SIS Journal of Projective Psychology & Mental Health

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 behavior. 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 (single-spaced throughout) submitted through E-mail or in CD to B.L. Dubey, Ph.D. Editor Emeritus, SIS Journal, E-mail:bldubey@gmail.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 OR sisamool@yahoo.com, Cell Phone: 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 $50 for foreign members and Rs. 300, for Indian members, Institutional subscriptions are US $100. for Foreign institutions and Rs.1000 for Indian institutions. Life membership is US $400 for foreign members and Rs. 2500/- for Indian members. Indian institutional life membership is Rs. 10,000/-. Non-members may subscribe for $60 or Rs. 250 per issue. Cheques should be made payable to “SIS Journal of Projective Psychology and Mental Health” at Ranchi and should reach Amool Ranjan Singh, Ph.D. Editor In Chief, Head, Dept. of Clinical Psychology,RINPAS,Kanke ,Ranchi-834006.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 $10/Rs.50/- if you are sending subscription through cheque.

CHANGE OF ADDRESS. Society/Journal members should inform B.L. Dubey, Ph.D, Director SIS Centre, Email : bldubey@ gmail.com of any change of mailing address. Copyright @ 1994. SOMATIC INKBLOT CENTRE, India/ Anchorage U.S.A. Website: http://www.somaticinkblots.com Online Testing: http://psyche.dubay.bz/ http://122.160.96.85:1001/SISTest OFFICE BEARERS President : B. L. Dubey (USA) Vice President : Brig. D.Saldanha (India) Gen. Secretary : Masroor Jahan (India) Joint Secretary : P.K.Singh (India) Treasurer : Mrs. Padma Dwivedi (USA) Executive Members : Wilfred A. Cassell (USA) Nalinini Mishra (India) Mridula Mishra (India) Arcahna Singh (India) K. S. Sengar (India) Manisha Kiran (India) Mary Cassell (USA) Asheem Dubey (USA) George Savage (S.Africa) Mrs. Silvia Daini (Italy) Somatic Inkblot Society

Abstracted in “APA’s PsycINFO “ Regd. No. 71632/99, RNI Delhi SIS JOURNAL OF PROJECTIVE PSYCHOLOGY & MENTAL HEALTH Volume 17 Number 2 July 2010 EDITORIAL CONSULTANTS : Kristian Aleman, Ph.D., Sweden Mahesh Bhargava, Ph.D., India K.R.Banerjee. MRCP India Saugata Basu, Ph.D., India Carina Coulacoglou, Ph.D., Greece N. G. Desai, M. D., India Philip Greenway, Ph.D, Australia S. Haque, M. D., India M. Jahan, Ph.D., India Arvind Keshary, Ph.D., India Anatoly B. Khromov, Ph.D., Russia H. Kumar, Ph.D., USA R. Kumar, Ph.D., India Sudhir Kumar, M. D., India A. S. Kundu, Ph.D., India Ram Jee Lal, Ph.D., lndia Anu S. Lather, Ph.D., India Lisa Milne, Ph.D., Australia Mridula Mishra, Ph.D., India Nalini Mishra, Ph.D., India Ashok Kumar Nag, M.D., India Paola Nicolini, M.A., Italy Paul E. Panek, Ph.D., U.S.A. Edward M. Petrosky, Ph.D., U.S.A. Marisa Porecca, Ph.D., Italy Kiran Rao, Ph.D., India Stefano Reschini, M.A, Italy Barry A. Ritzier, Ph.D., U.S.A. D. Saldanha, M. D., India Nilanjana Sanyal, Ph.D., India K. S. Sengar, Ph.D., India D. K. Sharma, MHA, India Radhe Shyam, Ph.D.lndia Archana Singh, Ph.D., India V. K. Sinha, M.D., India David Sperbeck, Ph.D., U.S.A. A. K. Srivastava, Ph.D., India Kalpana Srivastava, Ph.D., India Ramjee Srivastava, Ph.D., India Ailo Uhinki, Ps.D., Finland A. N. Verma, Ph.D., India Yasho V. Verma, Ph.D., India EDITORS EMERITUS : Wilfred A. Cassell, MD, Director, SIS Center, 4501E, 104th Avenue, Anchorage, AK.99516 (USA). E-Mail: siscassell2@yahoo.com Bankey L. Dubey, Ph.D., Director SIS Centre, 4406 Forest Road, Anchorage, AK 99517 (USA) E-mail: sisdubey@rediffmail.com, bldubey@gmail.com, Cell : 907-250-8834, EDITOR-IN-CHIEF : Amool Ranjan Singh, Ph.D. Prof. & Head, Dept. of Clinical Psychology, RINPAS,Kanke,Ranchi- 834006 (India). Tel. : 91-651-2233687(H), Mob.:91 -9431592734, E-mail:sisamool@yahoo.com EDITORS : Suprakash Chaudhury, MD, Ph.D., Prof. & Head, Dept. of Psychiatry, RINPAS, Kanke, Ranchi- 834006 (India). Mob.:91-09334386496, E-mail: suprakashch@gmail.com Anand Dubey.B.E., MBA, SIS Centre, 4406 Forest Road, Anchorage, AK 99517 (USA), E-Mail: anand. dubey@gmail.com Padma Dwivedi, M.A., 4406 Forest Road, Anchorage, AK 99517 (USA), E-mail: sisdubey@ yahoo.com Jai Prakash, Ph.D., Associate Professor of Clinical Psychology, Dept. of Clinical Psychology, RINPAS, Kanke, Ranchi-834006, (India). Cell: 91- 9934582290, E-mail: drjaiprakashrinpas@rediffmail. com Umed Singh, Ph.D., Dept. of Psychology, Kurukshetra University, Kurukshetra, Haryana, (India). Email Umedsingh_78@yahoo.com. Tel: 91- 1744-238267(H), Cell: 91-9416511077

JOURNAL OF PROJECTIVE PSYCHOLOGY AND MENTAL HEALTH : ACHIEVEMENTS Journal in WHO Listing Members of Somatic Inkblot Soceity will be glad to know that SIS Jr. of Projective Psychology and Mental Health has been listed by World Health Organisation (Global Forum for Health Research) among 25 indexed journals that have published the highest number of articles on mental health from LMICs in Latin America, Africa and Asia (Medline and PsycINFO). Extract from table-6 of “Research Capacity for Mental Health in Low - and Middle - Income Countries : Results of a Mapping Project “ (www.globalforumhealth.org) is given below : Rank Journal Country Language Revista de Psicoanalisis Argentina Spanish Revista de Neurologia Spain Spanish Revista Brasileria de Psiquiatria Brazil Enlgish, Portuguese, Spanish Arquivos de Neuro-psiquiatria Brazil Portuguese Acta Psiquiatrica y psicologica de Amercia Laina Argentina Spanish Journal of the Medical Association of Thailand Thailand English, Thai British Journal of Psychiatry United Kingdom English Acta Psychiatrica Scandinavica Denmark English Salud Mentale Mexico Spanish Vertex Argentina Spanish Journal of Personality and Clinical Studies India English Social Psychiatry and Psychiatric Epidemiology Germany English Revista Medica de Chile Chile Spanish South African Journal of Psychology South Africa Afrikaans, English Psychological Reports USA English South African Medical Journal South Africa Afrikaans, English The Australian & New Zealand Jr. of Psychiatry Australia English International Journal of Social Psychiatry United Kingdom English Psychiatry Research Ireland English Social Science & Medicine United Kingdom Engish Revista De Saude Publica Brazil Portuguese International Journal of Geriatric Psychiatry United Kingdom English SIS Jr. of Projective Psychology and Mental Health India English Jornal Brasilerio de Psiquiatria Brazil Portuguese Psychiatry and Clinical Neurosciences Australia English Journal in ProQuest Listing We are glad to inform you that SIS Journal of Projective Psychology & Mental Health has been listed in academic research database ProQuest Psychology Journals™. ProQuest is a company in Michigan, United States. It is a leading provider of electronic databases for academic libraries. Databases are used in over 20,000 academic libraries around the country and around the world including some of the most prestigious higher education institutions such as Harvard, Yale, Princeton, Oxford ect. ProQuest provides abstracts and indexing for more than 640 titles, with over 540 titles available in full text. Users get access to charts, diagrams, graphs, tables, photos, and other graphical elements essential to psychological research.

A 21st century scientist, conceptualizing the neuropsychological mechanisms underlying projection, has available more sophisticated scientific studies than in the past. This information is available to those building on SIS body-mind-spirit concepts envisioned in the preceding century involving visual and auditory sensory input. Now, more advanced systems based on evolving projective theory can incorporate additional sources of ambiguous multidimensional sensory input. Smell has potency as a trigger for the release of deep seated memories, including olfactory stimuli, and warrants consideration. Such inclusion should prove promising, especially in certain disorders triggered by stressful life events. In futuristic thinking, look forward to scientific breakthroughs by innovative developers of projective procedures. It is predicted that many will concurrently monitor and/ or stimulate various physiological and psychological dimensions. Advanced research centers using sophisticated computer controlled electronic technology have methodologically moved beyond clarifying diagnostic considerations and focus more on therapeutic applications. As an illustration, in America investigators are now actively exploring the use of “Vestigial Reality” inducing technology in combat induced PTSD. Of course, such work is not without its hazards. (It may be recalled that in 2009 a psychiatrist in the United States military that was occupationally exposed to secondary or empathetic PTSD ended up homicidal. Of course, because he was Moslem, many asserted that his true motivation for homicide really was terrorism.) Overall there has been an explosion in the both the professional literature and the public media related to PTSD. One promising area of scientific research involves pharmacologic attempts to reduce symptoms triggered by severely stressful events. For example, morphine has been found to have this effect in civilian victims of road accidents, children suffering from major burns and injured American combat soldiers. It is unclear the extent that this preventative action reflects the opiates’ analgesic action, as contrasted to its noradrenergic effect in blocking the consolidation of PTSD memories. Editorial Genetic Determinants of SIS Projection Wilfred A. Cassell There are similar unknowns with SIS research. While there is considerable clinical evidence based upon individual case histories describing the therapeutic value of the technique, as yet there have been no controlled studies attempted. Caution is definitely indicated. Evidence is emerging that for some PTSD victims, that triggering stressful memories can actually aggravate their symptoms. The current literature is controversial due to the inherent complexity of mental disorders. Yet, many of our original published clinical cases showed dramatic improvement, after emotionally painful imagery was triggered by a traumatic scene reactivating SIS “inkblot”. Such a stimulus clearly can have the pulling power to bring back to the victim’s mind confused cognitions/emotions. In the detailed enquiry, cognitively reprocessing these in a secure empathetic therapeutic environment, away from the original stressful situation, seemed to be helpful. Also, the repetition of the key triggering stimulus that effectively brought into projective awareness traumatic imagery, followed by relaxing nature scenes may have added a behavioral therapy like effect. This aspect of SIS viewing may activate the high-frequency waves associated with attention and introspection during meditation. Such repetitive reconditioning of the brain’s memory neurons mimics Nature’s homeostatic healing process. Since this may occur during REM sleep in less intelligent animals, it may not require much in the way of conscious cognitions. However, with humans, SIS therapy, in addition to neural conditioning, can be worthwhile for the victim to learn to interpret symbolic imagery, linked to PTSD dreams. Over time, these change from photographic like traumatic scene reproductions, to less stressful disguised dream symbols. With successful SIS therapy, ultimately these become affect neutral, and the individual’s sleep is no longer disturbed. Also, when the victim observes, or senses that the therapist concurrently suffers secondary empathetic emotional discomfort during repeated sessions, the intimacy and bonding is enhanced. Severe pain, either from physical or psychological injury, invariably is associated with an observable degree of age

regression. Clinical manifestations of this phenomenon may emerge in such a way, as immature voice, and profuse crying out to an imagined parental figure. When the therapist empathetically plays this role, no longer does the individual have to feel child like and alone, in suffering subjective torment. Facilitating this dysphoric affect transfer (i.e. “Dumping on the therapist”) can play a supportive role. Over time, it can also enable the sufferer to conceptualize the misperceived original stressful circumstances more maturely, in a reality based fashion. If the original stressors involved abuse by a perpetrator, witnessing the therapist experience a degree of anger towards that individual can enable the victim to do the same. This can assist in removing self blame, and irrational based guilt. In addition, it can augment insight when the victim realizes that the human imagery projected onto SIS figures depicting past abusive figures may also erroneously distort current social perceptions - including false transference impressions of the empathetic psychotherapist. Next, for illustration purposes consideration will be given to instances of protracted severe childhood stress. In vulnerable children this can theoretically result in ego splitting, such as observed in the Dissociative Disorders. Consider an Identity Disorder condition, which was formerly called “Multiple Personality Disorder”. Here part of the victim’s identity may have been linked with the aggressor, so the above outlined empathetic transfer therapeutic process may be especially critical. Otherwise the victim may be prone to acting out patterns mimicking the original abuser. The history of knowledge is rapidly expanding in regard to the stress related disorders. There is more recognition, in this age, being given to the fact that managing cases of PTSD expose mental health workers to occupationally induced secondary empathic dramatization. SIS therapists have a relatively greater hazard, because of this projective technique’s great pulling power to evoke emotionally charged horrible scenes. In jointly viewing a triggering SIS stimulus pattern, the professional’s visual apparatus and its related emotional/cognitive brain centers involving higher function are activated, albeit at a lower intensity level, but still in an analogous way to the victim’s nervous system. . Similarly, professionals working in other fields concerned with human suffering are also at risk. For medical providers, emergency room physicians have a much higher “burnout” rate and shorter life span than those in other medical specialties. In a like fashion, those who provide emergency care in war torn countries expose their own dream REM states to secondary empathetic PTSD imagery. Ordinarily such professionals tend to minimize this hazard in verbal reports, so it is hard to obtain objective data. An exception exists in a book published in 2009 by James Orbinski entitled “An Incomplete Offer.” In this he documented both the reality of his original traumatic experiences in Rwanda. These included treating physically/ psychologically brutalized adults and children during the genocide period (e.g. One girl’s traumatic memories shared with him included recollection of hiding in a latrine covered by human wastes, then peering out and witnessing her mother’s torture and bleeding to death after limb amputation. Throughout the period perpetrators cut off children’s body parts and sent them to care providers as a warning etc. etc.). His documentary provides examples of his related sleep disturbing dreams and “flashbacks” suffered years later. In considering the importance of empathy during SIS clinical work, this phenomenon has been studied by investigators in a number of scientific disciplines. Relative to this discussion, the ability to empathize is impaired in psychiatric/neurological conditions. On the positive side, some individuals can be taught empathetic skills, and this may prove to be one helpful function of psychotherapy. Experiencing the therapist’s empathetic suffering may allow the intact portion of such a “split personality” to identify with the professional’s corrective empathetic affect towards the disturbing SIS released PTSD imagery. In this way the individual with the fractured sense of self, in therapy, may learn to identify less with a powerful past perpetrator. Concurrently, the healthy portion of the ego may become more empathetically compassionate to its own long forgotten “inner cry”. Clearly, future attention needs to be given to the investigation of such intimate psychophysiologic phenomenology of the two person interaction during SIS detailed enquiry. For example, an investigator might use a standard illustrative recorded SIS PTSD interview, involving a traumatic accident scene as a test stimulus, and then monitor the empathetic reactions of various subjects. Against this background, it might be helpful to add to existing SIS projective theory by incorporating in the conceptual model, genetic factors. Some vulnerable individuals may be genetically predisposed, 102 Cassell

under stressful conditions, to develop PTSD. As yet, SIS investigators have not initiated studies involving identical twins. Some may believe that contemplating such research requires too great a leap in conceptualization. Still, it may provide guidelines to keep in mind the various related studies that this journal has published. It may be recalled that in many of these illustrate how SIS response patterns that have anatomical/human content relate to socialization and empathy. In the basic sciences, studies relative to an organism’s interest in social interaction indicate that an organism’s DNA content can shape this basic process. For example, flat worms that possess a predominance of a particular gene have been observed to isolate themselves. In contrast, those at the opposite genetic pole have been found to seek out groups. In primates, neuroscientists have also studied basic biological mechanisms, shaping socialization and empathy. Work completed on the so-called “Mirror Neurons” in the brains of monkeys is an example. As more is learned about genetic determinants in humans, researchers may eventually determine the extent to which comparable genetic influences might shape avoidance or seeking out human content in the SIS. Of theoretical relevance are clinical studies involving the Autism spectrum. If one identical twin suffers from Autism, the likelihood is approximately 90% that his Editorial 103 or her twin would also be autistic. Children with this disorder (like the flat worms loaded with social isolation gene) also prefer being alone. Consistent with this, eye movement studies indicate that, when viewing a picture of the face, characteristically they avoid looking at the person’s eyes. It would be helpful to ascertain if this same autistic avoidance would show up with SIS facial stimuli. Since the severe form condition occurs in about one percent of births and is increasing in prevalence, this could open up a fascinating avenue of future investigation for SIS scientists. Many modern geneticists think that in the overall population, various degrees of the genetic defect exist on a spectrum. Projective studies could be designed, using advanced technologically supported multidimensional input, to statistically sort out the degree to which empathy relates to social learning versus genetics. SIS scores assessing projected human imagery might provide useful aids in pursuing future scientific knowledge concerning this positive aspect of human identity. Wilfred A Cassell, M.D., FAPA, APC. Editor Emeritus, SIS Jr. Proj. Psychology & Mental Health, Director, SIS Center, 4501E, 104th Avenue, Anchorage, AK - 99516 (USA) E-Mail : siscassell2@yahoo.com

Dr.: “M., I appreciate your willingness to be interviewed in this television studio. Thank you for your willingness and courage to share some of your emotional pain in this educational setting. Perhaps you could again express how the SIS images that you viewed recently in the television version of the SIS II aided you in expressing your feelings. Please tell us as well about your worthwhile work with Alcoholic Anonymous (AA).

Let’s begin with A30, the SIS image that bothered you the most. M.: “I see death there…a lot of despair and pain…basically what I’m feeling now. (In responding to the SIS stimulus that bothered him the most, he spontaneously spoke about his severe depressive feelings and its cause). Dr.: “In what way are you feeling despair and pain at this point? What is going on in your life?” M.: “I have abused alcohol and other drugs for 25 years…and it has finally caused my marriage to break up and I’ve lost my family…I am having a very hard time dealing with that… A30 just reminded me of all the pain and hurt that I have caused. Dr.: “In what way did the drugs and alcohol impact your love relationship with your wife and children? M.: “Emotionally…I wasn’t there for my family… I’ve wasted tons of money over the years on drugs and alcohol, that should have been spent on my family…I mentally and physically abused my wife for a number of years…and, basically, they couldn’t take it any more … and I’m not with them any more. Dr.: “That’s a tremendous loss! Could you tell us the drugs that you did use, and how you originally got involved with them J.?” (Next the interviewer directed his attention to the onset of his chemical abuse problems.) M: “I drank a little in high school…but right after high school and into college I experimented with all kinds of drugs…settling into the use of a lot of alcohol, cocaine and marijuana for the last 25 years…I’ve known for a number of years that I’ve had a serious problem with them…Like I say…it led to numerous mental hassles with my wife…neglect…basically no emotional support for my family and tons and tons of pain and hurt that I caused over the years and now regret…but being in the depths of drug and alcohol abuse I didn’t see it happening really.” Dr.: “One of your associations to A30 was death. Has death been on your mind?”(In any severely depressed person it is important to ask about safety issues. Previously it had been determined that he was no longer suicidal and safe for psychotherapeutic work outside the hospital) J.: “Yeah…I’ve thought about it a lot.” Dr.: “Could you share that please?” J.: “Thoughts of suicide…In a sense I know how much hurt I’ve caused my family and how guilty I feel…and how bleak the future looks without my family.” Dr.: “And this all recently came about that you lost your family…How many days has it been?” SIS II-Video and Treatment of Alcoholism Wilfred A. Cassell and Bankey L. Dubey Wilfred A. Cassell, M.D., FAPA, Director SIS Center, 4501 East, 104th Ave, Anchorage, AK 99508, Email:siscassell2@yahoo.com, Bankey L. Dubey, Ph.D.,DPM, Director, 4406 Forrest Road, Anchorage, AK 99507(USA) Email:bldubey@gmail.com Key Words: SIS in Alcoholics, therapeutic intervention The Somatic Inkblots Video was administered to a person who has been abusing Alcohol and other drugs for the last 25 years. The SIS images helped in planning therapeutic intervention leading to positive attitude towards life. He shared emotional pain which he has felt during past years on his job. The Video interaction will help in understanding the psychopathology of such cases that have lot of inner cry to share with some one particularly with the therapist. The following televised teaching interview illustrates the use of the SIS II- Video version in the psychotherapy of a man recovering from alcoholism.

J.: “My wife and children left me about two months ago.” Dr..: “Another image that I would like you to comment on is A31.” (The second most “Disliked” image.) M.: “That reminds me a lot of my wife and myself and our fighting…and the conflicts that we have had over the years…it just reminds me so much of the conflicts and pain that we both have been through and that I’ve put them through…and how it was so stupid and worthless…if I had just sooner…” Dr.: “Do you have a lot of anger towards yourself right now?” (exploring the roots of his suicidal ideation.) M: “Anger is probably not the right word… before I stopped abusing drugs and alcohol I had lots of anger…lots of paranoia.” Dr.: “Rage?” M.: “Yes rage! I was angry all the time…Since I’ve had my spiritual awakening (Here he refers to the AA spiritual notion of a “Higher Power”) I really haven’t had any anger or resentment. I have a lot of pain and a lot of guilt over what I have done…guilt would be the best word.” Dr.: “What about paranoia when you were using cocaine?” (Exploring a toxic side effect of cocaine.) M.: “Unbelievable!...Every noise I heard…every time a car drove by I was sure that it was the cops coming to put me in jail…all kinds o delusional thinking.” Dr.: “Such as what? Give us an example please.” M.: “Mostly that someone was coming to get me…coming to take me away and lock me up for what I was doing.” Dr.: “What was your early experience with cocaine?...What sense of high did it make you feel and get you away from your immediate problems.” M.: “When I originally started doing pot and cocaine it was an escape…it made me feel good.” Dr.: “Artificially good.” M.: “Yeah…and then…especially the last number of years it was an escape to deaden the pain hat I felt for the crap that I’ve done.” Dr.: “Yes…the third image that bothered you was A10…I’d like you to comment on what you see there, please” (Pointing to TV screen) M.: “this one reminded me of myself…I guess that it really shows the despair and pain that I feel…the blackness f my eyes…the one spot reminds me of the tears that I have…mostly the image of just total despair.” Dr.: “Is it so painful for you because even though your wife has rejected you, you still love her?” M.: “Oh very much! I always knew that I loved her…but really until I lost her I didn’t know how much I did love her…I guess the drugs had deadened most of my feelings as far as that goes.” Dr.: “Could you tell us about that?” J.: “We hadn’t got along for years because of my drug abuse and behavior and we had grown apart. I seemed like the only relief I got was the drugs which only made the matter worse because it drove a wedge… deeper and deeper apart…so I started using more and more cocaine and marijuana and alcohol to deaden that pain and deaden my feelings basically.” Dr.: “And you are feeling the loss of the children as well?” M.: Very much so…I never abused them physically or anything like that…but just the neglect…not being whole person around them…I do get to see them once in a while which helps…at first every time I had to leave them it tears my heart apart and each time they leave.” Dr.: “At this point we might consider some of the images that had meaning in terms of the healing process and the spiritual transformation that occurred. I would like you to comment on 3A please.” M.: “I guess that of all the images that I saw that this was the most uplifting. It reminds me of a cross and of course, meaning the spirit of God and the lines that I see coming out of that is the energy and the colors flashing on are the energy of God penetrating me and giving me hope and courage to overcome my addictions.” (The spiritual component of AA has been found to be an important therapeutic dimension. Atheists may contend SIS II-Video and Treatment of Alcoholism 105

that this is invalid. However, for a pragmatic therapist, the question is not about its validity in reality. The issues is whether or not for a particular person if it is a useful aide in combating impulses to use chemicals, that otherwise would not be controlled.) Dr.: “When I saw you today earlier in the clinic you said that previously all your life that you were an atheist…and then you had a transformation recently. Could you share that transformation please?” J.: “Yeah, I’ve been a devout atheist all my entire life. I never believed in God until three weeks ago…I guess after my wife left me…and the depth of despair that I had gone into…I had been on a cocaine binge trying to kill the pain of them leaving…and for some reason god finally entered me…and I knew from that very second that there was a God and that he was there to help me.” Dr.: “What was the feeling like M.?” M.: “Warm comforting feeling even though… after feeling…even though I still hurt, I knew that I w wasn’t alone any more and I was instantly on my knees praying to him. Since that moment I never have had a desire to do drugs. It has been a short time, but I feel a lot of hope and courage from Him that I can be a new person and that I can overcome my addiction…now because I know that I am not alone fighting it any more…it has felt like it for years that I have been fighting this alone in self -will.” Dr.: “It has been a terrible lonely battle for you up hill and alone. When you felt God’s love fill you, somehow you sensed that you could reach out to AA. Could you tell us more about that and what that is involved because there are many people who don’t understand that principle?” (The interviewer speaks in his language, rather than using the term “Higher Power” traditionally used in AA meetings.) M.: “Alcoholics anonymous is a support group developed by nonprofessionals. They have helped literally millions of people over the years. I had been in AA meetings in the past years ago, but being a nonbeliever in anything spiritual, it meant nothing to me… and I got no benefit from it…I just knew the second that I realized that there was a god that I needed to be in AA. I have been going o AA meeting and receiving a lot of support and love. I receive help from strangers who have been through the same pain and agony. I realize that there is hope for the future.” Dr.: “There is hope. What about your impulses to use M.?” M.: “My first impulse to use basically disappeared as soon as God entered me. I really have not had the urge to use… I’ve had cravings at times, but it really has been miraculous…I have no desire to use drugs. The support of the AA…the times that I’ve had the craving or the weaknesses…going to the meetings and listening to the people…and talking to the people and the support groups through the phone networks…and some very, very wonderful people who are willing to help total strangers has been very uplifting and very supportive.” (Here he speaks about his recent “religious experience” with AA. In an overly optimistic almost euphoric way. His depression had largely been resolved since concomitant marital therapy had successfully reunited him with his family. His long term prognosis was contingent upon active participation in AA and long term psychotherapeutic involvement.)

In this regard, the SIS II Video/computer versions may be presented as a stimulus for AA meetings, as well as other forms of group psychotherapy. SIS Assessment of Somatic Conversion Symptoms: Earlier in this handbook a theoretical model outlined how psychological stress may get mentally converted into a variety of physical symptoms. This case history illustrates the use of the SIS II Video in a middle aged woman. She experienced an activation of her Dissociative Disorders conversion symptoms during the stress of conjoint marital psychotherapy. She was referred for projective testing by her female psychotherapist for this televised teaching program. A transcript of the educational interview follows: Dr.: Thank you for agreeing to participate in this teaching tape S. If you don’t feel like answering a question just say, or if you don’t feel like answering everything, I understand and we can stop at any time. 106 Cassell and Dubey

I think that you’ll find this really helpful… and I certainly appreciate you coming in… I’m very interested in your reaction to the psychotherapeutic interview that you had with J. your marital therapist earlier this week, especially in terms of some of the physical aspects, S. Could you share that with us, please? S: Well, it was very scary. I was having a session with J. and my husband was there… and we were talking about some childhood things and all of a sudden I got real disoriented. And my body got real heavy and I got real dizzy and I couldn’t walk, I couldn’t concentrate, I couldn’t think. It was like I was down in a tunnel. I could hear J. and I could see them but they were just way far away. (The psychological stress of recalling the trauma of psychological stressful childhood events activated her Dissociative Disorder’s psychological defenses and underlying neural inhibitory processes.) Dr.: Tell us a little more about this heavy body feeling. Was there any pain with this or? J.: There was no pain. It felt like, it felt like when a person almost passes out and it feels like they’re enough conscious to know what’s going on but they’re not able to do anything. Dr.: Was there a sensation of dizziness? (reported by he psychotherapist prior to the interview.) J: Yes. Dr.: Tell us about that please? J: I was sitting in a chair very similar to this and I started to get very dizzy and it got worse. It was more than dizziness. It was like my brain stopped processing. Like I couldn’t think. J. asked me to write down my feelings, she told me that she understood what was happening to me and if I wanted to remember anything about the session I needed to write it down because when I came out of it I wouldn’t remember anything. And I couldn’t write. Dr.: So there was… T: I was able to write one sentence and that was all I could do. Dr.: Sort of almost a motor paralysis too? (The thought and PTSD memory blocking neural inhibition spread from the higher cognitive systems involving self and body awareness to the motor cortex inducing a type of catatonia. Initially the resultant reduction in somatic awareness led her to experience “Dizziness”. Subsequently this was followed by paralysis of her arm muscles used in writing. This sequence illustrates the close temporal connection between cerebral activation of psychological “Repression” and transmission of neural stimulation to external body skeletal muscle fibers. An observant interviewer can detect the onset of this defensive process by noticing changes the ongoing concomitant changes in body posture and movement. Techniques which reduce skeletal muscle tension, such as hypnotherapy and intravenous muscle relaxing drugs, can reverse the process.

The reader interested in this phenomenon and its effect on SIS evoked imagery is invited to review in the book Body symbolism, clinical cases outlined in the chapter on “Somatic Repression”. Moreover, in the chapter on Schizophrenic disorder, there is an example of reversing this sequence in an individual experiencing catatonic features) J: Yeah. Dr.: What was the sentence that you wrote? Do you remember? T: “MY HUSBAND VALUES ME.”(This represented a central issue in the marital therapy previously reported by her female psychotherapist. Because of her multiple) psychological and physical symptoms, including sexual dysfunction her husband was getting impatient. It was important for her psychologically to accept his commitment to her. Otherwise, she would have feared his leaving her, which would have activated long term memories of unresolved childhood grief.) SIS II-Video and Treatment of Alcoholism 107

Dr.: Yeah. T: D., my husband, values me. That was the only thing I wrote. Dr.: Did you have any nausea with that S.? (She had previously reported along with “Dizziness” to her therapist a feeling of “Nausea”. Here, it may be recalled that changes in body orientation, such as associated with motion sickness involve input from the vestibular apparatus via the 8th cranial nerve to primitive vomiting neural centers in the floor of the 4th ventricle. These in turn then communicate with cognitive connected sensory cortical centers giving rise to the conscious feeling of “Nausea”.) S.: I was nauseated and I felt like I had a cold, hot and cold flash (stress induced cardiovascular sensations) but just the cold, you know. Almost like fear and when I got up to get out of the seat, that was when I realized there was really something was wrong. I could not walk. I literally did not have any balance at all. And I couldn’t communicate. I couldn’t think. Dr.: How long did that last? S.: About 7 hours. Dr.: That was pretty scary. (Recognizing her anxiety in a supportive empathetic comment.) S.: Real scary. So D. had to drive me home and on the way home I realized I had had it happen to me before once but when I was at home and I was sitting at the kitchen table. I remembered that it had happened to me two or three times before. And then it got worse. (Her conversion symptoms had become activated by previous stressful marital situations.) J. told me that trying to do normal activities and that would probably bring me back. And my son was being babysat so I didn’t have any distractions worrying about him. And I tried to wash the dishes and I couldn’t. I couldn’t, I couldn’t focus, you know it was almost like a person feels when they’ve been kicked in the head. They, they’re just not able to do it, you know. Dr.: Now you were telling me a little bit about the content of the interview. Could you share that? What you were focusing on? S.: In particular there were two things… D., my husband, was there this time and was in the therapy session with me so J. could educate him on what was happening to me.(Educating the spouse in regard to what was happening in regard to her symptoms as well as the positive prognosis with psychotherapy was important. This serves as a reinforcing force to support his long term commitment to the marriage.) Dr.: Yes, that was good. S.: And to help me and him to really see what was going on because I have a hard time communicating it and that helped a lot. And in the process we were talking about the similarities in my behavior. How my behavior is a lot like my mother’s in a way that I’m demanding and intolerant at times. (Historical material linking her behavior with her mother’s past personality problems proved highly stressful. While children tend to acquire characteristics of their parents, it often is anxiety provoking in adult therapy to examine the similarities and differences.) Sometimes I say D., I need to do this. I don’t ask. I just shove it in front of him, you know. And I get mad if he doesn’t understand that’s what I want, you know. I don’t ask and I just shove it in front of him and I think that was where I started feeling bad and I’m starting to feel bad now. I’m starting to feel things shut down just thinking about that.(In this illustrative interview, in describing her irritable, maternal like marital behavior, she then began to experience similar Conversion symptoms.) Dr.: OK, we’ll stop for a minute. (Pause… then after period of relaxation when she was less anxious…) We will now go over your responses to the video. Would that be OK? Perhaps we will begin with the three you liked most. (To further reduce her anxiety, the interview began with the three SIS stimuli that she “Liked most” .) I know that your favorite was 5A. And you indicated that it’s 108 Cassell and Dubey

a clown and a very friendly person. Do you want to say anything more about that? Why it appealed to you and so on ? S.: Well, when I first looked at it, it just looked like a clown to me and it felt safe and friendly. Dr.: Good. Well, that tells us that you have a capacity for a sense of humor and that things are going to be safe for you after a while, after you process some of this difficult material. (Supportive emotional comments emphasizing the positive prognosis and hope.) And 8A you indicated seemed to resemble “A child who is happy and having fun.” S.: I see a very happy child, delighting in life, playing and just feeling free and at peace. Dr.: What does that bring to mind for you? S.: It brings to mind for me a feeling of completeness. Dr.: OK and then B17 (A moving, red, pulsating, heart like SIS viewing pattern.)you “Liked”. You indicated that this reminded you of “A feeling of being healed”. Could you enlarge on your response there, please and what you remember? S.: B17. It was a heart that just kept growing and getting bigger. That’s what I saw in it. And it was a type of color that was peaceful to me and I felt joy, compassion and love. That’s what it made me think of. Dr.: Yes and that tells us that you have a capacity for joy, compassion and love and that’s going to grow as time goes on with your therapy. (Supportive comments to further reduce anxiety.) “Disliked” SIS Projected Imagery Dr.: Now to go to the ones that bothered you. A3 was particularly upsetting. Can you tell us what you saw in A3 please? S.: Well, the reason that was upsetting is that I keep having that one in my dreams.(Recall the earlier discussion in this handbook concerning how the SIS electronic technology taps into the same stream of consciousness as PTSD dreams and anxiety charged memories.) Dr.: What are your dreams??? and what is the parallel, would you say? S.: It represents to me – it looks like a fungus animal that could hurt me. And in my dreams I keep having this type of fungus that attaches itself to me, to my skin. (Here a defensive dream symbol emerges involving threatening body imagery. Although this has high anxiety linkage, it serves to defensively hide her deeper more heavily affect charged painful emotions… the source of her Conversion somatic symptoms.) Dr.: That must be horrible? (Empathetically recognizing her distressed emotions.) S.: And I’m pulling it off and getting rid of it and it’s very threatening but I’m getting rid of it in my dreams. Dr.: What do you think those dreams mean? S.: I know they have something to do with the depth of pain, that the hurt that I have represents or it wouldn’t look like a fungus. It wouldn’t look so threatening to me.(Previously in psychotherapy she had began to realize the therapeutic value of dream analysis.) Dr.: It’s very deep and very threatening. S.: And it’s alive. That’s the other thing that makes it very threatening to me. It has a life of its own. And then I’m able to pull it off of me and get rid of it. Dr.: And what does that symbolize? S.: That it will be OK. Dr.: That you can work things through.(A positive statement to encourage to face the emotional discomfort of analytic psychotherapy.) S.: That I can work things through and that it will be painful too because it always leaves a sore. Dr.: It’s very painful. Remember that I said that. S.: I’ve had the dream about three times. (Recurrent dreams are important to analyze.) Dr.: Three times. If you go to a dentist you can get something for the pain but for this pain of SIS II-Video and Treatment of Alcoholism 109

the heart it is more difficult. A13 was one that troubled you. as well What do you see there, please? S.: This is a hand, to me, that is reaching out for help, that’s trapped. Somebody that’s in distress it symbolized to me my mother’s hand and I felt very helpless and I felt like the person, somebody that was suffering and I was helpless to help them. And that’s what it represented to me. Dr.: What does that bring to mind in terms of your relationships with your mother? S.: You mean my relationship with her? Dr.: Either now or in the past? T: In the past I was the caretaker. Dr.: Tell us a little bit about that? T: My mother was a drunk when I was a kid. And I was her caretaker basically. I don’t remember, I don’t remember hardly any of my childhood, it’s just, it’s just all blocked out. But I do remember always being the one to bring her this, to mop the floors, to clean the house, to bring her, her cigarettes and buy things for her at the store. I’d do those kinds of things for her and being real concerned for her. I specifically remember one time crying on the way to school because mom had told me that when I got back she would be dead because she was going to kill herself while I was at school. Dr.: How did you feel when she said that? S.: Very helpless and very scared. And I was – I know I told somebody about it. I don’t remember if it was the bus driver or the teacher but … Dr.: It was horrible. S.: But I particularly remember going through that and I was wondering what was going to happen to me. That I didn’t want her to die. Dr.: It was scary. S.: The whole thing was threatening and scary to me. That was about 7 years old. Dr.: 7 years. S.: Grade school. Dr.: Appreciate your sharing that.

And then B19 was the third one you rated as being threatening. What do you see there? S.: Well, it definitely wasn’t a sun. It looked like an amoeba to me. It looked like more of the same. It looked like a living organism that was going to attack. And the two hearts to me, represented, on each side of it, one represented me, one represented my husband and this was a threat to us but it also looked like was, it also looked like in the picture that it was already beginning to well, it, the amoeba looking thing’s got cracks in it so it looks to me like somebody’s already hit it once or twice to get rid of it. But it represented a threat to me. Dr.: What way does it relate to your love relationship to Ken? (Bringing her back to the present marital problems.) S.: The disharmony between us. The inability to really communicate and understand each other. Dr.: That’s going to improve especially now that Ken’s getting involved a little bit. Thank you. I would like to go through these others. But before we do could we review your drawings that you did? I think that would be of interest. Tell us now what they all represent if you would, starting with the first one. (Just as dream symbols emerge with the SIS, comparable symbolic imagery may appear during Art Psychotherapy. An important variation of the SIS technique is to initially avoid the limitations of language by having the responder draw impressions to the SIS stimuli.) S.: The first one represents my home. It’s a drawing of a crooked house with a broken window with bars on the front door. Dr.: And what does that symbolize? S.: For me it’s a visual drawing of the war that was going on in our family. I don’t really have any memories, per se, of the exact things. I know that looking at that I’m almost ready to cry. 110 Cassell and Dubey

Dr.: You realize sadness and … S.: I feel a lot of anguish and pain. Dr.: How about this second one? What do you have to say about that one? T: It’s a drawing of a child, a little child, preschool with a spike and a nasty face in front of the spike, which doesn’t have really it’s just the eyes and the mouth and the mouth have teeth. It represented the heaviness, the weight, the weariness and the pain that the certain something that I was so afraid of that hurt me. I don’t know if it was, it was nameless that’s why it was a face. I couldn’t put a man or a woman’s face on it. Dr.: The weighty feeling, was that anything like the weighty feeling you had when your body … S.: Yeah. Dr.: How was it parallel? S.: The way that I feel emotionally and psychologically and the weight that I was physically feeling. Dr.: How about the next one there, S.? The third one, I guess. S.: It’s a picture of the same child, in a box with a maze around it. Then and there’s no way out. The box is closed off. Although the maze has an entrance the box doesn’t have an exit. With a pair of scissors and it’s in black and white. These are in black and white, the first drawing and the third one, because my world was black and white. There was no love, there was no color. There was no life. The scissors are cutting through the maze. They have wings on them because they are from God. I feel like that God himself is healing me through therapy and what other ways He’s choosing to do it. Dr.: Anyway, you’re feeling God’s healing with this pain.(Supportively speaking her spiritual language) Let’s do the next drawing. Let’s see. S.: One, two, three, four. Four. Four is a little child in a tunnel. It was what I was feeling when I was out of it, unable to concentrate and unable to really move around. I felt like I was in a tunnel. Dr.: Could you tell us now, when you went into the interview you felt like an adult woman and then sort of changed to be more of a child. Could you tell about that age transformation? S.: I would feel like I regressed all the way back to infancy, if that’s possible. Not quite infancy but toddler hood. Dr.: It’s possible. T: Preschool. I felt like on my way out that I was that I needed to be carried, literally carried like a little child. That I’d been severely hurt. Dr.: Yeah. You needed comfort and love. S: Yeah. I felt, I felt that I got in touch with those real tender, tender feelings. Dr.: Um huh. That was good. S: That I don’t think I felt before. Dr.: It was good that D. was with you. S: For a long, long time.(In the above comments, she documented the significant age regression that is associated with the expression of severe psychological stress in psychotherapy. Like the above outlined “Repression” mental /neural mechanisms, this too is associated with clinical changes. Dramatic examples involve remarkable alterations in the human voice: A subject may speak with a voice replicating their childhood immature one or in severe Dissociative Disorder speak with the voice of an alter identity representing a perpetrator of the opposite sex etc.) Dr.: So what’s the next drawing? S.: The next drawing I tried to put a face on what it was that I was so afraid of. What it was that, the nameless thing that put me in a state of semi-shock. And I know there was sexual abuse in my family. I’m making an X with my hands because I crossed out the face after I did it. It didn’t feel right. It didn’t feel like that that was the right representation. I couldn’t, I couldn’t figure out what it was. And I started with a man’s face because I know there was sexual abuse in my original family. I was adopted. My very original, natural family I have no history. I was adopted when I was SIS II-Video and Treatment of Alcoholism 111

four days old so the sexual abuse happened in my adopted family. Dr.: And who did that involve, do you know? S.: The perpetrator was my step father and involved my cousins. It supposedly did not involve me. My mother says but I’m not so certain about that and anyway when I drew the man’s face there it didn’t feel right so I crossed it out. And number six is a picture of representation of my mother. She has on a red dress because she is angry. Her nose is red because she’s drunk. She has a beer in her hand and there are swirls around her head because she’s not, she’s not sober. She’s incoherent like she was most of the time. That felt right. I knew that had really happened in my life. When I drew that it felt like truth to me. Dr.: Yes. S: And, the next one, the next two were all faces. I was trying to draw myself again, to focus on who this little child was, what it was, who I was, what age I was, this trauma was going on at that I was in touch with and they weren’t right so I crossed those out and when I got to this one, I feel like that this one was right. S: This next one is just a little child, scared, alone and hurt and I’m drawing her inside of a tunnel because I felt like I was in a void. I felt like I’d been sucked into a vacuum. Dr.: That’s very scary. S: Yes, it was very scary. And, it was very, very painful. And I felt like there was a lot, a lot of grief, I was feeling a lot of grief, a lot of pain and it was just plain shock like something and I kept saying over and over again to myself, “something happened to me and but that was it?” And I couldn’t remember but I had this sense that something happened to me and I didn’t know what it was. Dr.: Thanks, S. I want to go on, do you feel comfortable doing some of the other video images? S.: Um huh. Dr.: Let’s have you look at them in order. A1. Can you tell us what you saw and what that brings to mind? We have a number to do so we are going to move a little more quickly this time. S.: A1. Two seahorse heads. First it reminded me of blood because the video image had red in it. Dr.: And when you think of blood what comes to mind? S.: Violence. Knives. Dr.: Have you been experienced or been exposed to violence? S.: I was in my adolescence and young adulthood. I don’t remember any of my childhood. I can’t tell you about that because I don’t remember. (Repression) Dr.: Let’s move on to A2 then, please? S.: A lady dancing in the mud and getting hurt. Dr: And what does that bring to mind for you? S.: It brought to mind fear, like there was danger. Dr.: You feel in the mud at times, I imagine. S: Um huh, or I’ve been in the mud. Dr.: And the next one, A3? S.: That was the one that looked like the fungus that we spoke of. Dr.: Okay. And A4? S.: A broken toy and I was upset by that. Dr: Tell us about that. S.: I really felt that broken toy really strongly, like something really precious to me that somebody had deliberately broken it out of spite and I was upset. Dr.: And that took you back to a childhood experience? S.: Yes. I don’t recall that childhood experience but that’s what it. Dr.: And 5A? S.: A5 was the clown that made me happy and felt safe. 112 Cassell and Dubey

Dr.: Right. Good. A6? S.: 6A was the child. A child who has a teddy bear next to it that looks like he’s been scared to me. Something had happened and scared him and he stopped playing and he’s frightened. Dr.: And that brings to mind something from childhood? S: Just feelings, no memories. Dr.: Nothing specific? Okay and the next one, please? S.: The next one is the victim whose mouth is masked and unable to cry for help and the top of it looked to me like a large object that was going to crush him. Although it looked like an apple too. It looked like it was larger than the person and I felt threatened by it. Dr.: And what does that relate to, do you suppose? S.: The many times in my life that I’ve been physically restrained and not been able to help myself. Dr.: Those are horrible. And the next one? S: This one was the happy child playing and feeling completeness. Dr.: Okay. And then the next one. Just repeat the number? S: A9. This one looked like a puppy dog to me. It reminded me of him. Dr.: Of B. (Interviewer‘s dog…calm pets reduce a responder‘s test anxiety) S: Yes, B. It reminded me of B. and there was comfort in that because I felt that this particular puppy dog knew that I was hurting inside and he was also sad. Dr.: Come here, Buddy. Let’s get a little shot of him in the video here. Come here, Buddy (Animals are supportive in stressful interviews.). S.: This is the real therapist. Dr.: Okay. And the next one, please? S: The next one was a person whose eyes were out of focus. That’s the way I felt when I went into the Posttraumatic Stress Disorder. I really identified with that. Dr. And the next one, please? S: A11 looked like a child’s drawing to me, scribbling because they were mad and I felt relief because I had scribbled out that anger when I looked at it. Dr.: We need to have you do a lot of scribbling because there is a log of anger inside, right? A12? S.: An ear. It made me feel cared for. It represented to me that someone was listening to me. Someone was actually listening to me, being attentive. Dr.: How does it feel having J. as a therapist? S.: It’s wonderful! Dr.: It’s nice to have someone listen, isn’t it? S.: Yeah. I really experience that with her. Number 13A was my mom, the hand reaching out that was trapped. The one that we spoke of that was distressing. Dr.: A14? S.: A14 looked like a womb to me. And I was worried because the baby didn’t look normal. Dr.: What way were you worried about the baby? S.: That it was sick. A15 looked like a womb to me of a dead baby, an embryo. Dr.: What does the sick baby and the dead baby bring to mind? T: The way I’ve been feeling inside. (There is much age regression in individuals experiencing emotional pain.) Dr.: Right. A16? S.: A16 looked like a symbol of healing. Two birds and a heart. A wounded heart but then there was rain coming down which represents growth and nurturing and two birds who are fluttering represents spring. I felt like it was just hopefulness in spring time in the drawing. SIS II-Video and Treatment of Alcoholism 113

Dr.: There’s lots of hope for you, S. with therapy. A17 S.: Scabs on the outside and the inside is fresh and new and the scab is falling off and it’s being reborn. Dr.: I love that symbol. What does it mean? S.: It means healing. Dr.: Yeah. As a result of you working through this pain in your therapy. A18? S.: A18 is my heart, looked to me like my heart inside, deformed from sin and suffering and I felt great compassion in looking at that in particular. Dr.: A19? S.: A19 looked like a serpent that was leaving, not coming to me but leaving and I felt great relief in that they weren’t coming to me. Dr.: Symbolizing? S.: Symbolizing a change of life, a change of the way of thinking, a change of the way of doing things. Dr.: Getting out the hurt and the anger. S.: Getting out the hurt and. Dr.: You’re going to feel better. A20 please. S.: Unity of two souls still in the womb. It looked like twins to me and in a uterus. Oneness, I felt oneness looking at that. Dr.: A21? S.: It looked like a joyful transformation of my heart, getting ready to be free and flying. It looks kind of like a bird with a heart in the middle getting ready to take flight. Dr.: That’s what you are. S.: I identify with that bird, yes. Dr.: A22. S.: I am the tunnel and this is the crisis that I’m coping with is what I felt. I felt really weary, really heavy, real tired. Dr.: All this is very demanding. It takes a great deal of energy. It’s important that you realize that. I mean, it’s heavy duty demand. A 23? S.: I felt like, it looked like a bone. I felt it was more danger, another threatening thing. Dr.: A 24? S.: Spilled paint on a pallet. Also it looked like a woman’s legs and inside of her vagina and it made me feel uncomfortable. Dr.: In what way uncomfortable, S.? S.: Because the spilled paint, I felt that there had been an accident and then I felt uncomfortable with the fact that it looked like a woman because she looked like she was in pain. Dr. I know you are in pain. A25? S.: Looked like a vagina and it was more than that to me. It was emotional aspects of sexuality and all the things that are attached that go in with that, marriage and that and I felt very vulnerable. (Referring to marital conflicts regarding sex,) Dr.: A26? S.: A baby sleeping. Very, very safe, secure, very happy with that. Dr.: A27? S.: Lying in the flowers naked and I identified with that, freedom like the little child, unafraid and playful. Dr.: A28? S.: A muscled arm and wrist. The hand of God. I felt like it was a hand reaching down to rescue. Dr.: God’s helping you. A 29? S.: At first it looked like something to fear and then I realized it was just a shadow, my imagination, nothing to fear. Dr.: Good. A30? S.: A skull, death, sickness. And this is what interested me about that. I felt total and complete relief looking at that. Like the torment is over, the pain is over, the weariness is over. Like I’m finally at the end of my journey and now I can go play. Dr.: There is a light at the end of the tunnel. (Emphasizing positive prognosis.) A31? S.: A man and woman brainstorming, teamwork. A feeling of being helped and cooperation. 114 Cassell and Dubey

Dr.: What does that bring to mind? S.: Two people cooperating for a common goal. Me and D. for my healing or for a project we’re working on or the inner reaction between me and my therapist. Dr.: Don’t you feel good having D. giving the support and be present and that he’s going to be more involved as it’s explained to him. S.: Yes, I feel wonderful about that. Dr.: It’s been tough for D.. He’s been in the dark up until now. B1? S.: This looked like a demon to me. It looked like a fire and a demon and potential danger. ( A direct projection of dream symbolism,) Dr.: B2? S.: A volcano erupting and I felt concern over that. B3 is two souls being taken to hell by rebel angels. That’s what that looked like to me. Dr.: What does that bring to mind? S.: I felt great sorrow. It brought to me the realization, conscious realization of my accountability before God for my actions and the total end results which ultimately will be what I do here now. Dr.: B4? S.: Death of a mother and child. It looked to me like a mother and child’s death. It brought to me sadness. Dr.: B5? S.: Boy and girl in seats, pictures on the wall. Both unhappy. They’re both disturbed because they’re Black. Dr.: B6? S.: Fantasy, mushroom, umbrella tree. It looked like something out of science fiction. It looked very comfortable like I wanted to go sit under it, pick some of the leaves off and just sit there. Dr.: It’s important that you get out and enjoy the beautiful weather of Maine and all that. That can heal us too, S., you know? I’m going to be out on my mountain bike in a few minutes. S.: Good for you. Sounds real good. Dr.: B7 S..: B7. I was delighted with this one. It looked like a jelly fish and some leaves in some water and I was ready to jump in (laughing). Dr.: B8? S.: The world. It looked like the world alive and breathing but I was disturbed by it because I’m not used to seeing the world throb. And that was out of character from what I normally see. Dr.: You were throbbing the other day really strongly in your session with J! B9? S: Two stomachs and a larynx with indigestion. I felt real discomfort like too much Mexican food. (Pathological anatomical responses relate to somatic symptoms experienced.) Dr.: Do you get much indigestion when you’re stressed out? S: Anxiety. Dr.: How does that affect your gastric functioning? S.: Yeah, I think I do. See I’m not that in tune with my body. Dr.: Right. B10? S.: Child’s drawing of a critter and a woman’s legs with a vagina with a cut. At first glance it looked like a Panda bear. At a second glance it looked like a pair of legs and I was alarmed by it because it looked like the particular woman had been cut. (Pathological sex anatomical response consistent with past abuse trauma.) Dr.: B11? S.: B11. And area on my shoulder that is sore. It looked like the back of my shoulders, if you used one of the cameras that shows the heat. Heat sensing camera. Dr.: What do you mean? S.: My shoulders would look like that. SIS II-Video and Treatment of Alcoholism 115

Dr. Do they? When do they feel like that? S.: Yeah. All the time. Dr.: They’ll go away as we relieve the psychological load on you. B12? S.: Lettuce, onion, celery by the road in the sun like I was happy. I felt like I was on a farm and that I was ready to go pick some vegetables and sit down in the sun. Dr.: That’s going to be down the road for you in therapy. B13? S.: A woman found in the water. I was happy that I was in the water again just like the jelly fish and the leaves and that was like a treasure I’d found. Dr.: B14? S.: A glass with smoke in it. I was, it felt like there was potential danger there. Dr.: B15? S.: A person under brutal attack. It looks like their face had been sliced off or they’d been hit by something. There were lots of knives in the picture.(Imagery depicting past exposure to violence.) Dr.: How does one make you feel? S.: Fear, anguish. Dr.: B16? S.: A concern, another crisis but one that’s been tamed or is controllable and I felt relief. Dr.: Good. B17? S.: The one that I liked. A heart filled and growing with love. Dr.: Right. B18? S.: B18. Another on coming problem that is controllable. I felt confidence. Dr.: Good. B19? S.: That was the one that was threatening to me about our marriage. Dr.: Right. B20? S.: The healing of the brain. I felt relief and happiness, psychological healing. It was, it looked like a brain but it had green in it like it was going through a transformation. Dr.: Your brain is healing. B21? S.: A squashed gun. It looked like somebody had polarized gun. It would that, whoever, whatever was going to do, whatever they were going to do there was a victory and it was all over with and I felt determined joy and a victory over that. Dr.: B22? S.: A person barely alive waiting for help. Dr.: B23? You felt bad after that interview with psychotherapist didn’t you? S.: Yeah, but in this I felt total trust. Dr.: Yeah. S.: Total trust that help would come. Dr.: You trust J., D., myself and God and you’re in good hands. B23? S.: A blackened lung and inflamed ribs and it made me feel uncomfortable and reminded me of somebody with asthma or smoked a lot of cigarettes or something. My son has asthma.(Projected health concerns regarding her son.) Dr.: You worry much about his asthma? S.: Not any more. He’s gotten better. Dr.: B24? S.: Decayed lungs. It looked like lungs that were passed help. I felt sorrow. Dr.: B25? S.: A hole in the universe. I felt fear and anxiety. Dr.: B26? S.: Spilled lotion and the upright, up righted bottle of lotion next to it. I felt concern about that. Dr. B27? S.: Two embryos, one is dying and the other one is already dead. I felt sorrow (repeated 116 Cassell and Dubey

death themes related to her inner psyche core of sadness, loss and depression…an opportunity to explore suicidal ideation not pursued here,) Dr.: B28? S.: A mother saving a child from danger. I felt fear. Dr.: B29? S.: A child running into danger. I felt fear.(Age regression again) Dr.: B30? S.: Two ears. Two people being attentive. This was a situation where a person needed to be listened to. What was going on was very serious and I felt concerned, very concerned for that person. Dr.: You’re a very loving woman, you can reach out. B31? S.: A family hiding in a safe place. I felt anxiety because this looked like a family that was in a place of warmth but they were there. Safe and security because they were frightened and it was a place of refuge. Dr.: How do you feel about your family at this time? S.: About my family at this time? We’re getting there because my husband is participating now. Dr.: Yes. Did you want to add anything about any of these images, S.? I know the one you mentioned. You got some relief from this scribbling. Did you want to mention any? T: Oh yeah. I was surprised at the drawing, A11, looked like a child had scribbled and I felt real relief like I needed to sit down and just do some real scribbling. Dr.: Right. S.: And I’ve had this, on the back side of my house is a home but it needs some repair work done on it so on the back side, it is going to need painted and some wood but in the mean time there is this whole bottom half of a house, it runs along the whole side of the house, there’s no windows, this has got plywood on it and I thought, “hey what a great place to do a mural” Now I’m thinking what a great place to do some scribbling. Dr.: Go for it! Go for it! S.: I think I’m going to. Dr.: On the one response you noted the parallel between your dream, the content of feelings of dreams and the responses here. Could you say more about that or any of the others? S.: That one with the fungus was the only one in particular that I identified with a dream. Dr.: How long have you been having that dream? S.: For about three months. Dr.: And it’s come on during the period that you’re working in therapy. S: Um huh. Dr.: That’s going to go away as you process the trauma. What’s your worst fear? S.: That I’ll be abandoned to stay this way. Dr.: That’s a horrible feeling. That’s because you have feelings of being abandoned. You feel secure with J. and your husband and with all of us. You’re going to be fine. Any questions or anything? S.: When we were beginning to talk about what happened in that session I was starting to feel disoriented again. Dr.: And now you’re coming back Okay? S.: Yeah. Dr.: Good. Well, thank you. I think we’ll chat with Ken for a moment or two. S.: Okay. Dr.: Appreciate your involvement and I hope you do get out and enjoy that pretty afternoon a little bit. S.: I intend to. Dr.: Good. Thanks. S’s Husband: SIS II-Video and Treatment of Alcoholism 117

Dr. We appreciate your coming in, D. Tell us a little bit about the interview the other day with S. and J. You were sitting in on that. That must have been quite an experience. D: Well there were a couple of interesting things. One especially in light of what happened, S. said she and I were talking about her childhood. Dr.: Yeah. D.: Which in fact she related what we were talking about to her childhood. We weren’t really talking about childhood. What we were talking about was some of behaviors, towards me, that she has and at the time there were several I think. I was doing the talking at the time this happened. We were talking about that she has this real strong need to have my love for her affirmed and affirmed through actions. Dr.: Um huh. D.: And it has to be not just that you do things for me but there’s sacrifice involved. It has to be continually reaffirmed. You can do things, to demonstrate your love, you know, ten times but if you fail, but if you fail on the eleventh time there’s going to be a lot of anger and stuff and you feel pretty much shows, that reaffirms to her that you really don’t love. And she was saying to J. she felt like I really didn’t value her and I was talking a little bit about that and how that was really hard for me because in fact that I did and that I had done things to demonstrate that. And that was the one thought that she, the one thing that she was able to write down was that my husband does value me. But it was in the midst of talking about that it was like, it was like someone flipped a switch, it wasn’t like she gradually fell into this, it was like one minute she was fine and the next minute all these physical things were going on. Dr.: She had a number of physical things. Could you share what they were in your eyes, what she was experiencing physically? D.: Well, when we went to leave it was, the nearest thing I can compare it to was when we had our son she had to have a c-section and it reminded me of the first time we got her up to try and walk. And she was in so much pain and stuff, and if you see patients in the hospital, you notice they’ve had surgery and they are walking around trying to, you know, expedite their recovery and they shuffle real slow because it’s so painful and. Dr.: Yeah. D.: They’re stiff and real slow and like they’re reaching out for a wall and even if it’s not there something to hang on to. Dr.: Real Shaky. D.: That’s what she was like and I had to, had to hold on to her because she couldn’t have walked on her own. Or she would have gone down. Dr.: What other physical manifestations were you aware of? S.: Numbness, like she had a cloud over her. Dr.: Did she complain of numbness? D.: Well, when I say numbness I’m thinking not so much physical in a sense of touch but mentally. Dr.: I see. D.: And her mental faculties were numb and she seemed distant like she was kind of off somewhere else. Dr.: Were you concerned that she was having some sort of physical problem, attack or something or worried about her health in any way? D. No, it was obvious it was all related to what was going on. It wasn’t fear for her physical well being. I was concerned for. Dr.: Her psychological self? D.: Yeah, plus it emphasized that the depth of what was going on, had gone on in her childhood and everything. The severity of the whole situation. I don’t think I’ve ever been around … I’ve been around people that have been in that state but I’ve never been in a situation where I’ve seen someone just go from one to the other in a matter of seconds. Dr.: If you didn’t have the understanding of the psychological context of the interview 118 Cassell and Dubey

though, you can imagine how you might feel something physical was happening to you like a stroke. D.: Oh, yeah, something. Dr.: Or an epileptic seizure. D.: Or anemia or Dr.: Yeah. Right. Have you some more understanding after the interview the other day and then our discussion and hearing the video and art work? Do you feel you understand her pain more now? And her? D.: I have a better understanding of the extent of it and depth of it, that it’s more extensive than I realized or appreciated before. Dr.: And the need for you to be with her and reassure her of your love and all and that you won’t abandon her and all this. D.: Yeah, that’s one thing she’s, over the years she’s had a lot of dreams that reflected that fear of abandonment. Dr.: Could you site some of those dreams? D.: She’d have dreams where she was in it and if I was in the dream, it would be in the context that she would be gone and I would ignore her or I would be with another woman or something else or I would be leaving or not ever expecting very, very rare that we were conscious that we were together in the same dream. And there’s not. Dr.: So what do those dreams tell you? D.: That it’s, she had this deep fear of that, that she’s going to lose my love for what we have. Dr.: What would you like to tell her to reassure her? She can hear us now. D: I think the fact that I’m getting involved with her therapy stuff that it’s real critical to her because she vocalized it a lot of times. The fact that I’m involved, she sees that as a response more than anything else. Dr.: Yeah. And you’re doing that because you love her and you’re going to stick with her and all that. D.: Yeah. Plus the fact that you can’t, I don’t think that in a marriage, that you can separate one individual from the other, obviously they are both intertwined and they affect each other so. Dr.: That’s why J. had you in and we have you in now. Do you have any questions or anything this morning? D.: I don’t know if any of the questions I have can be answered. I mean it seems like the same questions we all have. Dr.: Well, look, I appreciate very much your coming in and the same as I said to her, go play. It’s a beautiful Maine day and it can be healing to be outdoors and thank you very much for. D.: Right. Thank you for your help. Conclusion: The Somatic Inkblots Video was administered to a person who has been abusing Alcohol and other drugs such as cocaine and marijuana for the last 25 years. He was aware of numerous serious problems with his wife, no emotional support for the family and tons and tons of pain and hurt that he caused over the years and now feeling regret for that. He also had suicidal ideas and always thought about his family. The SIS images helped in planning therapeutic intervention leading to positive attitude and better mental health. SIS II-Video and Treatment of Alcoholism 119

Development of a Comprehensive Scoring System for SIS-I S. Kandhari, J.Sharma and R. Kumar Many researchers working with SIS-I have felt the need of an extended scoring system for the test. After an extensive review of the literature available on inkblots, the Comprehensive Scoring System (CSS) for SIS-I was developed on the basis of Beck’s scoring system for Rorschach. The present study aims at delineating the pattern of responses on SIS-I in normal persons. SIS-I was administered on 200 normal persons drawn from general population. The CSS indices were enumerated and defined operationally for objective scoring. The SIS-I protocols of the sample were scored as per the developed CSS. Mean and S.D. of each scoring indices of Comprehensive Scoring System were computed. The results are presented. SIS is a semi-structured projective diagnostic instrument and an adjunct to psychotherapy. It is based on spontaneous, individualized responses to semi-ambiguous inkblot figures which elicit intrapsychic associations. Since inkblot images are not based on verbal communication, they more effectively penetrate the 'outer shell' of defenses and surface behavior. SIS uses the language of dream, visual imagery and symbolic thought, the most basic forms of thinking and expression. It is also the language of repression and brings whatever is buried in the mind closer to consciousness, accessible for processing (Cassell, 1980). The SIS was initially developed in 1960 (Cassell, 1980) to extend the Rorschach’s concept that ambiguous and semi-ambiguous visual stimuli evoke spontaneous responses associated with body images, needs, drives, and personality dynamics. It has Cards (SIS-I), Booklet (SIS-II) and Video Versions(SIS Video/DVD). SIS-I is widely used by researchers. The test has been administered on a variety of population: adults and children (Kumar and Singh, 2007); normal army subjects (Rathee and Singh, 1995); militants (Saldanha, 2002); managers and students (Singh and Dwivedi, 1998); professional murderers (Singh et. al., 2002); normal, neurotics and psychotic patients (Pershad et. al., 1997) and ADHD (Jain, Singh and Kumar, 2002). SIS-I has also been used on Schizophrenics, to measure their ego strength (Mahapatra et. al., 2009); for detection of invisible imagery in bipolar depression (Shyam et. al., 2009). Despite the fact that SIS-I is being used effectively as a diagnostic tool, the current scoring system for the same emphasizes content analysis for the interpretation of responses (Kumar, 2004). It includes only eleven indices: total responses, human responses, animal responses, anatomical responses, sex responses, movement responses, typical responses, atypical responses, image rejection and pathological scales. The need for an extended scoring system for SIS-I has been voiced by many researchers working with the test (Deepak and Jagdish, 2002, Ruchi, Singh and Kumar, 2002). Kumar (2004) proposed an Extended Scoring System for SIS-I. It was felt that a little elaborate scoring system would add many missing scoring indices particularly blot areas and colors; this would facilitate group comparisons across more indices. To expand the scoring system for SIS-I the popular scoring systems for Rorschach like Beck, Klopfer & Kelly and Exner were reviewed. After much contemplation and more familiarity with Beck’s system, it was decided to pattern the CSS after Beck’s method. The framework of CSS was developed and all the scoring indices were operationally defined (Kandhari, 2007). The outline of CSS is provided below: This scoring index refers to total number of scored responses produced by a subject on a protocol. Blot Area: Blot area refers to the part of the blot which forms the basis of the response provided by a subject. It could be as follows:

• Total Blot Area (TBA): It is scored when a subject uses the entire blot in his percept.

• Common Blot Area (CBA): This is the portion of a blot which is commonly selected by normal subjects to produce associations. S. Kandhari, Ph.D., Assistant Professor, International College for Girls, Jaipur; J. Sharma,Ph.D., Head, Dept of Psychology, D.J.College, Baraut and R. Kumar, Ph.D., Co-ordinator, Dept of Psychology, Institute of Mental Health and Hospital, Agra. Correspondence Email: mindpowerlab@gmail.com. (paper is a part of Ph.D thesis of first author Ch. Charan Singh Univ.Meerut ,2008). Key Words: SIS Indices, Comprehensive Scoring of SIS.

• Uncommon Blot Area (UBA): This is the portion of a blot which is infrequently selected by normal subjects to produce associations.

• White Background Area (WBA): When a subject produces a response on white background of the blot, WBA is scored. Response Attributes: Response attribute refers to the qualitative characteristics of a response. The response attribute shall fall in any of the following categories:

• Shape: Whenever a subject’s response is determined exclusively by the shape, this attribute is scored. The typical language of the subject in enquiry is – looks like that or because of shape. Further, all shape determined responses are scored as either shape appropriate (SA) or shape inappropriate (SI).

• Shape Appropriate (SA): Whenever, shape of a perceived object resembles with the selected blot area it is considered as shape appropriate.

• Shape Inappropriate (SI): Whenever, shape of a perceived object does not resemble with the selected blot area it is considered as shape inappropriate.

• Human Action (HA): All human activities, emotions, expressions, and postures are scored as human action. The animal activities, expressions, and postures are not scored in this category. Similarly, all natural actions of inanimate objects are not scored in this category. However, if an animal is involved in human activities, emotions, expressions and postures, then this attribute is to be scored. Likewise, for the actions of inanimate objects produced by human beings, this attribute is to be scored.

• Color Chromatic (CC): If a response incorporates any of the chromatic color, this attribute is scored.

• Color Achromatic (CA): If a response incorporates any of the achromatic color, this attribute is scored.

• Three Dimensional Response (3D): If a subject perceives third dimension in a response, this attribute is scored. Response Categories: There can be n number of response categories. The common categories are as under:

• Human Complete (HC): Includes complete human forms.

• Human Part (HP): Includes external parts of human body like hands, arms, eyes.

• Animal Complete (AC): Includes complete animal forms.

• Animal Part (HP): Includes external parts of animals like dog’s tail, elephant’s trunk.

• Internal Organs (IO): Includes all references to internal body parts like heart, kidney, intestines. Most Common Responses (Mc): These are the responses which are produced by normal persons quite frequently to a blot area. Rejection of Images (REJ): REJ is scored when a subject fails to perceive even a single response to any of the images. Material and Method: The sample consisted of 200 normal persons drawn from general population. The normal subjects with positive history of major psychiatric or physical illness were not included. The screening of normal subjects was done through PGI Health Questionnaire N-1 (Verma et al.,1985). This was followed by individual administration of SIS-I in one sitting. Scoring of SIS-I protocols was done as per the Comprehensive Scoring System. The characteristics of the sample are listed in Table 1. Table1 Sample Characteristics of Normal Group Characteristics Normals (N=200) Gender Male 41%(82)

Female 59%(118) Age 18-30 yrs. 52.5%(105)

31-45 yrs. 47.5%(95) Education Upto 5th Class 21% (42)

5th to 12th Class 44.5%(89)

12th Plus 34.5%(69) Domicile Rural 46.5%(93)

Urban 53,5%(107) Comprehensive Scoring System 121

122 Kandhari et al Results: The mean and S.D. of each scoring indices of Comprehensive Scoring System for 200 normal persons were computed. Additionally, percent mean and S.D. were also computed by taking Total Number (TR) of responses as denominator. The results are presented in the following table: Table 2 Mean and Standard Deviation of Normal Group on SIS-I

CSS Indices Mean S.D. Percent Mean

Total Number of Responses 39.00 11.97 39.9

Total Blot Area 10.27 03.96 27.22

Common Blot Area 22.85 07.89 57.06

Uncommon Blot Area 06.23 06.75 14.38

White Background Area 01.00 00.96 02.64

Shape Appropriate 32.7 10.05 81.77

Shape Inappropriate 03.36 04.59 08.54

Human Action 02.21 02.56 05.29

Color Chromatic 00.25 00.54 0.63

Color Achromatic 00.15 00.39 0.35

3-Dimensional 01.25 01.02 3.44

Human Complete 04.08 03.01 9.95

Human Part 02.96 02.62 7.09

Animal Complete 09.08 09.01 22.97

Animal Part 02.45 02.36 5.80

Internal Organs 06.79 03.30 17.26

Most Common Responses 06.02 02.70 15.33

Image Rejection 00.24 00.99 1.24 Total Number of Responses (TR): The number of responses on inkblots is indicative of scored productivity (Beck et.al.1961). According to Cassell (2002) the total number of responses suggests imaginative capacity and functioning intelligence of a subject. In the present study the mean of TR is 39.90 ± 11.97. Total Blot Area (TBA): Total Blot Area has a direct relationship with intellectual ability and is a measure of conceptual activity (Beck, 1952). In the index study the obtained mean value is 27.22±11.56. Blot Area (CBA): The responses to common blot area indicate the ability to perceive and react to clear and distinct characteristics of world (Rorschach, 1942). Generally, the common blot area responses are easier to give than total blot area responses because they represent the easiest perceptual cognitive mode to act when faced with ambiguity. In the index study, for normal subjects, the mean value obtained is 57.06±11.97. Uncommon Blot Area (UBA): The UBA responses are lesser as compared to the CBA responses with a mean value of 14.38±11.77. White Background Area (WBA): The white background area responses indicate negative or oppositional features (Rorschach, 1942, Beck 1945, Rapaport, 1946). The primary significance of the white background area has been that of some form of oppositional behavior emerging in a variety of

symptom patterns contrariness, negativism, hostility (Beck and Molish, 1945). The responses to the white background area are the least frequent in the present study. The mean responses on white background area for normal subjects were 2.64±.2.77. Human Action (HA): The human action responses indicate the phenomena of “internalization”, reflecting the ability of an examinee to handle the more deliberate and sophisticated experience in a way that can be controlled emotionally (Rorschach, 1942). The responses indicating human action indicate awareness towards the external world and reflect some conflicts or emotions which do not get obvious expression in the world of reality (Beck, 1952). In the present study obtained mean value is 5.29±5.49. Shape Appropriate (SA): A response indicating an appropriate shape reflects that the examinee has respect for the reality of the environment (Beck 1945). Rorschach (1942) assigned it a cornerstone position in his overall thinking about personality. He sets up four basic requisites: (a) ability to centre the attention, making possible clear perception; (b) possession of clear mental pictures, (c) power to bring those clear memory pictures into consciousness; (d) ability to select, from among the memory pictures, that one which resembles the stimulus most, a process that again depends on control of the perception and on critical interpretation. It also indicates adequate affective delay or control necessary for occurrence of the form response. In the index study the shape appropriate responses are 81.77±11.79. Shape Inappropriate (SI): According to Cassell (2002), shape inappropriate responses are those of poor quality and with vague percept either in structure or verbalization. The number of shape inappropriate responses is proportionate to the degree of psychological or psychiatric disturbance. In normal subjects the shape inappropriate responses are less frequent as compared to the shape appropriate responses. In the index study, the shape inappropriate responses are 8.54 ±10.59. Color Chromatic (CC): Chromatic color responses indicate affectivity or emotional excitability (Rorschach, 1942). For normal subjects the color chromatic responses are 0.63±1.39. Color Achromatic (CA): Color Achromatic responses in general indicate anxiety and withdrawal from the environment or passivity. Such responses indicate a free floating anxiety against which the individual remains unable to build any defenses. In the present study, normals produced 0.35±0.97 CA responses. 3-Dimensional (3D): The 3-demensional responses are based on dimensionality. Adler (1929) described the personal dynamics involved in looking at distant objects and its relationship to feelings of inferiority. Generally, 3-dimensional responses are indicative of a sense of inner incompleteness and a painful feeling tone in which depression of affect and interiority feelings are also involved. In the present study obtained mean value is 3.44±3.12. Human Complete (HC): Human complete responses include the responses pertaining to the whole human body. Human responses in general indicate high potential for good relation. According to Cassell the number of human responses suggests the patients’ interpersonal relationship with human beings. In the study the mean of HC responses for normal subjects is 9.95±6.05. Human Part (HP): This category includes the external parts of human body like face, ear, nose legs etc. In the index study obtained mean value is 7.09±5.91. Animal Complete (AC): A large number of animal responses indicate immaturity and frustration. In general an excess of animal content indicates intellectual constriction and/or emotional disturbance. The person recognizes chiefly the more mundane stimuli and fails to venture in novelty. In the present study, obtained mean value is 22.97±7.60 for Animal complete responses. Animals Part (AP): AP responses are found to be 5.80±5.12. Internal Organs (IO): Internal organ responses pertain to internal parts of living beings. These responses are consistently high in those who have a poor self- image and who are preoccupied with internal body organs (Cassell,2002). Rav (1951) theorized that restriction and reduction in intellectual drive increases recourse to IO responses. Phillips and Smith (1953) regarded IO responses as reflecting a concern with destructive impulses. In Comprehensive Scoring System 123

the present study the mean score of IO responses for normal subjects is 17.26±9.06. Most Common (MC): According to Cassell (1990), the most common responses are suggestive of coherent, logical thinking and ability to keep up with the demands of society. It may also be interpreted as a measure of ego strength and team concept. The most common responses reflect the ability to participate in communal or popular thinking within a specific culture or the conformity of the individual’s thinking to that of the group. The obtained Mean in the present study was 15.33±6.96. Rejection (Rej): Cassell (1990) stated that rejection of images shows thought blockage and an inability to think properly. Rejection is the result of an inhibition or blocking of thought, more often shock phenomena in most cases (Bohm, 1958). The rejection of images in the normal subjects was found to be 1.24±6.91. Conclusion: The CSS has successfully incorporated many additional scoring indices for SIS-I. The obtained Mean score on various indices was found to be in normal range. The enhanced discriminating power of CSS Indices would appear in future. References: Adler, A. (1929) : The problem of distance. In the practice and theory of individual psychology New York : Harcourt, Brace & World, 100- 108. Beck, S.J. (1945) Rorschach’s test vol II. A variety of personality pictures. New York : Grune & Stratton. Beck, S.J. (1952) Rorschach test, Vol, III. Advances in interpretation. New York : Grune & Stratton. Beck, S.J., Beck, A.G., Levitt, E.E., and Molish, H.B. (1961). Rorschach’s Test Basic Processes. New York : Gurne & Strattons. Bohm, E. (1958) A textbook in Rorschach test diagnosis (Tr. by A. Beck & S.J. Beck) New York : Grune & Stratton. Cassell, W.A. (1965). Body perception and symptom location. Psychosomatic Medicine, 27, 172- 176. Cassell, W.A. (1980). Body symbolism and the somatic inkblot series. Alaska, Aurora Publication. Cassell, W.A. (1990). Somatic Inkblot Series Manual. Anchorage: Alaska. Cassell, W.A. (2002) Intellectual struggle in advancing SIS knowledge. SIS Journal of Projective Psychology & Mental Health,9.1. Cassell, W.A., and Dubey, B.L. (1996). The use of Rorschach and somatic Inkblot series releasing somatic grief. SIS Journal of Projective Psychology & Mental Health, 3, 3-32. Cassell, W.A. and Dubey, B.L. (2003) Interpreting inner world through somatic imagery: Manual of the Somatic Inkblot Series. Anchorage: Somatic Inkblot Centre. Exner, J.E. (1974) The Rorschach systems. New York: Grune & Stratton, Inc. Jain, R., Singh, B., and Kumar, R. (2004). Diagnostic Indicators on SIS-I and Rorschach among the Children with Attention Deficit and Hyperactive Disorder. Kandhari,S. (2007) Development of a comprehensive scoring system for SIS-I. A Thesis submitted to Ch. Charan Singh University, Meerut. Kumar, D, Kumar, J, and Kumar, R. (2005) Diagnostic Indicators on SIS-I and Rorschach among Manic and Depressive Patients. SIS Journal of Projective Psychology & Mental Health, 12, 53-60. Kumar,R. (2004) An Extended Scoring System of SIS-I. SIS Journal of Projective Psychology & Mental Health, 12, 44-47. Kumar,R. (2007) A Comparison of Somatic Inkblot Series-I Indices in Normal Children and Adults. SIS Journal of Projective Psychology & Mental Health, 14, 44-47. Klopfer, B. and Kelly, D.M. (1954) Developments in the Rorschach techniques. Vol. I. Yonkers: World Book Co. Klopfer, B. and Kelly, D.M. (1956) Developments in the Rorschach techniques. Vol. II. Yonkers: World Book Co. Mahapatra, J, Sahoo, D., Mishra, P.K., and Kumar, R. (2009) SIS-I Indices as a Measure of Ego Strength in Schizophrenia. SIS Journal of Projective Psychology & Mental Health, 16, 152-154. Mitra, G., and Mukhopadhyay, A. (2000). Psychological factors in drug addicts and 124 Kandhari et al

normals : A comparative study SIS Journal of Projective Psychology & Mental Health, 7, 53-78. Pershad, D., Verma, S.K. and Bhagat, K. (1997). Body image distrubances in psychiatric cases. SIS Journal of Projective Psychology & Mental Health, 14, 75-84. Phillips, L., & Smith, J.G. (1953) Rorschach interpretation advanced technique. New York : Grune & Stratton. 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. Rapaport, D., Gill, M., and Schafer, R. (1946) Diagnostic Psychological Testing. vol II Chicago : New York. Rav, J. (1951) Anatomy responses in the Rorschach test. Journal of Projective Techniques., 15, 433-43. Saldanha, D. (2002). Profile of militants : An attempt to study the mind of militants. SIS Journal of Projective Psychology & Mental Health, 9, 23-32. Shyam, R., Wilfred A. Cassell and Dubey, B.L. (2009). SIS detection of Invisible imagery in Bipolar Depression. SIS Journal of Projective Psychology & Mental Health,16, 24-31. 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, 7, 49-52. Singh, M.P., and Dwivedi, P. (1998). A comparative study of managers and students on SIS-II. SIS Journal of Projective Psychology Mental Health, 5, 63-68. Verma, S.K., Pershad, D. (1985). PGI Health Questionnaire Agra. National Psychological Corporation. Comprehensive Scoring System 125 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.

Prior Exposure to the Rorschach Test and Differences in Selected Rorschach Variables Felicia Castro-Villarreal The present study examined the effect of prior exposure to the Rorschach on selected Rorschach variables. An availability sample of Mexican-American undergraduate students (N = 59) was randomly assigned to one of two conditions: (a) an experimental group (n = 28) or (b) a control group (n = 31). Experimental participants were exposed to Card I of the Rorschach at Time 1 and one week later at Time 2. Control participants were exposed to the same card at Time 2 only. Both groups provided demographic information. Response differences were investigated using independent t-test analyses. As hypothesized due to increased media and pop-culture exposure and the release of all ten cards on Wikipedia, the majority of participants reported having seen the Rorschach before. However, between-group differences on the dependent variables were not significant; thus prior exposure did not differentially impact response on selected Rorschach variables. Implications are presented with regard to the validity of Rorschach administration, scoring, and interpretation, support for the appropriateness of re-testing, test security issues, and to undercut efforts to opt out of being administered the Rorschach on the basis of prior exposure. Research with a Mexican- American sample is also noted as a much needed addition to the Rorschach literature base. Historically, personality assessment instruments have been categorized as either objective or projective. However, Meyer and Kurtz (2006) proposed the retirement of these terms in the interest of advancing personality assessment as a science. Therefore, any projective instruments referenced in this paper will be referenced by name or will be generally referred to as “implicit methods”. Although personality assessment has always been a core element in psychology, the use and status of “implicit methods” has decreased over time. This decrease is due, in part, to criticism of complex scoring systems, subjectivity of scoring, and inadequate evidence of reliability and validity (Weiner, 2003). In fact, a recent study investigating Rorschach usage by psychologists (Musewicz, Marczk, and York, 2009) found a strong tendency toward the use of instruments with stronger psychometric properties. Among the more noted factors that have contributed to the decrease in the use of “implicit methods” is the greater time required to administer and interpret these tests, compared to the relative time and cost efficiency of self-report inventories (Exner, 2003; Ryba, Cooper, and Zapf, 2003). The Rorschach Inkblot Test is one of many “implicit methods” personality instruments yet it ranks as the most frequently used among Clinical, Counseling, Forensic, and Neuropsychologists (Hogan, 2005; Ryba, Cooper, and Zapf, 2003). Moreover, it ranks second only to the MMPI in personality assessment usage in general (Hogan, 2005). As a result of its popularity as an assessment tool, it is also one of the most frequently researched instruments and since the inception of the Comprehensive System (CS) it has enjoyed increased reliability and validity (Ganellen, 1996; Weiner, 2001). In spite of its common usage there are many areas that remain unexplored. As such, additional Rorschach research is much needed, particularly with regard to the impact that prior or repeated exposure to the test may have on response. In addition, Frank (1993) emphasized the need to conduct Rorschach research with Hispanic populations as there are 9 known studies using Hispanic populations since 1995 (Valentino, Shaffer, Erdberg, and Figueroa, 2007). The probability of accidental exposure to psychological test instruments, such as the Rorschach, has increased as a result of the media’s interest in mental illness, the release of all ten inkblots on Wikipedia, self-help books, college classroom exposure, and television talk shows (Carll, 2003). It appears that the media and public interest in psychology have affected the confidentiality of psychological instruments, such that prior exposure to the Rorschach is relatively common. Due to the recent increase in interest in psychology coupled with the important, yet unknown effects of prior exposure, research in this area is warranted. Prior exposure to an assessment instrument is an important factor in psychological evaluation, and it is quite possible that exposure to an instrument prior to evaluation may differentially impact one’s attitude toward testing and subsequently impact response. Prior exposure is of particular relevance to Felicia Castro-Villarreal, The University of Texas at San Antonio, Department of Educational Psychology; 501 West Durango Blvd.; San Antonio, TX 78207-4415. (USA) Tel: 210-458-2420(W), Fax: 210-458-2019; E-mail: Felicia.castrovillarreal@utsa.edu Key Words: Rorschach variables, pop-culture

the Rorschach because of the nature of the stimulus material and because one’s attitude toward the test may be revealed in terms of the structural variables that result from the verbal response. Objective of the Study: The primary goal of the present study was to examine the effects of previous exposure to the Rorschach on selected Rorschach variables. Based on CS interpretative data and mere exposure theory, it was hypothesized that prior exposure to the Rorschach would result in significant response differences on selected Rorschach variables. Despite a vast amount of literature devoted to the Rorschach response process, there is little that has focused on previous exposure and its effect on response. The fact that research is sparse in this area is surprising in light of the multiple avenues for exposure and the highly replicated attitudinal, persuasive, and behavioral effects of repeated exposure to various stimuli (Zajonc, 2001). Furthermore, the association between familiarity and liking has profound implications in clinical settings and stereotypes (Bornstein, 1989). From an assessment viewpoint, stereotypes, prejudice, negative sets, and attitude formation are significant factors in the administration and scoring of the Rorschach as they contribute significantly to the response process. To further emphasize the need for research in this area, Mere Exposure Effect studies have consistently demonstrated direct application in the persuasion and consumer behavior areas (Zajonc, 2001). This is relevant to the Rorschach since during the administration phase the examinee must be persuaded of the importance, relevance, and validity of the test to ensure valid and accurate results (Exner, 2003). Moreover, the examinee must be persuaded of the assessor’s expertise. Extrapolating from the research findings, several hypotheses seem plausible. At one extreme, repeated testing may jeopardize both persuasion and compliance by producing boredom, habituation, or overexposure to the stimulus (Berlyne, 1970). On the other hand, repeated testing may produce an increased liking of or preference for the exposed stimulus (Zajonc, 2001). Under such circumstances, increased liking may lead to greater disclosure and openness and less censor and guardedness (Hansen & Bartsch, 2001). If the latter is found to be the case, the findings would be of particular relevance since honesty, accuracy, comfort level, and compliance have been shown to increase the validity of test results. Given that prior exposure to a psychological instrument is a common occurrence, it is important to determine the effect this has on individual responses. Hypotheses: The present study investigated the effects of prior exposure to Rorschach Card I. Based on CS interpretive data, it was hypothesized that prior exposure would induce differences in selected Rorschach variables as the variables chosen were selected based on their interpretive significance including willingness to participate, censorship, guardedness, familiarity, and comfort with the examiner (Exner, 2003). Consistent with the mere exposure effect, it was predicted that participants in the prior exposure condition would rate the experiment as more “pleasurable”. In addition, it was predicted that participants in the “no prior-exposure” condition would give more Space and Popular Responses than the “prior exposure” condition, a result of increased censorship, guardedness, unfamiliarity, and decreased “liking” of the stimulus. It was also hypothesized that a high number of individuals in both groups would report that they had been exposed to all or part of the Rorschach. Last, response frequency and the frequency of special score responses were also examined to measure degree of censorship and guardedness and/ or increased “liking” of the stimulus. Rationale for selected Rorschach variables: The following are the variables that were scored in the present study: Popular Response, Space Response, Frequency of Response, Form Quality, and Special Scores. The present study used Card I due to its strong pull for the popular “bat” response. Prior research has reported that 48% of non-patients give this popular response to Card I (Exner, 2003). Inter-rater reliability studies in general indicate 99% agreement for coding Popular responses (Exner, 2003). One of the primary reasons the popular response was analyzed was its interpretive significance. A higher than average number of popular responses indicates that the participant has responded to the commonplace features of the blot (Exner, 2003), which suggests convention, safeguarding, and conformity (Exner, 2003). One study found that participants high on social desirability gave more popular responses than participants low on social desirability (Exner, Armbruster, & Mittman, 1978). This finding suggests that an increased number of popular responses are likely to indicate a commitment to conventionality (Peterson & Horowitz, 1990). Prior Exposure to the Rorschach Test 127

On the other hand, a relatively small number of popular responses can indicate the inability or unwillingness to verbalize the most obvious answer. A small number of popular responses can also suggest comfort with the test or confidence in testing (Exner, 2003). To illustrate, Exner et al. (1978) found that participants who were comfortable and confident were less influenced by the need to verbalize conventional answers and were more likely to be open and honest. This finding is important as the validity of an instrument is in part contingent on the participant’s comfort level and ability to be honest. The Space response was included as a scoring category to test for defiance and noncompliance. Studies show that individuals who give space responses are doing the opposite of what has been asked of them (Weiner, 2003). It has been shown that a high number of space responses reflect oppositional tendencies and underlying feelings of anger or resentment (Weiner, 2003). By corollary, space responses may indicate an unpleasant affective state. If such is the case, individuals with prior exposure to the Rorschach may give fewer space responses while participants who are exposed to the stimuli only a single time may give more space responses. The current study also scored for response frequency (R). Low R protocols may be related to defensiveness or resistance (Exner, 1989). When a low R protocol occurs with a high Lambda score (indicating overreliance on form dominance and minimization of determinant responses), it is likely that the individual oversimplified the stimulus field as a defensive mechanism for the purpose of control, which may indicate a rigid response style (Exner, 2003). Depending on the elevation, a high lambda score can suggest an invalid protocol. It is argued that R relates to the individual’s psychological involvement with the test such that a low Lambda score suggests more involvement and more interest, whereas a high Lambda score suggests less involvement and less interest (Exner, 2003). According to Lipgar (1992), variability in R yields valuable information. In agreement with Exner, Lipgar (1992) asserts that a high R may indicate that the individual is under pressure to respond or highly willing to respond. In contrast, a low R may indicate that the individual is depressed or unable to respond. As such, test interpretation is partly contingent on variability in R. The finding that R emerged as a key discriminating variable when determining if there were psychologically meaningful differences between two groups further supports the notion that variability in R provides important clinical data (Lipgar, 1992). Form Quality was another variable scored in the current study. This scoring category gives an indication of an individual’s capacity to form percepts that resemble real objects based on the use of the existing dimensions of each inkblot. As responses deviate from the contours of the blot, they suggest a tendency towards idiosyncrasy or distorted perceptions of reality. To the extent that participants distort the stimulus features, they are judged to be overcommitted to individuality or unable to perceive stimuli accurately, leading to misinterpretation and misrepresentation of people and events (Weiner, 2003). However, data also suggest that distorted form quality responses may occur in individuals with intact perceptual processes when they are overly comfortable, under altered states of consciousness, when tested by familiar people, or when provided incentives for their responses (Exner, 2003). It is possible that participants who have been previously exposed to the inkblot are more likely to generate poor or less form quality responses that would have been suppressed under circumstances of normal test administration. The decision to score for Special Scores was based on research suggesting that social desirability influences participant responses unless tested by their own therapist. It can be argued that prior exposure may lead to a more comfortable testing experience and may produce greater openness, similar to the above argument with regard to form quality responses. Research suggests that special scores reflect, at least in part, greater disclosure and openness, which is associated with being comfortable with testing. Consistent with the above-cited findings, it was predicted that a higher frequency of special scores would be found in the prior exposure condition. Method: Participants: Participants in the current study consisted of 59 undergraduate students at a private university in the southwest. Males represented a smaller proportion of the sample (n = 18) than females (n = 41). The participants’ ages ranged from 18-36, with a mean of 20 years. The majority of participants identified themselves as Hispanic (61%), followed by Caucasian (22%), and “other” (13.6%). The current sample was representative of the local community in terms of ethnicity. Frequency analyses were conducted to determine the number of participants who indicated that they had seen the Rorschach prior to the experiment. As predicted, the majority of participants indicated that 128 Villarreal

they had seen the Rorschach prior to the experiment (69.5%). Another related question asked where or how they had previously viewed the Rorschach. Descriptive statistics indicated that most participants had seen the Rorschach in movies and books (47.5%). The information is summarized in Table 1. Table 1 Sample Descriptive Statistics Question Frequency in Sample Sample (%) Gender

Male 28.8 Female 69.5 Ethnicity

Hispanic Caucasian Other 13.6 Ever Seen the Rorschach Yes 69.5 No 28.8 Where Have You Seen the Rorschach

Movies 47.5 Advertisements Internet Books 47.5 Court Documents 6.8 Other 28.8 How Likeable was the Experiment

Very Unlikeable 1.7 Somewhat Unlikeable 4 6.8 Somewhat Likeable 23.7 Likeable 57.6 Very Likeable 10.2 Procedure: Participants for the current study were solicited based on availability and willingness to participate. No monetary incentives were provided. However, in exchange for participation, volunteers fulfilled course requirements for research credit or received points that were added to their final course grade, at the discretion of the instructor. To ensure participation was free and voluntary, consent forms were distributed and collected before the experiment. Confidentiality of responses was maintained by entering information into data files only. Volunteers were treated in accordance with the ethical guidelines set forth by the (APA, 2001) and in compliance with the university’s Institutional Review Board. The current study used an experimental design. Participants were randomly assigned to one of two groups: the experimental group (n = 28) or the control group (n = 31). Random assignment was achieved using an online program that generates random numbers in response to specified parameters. The total number of participants and the number of groups (n = 2) was entered, and each participant was randomly assigned to group A (prior exposure) or group B (no prior exposure). Both groups completed a single page demographics questionnaire after the response phase of the experiment. Experimental Condition: The experimental group was exposed to Card I of the Rorschach on two occasions, separated by one week. At Time 1, the experimental group was shown Card I on a projector screen for 10 seconds. Immediately following exposure, participants were verbally reminded to return for the final testing date at Time 2, one week later, and reminded of the importance of attending both sessions to fulfill research requirements. One week later, at Time 2, experimental group participants were exposed to the same Rorschach card for 10 seconds on a projector screen. Experimental participants received a response page with written instructions and a reproduction of the same inkblot as the one on the projector (Card I). At the same time participants were handed the response page they were given verbal instructions. Both verbal and written instructions were the same: “What might this be? Please write your responses clearly and outline and label your responses on the photocopied inkblot. Most people see more than one thing.” Verbal instructions were given 3 seconds after exposure to Card I. At the bottom of the response page, participants marked “yes” or “no” in response to the following question: “Was this the Rorschach Inkblot card shown to you during the first part of the experiment?” This item was included as a manipulation check. All participants in the experimental group marked “yes” Prior Exposure to the Rorschach Test 129

to this question. Immediately following exposure, the experimental group completed the demographics questionnaire. The demographics questionnaire was stapled behind the response sheet for the purpose of matching it to participants’ responses. Card I was administered with standard administration procedures in mind (Exner, 2003). People who give only one response to Card I are prompted for additional responses. In contrast, according to standardized test administration procedures, the only verbal instruction given for all the other Cards (with the exception of Card IV) is “What might this be.” Thus, the statement: “Most people see more than one thing” was in close compliance with standard administration procedures. Given that prior exposure and its relationship to “liking”, censorship, and guardedness was under investigation, Card I was chosen because 85% of all subjects give at least one popular response to this card (Exner, 2003). In addition, prior research has demonstrated that the most broken blots (more space gaps within the blot relative to the other blots) yield the highest average number of answers (Exner, 2003). Popular responses indicate conformity, guardedness, and censorship where fewer popular responses and poor form quality indicate idiosyncrasy, pathology, and comfort level (Exner, 2003). Card I was mass presented on a projector screen following the methodology used by Martin and Thomas (1982), who administered the Rorschach in a group format using an over-head projector. In order to test in a timely fashion and to test a large number of participants, group testing has been used in many mere exposure experimental designs (Bornstein, Bonner, Kildow, & McCall, 1997). Further, a recent experimental design revealed no differences between individual and group administration on certain Rorschach scores (Bornstein et al., 1997). The method of exposure was chosen for three reasons. First, Bornstein et al. (1989) concluded that the Mere Exposure Effect is greatest with complex stimuli (such as Card I), for a brief stimulus-exposure duration time (such as 10 seconds), and with long delays between stimulus exposure and attitude ratings (such as 1 week). Second, research on the Rorschach response process has found that responses to the stimulus cards are made within six seconds of exposure (Exner, 2003). In light of this finding, exposure time of 10 seconds was not expected to impede the typical number of responses or their quality. In addition, research has found a strong positive relationship between exposure time and an increase in responses based on the form contours of the blot (Exner, 2003). Brief exposure was also used to simulate brief exposure of the card through television, cinema, advertisements, Internet, or class presentation. Finally, participants were instructed to outline and label their responses on the photocopied inkblot since an inquiry phase of the standardized administration protocol was not conducted. An inquiry phase was not feasible due to the large number of participants. The absence of an inquiry phase was not believed to impair the validity of responses given that scoring was only conducted for the frequency of responses, popular responses, space responses, form quality, and special scores. For example, scoring for determinants would have proven difficult and might have impaired the validity of such responses. It follows that the other criteria that are normally scored on the Rorschach were not scored because this was not feasible in a group format. Upon completion, experimental group participants were asked to complete the demographics questionnaire. At the conclusion, participants were given the following verbal instructions: “Because of the sensitivity of this research project and because others will be participating, please do not talk to other students about the details of this procedure for at least two weeks.” This request was included to minimize the influence of treatment diffusion as many students in both groups had frequent opportunities for interaction during classes and work-study assignments. Control Condition: Participants in the control group were shown Card I of the Rorschach on a projector screen for 10 seconds. Immediately following exposure to Card I, participants were given the same instructions as participants in the experimental group: “What might this be? Please write your responses clearly and outline and label your responses on the photocopied inkblot. Most people see more than one thing.” Upon completion, control group participants were asked to complete the demographics questionnaire. At the conclusion, participants were given the following verbal instructions: “Because of the sensitivity of this research project and because others will be participating, please do not talk to other students about the details of this procedure for at least two weeks.” This request was identical to the one given to experimental group participants for the same reason of minimizing treatment diffusion. 130 Villarreal

Scoring: Rorschach Inkblot Card I responses from the experimental and control group participants were scored according to the Exner Comprehensive System (Exner, 2003) for (a) frequency of responses, (b) popular responses (c) space responses, (d) form quality of the response, and (e) frequency of special scores. Inter-rater reliability was established by having two independent raters score the response page protocols. The raters both had advanced Rorschach training. Inter-rater reliability was established after 25% of the response page protocols were scored. A Kappa statistic was computed between raters. Kappa (k) values ranging from .60 to .74 are considered good (Meyer et al., 2002). The pooled Kappa value in the present study for all variables was k = .88, which is at a level of agreement considered to be acceptable in the literature (Meyer et al., 2002). Results: To evaluate differences between the Experimental and Control groups on (a) how likeable the experiment was, (b) reports of having seen the Rorschach, (c) number of Special Score responses, (d) Popular responses, (e) Space responses, (f) frequency of response, and (g) Form Quality of Response, six independent sample t- test analyses were conducted. An alpha level of .05 was used for all statistical analyses. It was not necessary to control for Type I error rate inflation, as all the t-tests conducted were independent. Results are summarized in Table 2. Table 2 Group Differences on Rorschach Variables by Condition

Experimental (n=28) Control (n=31) Rorschach Responses M SD M SD t (57) Cohen’s d Likeable 4.61 1.11 4.58 .89 .097 .025 Special Scores .46 .744 .55 .81 -.414 -.109 Popular .14 .356 .26 .45 -1.090 -.288 Space .50 .745 .52 .57 .094 -.024 Response Frequency 2.39 1.41 2.06 .96 1.010 .267 Form Quality 2.52 .61 2.56 .47 -.253 -.067 Note: Likable= “How Likable was the Experiment” To assess the effectiveness of the experimental manipulation (prior exposure), a descriptive analysis was performed. To assess whether participants in the experimental condition reported seeing the Rorschach Card I at Time 1, a manipulation check question was included on Form A of the response Sheets and a frequency analysis was conducted. As expected, 100% of the participants in the experimental condition indicated “yes” when asked if the stimuli at Time 2 was the same stimuli to which they were exposed at Time 1. As such, the experimental manipulation was judged to have been successful. The first hypothesis predicted that the experimental group would rate the experiment as more likeable than the control group. Group means were obtained from the responses given on a 5-point Likert scale. Participants were asked to rate how likeable the experiment was on a scale ranging from 1 = very unlikable to 5 = very likable. The independentsample t- test analysis indicated that the experimental group had a mean of 4.61 (SD = 1.197) and the control group had a mean of 4.58 (SD = .886), and the means did not differ significantly, t (57) = .097, p> .05, d=.025. The second hypothesis sought to determine if a difference existed between the two groups on their report of having seen the Rorschach, independent from the experimental manipulation. Chi-square analysis indicated that there was no difference between the experimental and the control group on reports of ever seen the Rorschach, χ² (1, N=58) = .905, p = .05. Results suggested that both groups reported having seen the Rorschach at the same frequency, as 48.8% of the experimental group and 51.2% of the control group reported to have seen it. Both groups had more participants report to have seen it than expected. Results showed that the majority (69.5%) of participants indicated that they had seen the Rorschach. The third hypothesis predicted that the experimental group would give more Special Score responses than the control group. This hypothesis was tested by Prior Exposure to the Rorschach Test 131

comparing the total number of Special Scores, not type, given by each participant in the experimental group and control group. The independent sample t-test indicated that the experimental group had a mean of .46 (SD = .744), the control group had a mean of .55 (SD = .810), and the means did not differ significantly, t (57) = -.414, p > .05, d= -0.109. The fourth hypothesis predicted that the experimental group would give fewer popular responses than the control group as measured by the total number of popular responses given by each participant. The results of an independent sample t-test failed to support this prediction, t (57) = -1.090, p > .05, d= -0.288. Results indicated that the mean number of Popular responses for the experimental group was (.14, SD = .356) and the mean number of Popular responses for the control group was (.26, SD = .445). The fifth hypothesis predicted that the experimental group would give fewer Space responses than the control group as measured by the total number of Space responses given by each participant. The results of an independent sample t-test failed to support this prediction, t (57) = -.094, p > .05, d= -.024. The mean number of Space responses for the experimental group was .50 (SD = .745) and the mean number of Space responses for the control group was .52 (SD = .570). The sixth hypothesis predicted that experimental group would give a higher frequency of Rorschach responses than the control group as measured by the Total R given by each participant. The results of an independent sample t-test failed to support this prediction, t (57) = 1.010, p > .05, d= .267. The experimental group had a mean of 2.39 (SD=1.499) and the control group had a mean of 2.06 (SD = .946). The seventh hypothesis predicted that there would be differences between the experimental and control groups on Form Quality of responses. This was analyzed by scoring for and then calculating the total Form Quality of all responses given divided by the number of responses given. Form Quality responses were converted to numerical scores by coding each response in the following manner: (1) no response was coded ‘0’, (2) a ‘+’ response was coded 4, (3) an ‘o’ response was coded 3, (3) a ‘u’ response was coded 2 and (4) a ‘- ‘was coded a 1. The results of an independent sample t-test failed to support this prediction, t (57) = -.25, p>. 05, d= -.067. The experimental group had a mean of 2.52 (SD=.61) and the control group had a mean of 2.56 (SD=.47). Discussion: The purpose of this study was to determine the effects of previous exposure to the Rorschach Inkblot Method on selected Rorschach variables. Based on the literature reviewed, it was predicted that differences would be found between participants in the experimental condition (prior exposure) and participants in the control condition (no prior exposure) on several Rorschach variables. It was also predicted that participants in the prior exposure condition would rate the experiment as more likeable than participants in the no prior exposure condition. The results failed to reach statistical significance for (a) response frequency, (b) space responses, (c) special scores, (d) form quality, (e) popular response, and (f) likeability of the inkblot. It was also hypothesized that the majority of participants would indicate that they had seen all or part of the Rorschach before. This hypothesis was supported in that the majority (69.5%) of participants indicated that they had seen all or part of the Rorschach. Moreover, the majority of participants reported having seen the Rorschach through the various media outlets discussed in the current study. Non-significant findings of this study have important implications for psychological assessment. The results suggest previous exposure, even superficial, did not lead to the hypothesized response differences. As such, practitioners and evaluators alike can be reasonably confident that previous exposure to a “Popular” psychological instrument like the Rorschach does not differentially impact response which supports the appropriateness of re-testing and provides evidence to negate efforts to opt out of Rorschach testing based on prior exposure to the test. However, it is important to note that participants who reported having seen all or part of the Rorschach were not removed from the analyses. The majority of participants, 69.5%, indicated that they had seen all or part of the Rorschach and there was no difference between the experimental and control group on their indications of ever having seen the Rorschach. It is likely that having seen the Rorschach before was a confounding variable that contributed to the non-significant findings. To illustrate, if reports of having seen the Rorschach across the two groups were equal, there should have been no difference between the two groups, as both groups experienced prior exposure. Therefore, it is likely that participant indication of having seen the Rorschach before diluted the experimental manipulation of prior exposure, and thus contributed to the null findings. However, data concerning which specific Rorschach card or cards 132 Villarreal

participants had previously seen was not collected. Future research should attempt to identify and control for variability due to those participants who have seen the Rorschach in the past. In addition, future research may contribute to the current understanding of the impact of prior exposure on response quality and frequency by using a larger sample size and all ten inkblots. The hypothesis that the experimental group would give fewer Popular responses than the control group was not supported. Results revealed that participants in the experimental group (prior exposure condition) were equally comfortable and compliant after prior exposure as participants in the control group (no prior exposure) as less than half of all participants gave the popular response to Card I. This finding is important as it demonstrates a general sense of openness across conditions. Almost half of non-patients verbalize the popular response for Card I (Exner, 2003) and the findings of the current study indicate significantly fewer were verbalized by both groups. The fact that no differences were found and the majority of participants reported prior exposure, suggests that the popularity of the Rorschach and increased likelihood of exposure may improve openness and decrease self-censorship which would indicate improved validity of responses. On the other hand, non-significant differences between groups suggest certain Rorschach variables are not compromised by previous exposure. This finding, which confirms that prior exposure can influence one’s responses, has practical implications, as chance exposure to a psychological instrument is a likely occurrence. It is therefore important to understand the impact of prior exposure on scoring and interpreting the Rorschach. For example, because a high/low number of “Popular” responses in a protocol contribute to the overall description of the individual, it is important to determine the impact of prior exposure. From a clinical standpoint, the current findings may help the assessment process by improving examinee compliance and comfort level. Moreover, such desired examinee characteristics may improve the validity of assessment by increasing the accuracy of the results and the interpretation of data. One practical implication of the current finding may be that prior and brief exposure to any assessment instrument may improve examinee compliance and comfort prior to testing. This may be accomplished by showing a brief power point demonstration, booklet, or video on psychological assessment accompanied by an explanation of what to expect from testing and a sample of stimulus materials similar to those included in the actual test (without violating test security). Determining the impact of prior exposure to a psychological instrument is necessary for several reasons. The results of the current study provide some support that prior exposure does not significantly impact one’s response to the Rorschach. These findings may assist practitioners in interpreting results and obtaining more valid protocols. Moreover, these effects may be useful in further validating Rorschach scoring and interpretation. Conclusion: Prior exposure to secure psychological instruments needs to be more thoroughly investigated in order to understand how this impacts individual responses. Because of the frequency with which individuals are exposed in the media to psychological test instruments, as this research demonstrated, subsequent research on the impact previous exposure with a larger and more diverse sample is indicated. Ultimately, research in this area will be of benefit to professional psychology by improving the psychometric qualities of the instruments that underlie its practice. References: American Psychiatric Association. (2000). Diagnostic and Statistical Manual of Mental Disorders (4th ed.) Washington, DC. American Psychological Association. (2001). Publication manual of the APA (5th ed.). Washington, DC. Berlyne, D. E. (1970). Novelty, complexity, and hedonic value. Perception and Psychophysics, 8, 279-286. Bornstein, R. F. (1989). Exposure and affect: Overview and meta-analysis of research, 1968-1987. Psychological Bulletin, 106, 265-289. Bornstein, R. F. , Bonner, S. , Kildow, A. M., & McCall, C. A. (1997). Effects of individual versus group test administration on Rorschach oral dependency scores. Journal of Personality Assessment, 69 (1), 215-228. Carll, E. K. (2003). Psychology, news media, and public policy: Promoting social change. American Behavioral Scientist, 46 (12), 1591-1593. Exner, J. E. (1989). Searching for projection in the Rorschach. Journal of Personality Assessment, 53 (3), 520-536. Prior Exposure to the Rorschach Test 133

Exner, J. E. (2003). The Rorschach: A comprehensive system. Hoboken, NJ: John Wiley & Sons. Exner, J. E. , Armbruster, G , & Mittman, B. (1978). The Rorschach response process. Journal of Personality Assessment, 42 (1), 27-38. Frank, G. (1993). The use of the Rorschach with Hispanic Americans. Psychological Reports, 72, 276-278. Ganellen, R. J. (1996). Integrating the Rorschach and the MMPI-2 in personality assessment. Hillsdale, NJ, England: Lawrence Erlbaum Associates, Inc. Groth-Marnat, G. (2003). Evaluating psychological tests. Handbook of Psychological Assessment, (pp. 10-22). Hobonken, NJ: John Wiley & Sons. Grube, J. W. & Wallack, L. (1994). Television beer advertising and drinking knowledge, beliefs, and intentions among school children. American Journal of Public Health, 84, 254-259. Hansen, T. & Bartsch, R. A. (2001). The positive correlation between personal need for structure and the mere exposure effect. Social Behavior and Personality, 29 (3), 271-276. Hogan, T. P. (2005). 50 Widely used psychological tests. In G. Koocher, J. Norcross, & S. Hill (Eds.), Psychologists’ desk reference (pp. 1-735). New York: Oxford University Press. Lipgar, R. M. (1992). The problem of R in the Rorschach: The value of varying responses. Journal of Personality Assessment, 58 (2), 223-230. Martin, L. S. & Thomas, E. E. (1982). Selection of preferred responses by high school students. Rorschach Workshops (Study No. 278, unpublished). Meyer, G.J., Hilsenroth, M.J., Baxter, D., Exner, J.E., Fowler, J.C., Piers, C.C., & Resnick, J. (2002). An examination of interrater reliability for scoring the Rorschach comprehensive system in eight data sets. Journal of Personality Assessment, 78(2), 219-256. Meyer, G. J. & Kurtz, J. E. (2006). Advancing personality assessment terminology: Time to retire “objective” and “projective” as personality test descriptors. Journal of Personality Assessment, 87, 223-225. Musewicz, J. ,Marczyk, G., Knauss, L ,& York, D. (2009). Current assessment practice, personality measurement, and Rorschach usage by psychologists. Journal of Personality Assessment, 91, 5, 453-460. Peterson, C. A. & Horowitz, M. (1990). Perceptual robustness of the nonrelationship between psychopathology and popular responses on the hand test and the Rorschach. Journal of Personality Assessment, 54 (1&2), 415-418. Rose, T., Kaser-Boyd, N., & Maloney, M. P. (2001). Essentials of Rorschach assessment. New York, NY: John Wiley & Sons. Ritterfeld, U. & Seung, A. J. (2006). Addressing media stigma for people experiencing mental illness using an entertainment-education strategy. Journal of Health Psychology, 11,(2), 247-267. Ryba, N. L., Cooper, V. G., & Zapf, P. A. (2003). Juvenile competence to stand trial evaluations: A survey of current practices and test usage among psychologists. Professional Psychology: Research and Practice, 34, (5), 499-507. Sieff, E. M. (2003). Media frames of mental illness: The potential impact of negative frames. Journal of Mental Health, 12 (3), 259-269. Valentino, M. A., Shaffer, T. W., Erdberg, P., & Figueroa, M. (2007). Rorschach Comprehensive System data for a sample of 42 nonpatient Mexican American Children from the United States. Journal of Personality Assessment, 89 ,(S1), S183-S187. Wahl, O. F. (2003). News media portrayal of mental illness. American Behavioral Scientist, 46 (12), 1594-1600. Weiner, I. B. (2001) Advancing the science of psychological assessment: The Rorschach Inkblot Method as exemplar. Psychological Assessment, 13, 423-432. Weiner, I. B. (2003). Principles of Rorschach interpretation. (2nd ed.) Mahwah, NJ, US: Lawrence Erlbaum Associates. Zajonc, R. B. (2001). Mere exposure: A gateway to the subliminal. Current Directions in Psychological Science, 10 (6), 224-228. 134 Villarreal

Emotion and Health: An overview Rakesh Pandey and Anil K. Choubey The relationship emotion and health has been a focus of scientific inquiry in psychology for a long time but it occupied pivotal position with the advent of Alexander’s psychosomatic paradigm. Since then, a number of affect related constructs have been explicated with potential implications for health. The present paper makes an attempt to review the role of some affect related constructs in health that have been centre of attention in the contemporary psychological researches. We have reviewed empirical evidences that demonstrate the relationship of such affect related constructs, as emotion regulation, emotional disclosure, emotional intelligence, alexithymia, positive/negative affect, and affect intensity with health. In general, the review suggests that some affect related constructs such as cognitive regulations of emotion, emotional disclosure, positive emotional experiences and most of the dimensions of emotional intelligence have a beneficial influence on the health status of an individual. On the other hand, such affect related variables as effortful suppression of emotions, alexithymia, affect intensity, and negative emotional experiences have adverse consequences for health. As far as the role of valence and magnitude of emotional experience is concerned, the existing literature suggests that high intensity of experienced emotion has an adverse effect on health irrespective of the emotional valence. The potential mediating mechanisms linking various affect related dimensions to health have also been reviewed. Future research, however, is needed to develop an integrated holistic theory of health based on affect related variables. Emotion-heath relationship occupies a pivotal position in the area of health psychology in general and psychosomatic/behavioural medicine in particular. However, the hypothesis that the nature of emotional experience and expression may be an important determinant of one’s health status gained popularity in scientific psychology with the advent of psychosomatic paradigm (Alexander, 1939) of health and illness. Within the psychosomatic paradigm, attempt to suppress negative emotions is the central element leading to the development and progression of various physical illnesses (Alexander, 1939, Alexander and French, 1946; Dunbar, 1954). After few decades of the Alexander’s psychosomatic paradigm, Sifneos (1972) introduced the construct of alexithymia (the core feature is the difficulty in identifying and communicating emotions and feelings) that emerged as an alternative paradigm for linking emotion with health (see Taylor, 1984, 1994 for a review). The continuing efforts of psychologists to link emotion and health lead to the identification of several other affect related constructs that can explain a significant proportion of variance in the health status of an individual. For example, the affective disposition to experience positive and negative emotions (hereafter referred to as positive and negative affectivity), the disposition to experience extremes of emotional states irrespective of the emotional valence (hereafter revered to as affect intensity) have been identified as important predictors of health. Similarly, the ability to control or regulate the experience and expression of emotions (emotion regulation), the tendency to socially share and verbally express traumatic emotional experiences (emotional disclosure), and the ability to perceive, express, understand, monitor and manage emotions (emotional intelligence) are certain other affect related variables that might influence the health status of an individual. In this paper, we have attempted to present an overview of the findings related to the role of the said affect related variables in health and illness. Emotion regulation and health: Emotion regulation, that is, the conscious effort for reducing the influence emotion-arousing situation by controlling the experience and expression of emotions has been found to exert significant influence on the health status of an individual (see review by Gross, 1998a). Researchers in this area make a distinction between the conscious effort to suppress expression of emotion and the effort to cognitively restructure the situation or its interpretation so that the situation no longer produces emotional responses (e.g., Gross, 1998). The former is labelled as emotion regulation at response or output level and the latter as emotion regulation at input level in which the antecedents of emotions are cognitively regulated to reduce the emotional influences (Gross, 1998b). This distinction is important for health researchers inasmuch as empirical evidences suggest that the emotion regulation at response level may have detrimental effect on health but the cognitive regulation of emotion at the input level may have beneficial effect on health (Gross, 1998b). Rakesh Pandey, Ph.D. Associate Professor, Department of Psychology, Banaras Hindu University, Varanasi-221005, E-mail: rpan_in@yahoo.com and Anil K. Choubey, M.A.Research Scholar, Department of Psychology, M.G. Kashi Vidyapith, Varanasi. Key Words: Emotion and Health

The emotion regulation at response level (i.e., suppression of emotion) has been found to have deleterious effect on health. For example, the chronic inhibition of sadness and crying has been linked with such respiratory disorders as asthma (Alexander, 1950; Halliday, 1937). Similarly, the chronic inhibition of affiliative tendencies was linked to gastrointestinal disorders, such as ulcers (Alexander, 1950); and the chronic inhibition of anger was found to be associated with cardiovascular disorders, such as hypertension (Alexander, 1939). The view that chronic hostility and anger inhibition are linked to hypertension and coronary heart disease is still popular among health psychologists (e.g., Friedman & Booth-Kewley, 1987; Julkunen, Salonen, Kaplan, Chesney, and Salonen, 1994; Manuck and Krantz, 1986; Smith, 1992; Steptoe, 1993). In addition, innovative hypotheses involving emotion regulation have been proposed which suggest that emotion inhibition may exacerbate minor ailments (Pennebaker, 1990) and that inexpressiveness may accelerate cancer progression (Fawzy et al., 1993; Gross, 1989; Spiegel, Bloom, Kraemer, & Gottheil, 1989). The emotion regulation strategies involving suppression or inhibition of emotion, thus, appear to be dysfunctional way of emotion regulation. Emotion dysregulaton has not only been linked with onset or progression of medical illness but also with various types of mental disorders. For example, Tull (2006) demonstrated that dysregulation of emotion emerged as an important predictor of panic disorder. Recent studies suggest that difficulty or dysfunction in emotion regulation may lead to health compromising behaviour such as substance abuse and may enhance the risk of developing mental health problems among drug users (e.g., Dorard, Brethoz, Phan, Corcos, and Bungener, 2008). The foregoing studies extend the hypothesis that suppression of negative emotions and/or dysregulation of emotion has a harmful effect on health. However, the mechanism that link emotion regulation and health is still not clear. One popular hypothesis is that suppression of negative emotions enhances the physiological responses, which in long term may produce bodily damage (Krantz and Manuck, 1984). Researchers have shown that emotional suppression leads to acute increases in sympathetic activation of the type discussed in the aforesaid hypothesis (Gross and Levenson, 1993, 1997). The abovementioned empirical evidences, though, suggest that controlling the negative emotions (by consciously suppressing them) can lead to a number of physical health problems, the same is not true for regulating the negative emotions using cognitive strategies. For example, Beck, Rush, Shaw, and Emery (1979) and Seligman (1991) have argued that cognitive strategies may be used to prevent or alleviate depression. From this perspective, the cognitive regulation of emotion is assumed to have beneficial effect on health whereas the dysregulation or dysfunctional regulation of emotion (e.g., emotion suppression) might give rise to a number of physical and psychological health problems. Emotion dysregulation, for instance, has been found to be associated with such mental health problems as binge eating (e.g., Leahey, Crowther, and Irwin, 2008; Whiteside, Chen, Neighbors, Hunter, Lo, and Larimer, 2007), alcohol and other substance abuse (e.g., Cooper, Frone, Russell, and Mudar, 1995; Fox, Axelrod, Paliwal, Sleeper, and Sinha, 2007; Fox, Hong, and Sinha, 2008; Sayette, 1993) along with anxiety and the mood disorders (e.g., Campbell-Sills, Barlow, Brown, & Hofmann, 2006; Beck, Rush, Shaw, & Emory, 1979; Tull, Stipelman, Salters-Pedneault, and Gratz, 2009). Taken together, the studies linking emotion regulation to health suggest that it might have beneficial or harmful effect on health depending on the strategy used to regulate emotions and/or success (or failure) at regulating emotion. If the emotions are regulated by suppression of experience and expression then it is likely to deteriorate health whereas the attempt to regulate the emotional experience and expression by cognitively restructuring or positively reappraising the emotion-arousing situation might lead to beneficial effect on health. Similarly, the inability to regulate emotions or dysfunctional regulation of emotion may also lead to exacerbation of health problems. As far as the mechanism of action is concerned, there is still a striking gap in the literature and one possibility that has been extended is through tonic autonomic arousal. Disclosure and social sharing of emotions and health: The preceding section reviewed evidences indicating the adverse effect of emotion suppression on health. If emotion suppression leads to poor health, then as a corollary it can be postulated that emotional expression (disclosure) will be associated with better health and well-being. Contrarily, non-disclosure or concealment of emotion will have an adverse effect on health similar to that of emotion suppression. During the past few decades, researchers have made attempt to test this hypothesis by examining the effect 136 Pandey and Choubey

of emotional disclosure and/or concealment (both written and oral) on health. For example, Cole, Kemeny, Taylor, and Visscher (1996) observed that gay men who hide their homosexual status are more likely to suffer from major illnesses such as cancer if they are HIV-negative and to die more quickly from AIDS if they are HIVpositive than men who are more open about their homosexuality. Similarly, in a study of college students Pennebaker and Susman (1988) found that inhibition of verbal expression of traumatic experiences was associated with a variety of health problems, On the other hand talking about the traumatic experience has been linked with better health followed by reduction in the traumatic experience. For example, researchers have noted that if bereaved individuals are able to talk more about their spouses’ death, the healthier they are in the year following the death (Pennebaker and O’Heeron, 1984). Numerous empirical studies demonstrate that emotional disclosure has been effective in promoting better overall health in addition to better adjustment to traumatic situations (Cameron and Nicholls, 1998, Pennebaker, Barger, and Tiebout, 1989; Pennebaker and O’Heeron, 1984; Pennebaker and Beall, 1986; Pennebaker, Kiecolt-Glaser and Glaser, 1988; King and Miner, 2000). Emotional disclosure has also been found associated with improved immune system function in terms of enhanced T-helper cell activity (Pennebaker, Kiecolt-Glaser, and Glaser, 1988) and other parameters of better immune competence (Esterling, Antoni, Fletcher, Margulies, and Schniederman, 1994; Petrie, Booth, Pennebaker, Davison, and Thomas, 1995). Furthermore, studies demonstrate that emotional disclosure has a beneficial effect on psychological functioning and mental health as well. For example, some studies report that emotional disclosure improved psychological functioning in rheumatoid arthritis patients (Kelly, Lumley, and Leisen, 1997). Similarly, there are empirical evidences, which suggest that disclosure or sharing of emotions lead to fewer self-report symptoms or health problems (Greenberg and Stone; 1992; Pennebaker and Beall, 1986; Pennebaker, Barger, and Tiebout, 1989). To sum up, the preceding two sections bring to fore the role effortful suppression and/or disclosure of emotion and emotional experiences on health. The former has been demonstrated to exert negative influence on health by increasing chance of developing various types of health problems whereas the latter helps to reduce the adverse influence of negative and traumatic emotional experiences on health along with decreasing the likelihood of symptomatic complaints and health problems. Thus, it appears that social sharing or disclosure of negative emotional experience may be considered as specific action oriented strategy in regulating emotions. However, this action-oriented approach of regulating emotion by sharing and disclosing emotions has not been included in operationalization of the construct of emotion regulation. Attempts to measure emotion have largely focused on the cognitive strategies of regulating emotion and/or the conscious effort to inhibit or suppress emotions. Sharing or disclosure of emotions may appear as a behavioural component of emotion regulation that has a beneficial effect on health. However, this speculation needs further psychometric verification. Emotional Intelligence and health: Emotional intelligence (EI) involves an interaction between emotion and cognition in such a way that it leads to adaptive functioning (e.g., Salovey and Grewal, 2005). In conceptualization of emotion intelligence, though, there exists a lot of variation, the four branch ability model of Mayer and Salovey (1997) has received greater scientific acceptability. The four-branch model of emotional intelligence (Mayer, Salovey, and Caruso, 2004) posits that emotional intelligence involves a set of interrelated abilities such as, perception of emotion in the self and others, using emotion to facilitate decision making, understanding emotion, and regulating emotion in the self and others. However, there are alternative models of EI also that include non-ability factors such as motivational dispositions, general mood and global personal and social functioning along with some cognitive aspects (e.g. Bar –On, 1997; Goleman, 1995). Such models of EI are often labelled as mixed model of EI (Mayer, Salovey and Caruso, 2000). Attempt to relate EI with health has been made from both the perspectives – the ability and the non-ability perspectives. In the following sections, we present a brief overview of the major findings relating EI with health. Associations between EI and health/well-being indicators are relatively consistent across studies using performance and self-report measures (Schutte, Malouff, Thorsteinsson, Bhullar, and Rooke, 2007). EI has been found to be positively correlated with measures of psychological well-being such as life satisfaction and happiness, while associations with measures of depression, stress and loneliness have been found to be negative (Austin, Saklofske, and Egan, 2005; Dawda and Hart, 2000; Day, Therrien, and Carroll, 2005; Palmer, Donaldson, and Stough, Emotion and Health 137

2002; Schutte et al., 1998; Tsaousis and Nikolaou, 2005). Positive associations of EI with higher levels of self-rated physical health have also been reported (Tsaousis and Nikolaou, 2005). Further, the available empirical evidences suggest that high EI individual are less likely to be involved in health compromising behaviour whereas those with low EI are prone to engage themselves is health compromising or damaging behaviour. For example, several studies indicated an association of EI with reduced tendency to smoking and alcohol consumption (Austin et al., 2005; Trinidad and Johnson, 2002; Tsaousis and Nikolaou, 2005) and with better self-capability for mood regulation in high-EI individuals (Thayer, 1996). Similarly, Pau and colleagues (Pau, Croucher, Sohanpal, Muirhead, and Seymour, 2004) reported that low EI students were more likely to engage in health-damaging behaviours. Some preliminary evidences indicate that high EI is related with adaptive coping, and an EI/coping composite has been found to mediate the association between personality and health behaviours (Saklofske et al., 2007). People with higher EI are thought to possess a greater capacity to perceive and reason around emotion, which facilitates greater positive affect and happiness (Mayer and Salovey, 1997; Salovey and Mayer, 1990; Salovey et al., 1999). Although there is some controversy regarding EI’s discriminant validity, researches support EI’s utility for reducing stress and promoting health (Ciarrochi, Chan, and Caputi, 2000; Ciarrochi, Deane, and Anderson, 2002; Gannon and Ranzijn, 2005; Schutte et al., 1998). Further, with emerging evidences that EI can be taught and developed (Reshmi, 2006; Slaski and Cartwright, 2002; Caruso & Wolfe, 2001),exploration of EI–health association has become a topic of applied interest. Accumulating body of empirical evidences have demonstrated EI as a significant positive predictor of well-being (Austin et al., 2005; Bar-On, 2005; Ciarrochi and Scott, 2006; Ciarrochi et al., 2000; Gannon and Ranzijn, 2005; Gignac, 2006; Palmer, Donaldson, and Stough, 2002; Saklofske, Austin, and Minski, 2003). Higher emotional intelligence has also been linked with aspects of better psychosocial functioning (e.g., Brown & Schutte, 2006; Salovey and Grewal, 2005; Schutte et al., 1998; Schutte et al., 2001), including intrapersonal factors such as greater optimism and interpersonal factors such as better social relationships. Some of these psychosocial factors, such as more social support and more satisfaction with social support observed among individuals with higher emotional intelligence (Brown and Schutte, 2006), may serve as buffers to physical illness. Efforts have also been made to explore the effect of various dimensions of the multidimensional construct of EI on health For example, ability for emotional repair was found to be positively related with perceived physical and mental health (Extremera & Fernandez-Berrocal, 2002; Mikolajczak et al., 2006), work satisfaction (Berrios et al., 2006) and life satisfaction (Augusto et al., 2006a, b). Similarly, some studies have examined the effect of ‘attention to emotions’ and ‘emotional clarity’ (the components of emotion perception) on health. For example, it has been observed that people who score high on ‘Attention to Emotions’ report more physical symptoms, depression and anxiety (Salovey et al., 2002) than individuals who obtain a low score in this factor.. On the other hand, high scores on Clarity and Emotional Repair are related to lower anxiety and depressive symptoms and higher life satisfaction (Augusto Landa et al., 2008). The role of EI in understanding mental disorders has also been examined. For example, Matthews, Zeidner, and Roberts (2002) pointed out that level of emotional intelligence might have implications for both mental disorders in which emotion plays a central role as well as disorders that relate to non-emotional features of emotional intelligence. Mood and anxiety disorders are examples of disorders that have maladaptive emotional state as core symptoms (Matthews et al., 2002). The better perception, understanding, and management of emotion (indicator of higher emotional intelligence) may prevent development of maladaptive emotional states associated with mood and anxiety disorders (Matthews et al., 2002). Research has shown that those with higher emotional intelligence do tend to have typically more positive mood and are better able to repair mood after a negative mood induction (Schutte, Malou, Simunek, Hollander, and McKenley, 2002). Similarly, Mathews and associates (2002) theoretically linked personality disorders and impulse control disorders with one component of EI- emotional awareness. They argued, that lack of awareness of emotion and inability to manage emotions are key symptoms in some personality disorders and impulse control disorders (Matthews et al., 2002) and thus lower EI (low emotional awareness) may be linked with these disorders. The stress preventive and health enhancing function of EI has been demonstrated not only in the personal life but also at work place. For example, in a study Augusto Landa and associates (2008) examined the 138 Pandey and Choubey

relationship between EI, stress and health among nurses. Their study shows a clear effect of the dimensions of EI on stress and health in the sense that EI emerges as a protective factor against stress and a facilitative factor for health (especially the Clarity and Repair dimensions) in a specific group of workers: nurses. Similarly, Ogińska-Bulik (2005) has also suggested that the ability to effectively deal with emotions and emotional information in the workplace assists employees in coping with occupational stress. Despite these empirical grounds for predicting that higher emotional intelligence would be related to better mental health, under certain circumstances higher emotional intelligence may have maladaptive consequences. For example, Petrides and Furnham (2003) found that individuals with higher emotional intelligence reacted more strongly to mood induction procedures, including a negative induction. Such greater sensitivity to mood-related stimuli might for some individuals lead to greater distress under adverse circumstances. Similarly, Gohm and associates (2005) observed that emotional intelligence is potentially helpful in reducing stress for some individuals, but unnecessary or irrelevant for others. They reported that the confused participants having average emotional intelligence were found to be highly stressed. Such participants despite having the emotional intelligence do not get benefit from it presumably because they lack confidence in their emotional ability and therefore do not appear to use it. In spite of these caveats, the available empirical evidences, on the average, favour the hypothesis that high EI helps to reduce stress experiences and promote health. For example, a recent meta-analysis (Schutt et al, 2007) of 44 effect sizes based on the responses of 7898 participants reports that higher emotional intelligence was associated with better health. The foregoing review clearly demonstrates that high EI works as protective factor against stress and ill health. However, the question remains that how and by what mechanisms the EI help to reduce stress experience and promote health. Several hypotheses have been forwarded to explain the observed EI –stress and EI-health relationship. Findings of some studies suggest that high EI enhances the inner resources to cope with stress and its adverse effect and thereby lead to better helath. For example, Mikolajczak and associates (2008) found that high trait EI individuals’ choice of adaptive strategies to down-regulate various negative emotions and maintain positive ones explained their decreased propensity to experience these negative emotions and their increased propensity to experience positive ones. Enhanced positive emotional experiences have been reported to protect the individuals from the maladaptive neural, endocrine, and immune responses to chronic stress that can lead to disease (Epel et al., 1998; McEwen, 1998). Further, such positive experiences also broaden the individual's attentional focus and behavioural repertoire and consequently build social, intellectual, and physical resources--resources that depletes under chronically stressful conditions (Fredrickson, 1998). The hypothesis that emotional intelligence equips the individuals with better coping strategies and thereby helps them to combat with stress and its ill effects is also supported by recent empirical findings. For example, in a recent study Mikolajczak and Luminet (2008) observed that high trait EI individuals exhibited greater self-efficacy to cope and they appraised the situation as a challenge rather than a threat. Similarly, Ciarrochi and associates (2002) observed that people with high EI are able to deal with environmental demands better than people who score low on this variable. Another mechanism, through which the EI may have its stress preventive and health promotive function, is the mobilization of social resources and enhancement of psychosocial functioning. Higher emotional intelligence is linked with aspects of better psychosocial functioning by several researchers (e.g., Brown & Schutte, 2006; Salovey and Grewal, 2005; Schutte et al., 1998; Schutte et al., 2001), including intrapersonal factors such as greater optimism and interpersonal factors such as better social relationships. Some of these psychosocial factors, such as more social support and more satisfaction with social support for those with higher emotional intelligence (Brown & Schutte, 2006), may serve as buffers to physical illness. Further, those with higher emotional intelligence might be better able to follow through on commitments to health behaviour and show better medical compliance. Several studies suggest that high EI is associated with greater social support network (Austin et al, 2004) which in turn may help to buffer the negative effect of stress. To sum up, the preceding review brings to fore that emotional intelligence and its various components, in general, have beneficial effect on health and well-being. However, certain components, such as attention to emotion or ability to perceive emotion may have negative influence on health. Further, it also evident from the preceding review that EI may exert Emotion and Health 139

positive influence on health by number of mediating mechanisms such as enhancing the coping and adaptive resources, enhancing immune competence etc. However, further research is needed to explore the mechanisms through which EI influences the health status of an individual. Alexithymia and health: Alexithymia refers to a relative narrowing in emotional functioning. The salient clinical features of alexithymia include difficulties in recognizing and verbalizing feelings, endless description of physical symptoms instead of emotions, concrete speech and thought closely tied to external events, paucity of fantasy life (Taylor, 1984, 1994). Although initially described in the context of psychosomatic illness, alexithymic characteristics may be observed in patients with a wide range of medical and psychiatric disorders. A growing body of literature suggests that alexithymia is associated with a variety of physical and mental health complaints (Taylor, 1984). Recent reviews done by Lumley and associates (Lumley, 2004; Lumlely, Neely, and Burger, 2007) suggest that alexithymia is a potential risk factor for symptoms and illness behaviour. These reviews also indicated that alexithymic patients may respond poorly to psychological treatments and presence of alexithymia interferes with or attenuates the health benefit of emotional disclosure. They have also observed that alexithymia is associated with heightened physiological arousal, the tendency to notice and report physical symptoms, and unhealthy compulsive behaviours (Lumley et al. 2007). Alexithymia has been found to be associated with various mental disorders including anxiety and depression. For example, Berthoz, Consoli, Perez- Diaz and Jouvent (1999) found a positive correlations between depression, anxiety (state and trait) and alexithymia scores. Partial correlations revealed a tight link between trait anxiety and alexithymia. Similarly, Devine, Stewart and Watt (1999) observed elevated level of alexithymia in a group of high anxiety sensitive participants. Similarly, Honkalampi, Hintikka, Tanskanen, Lehtonen and Viinamaki (2000) have reported a high prevalence rate of alexithymia (32.1%) among participants having elevated depression score on Beck Depression Inventory. Further, alexithymia has been found to be associated not only with physical and mental health complaints but also with elevated maladaptive and health compromising behaviour, which in turn adds to the risk for ill health of alexithymics. For example, in a study Helmers and Mente (1999) observed an association between alexithymia and maladaptive health behaviours. Findings indicated that: (1) the alexithymia and one of its component- difficulty identifying feelings was associated with poor nutritional consumption; (2) difficulty identifying feelings was also associated with greater alcohol and drug use; and (3) difficulty communicating feelings was associated with a more sedentary lifestyle. Overall, the findings of this study suggest that difficulties with identifying emotions and communicating emotions are associated with maladaptive nutritional habits, a sedentary lifestyle, and substance abuse. The preceding empirical evidences clearly suggest that alexithymia has negative influence on the health status of an individual and may lead to a variety of physical and mental health problems. However, the mechanisms that link alexithymia with poor physical and/or mental health has not been clear yet. Several hypotheses have been extended to explain this relationship. One hypothesis extended to explain the link between alexithymia and psychosomatic illness suggests that the alexithymic’s trait like deficit in identification and understanding of emotions associated with a deficit to express emotions amounts to emotion suppression. Health enhancing effect of emotional disclosure and health deteriorating effect of nonexpression or suppression of emotion has been widely documented (see emotion regulation and health section of this paper for details). For example, Pennebaker (1993) reviewed researches dealing with the role of spontaneous and habitual disclosure of emotion and health and suggested that emotional disclosure in general have a positive effect and emotion suppression has a negative effect on health. He argued that the spontaneous nonverbal expression of emotion is related to immediate reductions in autonomic nervous system activity. Similar changes in specific autonomic channels occur when individuals are encouraged to express verbally their emotions. Indeed, these physiological changes are most likely to occur among individuals who are either verbally or nonverbally highly expressive. These data suggest that when individuals must actively inhibit emotional expression, they are at increased risk for a variety of health problems. He cited several experiments that indicate that verbally expressing traumatic experiences by writing or talking improves physical health, enhances immune function, and is associated with fewer medical visits. Thus, the non-expression of emotion due to poor understanding leads to tonic hyper-arousal of autonomic system, which in turn 140 Pandey and Choubey

increases the susceptibility to various psychosomatic disorders (Pandey, 1993). Another hypothesis that link alexithymia with various physical and mental disorders is that these disorders result from the alexithymics’ inability to differentiate and elaborate affect, which gives rise to physiological arousal and a negative subjective state, which are not regulated by psychological strategies. Friedlander, Lumley, Farchione and Doyal (1997) tested these hypothesized mechanisms by comparing 42 alexithymic subjects with 42 sex- and racematched non-alexithymic subjects on physiological and subjective responses to an autogenic relaxation exercise and three different laboratory stressors. Alexithymic subjects had tonically greater electrodermal activity and reported more arousal and displeasure in general than nonalexithymic subjects. Groups did not differ in the degree to which they relaxed, but alexithymic subjects reported less enjoyment of, less involvement in and poorer imagery during relaxation. All three stressors evoked reactivity and alexithymic women had less heart rate change when viewing disgusting scenes than did nonalexithymic women; in general, however, groups did not differ in reactivity or recovery to the stressors. This study provides some support to the speculation that enhanced physiological arousal and sensitivity to negative emotional states in alexithymics may be a factor for their poor health. The available empirical evidences though, clearly suggest that alexithymia makes an individual vulnerable to develop a variety of physical and mental health problems, the mechanism through which it impairs health is yet not clear. Further research is needed to uncover the mediating mechanisms that link alexithymia with health. Positive, negative affect and health: The trait like disposition to experience positive and negative emotions (hereafter referred to as positive and negative affectivity), have been a centre of attention for health psychologists for explaining the variance in the health status of an individual. The positive affect (PA) reflects the pleasurable engagement and subjective experience of happiness whereas the negative affect (NA) reflects the level of subjective distress and unpleasurable engagement. High trait NA individuals are characterized by the tendency to experience a range of distressing negative emotions such as anxiety and depression whereas the high trait PA individuals are characterized by the disposition to experience a range of positive emotions such as enthusiasm, alertness, joy etc. Researches dealing with the role of trait PA and NA in health have in general noted that the former works as a health promotive and protective factor while the latter leads to a number of physical and mental helath problems. For example, several researchers noted that NA was found to be associated with complaints of physical symptoms but it was unrelated to objective physical illness (Costa and McCrae, 1987; Van Hemert, Bakker, Vandenbrouke, and Valkenburg, 1993; Watson and Pennebaker, 1989). Similarly, researchers examining the role of negative affect in self-report of illness have noted that individuals scoring high on NA reported two to three times as many physical symptoms as compared to individuals low on NA (Costa and McCrae, 1980). Recently, Hu and Gruber (2008) also observed that individuals low on NA and high on PA were found to have lower levels of symptoms of distress and depression, higher daily activity scores, and higher perceived physical and mental health-related quality of life. Thus, such empirical evidences suggest that high trait NA is associated with poor health whereas low trait NA is associated with better health. Factor analytic studies have also reported that negative affect may be a common factor associated with various psychiatric illnesses. Such studies (e.g., Brown, Chorpita, & Barlow, 1998; Mineka, Watson, and Clark, 1998; Zinbarg and Barlow, 1996) have demonstrated that negative affect reflects a higher order factor (i.e. variance common to all psychiatric diagnoses) and each psychiatric disorder a second order factor (i.e. variance unique to that disorder alone). The preceding review, though, suggest that negative affective experience, in general, have adverse effect on health, some studies indicate that NA may have adaptive significance also. For example, researches have noted that by influencing motivation and attention negative affect may serve several adaptive functions. For example researchers have demonstrated that negative affect focuses attention on the problem at hand (Frijda, 1988) and is associated with specific evolutionarily adaptive forms of action (e.g., anger prompts the urge to attack, fear prompts the urge to flee; Frijda, 1986; Frijda, Kuipers and Schure, 1989; Laza- rus, 1991). In contrast to negative affect, the positive affect is of less adaptive significance. Early emotion theorists, when they considered positive affect at all, proposed that it served as a safety signal and was likely to lead to decreased vigilance and shallower processing of information compared with negative affect (for reviews, see Aspinwall, 1998; Fredrickson, 1998). Such views of positive and Emotion and Health 141

negative affect suggest that positive affect would be maladaptive in the context of chronic stress because it would counteract the adaptive attentional and motivational effects of negative affect and thereby will reduce the coping and adaptive efforts. There have been a number of explanations proposed for the relationship between NA and symptom reports. Empirical evidences suggest that in healthy individuals, high NA may lead to an increased scanning for symptoms and an increase in the negative interpretations of common symptoms (Affleck, Tennen, Urrows, and Higgins, 1992; Watson and Pennebaker, 1989). Similarly, in patients with diagnosed illness, the NA has been found to increase watchfulness to symptoms and accordingly the patient sees symptoms as illness-relevant (Cameron, 1997). These empirical evidences extend the hypothesis that negative affect is associated with symptom reporting and perceived somatic complaints because of the cognitive biases (such as scanning, attention focusing etc.) introduced by the NA. Contrary to the effect of NA on health, the positive affective experience has been described to have beneficial effect on health. Positive affective experience, in fact, is considered as an important component of mental health (e.g., Jahoda, 1958; Taylor and Brown, 1988) and it would not be surprising to find that happy individuals are more mentally healthy than their less happy counterparts are. Diener and Seligman (2002) reported that their happiest group of people had few symptoms of psychopathology, such as depression, hypochondriasis, or schizophrenia (see also Chang and Farrehi, 2001; Lu and Shih, 1997; Phillips, 1967). Researches demonstrate that positive affect is associated with fewer unpleasant physical symptoms (Kehn, 1995; Mroczek and Spiro, 2005; Røysamb, Tambs, Reichborn-Kjennerud, Neale, and Harris, 2003). Individuals high in trait positive affect have been found to be at lower risk for various types of psychopathology such as, depression (e.g., Diener and Seligman, 2002; Lyubomirsky et al., 2005), social phobia or anxiety (Kashdan and Roberts, 2004), and hypochondriasis, or schizophrenia (see also Chang and Farrehi, 2001; Lu and Shih, 1997; Phillips, 1967). As the absence of positive affect has been argued to be a distinguishing characteristic of depression (Clark, Watson and Mineka, 1994; Watson & Clark, 1995), individuals high in trait positive affect are, of course, less likely to suffer from this debilitating condition (e.g., Lyubomirsky et al., 2005), as well as from social phobia or anxiety (Kashdan and Roberts, 2004). The preponderance of positive emotional experience not only reduces the risk of physical and mental health problems but it also reduces the chance of engaging in health compromising behaviours such as drug abuse, alcoholism, smoking etc. For example, researchers suggest that positive mood is related to a lower probability of drug use (Lymbomirsky and King, 2005). Thus, not surprisingly, happy individuals are less likely to report a history of substance abuse (Bogner, Corrigan, Mysiw, Clinchot, and Fugate, 2001). Contrary to it, lowered positive affect may lead to problem behaviours such as engagement in delinquent activity (Windle, 2000). Apart from enhancing the health and reducing the likelihood of health compromising behaviour, the positive emotional experience has been found to work as a protective factor in face of illness and other adversities of life. Positive affect, for instance, has been shown to relate to quality of life in cancer patients over the course of their illnesses (Collins, Hanson, Mulhern and Padberg, 1992) and to smaller allergic reactions among healthy students (Laidlaw, Booth and Large, 1996). In a study of individuals with sickle cell disease, positive mood was associated with fewer emergency room and hospital visits, fewer calls to the doctor, less medication use, and fewer work absences (Gil et al., 2004). Several other researchers have reported similar beneficial effect of positive affect in illness. For instance, in a study of AIDS-related care giving, Moskowitz, Acree, and Folkman (1998) observed that positive affect helps prevent clinical depression. Positive affect may also serve as a buffer against adverse physiological consequences of stress. Positive affect, for example, has been shown to offset the potentially damaging physiological concomitants of negative affect. Fredrickson and Levenson (1998) induced negative emotion in participants by showing them a film that elicited fear. Participants were then shown one of four films designed to elicit contentment, amusement, sadness, or no emotion (neutral condition). Measures of cardiovascular reactivity indicated that those individuals who were shown the contentment or amusement film had faster recovery to baseline than did participants shown the sad or neutral film. Attempts to explain the link between positive affect and health have generated several hypotheses that can be clubbed into two broad categories: 1) by enhancing and/or optimizing the functioning of the biological system (such as immune competence, endocrinal balance etc) and 2) by enhancing the psychosocial resources. 142 Pandey and Choubey

Under the first category of explanation, several psychobiological routes have been proposed. For example, one route through which positive affect has been hypothesized to offset the deleterious physiological effects of stress is through the neuroendocrine system. Suggestive preliminary data come from a study by Epel, McEwen, and Ickovics (1998) in which women who reported finding positive meaning in response to a traumatic event had more adaptive hormonal responses to a subsequent laboratory stressor. The women's positive affect because of meaning-based coping in response to traumatic events may have made them more physiologically resilient in the face of subsequent stress and may have helped protect them from the maladaptive neural, endocrine, and immune responses to chronic stress that can lead to disease (Epel et al., 1998; McEwen, 1998). The possibility that positive affect may have a role in the prevention of adverse physiological effects of stress is further reinforced by findings that positive and negative affect are associated with different neural structures (Ca-cioppo and Gardner, 1999; Davidson, 1992; LeDoux, 1995; Tomarken and Keener, 1998). The second broad category of explanation linking positive affect with better health is based on the assumption that such emotional experiences help to generate greater psychosocial resources to cope with adversities of life. One such theory that has gained wide popularity in the area of positive affect research is the broaden-and-build model of Fredrickson (1998). Fredrickson reviewed evidences showing that positive emotions broaden the individual's attentional focus and behavioural repertoire and consequently build social, intellectual, and physical resources--resources that generally depletes under chronically stressful conditions. Empirical evidence for the function of positive affect has begun to accumulate. For example, in a number of studies Isen and colleagues (Isen and Daubman, 1984; Isen, Daubman, and Nowicki, 1987; Isen and Geva, 1987; Isen, Johnson, Mertz and Robin- son, 1985) have shown that positive affect promotes creativity and flexibility in thinking and problem solving. Positive affect also facilitates the processing of important (e.g., self-relevant) information even if that information is negative and may potentially damage self- esteem (Reed and Aspinwall, 1998; Trope and Neter, 1994; Trope and Pomerantz, 1998). Briefly, the foregoing review suggests that the tendency to experience negative emotions has an adverse effect on the health whereas the disposition to experience positive emotions enhances the health and works as a protective factor against development of ill health. However, the mechanism through which the NA and PA relates with health are different. The NA impairs health by cognitively biasing the individual to focus more on the symptoms and negative aspects of life whereas the PA enhances health by broadening the coping resources and enhancing and /or optimizing the biological functioning of the individual. Affect intensity and health: Affect intensity (AI) is another affect related disposition that has recently been linked with health and well-being. Affect intensity refers to the degree to which individuals experience the strength of emotions. It is a stable dimension of personality the tendency to experience extreme emotions pertains to all emotions, regardless of content or hedonic tone (Larsen and Diener, 1987). Individuals high in affect intensity are theorized to exhibit stronger emotional responses than individuals low in affect intensity. The empirical observations that individuals high in affect intensity rate their emotions as greater in magnitude as compared to those who are low, regardless of the severity or hedonic tone of those events (Flett, Boase, McAndrews, Pliner, & Blankstein, 1986; Larsen, Diener and Emmons, 1986), support the said conceptualization of AI. The aforesaid theoretical formulation that individuals high on AI are likely to experience extremes of emotions leads to the speculation that high affect intensity individuals will also experience intense stress and therefore would likely to suffer from more health problems. During the last two decades, some empirical evidences have been accumulated to support the said speculation. For instance, Larsen and Diener (1987) reported that greater affect intensity is associated with greater somatic symptoms and neurotic symptoms. Similarly, Williams (1989) also reported a significant positive relation between affect intensity and neuroticism. Other researchers have also demonstrated the relationship between affect intensity and somatic disturbances, such as nauseas, headaches, muscle soreness, shortness of breath (e.g., Salovey, Detweiler, Steward and Bedell, 2001). The high AI individuals have been found to report a number of somatic problems (e.g., Diener, 1984; Larsen and Diener, 1987) and symptoms of mental ill health such as depression in addition to other problem behaviours (Silk, Steinberg and Morris, 2003). The preceding review extends the hypothesis that the experienced intensity of emotion irrespective of the valence of emotions (positive versus negative) has significant influence on the health status of an individual. Greater intensity of the perceived or Emotion and Health 143

experienced emotion may have deleterious effect on health and the moderate intensity of experienced emotions, either positive or negative, may help to promote health. For example, Mayne (1999) argued, “short bursts of emotion-associated sympathetic activation can stimulate parts of the immune system, whereas more chronic activation can cause ''wear and tear'' on the cardiovascular system. Anxiety and guilt have been associated with preventive health behaviours and care seeking, whereas distress and depression increase symptom sensitivity, accuracy of illness perception, and can facilitate care seeking and receipt of support. However, intense and chronic negative affects may lead individuals to engage in risky health behaviours, such as substance abuse, overeating, and high-risk sex, as a coping mechanism to regulate negative emotion. They may also undermine social support systems, leading to a selfperpetuating cycle of conflict and isolation” (Cited from abstract). The observations of Mayne (1999) suggest that negative emotional experiences, thought to exert harmful effect on health, are not always damaging for one’s health. According to Mayne, it is not the valence of emotion (positive or negative) per se, rather it is the intensity of the experienced emotion that determines whether it would exert a beneficial or harmful effect on health. The preceding review, thus, suggest that high affect intensity is associated with somatic problems and symptoms of mental illness, and its effect on health is independent of the valence of the experienced emotions. Further, the review also suggests that high AI is associated with such factors that may predispose an individual for developing health problems. For example, it has been noted by several researchers that high affect intensity may predispose to substance abuse and addiction (Thorberg and Lyvers, 2006), suicidal ideation (Lynch, Cheavens, Morse and Rosenthal, 2004). Similarly, high AI has been linked with a variety of phenomena that may lead to depression, such as negative cognitive operations (Larsen et al., 1987), self- consciousness (Flett et al., 1986a), and dysfunctional attitudes (Dance, Kuiper and Martin, 1990). Therefore, the available research findings suggest that high AI may directly impair the health of an individual as well as it can influence the onset and progression of health problems by leading an individual to health compromising behaviours such as drug abuse that in turn may increase the risk for physical and mental health problems. Conclusion: The major objective of the present paper was to present an overview of the current trends in relating emotion with health. In an attempt to address the objective we focused on some affect related abilities and dispositions that may influence health. The review indicates that the ability to regulate one’s emotions by cognitively reappraising the situation is such as way that it does not arouse emotion is beneficial as compared to the effortful attempt to inhibit or suppress the expression of emotion. The studies exploring the effect of social sharing of emotions suggest that disclosure of emotional experiences (particularly the negative ones) may be beneficial in adjusting with traumatic situation and improving health. The studies linking alexithymia with impaired health also indirectly substantiate the findings that non-expression of emotion may lead to poor health. Alexithymia is trait like affective deficit in which individual find difficulty in identifying and describing their feelings. Another affect related construct reviewed in the present paper is emotional intelligence that consists of a set of interrelated abilities to perceive, understand, regulate emotions and use emotions for one’s personal growth. The review indicated that emotional intelligence and its components have in general a beneficial effect on health and such abilities equip the individual to cope with the adversities of life and protect one’s health. Review of findings dealing with the role of positive and negative emotional experiences (positive and negative affectivity) revealed that in general negative affect adversely influences the health of an individual. However, there are some studies, which suggest that negative affect may also serve some adaptive functions and it is not always harmful for the individual’s health. It is also evident from this review that the positive affect plays a protective role and is beneficial for promoting health and well-being. Thus, it can be concluded that the valence (positive versus negative) of emotional experience is differently related with health. Contrary to it, the studies dealing with relationship of affect intensity with health suggest that it is not the valence of emotion rather it is the intensity of the emotional experience that influences health. The tendency to experience emotions in greater intensity may have adverse effect on health irrespective of the emotional valence. Whereas even the negative emotions experienced in moderate magnitude may have beneficial effects (Mayne, 1999). To sum up, the present review suggests that there are some affect related traits and abilities that have beneficial effect on health whereas others may have adverse negative effect. One thing which s apparent from the prevent review is that the most of the studies have examined the 144 Pandey and Choubey

role various affect related constructs on health independent of each other. However, given the interrelated nature of these affect related constructs it would be a better research strategy for future to examine the effect of these affect related variables on health in relation to each other. However, for research purpose we examine such constructs independently, in real life they co-occur. For example, individual high on EI is less likely to alexithymic and chances are high that he/she would not be disposed negative emotional experiences and would not exaggerate the feelings (affect intensity). Thus, it is very likely that such emotional constructs co-occurring together may modify the effects of each other on health and therefore it would be helpful to investigate their relationship with health in relation to each other. Such attempt would help to develop a more holistic affective theory or model of health. One limitation of the present review is that we have sampled some representative studies in each of the previously mentioned areas of emotion-health relationship. Our attempt was to present a general trend existing in the present literature dealing with emotion-health relationship and therefore we do not claim that we have made exhaustive review of the literature in the concerned area. Further, we also do not claim that we have reviewed all the affect related constructs that may potentially relate with health. However, the affect related constructs reviewed in this paper are some examples of affect related variables, which have been widely studied and may be a focus of future research. Our observation is that the attempt to relate emotion with health from holistic perspective is a striking gap in the present literature and such attempt would definitely add to the existing body of knowledge. References: Affleck, G., Tennen, H., Urrows, S., and Higgins, P. (1992). Neuroticism and the Pain-mood relation in rheumatoid arthritis: Insights from a prospective daily study. Journal of Consulting and Clinical Psychology, 60, 119–126. Alexander, F. (1939). Psychological aspects of medicine. Psychosomatic Medicine, 1, 7-18. Alexander, F. (1950). Psychosomatic medicine: Its principles and applications. New York: Norton. Alexander, F., & French, T M. (1946). Psychoanalytic therapy: Principles and applications. New York: Ronald Press. Aspinwall, L. G. (1998). Rethinking the role of positive affect in self-regulation. Motivation and Emotion, 22, 1-32. Augusto Landa, J. M., Lopez-Zafra, E., Berrios Martos, M. P. and Aguilar-Luzon Mdel, C. (2008).The relationship between emotional intelligence, occupational stress and health in nurses: a questionnaire survey. International Journal of Nursing Study, 45(6), 888-901. Augusto, J. M., Berrios, M. P., Lopez-Zafra, E., & Aguilar-Luzon, M. C. (2006a). Relationship between burnout and emotional intelligence and its impact on mental health, welfare and job satisfaction in nursing. Anxiety and Stress, 12 (2-3), 479-493. Augusto, J. M., Lopez-Zafra, E., Mart?nez, R., & Pulido, M. (2006b). Perceived emotional intelligence and life satisfaction among university teachers. Psicothema, 18, 152– 157. Austin, E. J., Saklofske, D. H. & Egan, V. (2004). Personality, well-being and health correlates of trait emotional intelligence. Personality and Individual Differences, 38, 547–558. Austin, E., Saklofske, D., & Egan, V. (2005). Personality, well-being and health correlates of trait emotional intelligence. Personality and Individual Differences, 38, 547–558. Bar-On, R. (1997). The Emotional Quotient Inventory (EQ-i): A Test of Emotional Intelligence. Multi-Health Systems, Toronto. Bar-On, R. (2005). The impact of emotional intelligence on subjective well-being. Perspectives in Education, 23, 41–62. Beck, A. T, Rush, A. J., Shaw, B. F., and Emery, G. (1979). Cognitive therapy of depression. New York: Guilford Press. Berrios, M.P., Augusto, J.M., Aguilar-Luzon, M.C., (2006). Perceived emotional intelligence and job satisfaction in hospital: An exploratory study with nurses. Nursing Index : Bibliographic Information, Research and The Humanities. 54, 30-34. Berthoz, S., Consoli, S., Perez-Diaz, F., and Jouvent, R. (1996). Alexithymia and anxiety: compounded relationships? A psychometric study. The European Psychiatry, 14(7), 372-8. Bogner, J. A., Corrigan, J. D., Mysiw, W. J., Clinchot, D., and Fugate, L. (2001). A comparison of Emotion and Health 145

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Mental Health and Quality of Life of Chronic Pelvic Pain and Endometriosis Patients Anand Kumar, Vidhi Gupta and Avita Maurya The study explored depression and alienation aspects of mental health in chronic pelvic pain and endometriosis patients and assessed their quality of life in Indian cultural conditions. Asha - Deep Depression Scale (Kumar, 2002), Alienation Scale (Patil, 1989) and P.G.I. Quality of Life Scale (Moudgil et al., 1998) were administered to100 female with chronic pelvic pain, 100 endometriosis patients and 100 normal females.. Findings revealed that chronic pelvic pain patients were found to be depressed, highly alienated and they exhibited impaired quality of life as compared to endometriosis patients. Such patients have pessimistic attitude, exhibit marked social withdrawal, negative self image, fatigue, lack of interest in their work, worthlessness and, decreased sex desire and motor activities as compared to endometriosis patients. Cognitive behavior therapy is suggested for improvement of their mental health. Pain is a complex, multidimensional and universal human experience. It is also a communicative process and is developmentally linked with solace, punishment, aggression, and loss of sexuality. In recent years chronic pelvic pain and endometriosis have been a great health concern in women of the contemporary society. The cost of chronic pelvic pain and endometriosis to the individual sufferers is one of the most severe consequences of the condition. In some of the studies associations have been reported between chronic pelvic pain and factors including personality, mood disturbances, sexual abuse during childhood and difficulties in relationship. Chronic pelvic pain effects approximately 15 percent women in the age group of 18-50 years. Review of research reports indicate that mental health and mood states are directly associated with onset of chronic pelvic pain and endometriosis. It was found that persons with chronic pelvic pain and endometriosis may have negative expectations about their ability and their future and they view themselves as helpless and enable to control their life. Franz et al. (1986) reported that patients with chronic pelvic pain exhibit high indices of hypocondriasis, hysterical symptoms, depression and alienation. Peveler et al. (1996) compared pain severity, mood symptoms, psychosocial aspects, personality characteristics of women with unexplained pain and women with endometriosis. No differences in mood symptoms or personality characteristic were identified, but women with chronic pelvic pain had some what high alienation and greater social dysfunction. Lorencatto et al. (2006) reviewed previous research reports and found that complaints of depression, such as somatic concerns, work inhibition, dissatisfaction, and sadness, were observed at a significantly higher rate in the group with chronic pelvic pain. Quality of life of chronic pelvic pain and endometriosis patients has been found to be significantly impaired. Huntington and Gilmour (2005) explored women’s perceptions of living with endometriosis. They found that endometriosis significantly affects women’s quality of life. Belaisch and Allart (2006) have stated that endometriosis is a recurrent and painful disease which sometimes disturbs severely the quality of life of women. However, authors have not come across any research works carried out in India on association of depression and alienation with chronic pelvic pain and endometriosis. The present study is a modest attempt to explore the quality of life, depression and alienation among chronic pelvic pain and endometriosis patients. Operational Definition: Chronic pelvic pain is the pain that apparently has a gynecological origin for at least 6 months but of which no definitive cause is found. Women with chronic pelvic pain complain about deep pain either unilateral, bilateral or in the midline, radiating to the low back, anterior abdominal wall, buttocks, hips, perineal area and anterior thighs. Endometriosis is a lower abdominal pain due to foci of ectopic endometrium located outside the uterus. The pain may be located in one or in both iliac fossae or over the whole lower abdomen. The main symptom of endometriosis is pain that may start as premenstrual pain with menstrual exacerbation or may become continuous. Method: Sample consisted of 100 female with chronic pelvic pain and 100 female patients with endometriosis, in the age range of 16 to 40 yrs. After establishing rapport, following psychological tests were administered individually to each patient. Anand Kumar, Ph.D., Prof and Head, Vidhi Gupta and Avita Maurya, Research Asistant, Dept of Psychology, Kashi Vidya Peeth, Varanasi-221002 Key Words: Pelvic Pain nd Quality of Life.

154 Kumar et al 1. Alienation Scale (Patil, 1989): This scale was developed by Patil (1981) which consists of 20 highly discriminating items followed with three alternative answers ‘Yes’, ‘Undecided’ and ‘No’. The ‘Yes’ response is assigned a numerical value of three, ‘Undecided is assigned a numerical value of two and ‘No’ response is assigned a numerical value of one. High score on the scale is indicative of highlevel of alienation. 2. Asha-Deep Depression Scale (Kumar, 2002): This scale was developed by Kumar (2002) consisting of 26 items, which are in form of positively worded and negatively worded statements. Each statement is followed by three alternative answers 'Yes', 'Undecided' and 'No'. High score on the scale is indicative of high-level of depression. 3. P.G.I. Quality of Life Scale (Moudgil, Verma and Kaur, 1998): P.G.I. Quality of life scale was developed by Moudgil, Verma and Kaur (1998). The test comprises of 26 statements. Each statement has 5 alternatives ranging from low to high degree. High score on the scale is indicative of high-level quality of life. Results and Discussion: Depression Measures: Mean and SD for three groups are shown in Table 1. Result of ANOVA is given in Table 2. Table 1: Mean and SD values of three groups on Depression Scale

Groups N Mean SD

Chronic Pelvic Pain Patients 26.15 8.81

Endometriosis Patients 24.04 8.14

Control Group 21.69 7.84

Table 2 Summary of ANOVA on Depression Scale

Source of Variance Sum of squares Df Mean Sqaure F

Between Groups 995.540 497.770 7.28**

Within Groups 20317.980 68411

Total 21313.529

** Significant at 0.01 level Findings of this research reveal that chronic pelvic pain patients scored higher (Mean= 26.15, SD=8.81) than endometriosis patients (Mean=24.04, SD=8.14) followed by control group (Mean=21.69, SD=7.84) on depression scale. Result of ANOVA shows that the three groups differ significantly on depression scale. The obtained value of [F (2,297) =7.28] was significant at .01 level. The mean difference amongst the three groups on Tukey’s post hoc comparison of means on depression scale reveals a significant difference between a1 a3 at.05 levels, however no significant difference was found between means of a1a2, a2a3 on depression scale. These findings confirm that chronic pelvic pain patients experience high level of depression followed by the endometriosis patients and control group. Slocumb et al. (1986) compared gynecologic patients with the abdominal pelvic pain syndrome with other gynecologic patients. The findings are consistent with the view that depression and low level of self-efficacy may be consequences of persistent abdominal pelvic pain. Stones et al. (2000) found that psychosocial impact of chronic pelvic pain is reflected in depression, alienation and disruption of normal activity. Belaisch and Allart (2006) have stated that chronic pelvic pain without obvious organic pathology might

Mental Health and Quality of Life 155 be an expression of a depressive disorder. Findings of this research also supports the above findings that chronic pelvic pain patients are comparatively highly depressed than the endometriosis patients and both the patients groups are high on depression compared to the control group. Measures of Alienation: Mean and SD for three groups are shown in Table 3. Result of ANOVA is given in Table 4. Table 3 Mean and SD values of three groups on Alienation Scale

Groups N Mean SD

Chronic Pelvic Pain Patients 38.22 9.38

Endometriosis Patients 36.08 8.53

Control Group 33.36 8.61

Table 4 Summary of ANOVA on Alienation Scale.

Source of Variance Sum of squares df Mean Square F

Between Groups 1186.59 593.29 7.58**

Within Groups 23239.560 78.25

Total 24426.15

** Significant at.01 level The findings reveal that patients with chronic pelvic pain scored higher (Mean= 38.22, SD=9.38) than endometriosis patients (Mean=36.08, SD=8.53) followed by control group (Mean=33.36, SD=8.61) on alienation scale. Result of ANOVA shows that chronic pelvic pain patients, endometriosis patients and control group differ significantly on alienation scale. The obtained value of [F (2,297) =7.58] was significant at .01 level. The mean differences of chronic pelvic pain patients, endometriosis patients and control group on Tukey’s post hoc comparison of means of three groups on alienation scale reveals significant difference between a1 a3 at .05 level, however no significant difference was found between means of a1a2, a2a3 on alienation scale. These findings confirm that chronic pelvic pain patients possess high level of alienation followed by the endometriosis patients and control group. Henker (1979) reported that patients with chronic pelvic pain revealed some psychological disorder including hysteria, passive aggressive behavior, alienation, depression and alcoholism. Franz et al. (1986) studied psychological profile of patients with chronic pelvic pain. Patients reported significantly high score on hypochondriasis, hysteria, depression, alienation, personal efficacy as compared to control group. Low et al. (1997) investigated the possibility of a specific psychological profile associated with endometriosis women and pelvic pain patients. Chronic pelvic pain patients obtained higher alienation, and anxiety scores in comparison to endometriosis patients. Findings of this research also support the above findings. Measures of Quality of Life: Mean and SD for three groups are shown in Table 5. Result of ANOVA is given in Table 6.

Table 5 Mean and SD values of three groups on Quality of Life Scale

Groups N Mean SD

Chronic Pelvic Pain Patients 57.95 21.04

Endometriosis Patients 65.90 23.11

Control Group 27.84 24.18

Table 6 Summary of ANOVA on Quality of Life Scale

Source of Variance Sum of squares df Mean Sqaure F

Between Groups 5492.60 2746.30 5.28*

Within Groups 154581.19 520.48

Total 160073.8

** Significant at.01 level Findings revealed that chronic pelvic pain patients scored low (Mean= 57.95, SD=21.04) than endometriosis patients (Mean=65.90, SD=23.11) followed by control group (Mean=67.84, SD=24.18) on Quality of Life Scale. Results of ANOVA shows that the three groups differ significantly on QLS. The obtained value of [F (2,297) =5.28] was significant at .05 level. The mean differences of three groups on Tukey’s post hoc comparison on QLS revealed significant difference between a1 a2, a1 a3 at .05 level, however no significant difference was found between means of a2a3 on quality of life scale. These findings confirm that chronic pelvic pain patients exhibit lower indices of QLS followed by the endometriosis patients and control group. Mathias et al. (1995) reported that women with chronic pelvic pain exhibit health distress, low level of personal efficacy and quality of life. Choi and Jung (1995) studied quality of life in women with endometriosis. Jones et al. (1996) found that women with chronic pelvic pain report worse health related quality of life. Huntington and Gilmour (2005) explored women’s perceptions of living with endometriosis. They found that endometriosis significantly affects women’s quality of life. Gao et al. (2006) found that endometriosis was associated with perception in pain; social functioning and health related quality of life. Findings of this research also support the above findings that chronic pelvic pain patients exhibit impaired quality of life than the endometriosis patients and both the patients group exhibit impaired quality of life as compared to the control group. Conclusion: Findings indicate that cognitive factors are positively associated with mental health of chronic pelvic pain and endometriosis patients. Chronic pelvic pain patients were found to be highly alienated and depressed as compared to endometriosis patients, which reflects that chronic pelvic pain patients escape from social situations and they feel themselves to be estranged from their social surroundings. Such patients have pessimistic attitude, marked social withdrawal, negative self image, fatigue, lack of interest in work, worthlessness and, decreased sex desire and motor activities. Quality of life was found to be significantly impaired as compared to endometriosis patients. Cognitive behavior therapy may improve mental health. References: Belaisch,J. and Allart, J.P. (2006) : Endometriosis and surviving adolescent. Gynecol Obstet Fertil, 34:3, 242-247. 156 Kumar et al

Choi, S.Y. and Jung, E.M. (2005) : Influencing factors of depression in women with endometriosis. Taehan Kanho Hakhoe Chi, 35(5), 879-887. Franz, C., Paul, R., Bautz, M., Choroba, B., & Hildebrandt J. (1986): Psychosomatic aspects of chronic pelvic pain a new way of description based on M.M.P.I. Item analysis. Pain, 26, 33-43. Galiano, L., Montiel, L, Falip, R., Asensio, M. and Mat, L.J.(1995): Stress as a precipitating factor in migraine. Rev Neurol, Vol.23 (122), 830- 832. Gao X, Yeh YC, Outley J, Simon J, Botteman M, Spalding J, (2006): Health-related quality of life burden of women with endometriosis: a literature review. Curr Med Res Opin, 22(9), 1787-1797. Hartmaier, L., Santanello, C., Epstein, R.S. and Silbertein, D.(1995): Development of brief 24-hours migraine-specific quality of life questionnaire. Rev Neurol, Vol.23 (122), 866- 872. Henker, F.O. (1979): Diagnosis and treatment of non organic pelvic pain. Southern Medical Journal, 72, 1132-1134. Huntington, A. and Gilmour, J.A. (2005): A life shaped by pain: women and endometriosis. J Clin Nurs. 14(9), 1124-1132 Kumar, A. (2002) : Mannual for Asha-Deep Depression Scale. Kumar Publications, Varanasi. Lorencatto, Vieira MJ, Pinto CL, Petta CA (2006) : Evaluation of pain and depression in women with endometriosis after a multi-professional group. Rev Assoc. Med Bras, 53(5), 433- 438. Low, W.Y., Edelmann, R.J., Sutton, C. (1993): A psychological profile of endometriosis patients in comparison to patients with pelvic pain of other origins. Journal of Psychosomatic Research, 37 (2), 111-116. Magni, G., Almi, A., de Leo D., Ceola, A. (1984): Chronic pelvic pain and depression. Psychopathology,17 (3), 132-6. Mathias, S.D., Kuppermann, M., Liberman, R.F., Lipischutz, R.C., & Steege, J.F. (1996): Chronic pelvic pain : Prevalence, health-related quality of life, and economic correlates. Obstetrics and Gynecology, 87(3), 321-7. Mongini,F., Defilippi, N. and Negro, C.(1997): Chronic daily headache.A clinical and psychological profile before and after treatment. Headache,Vol.37(2),3-7. Moudgil, A.C., Verma,.S.K .and Kaur, K.(1998): Manual of P.G.I. Quality of Life Scale. Rupa Psychological Centre, Varanasi. Patil, R.V.(1989) :Manual for Alienation Scale. Psychological Research Cell, Agra. Peveler R. Edwards J, Daddow J and Thomas E (1996) : Psychosocial factors and chronic pelvic pain : a comparison of women with endometriosis and with unexplained pain. J Psychosom Research, 40(3), 305-315. Santanello, N.C., Hartmaier, S.L., Epstein, R.S. and Silberstein, S.D.(1995): validation of new quality of life questionnaire for acute migraine headache.Headache, Vol.35 (6), 330-33. Slocumb, J.C., Kellner, R., Rosenfeld, R.C. & Pathak, D. (1993) : Anxiety and depression in patients with the abdominal pelvic pain syndrome. Obstet Clin North Am, 20(4), 643-661. Mental Health and Quality of Life 157

Rorschach Profile of Manic Patients Deapti Mishra, A. Khalique and Ranjeet Kumar This study has been designed to find the response pattern of mania patients on Rorschach by using the Exner comprehensive system. Main objective of the study was to develop a profile of mania patients on Rorschach variables. 120 Bipolar Affective disorders patients, current episode mania with psychotic features, ranging in 18-55 years of age, diagnosed as per ICD-10, and 50 randomly selected normal subjects from the general population, matched with respect to age and sex with mania group were included. Findings of the study indicate that mania patients differ significantly from normal control on several Rorschach variables Lot of literature on various systems of Rorschach are available which provide insights into the profiles of main psychiatric disorders, to help in differential diagnosis.(Sharma et al, 1975; Dubey et al, 1981; Hilsenroth et al, 1998; Ilonen et al, 1999; Jorgensen and Andersan, 2000). Though mania is one of the most commonly seen mental disorders, none of the major Rorschach scholars including Rappaport, Gill Schafer, and Exner had offered major contributions to differentiate this disorder. Herman Rorschach (1921) first describe the responses of a few mania patients and he noted that mania patients reflect excessive ideational activity and intrusive thinking, shown by the large number of movement , color responses, and also noted that mania patients give varied content and have tendency to combine various aspect of inkblots. Review of literature, however, shows a paucity of studies regarding Rorschach on manic patients (Khadvi et al, 1997; Pratap and Kapur, 1984; Boral and Bagchi, 1974; Pinto, 1980; Beck et al, 1950; Levey and Beck 1934; Kumar, 1960, 1965). Through review of literature, it is also evident that there is dearth of studies using Exner system on mania (Kumar et al, 2003, Kumar and Khess, 2001, 2004, 2005). A few earlier studies have used small sample size (Rorschach, 1921; Singer and Brabender, 1993; Kumar and Khess, 2003, Pratap and Kapur, 1984), the present study will go a long way in identifying the condition early and making appropriate interventional strategies. Considering these facts in view, the present study is a modest attempt to prepare the profile of Indian Manic patients on Rorschach and how it differs from normal population. It was also felt to see whether the responses given by Manics in India are the same as those in western cultures (Mishra et al, 1996). Methodology: The study was conducted on inpatient and OPD of Post Graduate Institute of Behavioral and Medical Sciences, Raipur (India). 120 Bipolar Affective disorders patients, with current episode of mania and psychotic features, ranging from 18-55 years, diagnosed as per ICD 10 (WHO, 1992) and 50 normal subjects, matched with respect to age and sex with mania group comprised the sample. Patients with any other co-morbid illness, substance abuse, neurological and sensory impairments were excluded from the study. The primary information regarding demographic and clinical variables was collected on a semi-structured Pro forma. The patients were rated on Young Mania Rating Scale (YMRS) to assess the severity of mania and normal subjects were screened for psychiatric morbidity using General Health Questionnaire (GHQ). The Rorschach test was administered individually at the end of the procedure and scored and interpreted as per Exner’s comprehensive system. Out of 140 patients initially, 20 were dropped out from the final study because of the low number of responses on Rorschach (less than 14) and/or incomplete inquiry and similarly 10 normal subjects were dropped because of non-cooperation or less than 14 responses on Rorschach. Thus, the final pool consisted of 120 mania patients and 50 normal controls. Tools used: • Rorschach psycho diagnostic (Herman Rorschach, 1921) • General Health Questionnaire (Shamsundar et al., 1986) • Young Mania Rating Scale (YMRS; Young et al, 1978) Analysis: The data were statistically analyzed using t-test and chi-square. Profile of mania was prepared after finding out the variables that differentiated mania from normal subjects. Deapti Mishra, M.M & S. P., PhD, Assistant Professor Clinical Psychology, Post Graduate Institute of Behavioural & Medical Sciences, Raipur, Email Id: deaptimishra@rediffmail.com, A. Khalique, Ph.D. Reader, Department of Psychology, Ranchi University, Ranchi and Ranjeet Kumar, M. M & S.P., Ph.D., Assistant Professor Clinical Psychology, Gwalior Mental Hospital, Gwalior. Key Words: Rorschach Profile, intrusive thinking

Results and discussion: Demographic Variables: The two groups were matched with respect to age and sex. Mean age of mania patients was 30.75 years and that of normal group was 33.85 years. Majority of subjects in both the groups were male. The mania patients and normal group differed significantly on marital status, education, occupation, monthly family income and types of residence. Rorschach Findings: Findings of the study reveal that no significant differences were found between the mania and normal (Pinto, 1980). They found that those who belong to low educational background give low number of responses and that number of responses is higher in the higher socioeconomic group. In this study mania patients had a trend to give comparatively low number of responses (mean 19.83), it might be explained on the basis of their educational background as majority of mania patients had low educational background (70.67%). Qualitative analysis indicates that the number of responses on card VIII, IX and X was found to be significantly more for the mania patients. This aspect has not been reported in any of the earlier studies. Klopfer et al (1954) has observed frequent Color responses in Mania patients. Rorschach Profile of Manic Patients 159 Table 1 Comparison of Location, Developmental Quality and Form quality of Maniac and Normal Subjects

Groups

Variables

No of responses 18.45 ±4.60 20.17± 6.75 1.81 NS

Whole (W) 5.73± 2.68 5.72± 3.39 .01 NS

Common detail (D) 8.65±3.96 11.00±5.72 2.87 .005

(Dd) 4.05±2.642.34 3.95±2.49 .021 NS

Space (S) 1.95±1.73 1.75±1.82 .62 NS

Popular (P) 1.41±1.30 2.15±1.33 3.06 .003

DQ+ 2.04±2.34 5.22±2.30 3.42 .001

DQo 15.09±4.92 17.40±5.98 2.42 .001

DQv 1.15±1.56 0.82±1.08 1.21 NS

V / Plus 0.06±.08 0.12±0.33 1.07 NS

FQ - 11.28±3.74 8.47±7.50 3.10 .002

FQ Ordinary 5.40±2.29 10.35±3.19 10.63 .001

FQ No form 0.07±0.29 0.07±0.34

0.00 NS

FQ Unusual 1.75± 2.55±1.98 1.93 NS

DQ+ = Developmental Quality Plus, Dqo = Developmental Quality Ordinary

DQv = Developmental Quality Vague, V / Plus Developmental Quality Vague/Plus group on number of responses. It is contradictory to most of the earlier findings that usually patients of mania give large number of responses in comparison to other clinical conditions and normal group (Rorschach, 1921; Beck, 1961; Exner 1973; Pratap and Kapur, 1984). A few studies have also reported low number of response in mania patients Current findings (Table 1) suggest that mania patients have obtained significantly low on common detail (D) location in comparison to normal control. Common detail (D) is coded for the frequently identified area of the blot. D responses reflect the degree to which a person perceives and reacts to the obvious aspects of a situation (Rorschach 1921). Mania (n=120) Mean and SD Normal (n=50) Mean and SD t Value Significance level

D has been reported to be low in patient groups as compared to normal population in earlier studies (Exner, 1974). It indicates that mania patients have problem in perceiving and reacting to the obvious aspect of a situation. Low D can reflect inadequate perceptual habits (Klopfer et al, 1956). In relation to other approaches especially Dd, mania patients were found to be higher in comparison to normal but findings were not significant, and the presence of higher unusual responses may be due to poor reality contact. In earlier study also it was found that mania patients give significantly higher unusual responses (Pratap and Kapur, 1984). Mania patients has also given comparatively low popular responses. Low popular responses suggest that they reject conventional modes of thinking; it is consistent with earlier findings that psychotic patients give low popular responses (Exner, 1993). Regarding the issues related to developmental quality, results indicate that patients of mania scored low on developmental quality plus and ordinary as compared to normal individuals. High scores on developmental quality plus and ordinary indicate that person is intelligent, complex and well adjusted in various conditions. Current findings reflect that mania patients have problem in adjustment area. Determinants (Table 2) are one of the important issues in Rorschach that provide information about complete personality of the individuals. Findings reveal that patients of mania gave a significantly greater number of Form Quality minus, low number of Ordinary form quality and higher number of pure Form responses as compared to normal control. It is in congruence with previous research that psychiatric patients have problem in reality testing and those who face emotional turmoil are likely to produce significantly higher number of pure form responses, reflecting their inability to remove their affect from their experience (Exner and Murillo, 1973). It was also observed that patients of mania gave significantly high number of Human movement (M) responses as a whole and quality of M was mostly poor. Human movement responses are generally interpreted as being related to an inner directed orientation and capacity for imagination and fantasy (Lerner, 1991; Exner, 1991; Blatt and Ford, 1994). It can be said that patients of mania are overly invested in their fantasy 160 Mishra et al Table 2 Comparison of Rorschach Determinants of Mania Patients and Normal Subjects

Groups

Variables

Human movement 5.50±2.97 2.02±2.40 2.37 .003

M Minus 2.67±2.02 0.52±1.21 2.02 .005

Animal movement (FM) 3.38±2.05 2.07±2.12 1.01 Ns

Inanimate movement (m) 0.77±1.17 0.65±1.09 0.51 NS

Colour-Form 2.07±1.82 0.52±0.87 4.71 .001

Form-Colour 0.34±0.83 1.33±0.82 3.12 .002

Colour-CN 1.23±1.33 0.27±0.52 4.12 .001

Weighted Colour 5.51±3.07 1.03±1.48 5.21 .001

Achromatic 1.48±1.60 0.82±1.20 2.01 .004

Texture 0.42±0.83 0.65±0.92 1.16 NS

Vista 0.16±0.55 0.27±0.45 1.11 NS

Shading 0.35±0.71 0.27±0.45 .68 NS

Reflection 0.02±0.27 0.40±1.69 1.34 NS

Pair 4.85±2.98 5.30±3.89 1.11 NS

Form Dimension 0.20±1.18 0.02±0.15 0.92 NS Mania (n=120) Mean and SD Normal (n=50) Mean and SD t Value Significance level

life and poor quality of human responses indicate that they are likely to be deficient in social skills and have poor interpersonal relationship. Animal movement is found to be significantly high (p<.001) in mania patients. Higher number of animal movement correlate positively with MMPI scales that measure irresponsibility, aggressiveness and distractibility (Thompson, 1948). None of the earlier studies have found it to be significant in mania. Exner (1993) holds that animal movement response correspond to person who complain of racing thought and have too much on their minds (Table 2).The findings of the present study indicate that patients of mania suffer more from affect related problem (high CF, C, CN, W sum C). It is consistent with previous studies (Rorschach, 1921; Schmidt and Fonda, 1954; Wagner and Heise, 1981; Exner 1986, 1991; Khadvi et al, 1997). The Manics have problems in modulation of affect which leads to inability to control the affective expression and causing disorganized behavior. Disruptive affect in mania could be expected to be emotional, labile, and over reactive (Pratap and Kapur, 1984). The Manics have given high number of achromatic responses suggestive of constrained internal and painful affect. Though this finding was not reported by any of the contemporary research studies but is consistent with psychodynamic explanations of mania being Table 3 Comparison of various Rorschach variables such as Perceptual, Form Appropriate and Psychological Resources Responses of Mania patients and Normal Subjects

Groups

Variables

X +% 0.29±0.12 0.72±0.15 8.10 .001

X --% 0.61±0.15 0.36±0.14 8.02 .001

F +% 0.08±0.09 0.14±0.16 2.81 .006

X Unusual % 0.23±0.15 0.47±0.18 8.00 .001

Form 9.82±3.89 12.55±6.25 3.24 .001

WDX Minus 8.19±3.12 4.85±3.05 5.89 .001

WDX Ordinary 5.00±2.15 9.50±3.28 9.92 .001

WDX Unusual 1.75±1.70 0.12±0.84 1.34 NS

ZF 5.91±2.86 7.10±3.80 2.07 .004

Psychological resources D .20±1.32 .95±1.07 2.81 .005

ADJD .09±1.25 .82±1…07 2.88 .004 defensive against feelings of depression (Klein, 1940; Gabbard, 2000) (Table 2) Table 3 indicates that mania patients showed serious processing and mediational problems ( X-%,p< .001 and low X+ % p< .001) that contribute to difficulties in adjustment. The high amount of mediational problems found in the mania patients in this study are consistent with studies done on patients with schizophrenia spectrum disorders (Mason et al, 1985; Exner 1986, 1991; Gordon, 1988; D Naovo et al, 1988; Hilsenroth et al, 1990) (Table 3) The results confirm the findings of earlier studies (Exner 1986, 1991) concerning the poor tolerance for stress in psychotic patients. They perceive lot of stress and lack the resources to deal with it (low D, ADJD,). Most of the mania patients tend to have difficulty contending with the demands of the social model and often feel helpless or inept because of their coping limitation or deficiency. Mania patients have also given significantly low responses on Zf (p<.05) in comparison to normal control suggesting their organizational capacity. Significantly low Zf reflects that mania patients expend less effort than needed to adequately process information and thus have poor capacity to understand and organize their internal resources (Exner, 1993). Rorschach Profile of Manic Patients 161 Mania (n=120) Mean and SD Normal (n=50) Mean and SD t Value Significance level

Table 4 Comparison of Special Scores in Mania Patients and Normal Subjects

Groups

Variables

D V 0.04± 0.20 0.00±0.00 1.29 NS

D R 1.20±1.60 0.00±0.00 4.74 .001

INCOM 0.68±0.90 0.05±0.22 4.36 .001

FABCOM 0.50±0.90 0.12±0.51 2.48 .001

ALOG 0.37±1.03 0.00±0.00 2.28 .002

CONTAM 0.00±0.00 0.00±0.00 NS

RSUM6 8.06±9.81 0.72±2.30 5.57 .001

WSUM6 5.51±3.07 1.01±1.48 5.21 .001

LEVEL 1 2.05±2.04 0.12±0.51 5.89 .001

LEVEL2 0.97±2.36 0.05±0.22 2.47 .01 Ideational dysfunction is a feature usually attributed to patients diagnosed with functional psychoses. The findings of this study are similar to most of the earlier studies (Exner 1986, 1991, 1993; Archer D Gordon, 1988; Hilsenroth et al, 1990; Weiner, 1998). Patient with mania showed remarkably high signs of pathological ideation (high Rsum6, Wsum6 special scores, M- and PTI Index). It is also noted that the occurrence of high ideational dysfunction is expected in a mania patient along with high signs of distortion and problem in thinking (Johnson and Holzman, 1979) (Table 4). Table 5 Comparison of Contents in Mania and Normal Subjects

Groups

Variables

Human 2.10±1.98 2.65±2.87 1.38 NS

Para-human 0.92±1.71 0.40±0.72 1.87 NS

Human Detail 0.90±1.33 0.80±1.30 0.41 NS

Animal 9.60±4.09 .6.86±3.77 3.90 .001

Para-animal 0.11±0.37 0.07±0.26 0.65 NS

Animal-detail 0.33±0.66 1.12±2.07 3.66 .001

Anatomy 1.53±2.53 0.83±1.42 1.61 NS

Sex 0.45±1.20 0.27±0.84 0.89 NS

X-Ray 0.08±0.51 0.39±0.81 0.81 NS

Blood 0.51±1.24 0.20±0.60 1.54 NS

Religion 1.06±2.29 0.60±1.67 1.16 NS

Art 0.32±1.07 0.30±0.83 0.09 NS

Botany 1.43±1.83 1.37±1.47 0.18 NS Content is another important aspect of Rorschach test. Mania patients have given significantly less number of animal and animal detail (p<.001) responses. It is supported by earlier researcher (Schmidit and Fonda, 1954). Current study also indicate lack of rewarding social relatedness and lack of proper interest in other people in mania patients and less cooperative movement as compared to normal control. Person with psychiatric history tend to give low good human responses (Exner 2003) (Table 5). 162 Mishra et al Mania (n=120) Mean and SD Normal (n=50) Mean and SD t Value Significance level Mania (n=120) Mean and SD Normal (n=50) Mean and SD t Value Significance level

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A Single Case in Interpretative Wrappings of Multiple Psychological Theories Somdeb Mitra and Nilanjana Sanyal Throughout the history of clinical psychology, different psychological theories have provided insights into psychological distress from different perspectives. The current paper attempts to provide an integrated understanding of different theories while understanding the psychopathology of a single case. It is argued here that such an understanding can help in effective treatment process as the therapist can be more flexible, empowered by a more in-depth understanding of the phenomena that arise during the process of psychotherapy. Psychology since its inception has made major advancements in development of an understanding of human behaviour and its underlying mental processes. Various stalwarts like Sigmund Freud, Ivan P. Pavlov, Carl Rogers have in their own way contributed in this pursuit. However in the modern age a major pressure on the clinical psychologists arrive from the aspect of economy and precision. Quick results and fast relief seem to the rising demand on the service providers from the population which approach them resulting in the growth of short-term therapies (Dutta and Sanyal, 2009). Keeping such a backdrop in mind it will seldom be possible to treat a patient for a long period of time as in classical psychoanalysis; even though we know that the Noble Laureate Prof. Erik Kendel (2005) has mentioned “psychoanalysis still remains the most intellectually satisfying theory of human mind”. It must be remembered that theorists like Beck, Skinner, Bandura and others have enriched the discipline of psychology and psychotherapy with their invaluable inputs. The followers of these theorists often are antithetical to the views of Freud and Psychodynamic school at large. However in the present paper with a case example is an attempt to narrate how all these theories unique way can provide us insights in understanding the case. Moreover in the process it will emerge how they are closely interlinked with each other. Such an understanding is likely to help in the therapeutic process even in the short term treatment modality The clear multidimensional understanding will not only help the therapist to handle any issue coming up, this can in turn enhance the confidence of the therapist. The expression of confidence again as a non-specific character enters into the therapeutic intervention and enhances the chance of therapeutic success. In this contention it is noteworthy that in the current times various therapists e.g. Lazarus (2005) propound the use of eclectic mode of psychotherapy, not being confined in any one mode. They also propose for a conceptual integration which can serve as the theoretical grounds for the Eclectic practise. The current paper also endeavours to make a conceptual integration and make a comprehensive, flexible understanding of psychopathology of a given case. Case Report: The participant was a 22 years, unmarried Hindu male hailing from urban area, middle class background, a student of engineering (diploma) and BCA first year. His major complaints were i) Being unmindful to others’ instructions or requests to him, ii) General behaviour pattern was of explosive type with utter rudeness, iii) Lack of concentration on given work, iv) Fickle mindedness. All these complaints had been present for the past two years. Prior to this he got chance in engineering (regular, degree course) through joint entrance exam. However as his parents could not afford the expenses, he could not take admission. This probably led him to consume 50 sleeping pills in the attempt to suicide. Since then the problems gradually increased but not reported by patient or the informant. According to his mother, the patient is quick tempered and explosive, is stubborn and others have to follow his way. These traits are present in him since childhood, as he gets angry with little provocation. He was very impulsive, energetic and courageous since childhood. At the age 3 he ate soap and at the age 5, he ate rat poison for which he required treatment. He was sociable but not very responsible. He made friends with some slum area dwellers and developed delinquent behaviour such as truancy, stealing utensils from own home and selling them for money. He could not accept criticism, had poor moral Somdeb Mitra, 2nd year trainee, M. Phil in Clinical Psychology and Nilanjana Sanyal, Ph.D Professor, Department of Psychology, University of Calcutta. 92 APC Road, Kolkata, E.Mail: mitrasomdeb@yahoo.co.in Key Words: Multiple psychological theories.

values and poor adjustment even since childhood. He is interested in technical instruments.He gained knowledge about sex from peers, stray books, porn sites during his early teenage. Attitude towards sex was reported to be balanced. He masturbates occasionally and had sexual experience once. The patient had a disturbing home environment as his father was non-working, and uncaring towards the child, and his mother too seemed to be emotionally unstable and attempted suicide a few days after marriage. Later on she developed anxiety disorder. Since childhood, there were disputes over property within the family and the joint family ultimately was disintegrated. The child’s attitude is mostly negative towards the father, and ambivalent towards the mother. He did not have a cohesive bond with elder sister. At present, the family interaction pattern seems loose because of inadequate communication; both the parents had physical or mental ailments. The patient’s father being ill after a prior accident had poor vision. His mother was under psychiatric medication. In spite of being a psychiatric patient, the mother had to take all decisions and was on the lead role. Mental Status Examination: He is well kempt and tidy, had touch with the surroundings, could maintain eye contact, rapport could be easily established owing to his cooperativeness, his motor behaviour, speech, volition, affect, cognitive functions of thought and perception did not bear any mark of deviation. He showed interest in coming out of his problems and his emotional insight was found to be of sixth grade level. Tests administered: Temperament and Character Inventory (TCI) (Cloninger et al. 1994) International Personality Disorder Examination (IPDE) Loranger et al. (1997) Rorschach Inkblot Test (RIT) (Klopfer et al. 1954) Thematic Apperception Test (TAT) (Bellak 1975) Results: Temperament and character inventory (TCI): The patient’s low score on the Harm avoidance domain reveals that he is carefree, relaxed, and confident in most social situations, has high energy level, is dynamic. He has low fear of uncertainty and prefers risks, is daring and courageous. This is corroborated by the information obtained from case history that “he is not afraid of making mistakes, he completes the tasks which which he feels is right”(reported by client’s mother). In childhood also he was not afraid of lizards or insects, could climb down high walls where others would be afraid to do so, etc. High score on the domain of Novelty seeking indicates that he is quick tempered, impulsive, disorderly, and has excessive anger. He is excitable, exploratory, curious, enthusiastic, exuberant, and easily bored. During Mental Status Examination, in response to “what made you to attempt suicide and what thoughts came in your mind” he replied “i felt, what is the use of being alive ? I don’t want to live. To express my anger on my parents I took those sleeping pills. I felt nobody gives importance to me” When he gets aggressive he throws away things like VCD player. In childhood he ate soap and also rat poison, his attitude as observed revealed his enthusiasm in testing sessions. He himself said “I am frickle minded.” Low score on the dimension of Reward dependence reveals that he is practical, tough minded, cold, socially insensitive, keeps distance, rarely openly communicates to others..He is objective but socially detached. He neither depends on nor actively seeks emotional support and approval. He is not sensitive to social pressure and does not try to please others for protection or emotional support. The patient is independent and self sufficient. While administering IPDE mother repeatedly said “I cannot tell you exactly about him. Actually he stays by himself most of the time.” History also reveals few close friends. Mother also reported, “He does not think about what others say... he always protests when there is injustice, although we stay quiet due to unpleasant social consequences.” Low score on the Cooperativeness dimension indicates he is self absorbed, intolerant, critical, unhelpful, revengeful, and opportunistic. He looks out for himself, is inconsiderate of others, and lacks empathy and compassion. Thus he is intolerant, unfriendly, impatient, critical of other people, has poor empathy. He is manipulative and deceitful, has poor ethical principles. he holds grudges, forgets deliberately, is stubborn and procrastinates. History reveals that he prefers to stay alone. Moreover, mother wants to give portion of property to elder sister but he opposes it. In this regard he is critical about both mother and sister as reported by mother. This may be due to his sibling rivalry and extreme self centeredness .“If someone says the same thing repeatedly, i feel angry. I feel like giving a tight slap” “I don’t care about what others feel, I tell the truth on the face” Case history reveals that at the age 15/16 he took utensils from own home and sold them off 166 Mitra and Sanyal

to meet his own impulsive needs. The presenting complaints of rude behaviour and forgetting are consistent to the finding of lack of empathy and procrastination. His scores on the dimension of Self transcendence reveal that he has difficulty accepting suffering and death. He is self aware, self-conscious, and unimaginative, not deeply moved by art or beauty, and is conventional and prosaic. He accepts materialism, objective empiricism and does not accept things that cannot be explained scientifically. Case history reveals that when his mother was ill father gave her a ‘holy string’ to wear but when the patient came to know about it he tore it off and said “if you want her to be better go for medical treatment. Nothing is going to happen by these damn things.” RIT: The client’s responses on RIT indicate high intellectual and organizational ability. He has disturbed relation with father figure. Responses also reveal neurotic constriction i.e., anxiety, worry, tension, conflict, frustration, aggression, inferiority and insecurity. He also has doubts about inner self, extreme insecurity, perceived inadequacy which probably contribute to his Emotional instability and emotional immaturity. Case history reveal he got chance to study engineering by cracking joint entrance exam consistent to the finding of high intellectual and organizational ability. History also suggests disturbance in father-son relationship. The aggressive outbursts corroborate the finding of emotional constriction and immaturity. He broke a relationship with one of his girlfriends only because she did not accept his direction to get on an escalator, which she was afraid of. This reveals his impulsivity and lack of social maturity resulting from emotional inadequacies. The features of extreme insecurity and perceived inadequacy are not manifested overtly and are probably largely unconscious.(This will be later explained by Kernberg’s understanding of NPD) TAT: The stories given by subject in TAT were structured, organised and dynamic. The hero has high aspirations in life, is conscious of his masculine identity and superiority. He looks for a congenial family bond. He has obsessive trend in character pattern, prominent doubt pattern is there in the mental plane Anxiety component is also high, trace of separation anxiety is hinted at. He seems to have inversional trend in character over which he has guilt, a sense of nonapproval by society, and consequently suffers from depression. He enjoys active masculinity but has a strong fear of passivity. He has paranoid ideation and feels revengeful at it. He has proper concept regarding heterosexual sex but he does not feel interest in heterosexual sex. He does not feel comfortable in heterosexual bond. Poor identification with female figures is revealed, and sense of discomfort persists in the stories. Emotional silence is observed regarding father figure. He has need for close affinity with the father which is not fulfilled in life. The presence of high aspirations in life can be inferred from his suicidal attempt following family’s inability to allow him admission to engineering college. Probably it was highly valued as a means of achieving masculine superiority. When TAT was being administered he was asked to keep the cards facing the table. After card 4 card 6 was administered. He noted even that and said “you have given me Card 4 and Then Card 6, what about card 5?” This observation is congruent with his obsessive trend. His frequent and non enduring relations probably hint not only a poor identification with mother figure and give rise to separation anxiety, but this also reflects his latent homosexuality which he has denied and repressed. Due to fear of social disapproval he has to repress it. This interferes with him getting pleasure in heterosexual relationship and process of sex. This frustrated homosexual desire might have led to aggression and consequently to depression. History reveals that he has a fear of being exploited or belittled. (over minor issues like travelling in a bus and getting a seat by the window, he quarrelled. He remembers it and reported it to the clinician.) IPDE: The subject’s as well as informant’s reports on IPDE confirm the diagnosis of Emotionally Unstable Personality Disorder- Impulsive Type. Understanding the case with respect to theoretical frameworks The prominent features of the case confirm the diagnosis of emotionally unstable personality disorder – impulsive type. He also has features of anankastic personality disorder. According to the DSM-IV(TR) the patient can be diagnosed as having Narcisstic Personality Disorder with features of obsessive compulsive personality disorder. The etiology of NPD suggests, temperamental factors may include high level of energy, over-consciencousness, increased sensitivity to unverbalised affect or a lack of tolerance for the anxiety caused by aggressive drives. Attempt to explain symptoms of present and their linkage with the past: The model of memory by Craik & Tulving (1975) suggests that deeper levels of processing i.e., elaborative rehearsal using prior conceptual links are better linked and better remembered. Again parallel distributed processing approach will suggest that these A Single Case and Multiple Psychological Theories 167

informations are linked with more memory traces (neural networks) and thus are likely to be activated due to activation of various informations (apparently distal). Moreover the self reference effect (Rogers et al, 1977) concept suggests recall to be best when the information is stored in the context of self. Bandura’s social learning theory also deserves to be mentioned in the context as further explanatory mode. As already discussed the child stayed in a mostly negative and threatening environment. This early learning not only conditions the individual towards picking the negative cues from the environment but also serves as his apperceptive mass ( top down) which makes him biased towards perceiving even neutral cues(bottom up) as hostile and threatening to his impoverished self concept developed in early childhood. Moreover these learned information is related to emotional centres, receive elaborative rehearsal and are stored better. Furthermore these informations having self referential quality are better remembered and recalled and also being linked to several neural networks (PDP approach) gets activated easily. As the individual feels threat to his self concept easily, he reacts with aggression. If manifested actively, it takes the form of anger outburst. If active aggression is repressed, his hostility makes him passively aggressive and he procastinates, that is, forgets and thus becomes non-cooperative. The classical psychoanalyst will probably say: the patient is fixated at the anal stage as all his personality traits reflect that characteristic (stubborn, aggressive, poor impulse control, anakastic etc.). Probably due to faulty parenting he was deprived at the anal stage and still the fixation exists and forms the apperceptive mass. However some of the libidinal energy progressed to the latter stages. But the child could not attain a proper secure base (attachment theory of Bowlby, 1980) and proper object relations (reciprocal) could not be formed. This deprivation/inconsistency developed the self doubts (as in Rorschach test findings) and paranoid ideations which makes him non cooperative. Further his libido could not progress adequately to the oedipal stage. Hence he lacks interest in heterosexual sex- although he is aware of it (TAT responses). Moreover failure to develop proper object relations causes his narcissism to be concentrated within him. Hence he can only love himself and reflection of himself (projected). This leads to his latent homosexuality which is the core of his paranoid ideations in the line of classical psychoanalytic view. His symptoms are nothing but repetition compulsions rooted in anality (to aggress, to defy). In brief, from the Psychodynamic point of view, supplementation of love was inadequate leading to impoverished self concept. Hence the destructive aspect (Thanatose) of libido led to aggression and he fails to accept others as well as his own self. These features combine to lead to his maladaptive personality style that hinders positive self growth. From the perspective of Cognitive Therapy the individual’s cognitive processes also get distorted due to underlying emotional disturbances (indicated earlier in the psychodynamic formulation) while appraising events and these cognitive errors in turn bias his experience and increase his emotional distress. This distress gives him the behavioural inclination to act inappropriately (most of the times aggressively). Thus his behaviour becomes maladaptive and leads to further unpleasant events. Thus his experiences also contribute and perpetuate his cognitive errors and maintain a vicious circle, deepening his crisis. Now if we attempt to formulate an Integrated Model incorporating all the information and theoretical perspectives, we may say that the child was reared up by parents who themselves were emotionally unstable, within a disturbing family environment. As Kernberg (1975) points out, narcissism is a pathological process involving a psychic hunger or oral rage caused by indifferent or spiteful parenting. However some positive aspect of the child or the environment may allow an escape from parental threat or indifference. This specialness facilitates a sense of grandiosity that blankets and splits off the real self which consists of envy, jealousy and deprivation. Kohut (1971) posits that seeds of NPD are sown when caretakers do not validate a child’s response. This empathetic failure causes the child to develop an idealised image of the parents and not one based on real limits. According to Young (1990), it is the resultant effect of early maladaptive schema(EMS) which are unconditional self perpetuating beliefs learnt from interaction patterns in early childhood. Millon (1985) views such pathology as a result of parental overvaluation. Other theorists posit, such children may be narcissistic extension of their parents. Bandura’s (1969) social learning theory also implies the importance of models in life. Thus, all the above theorists who belong to different schools of thought emphasise the role of caregivers in the early developmental stage. The current client not only received faulty models in his father and mother, who also failed to provide him with figures for identification. From the classical psychoanalytical view, the child might have been taken care of as an infant when the major need was to be fed and sleep (in the early oral stage). However when in the late oral stage he began to crawl and walk, his mobility may not have been liked by the unstable parents. Therefore, the caring, nurturing model of mother 168 Mitra and Sanyal

might have been perceived as aggressive (from Klein’s (1975) point of view this is also around the time of paranoid-schizoid position which could have been poorly handled by the mother. Thus in the oral sadistic phase, the child may have begun to have aggression towards the mother figure. This problem of handling might have increased during the anal stage and he might have received a harsh or non-disciplined toilet training which further sowed the seeds of aggression in him in the anal sadistic stage. A fixation here might have occurred and the libido could not adequately progress to the latter stages, rendering him with a rigid, explosive character structure. Moreover as he had aggression towards the mother figure and libido could not progress adequately to the phallic stage he might have failed to develop the strong oedipal tie with the opposite sex parent. His frustrated libido could not probably progress to form mature object relationships and this results in primary narcissism, probably giving rise to latent homosexuality. Denial of this, probably give rise to paranoid ideations in him and he perceives threat and mistrust everywhere. This might have contributed to the short standing fickle heterosexual relationships in his adulthood. Thus as the above discussion reveals, major fixations occurred during the developmental stages within the individual and the essential ego structure is weak, ridden with conflicts and hostile impulses. Beneath all these probably lies a strong need for succorance – the prototype being laid in the early oral stage as well as in later stages when sometimes the caregivers extended their love, support and warm affection to the growing child. However this conflict ridden ego probably took the side of the id during the adolescent years when the impulses gain in strength due to maturational causes and he displayed impulsive, delinquent behaviour. With maturity he probably realised the futility of such behaviour. When his mother denied him from gaining admission in engineering course, he probably could not handle the ‘rejection’ and the distress, all his aggression were directed inwards, also probably as last cry of help he attempted suicide. From the point of view of Carl Rogers (1961) the current client is also powered by self actualisation motive, but due to faulty parenting, non-conducive environment and need for positive regard the growth of the self actualisation motive has not been optimum and there is conditional self regard. Thus there exists a wide gap between the real self and the actual self, and the self and the organism. He distorts his experiences in order to be in line with his constricted view of self, but through the process of subception, the negative emotions creep in. These features have thus made him to become a person with emotionally unstable personality disorder with features of anankastic personality disorder. Contribution to therapy: The above formulation gives the therapist a wide range of choice about which treatment modality he wants to choose. Moreover it supplies with the insight that even in the short term therapy the transference issues may crop up leading to resistance. He may want to repeat earlier life situations and try to bring about a power struggle and he may experience similar aggressive desires and also sexual ones. If the therapist is aware, he is in a better position to handle this transference and resistance issues and make a meaning from them – no matter which modality of treatment is being used. (Wolberg, 1995)The calm therapist will also be able to satisfy some of his desire for order in life and in the nonthreatening environment he will get a scope to develop his “Self” in a more integrated fashion. The theme of realization of this attempt is that each and every single theory of personality is helpful in understanding the dynamics of a case, as they all have the common thread inside is to understand the distress or profile of a case and help him/her to be in an organized frame of life to make life worth living. References Bandura A.(1969) Principles of Behavior Modification. Holt, Rinehart & Winston, New York. Bandura A: (1997)Self-efficacy: The Exercise of Control. Freeman, New York. Bellak .(1975) The thematic apperception test, the children’s apperception test and senior apperception test in clinical use. Grune & Stratton. New York. Bowlby. J. (1980)Attachment and loss Vol. 3. New York: Basic Books. Cloninger, C. R.; Przybeck, T.R.;Svrakic, D.M and Wetzel, R.D.(1994). The Temperament and Character Inventory (TCI) A Guide to its development and use. Craik, F. I. M., and Tulving E. Depth of processing and the retention of words in episodic memory(1975). Journal of Experimental Psychology: General, 104, 268-294. Dutta, M. M. and Sanyal, N (2009). Adoption of cognitive Behaviour Therapy in probing of A Single Case and Multiple Psychological Theories 169

Unconscious Dynamics: A case report. SIS Journal of Projective Psychology & mental Health, 16, 46-50. Kendel, E. (2005) Psychiatry Psychoanalysis and the New Biology of Mind. American Psychiatric Publishing. Washington DC. Kernberg O.F (1975): Borderline Conditions and Pathological Narcissism. Aronson, New York. Klein M(1975): Envy and Gratitude and Other Works, 1946–1963. Free Press, New York. Klopfer, B., Ainsworth, M.D., Klopfer, W.G. and Holt, R.R., (1954) Developments in the Rorschach Technique: Vol.1, Technique and Theory, World Book Co, (Yonkers-on-Hudson). Kohut H:(1971)The Analysis of the Self: A Systematic Approach to the Psychoanalytic Treatment of Narcissistic Personality Disorder. International Universities Press, New York. Lazarus, A. A. (2005)Multimodal therapy. In J. C. Norcross & M. R. Goldfried (Eds.), Handbook of psychotherapy integration (2nd ed., pp. 105-120). New York: Oxford. Loranger, A. W., Janca. A., Sartorius. (1997)Assessment and diagnosis of personality disorders, The ICD-10 international personality disorder examination. Cambridge universitry press, United Kingdom. Millon, Theodore, and Roger D. Davis.(1996) Disorders of Personality: DSM-IV and Beyond. 2nd ed. pp. 411-12.New York: Wiley. Rogers C.R. (1961): On Becoming a Person: A Therapist's View of Psychotherapy. Houghton Mifflin, Boston. Rogers, T. B., Kuiper, N. A., and Kirker, W. S. (1977) Self reference and encoding of personal information. Journal of Personality and Social Psychology, 35, 677-688. Wolberg L.R, (1995). The Technique of Psychotherapy. 4th ed, John Aronson Inc New Jersey. 170 Mitra and Sanyal

Attempted Suicide: Psychopathology and Wartegg Test indicators S. Daini, A. Manzo, F. Pisani and A. Tancredi In this work we suggest the potential clinical utility of the Wartegg Test, on the pathway of patients attempting suicide. The Wartegg test is a projective procedure composed of eight panels with eight semi-structured stimulus-signs.The exploration of the projective dynamics seems to play an important role in gaining further in knowledge of psychopathological issues, which is the reason why a projective test administered as a simple and fast Wartegg test was chosen. The study comparatively analyzes the differences in the responses given to each test panel, drawn by subjects who attempted suicide, both with and without psychiatric disorders, and by a further group of depressed patients having no history of suicide attempts. The study was also aimed at carrying out an initial exploration of the Wartegg method as source indicators of suicidal risk. The survey sample consists of three groups registered as Attempted Suicide (AS= No. 25), Depression (D=No.29), Control (C=No.29). Groups AS and D consist of patients diagnosed and treated at the Day Hospital Service of the Gemelli Hospital. The control group consists of students of the Gemelli Hospital and other subjects who never received any kind of treatment. In conclusion, our work confirms the importance of the depressive component in suicide attempts, indicating a failure to differentiate between the results obtained by the group of patients who attempted suicide and the group of depressed patients. Significant differences appear to be more relevant for what concerns the control group. In t his comparison, the suicide attempt seems connected to the emergence of a conflict in feelings. Attempted suicide is a phenomenon of wide social significance, whose frequency varies according to age and cultural background. The psychological and social variables which may be taken as risk factors are many. Suicidal ideation or behaviours may appear in various forms in many psychiatric disorders, but suicide is more frequently associated with mood disorders, especially in cases of major depression. The hinge symptoms of its ideation are loss of hope and despair, e.g. often detectable in depression, or a lowering of the inhibition threshold in front of action, e.g. a common symptom in alcohol abuse. Each year suicide causes 1.5% of the 54 million deaths estimated to occur in the world. About two thirds are men, and half are Chinese, despite the Chinese population only accounting for 21.5% of the entire world population. Nowadays, suicide is considered to be one of the three main causes of death amongst individuals aged 15 to 44, for both sexes. Whereas attempted suicides are up to 20 times more frequent. Hence, suicide is obviously considered one of the largest public health problems of our time, also in light of the fact that during the past 45 years the world suicide rate grew by 65%, with a peak of 200-300% amongst the youth (data WHO 2002). It is interesting to note that the mean rate of suicides amongst the population decreases the further south you go. The highest rates of suicide (data WHO 2000) are recorded in Europe, and particularly in Eastern European countries such as Estonia, Latvia, Lithuania, Finland, Hungary, Russia, as much as in Asian countries such as China and Japan. Latin America and Arab countries – e.g. Argentina, Brazil, Kuwait and Thailand – have the lowest rates. African countries do not provide sufficient data for an estimate. In absolute terms, the highest number of suicides occurs in China and India, accounting alone for approximately 30% of the overall number of cases. In general, according to the World Health Organization, risk factors can vary for each continent and country, depending on various cultural, social and economic variables. For instance, every year in the United States – besides the 30,000 suicides occurring – about half a million people needs hospital treatment as a consequence of an attempted suicide. The ratio is higher for women and young people and lower for men and the elderly. In Europe 90% of the 58,000 suicides (World Health Organization 2003) committed annually, plus a large number of attempted suicides, have at their basis a psychiatric disorder, in most cases a clinical depression (Lönnqvist et al., 1988). The data published in 2004 by the European Commission (relating to the number of deaths by suicide which occurred in 1999) have shown that the number of suicide cases varies greatly from country to country. The citizens who less exposed to this risk seem be those living in Mediterranean countries such as Greece, Portugal and Italy (8.3 suicides per 100,000 inhabitants), while S. Daini, A. Manzo, F. Pisani and A. Tancredi, 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: Attempted Suicide, depression, personality, Wartegg Test

the incidence of suicide seems to be particularly worrying in northern Europe, for example in Lithuania (43.7 cases per 100,000 inhabitants). In 2004, in Italy (ISTAT report) suicide had a rate of 5, 6 / 100.000 people, with prevalence in the north eastern regions and much lower values in southern Italy. The Italian region recording the highest rate is Friuli Venezia Giulia, with a percentage of 9,8%, and the lowest is Campania, with 2,6. Again in the year 2004, less than 1 percent of subjects that acted suicidal behaviour had 18 years of age, a little less than twothirds were in working age (18 to 64 years of age) and more than a third was over 65. The suicidal tendency hence increases in percentage as the age increases. According to a 2005 European Commission report, every year there are about 58,000 cases of suicide occurring within the European Union. According to the research data, more men commit suicide than women, with age peaks ranging between 15 and 24, and between 25 and 34. In 2007, in Italy, the estimate number of suicides per year ranged between 3,500 to 4,000. The complexity of the phenomenon is due to the interaction of multiple variables which are not always identifiable, making the phenomenon difficult to study. Also because, in social contexts where such as an act is condemned by cultural or religious principles, family members – or the patients themselves if survivors – tend to hide it and to avoid reporting the circumstances accurately. The relevant literature describes primary, secondary and tertiary Risk Factors (Rihmer et al 1996) as conditions and events showing a statistical correlation with suicide. In particular, primary risk factors are represented by Psychiatric disorders such as mood disorders, schizophrenia, drug abuse, or personality disorders such as borderline and antisocial behaviour, etc. Negative Life Events at a level of family, work, and health, are defined as secondary risk factors. Tertiary risk factors are represented by demographic variables. Moreover, risk factors may be divided into short-term and long-term, biological-clinical, and socio-demographic factors, and into generic risk factors or precipitating factors (Hawton 1987; Heikkinen et al 1993). These factors categories frequently intersect and overlap, and are closely interconnected. Risk factors are considered to have a predisposing nature. They act as acute precipitating factors, but are not considered to be necessary and sufficient in themselves; while chronic risk factors associated with acute events seem to be a necessary and sufficient condition for a suicide to occur (Rich et al 1986 Meneghel and De Leo 2002). Other studies focus more on the definition of personality traits that can enable the prediction of suicide attempts. In most cases, objective personality tests investigating the personality structure have been used, such as MMPI, or stairs, created to identify personality traits like anxiety, anger, aggressiveness and impulsivity. Gieglin et al. in 2009 have conducted a study analysing the components of anger, aggressiveness and impulsivity, temperament, using self report stairs as a state-trait anger expression inventory (STAXI), Questionnaire for measuring aggression factors , FAF) and temperament/character (temperament and character inventory, TCI). They conclude that impulsivity and avoidance of damage (harm avoidance) are personality traits associated with auto-aggressive tendencies and that anger and self-directedness increase the likelihood of a suicide attempt. Other studies have used projective techniques to highlight personality traits tracers of the likelihood of suicide. Grava et al. demonstrated, through the administration of two projective tests – Rorschach and the Object Relation Technique –, that higher depression and borderline personality disorder have a strong relation with suicidal behaviour, when associated with a negative personal life balance. The Rorschach Comprehensive System's suicide constellation (S-CON; Exner, 1993; Exner & Wiley, 1977) has been validated by many studies that used it, proving the highly predictive nature of this composite index. For example, Fowler et al. verified a high predictive validity of S-CON, particularly in patients with serious psychiatric disorders. The research sample included 104 subjects, amongst patients who had attended the Austen Riggs Center, with an average age of 29.3. The control group was formed by University students. Researchers explored the diagnostic efficiency, using a cut-off of 7 or more for the S-CON indicator: this level successfully predicted which patients would implement suicide attempts, compared to parasuicidal and non-suicidal patients, and to students. Another study examined the predictability of behaviour ideation in teenagers via the Human Figures Drawing (HFDT), stressing the possibility of using this projective technique as a detector of a suicidal trend (Zalsman et al.; 2000). The research sample was composed of thirty-nine teenage patients hospitalized after suicidal behaviour, and another 51 who had been hospitalized for other reasons. All participants performed HFDT. The authors analyzed the sample of adolescents with suicidal behaviours (n.19) and with suicide attempts (n.20), and compared it with the group of adolescents with other diseases 172 Daini et al

(n.51). This analysis yielded significant differences in test scores, mainly consisting of regression indicators. The indexes significantly associated with the risk of suicide were failure of defences (unstable lines), deficit of impulse control, immature drawings), psychosis indicators (symbolic rather than realistic images; shading, sharp lines), aggressiveness signs (nails emphasized). HFDT depression indicators (figures small, empty, undifferentiated, positioned in low or in corner in the top left of the sheet) were not significantly associated with suicide in this study. The authors interpreted this constellation of indices, expressing the character and an impulsive behaviour, as an angry ideation in adolescents. The Wartegg test has not been investigated in terms of its predictive validity regarding suicidal behaviour. The purpose of our research was to study Wartegg differences between subjects who attempted suicide and subjects without psychiatric pathologies, and further compare them with a group of depressed subjects with no history of suicide attempts. The exploration of projective dynamics was an important part in the knowledge of psychopathology, to guide the therapeutic approach. Another aim of the work was to carry out a first exploration of the Wartegg method as a source of suicide risk indicators, considering Wartegg is simpler and quicker to administer in emergency situations compared to other projective tests. Methods: Participants and procedures: Three groups of subjects participated in the study: Attempted Suicide (AS), Depression (D), Controls (C). AS and D groups consisted in patients treated at the Day Hospital Service (DH) of the Gemelli Hospital. C group consisted in healthy subjects, who never received treatment for psychiatric disorders. The AS group was composed of 25 subjects (5 men and 20 women; mean age 36.58 ±14.66). Five of them were already following a psychiatric or psychological therapy when the attempted suicide had occurred, while the others had contacted a psychiatric facility only after the suicidal episode had happened. In terms of clinical stories, only 5 subjects had repeatedly attempted suicide. The time distance between the suicide behaviour and the administration of test was of six months. All subjects presented psychiatric comorbidity: depression in 10 subjects, eating behaviour disorders in 2 subjects, and histrionic or borderline personality disorders, obsessive Attempted Suicide : Psychopathology 173 Table 1 Samples Characteristics

Group

Sociodemographic Variables

AGE (mean±SD) 36.58 ±14.66 37.28±10.48 39.95±11.26

Gender (M/F) 5/20 5/24 9/20

EDUCATION%

Secondary school 29.41% 16% 4.76%

High school 65.29% 60% 61.90%

Degree 5.88% 24% 33.33%

OCCUPATION%

Unemployed 22.22% 13.64% 6.90%

Student 22.22% 18.18% 13.79%

Dependent work 11.11% 31.82% 31.03%

Employed 33.33% 22.73% 17.24%

Professional 5.55% 13.64% 24.14%

Pensioner/retired 5.55% Nil 6.90% Attempted Suicide (N=25) Depression (N=29) Controls (N=29)

the perceptive function and the associative processes of the subject. It describes his symbolic ability to perceive and process stimuli in the environment. The scores vary between 0 if the evaluation of the picture completely fails the stimulus-sign of the panel; and 1 if the evaluation fully integrates the stimulus-sign. The Affective quality evaluates the connotative meaning of the content of the drawing. The AQ describes the affective trend and quality of the subject’s relation to the environment. The scores vary between 0 when the subject draws emotionally negative content; and 1 when the subject draws emotionally positive content. The Formal quality evaluates the cognitive integrity of the subjects compared to their reality testing. The scores vary between 0 when the meaning is unclear or unrecognisable; and 1 when the meaning is immediately recognisable. The Anxiety Index varies between 0 and 1. It is the ratio between the eight panels and those with deleting or blackening. The Impulsivity index varies between 0 and 1. It is the ratio between the eight panels and those with an overtaking frame, where the drawing exceeds the panel margins. Global Refusal is a particular phenomenon. The subject refuses to draw anything at all in a panel. Statistical Analysis: We first observed that the sample was homogeneous for age and gender variables, so we decided to use the statistical method of variance analysis (ANOVA) in order to analyse the group’s incidence (factor or independent variable) for every dependent variable, and the Duncan‘s post hoc test to explore the differences in terms of group means. Statistical elaboration was performed with an SPSS 13.0 program. Results: Table 2 shows ANOVA results for fundamental indexes of the Wartegg test. Affective quality (AQ) yields significant differences: subjects who attempted suicide showed significantly higher means than those of the Control group ( F=3.739; p‹.05 ). A further analysis of AQ in terms of the Ego and Es areas highlighted that the difference depends on the Ego area (F=3.574; p‹.05), since there appear to be no significant differences at the level of the Es area between the AS group and the C group. disorder, delirium. In 5 cases, suicidal behaviour had occurred after an affective abandonment, while for the others there was no evidence of a chronological correlation with a traumatic event. The most frequent way to attempt suicide, for both men and women, was that of taking inappropriate medications. In one case, a fire-arm was used, and another one case toxic substances were assumed. D group consisted of 29 subjects (5 men and 24 women; mean age 37.28±10.48). All subjects presented a clinically relevant depression status, in some cases comorbid with other mood disorders or eating behaviour disorders. C group consisted of 29 subjects (9 men and 20 women; mean age 39.95±11.26 ). Sample characteristics are shown in Table 1. Measures: The Wartegg test is a projective procedure. It is composed of eight panels with eight semi-structured stimulus-signs. The subject is invited to draw a meaningful picture for each of the eight panels starting from the stimulus-sign. Through these stimulussigns, each panel suggests different psychological dimensions and elicits answers in profound areas of personality (Wartegg, 1957). From an integration of different proven interpretations in several studies (Falcone et Al., 1986), we can describe the panel’s characteristics as the following: panel 1 is related to the actual state of identity; panel 2, vitality and sensibility; panel 3, ability to direct own psychic resources towards aims and objectives; panel 4, relation to rules and authority; panel 5, directionality of aggressive dynamics; panel 6, integrity of reality testing; panel 7, relation to femininity; and panel 8, social relations. The tests were codified by independent scorers according to the A. Crisi scoring system (Crisi, 2007). The Evocative character (EC), the Affective quality (AQ), the Formal quality (FQ) of graphic answers for each of the eight panels of all 83 tests were determined. For each test the EC, the AQ, the FQ total index and the Anxiety Index, and the Impulsivity Index were calculated. Each index was also subdivided into an Ego area index and an Es area index. The number of Global Rejections was then calculated for each test panel. The Evocative character gives information on how the subject, both from a purely perceptive-gestalt and associative point of view, reacts to the stimulus-signs of the test. The EC focuses on 174 Daini et al

Another significant difference was found in Vulgar answers: Attempted Suicide group showed significantly higher means than those of both the Depression and the Control group (F=4.640; p‹.01). This difference too only depends on the Ego area (F= 4.689; p‹.01). The study found no significant means differences for what concerns the Anxiety Index, and the Impulsivity Index. For what concerns the Refusal frequencies to the Wartegg panels, a compared analysis between the groups highlighted the absence of rejects in the Control group and a significant difference between the Control and Attempted Suicide group. The means of the AS group are indeed significantly higher than those of the C group (F=3.387; p‹.05). In terms of the distribution of Refusals for the eight Panels, no significant differences were found. Table 2 ANOVA Diagnosis (Attempted Suicide Group, Depression Group, Control Group) Group AS ( N=25) D (N=29) Controls (N=29) F Duncan Variables mean±SD mean±SD mean±SD Value Post-Hoc Test

EC 68.50±17.07 64.34±16.18 71.77±16.33 0.293 -

AQ 58.75±17.68 63.58±13.16 69.40±12.08 3.739 AS<C*

FQ 72.84±19.87 75.19±22.97 79.31±13.37 0.800 -

V 37.25±23.67 25.86±13.54 24.35±11.85 4.640 AS>C**, AS>D**

ITI 0.52±0.47 0.61±0.57 0.59±0.43 0.240 -

II 0.17±0.20 0.18±0.20 0.18±0.20 0.70 -

IA 0.38±0.39 0.42±0.42 0.43±0.36 0.93 -

GR 0.52±1 0.14±0.74 0.03±0.18 3.387 AS>C* * P<0.05; ** P<0.01 Discussion: In studies on suicide behaviour, psychological and dynamic observations must be carried out after the attempt has occurred, and this represents a methodological and interpretative problem. Indeed, these observations will also include the reactions to the event and its traumatic consequences (emergency visits and subsequent therapies, psychological reactions of the family and of the social context, and the considerations of the Subject himself/herself on his/her suicidal behaviour). The elaboration of this kind of dynamic content requires a long process. Moreover, the suicide ideation is highly frequent in depressed patients, but these patients rarely act out the suicide (Moscicki, 1995; Remberg, 2001). Our study, just like Zalsman’s study, does not highlight many differences between patients who attempted suicide and depressed patients, confirming the importance of depressive components in attempted suicide. If we compare attempted suicide patients with depressed patients, the significant difference we observe regards the higher frequency of Vulgar answers in the first group. Subjects who attempted suicide seem to gloss over the common way to feel about things, mainly for what concerns their own identity, and their ability to organize their lives and think rationally about things. In overall terms, this could mean that subjects who attempted suicide do tend to rationalize, but they do it ineffectively, disinvesting from both their relationship with the external reality and from that with their own deeper instances. A dynamic with external reality, which is totally or ambivalently refused, is inherent to attempted suicide: the Wartegg test seems to confirm the existence of this dynamic of reject as consequence of unconscious conflicts. This could explain why significant differences are observed only in the Ego area. The fact that tests are completed after suicide has been attempted could explain the absence of Attempted Suicide : Psychopathology 175

group differences in the Impulsivity Index. Suicidal behaviour could have a cathartic function regarding deep conflicts. So subjects who attempt suicide may show an Impulsivity Index on the average. An alternative interpretation could be that of taking into consideration the age of the subjects. Our sample was mainly made of adults, who are less impulsive towards projective test, unlike other samples like adolescents. On the other hand, significant differences appear between the Attempted Suicide and the Control group. The attempted suicide group seems to be associated with affective conflicts onset, as suggested by the higher means in the AQ of the Ego area. The association is observed also when the attempted suicide is not historically connected with abandonment by an important relational figure. This affective object role could be represented by any other psychological object (work, hobby etc.). Again compared with the Control group, the higher frequency of Global Refusal of subjects who attempted suicide could imply both a test disinvestment and a communicative difficulty of these subjects. In the first case, this dynamic data seems to show a possible resistance toward carers, whereas in the second case it could be associated with a relational disinvestment attitude. In fact, clinical experience suggests that this specific group tends to have both a difficulty in disclosing with other persons and a difficulty and ambivalence in accepting psychological care. Within this comparative analysis, depressed subjects hold an intermediate position between subjects who have never treated and subjects who attempted suicide. Further studies could explore the vulgar answers and the Global Refusals roles as indicators of suicide risk in the Wartegg test. References: Crisi A.: Il Manuale del Test di Wartegg. Magi Edizioni Scientifiche - 2007 Exner, J.E. (1993), Structural data IV. Special indices, in J.E. Exner, The Rorschach: A Comprehensive System. Vol. 1. Basic foundation (3rd ed., pp. 453-458), New York, John Wiley. Exner, J.E., Wylie, J. (1977), Some Rorschach data concerning suicide, Journal of Personality Assessment, 41, 339-348. Fowler J. C., Piers C., Hilsenroth M. J., Holdwick D.J. Jr., Padawer J. R.:The Rorschach Suicide Constellation: Assessing Various Degrees of Lethality. Journal Of Personality Assessment, 76(2), 333–351Copyright © 2001, Lawrence Erlbaum Associates, Inc. Giegling I., Olgiati P., Hartmann A. M., Calati R, Möller Hans-Jürgen, Rujescu D., Serretti A.: Personality and attempted suicide. Analysis of anger, aggression and impulsivity. Journal of Psychiatric Research xxx (2009) xxx–xxx Grava G., Berti Ceroni G., Rucci P., Scudellari P.: Suicidal Behaviors and Personality Structure. Suicide and Life-Threatening Behavior 36(5) October 2006 569  2006 The American Association of Suicidology Hawton K: Assessment of suicide risk. British Journal of Psychiatry, 1987, 150, 153-154; Heikkinen M,Aro H, Lonnqvist J: Life e v e n t s and social support in suicide. Suicide Life- Threatening Behaviour, 1993, 23, 343- 358. Lönnqvist J, Koskenvuo M. Mortality in depressive disorders; a 3-year prospective followup study in Fin¬land. In “Depressive illness: Prediction of course and out¬come”. TDR Helgason (Ed)., 126-130, 1988. Martinotti G., Mandelli L., Di Nicola M., Serretti A., Fossati A., Borroni S., Cloninger C. R., Janiri L.: Psychometric characteristic of the Italian version of the Temperament and Character Inventory—Revised, personality, psychopathology, and attachment styles. Comprehensive Psychiatry 49 (2008) 514–522 Meneghel G., De Leo D.: Il comportamento suicidario negli adulti e negli anziani. In: De Risio S, Sarchiapone M (eds) Il Suicidio. A s p e t t i biologici, psicologici e sociali. Masson, Milano, 2002 Moscicki EK.: Edidemiology of suicidal behavior. Suicide Life- Thraet Behav 25. 22-35, 1995. Renberg ES.: Selfreported lifeweariness, death- wishes, suicidal ideation, suicidal plans and suicide at¬tempts in general population surveys in the north of Swe¬den 1986 and 1996. Soc Psychiatry Paychiatr Epide¬miol 36 (9) : 429- 436, 2001. Rich CL,Young D, Fowler RC: San Diego suicide study: I.Young vs old subjects. Archives of General Psychiatry, 1986, 43, 577- 582. 176 Daini et al

Rihmer Z: Strategies of suicide prevention: focus on health care. Journal of Affective Disorders, 1996, 39, 83-91. Zalsman, Gil M.D.; Netanel, Relli M.D.; Fischel, Tsvi M.D.; Freudenstein, Ornit M.A.; Landau, Edwina B.A.; Orbach, Israel Ph.D.; Weizman, Abraham M.D.; Pfeffer, Cynthia R. M.D.; Apter, Alan M.D. :Human Figure Drawings In The Evaluation Of Severe Adolescent Suicidal Behavior”. Journal Of The American Academy Of Child & Adolescent Psychiatry: August 2000 - Volume 39 - Issue 8 - Pp 1024-1031; World Health Organization. The World Health Re¬port 2003

www.istat.it/dati/dataset/20090703_00/ Attempted Suicide : Psychopathology 177 Important Announcement Dr. Amool Ranjan Singh has taken charge of the office of Editor In Chief SIS JOURNAL OF PROJECTIVE PSYCHOLOGY & MENTAL HEALTH From January 2006 because Prof. B. L. Dubey has been shifted from Chandigarh (India) to U.S.A. Institutional Members (Libraries of National and International Universities) are requested to send their Annual Subscription/Dues to Dr. Amool Ranjan Singh, Ph.D., Professor and Head, Department of Clinical Psychology, Ranchi Institute of Neuro-Psychiatry and Allied Sciences (RINPAS), Kanke, Ranchi - 834 006 (India) The Subscription Cheque should be made in favour of “SIS Journal of Projective Psychology & Mental Health” payable at Ranchi (India)

SIS-II Profile of Patient with Antisocial Personality: A case report Kiran Bala, Deepak K. Mishra and Masroor Jahan This is a case report of 20 years old male, educated up to ninth standard, taking alcohol, ganja, brown sugar (smack), cigarette, and tobacco from last 5 yrs. According to ICD-10 he was diagnosed as a case of Mental and Behavioral Disorder.. On psychological evaluation he was guarded and nothing could be elicited except inadequate parenting and family problems. However, on SIS he could not conceal his personality and antisocial traits. The diagnostic /treatment applications of this projective interview aide are the main objective of this case history presentation. Index patient a 20 years old male, studied up to ninth standard with no past history of physical or mental problem. All of his birth and developmental milestones were normal. However, he started stealing money from home for ice-cream and chocolate in childhood. He was poor in studies. He lost his father at the age 2. His mother is working and able to take care of family. He is the youngest and only son amongst four siblings. He is a pampered child and the mother will take his side even when he is wrong. She would try to fulfill his demands. Since she is away to work, she does not know how he spends his time and who others are accompanying him. Family relationship inventory was administered to assess the nature and quality of the patient’s relationship with his mother. The results suggest that his mother never let him act independently and take responsibility. He is overprotected and controlled by mother with lots of restrictions. She has high expectations from him particularly good academic performance. He was a poor student until class 9th and after that he discontinued schooling. During class 9th, he came in close contact with some boys and learned using Cigarettes and Ganja. With friends he developed bulling others and kept un licensed country made pistol in his possession. Once he fired on a person after argument and caught by police. The person luckily escaped injury. He also started taking brown sugar 1 packet per day (at night) and the dose increased slowly and currently he is taking 6-7 packets per day. He started taking alcohol, Ganja, Cigarette and Indian tobacco. He feels giddiness, decreased sleep, weakness, shivering and dry mouth without drugs .He started assaulting his mother physically when she refused money to him. He will also threaten her to commit suicide if she refuses giving him money. The parenting stress index was administered to identify the development of the dysfunctional parenting behavior or behavior problems in the person involved. The results suggest extreme distress in the areas of personal parental distress. The mother perceives that he does not meet her expectations. This mother projects the feeling that the patient is a negative element in her life. Commonly, her description of the parent-child relationship suggests that she either sees herself as rejected by the patient, or she is disappointed in and feels alienated from the patient. The results further suggest that the mother perceives him as a difficult child. He has been showing defiance, noncompliance and demanding behavior since childhood. After six months of extreme distress, her mother decided to admit him in Central Institute of Psychiatry, Ranchi for treatment. His present symptoms included taking multiple substances i.e. alcohol, ganja, brown sugar (smack), cigarette and tobacco for the last 5 years along with aggressive, abusive behavior and criminal activities for the last 6 months. Based on clinical picture as per ICD-10, he was diagnosed as having Mental and Behavioral Disorder due to multiple drug use and use of other psychoactive substance with dependence pattern. On EEG no abnormality was found in cerebral activity. As part of the psychological assessment, he was administered the Rorschach and the Somatic Inkblots Series. The findings are discussed ahead: RorschachTest: The test was administered to assess the patient’s structure of personality. He took usually long time to respond the inkblot images. The total number of responses with poor form were much below average indicating that is not paying proper attention to the stimuli and is reluctant to respond. Absence of movement responses indicate his inability to use internal resources to cope with the demands of the surroundings. Very few color responses indicate to his inability to feel and express emotions and enjoy life. Presence of more white space response may indicate Kiran Bala, Ph.D. Scholar, Central Institute of Psychiatry, Ranchi, Deepak K. Mishra, Ph. D. Scholar; Masroor Jahan, Associate Professor; Dept. of Clinical Psychology, Ranchi Institute of Neuro Psychiatry and Allied Sciences, Kanke, Ranchi-834006 (India). Key Words: multiple substance dependence, antisocial traits, SIS-II profile

clinically significant suspicious tendency. Content analysis suggests his restricted range of interest in the surroundings. Absence of human responses indicates poor interpersonal relations and no feelings for others More anatomical responses might indicate somatic preoccupation and absence of popular responses indicates poor social conformity and psychotic preoccupation.. Affective ratio indicates to his shallow emotionality and EB ratio indicates to his extroversive trend of personality. SIS Responses: The three least liked images in order: B 31: “People standing close, a bad practice” This image brings out the imagery of “Happy Family- Father, Mother and two Children” but he has avoided seeing a family because of the broken/disturbed family relationships. B 11: “Lady’s breasts exposed” might be indicating his desire to see a naked lady than the usual anatomical imagery. Therapist should enquire his sexual exposure with females, which is often seen in drug addicts. B 27: “Babies’ body” is a normal response. The three most liked images in order: A 7: “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. A 10: “Two eyes” may indicate his suspicious tendency. A 31: “A woman scolding her son” signifies his own projection of the situations and unwanted action for which he has been scolded by his mother. Analysis of a few significant responses: A 8: Rejection of this card may indicates sexual conflict. A 9: “A man and a woman” is a normal response but without any interaction may suggest poor relationship particularly with mother. A 16: Two birds making love” is a good response and may also indicate his wishful thinking to have love relationship. A 21: “A man dancing and two children looking at him” is a good response might take him back in time when he had good relationships with her mother and siblings. The therapist should take it as a sign of good prognosis. B 4: “A man telling something to the other person very secretly” may indicate his suspicious tendency. B 5: “A man demonstrating a pistol to other person” indicates his aggressive and hostile attitude. Such behavior should be addressed during psychotherapy. B15 and B 21: Rejection of these images which brings out aggressive response might indicate his effort to avoid perceiving Knives and Pistol. B26: “Headless body” signifies the inherent aggressive feeling. Such responses are also seen in psychotics. B 28: “Two ladies in distress” may indicate his wishful thinking to see his mother and sisters in distress. Usually people perceive “Mother with Child” on this image. The short term treatment plan involved improving coping strategies, family intervention and supportive psychotherapy supplemented by introducing SIS symbolism in the therapeutic process. This combination appeared to have marked therapeutic effects. The family members have reported considerable improvement after therapeutic intervention. Long term therapeutic goals will be behavior modification and rehabilitation of the patient. Conclusion: The patient was 20 years old male, studied up to ninth, with no past history of physical or mental problem. All of his birth and developmental milestones were normal. However, he started stealing money from home at about the age 8. He was poor in studies. He also used to become very aggressive at minor provocation.. On psychological evaluation he showed disturbed interpersonal relationship with mother and sisters. Therapeutic intervention has shown significant improvement. The projection on Rorschach and SIS images has been discussed in the paper. SIS-II Profile of Patient with Antisocial Personality 179

Rorschach Profile of Indian Adults Shweta, R. C. Bajpai, K. S. Sengar, Amool R. Singh and N. G. Desai The present study aimed to develop the normative data on Rorschach Test and present a comparative view of Indian male and females. Subjects for the study were taken from Delhi by using systematic random sampling technique. The Rorschach Ink Blot Test was administered on 238 subjects, consisting of 130 male and 108 females by following Beck system of administration. Chi-square, t-test and U-test were computed to compare the Rorschach variables. Result obtained on Rorschach protocol of normal Indian adults does not show significant difference between Male and females except on two variables-Dd and Sex. Results are in contrast with western norm and to some extent with Indian studies also. In addition religious responses on Rorschach Test focus on some newer type of content and opened new dimension of further research. In the absence of any standardized Indian norms, analysis and interpretation of Rorschach protocols would be mala-fide. So, the foremost work will be to set standard Indian norms which may comply with parameter of Indian socioculture settings. Projective Personality test, such as the Rorschach frequently has been used cross culturally with varying degree of success. Many studies suggest that particular language strongly influences the shape and form of perceptions. In cross cultural studies on Rorschach harvested some differences in perception as a result of cultural influences (Moon and Cyndick; 1983). Banks (1997) maintained that cross cultural misdiagnosis and erroneous assessment often when evaluators from a dominant cultural group test participates from a less powerful group using instruments that originated in the dominant culture (Frank, 1994; Krall et al, 1984). Application of Rorschach test has been explored by many researchers in various situations. A number of scoring systems has been evolved to aid scoring, interpretation and diagnostic formulation. A comprehensive review of literature on Rorschach is indicated that researchers are still in search of uniformity. The responses of normal Indian subjects significantly differ from the western norms and the interpretation of Rorschach protocols of Indians using these norms would be fallacious and misleading (Pershad et al,1979, Dubey,1982,Chaudhury et al 2006). The Rorschach protocol of Indian population should be interpreted by using Indian norms. Indian clinician and researchers strongly feel that there is need to develop Indian norms on a large population which can help in diagnostic evaluation as well personality assessment as it differs from Beck’s finding (Singh et al 2004). It has been a known fact that social and cultural situation predominantly influences behaviour and this is also true with projective responses (Boykin, 1986; Jones, 1991).The Rorschach test is used in various national and international psychological studies for assessing personality and psycho-diagnosis. There are a few studies attempted to develop the norms needed to score and interpret Rorschach Inkblot Protocol of Indian population. The present study is an exclusive manoeuvre regarding score wise data presentation. This is a pilot study comprising 238 subjects (130 male and 108 female. Material and Method: Two hundred and thirty eight normal adults (both male and female) in the age group of 20 to 30 years, with the minimum qualification of 10th standard and have no history of any physical or psychological illness were taken for the study. The subjects having positive family history of mental illness were also excluded from the sample. Each subject was interviewed individually and demographic details were collected. The GHQ -12 was administered to screen out the well being of the participants. Those who scored below cut off point (≥2) were included in the study. The Rorschach Inkblot Test was administered following the Beck procedure (Beck; 1961). Data was coded, entered and analyzed using SPSS package (version 16.0) and presented in percentage. Chi-square test was used for evaluating association between gender and socio-demographic characteristics and t test / Mann-Whitney U test was used to establish the relationship between two genders and different variables of Rorschach. ‘P’ value for the level of significance was calculated and the same less than 0.05 was considered. Shweta, M. Phil, Senior research fellow (Clinical Psychologist)), R. C. Bajpai, MSc, Ph.D, Senior research fellow (Biostatistics), Dept of Psychiatry, IHBAS, Delhi, K. S. Sengar, Ph. D., Assistant Prof., Amool R. Singh, Ph. D. Professor & Head Department of Clinical Psychology and Psychiatric Social Work, RINPAS, Ranchi, (India) and N. G. Desai Director, IHBAS, Delhi, (India). Correspondence to: Dr. K .S. Sengar, Department of Clinical Psychology, RINPAS, Kanke, Ranchi – 834006. INDIA. Cell: 91 9431769001,Email: kssengar2007@ rediffmail.com Key Words: Rorschach Norm

Results: The demographic data of Male and Female groups have been presented in Table 1. Rorschach Profile of Indian Adults 181 Table 1 show that almost two third of the subjects were in the age group of 26 to 30. The majority of the subjects were Hindu, unmarried, graduate and belonging to nuclear family. No significant difference was found in age, religion, marital status, family type, education and family income except employment and occupation between male and female groups. This difference is apparently understandable in the contest of socio cultural structure where males normally take employment and are family head. Table 2 shows that the total number of Responses did not differ significantly between Male and Female groups. Similarly except Dd responses, no difference was found on W, D, DS, D, Dds. Also,no difference was noticed on M,C Sum, C,CF,FC and F+% between Male and Female groups. Amongst the Content categories, except Sex responses, no difference was found on H, A+%, Botanical, Anatomical, Cloud, Land scape, Blood, and Religion between the two groups. Scores on Popular (P) responses also did not differ significantly in the two groups. Table 1 Socio-Demographic Profiles of the Participants Socio-demographic Characteristics Male N=130 Female N=108 χ² value (df) P-value Age in years 20-25 26-30 0.001(1) 0.979 Marital status Married Unmarried 2.125 (1) 0.145 Type of family Nuclear Joint 0.331 (1) 0.565 Education Up to 10th Up to 12th Up to graduate Postgraduate & above 4.204 (3) 0.240 Employment Status Employed Unemployed 16.326 (1) 0.000* Occupation Gainfully not employed Student Job Business / Professional 8.979 0.030* Monthly Family income in Rs. ≤15000 15001-30000 30001 & above 0.311 (2) 0.856

Table 2 Gender Wise Comparison of Rorschach Variables

Gender N=238 Male (n=130) Female (n=108) P- value

Variables Mean (SD) Mean (SD) Mean (SD) (P<0.05)

R 26.81 (4.92) 26.79 (4.82) 26.82 (5.07) 0.9611

W 4.17 (2.15) 4.32 (2.19) 4.0 (2.07) 0.2601

D 18.75 (4.58) 18.36 (5.09) 18.5 (4.81) 0.9831

DS 0.99 (0.92) 0.99 (0.94) 0.99 (0.91) 0.9352

Dd 1.88 (1.17) 1.74 (1.06) 2.05 (1.26) 0.0292

Dds 1.01 (0.89) 1.0 (0.89) 1.03 (0.89) 0.8112

M 3.21 (1.56) 3.25 (1.35) 3.16 (1.79) 0.6641

C sum 2.75 (1.72) 2.79 (1.64) 2.71 (1.81) 0.7491

C 0.74 (0.72) 0.79 (0.74) 0.68 (0.69) 0.254

CF 0.85 (0.88) 0.89 (0.81) 0.81 (0.93) 0.2952

FC 1.17 (0.92) 1.12 (0.85) 1.23 (0.99) 0.5912

F+% 59.72 (6.57) 60.07 (6.94) 59.29 (6.09) 0.3601

H 3.89 (2.02) 4.09 (1.98) 3.66 (2.07) 0.0682

A+% 37.17 (12.19) 37.37 (12.85) 36.94 (11.39) 0.7891

Bt 1.35 (1.03) 1.39 (1.05) 1.29 (1.01) 0.5412

An 0.96 (1.08) 1.0 (1.21) 0.92 (0.91) 0.9042

Sx 0.63 (0.79) 0.72 (0.77) 0.53 ( 0.83) 0.0162

CI 0.93 (0.76) 0.93 (0.79) 0.94 (0.73) 0.8492

Ls 1.14 (1.07) 1.12 (0.98) 1.13 (1.08) 0.8282

BI 0.88 (0.74) 0.90 (0.74) 0.86 (0.74) 0.6522

Rl 0.81 (0.86) 0.81 (0.86) 0.81 (0.96) 0.9862

Pp 3.24 (1.31) 3.30 (1.27) 3.16 (1.36) 0.4041 1. ‘t’ test is used 2. Mann-Whitney ‘U’ test is used and p < 0.05 is taken as significant. Discussion: The personality assessment is very sensitive and difficult issue. Beck aligns himself with the theoretical construct of three basic schools of thoughts. The first is represented by Hughlings Jackson in the field of neurology. The second is the Freudian psychoanalytic movements which focuses the interaction between ego and id and third, is the Gestalt psychology of Levin. This interpretation is inherent in the quantitative ratios between F+, C-Y, M, W-Z against one another in one multi dimensional set of operation. The various clinical manifestation of the individual is interestingly intelligible. There are the characteristics of the person which makes everyone distinct from other in the means of their behaviour, attitude and emotions. The Rorschach test undertakes to test the whole human personality and provide four sets of data. (i) The psychological structures (ii) Current functioning (iii) The adaptive solution of the person of his life problems and (iv) The information as to premorbid events. 182 Shweta et al

The productivity on the Rorschach protocol had been remained prime concern of the clinicians (Dubey, 1982, Fiske and Baugman,1953) Rorschach holds that an average of less than one response per card is inadequate and not useful for diagnostic purposes. However, if you follow content analysis, even only a few responses and the rejection of the cards might give sufficient clue to understand the psychopathology of the case (Cassell and Dubey,2003). Most of the earlier Rorschachians do not agree on interpreting if the protocol contains less than fifteen responses for diagnostic purposes. The average number of responses for normal group are 26.81 ± 4.89, is slightly lower than the findings of Asthana (1963; 1971), Prabhu (1967) and Beck (1961) but higher than Kumar (1961), Dubey (1979), Singh (2004) and Chaudhury (2006). The productivity on the Rorschach is one important variable which also reflects the intellectual endowment of the individual’s. This slight lowered trend of total number of responses / productivity in the present study might have been influenced by the socio cultural background. Results further indicate that the females have given more responses than males though the difference was not found to be significant. Beck (1961) suggested that the protocol should be approached from both the qualitative and quantitative aspect. He further indicated that W responses are related to intellectual potential and suggested that the average length of the protocol of 30 Responses should contain 6 W, 20 D and 4 Dd. Rorschach (1921) originally believed that the Whole responses reflect as index in the person’s ability to organise, analyse, synthesise the concept and integrate his environment. He regarded the Whole responses as the key stone of intellectual functioning and potential of intellectual projection too. The present investigation reveals that the lesser mean value of W responses (4.32 ±2.15) in comparison of Beck’s finding (W: 5.50) is reasonably sound because both culture nurture and shape people’s thought and ideology in different form, and this might be contributing to their thought pattern. Results of this study further suggest that the percentage value of indices in this study are more similar to the findings of the earlier studies conducted in India. The detail response (D) has been interpreted as representing sense of clear recognition of crude fact rather than a drive for daring combination, or a sense for unusual aspects of nuances. The D is considered to the “common sense approach to the life”. It represents the practical, everyday common sense application of intelligence, an interest in the presented obvious fact which deals with the stress tolerance, tackling stressful situation successfully in the life of the individual. The D score of this study is also little lower, 18.36 ± 5.09 than the Beck’s norms (22.85). The lower D responses indicates that the person lacks recognition of everyday problems, is unable to differentiate between the obvious facts. Once again the lower pattern of D responses in Indian population reflects the more united psychosocial comfort and community bindings which help the individual to face the life challenges in comparison to fast, stressful and more competitive life style of western community. The Dd responses were interpreted by Rorschach, to imply critical attitude in healthy manner, if maintained in adequate proportion to other location scores. Over emphasis of Dd might suggest hyper criticality or even obsessive ness. Over emphasis of Dd responses also suggest an insecurity against which the individual defends himself by clinging to limited areas of certainty and fear of losing his bearings while under emphasis is suggestive of low level of interests in the minutia of his experience. The value of Dd responses (1.88±1.74) is reported lower than the Beck’s original scores of 3.02. The significant difference has been found between male and female group on Dd responses and the females have been found significantly higher than males. The Women in India mostly live in traditional family systems, where Male prevail more freedom and dominating role. The over emphasis on Dd response might have resulted from such reason. In the determinant category only F+%, M, C, CF and FC were included in the study. The Form of the blot is most important determinants in Rorschach interpretation. These are called good Form or poor Form. The F+% are perceived as the most reliable index of the conscious control and respect for reality / Ego (functioning). This is conceptualized based on the psychoanalytic theory. Psychological adjustment is enhanced with individual capacities to view themselves in favourable ways that maintain adequate self esteem and promote positive self regard. Feeling satisfied with the characteristics they recognize in themselves gives people a sense of well being and brings pleasure into their lives. Individuals with adequate self esteem (F+%) have ability to not underrate their attractiveness to other people or their abilities to succeed in various undertaking, and thereby become displaced with themselves and their efforts; and they do not overrate how appealing and talented they are, and thereby become enchanted with themselves and what they have done. The average F+% for healthy persons are at least 60%. Findings of the present study are consistent with the Rorschach Profile of Indian Adults 183

above value. However, these findings (59.72±6.57) are lower than the Beck’s mean value (F+% 79.25) as well as findings of other Indian studies (Asthana 1963, Kumar 1996) and higher than Singh et al (2004) and D’ Netto (1974). Cognitive and emotional repertoires of individuals are rooted in their social context. M associations are concerning the fantasy activity of the individual. The movement in the Rorschach protocol is considered conversions of emotionality and it is the phenomena of “internalization” (Rorschach; 1942). The emotions the person prefers to contain internally, thereby converting them in some manner. Neurotic converts these emotions in day dreams, psychotic into autistic living, and healthy adults into more acceptable sublimated manner. The normal mean score for M is 3.21± 1.56 which is consistent to Beck’s findings of 3.50. The findings of our study is consistent with the findings of Asthana, (1963) and Prabhu (1967) Beck interpreted color responses as an index of affect using Rorschach hypothesis as the nucleus of his interpretation. He suggested the pure C response occurs in the adult, it indicate the existence of governable impulse and rages amounting in some instance momentary psychotic episode in which there is a schism between affect and intelligence. Pure color responses are noted to absence of impulse delay and represent a general disruption of harmonious perception of and association process. The mean score of the color responses in present study is 0.74 ± 0.72 which is slightly higher than mean value of Beck’s scores (0.49) similarly for FC and CF responses mean score of the present study are 1.17 ± 0.92 and 0.85 ± 0.88 respectively in contrast to Beck’s mean value for FC 1.36 and CF 1.44. The findings of present study (mean value of color responses) are also higher than findings of Singh et al (2004). Beck also expands his interpretation of white space response and preferred to convert into percentage rather than the actual number. The overall mean value of white space (Ds and Dds) responses in the present study is 2.00 which is slightly more than Beck’s norms(DS and Dds: 1.90). The mean value of Sum C is 2.75 ± 1.72 in contrast to Beck’s Findings 3.11. The associational content has another significant contribution. How the projection has been structured and how the theme is significant. Two major aspect of the content has got the importance in the interpretation of the Rorschach responses. One is the range of content another is the type of the content. For example the whole human percept and the ratio of part human (H: Hd). The former goes with liberated intelligence and the later tells us the functional restriction affected by anxiety. The ratio between two is a measure of individual’s inhibition or freedom. The broader range of content are specially characterized content suggest the person’s versatility of the mind and enriched conceptualization ability. It tells the ability to translate his knowledge, curiosity and opportunity into achievement productive into world at large. Whereas narrow content project the person whose vision is channelized and horizon is lowered. It is apparent that the person is handling his life affaires level inferior to his capacity. Content categories are generally considered to contain information relating to a person’s need, preoccupation, and social interaction. Initially, it was not included in the interpretation of Rorschach protocol. In 1942 a brief section was included concerning the variations of content suggesting that subject of a higher intellectual potential should not produce more than 50% animal responses and that as a rule animal, human, geography and a few plants and object content would be typical in great majority of record. Basing on the careful analysis of breadth and depth of content more than 25% responses are needed to outside from four category (H, Hd, A and Ad) could be an additive indicator of higher intellectual functioning. The Human responses indicate potential for good relations and every human being develops age appropriate human relationship. The adequate empathic capacity makes an important combination to good social and interpersonal adjustment, the capacity to identify real people and the likelihood on having done so reflected in the Rorschach by the Human responses. People live in an interpersonal world attest the vital role of company and companion ship keeping one’s peace of mind of well being and identity formation.The mean value for H response in present study is 3.89 ± 2.02 which is lower than Beck (Mean: 4.02) and Chaudhury et al (2006). In the present study no significant difference was found between male and female groups on human responses. . Beck (1952) emphasised that the Animal content and popular responses are the basic indices for understanding the obvious aspect of adaptive thinking and reality testing. In the present study the A% is 37.17 ± 12.19 in contrast to Beck’s mean A% of 46.65 with a range from 35 – 65 percent. The findings do not show significant difference between two genders on animal responses. Findings are in agreement with Pandey et al, (2001) but lesser Animal responses than Chaudhury’s findings (2006). The Animal responses reported by various Indian researchers range from 184 Shweta et al

11.54% to 82.35% though majority falls on 20 to 40 percent. Anatomy responses mainly reflect preoccupation with multiple somatic complaints. The mean At responses were 0.96 ± 1.08 are lesser than Beck’s norms (Mean At: 1.55). The Anatomical responses of Indian adults ranges from 0 -7 though the majority falls between 0 to 3. The two groups differ significantly on Sex responses (mean value of Male 0.72 ± 0.77 and Female 0.53 ± 0.83). This might be because of conservative and orthodox mindset of Indians about sex and sexuality. Another interesting fact was revealed by the responders that score 0 was the best preferred option to choose by both groups; surprisingly females are at high with no response which reflect their inhibition and cultural restrictions imposed on sex related issues. Males have perceived more sexual responses than females. It suggests that the males are more open than females on sex related topics. The Sex responses in this study are less than Chaudhury’s findings (2006). The Botany (1.35 ± 1.39), Blood (o.88± 0.74) and Cloud (0.93± 0.76) responses did not differ significantly in the two groups. The religious responses are considered to provide spiritual values and helps in managing stressors, tension and fears. The mean value for religion responses in the present study is 0.81± 0.86. Popular response reflects the ability to have popular view of thinking within a specific cultures and the extent to which they confirm to social standards. In present study, score 2, 3 & 4 are most preferred option by both group. The mean of P response is 3.24± 1.31 which is much less than the Beck’s Norms (Mean P: 7). No significant difference was found between Male and Female groups. Findings of the present study are in agreement with Chaudhury et al (2006). The socio cultural fabric played a pivotal role in displaying the disparity among western and Indian norms. Interestingly our study opens avenues to rethink about the popular responses in context of Indian culture. Conclusion: The present study is a modest attempt to develop Rorschach Norms on Indian subjects. The Rorschach test following Beck’s method was administered on 238 subjects (130 male and 108 females) taken from in and around Delhi. Result obtained does not show significant difference between male and females except two indices Dd and Sex. In addition religious responses on Rorschach test focus on some newer type of content and opened new dimension of further research. In the absence of standardized Indian norms, analysis and interpretation of Rorschach protocol would be mala-fide. References: Asthana, H. S. (1963). A Rorschach Study of the Indians. Rorschachiana; 45:8;283-286. Banks, J. A. & Banks, C. A. (1997). Multicultural education: Issues and perspectives (3rd ed.). Boston, MA: Allyn & Bacon. Beck, S.J. (1942), Psycho diagnostics. Bern: Bircher (Transl. Hans Huber, Verley, 1942). The original work published in 1921. Beck, S.J. (1952) Rorschach Test Vol. III. Advances in Interpretation. Grun & Stratton 1952, New York. Beck, S. J., Beck, A., (1961). Rorschach’s test 1: Basic processes (3rd ed.). New York, NY: Grune and Stratton. Boykin, A. W. (1985). Black child socialization: A conceptual framework. In H. P. Chaudhury, S.(2006). Norms of the Rorschach Test for Indian Subjects. MJAFI; 62:153-160. D’Netto, T.B. Kishore, R. and Ruggo,R.K. (1974). Analysis of Rorschach Response of Normal Army Personnel. J. of Clinical Psychology. 2; 87-92. Dubey, B.L. (1979) Rorschach Indices of Psychiatric Patients in Army. Ind. J. of Clin. Psy. 6: 175- 179. Dubey,B.L.(1982) Pragmatic View of Rorschach Inkblot Technique. National Psychological Corporation, Agra. Fiske, D. W. and Baughman, E. E. (1953) Relationships Between Rorschach Scoring Categories and the Total Number of Responses. The Journal of Abnormal and Social Psychology,48:25- 32. Frank, G. (1994b). Socioeconomic states and the Rorschach. Psychological Reports,74, 95- 98. Irving, B. W. and Weiner (1997). Current status of the Rorschach inkblot method. Journal of Personality Assessment 68: 5-19. Jones, J. M. (1991). Politics of personality: Being Black in America. In Reginald Jones (Ed). Black Rorschach Profile of Indian Adults 185

Psychology. Hampton University, Hampton, VA: Cobb & Henry Publishers. Krall, V.; Sachs, H.; Lazar, B.; Rayson, B.; Growe, G.; Novar, L.; & O’Connell, L.(1984). Rorschach norms for inner city children. Journal of Personality Assessment, 47, 155-156. Kumar, P. (1961). Rorschach Test in Psycho neurotics and Normal Groups. Indian J. of Psychology. 36; 169-172. Lewin K. (1951) Field Theory in Social Sciences. Selected theoretical papers. Edited by Darwin Cartwright. New York Harper Moon, T. I. & Cyndick, B. P. (1983). Shifts and constancies in Rorschach responses as a function of culture and language. Journal of Personality Assessment, 47, 345-349. Pandey. R, Tripathi,V.R.M.,& Tripathi,S .(2001). Age related changes in SIS-II Response Content. SIS J. of Projective Psychology & Ment. Health. 8; 35-40. Pershad, D., Verma, S. K. and Dubey, B. L. (1979). Pathognomic Signs on the Rorschach: How Useful Are They? Bri. J.Proj. Psy. 24, 27-29. Prabhu, G.G. (1967). The Rorschach Techniques with Normal Adults Indians. Indian Psychological Review.97, 106. Rorschach, H. (1921). Psychodiagnostic, New York: Grune & Stratton. Singh, D.K, Singh A, & Singh A. R. (2004). Relevance of Beck Norms of Rorschach Inkblot Technique on Indian Population-an Exploratory Pilot Study on Normal Subjects ; SIS J. Proj.Psy.& Ment. Health 12; 49-52. Wood, J. M.; Nezworski, T. M., Lilienfeld, S. O., & Garb, H. N. (2003). What’s Wrong with the Rorschach? Science confronts the controversial inkblot test. New York, NY: Willey. 186 Shweta et al 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

SIS – II Profile of Epileptic Patients Deepak K. Mishra, Sarika Alreja, Masroor Jahan and Amool R. Singh The present study intends to investigate SIS II profile of patients suffering from epilepsy. Fifty epileptic patients attending OPD and community outreach program of Ranchi Institute of Neuropsychiatry and Allied Science (RINPAS), Ranchi, India and 50 normal participants were administered the Somatic Inkblot Series Booklet Version (SIS-II). Results reveal significant differences between patients of epilepsy and normal participants on most of the indices of SIS II. Most typical response, Depression and Rejection of images were found as most discriminating diagnostic indicators. Epilepsy is a medical condition which disturbs not only the patient but also the family members. It takes several months for a person to accept this condition and its limitations. This often seems unrealistic to those living around the person. The impact seizure disorders have on the life of a person is tremendous! Often it includes the loss of a job, the sudden inability to drive, and the total loss of control over their lives. Often due to the uncertainty of the impact on their future and the stigma associated with seizures the patient develops fear. He lives in denial and refuses to believe that their life has been altered and they cannot continue as before. They also develop feelings of frustration because your body no longer functions as it should. You have no control over what it will do and when. You find yourself relying on others for help with what was once a simple task for you. The people around you often don't understand why you have become so angry. This emotion results from the fact you feel as though something has been taken from you. It also comes from the lack of understanding exhibited from people. It in fact changes the personality of the patient. Grieving over the loss of your life as you knew it entails more than you think and can last a considerable amount of time. The realization that the medicine does not have all the answers, patients must look inside of themselves to find what helps them best. Educating themselves and finding support groups is often of great help. As the saying goes “sound mind in a sound body” and vice versa or disturbance of body perception in a disturbed person shows that body and mind are so intertwined that disturbance in one causes disturbance in the other. Somatic Inkblot Series is an important tool to study body image disturbances. A relationship has been proposed between physical disturbances and projected anatomical responses (Cassell, 1980). Only a few studies on epilepsy have been conducted with a typical battery of psychological tests, which cover a spectrum of psychological functions, and, so far as projective techniques are concerned, most of the research has been confined to the Rorschach with little or conflicting results. Chaudhuri et al. (2006) administered Rorschach and found that Epileptic patients had low productivity, slow reaction time, common rejection of more than 4 cards and slight increase in D location category, confabulatory responses, high F% and low movement responses as compared to normal subjects. The Ratio of M: Sum C in opposite direction with high A% and sex and Cn responses and low F+% and P% than normal subjects. The review of literature on SIS revealed that SIS-II (booklet form) has attracted more researches followed by the card form. The meta-analysis of SIS-II clearly indicates its power in discriminating various groups. It has been used in coronary patients, neurotics, schizophrenics, depressives, psychiatric patients, speech disorders, alopecia areata, impotence, drug addicts, and murderers (Kumar, 2000). SIS-I has been employed in coronary patients, drug addicts, normal population, obese patients, chronic schizophrenics, traumatically shortened extremities and militants. Since SIS has not been administered on Epileptics, the present study intends to find the personality profile with the help of SIS- II test. Methodology: This is a cross sectional study designed to find SIS- II profile of epileptic patients. Fifty Epileptic patients and fifty normal subjects were taken for the study. Mean age of the epileptic patients was 25.52+5.34 years and normal subjects was 26.92+4.38 years. Both the groups were matched on age and sex. Normal subjects were screened on the General Health Questionnaire-12 to rule out probable Deepak K. Mishra, M.Phil., Research Fellow, Sarika Alreja, M.Phil, Research Fellow, Masroor Jahan, Ph.D. Assoc. Professor and Amool R. Singh, Ph.D, Professor and Head, Dept of Clinical Psycho. & Psychiatric Social Work, RINPAS, Ranchi-834006 (India) Key Words: Epilepsy, SIS-II profile, SIS-II personality profile of epileptic patients, SIS in Epilepsy

psychiatric conditions and those obtained a score of 2 or below were taken for the study. Table 1 shows that most of the participants were in the age range of 25-35 years and educated up to 10th. Majority of participants were Hindu, single, working, from nuclear families belonging to middle socio-economic status of semi urban areas of Jharkhand and Bihar. Epileptic patients with any other psychiatric disorder/ major physical illness were excluded from the study Tools:

• Socio demographic and clinical Data Sheet: To collect information regarding socio demographic characteristics and other related clinical information of the sample a socio demographic and clinical data sheet was developed for the present study.

• General Health Questionnaire-12: The GHQ (Goldberg & Hiller, 1979) is a 60 items self administered screening test, which is sensitive to the presence of psychiatric disorders in individuals presenting in primary care settings and non-psychiatric clinical settings. The GHQ-12 is a shorter version of the GHQ containing 12 items.

• Somatic Inkblot Series-II (Cassell and Dubey, 1980,2003): In 1980, after initial success with SIS-I, the SIS-II Booklet test was developed in 1980 and the Manual with extensive research data was published in 2003. The test consists of Series A and Series B, each with 31 images with 62 images in combined series. The SIS- II can successfully identify various groups of Table 1 Socio-demographic characteristics of the participants 188 Mishra et al S.N. Variables Epileptic Group n (%) Normal Group n (%) Chi Square Value (df) Sex Male 27 (54) 27 (54) 0.00 (1) Female 23 (46) 23 (46) Education High School 26 (52) 19 (36) 2.22 (2) Intermediate 14 (28) 16 (32) Graduation 10 (20) 15 (30) Marital Status Married 21 (42) 14 (28) 2.51 (2) Single 29 (48) 36 (72) Religion Hindu 38 (76) 38 (76) 0.16 (2) Muslim 6 (12) 5 (10) Christian 6 (12) 7 (14) Occupation Student 13 (26) 9 (18) 3.23 (3) Service 14 (28) 15 (30) Business 15 (30) 19 (38) Housewife 11 (22) 7 (14) Residence Rural 5 (10) 7 (14) 1.49 (2) Semi Urban 26 (52) 20 (40) Urban 19 (38) 23 (26) Family Type Nuclear 32 (64) 33 (66) 0.04 (1) Joint 18 (36) 17 (34) SES Middle 38 (76) 42 (84) 1.00 (1) Lower 12 (24) 8 (16)

78SIS – II Profile of Epileptic Patients 189 clinical subjects, and can be used to screen out abnormal subjects from normal subjects. Procedure: Patients with Epilepsy attending psychiatric OPD and Community outreach program of RINPAS and normal individuals working at the same institute were screened following the inclusion and exclusion criteria. The diagnosis of the patients was made by the consultant-in-charge of the case. GHQ-12 was used to screen normal subjects. Socio-demographic characteristics were recorded after assuring the participants about confidentiality of their responses. SIS-II was administered and scored following standard procedures(Cassell and Dubey,2003). Responses on SIS were analyzed using t-test, chi-square and SPSS 16 technique. Results and discussion: The present study was conducted to find out the SIS II profile of epileptic patients. A sample consisting of 50 epileptic patients and 50 normal participants were Table 2 Comparison of patient and normal group on SIS-II indices

Indices Epileptic group Control Group t-value

(N=50) (N=50) (df= 98)

M±SD Range M±SD Range Total no of response (R) 55.34±5.17 47.0-63.0 63.70±4.79 53.0-80.0 8.37** Human responses (H) 14.10±3.01 9.0-21.0 20.42±4.03 13.0-31.0 8.88** Animal responses (A) 6.24±2.63 2.0-11.0 7.02±3.16 3.0-18.0 1.33 Anatomical responses (At) 15.74±4.86 6.0-30.0 13.84±4.70 4.0-24.0 1.98* Sex responses (Sex) 1.98±2.39 0.0-7.0 3.46±2.14 0.0-10.0 3.25** Movement responses (M) 2.20±2.41 0.0-9.0 7.10±4.35 0.0-20.0 6.95** Most typical responses (MT) 8.24±2.54 5.0-15.0 14.50±2.09 10.0-23.0 13.43** Typical responses (T) 23.12±7.06 14.0-37.0 30.20±5.89 19.0-43.0 5.44** Atypical responses (AT) 24.82±5.31 14.0-33.0 19.68±6.16 2.0-30.0 4.46** Rejection of images 6.94±5.77 0.0-17.0 0.90±1.82 0.0-9.0 7.05** Pathological Anatomy Scale (PAS) 4.56±3.36 0.0-12.0 0.54±0.70 0.0-2.0 8.27** Depression (D) 2.08±2.77 0.0-7.0 0.30±0.58 0.0-3.0 4.43** Hostile & Aggression Scale (HAS) 0.90±1.35 0.0-5.0 0.64±0.77 0.0-4.0 1.17 Paranoia (P) 0.32±0.76 0.0-3.0 0.00±0.00 0.0-0.0 2.94** **p < .01; *p<.05 administered SIS-II test and the responses of both the groups were compared on 14 indices of the SIS Test. Table 2 indicates that epileptic patients scored lower than normal participants on total number of response, human responses, animal responses, anatomical responses, sex responses, movement response, and most typical responses. Score of epileptic patients was higher in comparison to normal participants on atypical responses, rejection of images, pathological anatomy scale, depression, hostile and aggression scale, and paranoia. The difference was statistically significant for all variables except for animal responses and Hostility Aggression Scale. Significantly low productivity of epileptic patients suggests poor imaginative capacity and inadequate functional intelligence. This finding has also been supported by the results of a previous study done by Chaudhury et al. (2006). The findings also reveal that epileptic patients have produced significantly less number of human responses suggesting disturbed interpersonal relationship. This finding is in agreement with the result of Kawai and Aoki (1983).

Table 2 further reveals that epileptic patients perceived significantly high number of anatomical (At) percepts which indicates that they are preoccupied with their somatic symptoms and internal body organs. They have anxiety and concern about their health. It was also found that they were significantly less concerned with sex as compared to normal participants. This may be due to health concerns and the comorbid depressive symptomatology. These finding are also supported by Chaudhary et al. (2006). Significantly less number of Movement (M) responses of epileptic patients indicates that they were unable to utilize available resources to cope up with the demand of the situation. This seem to be inactive, unable to maintain functioning intelligence and may not get benefit from therapeutic intervention. It is further supported by low productivity and human responses in epileptic patients. Similar findings have also been reported by Chaudhary et al. (2006). Low number of most typical responses (MT) is suggestive of non-coherent illogical thinking and lack of ability to keep up with the demands of society. It also indicates weak ego strength and low team concept. Atypical responses were high in epileptic patients indicating poor quality and disturbed thinking pattern. Rejection of more images by epileptic patients suggests serious pathology and is a sign of poor prognosis. Pathological anxiety responses and depression was high in the patient group. Depression is more often present in epileptic patients. This can be explained as a natural reaction to all the discrimination they have to put up with. The sense of insecurity is very natural in a person who has experienced the attacks of many seizures. Although the difference between both groups was statistically significant for paranoia scale, only three patients gave more than one paranoid response. Since both the groups showed significant difference on most of the indices, stepwise discriminant analysis was conducted to find out SIS-II variables discriminating epileptic patients against normal subjects (Table 3). SIS-II profile was able to discriminate both groups with 92% accuracy. Most discriminating variables were Most Typical responses, Depression and Rejection of images. Conclusions: The SIS- II profile of epileptic patients revealed that they had poor imaginative capacity and inadequate functional intelligence, disturbed interpersonal relationship, preoccupied with somatic symptoms and internal body organs, inactive, poor ego strength, comorbid depressive symptomatology and poor quality of thinking. Most Typical responses, depression and rejection of images were most discriminating SIS- II indices in differentiating epileptics and normal subjects. References: Cassell, W. A. (1980) Body symbolism and the Somatic Inkblot Series. SIS Center, Anchorage, Alaska (USA). Cassell, W. A. (1980) SIS – II Booklet Test. SIS Center, Anchorage, Alaska (USA. Cassell, W. A., and Dubey, B. L. (2003) Interpreting inner world through somatic imagery: manual of Somatic Inkblot Series. SIS Center, Anchorage, Alaska (USA). Chaudhury, S., Augustine, M., Saldanha, D. Srivastava, K., Kundeyawala, S. M., Pawar, A. A., and Ryali, V. S. S. R. (2006) Norms of the Rorschach test for Indian subjects. Medical Journal Armed Forces India, 62, 153-160. 190 Mishra et al Table 3 Classification of Epileptic and Normal Subjects

Actual group membership Predicted group membership

Patients Normal

n (%) n (%)

Original count (%) Epileptic patient 42 (84%) 8 (16%)

Normal participant 0 (0%) 50 (100%) 92% of original grouped cases were correctly classified.

Goldberg, D. P., and Hiller, V. F. (1979) A scaled version of the General Health Questionnaire. Psychological Medicine, 9, 139-145. Kawai, I., and Aoki K. (1983) Primary Generalized Epilepsy and Temporal Lobe Epilepsy: A Psychological Study Using Rorschach Tests. Folia Psychiatrica et Neurologica Japonica, 37 (3), 245-251. Kumar, R. (2000) Meta Analysis of the Findings on SIS-II. SIS Journal of Projective Psychology & Mental Health, 7, 141-147. 78SIS – II Profile of Epileptic Patients 191 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.

Kumar, R. (2010) Rorschach Inkblot Test: A Guide to Modified Scoring System. Prasad Psycho Corporation, New Delhi. 159 pp. Rs. 400/0 / (US$15) ISBN 978-8-909923-0-5 (Popular) responses in a protocol. The scheme of presentation of Blot Areas and their corresponding Most Frequent Responses is wonderful. A beginner would enjoy scoring of this one of the most significant Rorschach variable through this book. The chapter on Qualitative Indices is rare compilations of full range of behavioural and test presentation by the subjects. The author has elaborated 60 qualitative indices which shall substantially aid a practitioner in arriving at a psycho-diagnosis. The Interpretation chapter gives a logical account of a wide range of scored indices in a Rorschach protocol. A standard format is presented to generate quick, brief and meaningful report on Rorschach results. To reinforce the skills of a beginner student, Dr. Rakesh has presented plenty exercises for both quantitative and qualitative indices. I would strongly recommend this book for both students and teachers of clinical psychology. Professor Bankey L. Dubey, Ph.D., D.M.& S.P., D.P.M., FSIS Adjunct, Dept of Psychology, University of Alaska,Anchorage(USA) Editor Emeritus, SIS J. Projective Psychology and Mental Health President Somatic Inkblot Society, Former President Indian Association of Clinical Psychologists 4406 Forest Road, Anchorage, AK 99517(USA) Email:bldubey@gmail.com Dr. Rakesh’s book Rorschach Inkblot Test: A Guide to Modified Scoring System will serve as a “Guide Manual” for Administration, Scoring and Interpretation of Rorschach Test. It will prove an asset to Post Graduate students of psychology and teachers interested in projective psychology. The book is full of clinical wisdom and diagnostic interpretation. A survey revealed that 80% clinical psychologists engaged in assessment services utilize the Rorschach and this technique has become a synonym to clinical psychology (p.4). The literary presentation of the book is very simple and itemized to facilitate understanding of the complex procedure (p.7). This book is full of skill, guidelines and pictorial illustrations which can be understood even by a layperson. The book effectively introduces the concept of projection and inkblot procedures. In administration chapter each and every step is formalized and made easy even for a novice to learn how to administer Rorschach and record responses. The terminology used to explain quantitative scoring is self-explanatory for most variables. For example; Common Blot Area (CBA) instead of Major Details (D); Most Frequent Response instead of Popular (P). The chapter on Blot Areas and Determination of Shape Appropriateness provides elaborate guidelines for determining appropriateness of shape in a given response and comprehensive listing of blot areas would serve as a ready reference to the practitioners. The innovative idea of integrating Most Frequent Responses within the index listing would ensure faster and accurate scoring of Most Frequent Book-Review

Advance Workshop on “The Application of Rorschach and Somatic Inkblot Series in Personality Assessment, Diagnostic Evaluation, Therapeutic Intervention, Screening and selection ” To be held During Jan, Feb, March and April 2011 At Hyderabad, Bangalore, Mumbai, Kolkata, Delhi and RINPAS, Ranchi Advent Inst. of Management, Udaipur Kurukshetra University, Kurukshetra Please contact if you are interested to attend at any of the above Institution: Prof.B.L.Dubey: email: bldubey@gmail.com Prof.Amool R.Singh, email:sisamool@yahoo.com Prof.Naveen Gupta: dr_naveengupta@yahoo.com Prof.Umed Singh, email: umed.psy@gmail.com

SIS CENTER, Anchorage, Alaska(USA) Dear SIS Members and friends, May the HOLIDAY SPIRIT provide peace, prosperity and happiness to every one in our extended family. You will be pleased to learn that both SIS-I and SIS-II instruments are available on Website for online assessment. If you want to use these techniques for personality assessment, clinical diagnostic/treatment or research, you are welcome to contact us regarding any help we might be able to provide. You are invited to view these on the following websites: http://122.160.96.85:1001/SIS2 http://psyche.dubay.bz We will welcome comments, suggestions and any constructive criticism about the above mentioned SIS applications. Please note down my new emails for future contact. Email: bldubey@gmail.com Email: sisdubey1@gmail.com We also invite your contributions to our SIS Journal, related to projective psychology and mental health. Looking forward to hearing from you in the New Year! Sincerely Wilfred A. Cassell, Bankey L.Dubey and Amool R.Singh Email: siscassell2@yahoo.com Email: bldubey@gmail.com Email: sisamool@yahoo.com

Important Announcement Dr. Amool Ranjan Singh, Ph.D., Professor and Head, Department of Clinical Psychology, RINPAS, Kanke, Ranchi - 834 006 (India) E-mail : sisamool@yahoo.com editor_sis@rediffmail.com has taken charge of the office of Editor In Chief SIS JOURNAL OF PROJECTIVE PSYCHOLOGY & MENTAL HEALTH From January 2006 Institutional Members (Libraries of National and International Universities) are requested to send their Annual Subscription/Dues to Dr. Amool Ranjan Singh, Ph.D., Professor and Head, Department of Clinical Psychology, Ranchi Institute of Neuro-Psychiatry and Allied Sciences (RINPAS), Kanke, Ranchi - 834 006 (India) The Subscription Cheque should be made in favour of “SIS Journal of Projective Psychology & Mental Health” payable at Ranchi (India)

SOMATIC INKBLOT SOCIETY IS PUBLISHING ITS JOURNAL SIS JOURNAL OF PROJECTIVE PSYCHOLOGY & MENTAL HEALTH a half yearly publication in January and July. It started in 1994 and has published 32 issues in 16 years. The Journal is available on Society’s Web Site at http: //www.somaticinkblots.com The Journal from Volume 1-17 is available in C D (Acrobat and Page Maker) Members of Somatic Inkblot Society can get it on a nominal payment of US $50 (for Overseas Members) and Rs.1500/- (for Indian Members). The Individual and Institutional Members of Somatic Inkblot Society/ SIS Journal of Projective Psychology and Mental Health Can get the current issue and future issues of the Journal through Electronic mail free of charge Please indicate if you wish to get the Journal in Hard Copy or through Electronic mail To: Bankey L. Dubey, Ph.D., DPM, Editor Emeritus, SIS J. of Proj. Psy. & Mental Health, E-mail : sisdubey@rediffmail.com E-mail : sisdubey@yahoo.com E-mail : bldubey@gmail.com Web Site at http: //www.somaticinkblots.com OR Wilfred A. Cassell, M.D., FAPA. Director SIS Centre Editor Emeritus, SIS Journal of Projective Psychology and Mental Health, 4501 E, 104th Avenue, Anchorage, Alaska - 99516 (USA). Email: siscassell2@yahoo.com

THE SOMATIC INKBLOT SOCIETY I wish to be a Member __________ a Life Member ________ of the Somatic Inkblot Society. Please submit this request to the Membership Committee. NAME _______________________________________________________Birth date __________ (Print or type) First Middle Last __________________________________________Zip ____________________________________ Business/Office Address : __________________________________________________________ _____________________Tel. : (W)__________________________H)________________________ EDUCATION Degree Year Institution Major Field of Study EMPLOYMENT : Current position, employer, dates (Graduate Students indicate area of study and degree toward which you are working). MEMBERSHIP : __________________________________________________________________ TRAINING AND EXPERIENCE IN PERSONALITY ASSESSMENT : SPONSOR (S) Name Address Telephone 1._________________________________________________________________________________ 2._________________________________________________________________________________ SIS subscription payable every year in January through Cash/Cheque at par/Demand Draft in favour of “SIS Jr of Proj Psy and Ment Health” payable at Ranchi. I certify that the information provided above is accurate and correct. An APPLICATION FEE Cheque is enclosed for Foreign Members $50 & Life Membership $ 400. For Members in India Rs. 300/- & Life Membership Rs. 2500/- Institutional Membership Rs. 1000/- Institutional Life Membership Rs. 10000/- Total Cheque $/Rs.__________________Drawn at_________________________ Signature of applicant : __________________________ Date :________________ PLEASE RETURN with your cheque to : Dr. Amool R. Singh,Ph.D. Prof. & Head, Dept. of Clinical Psychology, RINPAS, Kanke, Ranchi-834006 (India). Foreign members send their subscription cheque to B.L. Dubey, Ph.D. Editor Emeritus, 4406 Forest Road, Anchorage, AK-99517 (USA). N.B. : Please add Rs. 50 ($10) as one time registration fee; and Rs. 70 ($10 foreign Member) if you are sending subscription through out station cheque.

PROFESSIONAL QUALITY VHS VIDEOTAPES (SPECIFY NTSC, PAL OR SECAM), AS WELL AS AUDIO TAPES AND TRANSCRIPTS OF INTERVIEWS ARE AVAILABLE FOR TEACHING/CLINICAL PURPOSE. Police case—”Witnessing an Accident” Vietnam Veteran — “Unresolved Guilt” Therapeutic Dream Stimulation Anniversary Reaction to Miscarriage Grieving a Still Birth : Conversion Reaction Fear of Cancer and Hypochondriasis (includes Rorschach imagery) Alcohol and Cocaine Dependent : Father/Son Incest : Teen-age Alaska Native’s Death by Gas Inhalation Suicide Behaviour in Adolescent Alaska Native Nightmare Vision (Sexually Abused Adolescent Girl and Absence of Father Figures in Black Adolescent Boy) Auschwitz Revisited Neuropsychological Reactions to Life Threatening Accident & SIS Occupational Stress and the SIS The use of the SIS as an Aid in Meditation while Grieving a Miscarriage SIS-Video (A&B Series), SIS-II Images in CD, SIS-I Videotape and SIS-Living Images A Walk Through The Garden of Life and many more, Audio & Videotapes SIS Journal of Projective Psychology & Mental Health in C D (Acrobat and Page Maker) from Volume 1-17 Contact : SIS Centre, 4501 E, 104th Avenue, Anchorage, Alaska - 99516 (USA). E-mail : siscassell2@yahoo.com OR sisdubey@rediffmail.com Web Site : http://www.somaticinkblots.com for getting the above material

ANNOUNCEMENT The Somatic Inkblot Society is a Non-Profit International Organization with headquarters in India. The Indian Govt. has recognized it as a Corporation for Income Tax purposes where relief is given to donators and advertisers under section 80G of Income Tax. In America, a comparable non-profit organization similarly named the Somatic Inkblot Society gives Income Tax relief for residents of the United States. Please help the Society by Donation/Advertisement for it’s smooth functioning. President, Somatic Inkblot Society APPEAL Members of Somatic Inkblot Society are requested to kindly send their Annual dues before the 31st of January each year to : Amool Ranjan Singh, Ph. D. Prof. & Head, Dept. of Clinical Psychology, RINPAS, Kanke, Ranchi-834006 (India). E-mail: sisamool@yahoo.com Tel. : 91-651-2233687(H), Mob.: 91-9431592734, The Subscription Cheque should be made in favour of “SIS Jr of Proj Psy and Ment Health” payable at Ranchi (India)

STATEMENT SHOWING OWNERSHIP AND OTHER PARTICULARS ABOUT SIS JOURNAL OF PROJECTIVE PSYCHOLOGY AND MENTAL HEALTH PLACE OF PUBLICATION : Dept. of Clinical Psychology, RINPAS,Kanke,Ranchi-834006. India PERIODICITY OF PUBLICATION : Half Yearly EDITOR’S PRINTER’S Name : Amool Ranjan Singh PUBLISHER’S NATIONALITY : Indian ADDRESS : Dept. of Clinical Psychology, RINPAS,Kanke,Ranchi-834006. India OWNER : SOMATIC INKBLOT SOCIETY I, Dr. Amool Ranjan Singh, hereby declare that the particulars given above are true to the best of my knowledge and belief. Sd/ Dr. Amool Ranjan Singh, Editor-in-Chief SIS Journal of Projective Psychology and Mental Health Published by Dr. Amool Ranjan Singh on behalf of Somatic Inkblot Society at Annapurna Press & Process, Opp. Big Bazar, 5, Main Road, Ranchi-834 002, Jharkhand (India), Ph. : 2331800 Editor-in-Chief : Amool Ranjan Singh