Then the way that the objects are arranged is analogous to how they symbolically respond to structured human content in the SIS. Dr. Patrick: Exactly. Then they make a picture using these various miniatures in the sand. They start with a blank sand tray and put things in until they have composed a picture. Then we believe that the picture then represents their internal psyche. Then of course, there are certain ways that we then interpret what we see. There is certain universality as well as a personal representation of the psyche (Jungian psychoanalytic theory). Dr. C.: And there is something else I think too in the sand: The “Earthiness” of the sand, apart from the symbolic objects. Dr. Patrick: Exactly. In fact someone has said that the sand, because it is earth really represents the “Great mother” and the comfort of that mothering. Also because you work with your hands in the sand, then you involve the body. So then it becomes… Dr. C: An expression, a motor expression. It gets away from intellectual abstraction into something that is more real and yet is non-verbal. It goes beyond the limitations of language as a mode of psychotherapeutic communication. Dr. Patrick: Exactly. It is non-verbal. And that is really a wonderful part of this technique. The client doesn’t have to have verbal skills. So a very young child can use it. Moreover many of our North American native children don’t talk very much. Often they don’t know how to put some of these ideas into words. Consequently they can be very much helped by this. People who are very intellectualized, who live in their head you might say, can take advantage of this as well. It puts them into a different dimension of psyche in the work that they do. Dr. C: And I notice that the human figures are of various cultures…white, black, whatever, and different ages. The human representations in the SIS were also designed as much as possible to be universal in appearance. Dr. Patrick: Yes. And we try to represent in the figure as wide a variation as is possible. Then of course, sometimes you don’t have exactly what someone wants and then they can make it. We often have clay and paper and some things that can be made into something if it doesn’t quite fit with what that person feels, or want to express at that moment. So there is a wide variety available. Clinical Case Conference Material : Dr. C.: Maybe we could now talk about the results with the two teenagers. The first is a seventeen year old Alaska Native youth. He came into the hospital very depressed. He had a history of suicide attempts in various ways and had been self mutilating. Frankly we see a lot of suicidal youths, but not one that had marked himself up so much! He had cuts on his arms and his forearms, and all over his chest. What did you observe with his Sand Tray? Dr. Patrick: Let me show you. Dora Koff said that the first tray often tells us what the dilemma is that the person is facing. Here we have the first tray that this young man did. He actually is standing right here, as he is working, and I was sitting over here (gesturing), just to orient you in time and space. That is important because we think that the closer that the objects are to the person, the more unconscious the issues and the higher levels of up here would represent more consciousness. There is also a representation here, mother and father. Some people think that this side of the tray here tends to represent mother and this side of the tray here represents father. Other people think

94 Cassell & Dubey that the father part is the lower part of the tray and the mother part, the higher part of the tray. Sometimes this is reversed, so that this might represent father, this might represent mother. So you can see that each person is a little bit different as we would expect in the human condition and yet there are certain things that are similar or certain lines that you can follow. Dr. C.: One of the things that I didn’t mention is that one of the losses that this adolescent boy sustained was the drowning death of a cousin. This occurred several months earlier. Fred had been swimming and his two cousins had actually been wading in the water. Tragically neither one could swim and they both waded out beyond their depths. Fred was able to be brave and went in and rescued the one boy. However by the time he got that boy out, the other one had drowned. He had a tremendous amount of guilt and self directed rage. The latter was reflected in the extreme cutting on himself. So the source of one of his losses was this drowning death. Dr. Patrick: I think in his try we see some very interesting things. First of all, I think the most obvious thing that you notice right away is this large expanse of emptiness. Over half of the tray has nothing in it. And here, across the bottom are these animal figures. I think they are fairly identifiable. This is a black stallion here, bears, the moose. This is a Beluga whale. This is a gorilla. This is a wild cat, and a lion. You have human figures here, bridal couple and you have a Kachena doll here, a spiritual figure. Of course in front you have three flowers. There are some interesting things about these animals, I think. First of all, they are all at the bottom of the tray and they are all pointing towards the top. You will notice that they are all focused in one direction. Dr. C.: And they tend to look powerful. Dr. Patrick: They are all powerful. Dr. C.: Fred is sort of a macho guy whose strength and sexuality are important to him. Dr. Patrick: It is interesting that all of these are animals are at the top of the food chain. None of them are particularly aggressive animals, in other words they don’t go and look for problems. The Beluga whale, which in the next slide gives you another picture of the Beluga whale, kind of dominates the animals. Of course, is very mild mannered animal and not ferocious at all. Dr. C.: Some of the other animals that are in the background have a capability for aggression, but they are not put in there in a very aggressive way. Dr. Patrick: Right, they do not appear aggressive. In talking about this tray, he emphasizes, “Bridal couple”, saying that this was something that he hoped for in his own life - to get married, and to have a wife. I think the three flowers are very interesting in this tray coming as they do, almost dividing the emptiness from the animals, or the instinctual energy moving up. It is hard to know whether these three flowers are holding the animals in check, or whether they are releasing them out. But I certainly think that if one thinks of this as being of a consciousness and all of this being conscious, you can see that he does not have much going on consciously, except this kind of blanket you might say, holding down this instinctual energy. So it makes sense to me, certainly under the influence of alcohol or drugs that this young man would burst forth with some instinctual energy. Dr. C.: And that is what happened. His self mutilating episodes occurred when he was intoxicated. Dr. Patrick: That makes sense given this picture. Dr. C.: What about the flowers and the feminine aspect of his self. Dr. Patrick: Red flowers in particular are certainly a sign of love. You could say, also that these flowers might be funeral flowers. This may be representing some of his angst about all of this that has gone on,

SIS and Sand Tray 95 as a young man who has experienced a lot of deaths, unfortunately. Certainly that could be that…the passion of the red. It is interesting that he chose red flowers, not white flowers or yellow flowers. Dr. C.: And Fred is likeable. We all bonded to him and that passionate quality. I think that is significant. Dr. Patrick: I do too. I think that is one of the hopes in this tray. Certainly it has been devastating to him to have that energy that he uses against himself. But I also think that is where the hope for his future might come from too. Those are really at the highest point and more conscious. So he is more aware of that energy and might be able to use it. Like that Beluga whale, to use it to come moving up and into consciousness which I think would be part of the hope of therapy. With the therapeutic endeavor you could get some of that energy coming up or he could utilize it at a conscious level. Dr. C.: Certainly he has a clear phallic aspect. Dr. Patrick: Definitely…definitely. SIS Responses: Dr. C.: I wonder if we could maybe review some of the responses to the SIS. As you know, I have subjects indicate the three that they like most and the three that they like least. The first image that I wanted to comment on is 15B. This as you can see has some sharp-like objects (Pointing to his SIS answer sheet). He rated 15B as most threatening. Perhaps that is not surprising that he imagined these to be “Knives”. When asked why these were so threatening, he said that it was because “These knives could kill”. He then immediately related his memories of self mutilation. The second image that bothered him was 22B. He saw this as “Someone dead and going to heaven.” In the detailed enquiry, it immediately led him to recall the death of his cousin. He then spoke about his guilt, grief and how he felt at his cousin’s funeral. At that point in talking about it, a few tears appeared on his cheeks. However, he still had difficulty in the chest movements of expressing grief more completely by sobbing openly. Expressing such feelings (i.e. “Inner cry”) is ordinarily quite difficult for Alaskan native males. However, it was helpful to begin the grieving process with SIS stimulation of affect. Dr. Patrick: That really fits within with this third projection of his slide. This is taken from where I was sitting and I think you can see here some of the animals coming at you and how frightening that looks. I think that really fits with what you are saying with the images here. I think this boy is very much afraid of these feelings. These instinctual forces are breaking through and overwhelming him. I think that is what is reflected in the SIS as well. Dr. C.: Native male adolescents have the highest suicide rates in the United States. Their culture has been stressed by many socioeconomic and religious pressures which have undermined traditional native views of spirituality and death. Previously native people have had to live in close proximity, in igloos over the years. The expression of aggression is really minimized, more so than in many other cultures. When it is internalized, it usually gets released through the disinhibiting effects of alcohol. Certainly sitting and looking at his sand tray symbols is consistent with the SIS projective responses. Dr. Patrick: And there is a problem of course for these young folks, because they don’t have the fight against the elements to utilize their aggressive energies as they did in the olden days. Now they are in villages and in houses and locked into a different kind of culture, so they don’t have a really good means. I think that may be part of what we are seeing here, is this blockage that this boy is experiencing. He has all of this stuff going on and no good way to let it out and let it be expressed.

96 Cassell & Dubey Dr. C.: And his adolescent identity can be as a hunter of animals and so on. However as he gets older, he has to earn a living and survive in a modern economy for which he is not prepared. This is highly stressful! Coming back to his SIS responses… the third image that he rated as threatening was 29B. He imagined this to represent “Someone hurt”. Moreover, he saw it as a “Human without a leg”. This symbolized his thinking about the future. He foresaw gloom, imagining himself without a future - apart from a being a hunter or fisherman. He anticipated that eventually the native girls would lose interest in him, unless he got a well paying job. He envisioned his future, as sort of be without a leg to stand on. There are two additional responses that I would briefly comment on as follows: 13A. His response captured his inner suffering. He saw that as ‘A hand coming out of flames”. This symbolized the suffering that he has had with his grief and unexpressed inner cry. And 19B, the last reference to flames: “The earth and sun, flames and hearts”. Dr. Patrick: Here we have that red theme that you see in the sand. You see it again in the SIS “The red flames”. Dr. C.: Exactly. Case II: Dr. C.: The second adolescent was very psychologically impoverished and very, very depressed. She recently had made a serious suicide attempt with an overdose of medication. She had been chronically depressed. In one suicidal episode two years previously, she had jumped out of a second floor window and fractured her leg. Let’s look at her Sand Tray responses. Dr. Patrick: Alright. This is May’s tray. Dr. C.: And I might say that she had multiple losses. Her mother had died when May was young in a snow machine accident. Since the snow machine had gone through the ice and her mother’s body had never been found. Consequently there had been no closure. Dr. Patrick: This as you can see is a very impoverished tray. It has only these few objects in the middle…a house, a woman, a soldier and this Collie dog. While she was sitting after she had made this tray, she sat and you could see these two impressions here in the side. She took and worked the sand with her hands, clutching it and forming fists with her hands in the sand. Dr. C.: So her anguish and suffering was right into the soil - symbolically into her soul. Dr. Patrick: Right in, yes. I often ask folks to label or to name the picture that they make, and she labeled this “Happiness.” She said that this is what she thought would be happiness…having a family, a husband, a wife, a house and a dog. There is certain pathos for me in that. There you see this very empty child. Dr. C.: With the “Happy” fantasy. Dr. Patrick: This fantasy held in her centre. Let me show you another picture of this, so you can get another idea. Here is from the side. May worked from this end, and I was over at this end. I think another thing about this tray, here it is looking right at it, in addition to the emptiness, I would like to make mention that this is worked the long way. Often times when people work in the long aspect of the tray, they are working on body awareness issues. This is a girl who I know was sexually abused. Dr. C.: Yes, tragically yes.

SIS and Sand Tray 97 Dr. Patrick: And you might even say that while this is a picture of her body, these might be ovaries with a sexual parts here, and this is often something that is shown in trays, demonstrating that she is really trying to deal with that aspect of her psyche as well…the sexual issues that have been unresolved as a result of her early experiences. Dr. C.: And that would be consistent with what her female hospital psychotherapist had reported previously about her abuse issues. Dr. Patrick: Oh yes. And this youngster is very pathetic in a way, because the sand tray is so empty. I think there is real hope for this girl in that she has within her really the elements of her future and her happiness, if only she can let those thrive. I think that is really our job as psychotherapists to help her open up. I suspect that this youngster sees this insulation that she has developed around herself, around her core, as coming from the outside, that people don’t give me enough, people aren’t nice to me, people don’t love me enough, rather than that she has built this wall around herself to protect this very vital core. Of course that has to do with the early loss of her mother and the lost of trust and needs to be rebuilt for a long period of time with trusting relationships…therapeutic relationships that allow her this protection that might then allow her to open up. Dr. C.: And I like the notion, that with the sand tray she was actually working through and processing the old memories imagery that were traumatic, even thought she couldn’t verbalize them. She may need to verbalize them, as long as she is in a working symbolic processing psychotherapy. Dr. Patrick: Exactly…exactly. SIS Responses: Dr. C.: I wonder if we could review, perhaps in a little more detail, than we did with Fred, some of her responses to the Somatic Inkblot Series. The image that she liked most was 10A. She rated this as her favorite…she said that it looked “Pretty”. And I asked her what it reminded her of, and she said it reminded her of “A woman’s face”. This immediately led to associations of the mother. She spoke about how she thought her mother was “A beacon of light and hope” for her. It was significant that she pulled out of all these images, her favorite, was her mother. This was consistent with her fantasies of obtaining maternal nurturing and a secure home. At this point in the detailed enquiry, she was asked if she ever dreamed of her mother. She answered in the affirmative but referred to her dreams as “Nightmares”. One recurrent one involved images in which her mother’s eyes were eaten by worms. This symbolism reflected her cognitive distortions about the fact that her mother’s body had never been found and its ultimate fate. There had been no adequate grieving or closure. This concern about her mother’s deteriorating body appeared in her symbolic anatomical response to the most threatening SIS inkblot, 19B. This was imagined to represent “The sun with worms and heart”. The second most threatening image for her was 12B. She gave associations to 12B as being “A witch”. She said it was very “Scary”. That association historically went reflected the surfacing in consciousness of PTSD memories involving her abusive step father. The third SIS image that she disliked was 30A. She said, it looked like “A skull”. Looking at it actually made her feel nauseated. She also saw “Skulls” on 4B, saying it looked like “Two skulls”. One reminded her of the deceased mother, and one the adopted mother who died several months after the mother’s

98 Cassell & Dubey drowning. In other words, she had a double loss. As you know losses add up…the loss of her biological mother and then of the adopted mother. So her difficulty in bonding and her emptiness have partially to do with that. By the way, one of the parallels with the SIS too, was that her imagination was quite impoverished. Just like she didn’t select many objects in the sand tray, she rejected several SIS inkblots. Dr. Patrick: Yes. I’m not surprised. Dr. C.: Since these blots have a lot of color-form structure, the number of rejections is a major index of her psychopathology and the intensity of inner emptiness. Dr. Patrick: I would expect that there would be a correlation. If one were to be working with this youngster on a long term basis in psychotherapy, she would to begin to flower. I would predict that she would come out of this encapsulation that she is experiencing now. She would likely find more resources, both within and outside of herself. It would change her Sand Tray picture. She would probably open up in the SIS too and you would see many more responses. Dr. C.: Again, she has been seriously suicidal through overdose, jumping out the window and a hanging attempt. Self mutilation had also been frequent. Consistent with such emotional turmoil 9A was seen as “Eyes that looked very scary”. The eyes were “Penetrating” and so on, and brought to mind eyes of the step father. So there was a certain paranoid quality with the emphasis and the memories of the perpetrator in the background of consciousness. She had losses of mother and maternal figures. She didn’t have them to protect her from her perpetrating step father. By contrast her response to13A was somewhat positive. She indicated that looks like “God’s hand going through a ring of fire”. On this I was able to give her some support for the spiritual aspect of her life. The fire again, as with Fred, symbolized her intense inner suffering. A14: was seen as “A knife stabbing a liver”. This is a very unusual response- a horrible response. Then she flashed back to an incident in which the woman who had adopted her had been threatened by a man, one of her boyfriends and she had defended herself. Apparently her mother pulled a knife and stabbed the boyfriend. During the police investigation, she feared that this support figure would be taken away by being incarcerated in jail. After a loss of the biological mother, children are much more fearful that they are going to loose any future supportive relationships. A19: was seen as “A fetus… It looked like a miracle”. She spoke about how she was preoccupied with images of babies and consistent with the notion of eventually having family. At this point, rather than reviewing all of her responses, we will try to just hit some of the ones that were clinically relevant. B2: looked like “An alien”. This made her feel very scared. It brought to mind irrational fears of being attacked by aliens. She then revealed a fear of aliens and their “ghost” like “nightmare” symbols. B11: symbolically captured her depression. It was seen as “A human heart that looked broken”. So she had trouble really expressing sadness directly, but not symbolically. With the sand tray what sort of symbolic things come out with depression, broken hearted concepts? Dr. Patrick: One of the things that we see is this emptiness which we often see in depressed folks and which I certainly see in this youngster’s tray. There is this isolation, nothingness feeling that people talk about and it gets expressed in the sand. It is definitely part of the picture that we often see in the sand, an impoverishment due to the depression.

SIS and Sand Tray 99 Dr. C.: 15B was imagined to represent “Icicles”. She said they looked “Very cold”. Her associations to this took her to fears of her being hit on the head with an icicle. This clearly is a native problem during the long Alaskan winters. Then she spoke of how her mother’s friend had actually had this happened and had been severely injured. And as we were saying, one loss makes you afraid that other losses are going to happen. B18: looked like “Sperm”. This is an unusual response for a 17 year old girl and likely relates to the issue of her sexual abuse. B20: activated the defense mechanisms of repression and perceptual substitution. Here the reference to the imbedded brain SIS structure was avoided. This avoidance was consistent with anxiety about her confused thinking and brain function. Instead of recognizing the embedded anatomical structure, her mental defenses perceptually substituted an image of “A baby”. Her depression was sufficiently severe to have at times psychotic features involving transient hallucinations. In psychotic states, sufferers may be more conscious of the brain and either rapidly identify the SIS brain structure or because of the anxiety-threat avoid reference to it. This avoidance was clinically significant since later on in responding to30B. Then perceptual mechanisms did in fact project an image of a brain. This solely reflected “Projection” since it took place totally in the absence of any such embedded anatomical structure. So the anatomical SIS structure denoting the human brain was repressed at one point and then a brain image projected out in full conscious awareness moments later. That is why quantitative scoring of SIS and Rorschach anatomical responses is so numerically fraught with problems. In such cases one response pattern cancels out the other. This results in a potentially invalid summation score. Quantifying anatomical responses based upon psychological defenses and ill understood underlying brain inhibitory processes poses a challenge for twenty first century neuroscientists. B21: was seen as “A gun”. It reminded her of many episodes of relatives being threatened with guns. She had been socialized with a dysfunctional background with a lot of alcoholic violence. B22: initially she didn’t see anything here, and was totally perceptually inhibited. After a long pause, an image of a body surfaced in her conscious mind. This time the body became the “Body of the adopted mother”. A death scene was immediately recalled. Then she spoke of how when she had been alone with this woman in her final moments as she died of a “Heart attack”. May was alone with her at the end. She recalled feeling helpless, very unworthy and guilty… irrational guilt that she couldn’t prevent the death. So that again this response sequence symbolized her psychopathologic reactions to a second tragic loss. And her last response which we will look at will be 28B. This SIS stimulus has a nurturing quality. Dr. Patrick: Yes, that is a beautiful picture. Dr. C.: She couldn’t see anything in this. So the absence of maternal content, and her rejecting this, is consistent with the fact that… don’t you think… that she didn’t have the nurturing imagery and all support associated with that. Dr. Patrick: Oh yes. I think early sexual abuse. Here is a child who not only lost her mothers, but whose trust in mother was impaired early on because of the sexual abuse. So she didn’t probably get the kind of nurturing that she needed in order to really sustain herself early on. Then to lose that mothering object, is a terrible blow to psyche and requires a great deal of work later in life to repair that damage.

100 Cassell & Dubey I think that what we see in the sand and what you see in the SIS really reflects that distortion of the early object relationship with mother. That now becomes the prototype for all her relationships. Here she has isolated herself, holding on so dearly to just that little piece that she has inside of herself. She is fearful that she will lose it. Then of course, in the process is losing it to life. This is of course the paradox that we work with all the time. Dr. C.: I like the notion that both of these procedures in themselves have diagnostic/therapeutic aspects. They have the potential to help people, especially those who have trouble verbalizing. I first observed that many, many years ago. Someone would view the SIS and express immediate relief independent of professional aide What has been your experience in therapeutic response with the Sand Tray technique? Dr. Patrick: Oh, very similar... We have just looked today at the very first trays because we are really looking at the diagnostic piece. But as the tray process goes on, I think the beauty of the sand tray is that you don’t have to come into consciousness in order for the psyche to work. And that just simply by working in the tray, session after session, in this free and protected space, in which the person can remold their psyche, there is a flow, there is a process, and a healing that happens even without either the client or the therapist really knowing, intellectually knowing, what is going on, but just simply experiencing the process itself. And I think that is probably true with the SIS too. Often times I am sure you don’t know in an intellectual way what is happening or what this means…but something in the process happens and the psyche heals. Dr. C.: It is interesting in terms of the history of knowledge about treatment such as psychoanalytic theory. In the old days, the notion was that in a traditional analytic situation, the client was on the couch etc. The therapeutic process was intended to bring into consciousness repressed material verbally. However that pales in comparison to some of these non verbal techniques doesn’t it? Dr. Patrick: It does, yes. Dr. C.: It isn’t to say that insight techniques aren’t worth while, but the problem is that the therapeutic aspect is perhaps not as great, as when you process non-verbally, as well and symbolically. Dr. Patrick: Well I think particularly for people who are not comfortable with the verbal images. Children, folks of cultures who do not utilize the verbal communication that some of the western cultures do, people who are very shut down like this girl, I think they can benefit from these non-verbal approaches, and heal. Whereas if you were to try to put them on a couch or insist that they talk their way through something, it would not be effective, the defenses would be too much, too great. Dr. C.: And this was helpful for May as well. But we have to be very modest when we come to what we can actually accomplish with someone who is so impoverished and traumatized. But it is helpful. Overview: Apart from diagnostic and treatment aspect, these techniques can be a way to train individuals in the mental health field, in terms of understanding basic principles of projection- transference, symbolism and so on. Students can learn how attitudes and feelings and images get projected on figures on a sand tray or inkblots and then onto the therapists themselves, as various forms of “Transference”. They can also learn about cognitive distortions and affect gets projected onto the body image resulting in conversion symptoms. Do you want to comment on the training value of these techniques?

SIS and Sand Tray 101 Dr. Patrick: Well I think it is helpful to psychotherapists. For instance members of the hospital staff working with both these youngsters, who studied these trays, appreciated learning something more about the youngsters and what their problems were…or what they were experiencing internally, which then made it easier and more effective to work with them. So I think that can be very helpful. Dr. C.: It impressed me that one of the nurses who is not really that sophisticated in training was able to say, “This is Fred’s tray.” Wasn’t that impressive? Dr. Patrick: Yes. I thought that was very impressive and with this youngster too. I think this really gives a psychotherapist a sense of the desperation that this youngster is experiencing… the isolation and the lack of resources that she has. It is so clearly demonstrated here. At the same time I think the trays clearly give the understanding that the youngsters within themselves have the resources to heal… we must take advantage of what this girl has, and what this young man has and make those things useful to them. Not that we are going to give them something new, but that we can help them to evolve or to utilize what they already have…the psyche can heal itself if given an opportunity. Dr. C.: And that self healing is related to the natural spring of positive spirituality which is inherent in all children. Dr. Patrick: Of course. Dr. C.: Thank you very much for sharing today. Conclusion: Sand Tray and SIS is widely used diagnostic/treatment approach. The SIS and Sand Tray procedures were tried in two young cases. The first is a seventeen year old Alaska Native youth with a history of suicide attempts. The second adolescent was psychologically impoverished and very depressed with history of serious suicide attempts. The SIS images and Sand Tray helped in the healing processes.

NEO and Hand Test Differences Between Chronic Pain Patients and Non-pain Controls Paul E. Panek , John J. Skowronski, J. Michael George and Edwin E. Wagner The NEO-FFI and the Hand Test (HT) were administered to 100 individuals seeking treatment in a pain clinic and a control group of 100 individuals who did not report any past or present chronic pain complaints. Contradicting previous research, these results suggest that there are general psychological concomitants of the experience of chronic pain. Using NEO and HT scores, a discriminant analysis correctly classified 92 % of the pain group participants and 89 % of the non-pain participants. Important contributors to the best fitting discriminant function were the HT quantitative variables of Activity, Communication, and Acquisition and the latency variables of High-Low and Average Initial Response Time. Further, while there were five major discriminative variables, differences were noted on a variety of other variables, suggesting that, psychologically, persons seeking treatment at a pain clinic do differ from normal control participants in a number of ways. Chronic pain is a major health problem in the United States (Curtiss, Kinder, Kalichman, & Spana, 1988), and researchers suspect that the intensity of pain complaints is exacerbated by psychological factors (McGrath, Sweeney, O’Malley, & Carlton, 1998). In fact, medically unexplained physical symptoms such as chronic pain are probably the single most common reason for outpatient referrals to medical clinics (Wessely & Hotopf, 1999). Further, personality appears to be an important variable associated with how a person experiences chronic pain (Lichtenberg, Skehan, & Swensen, 1984). Although research has failed to find support for a “homogenous pain personality”(see Carpenter, 2002; Gatchel & Weisberg, 2000), there may be consistent personality differences among individuals as a function of the type or locus of the chronic pain (e.g., Kinder, Curtiss, & Kalichman, 1992; Panek, Skowronski, & Wagner, 2002a). The link between psychological characteristics and physical states is documented in the literature. For example, elevated levels of anxiety, tension, anger, and depression are thought to cause health problems (see Watson & Pennebaker, 1989). In fact, some theorists have speculated that personality characteristics such as depression, anger, hostility, and anxiety may even constitute a “disease-prone personality”(see Friedman & Booth-Kewley, 1987). Support for this position comes from studies such as those reported by Sammons and Karoly (1987), who found that depression and anxiety are linked to the etiology of Irritable Bowel Syndrome (IBS). Similarly, Walker, Gelfand, Gelfand, and Katon (1995) found that IBS patients had significantly higher lifetime prevalence rates of major depression and current panic disorder when compared to patients without inflammatory bowel disease. More support for this position comes from Tennant, Goulston, and Langeluddecke (1986), who reported that patients with gastric ulcers had higher neuroticism, psychoticism, and hostility scores on the Eysenck Personality Questionnaire than patients with duodenal ulcers. Further, Weinryb, Roessel, Gustavsson, Asberg, and Barber (1997) found that ulcerative colitis patients with excessive impulse control had problems coping with aggressive affects. Thus far, the test most frequently used to investigate the personalities of pain clinic patients has been the Minnesota Multiphasic Personality Inventory (MMPI; Hathaway & McKinley, 1983), Minnesota Multiphasic Personality Inventory –2 (Butcher, Dahlstrom, Graham, Tellegen, & Kaemmer, 1989). The MMPI and MMPI-2 have well-documented descriptive and predictive value Paul E. Panek, Department of Psychology, The Ohio State University at Newark, John J. Skowronski, Department of Psychology, Northern Illinois University, J. Michael George and Edwin E. Wagner, Alabama Pain Center, Huntsville, AL (USA) (Requests for reprints should be addressed to: Dr. Paul E. Panek, Professor of Psychology, The Ohio State University at Newark, Newark, OH 43055 (e-mail: panek.1@osu.edu). Key Word: Neo and Hand Test Differences

in the assessment of chronic pain patients and these instruments have a long history of identifying personality characteristics in chronic pain patients (Arbisi & Butcher, 2004; Deardorff, 2000). Thus, there are numerous studies that use these instruments to explore the relation between the experience of pain and personality. For example, Hanvik (1951) reported that chronic low back pain contributed to hypochondriacal depression. Lichtenberg et al. (1984) observed that hypochondriasis was related to the threshold for perceived pain. Kinder et al. (1992) found that, based on their responses to the MMPI, headache patients were less psychologically disturbed than chronic back patients. Curtiss et al. (1988) found four distinct MMPI profile sub-groups in male and female chronic back patients. However, the use of the MMPI and/or MMPI-2 for the assessment of pain patients is not without controversy, and may present problems that preclude their usefulness with chronic pain patients (see Arbisi & Butcher, 2004; Deardorff, 2000, for a discussion of the major criticisms). For example, evaluations on the hypochondriasis and depression scales may indicate organic disease rather than psychological status (Pincus, Callahan, Bradey, Vaughn, & Wolfe, 1986). While the MMPI is oriented toward the assessment of psychopathology, over the past decade a growing body of research has emerged demonstrating that normal personality dimensions, such as those included in the five-factor model, can be theoretically and empirically linked to health and wellbeing (Quirk, Christiansen, Wagner, & McNulty, 2003). Given the empirical and conceptual importance of the “big five” model of personality, however, it seems plausible that tests that assess these dimensions (such as the NEO-PI) would be related to pain experiences and health outcomes. Although the NEO-PI (Costa & McCrae, 1985) is considered a measure of “normal” personality functioning, it may tap important aspects of personality that are not fully covered by clinical instruments (Ben-Porath & Waller, 1992). For example, Costa, Busch, Zonderman, and McCrae (1986) commented that the MMPI provided a good measurement of Neuroticism but was not able to clearly assess other personality domains such as Extraversion and Openness. A few studies have already explored the relation between scores on the NEO-PI and various health outcomes. Indeed, there is good theoretical reason to do so. Costa and McCrae (1985) themselves suggested that individuals high in Neuroticism, who are characterized as impulsive, vulnerable, helpless, and low in self-esteem, should also experience chronic distress. In support of this idea, Costa and McCrae (1987) reported that Neuroticism scores were moderately-to-strongly correlated with subjective health complaints. However, these scores were also largely unrelated to objective health indicators, such as disease processes and mortality. Wade, Dougherty, Hart and Cook (1992) compared relations between the NEO-PI and the MMPI to numerous other variables, including whether a person was reporting chronic pain. These researchers reported that Neuroticism differentiated the emotionally overwhelmed MMPI subgroup from the other three pain subgroups. Furthermore, high Neuroticism was found to be associated with depression, anxiety, hostility and vulnerability. However, not all the data are supportive of a relation between pain and Neuroticism. Affleck, Tennen, Urrows, and Higgens (1992a) found that Neuroticism was not related to pain reports and did not predict pain over and above the ability of clinical and biological indicators of joint inflammation. Moreover, although Costa and McCrae (1987) reported that Neuroticism scores were moderately-to-strongly correlated with subjective health complaints, these scores were also largely unrelated to objective health indicators, such as disease processes and mortality. NEO and Hand Test Differences 99

104 Panek et al Given the limited number of studies that have been conducted and the inconsistent findings that have emerged, the clinical utility of the NEO for chronic pain patients is still a matter of debate. However, as suggested by Ben-Porath and Waller (1992), if non-clinical measures derived from the NEO could demonstrate an incremental contribution to diagnosis, they can be used as a supplement to traditional clinical tests. Hence, additional research is warranted. Accordingly, one goal of the research reported in the present paper is to explore possible relations between the variables measured by the NEO-PI and the extent to which individuals either are (or are not) experiencing chronic pain. A second goal of our research is to pursue an approach toward measuring the personality characteristics of pain patients based on work with the projective Hand Test (HT; Wagner, 1962/ 1983). Several studies have demonstrated that personality variables measured by the HT are related to specific types of experienced pain (Panek, Skowronski, & Wagner, 2000; Panek, Skowronski, & Wagner, 2002b). For example, Panek et al. (2002b) found that: (1) migraine headaches patients frequently gave Exhibition responses; (2) individuals with fibromyalgia frequently gave Fear responses; and (3) persons with arthritis frequently gave Active responses. Further, Wagner and Young (1999) propose that there are “pain types” which are characterized by their pattern of responses on the HT. Thus, results of the HT suggest that the personality characteristics associated with chronic pain are associated with psychological maladjustment as evidenced by a higher number of Tension, Crippled, Fear, Exhibition, Description and Failure scores. Although extensive research over 40 years has demonstrated the reliability and validity of the HT (see Sivec, Waehler, & Panek, 2004) it’s use with pain patients is recent and, like the NEO, seems worthy of further exploration. Interestingly, to-date, the literature is sparse in terms of research in which an objective and projective measure of personality were both administered in combination to observe the potential contributions of each instrument, singularly and in combination, in identifying the personality characteristics associated with chronic pain. Accordingly, a third goal of our research is to determine possible relations between an objective measure of personality (NEO) and a projective measure of personality (HT) in regard to chronic pain patients. Confluences among variables that significantly discriminate pain from non-pain patients would be of both theoretical and applied importance. If substantial overlap occurs between the two tests despite the differences in orientation (i.e., objective vs. projective), construct validity can be posited for any salient pain personality features that might emerge. This, in turn, could affect therapy regimes and, hopefully, bring about more positive outcomes in the treatment of pain patients. Additionally, given the limited time available in a clinical/medical setting, if substantial overlap between tests emerges, or if one test predicts pain membership substantially better, in order to save time and money, one test could be eliminated from the intake assessment battery. Previous studies either have not used a “pain free” control group, or have used control groups composed of individuals who are experiencing some medical/physical or psychological condition. Thus, the medical/ physical or psychological conditions experienced by members of such a control group may affect conclusions drawn from such research. Accordingly, an important aspect of our research is to compare the personality characteristics of the chronic pain group to those exhibited by a no-pain control group. Based on the literature, it could be posited that there would be a difference between the chronic pain and the non-pain control group on the NEO variable of Neuroticism, with pain patients exhibiting higher scores. Pain clinic patients might also be expected, on the HT, to give more Tension, Crippled, Fear, Malajustive, Exhibition, Dependent, Descriptive and Failure responses. Of special interest will be whether supposedly similar NEO and HT variables are unrelated, e.g., whether an individual’s level of NEO Neuroticism predicts pain group membership independently of scores on the HT variables indicative of psychopathology.

NEO and Hand Test Differences 105 Moreover, it should be possible not only to determine the salient personality characteristics associated with chronic pain identified by each test but also the incremental discrimination attainable by using an objective and projective test in tandem. Conversely, by administering both the NEO and the HT, the relative power of variables derived from an objective test of personality and from a projective test of personality in predicting whether an individual is (or is not) in chronic pain, can be compared. Method: Participants: Participants in the pain group (CCP) were 100 (M age = 45.88 yrs., SD = 12.23; range =15 to 72 yrs; Male N = 35, Female N = 65) individuals seeking treatment at a pain clinic in the southeastern United States. The pain was chronic but varied across loci (back pain, fibromyalgia, gastrointestinal pain, etc.). The mean number of years that these individuals experienced chronic pain was 10.45 years (SD = 9.70; range = 1 to 43 years). Participants in the non-pain control group (PF) were 100 students enrolled in various undergraduate psychology courses at a regional campus of state university in the Midwest (M age= 24.01 yrs., SD = 8.71; range 17 to 53 yrs; n = 33 males, n = 67 females). These students participated in the study as part of the course requirements. A screening questionnaire administered to these individuals ensured that these individuals did not have, and never had, chronic pain. It should be noted that, because we desired a control group that was pain-free, the two groups could not be matched on variables such as age and employment. Individuals in the CCP group were most often unemployed, while individuals in the PF group were always students. Moreover, while the groups were similar in gender composition, the groups significantly differed in terms of participant age, F (1, 198) = 115.95, p < .001), a variable known to affect HT responses. Therefore, we attempted to minimize the impact of these differences by statistically controlling for age in our analyses. Materials: Each participant was administered the Hand Test (Wagner, 1962/1983) and the NEO-FFI-Form S (Adult; Costa & McCrae, 1992) according to standard instructions for each instrument. The Hand Test (HT) consists of 10 cards, 9 of which portray hands in various ambiguous positions. The tenth card is blank. The person’s task is to describe, “what the hand could be doing.” Responses are scored on the basis of the behavioral tendency expressed in the response, such as communication, aggression, and activity (Wagner, 1962/1983; for examples, see Table 1). Table 1 describes the 15 separate quantitative scoring categories. Two other scores that are available from the hand test are the average time that was required to make a response to each hand card (Average Initial Response Time, or AIRT), and a measure of the difference between response times that is obtained by subtracting the shortest response latency from the longest (High-Low, or H-L). The NEO-FFI is the 60-item version of the NEO PI-R. Items on the NEO-FFI are aggregated to produce five separate scores. These are Neuroticism (N), Extraversion (E), Openness (O), Agreeableness (A), and Conscientiousness (C). Procedure: Participants in the pain group completed the HT and NEO as part of the routine admission procedure to a pain clinic. The tests were administered individually according to standard instructions. The administrator was a licensed psychologist employed by the pain clinic (J. M.G). All participants in the non-pain control group were administered the HT individually by a Ph.D. psychologist (P.E.P.), and the NEO was administered in a group format. As noted previously, to insure that members of the PF

106 Panek et al control group had never experienced chronic pain, all participants in this group completed a “Health Questionnaire” on which they were asked to: (a) rate their health from 1 (Very Unhealthy) to 7 (Very Healthy); and, (b) indicate whether they had ever experienced any chronic pain. Students reporting chronic pain experiences also reported the nature of their pain, the duration of the pain, and whether they were currently receiving treatment for the pain. It should be noted that, in order to obtain 100 non-pain participants, it was necessary to test 137 individuals, i.e., 37 (29.2 %) participants reported significant past or current pain experiences. These were excluded from the control group. Scoring: NEO scores are objectively derived, so scores for each of the 5 NEO variables were calculated by one member of the research team (P.E.P.) using standard scoring instructions. Scoring of the HT, however, requires that scorers make categorical judgments about the nature of peoples’ responses. All 200 protocols were scored “blind” with regard to group membership by the developer of the HT (E.E.W.). To provide a reliability check on this scoring, all HT protocols for the pain group were scored by J. M.G. and all protocols for the PF group were scored by P.E.P. Because of the importance of establishing inter-rater correspondence for a projective test, several measures of reliability were computed. When considered collectively, the 200 protocols and 15 HT scoring variables produced 3000 responses which, when correlated, yielded an inter-rater reliability of .91. This high inter-rater correlation was obtained for both the pain group scores (r = .91) and the control group scores (r = .91). Another way to examine reliability is to assess the extent to which the raters exactly agreed on assigning one of 15 possible scores to each response (Smith, Blais, Vangala, & Masek, 2005). This occurred for 81.93% of the 3000 responses: 85.1% agreement for the pain group and 78.8% agreement for the control group, a level of agreement considered quite satisfactory by Smith et al. (2005). Because of the high reliabilities generally reflected in the various estimates, the scoring of E.E.W. was used for subsequent analyses. Results: The15 HT scores, the overall response frequency, the HT latency variables of AIRT and H-L, and the five scores derived from the NEO were used as criterion variables in separate multiple regression analyses to predict group (pain vs. control), age, and gender. Both age and gender were included because of prior research suggestive of age and gender effects on the HT (see Panek, Wagner, & Avolio, 1978; Sivec et al., 2004; Stoner, Panek, & Satterfield, 1982). Because the average total number of HT responses differed between groups, for each participant the frequency count for each of the 15 descriptive categories of the HT were divided by the total number of responses for each participant. This method yields a score reflecting the proportion of total responses that were assigned to a particular scoring category. This procedure helps to equate scores across participants with different response frequencies (Panek et al. 2002a). Given the rather exploratory nature of the study, we used a somewhat liberal significance criterion (p < .10) to evaluate our results. However, as indicated by the effect size calculations reported in Table 1, all the significant effects reported are in the medium range of effect sizes (according to Cohen, 1988). Hence, there is reasonable assurance that the effects reported are not false positives.

NEO and Hand Test Differences 107 Table 1 Differences (P < .10) Between Pain and Non-Pain Groups for Hand Test and NEO Variables. F Test (1, 195) Results Derived from ANCOVA Controlling for Participant Age. Raw Means and Standard Deviations in Regular Font; Age-Adjusted Means in Italics; D Calculated from Age-Adjusted Means. Pain Pain No Pain No Pain Variable Group Group Group Group Name F p< Mean SD Mean SD d Aggression 3.26 .08 .078 .075 .060 .056 .377 .082 .057 Acquisition 5.24 .02 .037 .062 .060 .079 .479 .035 .069 Activity 6.93 .01 .144 .120 .234 .141 .542 .156 .227 Passivity 2.99 .09 .039 .055 .050 .059 .368 .034 .055 Crippled 3.02 .09 .046 .066 .017 .042 .362 .042 .022 Total 4.05 .05 12.91 3.55 13.59 2.84 .383 Responses 12.77 14.00 High-Low 16.37 .0001 9.28 4.04 14.63 9.97 .843 8.89 15.31 Neuroticism 3.01 .09 53.25 12.88 51.01 9.67 .353 53.85 49.83 Openness to 3.66 .06 49.87 10.17 52.14 10.53 .398 Experience 48.86 52.98 The significant between-groups results from the regression analyses are presented in Table 1. There were significant between-groups differences for seven of the HT variables. Participants in the CPP group provided more responses that were classified as Aggressive, Crippled and Bizarre than those in the PF group. Participants in the CPP group provided fewer responses that were placed into the Acquisition and Activity categories than participants in the PF group. Participants in the CPP group also provided fewer responses than those in the PF group, and showed a narrower time differential between their fastest and slowest responses. Two differences emerged on variables derived from responses to the NEO. As expected, patients in the pain group scored higher on Neuroticism than those in the no pain group. Participants in the CPP group also scored lower on the Open to Experience scale than those in the PF group. Additional analyses explored the extent to which these differences could be used to predict pain group membership. The first step in these analyses was to conduct regression analyses in which each variable of interest from the HT and NEO was regressed on both age and gender. The residuals of these analyses were calculated and were used in discriminant analyses. The intent of these discriminant analyses was to see whether the HT variables and the NEO variables could reliably predict pain group membership when the data were controlled for age and gender.1

108 Panek et al Table 2 Variables that Significantly Added to the Predictive Utility of the Discriminant Function Predicting Pain Group Membership and the Step at Which they were Added (or Removed) Variable Variable Partial Average Squared Step Entered Removed R-Squared F p< Canonical Correlation H-L .111 24.72 .0001 .111 AIRT .255 67.34 .0001 .337 Activity .118 26.24 .0001 .416 Communication .102 22.07 .0001 .475 Acquisition .037 7.43 .01 .494 Agreeableness .035 6.90 .01 .512 Extraversion .034 6.84 .01 .529 Total Responses .024 4.72 .05 .540 Conscientiousness .017 3.36 .07 .548 Neuroticism .021 4.09 .05 .557 Dependency .018 3.42 .07 .566 Description .016 2.99 .10 .572 Extraversion .010 1.93 .17 .568 The average squared canonical correlation is significant at the model’s first step and thereafter (p < .0001). The first analysis entered all residualized variables from the NEO and HT into the discriminant analysis (see Table 2). The analysis yielded a significant eigenvalue (.212), F(23, 176) = 1.62, p < .05. Hence, in combination, the NEO and HT could significantly predict whether an individual was in the CPP group or was in the PF group. This predictiveness is indicated by examination of the classifications yielded by the discriminant function, which indicated that 70 of the CPP group patients were correctly assigned to the pain group and 67 of the no pain individuals were correctly assigned to the PF group (both out of 100). Examination of the pooled-within canonical structure coefficients indicates that the HT variables of H-L (.44), ACT (.33), and ACQ (.28) were the variables that were most strongly correlated with the canonical variate. A second analysis entered only the residualized variables from the HT into the discriminant analysis. The analysis yielded a significant eigenvalue (.193), F(18, 1781) = 1.95, p < .02. Hence, by itself, the HT could significantly predict whether an individual was in the CPP group or was in the PF group. This predictiveness is indicated by examination of the classifications yielded by the discriminant function, which indicated that 66 of the CPP group patients were correctly assigned to the pain group, and 66 of the no pain individuals were correctly assigned to the PF group (both out of 100). Examination of the pooled-within canonical structure coefficients indicates that the HT variables of HL (.46), ACT (.35), and ACQ (.30) were the variables that were most strongly correlated with the canonical variate. A third analysis entered only the variables from the NEO into the discriminant analysis (see Table 3). The analysis yielded a nonsignificant eigenvalue (.021), F(5, 194) = .83, p > .54. Table 3 Variables that significantly added to the predictive utility of the discriminant function predicting pain group membership and the step at which they were added (or removed): NEO variables only. Variable Variable Partial Average Squared Step Entered Removed R-Squared F p< Canonical Correlation Extraversion 0.065 3.85 .001 .065 Conscientiousness 0.058 12.19 .001 .120 Agreeableness 0.023 4.62 .05 .140 The average squared canonical correlation is significant at the model’s first step (p < .001) and thereafter (p < .0001).

NEO and Hand Test Differences 109 Hence, by itself, the NEO could not reliably predict whether an individual was in the pain group or was in the non-pain group. This lack of predictiveness was also indicated by examination of the classifications yielded by the discriminant function, which indicated that 55 of the pain group patients were correctly assigned to the pain group, and 53 of the no pain individuals were correctly assigned to the control group (both out of 100). Discussion: The results of the present investigation clearly indicated that it is possible to predict whether a person is in chronic pain from their responses to both the NEO and the HT. This suggests that there is personality traits associated with the experience of chronic pain. With regard to the NEO, as expected, patients in the CPP group scored higher on Neuroticism than those in the PF group. This finding is consistent with previous research (e.g., Wade et al., 1992; Affleck, Urrows, Tennen, & Higgins, 1992b). Neuroticism assesses adjustment versus emotional instability and identifies individuals who are prone to psychological distress, unrealistic ideas, excessive cravings or urges, and maladaptive coping responses (Belsky, Crnic, & Woodworth, 1995). Thus, persons in the CPP group manifest personality characteristics associated with worry, nervousness, emotionality, insecurity, and feelings of inadequacy (Belsky et al., 1995). Also, participants in the CPP group scored lower on the Open to Experience scale than those in the PF group. This finding was not necessarily expected and possibly suggests that persons in the CPP group are more rigid (less flexible) than persons in the PF group. On the HT, participants in the CPP group gave more Aggressive (AGG), Crippled (CRIP), and Bizarre (BIZ) responses than the participants in the PF group. Thus, individuals in the CPP group have personality characteristics indicating that they are more prone to: manifest negative affect against others in the form of overt physical attack or verbal hostility (AGG); experience difficulty in producing environmental or interpersonal actions because of perceived feelings of inferiority (CRIP); and demonstrate perceptions and/or action tendencies that are not reality based (BIZ). With regard to AGG, this finding is consistent with previous research (e.g., Friedman & Booth-Kewley, 1987; Watson & Pennebaker, 1989) and further documents the relationship between anger/hostility and chronic pain. The finding that persons in the CPP group gave significantly more CRIP responses was anticipated since it represents difficulties in producing environmental or interpersonal actions because of “neurotic” feelings of inferiority. This finding is consistent with previous research (e.g., Leavitt & Garron 1982; Sammons & Karoly, 1987). That persons in the CPP group would give more BIZ responses than persons in the PF group was not necessarily predicted but is consistent with previous MMPI/MMPI-2 (e.g., Deardorff, 2000) and NEO (e.g., Belsky et al., 1995) findings in those persons who experience chronic pain may also demonstrate serious psychopathology. Participants in the CPP group showed fewer Acquisition (ACQ), Active (ACT), and Total Responses (R), and evinced a shorter interval between their longest and shortest response times to the HT stimuli. Thus, persons in the CPP group would be less likely, compared to persons in the PF group to: strive to obtain a goal or object (ACQ); exhibit constructive accomplishment in the impersonal world (ACT); manifest overall psychological reactivity to their environment (R); and, exercise caution and circumspection (H-L). This cluster of personality traits do not directly overlap but yet are not inconsistent with previous research findings with the MMPI/MMPI-2 (e.g., Slesinger, Archer, & Duane, 2002), and the NEO (e.g., Belsky et al., 1995). Thus, to summarize, persons in the CPP group, compared to persons in the PF group, could be described as being aggressive and impulsive; feeling inferior; perceiving reality unrealistically; being environmentally unproductive; and showing less goal-orientation. These results support the

110 Panek et al assumption that there are definite personality characteristics associated with persons who experience chronic pain. What cannot be addressed by the current study, however, is whether these psychological characteristics render a person more susceptible to the experience of pain to begin with, reflect coping mechanisms or strategies for dealing with pain, or elicit the kinds of thoughts and percepts that become accessible as a method for dealing with pain. The results also demonstrate that the personality characteristics assessed by the HT that predict pain group membership are largely separate from the “Big Five” personality traits assessed by the NEO. Further, while Neuroticism and Openness to Experience were weakly related to pain group membership, the variables derived from the NEO did not significantly predict pain group membership. This suggests that personality characteristics assessed by the HT are more salient than those personality traits assessed by the NEO for persons with a history of chronic pain. These findings are similar to those of Affleck et al., (1992a) who reported that the NEO variable of Neuroticism was not related to pain reports and did not predict pain over and above the ability of clinical and biological indicators of joint inflammation. Also, these findings are in marked contrast to the recent findings of Quirk et al. (2003), who investigated inpatient substance abusers and found that the NEO-PI-R increased Axis I and Axis II diagnostic classification an additional 7 % to 23 % beyond MMPI-2 scale scores. These results also contradict the observation that objective measures of personality are generally superior to projective measures (e.g., Lillienfeld, Wood, & Garb, 2000; Wood, Nezworski, & Stejskal, 1996). Instead, the present data suggest that it was scores derived from the projective HT and not from the objective NEO that were predictive of pain group membership. This may, however, prove to be a function of the type of discrimination attempted. In this respect, as previously suggested by Ben- Porath and Waller (1992), it may be that tests assessing normal personality, such as the NEO, are unsuited for discriminating among groups where psychopathology is involved. This finding is particularly relevant for the assessment of pain patients in applied settings such as medical centers and pain clinics in which time is often an important consideration and self-assessment instruments are the rule. Results of the present study suggest that patient information obtained from self-report instruments that assess normal personality traits such as the NEO may be of limited value for identifying psychopathological processes in persons seen in medical settings. Conversely, the projective HT shows promise in elucidating those personality variables that distinguish pain clinic patients. While the Wagner and Young (1999) study cannot be directly compared to the present research because of differences in methodology, both studies nonetheless suggest psychopathology in chronic pain patients. In the current study Crippled (CRIP) and Bizarre (BIZ), both pathological indicators, were significantly related to pain group membership. The current study is limited by the fact that the control group consisted of college students who may be different from chronic pain patients on a number of factors unrelated to pain per se. On the other hand, obtaining “normal” controls for the pain group is always problematic, inasmuch as most chronic pain patients are not working, and adult controls who are not working or engaged in productive activity in western industrialized nations are usually not considered normal. Hospitalized non-pain control patients, for example, could well be exhibiting temporary psychopathology due to immobility, anxiety or worry. These issues point to the fact that additional research is needed to confirm the psychological traits identified in the present research and to further explore the existence of characteristics typical of chronic pain patients as a whole, particularly as measured by the HT. It is further recommended that research paradigms comparing the relative efficiency of various psychological tests for assessing pain patients be instituted. Considering the cost in time, money and personnel, it seems advisable to determine which tests work best in specific medical settings such as chronic pain clinics.

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112 Panek et al Lillienfeld, G. O., Wood, J. M., & Garb, H. N. (2000). The scientific status of projective techniques. Psychological Science in the Public Interest, 1, 27-66. McGrath, R. E., Sweeney, M., O’Malley, W. B., & Carlton, T. K. (1998). Identifying psychological contributions to chronic pain complaints with the MMPI-2: The role of the K scale. Journal of Personality Assessment, 70, 448-459. Panek, P. E., Skowronski, J. J., & Wagner, E. E. (2000). The effects of age and gender on Hand Test responses of chronic pain patients. Journal of Projective Psychology & Mental Health, 7, 109-117. Panek, P. E., Skowronski, J. J., & Wagner, E. E. (2002a). The advisability of routinely computing percentages when comparing groups across projective test variables. Journal of Projective Psychology & Mental Health, 9, 2-4. Panek, P. E., Skowronski, J. J., & Wagner, E. E. (2002b). Differences on the projective Hand Test among chronic pain patients reporting three different pain experiences. Journal of Personality Assessment, 79, 235-242. Panek, P. E., Sterns, H. L., & Wagner, E. E. (1976). An exploratory investigation of the personality correlates of aging using the Hand Test. Perceptual and Motor Skills, 43, 331-336. Panek, P. E., Wagner, E. E., & Avolio, B. J. (1978). Differences in Hand Test responses of healthy females across the life span. Journal of Personality Assessment, 42, 139-142. Pincus, T., Callahan, L. F., Bradley, l. A., Vaughn, W. K., & Wolfe, R. (1986). Elevated MMPI scores for Hypochondriasis, Depression, and Hysteria in patients with rheumatoid arthritis reflect disease rather than psychological status. Arthritis and Rheumatism, 29, 1456-1466. Smith, S. R., Blais, M. A., Vangala, M., & Masek, B. J. (2005). Exploring the Hand Test with medically ill children and Adolescents. Journal of Personality Assessment, 85, 82-91. Quirk, S. W., Christiansen, N. D., Wagner, S. H., & McNulty, J. L. (2003). On the usefulness of measures of normal personality for clinical assessment: Evidence of the incremental validity of the revised NEO Personality Inventory. Psychological Assessment, 15, 311-325. Sammons, M. T., & Karoly, P. (1987). Psychosocial Variables In irritable Bowel Syndrome: A Review and Proposal. Clinical Psychology Review, 7, 187-204. Sivec, H. J., Waehler, C. A., & Panek, P. E. (2004). The Hand Test: Assessing Prototypical Attitudes and Action Tendencies. In M. Hilsenroth & D. Segal (Eds.), Objective and projective assessment of personality and Psychopathology. Volume 2 in M. Herson (Ed.-in-Chief), Comprehensive handbook of psychological assessment. New York: John Wiley & Sons. Pp. 405-420. Slesinger, D., Archer, R. P., & Duane, W. (2002). MMPI-2 Characteristics in a chronic pain population. Assessment, 9, 406-414. Stoner, S. B., Panek, P. E., & Satterfield, T. (1982). Age and sex differences on the Hand Test. Journal of Personality Assessment, 46, 260-264. Tennant, C. C., Goulston, K., & Langeluddecke, P. M. (1986). Psychological Correlates of Gastric and Duodenal Ulcer Disease. Psychological Medicine, 16, 465-371. Wade, J. B., Dougherty, L., Hart, R., & Cook, D. B. (1992). Patterns of normal personality structure among chronic pain patients. Pain, 48, 37-43. Wagner, E. E. (1962/1983). The Hand Test: Manual for administration, scoring and interpretation. Los Angeles: Western Psychological Services. Wagner, E. E., & Young, G. R. (1999). Hand Test characteristics of pain clinic patients. In G. R. Young and E. E. Wagner (Eds.). The Hand Test: Advances in application and research (pp. 205-211). Malabar, FL: Krieger Publishing Co. Pp. 205-211. Walker, E. A., Gelfand, A. N., Gelfand, M. D., & Katon, W. J. (1995). Psychiatric diagnoses, sexual and physical victimization, and disability in patients with irritable bowel syndrome or inflammatory bowel disease. Psychological Medicine, 25, 1259-1267.

NEO and Hand Test Differences 113 Watson, D., & Pennebaker, J. W. (1989). Health complaints, stress, and distress: Exploring the central role of negative affectivity. Psychological Review, 96, 234-254. Weinryb, R. M., Roessel, R. J., Gustavsson, J. P., Asberg, M., & Barber, J. P. (1997). The Karolinska Psychodynamic Profile (KAPP): Studies of character and well-being. Psychoanalytic Psychology, 14, 495-515. Wessely, S., & Hotopf, M. (1999). Is Fibromyalgia a distinct clinical entity? Historical and epidemiological evidence. Bailliere’s Clinical Rheumatology,13, 427-436. Wood, J. M., Nezworski, M. T., & Stejskal, W. J. (1996). The Comprehensive System for the Rorschach: A critical examination. Psychological Science, 7, 3-10. Footnotes: 1: There are other qualitative scores that can be calculated from the observations collected during administration of the Hand Test. However, because the fifteen quantitative scores and the two latency scores are the ones most frequently used and formally validated, additional qualitative categories were not investigated. Acknowledgement: The cooperation of K. Dean Willis, M.D. in securing the samples used in this research is gratefully acknowledged. SIS Instruments can be Obtained from : Somatic Inkblot Center 4501E, 104th Avenue Anchorage, AK.99516 (USA) E-Mail: siscassell@yahoo.com Somatic Inkblot Center 4406 Forest Road, Anchorage, AK 99517 (USA) E-mail:sisdubey@rediffmail.com

Gender Differences in Factor Structure of SIS-II Responses Umed Singh The present study was designed to investigate the pattern of responses on SIS-II in normal high school male and female students. The sample comprised of 100 male and 100 female high school students. SIS-II was administered individually. The mean, SD, and t-ratio were computed to compare the two groups. Principal Component Factor Analysis was carried out to understand the factor structure of SIS responses in two groups. T-test and factor structures have revealed significant gender differences in some SIS-response patterns. Females have been found scoring significantly high on SIS-II scales of Animal responses, Pathological Anatomy and Depression, and low on Anatomy and Sex than their counterpart males. Five principal components each have been located in the two data, which also differentiate the SIS response patterns of male and female subjects. The inkblot techniques have, no doubt, contributed significantly in personality assessment, clinical assessment and therapeutic intervention. There are three major standardized tests based on inkblots. The first pioneer amongst these was the Rorschach Inkblot Test published in 1921 and dominated the field of psychodiagnosis until 1956 when Holtzman developed his technique i.e. Holtzman Inkblot Technique, to overcome some of the limitations of Roschach by adding the psychometric properties. Because of indices based interpretation in Rorschach Inkblot Test and Holtzman Inkblot Technique, and advent of psychometric approach in psychology, practicing psychologists shifted their preference to questionnaire measures i.e. MMPI, CPI, 16 PF, EPQ etc. as alternative indices of diagnostic evaluation and personality assessment. The questionnaire measures have their inherent weaknesses i.e. faking, social desirability, response set etc. (Cattell, 1957). Cassell (1964, 1965, 1977, 1980, 1994) and Cassell and Dubey (2003) have attempted to deal with the above mentioned problems in traditional inkblot tests and questionnaire measures by introducing the Somatic Inkblot Technique popularly known as Somatic Inkblot Series (SIS). Somatic Inkblot Technique initially developed in 1960 introduced only eleven scoring categories such as Total Number of Responses (R), Human Responses (H), Annual Responses (A), Anatomical Responses (At), Sex Responses (Sex), Movement Responses (M), Most Typical Responses (MT), Typical Responses (T), Atypical Responses (AT), Rejection of Images (Rej), and Pathological Scales i.e. Pathological Anatomy Scale (PAS), Depression Scale (D), Hostility and Aggression Scale (HAS), and Paranoia Scale (P). SIS technique emphasizes more on content analysis and psychoanalytic interpretation of the responses. It has also contributed in clinical intervention. The somatic Inkblot series is an extension and advancement of the traditional inkblot projective technique (Cassell, 1994). The test has been developed primarily to understand the manifestation of problems through somatization and to hear the inner cry of individuals. It has been developed based on three theoretical conceptualizations i.e. Somatic Imagery Theory, Body Symbolism Theory, and Theory of Inner Volcano. Somatic Imagery Theory proposes that every individual has a unique and highly personalized system of attitudes, both conscious and unconscious, that is projected onto the body concept as spatial entity. Theory of body symbolism explains that an individual integrates mental and physical phenomena, and is based on the old philosophical principle of mind-body relationship. The inner-cry hypothesis contends that expressed behaviour is the physiological translation of pent up emotions in mental reservoir. Presently, Somatic Inkblot Series provides images in three forms: on cards (SIS-II, 20 cards), in a booklet (SIS-II, 62 images), and on videotape (SIS, I video, SIS-II video/CD). Umed Singh, Ph.D., Department of Psychology, Kurukshetra University, Kurukshetra – 136119. E-mail: umedsingh_78@yahoo.com Key Word : Gender Defferences, Somatic Inkblot Series

The review of literature on SIS reveals that SIS-II (booklet form) has attracted more researchers followed by the card form. SIS-II has been used in psychotics and neurotics (Prashad et al., 1997, Rathee et al., 1995, 2002), Schizophrenics and depressives (Prashad and Verma, 1995), Psychiatric patients (Verma et al., 1994, 1996; Singh and Duby, 1997; Singh et al., 1997), Speech Disorders (Nehra et al., 1997), Murders (Singh et al., 2000), ADHD (Jain et al., 2005), Meta analysis of SIS-II has indicated its power of discriminating various groups (Kumar, 2000). SIS-I has been used in coronary patients (Duby et al., 1994, Rathee et al., 1994), Drug Addicts (Mukhopadhaya et al., 1996), Obese patients (Cinzia and Roberto, 1998), Schizophrenics (Kumar et al., 2000, 2006), Manic patients (Kumar et al., 2003, 2005, 2006), Militants (Saldhana, 2002), Suicide (Cassell, 2005), Violence (Cassell and Dubey, 2006), PTSD (Cassell, 2006), and Problems of police personnels (Dubey and Dubey, 2005). With the advent of video technology SIS-I video, and SIS-II video (Cassll, 1980, 1984; Cassell and Dubey, 2003), have attracted researchers widely. The extensive survey on SIS through SIS Journal of Projective Psychology and Mental Health (vol. 1 to 13) reveals that most of the studies have been conducted in clinical setting, primarily to compare the clinical groups with normal subjects either to highlight the power of SIS as diagnostic tool or as a therapeutic aid. But another significant aspect of inkblot techniques is to assess the personality and inkblot correlates of various aspects of normal behavior and psychological processes. SIS can also be used to investigate various psychological processes of normal subjects of different gender, domicile, age levels, educational standards, and school environments. There is dearth of such studies with SIS. So, the present study is aimed at the understanding of factor structures of SIS-II responses of High School male and female students. Method: Sample: The sample consisted of 200 High School students (100 males and 100 females) drawn from 9th and 10th grade students of various Govt. High Schools of Jind District in Haryana. The sample was restricted to rural areas. The age of participants in both the groups ranged between 14 and 16 years with the mean age of 15 years. Measures: (i) Background information about the participants were collected through a personal data-sheet designed for the present study to ascertain the rural domicile and similar socio-cultural background of the participants. (ii) The SIS-II (Booklet Form) consisting of 62 images was administered individually after establishing proper rapport. SIS-II protocols were scored for 14 categories according to scoring system developed by Cassell and Dubey (2003). Results and Discussion: Frequency distributions for all the 14 variables used in the study were set up separately for both the groups (male and female). Descriptive statistics i.e. means, standard deviations, skewnesses and kurtosis were computed separately for the two groups to ascertain the normalcy of data; and t-ratios were computed to compare the two groups in terms of significance of means differences. (Table - 1). Perusal of table-I reveals that females have scored significantly high on SIS-II scales of animal responses, pathological anatomy and depression; and significantly low on scales of anatomy and sex than their counterpart males. It posits that female students tend to be more psychologically mature in interacting with animals, more concerned with personal physical health or hypochondrical Gender Differences in SIS-II 111

116 Singh and depressive. Here high score by females on the scale of animal is understandable in the light of social role of caring and feeding the domestic animals assigned to females in rural Haryanvic culture. Females in this study have been found to be highly concerned with their body image and hesitant in giving the sexual responses to the somatic inkblot images than their counterpart males. Table 1 Comparison of SIS-II mean scores of males and females Sr. No. Variables Male Group, Mean and SD Female Group Mean & SD t-value Sig. /NS 1. Total No. of Resp. (R) 59.73 59.89 -.84 NS 1.44 1.26 2. Human Responses (H) 12.91 12.15 1.31 NS 4.22 3.95 3. Annual Responses (A) 5.63 7.15 -2.81 Sig. 3.99 3.70 4. Anatomy Responses (At) 18.48 10.52 8.47 Sig. 7.65 5.48 5. Sex Responses (Sx) 1.73 .75 2.72 Sig. 1.99 3.02 6. Movement Responses (M) 1.42 1.87 -1.61 NS 2.01 1.93 7. Most Typical Responses (MT) 11.15 11.55 -1.25 NS 2.14 2.34 8. Typical Responses (T) 22.99 21.71 1.80 NS 4.85 5.14 9. Atypical Responses (AT) 2.28 1.91 1.85 NS 1.64 1.35 10. Rejection Responses (Rej) 2.19 2.05 .74 NS 1.44 1.35 11. Pathological Anatomy Scale (PAS) .53 .72 -4.79 Sig. .82 .93 12. Depression Scale (D) .17 .56 -2.05 Sig. .45 1.24 13. Hostility and Aggression Scale (HAS) .92 1.13 .95 NS 2.12 .99 14. Paranoia (P) .01 .01 .00 NS .10 .10 Correlational Analysis: After ascertaining the normalcy of data, Product Moment Correlations were computed among all the 14 variables of SIS-II in data from both the groups. It may be noted that degree of freedom being 98 (N-2) in both the groups, the correlation coefficients of .20 and .25 are significant at .05 and .01 levels of significance respectively. In case of males, inter-correlations among 14 variables of SIS-II are ranging from -.97 to .45. About 20% of correlations are significant at or above .05 level of significance indicative of factorial complexity of SIS-II measures. Similarly, in case of data from female group, only 27% of correlations have been found to be significant. No doubt, bivariate correlations provide significant information about the relationship between/among variables, but actual overlaps among variables are unveiled by factor analysis. So, the inter-correlations have not been interpreted (inter-correlations matrices for both the groups are not presented for economy of space) rather inter-correlations matrices have been subjected to Principal Component Factor Analysis. The obtained factor structures have been interpreted and discussed.

Gender Differences in SIS-II 117 Factor Analysis (Male Group): Principal Component Analysis was carried out on the inter-correlations among 14 variables of SIS-II, and five factors with eigen values greater than 1.00 were extracted which together accounted for 13% of total variance. Interpretations of factors were done after variamax rotation (Kaiser, 1958). Varimaxly rotated factor matrix is presented in table - 2. The commonalities (h2) for fourteen variables range from .348 to .957. Table 2 Rotated Factor Matrix (Male) Variables I II III IV V h2 Total No. of Responses -.105 -0.53 -.969 -0.17 -.026 .953 Human -.686 -.022 -.060 .014 -.396 .632 Animal -.119 -.763 -.126 -.196 .141 .671 Anatomy -.048 .792 -.159 -.105 .160 .691 Sex -.127 .743 .107 .043 -.149 .603 Movement -.580 -.017 -.007 -.071 -.078 .348 Most Typical -.785 -.097 -.157 .189 .099 .696 Typical -.704 .112 -.039 .003 .244 .569 Atypical .191 .523 .141 -.285 .134 .429 Rejection .093 .076 .970 .037 .004 .957 Pathological Anatomy .111 -.306 .117 -.099 .646 .546 Depression -.150 -.024 .202 .704 -.152 .583 Hostility and Aggression .175 .357 .116 -.132 -.574 .519 Paranoia .103 .025 -.112 .768 .147 .635 %variance 18.29 16.14 12.33 8.60 7.77 Factor I: includes the clustering of four SIS-II variables i.e. Most Typical (MT), Typical (T), Human (H), and Movement (M) responses with the loadings ranging from -.580 to .785. All the significant loadings are negative. It has accounted for 18.29% of total variance. Obtained structure suggests it to be a factor of Perceptual Maturity. The obtained negative pole of this factor here is indicative of incoherent and illogical thinking, inability to keep up societal demands, ego-weakness, group deviance, schizoid or social isolation tendencies, lack of dynamic energy, and hostile and aggressive impulsives. The positive pole of this factor will be indicative of organized cognition, ego strength, team concept, group conformity, high degree of interpersonal relationship, enthusiasm, and tranquilized affect. Factor II: is defined primarily by Anatomy, Animal and Sex responses, and to a lesser extent by Atypical, Hostility and Aggression and Pathological Anatomy Scales. Factorial combination of markers suggests it to be a factor of Poor Self-Image. It has accounted for 16.14% of total variance. Obtained structure is indicative of poor self-image, preservative and poor quality of percepts, implying psychological disturbance, heightened sexual anxiety, diseased anatomical imagery, and hostile and aggressive impulses. Factor III: mainly loads on total number of Responses and Rejection with very high contrasting loadings. Measures of depression, anatomy, and most typical responses have marked low loadings but useful in understanding the structure of this factor. Overall, this factor is indicative of Thought Blockade and Poor Imaginative Capacity. It accounts for 12.33% of total variance. Factor IV: primarily loads on two pathological scales viz. Paranoia and Depression with high positive loadings of .768 and .704, coupled with some considerable associations of scales of atypical responses, animals and most typical responses. Nature of defining variables suggests it to be a

118 Singh factor of Paranoid and Depressive Ideation. It has accounted for 8.60% of total variance. It portrays the respondents having paranoid ideation, depressive outlook, individualistic sensitivity to stimulus quality, and fear from animals. Factor V: Mainly loads on Pathological Anatomy, Hostility and Aggression and Human responses and it is a bipolar factor. It depicts the Hypochondrical Sensitivity and Hostile Impulsivity. It has accounted for 7.77% of total variance. It portrays the individuals pre-occupied with personal health concerns, hostile and aggressive impulses, and schizoid or social isolation tendencies. Factor Analysis (Female Group): Here also principal component analysis was carried out on inter-correlations among 14 variables of SIS-II, and five factors with eigen value greater than 1.00 were extracted which together accounted for 60.51% of total variance. Factors have been interpreted after varimax rotation (Table - 3). The communalities (h2) for 14 variables ranged between .353 and .939. Table 3 Rotated Factor Matrix (Female) Variables I II III IV V h2 Total No. of Responses .924 .130 .194 .016 -.007 .914 Human .004 .775 -.228 -.035 -.224 .711 Animal .095 .787 .156 -.040 .281 .736 Anatomy .168 -.082 .624 .201 -.303 .580 Sex -.014 .060 .083 .035 -.67 .939 Movement -.080 -.321 -.649 -.026 .269 .649 Most Typical -.039 .132 -.805 .090 -.279 .614 Typical -.198 .535 .032 .559 -.52 .643 Atypical .089 -.101 .100 .732 -.063 .572 Rejection -.923 -.099 -.194 -.022 -.009 .906 Pathological Anatomy -.031 -.178 -.153 .146 .773 .676 Depression -.137 -.217 -.038 .285 -.605 .515 Hostility and Aggression -.001 .006 -.537 .598 .082 .654 Paranoia -.517 .199 .156 .015 -.068 .353 %variance 17.94 13.06 11.43 10.41 7.67 7.13 Factor I: highly loads on Total Number of Responses and Rejection; and moderately on Paranoia Scale indicative of Proper Imaginative Capacity. It has accounted for 17.94% of total variance. This factor appears to deal with proper imaginative and thinking capacity and higher sense of selfconsciousness in social situations. Factor II: mainly loads on Animal, Human and Typical responses with positive loadings of .787, .755 and .535. Movement has marked negative association. Altogether defining variables suggest it to be a factor of Psychosocial Maturity. It has accounted for 13.06% of total variance. The obtained structure is indicative of subjects’ proper interpersonal relationship with human beings and interactions with animals, social conformity, and stability. Factor III: has been primarily defined by Most Typical, Movement, Anatomy and Hostility and Aggression Scales. Among these four markers, three have loaded negatively and anatomy positively suggesting it to be a factor of Perceptual Maturity. It has accounted for 11.43% of total variance. The obtained negative pole of this factor is indicative of incorent and illogical thinking, ego weakness, schizoid tendencies, lack of dynamic energy, hostile and aggressive impulses, and somatic preoccupation.

Gender Differences in SIS-II 119 Factor IV: has loaded positively on Atypical, Typical and Hostile and Aggressive Responses. Depression has also marked substantial positive association. All the significant loadings are positive. Obtained structure is indicative of Perceptual Conflict. It has accounted for 10.41% of total variance. It has provided unexpected combination of variables depicting personal conflicts and suppressed hostility toward societal demands. Factor V: defined primarily by Pathological Anatomy scale with high positive loading and depression with negative loading, to a lesser extent by anatomical responses, is indicative of Hypochondriatic Sensitivity. It appears to deal with subjects’ hypersensitive and active concerns for personal physical health. Conclusion: There are significant gender differences in some of response patterns to somatic images of SIS. Females have scored significantly high on Animal, Pathological anatomy, and Depression scales, and low on Anatomy and Sex. Obtained factor structure depicts some overlaps and some differences in the response patterns of male and female students. Females appear to have reflected higher psychosocial maturity, proper imaginative capacity, more perceptual conflicts, suppressed hostility and sexuality, and higher interpersonal relationships. The striking difference reflecting the high scoring by females on animal scale is understandable in the light of social role assigned to females for caring and feeding of domestic animals. The findings, though reflect significant gender differences in SIS-II response patterns, yet can not be generalized. For this, large scale investigations are suggested on different types of samples in terms of age levels, educational levels, domicile, occupation, and sociocultural backgrounds. References: Cassell, W.A. (1964). A Projective Index of Body Interior Awareness. Psychosomatic Medicine, 26: 172-177. Cassell, W.A. (1965). Body Perception and Symptom Localization. Psychosomatic Medicine, 27: 171-176. Cassell, W.A. (1977). Desensitization Therapy for Body Image Anxiety. Canadian Psychiatric Association Journal. 22: 239-242. Cassell, W.A. (1980). Body Symbolism and Somatic Inkblot Series. Anchorage, Alaska. Aurora Publishing. Cassell, W.A. (1984). Somatic Inkblot Series Video. SIS Centre, Anchorago, Alaska (USA). Cassell, W.A. (1994). The Somatic Inkblot Series: Continuing Rorschach’s Conceptualization, SIS. Journal of Projective Psychology & Mental Health, 3: 3-32. Cassell, W.A. (2005). Assessing Suicidal/Homicidal Impulses with the SIS. SIS Journal of Projective Psychology and Mental Health, 12(2): 99-106. Cassell, W.A. (2006). SIS Cognitive Psychotherapy for Spouse Induced PTSD. SIS Journal of Projective Psychology & Mental Health, 13(1), 25-36. Cassell, W.A. and Dubey, B.L. (2003). Interpreting Inner World Through Somatic Imagery: Manual of Somatic Inkblot Series. SIS, Centre, Anchorage: Alaska (USA). Cassell, W.A. and Dubey, B.L. (2006) Tracing the roots of violence by associating Dream and SIS Images: A vicarious visit to an Adolescent’s Birthday party. SIS Journal of Projective Psychology & Mental Health, 13(2), 87-106. Cattell, R.B. (1957). Personality and Motivation: Structure and Measurement. Chicago: World Book Co. Cinzia, S. and Robesto, F. (1998) The SIS-I and Body Image Evaluation in subjects suffering from serious obesity. SIS Journal of Projective Psychology & Mental Health, 5: 105-113. Dubey, S.N. and Dubey, B.L. (2005). Effect of Psychological Intervention through SIS-I Images on Police Personnel. SIS Journal of Projective Psychology & Mental Health, 12(2), 153-158.

Dubey, B.L., Mishra, M., Dwivedi, C.B., and Mishra, N. (1994). Diagnostic and Therapeutic Utility of Somatic Inkblot Series-II and Rorschach. SIS Journal of Projective Psychology & Mental Health, 1: 19-26. Holtzman, W.H. (1956). Inkblot Perception and Personality. University of Texas Press, Taxas. Jain, R., Singh, B., Mohanty, S.R., and Kumar, R. (2005). SIS-I and Rorschach Diagnostic Indicators of Attention Deficit and Hyperactivity Disorder. SIS Journal of Projective Psychology & Mental Health, 12(2): 141-152 Kaiser, H.F. (1958). The Varimax Criterion for Analytic Rotation in Factor Analysis. Psychometrika, 23: 187-200. Kumar, R., (2000). Meta Analysis of the findings on SIS-II. SIS Journal of Projective Psychology & Mental Health, 7, 141-147. Kumar, S., Singh, R., and Mohanty, S. (2001). A Study of Somatic Inkblot Series-I in Hospitalized Male Chronic Schizophrenics. SIS Journal of Projective Psychology & Mental Health, 10. Kumar, S., Mohanty, S., and Kumar, R. (2003). SIS-I Profile and its correlation with Rorschach in Manic Patients. SIS Journal of Projective Psychology & Mental Health, 8, 31-37. Kumar, D., Kumar, J., and Kumar, R., (2005). SIS-I and Rorschach Among Manic and Depressive Patients. SIS Journal of Projective Psychology & Mental Health, 12, 53-60. Kumar, D., Dubey, B.L. and Kumar, R. (2006). Gender Differences in SIS-I Profile of Manic Patients. SIS Journal of Projective Psychology & Mental Health, 13, 61-64. Mukhopadhyay, A., Banerjee, S., and Mitra, G. (1996). A Comprehensive Profile of Personality Characteristics of Male Drug Addicts. SIS Journal of Projective Psychology & Mental Health, 3, 33-41. Nehra, A., Raghunathan, M., Verma, S.K., and Mann, S.B.S. (1997). Recognition of Psychological Problems in Patients suffering from Speech Defects with the help of SIS-II. SIS Journal of Projective Psychology & Mental Health, 4, 1431-151. Prashad, D., and Verma, S.K. (1995). Diagnostic Significance of Content Analysis of SIS-II. SIS Journal of Projective Psychology & Mental Health, 20, 141-149. Prashad, D., Verma, S.K., and Bhagat, K. (1997). Body Image Disturbances in Psychiatric Cases. SIS Journal of Projective Psychology & Mental Health, 14, 75-84. Rathee, S.P., Goel, D.S., Chawla, M.L., Saldanaha, D., and Dubey, B.L. (1994). A Study of SIS-I in Coronary Cases. SIS Journal of Projective Psychology & Mental Health, 1, 51-64. Rathee, S.P., Pande, V., and Singh, A. (1995). Diagnostic Efficacy of Somatic Inkblot Series-II Among Psychiatric Patients of Armed Forces. SIS Journal of Projective Psychology Mental Health, 2, 61-66. Rathere, S.P., Pardal, P.K., and John, T.R. (2002). Diagnostic value of SIS-II Among Sub-groups of Psychotic and Neurotic Patients of Armed Forces. SIS Journal of projective Psychology and Mental Health, 9, 23-32. Saldhana, D. (2002). Profile of Militants: An attempt to study the minds of militants. SIS Journal of Projective Psychology & Mental Health, 9, 23-32. Singh, A.R., and Dubey, B.L. (1997). SIS-II Profile of Drug and Alcohol Dependent Cases. SIS Journal of Projective Psychology & Mental Health, 4, 69-74. Singh, A.R., Dubey, B.L., and Banerjee, K.R. (1997). Prognostic utility of Somatic Inkblot Series-II. SIS Journal of Projective Psychology & Mental Health, 4, 141-144. Singh, A.R., Dubey, B.L., Sahu, L.M., and Banerjee, K.R. (2000). SIS-II Profile of Murderers. SIS Journal of Projective Psychology & Mental Health. Verma, S.K., Prashad, D., and Nehra, R. (1994). Cross-validation of SIS-II in Psychiatric Population. SIS Journal of Projective Psychology & Mental Health, 1, 15-18. Verma, S.K., Prashad, D., and Kaur, R. (1996). Interdependence of SIS variables with Personality Traits in Psychiatric Cases. SIS Journal of Projective Psychology & Mental Health, 3, 51-58. 116 Singh

Projective Indices of Creativity: A Pilot Study Dharmendra K. Singh, Gobinda Majhi and Amool R. Singh Rorschach Inkblot test has been widely used for psycho diagnostic purpose; however, it is also used as a tool to measure intellectual functioning. Some indices of the Rorschach test were considered as the index of intelligence (W, N, C,F+%, A% & P). The present study was carried out to examine the validity of projective test as measure of creativity. The sample consisted of 100 normal subjects, who were chosen by purposive sampling. Individual scoring above cut off point on General Health Questionnaire (Shamsunder et al.,1986), in the age range of 18-20 years, of either sex, educated up to 12th were consisted the sample. As a tool, General Health Questionnaire (Shamsunder et al., 1986), Verbal test of creative thinking and Rorschach Test (Beck System), were used. Findings of this study show that both the groups (High Vs low creativity) differ significantly on total number of Response (R), Whole response (W) and Popular response (P). In psychology, creativity usually refers to production of any idea, action or object that is new. By extension, a creative person is one who stands out from the norm by producing such ideas, actions or objects. Numerous definition have been extended for creativity, which RUNCO (2004) have endeavored to condense into four distinct approaches as a) product b) as person c) as press and d) as process. Guilford (1967) developed a theory of cognitive functioning that took creativity into accounts, and a battery of tests that measured fluency, flexibility and originality of thoughts in both verbal and visual domain. His model and the test he developed are steel the foundation on which many creativity testing and research is based. Attempts to measure degree of creativeness had led to test and rating scales of divergent thinking, of creative thinking and creative perceptions. There are a few tests which are not primarily developed for the assessment of creativeness, but used as additional measure of creativity and Rorschach test is one of them. Stark 1965, has proposed that the projective measures, particularly Ink blot tests are true indices of meaning or traditional type of creativity. The Rorschach test has been vogue for last many decades especially for psycho diagnostic purpose. However, the Rorschach test has been used as a tool to measure intelligence. Certain types of intelligence are more satisfactorily reflected by use of stimuli materials similar to what Rorschach offers. This is particularly true of what one might term “Creative intelligence” which is bypassed by several intelligence tests. The capacity of organic stimuli, to use the imagination, and to express creative energies, represents the big void in present day intelligence testing. Some indices of the Rorschach tests were considered as the index of intelligence. According to Beck (1932), these are W, M, C, F+%,A%, Popular percepts and content range (R). A study of Beck (1932) revealed that both people with very superior intelligence as well as imbeciles have a relatively large number of pure color responses (4-7), and like wise a high percentage of Original (non-popular) responses. The differences can be found by inspecting the percentage of good Form responses. The striking differences between low and high intelligence record is seen in the number of Human movement responses. The capacity to see human movement seems to be related, not only to good emotional health, but also to effective use of creative imagination. Whole responses (W), do reflect intellectual activity, but this activity can be understood only by looking at the quality of W responses (relative number of W) and the relative complexity of responses (Exner 1993, Exner & Weiner,1995, Friedman 1952).Human movement responses have been associated Dharmendra K. Singh, Research officer, Gobinda Majhi, Research officer, RINPAS and Amool R. Singh Prof. & Head, Dept. of Clinical Psychology, RINPAS, Kanke,Ranchi - 834 006 (India). Key words: Beck Norms of Rorschach Creativity, Projective Test

122 Singh et al with creativity Dudek, 1968, Hersh 1962; Richter & Winter, 1966). Dana (1968) proposed that high M can represent any or all of several different psychological processes, including fantasy, an accurate sense of time, intellect, creativity and certain aspects of interpersonal relationship. A high number of human contents are present among individuals who possess greater intelligence (Beck 1968; Rawls & Slack, 1968). Persons who are spontaneous, nonconforming, unpredictable and of higher intelligence often have a lower number of Animal (A) responses (Allen, 1954; Kahn & Giffen, 1960). Joseph et al (1986) found that among various indices of Rorschach test (like N, W, P, RT), only W and R is significantly able to differentiate high and low creative individuals. Very few studies had been done in Indian population to intent to check the current efficacy of Rorschach indices to differentiate high and low creative individuals. So, this study was taken under consideration. Aim of the Study: The present study was carried out to examine the validity of projective test as measures of creativity. Methods & Materials: Sample: The sample consisted of 100 normal subjects, who were chosen by purposive sampling. Normal individuals (screened out by G.H.Q.-5) in the, age range of 18-22 years, of either sex were included in the sample. However, the individuals with history suggesting mental retardation, substance abuse, significant medical, neurological or psychiatric illness and with significant family or personal history of mental illness were excluded from the sample. All the subjects educated up to 12th class or above with predominant middle class socioeconomic status from urban and sub-urban areas, constituted the Sample. Tools:
Socio-demographic data sheet especially designed for the study.
General Health Questionnaire (Shamsunder et al.,1986),
Verbal Test of Creative Thinking (Baquer Mehdi ,1993).
Rorschach Test. Procedure: Initially, the prospective subjects were interviewed and subjects were chosen as per inclusion and exclusion criteria. There after subjects who were screened out as normal through G.H.Q.5 were selected for the study. Information was crossed checked by reliable informants. Verbal Test of Creative Thinking and Rorschach test were administered following standard procedure given by Beck. 42 subjects who scored 50th percentile or above were considered as high creative groups and 58 subjects who scored below 50th percentile on test were considered as low creative group. Analysis of Data: Mean, SD and t- ratio were used for the analysis of the data.

Projective Indices of Creativity 123 Table 1 Comparison of High Creativity Group and Low Creativity Group on Selected Indices of Rorschach Test. High Low Indices Creativity Group Creativity Group T-ratio p-value M SD M SD R 24.20 8.10 15.21 7.9 3.52* .01 W 6.9 2.5 2.8 2.04 6.15* .01 D 15.04 6.96 11.25 6.02 1.50 NS M 3.27 1.14 2.96 0.98 1.00 NS J 1.02 0.76 0.98 0.78 0.20 NS P 4.95 1.95 0.98 4.43* .01 F+ % 71.95 10.05 66.85 12.05 1.60 NS A% 24.89 9.58 27.50 10.78 1.01 NS H 3.5 1.15 3.9 1.60 1.08 NS Content Range 12.9 3.70 10.20 2.99 1.12 NS IRT 20.50 5.90 22.58 6.80 1.05 NS * Significant Results and Discussion: Findings of this study show that both the groups (high creativity group and low creativity group) differ significantly on total number of response (R), whole response (W) and popular responses (P) among various indices which are generally considered as the indices of intellectual functioning, like, R, W, D, M, Z, P, F+,%, A%, H, content range and IRT. Findings of this study is consistent with the findings of Joseph, et al (1986), who found that only R and W is able to significantly differentiate between high and low creative individuals among M, W, IRT and R. Findings of this study is also consistent with the findings of Exner & Weiner (1995) where in W was considered as a sign of creativity. However, the findings of this study did not confirm the findings of other studies in which movement response were considered as indices of fantasy, Creativity and intelligence (Dana, 1968; Beck, 1968; Rawls and Slack, 1968). The findings of these studies reveal that creative intelligent people are having good synthesizing and organizing capacity. They are also able to organize details of an environment into a unique and right way. They have high abstracting qualities or theoretical behavior. Creative people also show high productivity in comparison to non creative individuals. They have high intellectual energy. Another variable of intellectual sphere is P, (the popular response) and creative individuals have also shown more practical approach with good perceptual adequacy. Conclusion: Findings of the study show that total number of response ( R ) whole response ( W ) and popular response (P), were three more important indices of Rorschach test, which were able to differentiate high creative and imaginative people from low creative people. References: Allen, R. M. (1954), Elements of Rorschach Interpretation, New York: Harper & Row. Beck, S.J (1968). Reality, Rorschach and perceptual theory. In A.I. Rabin (Ed.), Projective Techniques in Personality Assessment. New York: Springer. Dana, R.H. (1968) Six Construct to Define Rorschach. In ”Handbook of Psychological Assessment” 3rd Edn. by Gary Groth- Marnet, (1999), John Wiley & Sons Inc. New York.

Dudek, S.Z. (1968). M and Active Energy System Correlating Rorschach M with Case of Creative Expression. Journal of Projective Techniques and Personality Assessment, 32,453-461. Exner, J.E. & Weiner, J.B. (1995). The Rorschach : A Comprehensive systems: Vol. III Assessment of children and adolescent (2nd ed.) New York: wiley. Friedman. H. (1952) : Perceptual regression in schizophrenia: An hypothesis suggested by the use of the Rorschach test, Journal of Genetic Psy. 81, 63-98. Groth Gray and Marnat (1999). Handbook of Psychological Assessment (3rd edn.). John Wiley and Sons, Toronto. Guilford, J.P. (1967), The nature of human intelligence. New York : Mc Graw – Hill. Hersh. C. (1962), The Cognitive functioning of the creative person : A developmental analysis, Journal of projective technique. 26, 193-200. Kahn. T.C. & Giffen, M,B. (1960)’ Psychological techniques in diagnosis and evaluation, New York: Pergamon. Rawls, J. R. & Slack, G.K. (1968). Artists versus non- artist: Rorschach determinants and artistic creativity, Journal of Projective technique and personality Assessement, 32, 233-237. Richter. R. H. and Winter W. D. (1996); Holtzman Ink Blot correlates of creative potentials. Journal of Projective technique and Personality Assessment, 30, 62-67. Runco, (2004), creativity, Annual Review of Psychology, 55, 657-87. Stark, S, (1965), An essay on romantic genius, Rorschach movement and definition of creativity. Perceptual and motor skills, 20,409-418. 120 Singh et al Appeal Members of Somatic Inkblot Soceity are requested to kindly send their Annual dues before the 31st of January each year, to enable the Society to meet its expenses and smooth publication of the Journal.

Rorschach Profiles of Mentally Challenged and Severely Hearing Impaired Children K. C. Vashistha and Shweta Bhardwaj Personality profiles of Mentally Challenged and Severely Hearing Impaired children will be helpful in developing the essential educational infrastructure, proper methodology of teaching and an effective teaching – learning environment for such children. Considering this in mind the personality profiles of special school going mentally challenged children and severely hearing impaired children, have been studied through Rorschach Inkblot Test in the present study. It was also assumed that they do have somewhat similar pattern due to their sensory-motor impairments directly influencing their cognition and learning abilities The findings reveal that mentally challenged children have extroversive personality , while severely hearing impaired children have introversive personality structure. Further the study uncovers some specific personality configuration of both groups. Personality assessment is one of the fascinating areas since ages. With the time the methods of personality assessment have been refined and now-a-days hundreds of well designed and well executed studies relating to the basic organization, development and evaluation of personality has expanded the scope of our knowledge. It has also added sophisticated tests and techniques to the array of tools for the assessment of personality. Rorschach Inkblot Test being a projective technique is promising and justifiable for the revelation of personality because it is based on unstructured stimuli. Personality has important role in determining behavior of an individual and through personality assessment, behavior modification can be done easily. Being an element of social and cultural milieu, a human being is required to make constant adjustment to his/her surroundings. To know the limit of ability, which makes an individual to make the required adjustment, is of vital importance, especially when one is dealing with children with disabilities. Present study primarily aims at a general understanding of personality traits of Mentally Challenged and Severely Hearing Impaired children. Mentally challenged children may be complicated by physical and emotional problems. The child may also have difficulty with hearing, sight or speech and these problems can further lower the child’s potential. Mentally challenged child is one who does not function according to age-appropriate expectations in the areas of emotional, cognitive, communicative, perceptual motor, physical or social development to an extent that they require special adaptations, program adjustments and related services on a regular basis in order to function in an adaptive manner. The effect of mentally challenged vary considerably among people, just as the range of abilities varies among people. About 87 percent of mentally challenged are mildly affected and are only a little slower than average in learning new information and skill. Their mental challenge is not readily apparent and may remain unidentified until they enter school. The remaining 13 percent of mentally challenged people are having IQs fewer than 50 and have serious limitation in functioning. In order to provide intervention, functional education and appropriate supports personality revelation is of great help. By knowing the general personality traits one can understand their needs better. On the other hand severely hearing impaired children also face problems in academic and emotional adjustment. A hearing loss limits their ease of acquisition of communication system, which further influences development of interactions with others, the ability to make sense out of the world, and the ease of acquiring academic skills. Many terms are used to refer to the population of individuals who have difficulty in hearing. The term ‘Hearing Impaired’ is used inconsistently around the country today. Some use it to mean all degrees of hearing loss while others use it to refer the hard of hearing K. C. Vashistha, Ph.D.,Reader, Faculty of Education and Shweta Bhardwaj, UGC – NET Junior Research Fellow, Faculty of Education, Dayalbagh Educational Institute, Dayalbagh, Agra (India) Key Words : Rorschach Profile, Mentally Challanged, Hearing impairment.

126 Vashistha and Bhardwaj population. The prevalence rate of hearing impairment is quite high in India. The National Sample Survey Organization (NSSO, 2001) reported that excluding children in 0-4 age group, there are about 3.02 million children with hearing disability. Considering the severity of the problem it becomes essential to accommodate the needs of these children and to gain insight of their needs, personality assessment is one of the essential things that need to be done. Recently Alexander and Cooray (2003) have tried to diagnose personality disorders in people having mental retardation and found the variation in the co-occurrence of personality disorder in mentally challenged, with prevalence ranging from less than one percent to ninety one percent in a community setting and twenty two to ninety two percent in hospital settings. Khan et.al. (1997) reported that communication problems, physical, sensory and behavioral disorders associated with mentally challenged condition affect the ability to diagnose personality. Mavromatis (2000) has found the prevalence of self-injurious behavior, impulsivity and affective liability, occurring commonly in mentally retarded. Hunter and Deb (1991) reported co-morbidity of affective disorders among mentally challenged which mimic the features of emotionally unstable personalities. Further Gupta (1976) studied the personality pattern of hearing impaired and normal children. Both the groups, however, were found to be shy, but the deaf were more sensitive, dependent, overprotected, depressed, less emotional and less intelligent. Pathak (1984) studied the personality traits, adjustment and aspirations of disabled children in normal schools. Jagdish (1992) studied the personalities of hearing impaired adolescents using the Rorschach technique and found that girls with hearing impairment are dependent, highly abhorrent and highly emotional. From all these studies it is clear that the field has vast developmental potential for psychosocial and educational profiles. The investigators feel it worth while to study the personality of mentally challenged and severely hearing impaired children for their effective adjustment, adaptation and management. Objective of the Study: 1. To study the personality profile of Mentally Challenged Children through Rorschach Inkblot Test. 2. To study the personality profile of Severely Hearing Impaired Children through Rorschach Ink blot Test. 3. To compare the personality profile of Mentally Challenged Children and Severely Hearing Impaired Children as revealed through Rorschach Inkblot Test. Material and Method: Ten mentally challenged and ten severely hearing impaired children were taken from special schools (Tears: Institute for Mentally Handicapped, Sikandra, Agra and Mook-Badhir Vidyalaya, Vijaynagar Colony Agra) in Agra, using purposive sampling. Rorschach Inkblot Test was administered individually following standard procedure suggested by Klopfer and Davidson (Klopfer and Davidson, 1962). Responses were scored for location, determinants, contents, popularity and originality. Calculations were made to determine percentages and relationships among various Rorschach variables. Statistical Techniques: The raw scores obtained from the Rorschach protocols were tabulated and mean was calculated. The qualitative proportions like M: FM, W:M, M:(FM+m) etc., along with the quantitative percentages of various scoring categories (W%, D%, Dd%, etc.) were calculated. Further comparative psychogram is plotted in order to understand the complexity of different ratios.

Rorschach Profiles 127 Analysis and Interpretation: Table 1 Rorschach Components and its Relationship in Mentally Challenged Children SN Rorschach Components Mentally Challenged & Relationship among Factor Children R 25.80 W% 11.43 D% 49.86 d% 4.10 (Dd + S)% 33.21 P% 0.59 O% M A% 38.05 W:M 2.7:0.3 M (FM + M) 0.3:0.5 M:FM 0.3:0.3 Sum C 2.95 FC:(CF+C) 1.9:1.8 (Fc+c+C’): 0.4:1.7 (FC+CF+C) 87.82 F% 97.29 (FK+F+FC)% 22.7:0.6 F:(FK+FC) 0.3:1.1 M : Sum C 0.5:0.4 (FM+m):(Fc+c+C’) 9.4:8.1 (H+A) : (Hd+Ad) 0.78 H% 9.4:17.7 (H+A) : Other Components Table 1 shows the relationship of Rorschach Components in mentally challenged children. From the table it is clear that the differentiated shading responses are less than one quarter of the F responses (22.7:0.6) which indicates the rejection experiences of these children are serious enough to wrap the personality development. The ratio of achromatic responses to that of chromatic responses (0.4:1.7) indicates that they have responsiveness to outside stimulation. The F% >80% (87.82) shows that these children have not sufficiently differentiated in their intellectual function. FC> (CF+C) i.e., 1.9:1.8 ratio represents control over impulsive expression emotionally. Sum C (2.95) indicates there average emotional reactivity. W% (11.43) < 20% indicates a low degree of interest in seeking relationships between the separate facts of experience and achieving an organized view of the world. W: M (2.7:0.9) > 2M indicates their high level of aspiration. d% (4.1) is smaller than five percent which further indicates that they have a low level of interest in minutiae of experiences. (Dd+S)% > 10% (33.21) indicates rich responsiveness to the environment in a perceptual sense. D% (48%) emphasizes difficulty in day to day life adjustment. (H+A): (Hd+Ad) (9.4:8.4) indicates that they are nearly oriented towards their own world to rationalize their own demands. The A% (15.08) < 50% further confirms their low intellectual capacity or disturbed adjustment.

128 Vashistha and Bhardwaj Table 2 Details of Rorschach Determinants Score of Mentally Challenged Children SN Statistic Al Value M FM m k K FK F Fc c C’ FC CF C Mean Response Value 0.3 0.3 0.2 - 0.5 0.4 22.7 0.2 - 0.3 1.9 - 1.8 Percent age 1.16 1.16 0.78 - 1.94 1.55 87.9 0.78 - 1.16 7.3 - 6.9 Figure 1 Psychogram of Determinants of Mentally Challenged Children Figure 1: Psychogram of Mentally Challenged Children Table 2 represents Rorschach determinant scores of mentally challenged children, which are plotted against average response value to obtain a psychogram as explicit in figure 1. According to the psychogram the responses of the mentally challenged children tend to bulk in the right half, indicating their extroversive personality, i.e., the perception of the subject has been influenced largely by “outer determinants” that is color and the surface use of shading. They are responding freely to all those aspects of external reality that happen to be implicit in the blot material. The hypothesis is that such persons are reactive, tending to respond external reality with a relative lack of restructuring in the light of their own needs and experience. The perception of these children is found to be stimulus oriented. Table 3 shows the relationship of Rorschach Components in case of severely hearing impaired children. From the table it is clear that the value of M:FM+m (1.4: 0.9) indicates that the individual is able to utilize his/her inner resources to provide stability and control of self. Ratio of F: (FK+Fc), 43.7:1.9, emphasized their poor personality organization. The value of achromatic responses is smaller than half of chromatic responses i.e. (Fc+c+C’): (FC+CF+C),0.2:0.7 tells that they feel relatively little need for approval and affection and are not held back by related anxieties which serve as resistance for their strongly developed reactivity to emotional stimulation from environment.

Rorschach Profiles 129 Table 3 Rorschach Components and its relationship in Severely Hearing Impaired Children SN Rorschach Components Mentally Challenged & Relationship among Factor Children R 47.5 W% 0.19 D% 28.89 d% 6.10 (Dd + S)% 62.7 P% 0.21 O% - M A% 15.08 W:M 0.1:1.4 M : (FM + M) 1.4:0.9 M:FM 1.4:0.5 Sum C 1.1 FC:(CF+C) 0.3:0.7 (Fc+c+C’): (FC+CF+C) 0.2:0.7 F% (FK+F+FC)% 96.21 F:(FK+FC) 43.7:1.9 M : Sum C 1.4:0.6 (FM+m):(Fc+c+C’) 0.9:0.2 (H+A) : (Hd+Ad) 6.3:31.6 H% 0.84 (H+A) : Other Components 6.3:41.5 Further overemphasis on the Form responses i.e. 92 percent depicts pathological symptoms. FC < (CF+C) indicates that there is weak control over emotionality. (Dd + S)% >10% indicates rich responsiveness to the environment in a perceptual sense. Low W% indicates a low degree of interest in seeking relationships between the separate facts of experience and achieving an organized view of the world. W: M (0.1:1.4) emphasized fantasy as a substitute for achievement. d% (6.1) is greater than five percent which further represents not only a differentiated interest in factual things but also insecurity against which the individual defends him/herself by clinging to the limited areas of certainty for fear of losing bearings. Dd and S are increased at the expanse of W indicates that they are too hesitant in drawing general conclusions from fine and detailed observations. The A% (15.08) < 50% further confirms that they have low intellectual capacity and narrow view of world. Table 4 represents Rorschach’s determinant scores of severely hearing impaired children which are plotted against average response value to obtain a psychogram as explicit in figure 2. The psychogram reveals that the responses of the severely hearing impaired children tend to bulk in the left half, it means that they have introversive personality, i.e., the perception of the subject has been influenced largely by “inner determinants” such as movement and use of shading to give depth. The perceiver restructures external reality through his/her own contribution. The hypothesis is that such persons tend to a relatively great degree of restructuring their world when they perceive it, drawing heavily upon their needs and experiences. The perception of these children is said to be perceiver - determined.

130 Vashistha and Bhardwaj Table 4 Details of Rorschach Determinants Score of Severely Hearing Impaired Children SN Statistic Al Value M FM m k K FK F Fc c C’ FC CF C Mean Response Value 1.6 0.3 0.4 0.5 0.1 1.8 43.5 0.2 - - 0.3 0.1 0.6 Percent age 3.37 0.63 0.84 1.05 0.21 3.79 91.5 0.42 - - 0.6 0.2 1.2 Figure 2: Psychogram of Severely Hearing Impaired Children Further to have a comparison of personality between mentally challenged and severely hearing impaired children have been shown in table 5 and 6. Table 5 Similar Rorschach Personality Traits between Mentally Challenged and Severely Hearing Impaired Children SN Rorschach Ratio/ Personality Rorschach Traits Content Value Traits (FK+FC):F (FK+FC) Feelings of They have rejection experiences which are serious Enough < _ F Rejection to wrap their personality F% > 80% Poor Intellectual Function i) They are not sufficiently differentiated in their intellectual & are function unable to respond to anything ii) They suffer from natural inhibition W% < 20% Inadequate Interest in They have low degree of interest in seeking relationships between world around the separate facts of experience and achieving an organized view of world D% < 45% Crisis of Identification They lack recognition of every day problems and facts of Problem A% < 50% Low Intellectual Capacity They have low intellectual capacity and narrow view of world Figure 2 Psychogram of Severely Hearing Impaired Children

Rorschach Profiles 131 Table 6 Dissimilar Rorschach Personality Traits among Mentally Challenged and Severely Hearing Impaired Children SN Rorschach’s Ratio/ Personality Traits of Mentally Ratio/ Personality Traits of Severely Hearing Content Value Challenged Children Value Impaired Children M: FM Impulsive Life 0.3:0.5 They have neither simple 1.4:0.5 Their impulsive life is subordinated acknowledgement of impulse to the value system of individual nor having imaginative ability available either in the sense of long range foresight or escapist fantasy (Fc+c+C’): (FC+CF+C) 0.4:1.7 They have responsiveness to 0.2:0.7 They feel relatively little need for Response to Stimuli outside stimulation which has approval and affection and are not been interfered by some kind held back by related anxities of traumatic experience FC: (CF+C) Control 1.9:1.8 They have control over 0.3:0.7 They have weak control Over Emotions impulsive expression over emotionality d% Level of Interest 4.1% They have a low level of interest 6.1% They have differentiated interest in in minutiae of experience factual things along with insecurity against which they defend themselves by clinging to limited areas Psychogram Variables They have Extroversive Variable They have Introversive Personality Bulk towards Personality Makeup Bulk Makeup right towards left Results and Discussion: From the above findings it can be concluded that mentally challenged children have extroversive personality and are easily stimulated. They are reactive rather than striving. They are creative in their relationship to objects and people. They have severe defect in personality organization like psychopathic personalities. On the other hand severely hearing impaired children have introversive personality. They have shown imagination either in terms of fantasy, long range goals or acknowledged impulses, while the responsiveness to and involvement with the outer world is reduced. They tend to restructure the world in terms of their own value and needs. As both of the groups have shown rejection of feelings, which may indicate escapist tendencies or severe withdrawals to thrust them into isolation from the world around them. It vigorously crumbles down their personality make-up. Hence it is advisable to make their comfortable living at home and teachers should provide due interventions to curtail its further advancements. High F % is evident of their impaired intellectual functions and devoid of coordination and implementation of their sensory-motor impulses. Although it is their natural limitation, it creates more obstacles in the life of both the groups-mentally challenged and severely hearing-impaired children. They have also shown poor integration of their experiences, which leads to the break down of their organized view of the external world. It disrupts their coping mechanism as well as adjustment and interest in the outer world. Both the groups of children feel a great crisis of identification. It shows their poor cognition, which is causing immense inadequacy in dealing with their routine problems of life. Further the study vividly verifies the fact that their poor cognitive ability may not permit them to streamline the general problems of life.

References: Alexander, R. and Cooray, S. (2003). Diagnosis of Personality Disorder in Learning Disability. The British Journal of Psychiatry, 182, pp 28-31. Asha For Education. (1991-2004). Asha projects. http://www.ashanet.org/projects-category.php? t=4&display=1. Audiology Online (2004). The hearing Journal Archives. http://www.audiologyonline.com/ articles/hi-archives.asp. AAMR (1995-2006). Disability Books Online. http://www.disabilitybooksonline.com. Dubey, B.L. (1982). Pragmatic View of Rorschach Inkblot Technique. National Psychological Corporation, Agra. Exner, J.E., Jr. (1974). The Rorchach: A Comparitive System (Vol. 1), New York: Wiley. Exner, J.E., Jr. (2000). A primer for Rorschach Interpretation. Asheville, NC: Rorchach Workshops. Gronnerod, C. (2003). Temporal Stability in Rorschach Method: a Meta-analytic Review. Journal of Personality Assessment, 80(2), 272-293. Genamics Journal Seek (2005). Resource Site for Several International Journals. http://www.journalseek.net/ cgi-bin/journalseek/journalsearch.cgi?field=issn&query=0092-6566. Hunter, D. and Deb, S. (1991). Psychopathology of people with Mental Handicap and Epilepsy III: Personality Disorders. The British Journal of Psychiatry, 159, pp 830-834. Janson, H. and Sattin, H. (2003). Prediction of Adolescent and Adult Delinquency from Childhood Rorchach Ratings. Journal of Personality Assessment, 7(3)), 51-63. Khan, A., Cowan, C. and Roy, A. (1997). Personality Disorders in People with Learning Disabilities, A Community Survey. Journal of Intellectual Disability Research, 41, pp 324-330. Klopfer, B. and Davidson, H.H. (1962). The Rorschach technique. Harcourt, Brace and World, Inc. New York. Vashishtha, K.C. (1982). The Differential Personality Traits among Institution Reared and Family Reared Boys and Girls. In M.B. Buch (Eds.) Third Survey of Research in Education. New Delhi: NCERT. Save The Children India (2004). Notes on Mental Retardation. http://www.savethe childrenindia.com/sccmr.htm. Save The Children India (2004). Notes on Hearing Impairment. http://www.savethe childrenindia.com/scchi.htm. Saraswat, G. (2006). Ordinary schooling for these children. http://www.cities. expressindia.com/ fullstiry.php?newsid=17479. 128 Vashistha and Bhardwaj

A Study of Potential Correlates of Reasons for Living in College Students Atanu Kumar Dogra, Sujoy Kar and Saugata Basu The present study aims to find out the relationship between reasons for living and a) presumptive stress, b) Various dimensions of ego functions among college students. The Presumptive Stressful Life Event Scale or PSLES (Singh et al., 1984), The Ego Function Assessment Scale-Modified or EFA-M (Bellak et al., 1989), Reasons for Living Inventory for Young Adults or RFL-YA (Gutierrrez, et al., 1992) were administered to 140 college students comprising of 70 males and 70- females, of 4 colleges of Kolkata. For statistical analysis, product moment correlation coefficients were done to fulfil the objectives. The results of present study revealed that there was no significant relationship between reasons for living and presumptive stress in last 1 year in college students, but significant negative relationship exists between reasons for living and presumptive stress during the past life. As far as the magnitude and direction of relationships of different ego functions with reasons for living are concerned, It was found that 1) Drive Control (DC), 2) Synthetic integrative Functioning (SF) and 3) Mastery Competence (MC) 4) Adaptive Regression (AR) as components of ego functions have significant positive correlation coefficients with reasons for living. A substantial proportion of the large body of empirical work on depression and suicidal behaviors focus on the concept of hopelessness and other maladaptive factors hypothesized to be operating in college population. The central issue in suicide is not death or killing; rather, it is the stopping of the consciousness of unbearable pain, that unfortunately, by its name, entails, stopping life. Suicide is the second leading cause of death among college students. So its causes have been analyzed by number of psychologists in various ways. Most emphasized on personality traits ( Peffer et al. 1995 ; Basu et al , 2000; ) or stress (Wagner, 1997;Furgurson et al., 2000; Dhar and Basu, ,2006) as a cause of suicide, but few emphasized on lowered reasons for living (Gutierrez, et al., 1992;Westfeld et al., 1992; Thakur & Basu; 2006) as a factor for committing suicide . So to prevent suicidal ideation, these above mentioned factors might be taken into consideration. The present study tries to find the relationship between reasons for living with 2 other important variables, i.e., presumptive stress and ego functions among college students. Reasons for Living refers to the set of life sustaining beliefs and cognitive expectancies which act as cognitive barriers in committing suicide and It may be prominent in non-suicidal individuals. The absence of it may potentially influence the intensity of suicidal ideations in suicidal individuals. The first Reasons for Living Inventory (Linehan & Goodstein, 1983) incorporated a range of beliefs and cognitive expectancies potentially important as reasons for not committing suicide. It is these reasons for living that provides one with a meaning in life which Victor Frankl (1984) posited. It is discovered in creative pursuits, in life’s experiences and “tragic triad” of pain or suffering, guilt and death. Though the concept started from existential perspective, reasons for living have gradually come under the purview cognitive domains. Literature delineated significant differences between suicidal and nonsuicidal individuals on the Reasons For Living (Connell and Meyer, 1992). Bonner and Rich (1991) conceptualized deficient reasons for living (along with loneliness and irrational beliefs) as vulnerability factors for suicide. Reasons for living provides potential explanations for the comparatively lower suicidal ideation among the college students. Survival and coping beliefs, college and future related concern and moral objection were found to be some of the reasons for living that provides them with support and strength. (Mascaro, 2005; Mehrotra; 1998). Stress as conceptualized by Selye (1956) describes the organism’s total reaction to environmental demand. Researches over the past 30 years have established that people’s psychological and physical health is profoundly affected by their life events. Presumptive stress indicates the summated quantitative Atanu Kumar Dogra and Sujoy Kar, Research scholar and Saugata Basu, Reader, Department of Psychology, Calcutta University, 92, A.P.C. Road, Kolkata-700009 (India). Key Word: Reasons for living, Presumptive Stressful Life Event Scale.

134 Dogra et al estimate (weighted scores) as experienced by the adult population on specified life events keeping 100 as the highest score. This was psychometrically determined in the Indian context by Singh et al. (1984). To explain stress, existential psychologists emphasized on the widespread phenomenon of the twentieth first century, as results of industrialization, loss of traditional values, modern bureaucratic and dehumanizing mass society where living is much more confrontation than previous day and act as stress. (Wong, p.t.; 2002). The study of ego has received immense importance in psychoanalytical literature in the past few decades. The ego is defined as the agent that coordinates and organizes impulses and wishes in accordance with the demands of reality (Fenichel, 1945). Ego functions are relatively stable personality variables concerned with organizing the outer and inner stimuli (Bellak et al., 1973). Under this theoretical framework, Basu et al. (1997) studied ego functions as personality variables. Bellak et al. (1973) suggested 12 ego functions along with their components as follows: Reality Testing (RT), Judgment (JD), Sense of Reality and Self (SR), Drive Control (DC), Object Relation (OR), Thought Process (TP), Adaptive Regression (AR), defensive Functioning (DF), Stimulus Barrier (SB), Autonomous Functioning (AF), Synthetic integrative Functioning (SF) and Mastery Competence (MC).Since empirical relation between Ego function and psychiatric morbidity has already been suggested by different researchers.(Bellak et al ., 1973, Bellak and Golgsmith, 1984), it may be stated that ego function may enter into the stress- morbidity paradigm as a stable tendency to contribute to the ultimate expression of the disease (Bellak and Golgsmith, 1984 ; Basu et al .,1997). From the previous study , it is observed that reasons for living varies with other some psychological factors such as – trait hope , state hope positively(Mehrotra,S.; 1998 Mascaro, 2005) and with depression, suicidal ideation negatively(Connell and Meyer, 1992; Thakur & Basu; 2006). But the potential correlation between reasons for living and 2 important components a)presumptive stress b) various dimensions of ego function among college population are not examined in Indian context . So, the present study aims to find out following 2 objectives: 1) To investigate the association of the reasons for living and presumptive stress. 2) To investigate the association of the reasons for living and various dimensions of ego function. Material and Methods: Sample: The sample of the present study comprises of 140 subjects (70 male and 70 female subjects), who were all students of undergraduate courses belonging to their age range from 19-21 years. Inclusion criteria for this study were 1) age between 19 to 21 years, 2) Students of 1st year, 2nd year and 3rd year class B.A., B.Sc. and B.Com course. 3) Students of recognized educational institutions. And exclusion criteria are 1) Students with physical handicaps 2) Students with past psychiatric illness. 3) Students not willing to answer all the questions of the questionnaires. Tools Used: (1) A detailed information schedule was used to collect personal and familial related information about the subjects. (2) The Ego Function Assessment Scale (Modified) (EFA-M) [Bellak et al., 1989]: This scale consisting of 120 items was used to assess different ego-functions of the subjects. The subjects respond on a three points scale for each item of 12 subscales. Indian adaptation (Basu and Banerjee, 1998) was used for the present study.

Reasons for Living 135 (3) The Presumptive Stressful Life Event Scale (PSLES) [Singh et al., 1984]: This scale was used to assess number of stressful life events that took place in the last 1 year and past life and to assess the amount of presumptive stress. It consists of 51 life events, where the subjects have to mark those that took place in their lives during the last one year and past life. (4) Reasons for Living Inventory for Young Adults (RFL-YA) [Gutierrrez, et al., 1992]: The RFL-YA is a 32 items, self report inventory designed to assess reasons (protective factors) for living in young college age adults aged 17 to 30 years. It is made up with five subscales. The survey requires respondents to rate each item ranging from 1 (not at all important) to 6 (extremely important), in terms of how important the reasons would be to one for not committing suicide. Higher scores represent stronger reasons for living and thus lower suicidal risk. The scale is effective in measuring the strength of the attitudes and beliefs that college students have with regard to suicide, and to what extent people present with suicidal ideation. Procedure: The study was cross sectional in nature. The data were collected between March and July 2006. Prior to the study paper, the principals of four different educational institutes were approached for their approval and cooperation to collect data from their students. After obtaining permission and ensured cooperation, the researchers visited the Institutions and made all the necessary arrangements for the administration of the test on the subjects to be selected for the study. Students pursuing graduation and belonging to the stream of science, humanities and commerce were selected as subjects for the present study. The sampling was purposive in nature. Researchers met the students in groups, in their respective colleges. The nature of the study and research objectives was explained to them. Clear instructions were given before administration of each questionnaire and its response categories. The researcher clarified ambiguities arising during and after administration of the questionnaires. Confidentiality of results was assumed for every student. With completion of the analysis of data, the researchers went back to the colleges and informed the authorities about salient findings. At the same time researchers discussed the findings with the students who wanted. Statistical Analysis: The obtained data have been analyzed using product moment correlation coefficients. For the analysis 0.05 and 0.01 levels of significance were accepted. Results and Discussion: Table1 Correlation coeciffient between reasons for living and presumptive stress in last one year and in past life. N r values Remarks Last one year -.155 Not significant Past life -.225 Significant** ** Significant at 0.01 levels. The results of present study reveal that there is no significant relationship between reasons for living and presumptive stress in last 1 year in college students but significant negative relationship between reasons for living and presumptive stress during the past life. Reasons for living refer to a set or life sustaining beliefs and cognitive expectancies, which acts as cognitive barriers in committing suicide. From the previous research study, it is observed that there

136 Dogra et al are few components behind the reasons for living and they are survival and coping beliefs, college and future related concern, positive self evaluation, family and peer relation, responsibility to friends and family, fear of suicide, fear of social disapproval (Gutierrez, et al., 1992;Westfeld et al., 1992). Survival and coping beliefs refer to the problem solving skills, beliefs in personal control, optimistic thinking, and respect for and enjoyment of life (for e.g., “I believe I can find other solutions to my problems”, “ I have the courage to face life.”) and these coping beliefs help people to cope with stresses. The present study indicates that the presumptive stress in past life decreases with increase in reasons for living. It might have occurred because the person who has high reasons for living, he uses more survival and coping beliefs to cope with stresses and faces little amount of stress. As far as the magnitude and direction of relationship of different ego functions with reasons for living are concerned, It is found that 1) Drive Control (DC), 2) Synthetic integrative Functioning (SF) and 3) Mastery Competence (MC) 4) Adaptive Regression (AR) as components of ego functions have a significant positive correlation coefficient with reasons for living individually. Other ego functions, i.e., Reality Testing (RT), Judgement (JD), Sense of Reality and Self (SR), Object Relation (OR), Thought Process (TP), Defensive Functioning (DF), Stimulus Barrier (SB), Autonomous Functioning (AF) have no significant correlation with reasons for living separately. Table 2 Correlation co-efficient between reasons for living and different ego functions. Ego functions. ‘R’ values Remarks Reality Testing (RT) 0.045 Not Significant Judgement (JD) 0.0123 Not Significant Sense of Reality and Self (SR) 0.055 Not Significant Drive Control (DC) 0.332 Significant** Object Relation (OR) 0.048 Not Significant Thought Process (TP) 0.005 Not Significant Adaptive Regression (AR) 0.277 Significant** Defensive Functioning (DF) 0.112 Not Significant Stimulus Barrier (SB) 0.004 Not Significant Autonomous Functioning (AF) 0.048 Not Significant Synthetic integrative Functioning (SF) 0.415 Significant** Mastery Competence (MC) 0.345 Significant** ** Significant at 0.01 levels. The present study indicates that the Drive Control (DC) increases with increase in reasons for living. Drive control refers to the extent of regulation and control of drives, affects, and impulses in terms of directness of impulse expression and ability to delay gratification. From the previous study, it is observed that Drive control (as a motivational component) is based on cognitive beliefs (Edward; 1961). So it is assumed that Survival and coping beliefs (especially beliefs in personal control) direct drive and helps to control drive. Beside this, some other components of reasons for living, i.e., college and future related concern, family and peer relationship and responsibility also help to reduce impulsiveness and regulation and control of drives, affects, and impulses. The present study indicates that the Mastery Competence (MC) increases with increase in reasons for living. Mastery Competence (MC) represents the individual’s self –appraisal in terms of his or her mastery of the environment, and the degree to which oneself is considered successful and it produces more positive self evaluation which is a component of reasons for living (Gutierrez, et al., 1992). This study also indicates that the Synthetic integrative Functioning (SF) and Adaptive Regression (AR)

Reasons for Living 137 increase with increase in reasons for living. Synthetic integrative Functioning (SF) refers to the integration of discrepant messages and the adaptation to sudden change, i.e., flexibility and adaptability of the individual and Adaptive Regression (AR) refers to the ability of the ego to regress and relax perceptual and conceptual acuity for the purpose of generating new configurations. These 2 components act as stress buffers to adjust with new situation and help to form coping belief (as a component of reasons for living) to prevent suicide. AR, SF, MC are grouped under the broad heading of a factor ‘Flexibility and self confidence’ (Basu et al., 2000). So, present study reveals that ‘Flexibility and self confidence’ factor varies with reasons for living directly among college population. So subjects with low reasons for living and high suicidal ideation have little amount of ‘Flexibility and self confidence’ factor. Previous study reveals that these three ego functions have been consistently found out lower in depressive groups. (Bellack, 1973; Basu, 1993; Basu & Basu, 1996). So, from the present study, it is also inferred that the subjects with low reasons for living have similarity with the depressed group, as suicidal ideation is one of major characteristic of the group. In other side, present study reveals that Drive control (DC) factor varies with reasons for living directly and DC is categorized as factor responsible for adequacy of everyday functioning found to be genuinely lower in clinical group reflecting gross impairment in daily living skill. DC is impaired to a pathological extent in anxiety disorders (Bellack, 1973; Basu; 1993; Basu & Basu; 1996). The findings of the present study so far indicate that the subjects with low reasons for living have similarity with the depressive group found in earlier studies but along with, there is an indication of experiencing some anxiety features which are reflected by the impairment inadequacy of everyday functioning. These impaired ego functions probably act like moderator factors along with greater amount of presumptive stress and increase vulnerability of attempting suicide-decreasing reasons for living. References: Basu, J. (1993). Applicability of ego function Assessment Scale. As a guided interview schedule on Schizophrenics, neurotics, and normals: A preliminary Report. Psychological Studies, 38 (3), 119-124.. Basu, J. and Basu, S. (1996). Ego function profile of male psychiatric patients in comparison to normal. Psychological Studies, 4(1&2), 16-22. Basu, J. and Banerjee, M. (1998). Adaptation of the English version of the ego function scale (modified) by Bellack for Indian adults, Indian Journal of Clinical Psychology, 25(1), 57-65. Basu, S.; Basu, J. and Bhattacharya, S. (2000). A factor analytic study of ego function assessment. Journal of Personality and Clinical Zstudies, 16(2), 132-136. Basu,S.; Basu, J. and Bhattacharya,S. (2002). A comparative study of ego function. Indian Journal of Clinical Psychology.29(2), 104-109. Bellack, L.; Hurvich, M. and Gediman, H. (1973). Ego function in schizophrenics, neurotics and normals. New York: John Wiley and Sons, Inc. Carson, R.C., Butcher, J.N. and Mineka, S (2004). Abnormal psychology and modern life. Pearson Education. Dhar, S. and Basu, S.(2006) .A comparative study of number of life events, presumptive stress and different ego functions of students with low and high suicidal risks. Indian Journal of Clinical Psychology.33(2),159-164. Edwards, W.(1961). Behavioural decision theory. In P.R. Farnsworth (Ed.), Annual review of psychology(Vol.12, PP. 473-498). Palo Alto, CA: Annual Reviews. Gutierrez, P.M., Osman,A., Barrias, F.X., Kopper, B.A., Baker, M.T. and Haraburda, C.M.(2002). Development of the Reasons for Living Inventory for Young Adults. Journal of Clinical Psychology, 58(4), 339-357.

Lazarus, R.S. (1966). Psychological stress and the coping process. New York: McGraw Hill. Linehan, M.M., and Goodstein,J.L. (1983). Reasons for staying alive when you are thinking of killing yourself: The Reasons for Living Inventory. Journal of Counsulting and Clinical Psychology, 51(2) , 276-286. Mascaro,N. and Rosen,D.N.(2005). Existential meaning’s role in the enhancement of hope and prevention of depressive symptoms. Journal of Personality, 73(4), 985-999. Mehrotra, S. (1998a). Reasons for living: exploring its potential correlates. Indian Journal of Clinical Psychology, 25(1), 39-45. Mehrotra, S. (1998b).Correlates of suicidal ideations: Looking beyond depression and hopelessness. NIMHANS Journal, 16(3), 167-175. Singh, G.; Kaur, D. and Kaur, H. (1984). Presumptive stressful life event scale –a new stressful life events scale use in India. Indian Journal of Clinical Psychology, 26(2), 107-114. Selye, H. (1956). The stress of Life. New York: McGraw Hill. Thakur, K. and Basu, S.(2006) A study of reasons for living and suicidal ideation among college students. Indian Journal of Clinical Psychology.33(1) , 40-46. Westfeld, J.S.; Cardin , D. and Deaton, W.L. (1992). Development of college students reasons for living inventory. Suicide and Life threaten behaviour, 22, and 442-452. Wong, P.T.P.(1998). Implicit theories of meaning in life and the development of the personal meaning profile. In P.T.P. Wong & P.S. Fry (Ed). The human quest for meaning: A handbook of psychological research and clinical applications(pp 111-140). Mahway, N.J.: Lawrence Eribaum. 134 Dogra et al

A Personality Perspective on Female Infertility: An Analysis through Wartegg Test S. Daini, L. Bernardini and C. Panetta Psychological aspects of Infertility have been analysed more through psychometric methods rather than through projective tests. We examined three samples of infertile women through Wartegg Test: primary organic sterility (20 patients), primary unexplained sterility (20 patients) and consecutive miscarriages patients (21 patients) being in diagnostic phase before starting therapy. They were compared to a sample of thirty healthy women. The quantitative analysis on Wartegg Test scores, by ANOVA and MANOVA, shows significant differences between infertile women and controls regarding to Evocative Character and Formal Quality. These differences confirm the emotional impact of infertility on imaginative life and rational ability to plan. The three patient subgroups appear significantly different. Unexplained sterility subgroup seems more similar to healthy women. The organic aetiology subgroup seems to have less adaptability and integration and the consecutive miscarriages subgroups seems to be affected by strong identity problems. Women affected by organic sterility and consecutive miscarriages showed lower affective stability than others. Regarding to Affective Quality, we didn’t find significant differences. Therefore, going on trying to be pregnant seems to happen on an unconscious level and also to be an element to reach psychological affective integration and to overcome depression. Infertility has been defined by OMS and American Fertility Society as the inability of a couple to bring pregnancy to term after having regular unprotected sexual intercourses for more than a year. A couple is to be considered infertile when one or both members are affected by a chronicle physical pathology that stops them from having a baby (Whitelaw, 1960). The first example covers couples not able to bring a pregnancy to term: unexplained sterility cases, a relevant percentage so far, up to 28% of the cases (Alaina and Coll,2007), consecutive miscarriages (when a woman can’t bring to term at least three or more pregnancies) and organic sterility. We have known both the resonance of this problem and the psychological reaction to treatment for a long time, and also the consequences on the couple’s quality of life. Infertility is, in fact, a huge problem which affects 8-12% of couple around the world. Even if we know that stress and anxiety highly affect male and female infertility, a connection between physical and mental stress with the couple’s inability to conceive is still to demonstrate (Inhorn, 2003). The first historical studies on infertility also focus on female sterility by an obstetrical and gynaecological point of view, which has a deep impact on woman’s mind. First psychodynamic hypotheses were about the unconscious conflict between desiring a baby and woman’s resistance in relation to becoming a mother. The contribution by woman psychologists have widened the observation of psychodynamic elements involved on infertility, showing possible connections between conflicting factors linked to woman’s condition and her role in family and in society, rather than to the desire of having a baby. The conceptual references of these early theories were psychosomatic theories, where psychological factors are possible aetiology of unexplained infertility cases. The evolution of biological studies has shown a close relationship between biological and psychological factors. It has also demonstrated that many infertility cases are due to the male partner. As a consequence, this has changed the way of studying infertility, both from a male point of view and placing psychological hypotheses about sterility in a wider and undefined biopsychosocial model. Silvia Daini, Lucia Bernardini and Carla Panetta, Psychiatry and Psychology Institute, Università Cattolica del Sacro Cuore, Rome, Italy, Corresponding Author: Silvia Daini. Istituto di Psichiatria e Psicologia, Università Cattolica del Sacro Cuore, Roma, Largo Francesco Vito 1, 00168, Rome, Italy, Mobile Phone: 0039 339 3798428, Tel/fax (0)6 3054850, Email:dainikatamail.com Key Words: Female infertility, personality, Wartegg Test, recurrent abortions, primary sterility.

140 Daini et al Many researchers agree in identifying stress as main factor of infertility, but it is still not clear which psychological processes are involved. Some situations are more stressful than others, and some people use different coping mechanisms to reduce stress (Stewart and Stotland, 1993). In reproductive health, knowledge and understanding of relationship between the degree of stress and personal and cultural differences were studied by various researchers. They have also tried to find out which particular psycho-diagnostic tools could be used to find the level of stress and what kind of psychotherapies to be administered besides the traditional ones, e.g. Hatha yoga. (Metha and Anand Kumar, 2005). An interesting research concerning infertility was carried out in Edinburgh. The research focused was on the cultural aspect of infertility and the need of culture, medical and psychological assistance to infertile couples. It shows that both clinics and patients consider assisted reproduction (known as “techno-science western) in India. This study shows how in India assisted reproduction techniques try to unify sacred and secular, human thing and transcendence, tradition and modernity, religion and science in a slow process of biomedical techniques “indigenization” (Bharadwaj, 2006). Some Austrian researchers (Schmidt et al, 2004) have carried out a study in which they found social and cultural background sometimes represents a relevant factor. In fact, in Europe, a group of emigrant Muslim women affected by polycystic ovary syndrome (PCOS) showed a higher level of psychological distress compared to a group of Austrian sterile women. Cultural factors can even influence public health regulations regarding prevention of infertility. Egypt, with 40 operational centres for IVF (In Vitro Fertilisation) techniques, has been the centre of an interesting study that demonstrates how new reproductive technologies produce the most effective solution to infertility problem, with a high percentage of resolved cases. This research highlights the importance of promoting a primary prevention about the infections which are responsible for organic infertility in developing countries. Therefore, it does not encourage to assisted reproduction techniques, which are too expensive and difficult to implement. however, the used techniques seem to affect the emotions of infertile couple during pregnancy. A study found out significant differences regarding both emotional responses towards pregnancy and personality dimensions. Women in this group showed higher muscular tension and higher level of anxiety towards loosing their child compared to the control group. Men in this group showed a higher level of somatic anxiety, indirect aggressiveness, sense of guilty and more separation anxiety towards loosing their child, compared to men belonging to control group (Hjelmstedt et al, 2003). Even if we concentrate on psychological reactions to infertility, the women are more emotionally involved and more suffering, though she is not the only one affected by sterility. Within the range of this study (Dhaliwal, 2004), it has been found a “female partner tendency” to show anxiety and depression during infertility treatment, both in female and in male infertility. The main objective of another study was to analyse the ability of different genders to build specific mechanism to cope with an IVF treatment. Using a questionnaire to find out socio-demographic data, it allowed us to know adaptation response and perceived tensions both in men and in women. This research also showed that women presented a higher control and defence from others regarding the pain they felt as compared to men. Above all they showed a higher level of “brooding” regarding their inadequacy not to succeed in conceiving (Pottinger et al, 2006). Schmidt et al (2003) highlighted the way women give more importance to the assistance they received inside the clinic before, during and after IVF treatment. In fact, women presented a higher level of satisfaction regarding medical services offered at the clinic and felt positive towards the treatments finalized to pregnancy. Belonging to a lower social class is an additional factor for satisfaction.

Personality and Female Infertility 141 Female infertility both organic and unexplained linked to psychological and psychiatric factors, was studied in different cultures. An interesting research found, in a group of 50 Turkish women, through a battery of quantitative tests (Beck Depression Inventory, Spielberg Stait-Trait Inventory, Rosenberg self-esteem scale and Symptom Checklist), how infertile women showed a higher level of anxiety and depression compared to the control group (Guz et al, 2003). A group of Japanese researchers carried out a study in which they underlined the relationship between anxiety and depression level and, on the other side, thought processes and emotions linked to infertility in a group of infertile women. The Hospital Anxiety and Depression Scale (HADS) was administered to see the attitude of women towards their own infertility. The factorial analysis puts in evidence how anxiety and depression are strictly and positively correlated to lack of support from their husbands and stress. These conclusions show the importance of building a psychological support in order to reduce anxiety and depression levels (Matsubayashi et al, 2004). Khademi et al, (2005) administered Beck Depression Inventory on a group of 251 women who asked for an assisted reproduction treatment, before and after the treatment, found that higher scores related to treatment failure and lower scores was related to treatment positive outcome. In another interesting study (Jedrzejczak et al, 2004) Beck Scale was submitted to a group of women in order to find depression levels and to show how Beck scale mean scores were higher for infertile women compared to control group. In relation to consecutive miscarriages, a less occurring event (recurrent miscarriage affects between 0.5 and 3 % of couples, Habayeb and Konje, 2005), a study carried out by Klock (1997) put in evidence how 32% of women affected by multiple miscarriages could be defined depressed. These women also reported higher anxiety levels. They felt like they couldn’t protect their own baby, amplifying endured psychological stress. Mourning reactions to child loss and possible mourning negation allow to think that this infertile woman group present peculiar psychological features (Daini, 1997). Taking into account these aspects of female infertility, this study aimed to find out the correlations between female infertility, consecutive miscarriages and specific personality traits projective through Wartegg test. Methods: Participants and Procedures: A sample of 61 urban Italian female patients affected by infertility, were diagnosed and treated at Policlinico Gemelli Hospital from 2003 to 2006 was selected for the study. According to gynaecological examinations, patients were divided into three groups: group A (N=21) consisting of women with consecutive miscarriages (ranging from 2 to 14 at various gestational age) and with no living babies (mean age 30.81 ± 1.18 years); group B (N=20) consisting of women with organic sterility (mean age 28.50 ±1.48 years); group C (N=20) including women with unexplained sterility for more than two years according to diagnostic checks (mean age 28.40 ±. 1.16). They were compared to a control group of 30 women with no infertility problems and matched with age and socio-economic status (mean age 30.03 ± 0.78). They were chosen randomly, among women who had a day hospital gynaecological check. The majority of them were married (70%) with children (ranging from 1 to 3), while the others didn’t try to be pregnant. All participants performed clinical interview and the Wartegg test as a part of a psycho-diagnostic assessment treatment. Test on sample group was performed before planning further attempts to be pregnant. The test was scored by one of the Authors.

142 Daini et al Measures: The Wartegg is a graphic, projective, semi-structured test, composed by a module containing eight panels, numbered from one to eight. They are arranged in two horizontal parallel series of four panels and separated from a wide black margin. The subject’s task is the graphic realization of any mental content that uses, as starting point, the graphic-signs already present in the various pictures, based on subject’s spontaneous choice of the sequence, and giving a sense to them. The diagnostic value of each panel is the actual state of identity (panel 1), vitality and sensibility (panel 2), ability to direct own psychic resources toward aims and objectives (panel 3), relation to rules and authority (panel 4), directionality of aggressive dynamics (panel 5), relation to reality and rationality (panel 6), relation to femininity and sexual energy (panel 7), social relations and wish to protection (panel 8). The graphic realization of the Wartegg makes it really a projective test. In fact, the graphic -signs takes shape as semi-structured stimuli on which subject “is tending to project specific contents and personality dynamics and they are, therefore, revealers of its organization” (Rapaport, 1977). The Jungian psychoanalytic matrix, from which it comes from, enables the choice of stimuli which recall unconscious meaning widely shared by all cultures. This test is suitable to be distributed to individuals and groups. Also it describes thoroughly, the personality organization of the examined subject, thanks to the new method of Crisi (1998), and the innovation and informatics support purposely devised. The 91 Wartegg tests, in this study was codified and analysed following Crisi (1998) method. It was analysed considering the three principal dimensions proposed by Crisi(1998): the Evocative Character (EC), the Affective Quality (AQ) and the Formal Quality (FQ). It was also taken into account the statistics frequency by which contents frequently made and named “vulgar” are presented (V%). Moreover, their more or less positive meaning depends on the value obtained by this contents during the formal quality evaluation (V+%). In this research, the comparison between Affective Quality and Formal Quality and nominated “Stabilization Affective Index” was also analysed (A/F). In addition, other two particular phenomenon more frequently found in the Wartegg were studied: the deletion or blackening of the stimulus-sign, called “Anxiety Index” (I.A.) and the overtook margin called “Impulsivity Index” (I.I.). The “Interior Intension Index” is deduced from the last two indicators (I.T.I). The Evocative character: Wartegg (1957) talked about the archetypal function of the 8 stimulussigns chosen by him. With this definition he meant the intrinsic and universal capacity/power of signs, also based on specific Gestalt rules, to evoke unconscious experiences for everybody to take part of. Therefore, the EC gives us information on how the subject reacts to the stimulus-signs of the test, both from a purely perceptive-gestalt and associative point of view. If the subject catches the hints of the stimulus-sign and make related graphic realizations is given the score 1. When the solutions only partially integrate the evocative character is given the score 0.5. When the pictures completely fail is given the score 0. The Affective quality: is only and exclusively an evaluation based on emotional connotation that characterizes each subject’s picture. The AQ tells us about subject’s emotional tone, its ability to get into relation with its affective and instinctual dynamics and to show them outside. Even in this case, each picture gets a score 1, 0.5 or 0, depending on subject’s draws positive, neutral or negative emotional contents. The Formal Quality: evaluates the ability to express the most important features that make picture “peculiar and recognizable to our eyes” (Crisi, 1998). This ability can be considered closely connected to subject’s cognitive level, because it is based on the ability to recognize the whole through a part. According to FQ criteria also, score 1 is assigned when picture significance is obvious and immediately

Personality and Female Infertility 143 recognizable by the examiner. Score 0.5 is assigned when this significance is suitable to various possibilities of reading, and 0 when picture is totally unclear, unrecognisable and arbitrary. On the basis of more used scores, vulgar answers are divided into vulgar answer properly gave (= V; the score 1 is assigned), and semi vulgar (= v; score 0,5 is assigned). The discovered value (V%) measures any thought stereotype and critical capacity absence in depressed, formal and conformist people. The vulgar answer percentage with positive formal quality (V+%) evaluates subject’s adaptation process to the reality and common thought not only in a quantitative way, which is V%, but also qualitative. The index of affective stabilization (A/F) describes in which way affectivity and rationality are related. It notices the presence or the absence of any emotional stabilization, of an affective balance, of selfcontrol and a maturity reached by the subject. In general, relevant prevalence of affective aspects can be considered in close relationship with Jungian extrovert type, while clear-cut prevalence of formal aspects with the introvert type (Crisi, 1998). The Interior Intension Index represents a “not specific signal of psychological discomfort”. It describes the inadequacy degree and/or emotional tension present in subject”. The Impulsivity Index evaluates impulsiveness, acting-out and therefore subject’s ability to check sexual and aggressive energy. The Anxiety Index shows anxiety, insecurity and indecision occurrence. All these three indexes (I.T.I.; I.I.; I.A.) vary from 0 to 1. Statistical Analyses: First, age differences effect on Wartegg variables was calculated. The effect of “group” variable was analysed by MANOVA, for Wartegg parameters, and the post hoc differences between group means were obtained by Multiple Comparisons. Non parametric dependent variables (as order of Panels in answers) were analysed by Chi square Test. Statistical elaboration was performed with SPSS11.0 program. Results: Regarding to Test performance times, the ANOVA shows a trend of B and C groups to have longer Test performance times compared to other groups even if this trend is not completely significant (F: 2.35, p<.08). This data is a defensive attitude index. Regarding to Panels sequence order, while 76% of control group executed Panel 1 first, only 50% of two sterility groups made the same choice. Finally, this choice is present only in 24% of subjects affected by recurrent spontaneous abortions. This difference is noteworthy on a statistical level (Chi square =13.36; p<.004). Instead there are no clear significant differences among groups about choosing last picture. Multivariate Analysis on key variables of Test correction (CE; QA and Q.F) shows significant differences between research groups (F: 3.218 p<.001). In particular, significant differences were noticed in Evocative Character (p .006) and Formal Quality (p .0001) means, while no significant differences were noticed in Affective Quality among groups. Recurrent spontaneous abortions group, instead, showed only a trend to have lower means as compared to organic sterility and control groups. Table 1 show differences related to Evocative Character in experimental group. Recurrent Spontaneous Abortions (RSA) sample has significantly lower means related to control and unexplained sterility groups. In particular, the post hoc analysis shows significant differences regarding Panel 1 control group compared to control and organic sterility groups. There are significant differences also concerning Panel 4 compared to unexplained sterility group and Panel 5 compared to controls. The

144 Daini et al organic sterility group shows lower means compared to unexplained sterility and control groups that can be attributed to Panel 4,5,6,7. Table 1 MANOVA Diagnosis (Recurrent Spontaneous Abortions, Organic Sterility, Unexplained Sterility and Controls) for Evocative Character scores in eight Panels Wilk’s R S A Organic Sterility Unexplained Sterility Control F LSD Lambda Group A (N=21) Group B (N=20) Group C (N=20) Group D (N=30) 3.218 Post-Hoc Test (P<.001) Mean (SD) Mean (SD) Mean (SD) Mean (SD) Panel 1 0.78 (0.4) 0.95 (0.1) 0.87 (0.3) 0.94 (0.1) 2.15 A<B* A<D* Panel 2 0.40 (0.4) 0.52 (0.4) 0.37 (0.4) 0.43 (0.4) 0.44 Panel 3 0.57 (0.3) 0.52 (0.3) 0.65 (0.3) 0.69 (0.3) 1.45 Panel 4 0.42 (0.4) 0.42 (0.4) 0.67 (0.4) 0.62 (0.4) 2.52 A<C* B<C* Panel 5 0.50 (0.4) 0.45 (0.4) 0.65 (0.3) 0.71 (0.3) 2.74 B<D* D>A* Panel 6 0.88 (0.3) 0.85 (0.3) 0.95 (0.1) 0.98 (0.1) 1.79 B<D* Panel 7 0.52 (0.4) 0.40 (0.4) 0.65 (0.3) 0.67 (0.3) 2.82 B<C* B<D* Panel 8 0.81 (0.3) 0.77 (0.3) 0.77 (0.3) 0.81 (0.2) 0.10 *W: p<.05W; Table 2 shows results related to Formal Quality. Even in this case, RSA group presents lower scores. In particular, differences in unexplained sterility and in control group are very significant. These results are above all ascribed to relevant differences related to Panel 4. Organic sterility group instead, presents significantly lower scores compared to unexplained sterility and control groups. Therefore, the unexplained sterility group is more similar to healthy controls concerning Formal Quality. Table 2 MANOVA Diagnosis (Recurrent Spontaneous Abortions, Organic sterility, Unexplained Sterility and Controls) for Formal Quality scores in eight Panels Wilk’s R S A Organic Sterility Unexplained Sterility Control F LSD Lambda Group A (N=21) Group B (N=20) Group C (N=20) Group D (N=30) 3.218 Post-Hoc Test (P<.001) Mean (SD) Mean (SD) Mean (SD) Mean (SD) Panel 1 0.66 (0.4) 0.67 (0.4) 0.81 (0.3) 0.71 (0.2) 0.86 Panel 2 0.59 (0.4) 0.58 (0.4) 0.76 (0.4) 0.80 (0.3) 2.14 B<D* Panel 3 0.28 (0.4) 0.36 (0.4) 0.37 (0.3) 0.50 (0.4) 1.44 Panel 4 0.25 (0.3) 0.58 (0.3) 0.74 (0.3) 0.66 (0.3) 7.37 A<B ** A<C *** A<D *** Panel 5 0.4 (0.4) 0.50 (0.3) 0.66 (0.3) 0.55 (0.3) 1.80 A<C * Panel 6 0.81 (0.3) 0.61 (0.4) 0.76 (0.3) 0.75 (0.3) 1.24 Panel 7 0.56 (0.4) 0.64 (0.4) 0.63 (0.3) 0.75 (0.3) 1.03 Panel 8 0.66 (0.4) 0.67 (0.4) 0.71 (0.3) 0.80 (0.3) 0.87 *W: p<.05W; **W: p<.01W; ***W: p<.001

Personality and Female Infertility 145 The results of Interior Intension, Anxiety and Impulsivity Indexes are reported in Table 3. Concerning Interior Intension, there are relevant differences among groups. This index appears significantly higher in unexplained sterility group compared to the other two experimental groups. Anxiety Index instead is similarly higher in unexplained sterility group compared to the other two groups, even if it is not in a pathological range. There are no significant differences compared to controls. Table 3 MANOVA Diagnosis (Recurrent Spontaneous Abortions, Organic Sterility, Unexplained Sterility and Controls) for Anxiety and Impulsivity Indexes Wilk’s R S A Organic Sterility Unexplained Sterility Control F LSD Lambda Group A (N=21) Group B (N=20) Group C (N=20) Group D (N=30) 3.218 Post-Hoc Test (P<.001) Mean (SD) Mean (SD) Mean (SD) Mean (SD) Interior 0.22 (0.3) 0.24 (0.2) 0.39 (0.2) 0.27 (0.3) 2.11 A<C Tension B<C Index Anxiety 0.01 (0.04) 0.04 (0.1) 0.14 (0.2) 0.07 (0.1) 3.27* A<C Index B<C Impulsivity Index 0.22 (0.2) 0.21 (0.2) 0.26 (0.2) 0.20 (0.2) 0.36 *W: p<.05W Table 4 shows results related to ratio Affectivity/Form. In this case, consecutive miscarriages group shows significantly higher means than unexplained sterility and control group. Organic sterility group instead, shows higher means compared to unexplained sterility group. As regards variable F (Form), these results are attributed to very significant differences among groups. With reference to subject’s Vulgar contents answers (V% e V+ %), significant differences were not found among samples. Table 4 MANOVA Diagnosis (Recurrent Spontaneous Abortions, Organic Sterility, Unexplained Sterility and Controls) Wilk’s R S A Organic Sterility Unexplained Sterility Control F LSD Lambda Group A (N=21) Group B (N=20) Group C (N=20) Group D (N=30) 3.218 Post-Hoc Test (P<.001) Mean (SD) Mean (SD) Mean (SD) Mean (SD) A Affectivity 2.33 (0.8) 2.72 (0.6) 2.60 (0.9) 2.64 (0.8) 0.88 F 1.52 (0.9) 1.97 (0.9) 2.57 (0.9) 2.45 (0.7) 7.46*** A<C Formal A<D B<C B<D A/F 0.81 (1.0) 0.75 (1.0) 0.02 (1.2) 0.19 (1.0) 2.96* A>C A>D B>C *W: p<.05; ***W: p<.001W

146 Daini et al Discussion: Our findings confirm that infertility problem involves female personality deeply, with a range of features correlated to infertility type taken into account. This study regarded the causal connection and the presence of previous pregnancies loss considering all that variables that make infertility a complex and articulate problem. Women affected by primary sterility and who haven’t lost their child, appear less problematic than women whose infertility is linked to a sense of mourning for not having pregnancy to term. Any type of organic sterility group presents a lower adaptability and ability to build social relationship. This group has a trend not to understand the evocative nature of panels regarding female and aggressive themes and relation to authority. In these dimensions, these women show differences compared to unexplained sterility and control groups. This organic sterility group is similar to consecutive miscarriages group but differs from it for a stronger sense of identity (Panel 1). The Formal qualitative analysis on same patients suggests a difficulty to make an adequate reality and to have a good self control. The significant difference of Panel 2 compared to control group suggests a poor integration regarding emotional themes. The sterility condition leads to sense of inferiority in women. In fact, although organic sterility underlines a body inability, it allows the elaboration of woman’s potential sense of guilt. In fact, in this case Interior Tension, Anxiety and Impulsivity Indexes are on average. The unexplained sterility group shows psychological features more similar to control group. In fact, there aren’t significant differences among these groups. Therefore, the absence of sterility allows maintaining a fairly good emotional, cognitive and relational equilibrium. This condition is probably associated to a hope of a natural or non medical resolution of sterility. But, the definition of a woman’s own identity appears potentially rigid and with internal tension (scores are higher than average, in both Evocative Character and Formal Quality – Panel 1). However, this group appears to have more anxiety compared to the other two groups of sterile women, but not in pathological terms. Concerning unexplained sterility, some authors (Bydlowski, 2003) underline the secondary gain of the illness. In our study we hypothesize that this secondary gain is not related to partner or family attention but to a more acceptable personal psychological equilibrium. This equilibrium could come to a crisis both because of a child’s existence and the diagnosis of definite sterility. Spontaneous consecutive miscarriages group shows a remarkable psychological effect on female personality, even if the hope to have a child has not been dropped. It follows a compromised identity regarding her inner world that is not able to make up for adequate rational defences. Relationship with the normative sphere also appears problematical (Panel 4). Women affected by recurrent spontaneous abortions show extremely significant differences as compared to all other groups. This makes to think that miscarriage experiences are correlated not only to disappointment regarding a pregnancy expectation, which is encouraged by the ability of conceiving, but also to an extremely strong unconscious conflict characterized by an irrational sense of guilt. Although anxiety and internal tension indexes are not so high, the relationship unsettling between affectivity and rationality makes us think about a subject’s immaturity and poor ability to control its reactions and to plan its activities. In this group, the psychological burden due to infertility seems to reflect on woman’s emotional and cognitive equilibrium completely, maybe due to the attachment relationship towards the child during pregnancy. A woman can experience this relationship since the early months of pregnancy and it can modify her narcissistic equilibrium. Therefore the spontaneous miscarriage can be suffered by a woman as a traumatic event and it can be a reason for her to come to a crisis.

Personality and Female Infertility 147 It is remarkable that the absence of significant differences regarding the affective quality among all infertile women and control groups. This would make us think about an absence of depressing feelings in a psychodynamic sense, contrary to findings based on psychometric tests. An interpretative hypothesis could refer to the situation in which tests have been performed. This could be related to a new examinations phase regarding a potential pregnancy attempt. Consecutive miscarriages group has shown lower scores as compared to other samples but the difference was not found statistically significant. For this and the other infertile women groups, a new attempt for pregnancy could represent a balancing element for affectivity. A significant tendency to Alexythimia, has been recently reported in organic and unexplained infertility groups, through Self Report Instruments (Lamas and Coll, 2006). The study used a graphic and Wartegg projective test and found that the poor communicative ability is an exterior defence rather than a shortage of emotions or affective feelings. The extension on sample dimensions could allow us to differentiate further variables which can intervene in modifying the psychological framework of infertility, for example the presence of different organic causes, linked to a greater or minor recovery expectation. However the variables analysed in this study allow differentiating various psychological profiles in female infertility. Conclusions: The demand of psychological service to infertile couples and especially to woman is recognized both by researchers adhering to a psychodynamic point of view and by those more critical towards it. (Wischmann, 2003). Studying this problem through projective tests allows us to highlight less clear perspectives from a symptomatological point of view and to outline various personality profiles. This can help us making a custom-made treatment for patients. Acknowledgement: We wish to thank Dr. Paolo Iliceto, for statistical analysis of the data. References: Abayeb, O.H., Konje, JC. (2005). Tje one-stop recurrent miscarriage clinic: an evolution of its effectiveness and outcome. Hum. Reprod., 20 (10), 2976-9. Alaina, B., Bouden, JW., Frey, KA. (2007). Infertility. American Family Physician, 75 (6), 849-59. Bharadwaj, A. (2006). Sacred conceptions: clinical theodicies, uncertain scienze, and technologies of procreations in India. Cult Med Psychiatry., 30(4), 451-465. Bydlowski M. (2003). Psychic factors in female unexplained infertility. Gynecol Obstet Fertil., 31(3): 246-51. Crisi, A. (1998). Manuale del test di Wartegg. (Ed.), Roma: Magi. Daini, S. (1997). Critical events and psychopathology in the woman: a dynamic point of view. Acta Medica Romana , XXXV, 283-295. Dhalival, LK., Gupta, KR., Gopaian, S., Khulara, P. (2004). Psychological aspects of infertility due to various causes-prospective study. Int J. Fertil Womens Med., 49(1): 44-48. Falcone, A., Grasso, M., & Pinkus, L. (1986). Presupposti teorici per l’uso clinico del test di Wartegg. (Ed.), Firenze, O.S. Guz, H., Ozkan, A., Sarisoy, G., Yanik, F., Yanik, A. (2003). Psychiatric Symptoms in Turkish infertile women. J Psychosom Obstet Gynaecol 24:267–271. Habayeb, Konje. (2005). Tje one-stop recurrent miscarriage clinic: an evolution of its effectiveness and outcome . Hum. Reprod., 20 (10) 2976-2979.

Hjelmstedt, A., Widstrom, AM., Wramsby, H., Matthiesen, AS., Collins, A. (2003). Personality factors and emotional responses to pregnancy among IVF couples in early pregnancy: a comparative study. Acta Obstet Gynecol Scand., 82(2), 152-161. Inhorn, MC. (2003). Global infertility and the globalization of new reproductive technologies: illustrations from Egypt. Soc Sci Med, 56 (9),1837-1851. Jedrzejczak, P., Luczak-Wawrzyniak, J., Szyfter, J., Przewozna, J., Taszarek-Hauke, G., Pawelczyk, L. (2004). Feeling and emotions in women treated for infertility. Przegl Lek, 61(12), 1334-1337. Khademi, A., Alleyassin, A., Aghahosseini, M., Ramezanzadeh, F., Abhari, AA. (2005). Pretreatment Beck Depression Inventory score is an important predictor for post treatment score in infertile patiens: a beforeafter study. BMC Psychiatry, 24; 5-25. Kiwi, R. (2006). Recurrent pregnancy loss: evaluation and discussion of the causes and their management. Cleve Clin J Med. 73( 10); 913-921. Klock, SC., Chang, G., Hiley, A., Hill, J. (1997). Psychological distress among women with recurrent spontaneous abortion. Psychosomatics,38(5), 503-507. Lachowsky, M. (1998). Habitual abortions: psychogenic or induced psychopathology? Contracept Fertil Sex. 26(10): 732-735. Lamas, C., Chambry, J., Nicolas, I,. Frydman, R. (2006). Alexythimia in infertile women . J Psychosom Obstet Gynaechol., 27 (1) 23-30. Matsubayashi, H., Hosaka, T., Izumi, S., Suzuki, T., Kondo, A., Makino, T. (2004). Increased depression and anxiety infertile Japanese women resulting rom lack of husband’s support and feelings of stress. Gen Hosp Psychiatry, 26(5), 398-404. Mattlar, CE., Lindholm, T., Haasiosalo, A., Vesala, P., Rissanen, S., Santasalo H., Veicola, J., Lethinen, V., Puukka, P. (1991). Interrater agreement when assessing alexithymia using the Drawing Completion Test (Wartegg Zeichentest). Psychother Pychosom, 56(1-2),98-101. Metha, R. and Anand Kumar, T.C. (2005). Stress and fertility. Indian J Med Res 122, 468-469. Muller, W., Burns, LH., Crow, S., Grambsch, P. (2002). Major depression in unexplained sterility. J Psyghosom. Obstet. Gynaecol. Mar; 23(1): 27-30. Pottinger, AM., McKenzie, C., Fredericks, J., DaCosta, V., Wynter, S., Everett, D., Walters, Y. (2006). Gender differences in coping with infertility among couples undergoing counselling for in Vitro Fertilization treatment. West Indian Med J., 55 (4), 237-242. Rapaport D., Gill Merton M., Schafer R. (1981). Reattivi Psicodiagnostici. Roma: Bollati Boringhieri. Schmidt, L., Hlstein, BE., Boivin, J., Tjornhoj-Thomsen, T., Blaabjerg, J., Hald, F., Rasmussen, PE., Nyboe Andersen, A. (2003). Hight ratings of satisfaction with fertility treatment are common: findings from the Copenhagen Multi-centre Psychosocial Infertility (COMPI) Researh Programme. Hum Reprod., 18(12), 2638- 2646. Schmid, J., Kirchengast, S., Vytiska-Binstorfer, E., Huber, J. (2004). Psychosocial and sociocultural aspects of infertility: a comparison between Austrian women and immigrant women. Anthrpol. Anz. 62(3), 301-309. Stewart, D.E., Stotland, NL. .Eds. (1993). Psychological aspects of women’s Health care. American Psychiatric Press , Washington. Stotland, NL. (1998). Abortion: social context, psychodynamic implications. Am erican Journal of Psychiatry.155 (7), 964-967. Wartegg, E. (1957). Verlag für Psychologie. (Ed.), Göttingen Whitelaw, M. J. (1960). Statistical evaluation of female fertility. Fertil Steril. 196 Jul-Aug. 11, 426-436. Wischmann, TH. (2003). Psychogenic infertility: myths and facts. J Assist Reprod Genet. 20(12), 485-494. 144 Daini et al

SIS in Paranoid Ideation: A Case Study Radhe Shyam Index subject is a 26 year old medical practitioner in Ayurvedic system with no past history of physical or mental problems. He was admitted to a Medical College on a payment seat after paying rupees 4.5 lacs and consequently believes that he over paid for admission. He feels guilty for spendings of his father’s money. After completing the internship, he started private practice. He soon decided to work with an experienced doctor to refine his clinical skills and knowledge. Consequently he joined a private nursing home located about 80 miles away from his home town. He was paid Rs.5000/- a month with accommodation near the hospital. At first he was happy working in the hospital. For about four months everything seemed fine, except he felt homesick. Eventually he developed friendship with other staff members in the hospital. However one day a physician colleague doctor and a nurse were sitting and cracking jokes. The fellow doctor cracked jokes and passed some personal remarks and laughed at him. Unfortunately he took it too seriously and felt humiliated. He asked them not to behave in this manner because it bothered him. Yet over time at work things did not improve and he felt picked on daily. This stress caused his work to suffer significantly, so eventually the senior doctor (the owner) of the hospital also became involved. This made him angry and he rebuked all of the medical staff. He warned them not to repeat it in future or he would resign. Unfortunately the situation was perceived by him in a somewhat paranoid way. Ultimately he believed that the senior administrator was cruel with no humane feelings. This distorted perception continued to influence his feelings of discomfort in the hospital setting. He started losing confidence and developed distressing negative thoughts and emotions. Finally he resigned and went back to his own city. At that time his goal was to again begin doing private practice in his own clinic. In this professional setting he still was having problems in functioning since his income was only seven to eight thousand a month. In spite of his financial issues, he was more satisfied with his work environment. He is unmarried but dreams about this for the future when his economic situation improves. He is the only child of school teacher parents. He had occasional calls from a few old colleagues from earlier work place. His own classmates have started visiting him and they had good time. Yet in his new medical practice his feelings of persecution recurred. For example, he began to believe that a few of his old friends were also beginning to crack jokes, pass personal critical remarks and laugh at him. In his distorted thinking he began to imagine the situation similar to that in the hospital. Current Symptoms: His presenting symptoms at initial psychological evaluation included the following: insomnia, loss of appetite, excessive sweating, restlessness, difficulty in concentration, sadness of mood, lack of confidence, lack of interest in self and work. He has low self and lack of confidence. Moreover, in spite of his academic and professional achievements he felt that his IQ was low. This clinical picture was consistent with a diagnosis of Major Depression. Eventually he consulted several psychiatrists of the town who prescribed medicine. However, he denied that he was seriously Radhe Shyam,Ph.D., Reader, Department of Psychology, M.D.University, Rohtak- 124001(India) Cell:91-9416312480 Email: radheyshyam1111@yahoo.co.in Key Words : Paronoid Ideation, Raven’s Progresive Matrices Test, Rational Emotive Therapy.

150 Radhe Shyam depressed and refused the medication that each prescribed. He believed that he had a psychological problem not requiring medication. As part of the psychological assessment, he was administered Ravens Progressive Matrices test. In spite of his depressive related cognitive disturbances, he was found to have at least average intelligence. In addition the Somatic Inkblot (SIS) Series-II (booklet version) was also administered. The diagnostic/treatment applications of this projective interview aide are the subject of this case history presentation. The treatment plan involved eight sessions of Rational Emotive Therapy supplemented by introducing SIS symbolism in the therapeutic process. This combination appeared to have marked therapeutic effects. He reported considerable improvement in mood, cognition and a significant reduction in neurovegative depressive symptoms. Therapy is still continuing once in fortnight. SIS Responses: Three least liked images in order: A13: 1. “Hand surrounded by a ring of fire” This response symbolized his distorted view of his earlier hospital environment, as well as that of his new medical practice. It reflected his depression related feelings of persecution and helplessness. In psychotherapy it was possible to review his stresses and cognitively correct his misperceptions. 2.\ “It seems that someone is being exploited” This response directly related to the reality of the real life stress. He was in fact “Exploited” by the agent who fraudulently took money from him at admission. Initially this loss played a significant role in his depression. He felt unduly obliged and under pressure to do well professional practice. Exploring this symbolism with him in the context of ongoing rational emotive psychotherapy was most effective. A10: 1. “Eyes of some crook person” Ordinarily the projection and emphasis on “Eyes” is consistent with paranoid feelings of being looked at. While this applies some what here, what is unique is that this recapitulates in the projective setting what really happened when he applied to medical school. B29: 1. “A handicapped person” projected his frustration towards life and low self. This has brought out his feelings that he is foolish and having low IQ, not able to have good medical practice. Three mostKliked images in order: A31: 1. He has seen “Two person one male and one female talking in good mood” is a good response. It indicates good relationship with others. A7: 1. “Female figure, lady in dancing position” is again a very good response indicating that he has good ego strength and wanted to enjoy life. It is also a good prognostic indicator. B5: 1. “Two persons talking in good mood” further project his desire to have good interpersonal relations and good mood. The also suggest a good prognostic indicators. Next an analysis will be given of a few additional responses which related to the above noted themes: A2: 1. “Photo of lord Ganesa” may connote spiritual symbol might help him in resolving his problems. 2. “Abdomen” may suggest preoccupation with body imagery and anxiety.

SIS in Paranoid Ideation 151 A3: 1. “Bomb blast” this symbolized his anger and frustration prior to psychotherapy. He felt like “exploding” with al his pent up emotions. A4: 1. “Worm in the intestine” is an atypical response. It symbolized his inner body image wherein his unexpressed rage was “eating at his intestines – like a worm’. A5: 1. Horizontal crosection of human body, symbol of love, 2. “Flying bird” is good response projecting his desire to be happy and stress free. A7: 1. “Structure of a lady in dancing position” is normal response suggesting his ego strength and positive attitude towards life. This is positive sign of good prognosis. 2. “Apple” is again a normal response. 3. “Looks like worm” this continues the earlier “worm” symbolism A8: 1. “Two persons standing in such a position having their faces in opposite direction as if they are expressing anguish by not talking (a sad person)”. This reflected his poor aggression and hatred towards earlier employer and colleagues. A9: ”Two persons (one male and a female) dancing” is a good response and indicates his desire to have happy relationship with others particularly with females. In a case of a single person like him it may suggest his wishful thinking to have happy moment with a lady. 2. “Structure of DNA” non conclusive in his case. A10: 1. “X ray taken from front side, diaphragm, and vertebra” is a normal response may also indicate bodily preoccupation and anxiety. 2. “Eyes of cat”. This once again depicted his paranoid like feelings. This theme continued in further associations to A10: 3. “Some one keeping watch” is a strong indication of paranoid ideation. 4. “Someone with ill will” also indicate paranoid ideation. A11: 1. “A saint is praying with garland in his hand” suggests that he is taking spiritual help to protect his ego. A14: 1. “A person in financial crisis” this is an important response because it reflected a major underlying stressor, namely financial issues. A15: 1. “A person in conflict, someone expecting mercy”. This directly expressed his life situation and feelings of helplessness prior to therapy. A16: 1. “A bird feeding to her infants” is a good response indicating healthy interpersonal relationship with his parents. 2. “Symbol of love” connoting desire to have loving relationship. 3. “Spoiled painting by putting some dark ink” symbolized his depressive feelings and frustration. A17: 1. “Corpse is hanging in butcher’s shop, leg is hanging (someone in miserable condition, dead body)”. This depicted in symbolic form his high degree of aggression and morbid thinking. 2. “Dissected mouse with scattered blood” This further indicates aggression. A24: 1. “Twins in womb” is an atypical response which symbolized regressive feelings in order to avoid the reality of his inability to resolve his problems prior to professional help.

152 Radhe Shyam A28: 1. “Cracks in wall/ broken glass” is an aggressive response. A31: 1. “Male and female talking in romantic mood” is good response projecting his desire to have happy moments with females. B1: 1. “Scattered blood/ photo of stomach”. This again brings out in projective consciousness the theme of his inner feelings of aggression.. B4: 1. Two men talking, one person wants to talk but the other did not. This recapitulates a scene in which the man who fraudulently took money for his admission refused to discuss it. B5: 1. Twp person sitting on chair and listening radio, one is tensed other is relaxed. This reflected his perception of psychotherapy in the initial phase when he was so tense. B6: 1. Depressed person:. This is a direct projective of himself prior to psychotherapy. It is unfortunate that initially medication was repeatedly prescribed rather than psychological intervention. B8: 1. Depressed and hopeless person, a person surrounded by problem from all side”, His feelings of “hopelessness” partly related to the above noted delay in having appropriate efficacious professional help. B9: 1. A self blaming person, a failed person who himself is responsible for it. This response clinically correlated with his initial low self esteem. The following responses continue the above outlined themes: B10: 1. Situations are dominating on a person, a person who is depressed because of someone else. B11: 1. A self blaming person, a failed person who himself is responsible for it. B12: 1. Situations are dominating on a person, a person who is depressed because of someone else. B13: 1. People are looking with bad intention, to harm someone, to look at some one to harm financially as well as emotionally with an intention to torture the other B14: 1. Photo of God 2. A friend is ditching. 3. An ignoring face B 15: 1. War scene/ bomb blast/ broken glass B 17: 1. Broken hammer/ pistol. B21: 1. Like a broken hammer, like a pistol. B22: 1. Dead body/ cigarette smoke/ someone who has murdered someone. The repetition of “pistol” and reference to “murder” reflected his homicidal feelings priot to treatment. B26: 1. Sword. This is another instrument for aggression. B28: 1. Face ignoring me while I am devoted to B29: 1. A handicapped person in sad mood. Finally, it might be noted that he liked the SIS interview aide as it help in expressing himself, and in recovering from the financial and emotional trauma.

SIS in Paranoid Ideation 153 Conclusion: Subject is a 26 year old medical practitioner. His presenting symptoms at initial psychological evaluation were insomnia, loss of appetite, excessive sweating, restlessness, difficulty in concentration, sadness of mood, lack of confidence, lack of interest in self and work. He believed that he had a psychological problem not requiring medication. As part of the psychological assessment, he was administered Ravens Progressive Matrices test and was found to have average intelligence. In addition the Somatic Inkblot (SIS) Series-II (booklet version) was also administered. The responses on SIS projected his aggression and inner cry. SIS further helped in expressing himself, and in recovering from the financial and emotional trauma. The treatment plan involved eight sessions of Rational Emotive Therapy supplemented by introducing SIS symbolism in the therapeutic process. This combination appeared to have marked therapeutic effects. He reported considerable improvement in mood, cognition and a significant reduction in depressive symptoms. A case study is reported in every issue of the Journal. The readers are requested to send their comments to Prof. Amool R. Singh, Ph.D., Editor in Chief, SIS Journal of Projective Psychology and Mental Health for publication in next issue of the journal. Also, please send your case study using projective test for publication in next issue of the journal.

Rorschach Responses of Indian Children and Adolescents with Psychiatric Disorders Suprakash Chaudhury, D. Saldanha, K. Srivastava, S.G.Jyothi, G.S.Sundari, and M. Augustine The Rorschach test by Klopfer’s method was administered to 313 children and adolescent patients with psychiatric disorders viz. schizophrenia (n=66) mania (n=10) depression (n=33), anxiety state (n=24) hysteria (n=45) nocturnal enuresis (n=48) head injury (n=16) epilepsy (n=32) and mental retardation (n=39). The Rorschach profiles of the various groups of patients showed significant differences among the groups and from normal Indian subjects and the Western norms. Interpretation of the Rorschach protocols of Indian children and adolescent with psychiatric disorders using the Western norms would be fallacious and misleading. The use of the Rorschach test as an aid to clinical diagnosis was strongly supported. Projective testing started with the Rorschach test remains the most studied, used and argued over technique of clinical assessment. Continuing interest in the Rorschach is evident from the fact that the number of publications on it has crossed over 5000. This is a most impressive testimonial to the Rorschach’s sensitivity to the needs of the clinician and speaks of its reliability, validity and diagnostic usability (Reynolds & Sundberg, 1976; Polyson et al, 1986). During the 1970’s and 1950’s its name was almost synonymous with clinical psychology. During these years the primary role of the clinical psychologists focused on assessment or psycho diagnosis. As the role of the clinical psychologist broadened and diversified during the 1960’s and 1970’s, the Rorschach remained among the most commonly used tests in the clinical setting and this status continues today (Exner, 2002). Even in India the Rorschach test is widely used and enjoys the highest rank among the tests used for psycho diagnosis and assessment of personality (Dubey, 1982). The clinical use of a psychological test like the Rorschach requires the existence of norms for normal individuals and also patients with various psychiatric disorders. Comparatively there are a few studies on children and adolescent using the Rorschach test in India. Moreover, within the researches conducted In India, the norms for normal subjects and patients with various psychiatric disorders established by various workers differ considerably (Bagh, 1955; Roy Chaudhuri & Maitra, 1965; Sethi et al, 1976; Dubey, 1982, Singh & Verma, 1990). In addition most of these studies had a number of shortcomings, the most important being the relatively small sample from a single center, which was not representative of the general population. In the absence of reliable norms, Indian mental health professionals are left with no alternative but to interpret the Rorschach protocols on the basis of their own experience acquired during their clinical practice. This personalized knowledge is, of course, to a great extent influenced by the various western and Indian norms. Naturally, this results in a lot of subjective bias in the interpretation of the Rorschach protocol. There is a need to have specific and reliable norms for Indian children and adolescents. The present study was undertaken to fulfill this need. Material and Method: The psychiatric patient population consisted of 313 patients in the age group of 5-16 years, drawn from inpatients and outpatients of Military Hospitals Bareilly, Gauhati, Meerut, Pune, Cannanore and Mental Hospital Bareilly. Patients with epilepsy and head injury were drawn from the medical and surgical wards of Military Hospitals Bareilly, Gauhati and Meerut. The Rorschach test was conducted when the patient was fully conscious and acute symptoms had subsided. The Rorschach test was Suprakash Chaudhury, M.D., Ph.D. Prof & Head, Dept of Psychiatry, Ranchi Institute of Neuropsychiatry & Allied Sciences, Kanke, Ranchi-834006, D. Saldanha, M.D. Prof & Head,K. Srivastava, Scientist ‘E’, Dept of Psychiatry, AFMC, Pune- 411040, S.G.Jyothi and G.S. Sundari, Specialist Sister (Psychiatry), Military Hospital, Meerut. and M.Augustine, Specialist Sister (Psychiatry), 151 Base Hospital, c/o 99 APO. Key Words: Rorschach test; psychiatric disorders; children and adolescents

not administered on the day of a seizure or the day following a seizure. Each subject was initially interviewed to collect the personal data. The Rorschach test was administered following Klopfer’s method (Klopfer & Davidson, 1962). It was ensured that there was no compulsion to take the test. It was emphasized that the test was not being used to find out their mental states and that he was participating in a research project to determine how various persons responded to the test. Statistical analysis was carried out using median test. Results: This study comprises of 313 Rorschach test records obtained from Indian children and adolescents suffering from psychiatric disorders. The distribution of the subjects by age and diagnosis is given in Table 1. The patients groups were compared with age and sex matched normal controls using the median test. The demographic data of the various groups of subjects are presented in Table 2. Table 1 Distribution of Subjects by Age and Diagnosis Age range in years Sublects >4-6 >6-10 >10-12 >12-14 >14-16 Total Schizophrenia - - Mania - - - Depression - - Anxiety State - Hysteria (Diss Rea) - - Nocturnal Enuresis - - Head Injury - Epilepsy Mental Retardation - Total Table 2 Demographic Characteristics and Regional Distribution of the Subjects DIAGNOSIS Variables Schizophrenia Mania Depression Anxiety State Hysteria Nocturnal Head Epilepsy Mental Enuresis Injury Retardation Mean age (in years) 15.02 15.1 13.64 13.5 14.53 10.25 10.5 12.38 13.85 Sex : Male Female Education : 0-5 6-10 >10 Domicile : Rural Urban Region : North East South West Religion : Hindu Sikh Muslim Christian Rorschach Responses of Indians 151

156 Chaudhury et al The number of responses and reaction time of subjects is presented in Table 3. The percentage of response per card by the various groups is given in Table 4. The frequency with which each card was rejected is shown in Table 5. Table 6 shows the frequency of one or more cards were rejected by subjects. Table 3 Total Number of Responses and Reaction Time (RT) in Seconds Total responses Reaction time (in secs) Group Mean Minimum Maximum Average Minimum Maximum RT ACH RT CH Schizophrenia 12.16 59.2 32.4 32.8 Mania 24.25 32.8 21.7 38.8 9.3 7.2 Depression 9.73 93.8 47.1 248.6 39.02 43.2 Anxiety State 11.5 71.03 21.3 167.1 36.3 33.5 Hysteria(DR) 9.33 53.3 23.9 80.5 19.8 23.3 Nocturnal Enuresis 13.17 56.9 29.2 10.3 13.8 Head Injury 8.25 63.3 11.8 13.9 Epilepsy 10.38 66.02 26.7 33.3 33.2 Mental Retardation 9.08 85.9 197.5 65.3 56.6 Table 4 Percentage of Response Per Card Group I II III IV V VI VII VIII IX X Schizophrenia 9.50 11.25 10.80 8.75 8.75 8.75 9.13 10.99 9.68 12.29 Mania 8.25 8.25 12.37 6.19 7.22 7.22 8.25 8.25 12.37 21.65 Depression 8.49 8.49 11.32 7.55 9.43 4.72 10.38 15.09 9.43 15.09 Anxiety State 13.98 9.68 9.68 10.75 8.60 8.50 9.68 11.83 5.38 11.83 Hysteria Diss. Reaction) 16.43 13.57 9.29 4.29 10.71 5.00 8.57 12.14 10.00 10.00 Nocturnal Enuresis 11.25 8.13 10.00 9.38 8.13 6.88 8.75 11.25 8.75 17.50 Head Injury 11.11 13.89 8.33 8.33 11.11 5.56 8.33 11.11 11.11 11.11 Epilepsy 9.76 10.98 10.98 8.54 9.76 8.54 8.54 10.98 7.32 14.63 Mental Retardation 12.71 12.71 10.17 8.48 11.02 6.78 8.48 14.41 7.63 7.63 Table 5 Rejection of Cards RORSCHACH CARDS Group I II III IV V VI VII VIII IX X I N(%) N(%) N(%) N(%) N(%) N(%) N(%) N(%) N(%) N(%) N(%) Schizophrenia 8(12.1) 7(10.6) 6(9.1) 15(22.7) 7(10.6) 8(12.1) 7(10.6) 4(6.1) 11(16.7) 13(19.7) 8(12.1) Mania - - - - - - - - - - - Depression 5(15.2) 18(54.6) 6(18.2) 12(36.4) 3(9.1) 15(45.5) 6(18.2) - 12(36.4) 3(9.1) 5(15.2) Anxiety State 3(12.5) 7(29.2) 7(29.2) 6(25) - 6(25) 6(25) 2(8.33) 13(54.2) 5(20.8) 3(12.5) Hysteria(DR) 2(4.4) - 6(13.3) 29(64.4) - 24(53.3) 14(31.1) 2(4.4) 9(20) 13(28.9) 2(4.4) Nocturnal Enuresis - 9(25) 5(13.9) 9(25) 8(22.2) 15(41.7) 9(25) - 9(25) 6(16.7) - Head Injury 3(18.8) - 7(43.8) 4(25) - 8(50) 4(25) - - 3(18.8) 3(18.8) Epilepsy 3(9.3) 8(25) 4(12.5) 8(25) - 5(15.6) 5(15.6) - 12(37.5) 4(12.5) 3(9.3) Mental Retardation 3(7.7) 2(5.1) 11(28.2) 12(30.8) 2(5.1) 13(36.2) 15(38.5) - 14(35.9) 13(33.3) 3(7.7)

Rorschach Responses of Indians 157 Table 6 Number of Rorschach Cards Rejected Number of Rorschach cards rejected Subjects 4 & more Schizophrenia Mania - - - - Depression Anxiety state Hysteria (DR) Nocturnal enuresis Head injury Epilepsy Mental retardation The Mean and range of Location categories is given in Table 7. The frequency of the Determinants of responses is given in Table 8. Mean value of ratios of Determinants is presented in Table 9. Table 7 Mean (M) and Range of Location Score Subjects Location W D d Dd S DW M range M range M range M range M range M range Schizophrenia 3.3 0-10 6.6 1-28 0.71 0-5 0.71 0-5 0.36 0-2 0.5 0-3 Mania 4.25 3-6 13.75 5-25 2.25 1-5 2.75 0-5 0.75 0-2 0.25 0-1 Depression 4.09 0-9 4.64 1-10 0.27 0-1 0.55 0-4 0.36 0-1 - - Anxiety State 4.50 1-8 6.13 3-14 0.63 0-2 0.25 0-1 - - - - Hysteria(DR) 4.20 1-8 4.47 1-7 0.20 0-1 0.27 0-1 0.13 0-1 0.07 0-1 Nocturnal Enuresis 2.75 0-8 9.42 2-31 0.83 0-4 - - - - - - Head Injury 2.75 2-4 5.25 3-8 - - - - 0.25 0-1 - - Epilepsy 3.63 1-7 5.63 3-12 .75 0-2 0.25 0-2 0.13 0-1 - - Mental Retardation 4.62 0-8 2.62 0-6 1.08 0-4 0.23 0-2 0.15 0-1 0.39 0-4 Table 8 Mean (M) and Range of Determinant Score Subjects Determinants F M FM m Fk FK Fc C’ FC CF C (range) (range) (range) (range) (range) (range) (range) (range) (range) (range) (range) Schizophrenia 5.98 0.98 1.96 0.05 0.02 0.25 0.93 0.64 0.32 0.73 0.21 (0-16) (0-11) (0-22) (0-1) (0-1) (0-4) (0-4) (0-7) (0-3) (0-4) (0-3) Mania 16.25 2.25 3.25 - - - 0.50 0.05 0.25 0.50 0.50 (0-6) (0-8) (0-6) - - - (0-2) (0-2) (0-1) (0-1) (0-1) Depression 5.09 0.91 0.50 2.73 - - 0.55 0.09 0.18 0.18 - (1-11) (0-4) (0-2) (0-7) - - (0-2) (0-1) (0-1) (0-1) - Anxiety State 3.25 4.50 0.13 - 1.13 0.13 0.75 0.25 0.38 0.50 - (0-6) (0-15) (0-1) - (0-8) (0-1) (0-3) (0-1) (0-3) (0-4) - Hysteria(DR) 4.60 0.40 1.87 0.07 - 0.20 0.80 - 0.13 0.87 0.33 (2-8) (0-3) (0-5) (0-1) - (0-1) (0-4) - (0-1) (0-2) (0-2) Nocturnal Enuresis 6.67 1.00 2.58 0.17 0.08 0.50 0.67 0.17 0.75 0.50 0.08 (1-20) (0-3) (0-6) (0-1) (0-1) (0-2) (0-3) (0-1) (0-5) (0-2) (0-1) Head Injury 5.25 0.25 0.50 - - - 0.75 - 0.50 0.25 - (2-10) (0-1) (0-1) - - - (0-2) - (0-2) (0-1) - Epilepsy 7.00 0.25 1.13 0.13 0.13 0.13 0.38 0.25 0.25 0.63 0.13 (4-11) (0-1) (0-3) (0-1) (0-1) (0-1) (0-3) (0-1) (0-1) (0-3) (0-1) Mental Retardation 3.39 1.15 1.92 0.69 0.15 0.46 0.69 0.15 0.23 0.15 (0-9) (0-6) (0-4) - (0-8) (0-1) (0-2) (0-6) (0-1) (0-1) (0-2)

158 Chaudhury et al Table 9 Ratio of Determinants Subjects Determinants F% FK + F + FC % A% H+A : Hd + Ad Sum C M : Sum C FM +m : Response Fc + c + C1 to Card 8+9+10% Schizophrenia 51.54 57.46 40.05 6.05 : 1.16 1.33 0.98 : 1.33 2.00 : 1.54 32.35 Mania 73.54 75.58 41.02 11.00 : 4.00 0.50 2.25 : 0.50 3.75 : 1.50 40.49 Depression 48.91 57.42 52.87 5.27 : 1.55 0.27 0.91 : 0.27 2.73 : 0.64 40.68 Anxiety State 30.25 35.67 48.88 7.25 : 0.38 0.69 0.50 : 0.69 4.63 : 1.00 27.53 Hysteria(DR) 51.49 60.39 49.65 5.47 : 0.60 1.43 0.40 : 1.43 1.93 : 0.80 34.26 Nocturnal Enuresis 50.17 58.27 59.76 8.25 : 2.17 0.63 1.00 : 0.63 2.75 : 1,17 37.53 Head Injury 56.77 73.82 41.78 5.00 : 0.75 0.63 0.25 : 0.63 1.00 : 1,50 35.48 Epilepsy 71.03 73.53 55.41 5.75 : 1.38 0.94 0.25 : 0.94 1.13 : 0.63 30.65 Mental Retardation 37.14 41.73 38.93 4.62 : 0.46 0.54 1.15 : 0.54 1.92 : 1.15 30.79 Table 9 (Continued) Ratios of Determinants, Form Level and Popular Response Subjects Determinants Achro- Differermatic: tiated : W:M M:FM M: FK + Fc Chrom- Unfiffer- FC:CF+C FLR F+% F-% P Mean FM+M F atic entiated (range) Schizophrenia 3.30 : 0.98 0.98 : 1.96 0.98 : 2.00 0.22 1.56 : 1.38 1.12 : 0.23 0.32 : 0.93 0.46 27.6 37.8 1.68 (0-4) Mania 4,25 : 2.25 2.25 : 3.25 2.25 : 3.75 0.04 1.50 : 0.50 1.50 : 0.00 0.25 : 1.00 0.53 21.9 18.5 1.50 (0-4) Depression 4.09 : 0.91 0.91 : 2.73 0.91 : 2.73 0.27 0.73 : 0.27 0.73 : 0.00 0.18 : 009 0.76 54.3 5.1 3.18 (0-6) Anxiety State 4.50 : 0.50 0.50 : 4.50 0.50 : 4.63 0.16 1.00 : 0.38 1.06 : 0.00 0.38 : 0.50 0.64 48.1 10.6 2.88 (0-5) Hysteria (Diss Rea) 4.20 : 0.40 0.40 : 1.87 0.40 : 1.93 0.23 0.80 : 1.33 1.03 : 0.00 0.13 : 1.20 0.67 49.6 7.5 2.27 (0-5) Nocturnal Enuresis 2.75 : 1.00 1.00 : 2.58 1.00 : 2.75 0.29 1.38 : 0.79 1.21 : 0.08 0.83 : 0.17 0.94 79.0 2.7 2.75 (1-6) Head Injury 4.00 : 0.25 0.25 : 1.00 0.50 : 1.00 0.63 1.50 : 1.13 1.75 : 0.00 0.83 : 0.25 0.64 37. 6 19.6 1.25 (1-2) Epilepsy 3.63 : 0.25 0.25 : 1.00 0.25 : 1.13 0.05 0.69 : 1.19 0.69 : 0.00 0.44 : 0.75 0.56 35. 5 20.3 2.13 (0-4) Mental Retardation 4.62 : 1.15 1.15 : 1.92 1.15 : 1.92 0.22 1.27 : 0.54 1.08 : 0.50 0.15 : 0.39 0.53 26. 1 24.7 1.92 (0-3) Popular responses: Patients with schizophrenia, mania, head injury, epilepsy and mental retardation gave significantly low number of Popular responses. The mean and range of content categories is given in Table 10. Patients with head injury and epilepsy gave less Human responses. Patients groups generally gave high number of Animal responses. Sex responses were high in schizophrenia, mania, head injury and mental retardation. On the other hand blood responses were high in schizophrenia, mania, anxiety state and epilepsy. Color naming was noted in schizophrenia, hysteria and mental retardation.

Rorschach Responses of Indians 159 Table 10 Mean (M) and Range of Content Score Subjects Content H Hd A Ad A obj At Sex Pl N Obj M M M M M M M M M M (range) (range) (range) (range) (range) (range) (range) (range) (range) (range) Schizophrenia 1.59 0.68 4.46 0.48 0.10 1.25 0.52 0.71 0.32 0.64 (0-14) (0-8) (0-14) (0-3) (0-1) (0-12) (0-9) (0-4) (0-5) (0-10) Mania 3.75 2.00 2.75 2.00 0.25 3.75 1.25 0.50 1.00 1.50 (0-10) (0-7) (0-11) (0-8) (0-1) (0-13) (0-4) (0-2) (0-4) (0-4) Depression 1.27 0.91 4.09 0.55 - 2.27 - 0.18 0.09 - (0-6) (0-3) (0-7) (0-3) - (0-5) - (0-1) (0-1) - Anxiety State 1.00 0.38 6.25 - - 1.25 - 0.38 0.50 0.50 (0-3) (0-1) (0-15) - - (0-8) (0-2) (0-2) (0-1) Hysteria(DR) 1.20 0.40 4.27 0.20 - 1.07 - 0.33 0.67 0.20 (0-6) (0-4) (0-9) (0-1) - (0-7) - (0-1) (0-3) (0-1) Nocturnal Enuresis 1.42 1.33 6.83 0.83 0.08 0.50 0.50 - 0.08 1.00 (0-5) (0-6) (1-15) (0-6) (0-1) (0-5) (0-1) - (0-1) (0-5) Head Injury 0.50 0.50 4.75 0.25 - 0.75 0.25 0.50 - 0.50 (0-1) (0-2) (1-9) (0-1) - (0-3) (0-1) (0-1) - (0-2) Epilepsy 0.50 1.00 5.25 0.38 0.13 0.75 - 0.63 0.13 0.50 (0-1) (0-4) (0-8) (0-1) (0-1) (0-3) - (0-4) (0-1) (0-2) Mental Retardation 1.54 0.31 3.08 0.15 - 1.00 0.15 0.54 0.77 0.39 (0-6) (0-3) (0-10) (0-1) - (0-8) (0-2) (0-2) (0-3) (0-2) Table 10 (continued) Mean (M) and Range of Content Score Subjects Content Blood Cloud Arch Art Geo A At Food Fire/explosion Cn M M M M M M M M M (range) (range) (range) (range) (range) (range) (range) (range) (range) Schizophrenia 0.25 0.14 0.18 0.14 0.05 0.18 - 0.05 0.34 (0-3) (0-2) (0-3) (0-6) (0-1) (0-3) - (0-1) (0-6) Mania - 0.50 - 0.25 - - 0.25 - - (0-2) - (0-1) - - (0-1) - - Depression - 0.18 - - - 0.09 - - - - (0-2) - - - (0-1) - - - Anxiety State 0.50 0.25 0.13 - - - - - - (0-4) (0-1) (0-1) - - - - - - Hysteria(DR) 0.70 0.40 - 0.27 - - - - 0.33 (0-1) (0-2) - (0-2) - - - - (0-2) Nocturnal Enuresis - 0.17 0.17 0.08 0.08 0.08 - - - - (0-2) (0-1) (0-1) (0-1) (0-1) Head Injury - - 0.25 - - - - - - - - (0-1) - - - - - - Epilepsy 0.25 - 0.13 0.25 0.25 - - - - (0-1) - (0-1) (0-1) (0-1) - - - - Mental Retardation - 0.46 0.31 - 0.08 - - - 0.23 - (0-6) (0-2) - (0-1) - - - (0-2) Discussion: The Rorschach test is the most commonly used personality test in the clinical setting in India. However, despite its popularity and extensive use, the research output on the test in Indian children and adolescents is very limited. Asthana (1965, 1966) presented normative data based on 216 children aged 4-11 years. Studies on small groups of children and adolescents were reported by Bagh (1955), Pati (1966), Lall (1968), Ray Chaudhury et al (1969), Suri (1973), Kundu (1980) and Panda (1991). All

160 Chaudhury et al these studies have limited value due to small sample size and local subjects which can not be considered as representative sample of the India. Another important shortcoming of these studies was that they were conducted at only one center and included subjects from that location. The present study is the first multi center Indian study, carried out at five locations situated in four corners of India viz Meerut and Bareilly in north, Gauhati in East Cannanore in South and Pune in West. Productivity: The maximum number of responses was given by mania patients, while the head injury and mentally retarded patients gave the least number of responses. The significantly higher productivity in mania (mean R =24.25) and significantly lower productivity in depression (mean R =9.73), hysteria (mean R =9.33), head injury (mean R =8.25) and mental retardation (mean R =9.08) patients compared to age and sex matched normal controls is in agreement with Rorschach (1998), Bohm (1996), Exner & Weiner (1982) and Exner (2002). Reaction time: The longest average reaction time was in depression while shortest was in mania. Interestingly, however, the quickest and the slowest individual reaction time were recorded in schizophrenia indicating the variability of the disorder. Patients with mania had significantly less reaction time as compared to matched control subjects, while patients with depression, anxiety state, head injury, epilepsy and mental retardation had significantly more reaction time indicating slow mental process. The finding is consistent with Klopfer & Davidson (1962) Halpren (1953) and Bohm (1996). Rejection of Cards: Among patient groups maniacs did not reject any card. Patients with depression rejected maximum cards followed by patients with mental retardation, hysteria, anxiety state nocturnal enuresis and head injury in that order. This is in agreement with Halpren (1953), Klopfer et al (1954) Bohm (1996). Location of responses: Patients with mental retardation, hysteria, anxiety state and depression produced large number of poor quality W responses. The poor quality W (Whole) responses are essentially regressive responses (Ames et al 1971). The S (Space) response indicates oppositional traits and is expected to be more in psychiatric patients (Margot et al 1992). In agreement with this high scores were observed in patients with schizophrenia, mania and depression. Confabulatory whole (DW) responses were given by patients with schizophrenia, mental retardation, mania and hysteria. This is in agreement with Halpren (1953), Ames et al (1971, 1974) and Exner & Weiner (1982). Confabulatory responses are pathological in nature and are characteristics of schizophrenia (Rorschach, 1998; Klopfer et al, 1954; Bohm 1996) but can also occur in normal children. Determinants: Form (F) response: High F responses were noted in schizophrenia, mania, hysteria, head injury and epilepsy indicating constriction of personality. Human Movement (M) responses: M responses are an index to the richness of the inner life of the individual. In their quantity, they reflect the accessibility to the individual of his own inner workingshis fantasies, wishes, images and capacity to withstand environmental stress (Donahue & Tuber 1993). The average number of M responses in schizophrenia, depression, hysteria, head injury, epilepsy and mental retardation were significantly low. Animal Movement (FM) response: Among patient groups the low number of animal movement responses in schizophrenia patients is in agreement with earlier studies (Bohm, 1996). FM was high in mania. Psychologists commonly interpret a high FM as a sign of frustration and unsatisfied instinctual need. Much importance, however, cannot be assigned to this interpretation because as per Klopfer et al (1954) the FM ratio cannot be interpreted unless there are three (3M) or more of Human Movement responses. In the present study M was not sufficiently large to satisfy this condition.

Rorschach Responses of Indians 161 Inanimate Movement (m) response: represent fantasies and partial identification. They denote inner tensions. Inanimate movement responses occurred frequently in depression. Shading responses: Shading responses give an indication of the subject’s emotional and intellectual sensitivity, his ability for empathy and the degree of concern with adapting to others and to the environment. Through them we have some insight concerning the anxieties of the individual (Klopfer et al 1954 ; Weber et al, 1992). As expected among the patient groups highest shading responses were given by anxiety state and hysterical patients. Color responses: Color responses reflect the individual’s openness to stimulation from his social surroundings. C responses can occur in two diverse clinical categories: on the one hand a childish demand and on the other hand, an aggressive destructiveness combined with attitude of hostility and surliness. In the present study patients with depression did not give any pure C responses. Not surprisingly C responses were frequently seen in mania, schizophrenia, hysteria, nocturnal enuresis, epilepsy and mental retardation. Form- Level Rating (FLR): FLR is the most important basis of the intellectual estimate. According to Klopfer et al (1954) the form level varies directly with the intellectual level. In the present study, patients with schizophrenia, mania, epilepsy and mental retardation obtained significantly lower FLR scores as compared to normal controls, indicating the low level at which the intellectual resources are available in these patients. F + %: A number of investigations have observed that schizophrenia patients give a lower F + % than the normal subjects. Beck (1965) reported that the F+% is more sensitive index than any other Rorschach factor in differentiating different normal and clinic groups. In agreement with the above, schizophrenia patients obtained significantly less F+% in the present study. The patients with mania and mental retardation also obtained significantly lower F+%. Over all F+% was high in patients with nocturnal enuresis and low in depression, anxiety state and hysteria, though the difference was not found significant. F-%: Two considerations suggest that an analysis of responses of inadequate form (F-%) may prove useful. First it has been observed that the F- responses of normal subjects characteristically deviate only slightly from the minimal requirements of F+ responses while, in contrast, the F- responses of schizophrenia patients are often grossly discrepant with this criteria. Secondly, the extent of perceptual distortion is related to the degree of behavioral disturbances. In agreement with the foregoing, highest F-% was observed in schizophrenia in the present study. The F-% of patients with schizophrenia, mania, head injury, epilepsy and mental retardation was significantly more than normal controls. Ratios of Determinants: F %: Table 9 shows that among patient groups F% was > 50% in schizophrenia, mania, depression, hysteria, nocturnal enuresis, head injury and epilepsy indicating constriction of personality with compulsive elements. In addition patients with mania, head injury and epilepsy had FK + Fc % more than 70%. Sum C: Among patient groups a significantly higher sum C was obtained by patients with schizophrenia, hysteria and epilepsy. However, the Sum C values are quantitatively low and should not be interpreted as a sign of too little responsiveness to the influence from the environment, but are a cultural variant. Proportions relating to Introversive- Extratensive balance: M: Sum C: When M responses outweigh the Sum C by 2:1 there is an introversive balance; whereas when Sum C outweighs M by 2: 1 there is an extratensive balance. Something approaching a 1:1

162 Chaudhury et al ratio is perhaps most common. In the present study introversive balance was seen in mania, depression and mental retardation while extratensive balance found in hysteria, head injury and epilepsy. (FM + m): (Fc + c + C): FM + m responses indicate potential introversive tendencies while achromatic responses indicate potentially extratensive tendencies. If this ratio is in the same direction as M : Sum C it confirms and strengthen the impression given by the latter. If it is at variance with M : Sum C there are several hypothesis from which to choose : the subject is in a state of transition from introversion to extratension, and the second ratio indicates the direction in which the change is progressing. It might be that the ratio indicates the direction in which the person is ret reading. Or it might indicate a persistent secondary orientation which the person has been unable to realize. In any event a discrepancy in the direction of the ratio reflects a conflict in tendencies within the personality (Klopfer et al 1954). Among patient groups the direction of the ratio was opposite in schizophrenia, hysteria and epilepsy but was in the same direction in the remaining groups. Percentage of responses to Cards VIII, IX & X: In the present study the percentage of response to the last 3 cards was above 40 in mania and depression and less than 30 in anxiety state. The above ratios taken together indicates that among patients introversive balance is present in mania, depression and mental retardation while there is transition to introversive balance in schizophrenia and anxiety state. There is extratensive balance in head injury. In patient with hysteria and epilepsy there is persistent secondary orientation which the person has been unable to realize but which remains as a source of conflict. W: M: This ratio gives an indication of the extent to which the individual is able to mobilize his creative or productive energies to back up his intellectual interests and ambitions. When W is greater than twice M the level of aspiration is too high. In all patient groups W is greater than twice M. M: FM: When there are twice as many FM as M responses the individual is ruled by immediate needs for gratification rather than by long- range goals. Among patient groups, color emphasis was seen in schizophrenia, mania, anxiety state, hysteria, epilepsy and mental retardation indicating that these patients tend to act impulsively. Ratio of FK + Fc : F: In patients with schizophrenia, mania, anxiety state, hysteria, epilepsy and mental retardation the ratio is less than 0.25 indicating denial, depression or un-development of the need for affection. This is believed to stem from rejection experiences serious enough to wrap personality development. Ratio of Achromatic to Chromatic responses: Achromatic = Twice Chromatic: When the achromatic responses outnumber the chromatic responses by two to one the person’s responsiveness to outside stimulation has been interfered with by same kind of traumatic experience and withdrawal has resulted. The implication is that the need for an affectional response from others is so great that the person is inhibited and toned-down in his overt reactions to others for fear of being hurt or repulsed. This type of response was seen in mania, depression and mental retardation. Content: Human (H) figures: Patients with mania gave high H responses while patients with head injury and epilepsy gave less H responses. The human form was noted by Rorschach (1998) and identified by his followers as varying with health, maturity and intelligence. Its absence or low quantity in an otherwise intelligent individual is likely to indicate repression of this theme (Beck, 1965).

Rorschach Responses of Indians 163 Anatomical (At) concepts: Increased At responses were seen in mania and depression. Sexual symbolism: As expected high sex responses were seen in schizophrenia, mania, head injury and mental retardation, which is in agreement with Klopfer (1954) Bohm (1996) and Dubey (1982). Blood responses: In agreement with Rorschach (1998), Bohm (1996), Klopfer (1954) and Dubey (1982) significantly higher blood responses were seen in schizophrenia, mania, anxiety state and epilepsy. Color naming (Cn) responses: The person who names colors is overwhelmed by emotional impact and incapable of handling his reaction with integrated control. Significantly high Cn responses were given by patients with schizophrenia, hysteria and mental retardation. The pathological nature of Cn was therefore, strongly supported and is in agreement with Rorschach (1998), Bohm (1996), Klopfer et al (1954) and Dubey (1982). Popular (P) responses : The fewer the popular responses the less able the person is to see the world in the same terms as other people do (Klopfer et al, 1954). This was confirmed by the findings of few P’s in patients with schizophrenia, mania, hysteria, head injury, epilepsy and mental retardation. Disease Patterns: Schizophrenia: While there is no single Rorschach picture typical of schizophrenia, there are a few signs which tend to point to such a diagnosis. Patients with schizophrenia gave somewhat less responses and moderate rejections. Reaction time was extreme variable. Dd responses were highest. W responses were slightly low. Animal movement was markedly reduced. Form Color responses were low but CF, C and Sum C were high. F+% and Popular responses were low. They perceived more Animal content followed by Human, Anatomy, Plant, Human details and Object. However, Sex, Blood, Fire, Explosion, Color naming was high. Confabulatory responses, Contamination and Perseveration were prominent. These are in agreement with Klopfer & Davidson (1962) and Bohm (1996). Mania: Rorschach records of patients with mania vary considerably with the degree of excitement. The highest productivity, low reaction time and absence of rejections were found in mania. High Dd and F were also present. Confabulatory responses appeared. Human movement was more while animal movement and shading responses decreased. CF and C responses increased at the expense of FC. F+% and Popular responses were markedly diminished. Content dealt with human, anatomy, animal, human details, animal details and sex. These findings are in agreement with Bohm (1996). Depression: Productivity was greatly reduced with more reaction time, maximum rejections, more W and low D, Form and shading responses were high; average movement responses, with low color responses and sum C. F+% were somewhat less than normal. Popular responses were more. Content dealt with animals, anatomy, human, human details, animal details, plant and cloud. These findings are in agreement with Rorschach (1998) and Bohm (1996). Anxiety State: they showed low productivity, with more reaction time and rejection of cards. Whole responses increased at the expense of detail responses. Form and human movement wee less while animal and inanimate movements were more. CF increased at expense of FC. F+% and Popular responses decreased. Content usually dealt animals, anatomy, human, nature, object and blood. Color shock and shading shock was seen. These findings are in agreement with Bohm (1996) and Halpren (1953). Dissociative Reaction (Hysteria): Productivity was reduced while rejection increased, Whole responses increased at the expense of detail responses. Animal movement was reduced. CF and C

164 Chaudhury et al responses increased at the expense of FC. Sum C was markedly increased. F+% and popular responses were greatly reduced. Content usually dealt with animal, human, nature, anatomy, human detail and cloud. These findings are in agreement with Bohm (1996). Nocturnal Enuresis: Productivity is reduced and rejection increased. Detail response increase at the expense of whole responses. Animal movements are less, while inanimate movement is more. Low FC with more CF and C. Sum C and F+ % are in normal range. Popular responses are reduced. Content deals with animals, human, human detail, object, animal detail, anatomy and plant. Head Injury: Productivity is very low with increased reaction time and rejections. Whole, usual detail, space and form responses are more. Movement responses are reduced. Color responses are in normal range. F + % and Popular responses are reduced. Content deals with animal, anatomy, human, plant, object, animal detail and sex. The findings are in agreement with Bohm (1996). Epilepsy: Low productivity with increased reaction time and rejection are prominent. Whole and Form responses are more. Inanimate movement increase at the expense of human and animal movement. Shading responses are less. Sum color is more with increased CF & C. F + % and Popular responses are reduced. Content deals with animal, human detail, anatomy, plant, human and animal detail. Perseveration is observed. Apart from low productivity and more human detail, these findings are in agreement with Bohm (1996), Guzman et al (1973), and Mormont and Sevias (1973). Mental Retardation: Productivity is much reduced, while reaction time and rejections increase. Poor quality Whole responses are prominent and Confabulatory responses appear. Form responses are less. Movement and achromatic colors are more while shading responses are less. C & CF responses increase at expense of FC. Sum C is low. F + % and popular responses are markedly reduced. Content deals with animal, human, anatomy, nature, plant and color. These are in agreement with Upadhyaya and Sinha (1974) and Huley & Sovnert (1982). Conclusions: The Rorschach responses of Indian children and adolescents show a number of significant differences when compared to various normative studies in Western countries. Interpretation of Rorschach protocols of Indian children and adolescents using the western norms would be fallacious and misleading and it should be interpreted using Indian norms. References: Ames, L.B., Learned, D., Metraux, R.W., & Walker, R.N. (1974). Child Rorschach Responses. Revised Ed. New York : Brunner Mazel Ames, L.B., Learned, D., Metraux, R.W., & Walker, R.N. (1971). Adolescent Rorschach Responses. Revised Ed. New York: Brunner Mazel Asthana, H.S., & Mohan, C. (1977). Perceptual development of the Indian child: A Rorschach study. Unpublished research report. Saugar : Saugar University. Asthana, H. S. (1966). A Rorschach study of child development in India. Harvard University Social Relations Colloquium. Bagh, D. (1955). Use of Rorschach’s ink blot test among school adolescents. Indian Journal of Psychology. 30: 61-64. Beck, S. J (1965) Psychological process in schizophrenic adaption. New York : Grune & Stratton. Bohm,E (1996) A text book in Rorschach test diagnosis. 7th ed. Berne: Hans Huber. Donahue, P.J., & Tuber, S.B, (1993), Rorschach adaptive fantasy images and coping in children under severe emotional stress. Journal of Personality Assessment. 60 : 421-434.

Rorschach Responses of Indians 165 Dubey, B.L. (1982). A pragmatic view of the Rorschach Inkblot Technique. Agra: National Psychological Corporation. Exner, J.E. (2002). The Rorschach. A comprehensive System. Vol. I. Basic Foundations. 4th Ed. New York: John Willey & Sons. Exner, J.E., & Weiner, I.B. (1982). The Rorschach. A Comprehensive system. Vol 3. Assessment of children & adolescents. New York: John Wiley & Sons. Guzman, B.V., Laighton, P.C. & Sepulveda, M.A. (1973). The Rorschach in idiopathic epilepsy children from 8- 10 years of age. Revista Latinoamericana di psicologia. 5: 165-189. Halpren, F. (1953). A clinical approach to childrens Rorschach. New York : Grune & Stratton. Hulry,A., & Souvner,R. (1982). Use of the Rorschach technique in mentally retarded patients. Psychiatric aspects of mental retardation. Newsletter. Vol 2 : 4-7. Klopfer, B., Ainsworth, M., Klopfer, W., & Holt, R. (1954). Developments in the Rorschach technique. 1. Technique and Theory. New York: World Book Company. Klopfer,B., & Davidson, H. (1962). The Rorschach Technique. New York: Harcourt. Kundu CL (1980) Rorschach Psychodiagnostics: An Indian case study. Kurukshetra: Vishal publications. Lal,K (1968) Comparative study of emotional atability of mentally superior and average adolescents. Thesis for PhD education. Agra: Agra University. Margot, H., Armsworth, M.W., Swank, P.R., & Vincent, K.R. (1992). Rorschach responses in traumatized children and adolescents. Journal of Traumatic Stress. 5 : 119-129. Mormont, C., & Sevias, J. (1973). The Rorschach of a young seizure free epileptic patient. Acta Psychiatrica Belgica. 73 : 379-386. Panda, S.K. (1991). Rorschach creative responses of high and low achieving adolescents matched on socioeconomic status. Journal of Psychological Research. 35: 10-14. Pati, G. (1966). Personality pathology of delinquents. Psychological Studies. 11 : 35-41. Polyson J., Peterson, R., & Marshall, C. (1986). MMPI and Rorschach. Three decades of research. Abnormal Psychology: Research and Practice. 17: 476-486. Raychaudhuri, M., & Maitra, A.K. (1965). A Rorschach study of normal, convicted and incipient delinquent adolescents. Rorschiana Japonica. 8: 170-184. Raychaudhuri, M., Mukherjee, K., & Raychaudhuri, S. (1969). Rorschach indices of aggression and maladjustment: A comparative study with normal and indisciplined boys. Archives of Child Health. 11 : 31-38. Reynolds, W.M., & Suundberg, N.D. (1976). Recent research trends in testing. Journal of Personality Assessment. 40 : 220-223. Rorschach, H. (1998). Psychodiagnostics. 10th ed. Berne: Ernst Bircher. Sethi, B.S., Gupta, S.C., Agarwal, S.S. & Sinha, P.K. (1976). A psychosocial study delinquents with special reference to aggression. Indian Journal of Psychiatry. 118 : 157-163. Singh, O.P., & Verma, R. (1990). Rorschach responses of delinquent and non delinquent adolescents : A discriminant analysis. Indian Journal of Criminology. 18 : 47-60. Suri, S. P. (1973). A study of differential personality traits in intellectually superior, average and below average students. Thesis for PhD education. Kurukshetra: Kurukshetra University. Upadhyaya, S., & Sinha, A. K. (1974). Some findings of psychodiagnostic tests with young retarded adults. Indian Journal of Clinical Psychology. 1 : 73-79. Weber, C., Meloy, J. R., & Gacoma, C. B. (1992). A Rorschach study of attachment and anxiety in inpatient conduct disorders and dysthymic adolescents. Journal of Personality Assessment. 58: 16-26.

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