SIS Journal of Projective Psychology & Mental Health

Fundamental memory retrieval processes influence what is seen or written, as a response sequence on the SIS Answer Booklet. For illustration purposes consider a most simple conceptual model involving a medical specialist (e.g. a hypothetical pathologist). Such a professional who had been previously trained in anatomy would likely identify the cardiac embedded somatic content more readily than an astronomer friend. This reflects “Familiarity” - a natural tendency to focus on, and then consciously recognize from memory storage, familiar objects. Conceivably the ability of these men to recognize somatic structure would be accentuated under different conditions of sensory feedback. For example, if the two friends were out jogging, the introceptive sensations from their exercise activated cardiovascular and respiratory systems would likely increase their perceptual sensitivity to embedded somatic SIS structure. A similar type increase might be expected if either experienced a flood of introceptive sensations from psychological stress autonomic nervous system arousal. However, under such conditions the conceptual model is more complex since, anxiety affect linkage to an organ such as the heart, can trigger alternating processes of perceptual sensitization versus inhibition. Similarly what anatomical structure is perceived can be greatly influenced by physical illness. A patient hospitalized experiencing angina pain or suffering from Congestive Heart Failure more readily detects SIS heart content. Moreover, the projected size of the heart may be larger. Psychoactive drugs, as well as basic drives such as hunger and sex can shape perception. When hungry a responder focuses on organ imagery depicting the gastrointestinal tract. Hormonal influenced reproductive impulses and fantasy can increase recognition of SIS embedded sexual structure. The ill understood interplay between activation of “Memory” mechanisms, “Perception” and “Projection” body-mind- spirit processes are illustrated in a case history published in this issue of the Journal (Assessing Sexuality “Homosexuality”). In interpreting their clinical significance, it is suggested that present conceptual models only partially explain the complexities of the underling phenomenology. For example, since the erotic content on image A1 of SIS Booklet falls well beyond normative data; such imagery reflects the mental mechanism referred to as “Projection”. In addition, what she imagined the blot to resemble may have been partially influenced by one or more forms of memory. For example, questions may be raised, was her response sequence related to “short term” recollection of pornographic lesbian art or erotic photographs? Perhaps alternatively, did it reflect “long term” memories of past fantasies and/or homosexual activity with her lost lesbian friend spiritually visualized in some of the SIS symbolism? All such historical referents need close examination by the test administrator when assessing the clinical significance of aggressive content. Often this becomes of paramount importance in interpreting responses with either suicidal or homicidal significance - especially in those with psychotic mental disorders. An example from our SIS case history files involves an adolescent girl who was planning to murder her sleeping mother. Fortunately her mother awoke to discover her daughter standing over the bed with a knife in hand threatening to stab her. After admitted to the hospital and administered antipsychotic medication, she visualized a SIS blot with embedded cardiac structure as “A heart with a knife in it”. To an inexperienced interpreter, this might have been simply dismissed as reflecting past murderous Editorial Memory Interaction with SIS “Perception” Versus “Projection”

78 Cassell impulses. A SIS clinician trained in exploring the time referents of the response deemed that it was prudent to continue in the hospital homicidal “Precautions”. Thus even though she denied still wanting to stab her mother, for safety reasons, she was continued on close observation. Her more experienced clinician early realized that her denial may have been motivated to obtain early release to the community while still homicidal. Look forward to expanding your knowledge in the field of introspective projective technology. If you eventually become an administrator of projective procedure, you should gain understanding not only in to the inner world of a patient/client more intimately than but as well as to introspection. In this interactive subjective world, kindly feel empathetic humility to you inner self, as well as that of others. In this psychic journey into inner spiritual space, look forward to leaving behind the mundane modern world with all its “craziness”, in humanity and unnecessary suffering. Fantasize for a few moments about entering into a wonderful “heavenly” mysterious uncharted world, not guided by the laws of present day science. During such meditation, actively identify with the original consciousness of the blessed pioneers of Yoga. Subjectively sense the beauty and healing power of this ancient bridge to healing body-mind-spiritual streams. Realize that no human mind can ever ultimately understand itself, let alone, totally comprehend, scientifically, that of another. Consider, as well, reviewing, if you have not already, some basic information on the nature of primitive human spiritual symbols throughout various cultures, as reflected in 3200 year old cave drawings. Look forward to acquiring skills that should enable you to be more able to empathetically feel reverence for your own, as well as another person’s suffering soul. Perhaps, additional explanation is due any reader who might question the need to include religious training in this “soft” scientific field that extends into the spiritual realm. A related resistance to projective testing concerns the facts that in the mental health field, a significant percentage of practitioners have their own unresolved psychological issues. These originally motivated them to enter the field. Such professionals hide their “inner cry” behind their professional persona. Many in their social life numb their own inner world suffering by self-medicating with alcohol, prescription drugs, street drugs, etc. Neither of the above SIS critics had availed themselves of personal therapy. The first was severely obese and suffered from a stress triggered medical condition called “Irritable Bowel Syndrome”. The second was episodically struggling with addiction to cocaine. No doubt it would have been threatening for either of them to have acknowledged that inkblot techniques can serve as a mirror of inner world imagery, including their own. Not being in introspective therapy, they were not prepared for the projective recall of the own early life stressful memories and childhood “nightmares.” Nor were they ready to introspectively face the additional burden of occupational secondary empathetic discomforting imagery superimposing itself on their early life memories. “Hopefully SIS clinicians will continue to expand their diagnostic/therapeutic and spiritual healing applications through 21st century communication technologies. Apart from their clinical value, many other promising fields may be envisioned for futuristic minded SIS scientists. An example follows. Since evoked SIS imagery releases a suffering person’s unexpressed “Inner cry”, the projective technology may be an educational aide for training “EMPATHY”. If an individual has not experienced some degree of suffering, how can he or she, identify with and empathize with others who suffer in silence. Members of the SIS society who have empathized with the painful affect released by otherwise inhibited patients/clients need

Memory Interaction with SIS “Perception” Versus “Projection” 79 no further explanation on the releasing power of SIS technology. Readers lacking such secondary empathetic exposure to PTSD affect are encouraged to review the various case history presentations in SIS journals. A more illustrative approach would be to view some televised teaching clinical interviews. On our war torn, economically unstable, fragile planet, too often international leaders seem to lack empathy. Many act in “sociopathic” ways, blind to both their own “Inner cry” as well as that suffering souls. For example, in America, an immensely wealthy minority, through modern media “Persona” image manipulation have acquired undue government power. With the aide of money motivated unscrupulous attorneys, basic humane guidelines, such as established by the American Constitution as well as humane international law are bypassed. Witness the unethical sadistic torture methods employed at Guantanamo Bay by “White House” directed American interrogators. Should SIS scientists extend their future investigations internationally assessing/ enhancing empathy as an important aspect of the preparation for leadership? Wilfred A Cassell, M.D., FAPA, APC. Editor Emeritus, SIS J. of Projective Psychology & Mental Health, Director, SIS Center, 4501E, 104th Avenue, Anchorage, AK - 99507 (USA) E-Mail: siscassell2@yahoo.com

Any prospective investigator, hoping to develop personal introspective skills and interpret symbols should consider first viewing the Rorschach, Holtzman and SIS-II inkblots procedures initially and documenting what is seen and felt in relation to each visual array. This is analogous to establishing a personal “diary” which may later serves as a baseline point of personal reference. In no other field of science is there such an intimate reliance on the interaction between the professional’s cultural/religious early memories and that of the client/patient’s background. Since there is a strong relationship between inkblot visual experiences and that of affect charged dream imagery, first complete this preliminary exercise while relaxed prior to bedtime. Consider first freeing your mind of stressful day residual by walking quietly in a beautiful garden, looking at calming nature pictures, or preferably a potent form of meditation, if so trained as for example yoga. This will set the perceptual stage for subsequent projection of deeply personal symbolic material (Cassell and Dubey, 2003, Cassell et al, 1997,1999, 2001) This exercise establishes a “blank body-mindspiritual screen” which historically documents in a conceptual model your uncontaminated subjective inner world as physiologically based in your genetic colored “virgin brain”. This records a subjective PHENOMENOLOGICAL data base on which to subsequently compare your projective viewing experiences with that of others. Because of the limitations of written language, it is strongly recommended that you first free your cognitive inhibitions concerning “artistic ability” and spontaneously record your responses in drawings (with colors if you are so inclined, Upon completing each of the three test procedures always elaborate on the “three most liked” and the “three least liked” blots. Now record your visual stream of cognitions and label their associated emotions. This document serves as a baseline with which to compare your personal experiences with the normative data presented in the later section of the book. This comparison may be considered as a new way of self-examination to enhance your insight into th e deeper aspect of your own body–mind– spirit functioning. Readers trained in Yoga, are encouraged to use this “virgin” brain based document as a blank page for self-reflection and spiritual enhancement during meditation (Cassell, 1979, 2011, Chatters,2000). Eons ago, master practitioners of Yoga, courageously explored intangible inner world seas, seeking as their mystical destination Brahman, the universal consciousness. Their Spiritual Warfare and SIS Spiritual Symbols Wilfred A. Cassell and Bankey L. Dubey “SPIRITUAL WAREFARE” is a symbolically deceptive religious practice that can rob primitive people of their historical culture/dream based positive spiritual symbols. Throughout recorded history, powerful authoritarian leaders have either openly, or deceptively, inflicted their religious/political views on the minds of weaker subjects – especially those of vulnerable children, Sometime such perpetrators MAY RATIONALIZE that they have the SPIRITUAL interest of those robbed of their culture’s historical symbols. Yet, a religious sanctioned undermining of a person’s HISTORICAL sense of personal identity can produce “irreparable damage” TO MENTAL HEALTH. This Hypothesis needs to be scientifically investigated by assessing the MIND ALTERING POWER OF SYMBOLS. 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

Spiritual Warfare and SIS Spiritual Symbols 81 courageous explorations of Nature’s secrets enabled them to expand volitional control over basic physiological functions. To their credit, they did so without the aid of inkblot projective procedures or modern neurophysiologic monitoring technology. The practice of SIS guided Yoga on a daily basis can nourish as yet, unknown underlying body-mind neural networks. Scientific research now indicates that the daily practice of Yoga improves brain function leading to improved overall health once this meditation training has begun, it will be necessary to adopt a “thick skin” mental attitude. Anyone planning to accept this challenge should be prepared for lifelong criticism. The in-depth inkblot memory releasing approach which can bring to projective awareness, long forgotten memories has benefited from the rich intellectual history in India. By contrast, in many western countries there is a bias against the notion that childhood events, such as the unexpressed grief from death of a parent. Later in adulthood this needs to be therapeutically processed through exploring inkblot and dream imagery, symbolically depicting age regressive nature. An example of the latter follows involving a highly intelligent professional American man who had been repeatedly subjected to ridicule for both daily practicing Yoga, as well as keeping a dream diary: “I had a dream about my Dad dying. I did not see him or talk to him it was more about the fact that he was dead and I was grieving over it. Some family members were there. I turned to Grace and said- my dad died last night. She looked at me with a puzzled look on her face and I said – wait a minute, my dad died forty years ago. Then I started to cry. I cried so hard I fell on the ground and rolled on to my back and pulled my knees up toward my chest and screamed. I was crying and screaming as hard as I possibly could. Then some part of the dream involved someone finding my dream note book and was making fun of me because I wrote down my dreams and journals. In the dream I felt grief…profound grief and loss… intense, profound grief nothing more. The symbolism in the dream was about grieving the death of my father. It was powerful but quite simple. I think Grace was there because she was part of our lives when Dad died. Maybe I wanted her to understand how profound my grief was after losing my Dad”. Unfortunately, many of those trained in the basic physical sciences view Yoga, dream analysis and projective inkblot techniques with suspicion. Such skepticism can rationally relate to issues concerning validity but more often fears of introspection into their own irrational emotions and “Nightmares”. It should be kept in mind that many such critics in the 20th century sold their souls by providing technology that underlies nuclear, biological and chemical modern warfare. Yet, to ignore the “softer” sciences which underlie projective assessment, and its related psychotherapeutic treatments, is to stay only a little ahead of the higher primates. Moreover, such “A head in the sand” attitude” enables the world’s bigoted cognitively restricted leaders to further undermine our human destiny, to move beyond our planet to explore the mysterious Cosmos for a suitable new home. SIS imagery exercises and clinical practice may serve to expand the consciousness of serious students. They present otherwise illusive information on complex mental processes, including the ambiguous nature of symbol interpretation. All new to the field are advised to supplement this work with reading from the modern literature in the health sciences of diet, exercise, and the need for positive human relationships, etc. A holistic approach is recommended. Next, begin formal education in the basic sciences of medicine and psychology. This needs to be enriched by additional reading material in philosophy and religion. Finally, it is suggested to review recent studies indicating that regarding affective disorders, Yoga gets positive results-comparable to potent psychotropic medication (especially for women, who may in particular benefit from its anti-anxiety effects).

82 Cassell and Dubey Look forward to expanding your knowledge in the field of introspective projective technology. If you eventually become an administrator of projective procedures, you should gain understanding not only into the inner world of a patient/client more intimately than but as well as to introspection. In this interactive subjective world, kindly feel empathetic humility to your inner self, as well as that of others. In this psychic journey into inner spiritual space, look forward to leaving behind the mundane modern world with all its “craziness”, inhumanity and unnecessary suffering. Fantasize for a few moments about entering into a wonderful “heavenly” mysterious uncharted world, not guided by the laws of present day science. During such meditation, actively identify with the original consciousness of the blessed pioneers of Yoga. Subjectively sense the beauty and healing power of this ancient bridge to healing body-mind-spiritual streams. Realize that no human mind can ever ultimately understand itself, let alone, totally comprehend, scientifically, that of another. Consider, as well, reviewing, if you have not already, some basic information on the nature of primitive human spiritual symbols throughout various cultures, as reflected in 3200 year old cave drawings. Look forward to acquiring skills that should enable you to be more able to empathetically feel reverence for your own, as well as another person’s suffering soul. Perhaps, additional explanation is due any reader who might question the need to include religious training in this “soft” scientific field that extends into the spiritual realm. Throughout the ages, this has been the domain of the world’s great religions. Their visionaries traditionally have claimed that “God” communicates through the mystical medium of their hallucinations and dreams. Unfortunately, many world religions have not updated and reality tested their historical foundation regarding guidelines for optimal body-mind-spiritual health, especially in regard to the role of dreams. Their authoritarian “brain dead” leaders rigorously deny the existential anxiety resulting from living with as yet the unknown. Most avoid incorporating scientific insights as reality testing principles into their archaic dogma and myths. While these may well provide cultural guidelines for “acceptable” behavior, in most countries their leaders have authoritarian economic/political power without scientific tests of validity. A major function of these is to reduce existential threat from pervasive death anxiety. To deny the time limits of our body, as well that of our solar system makes for human complacency. Moreover,, that expanding, their population power base by encouraging rabbit like reproduction in an overcrowded, small environmentally fragile and resource (economically0 limited planet constantly invites global military confrontations. A glaring example involves promising sexual rewards in the “afterlife” to testosterone driven mentally immature male terrorists. The authors adopt this religious hypothesis, as well as expanding on it. Dream-like imagery and visual hallucinations of a psychological origin when projected onto ambiguous inkblot stimuli, similarly mystically represent a psychic bridge of spiritual communication. Of course, this right brain thesis crosses the intellectual boundary from scientific based logic, to what critics would immediately call irrationality. While we do not understand the underlining mechanism, the authors are aware of many, many scientific studies that document the healing power of participation in religious activities and the emotional linkage to such symbols. Consistent with such beliefs, the authors have a deep reverence for the spiritual nature in all higher life forms. This especially applies to those that evoke in us empathetic feelings, by directly responding in a comprehensive fashion to human language, as well as to a variety of written/auditory symbols. Moreover, many pets show empathetic behaviors, when they somehow sense an owner’s sad mood. As further background, consider reviewing the vast scientific literature on the complexities of

Spiritual Warfare and SIS Spiritual Symbols 83 animal behavior. Include studies monitoring EEG electronically recorded REM state sleep behaviors mimicking those in dreaming humans. Projected animal responses to inkblots can reflect a subject’s awareness of his/her own body’s animal nature as well as a genetic linkage to man’s evolutionary background as hunters. Additionally for modern subjects, viewing inkblots, their projective responses related to animals can also tap into deeper guilt and ambivalent repressed emotions of themselves, as killers of animals, when functioning as “carnivores”. Almost at the top of the food chain, our species has domesticated various living creatures that a person may positively interact with at one moment, and then eat at another. With the exception of vegans, most in western cultures deny or repress this conflict. They pay to have the murderers kill their innocent victims, often subjecting them to horrible factory like living conditions out of public view. Language defenses also serve the defensive mode, such as referring to the dead bodies as “pork,”, “veal” etc. In Alaska, Eskimos deal with this death dilemma by speaking in a prayer-like manner to the deceased. For example, they thank the spirit of a whale for giving itself up to them for food. Apart from the above, in clinical situations, animal responses may assist in assessing a schizoid lack of empathy and interest as well as an element of disguised hostility and dangerousness. In regard to the latter, for example, a previous history of animal abuse can correlate with later life aggression. Such tendencies often hidden from traditional clinical interviews can be appraised by assessing projected animal responses and related symbols. Our understanding can be enhanced by projective technique involving greater degrees of human and animal structure. To provide additional test stimuli, an additional version of the electronic form of the SIS called “Living Images” was created solely by female artists. Not only does this subsequent series serve this function, it more directly taps into underlying streams of female spirituality. More exploratory work needs to be envisioned to explore the relationship between dream imagery and that projected onto inkblots. One promising approach is to administer the inkblot series, prior to sleep, and then analyze the “Day residual” of this stimulation in dreams. Another is to administer the SIS soon after waking, prior to the natural fading of the dream imagery and linked affect. This is a highly complex and sometimes illogical appearing homeostatic body-mindspirit phenomenon. After a stressful event, “Mother Nature” activates a restorative healing process by replaying images of the external event, either in a real or disguised symbolic form with linked anxiety affect. This establishes a homeostatic type process, comparable to behavior therapy, due to the fact that initially the dreamer is in a relatively relaxed level of arousal. The repetition of this over days, weeks, months and even years removes some of the image bound anxiety affect. Separation in time from the original stressor in dreams (or inkblot triggered memories) enables the individual to rethink the stressful events and cognitively correct misperceptions of the past external reality. Yet, because dream symbols are meant to protect sleep, due to psychological defense mechanisms most dreamers are partially blind to their meaning. Consequently, even professionals trained in dream interpretation may sometimes require assistance in interpreting their own symbolism. An interpreter with a religious background, trained within a specific culture to decode projected inkblot responses is most helpful, when dream imagery depicting deceased loved ones has documented spiritual connections. Unfortunately, many present day clinicians and religious leaders fail to recognize the importance of such “Beacon” dreams. In America dogmatic, authoritarian clergy tend

84 Cassell and Dubey to reject such communication approaches, accusing projective practitioners and dream analysts of heresy. Similarly, many scientists either are atheists, or erroneously consider such image based inkblot techniques outmoded, archaic and without validity. With regard to the political economic fallout of this bias, obtaining grant money in many countries for legitimate projective scientific research is difficult, if not impossible. As an illustration of this closed mental set, one of my introspectively ignorant, pharmacologically oriented, colleagues once told me derisively: “Using inkblots in psychiatry is as foolish as reading tealeaf patterns.” Another dismissed a detailed clinical SIS projective report that he failed to comprehend, describing the inner world of an abused, intensely suffering child: “It doesn’t relate to prescribing medication…I do not need all this information…reduce it to a few sentences!”. In general, expect such comments from critics untrained in Yoga depth psychology, symbolism and projective theory. In this clinical age, many modern psychiatrists are limited in such education. In western countries there are contaminating economic factors as well. Putting it succinctly in another way, the money is in drug prescriptions. Now, in America, psychologists are obtaining the legal right to prescribe medication and are less inclined to analyze the roots of mental disorder. Moreover, superficially trained counselors are replacing in-depth psychotherapists in the community because of the economic control of insurance companies. In America, the majority of these are women who often rely primarily on their feminine empathetic communication skills and secondarily on religious scripture more than evidence based techniques. A related resistance to projective testing concerns the facts that in the mental health field, a significant percentage of practitioners in western countries have their own unresolved psychological issues. These originally motivated them to enter the field. Such professionals hide their “inner cry” behind their professional persona. Many in their social life numb their own inner world suffering by selfmedicating with alcohol, prescription drugs, street drugs, etc. Neither of the above SIS critics had availed themselves of personal therapy. The first was severely obese and suffered from a stress triggered medical condition called “Irritable Bowel Syndrome”. The second was episodically struggling with addiction to cocaine and eventualy died from rare respiratory problems. No doubt it would have been threatening for either of them to have acknowledged that inkblot techniques can serve as a mirror of inner world imagery, including their own. Not being introspective they were not prepared for the projective recall of the own early life stressful memories and childhood “nightmares.” Nor were they ready to introspectively face the additional burden of occupational secondary empathetic discomforting imagery superimposing itself on their early life memories. Additionally, the embedded somatic structure suggestive of reproductive organs, while clearly not pornographic, sometimes makes prudish professionals reticent to use the SIS. Ironically in America, advertising and the media are flooded with highly suggestive (almost explicit) sexual content, but government funding for scientific sexual image research is largely unfunded. Fortunately the vast majority of mental health professionals is relatively “normal” and is able to cope effectively with projective released stressful scenes. Yet, like most people, even for professionals, focusing of either the “Mind” or the “Body” may evoke some degree of anxiety. Later an example of an anxiety laden dream that Rorschach experienced will be analyzed. Often in social situations many so-called normal people become defensive, when they

Spiritual Warfare and SIS Spiritual Symbols 85 meet a mental health professional. As an illustration of their anxiety, they may cover it with humorous comments such as “If I told you what is on my mind…you probably would think that I am crazy!” Most psychologically mature individuals are aware when introspecting, that they have some degree of hidden idiosyncratic anxieties, feelings of inadequacy, socially unacceptable basic sexual/aggressive impulses, body parts functioning like those of primates, guilt, jealousies, obsessive thoughts, complex moods, repulsive smelling body parts that function outside volition, and ultimately our bodies will stop functioning at death. An individual’s relative awareness for such affect charged images fluctuates in the background of awareness, and at night is rampant in dreams. Of course, such fluctuating imagery streams flow in the minds of all subjects during introspection into the inner world - including test administrators. In spite of any previously acquired resistances to introspection and projective techniques, if this presentation enables readers to peer into the depths of human consciousness more clearly, then it will be worthwhile. If those in training are able to apply the information more effectively, in an educational or healing profession, then its goals will have been achieved. Although there may be secondary empathetic risks, expect to eventually acquire more understanding of yourself, as well as insight, with regard to minimizing counter transference issues. If a reader’s occupation is outside of the health professions, what is presented may also be helpful. For example, if your occupational role involves selecting leaders for having introspective empathetic traits, a concern for others etc., you might also find the information worthwhile. In terms of the history of human knowledge, the physical scientists have far surpassed in measurement technology those trained in psychological assessment. Yet, this is a world beset by evil. Physicists, chemists and biologists have provided weapons of mass destruction that may now be reaching the hands of deranged terrorists. Projective procedures can expose the hidden motives of these and present day advertising media, which often fraudulently present a political leader’s persona as positive. Now, rich political leaders, religious fanatics and their incredibly wealthy drug based criminal supporters can undermine honest candidates. While the vast array of standardized psychological questionnaires and rating scales may be revealing,, they have definite limitations. Consequently they may be considered primarily as instruments for initial enquiry of surface psychological phenomenon. Often responders tend only to reveal what they know about themselves, and then secondarily screen, on the basis of social acceptability, to share. When test administrators utilize fundamental principles of projection they more readily penetrate below surface or outer defensive social facades of the individual. Moreover, when projective techniques are empowered with hypnotic trance, either with traditional induction procedures or the electronic mesmerizing floral scenes in the electronic forms of the SIS, then resistances tend to melt away. The reader will learn about how this second level of enquiry can technically facilitate the exploration of the depths of bodymind-spirit functioning to open innovative paths to treatment. Such new “Inkblot” therapies now demand more attention for less severe mental disorders. The emerging scientific literature indicates that side effect prone psychopharmacological interventions often are not much more efficacious that placebo. Since the days of Herman Rorschach, remarkable technological advances have expanded knowledge in all major scientific disciplines. Several of these have indirectly impacted an introspective human’s

86 Cassell and Dubey perspectives. These sometimes show up during projective testing with the inkblot techniques under review. As mentioned earlier, advanced instrumentation has enabled astronomers to look back in a vast ever changing explosive cosmos to the origin of the universe at the time of the “Big Bang”. In an analogous fashion, the imagery projected onto inkblots enables the examiner to view more clearly stressful events from the subject’s past life. The critical images that are projected may reflect, either directly or in disguised symbolic form, real life historical events. Interpreting these is a much more challenging task than faced by an astronomer whose concepts relate to time, space and energy. In addition to the above, the projected symbolism may be traceable to highly subjective phenomena such as inkblot responses, body imagery, dreams, visual hallucinations etc. Just as it has taken modern telescopic technology to enable astronomers to conceptualize “Black holes” Cosmic conditions, there are instances of “Psychic blindness” or not seeing the obvious content in SIS inkblots. Moreover, their astronomical theories predict an ultimate dire ending to our planet. There is a general consensus that the source of energy in our solar system will ultimately blow up in a massive ball of fire. However, most astronomers are religiously “blind” since they cannot conceive cognitively bound scientists of what preceded this monumental event. This philosophical void can trigger various mood disorders such as “existential anxiety.” Then in combination with real life socioeconomic stressors, genetically susceptible atheist individuals may experience stress triggered somatic symptoms such as, “chest pain,” “palpitations,” etc. Such susceptible people are more likely to project heart responses or perceptually inhibit cardiac -like inkblot structure. In seemingly irrational faith based spiritual psychotherapy, processing their death anxiety can be facilitated by certain of the SIS- II inkblots, such as B22 that depicts “a dying person’s spirit departing the body.” Alternatively, like those mentally threatened by Darwinian evolution theory, Cosmic theory can cognitively force others into the comforting balm of explicit, yet irrational, primitive superstitious religious dogma. Characteristically, such uneducated individuals are open to exploitation by authoritarian leaders. Consequently, they regress in social judgment to intellectually restricted or “brain washed” victims. During much of their lives, mentally constricted individuals function in society in a trance like mental state. One example involves those erroneously labeled by primitive religious authorities, such as shaman, witch doctors, etc., as “Satanic possessed”. Projective testing can aide in clinically uncovering their real psychological causations origins, psychological blindness and extreme somatic repression with severe concomitant sensory/motor inhibitions. Characteristically these “Dissociated” individuals have normal appearing lucid behavior, and then suddenly behave irrationally with another personality. Many have affect storms traceable to highly stressful childhood events of which they are amnesic. Dictators, who repress the free flow of information in a culture, can seize upon the immaturity of such individuals to exert dictatorial mental control. To foster this, they can infect social systems and educational programs with a virus of repression. The repressed may come to erroneously believe that if an inflammatory issue is not presented in the media or talked about in private, then it somehow magically doesn‘t exist. For example, there are still physicians who fail to discus with a terminal patient their prognosis. Universities may be administrated by “Mind police” such as retired military generals having connections to dogmatic religious groups, who spy on the social sciences professors for those

Spiritual Warfare and SIS Spiritual Symbols 87 who might dare to challenge their students to think realistically. Teachers, in school, may sense that children are being neglected or abused, but dare not ask about either their social environment of their inner world of fantasies and “nightmares.” Any professional who questioned the significance of real or symbolic traumatic inkblot responses living in such repressive environments would be similarly censored. In such countries, there could never be an honest medical science of epidemiology regarding the prevalence of body-mind-spirit disorders. Nor could there be a comprehensive community mental health program blending introspective inkblot projective techniques, with Yoga based therapies supplemented by the use of closely monitored psychotropic medication (when clinically indicated). Unfortunately, this is idealistic, since most nations lack political leaders trained in public health systems, which require adequate taxation- based funding. In Mexico, it is reported that the Italian Papal based religious authorities; financially linked to powerful warring drug traffickers have long repressed independent thinking in schools. Over the years this has produced a defeatist mentality, where thinking outside the “religious box” is limited and the public, seeking immediate gratification, alternatively turns to drugs and alcohol. The chemical “virus” is rapidly spreading north to the United States (and Canada) playing a major role in the ongoing serious economic downturn. This is especially evidenced by the great number of unemployed people,” many suffer from untreated mental illness. Lack of mental health funding in the public sector is responsible for many of these ending up in America’s extensive prison industry Part of this deficiency relates to the ever blurring of boundaries between religion and politics in western countries which has undermined economic government support for community mental health programs. Relative to the ever expanding tax free role of the Italian Papal government in Alaska, the Roman Catholic Church rapidly expanded from originally, being a small entity to now being the second largest employer of Alaskans. Moreover many other religious groups also exploit this tax loophole. For media manipulated voters, such economic seduction, now endemic in bankrupt America is facilitated by religious based mythology which simultaneously anesthetizes their existential “Body Image” death anxiety. In spite of such problems, the beautiful state Alaska has provided a measure of real intellectual freedom and opportunity to use projective technique to explore the depths of human consciousness, not possible elsewhere in closed minded societies. As a dramatic example of repressive mind control, I recall in the early 1960’s attending at a meeting of the American Psychiatric in Chicago. There I had the opportunity to listen to a paper presented by a psychiatrist from China speaking on the prevalence of Schizophrenic Disorder. Afterwards as a follow-up, enquiry questions were raised by the audience about other mental conditions. When asked about Depressive Disorders, he claimed that the Chinese communistic society was functioning so well, that no one ever suffered from depression! It would be occupationally forbidden for an inkblot examiner to openly interpret projected symbolic responses such as “A broken heart,” “A sad heart,” etc. Fortunately in India and in western societies elsewhere, mental health professionals are less restricted in their scientific based body-mind-spirit occupational roles! Historically, SIS work is dedicated it all those departed souls, who when alive enhanced the quality of life on our planet. We especially recognize those early meditating Indian gurus, who contributed to mental science. Their introspective explorations within the inner world led to powerful Yoga techniques. Although often overlooked in the modern scientific literature,

88 Cassell and Dubey these provided a historical basis for depth studies involving inkblot projection. Fortunately, after Rorschach, a great number of psychologists took up the challenge. They have made extensive contributions not only in clinical diagnostic settings, but as well many other test assessment applications. Examples of widely used scoring systems that they developed are presented in this book. As compared to projective procedures, these may be conceptualized primarily as instruments for initial enquiry of surface phenomenon. Often responders tend only to reveal what they know about themselves and choose for reasons of social acceptability to share with a test administrator. In contrast, a deeper level of data is accessed when the test administrators utilize procedures based upon fundamental principles of projection. These more readily penetrate defensive social facades of the individual’s “Persona,” thereby symbolically open windows of the mind. Moreover, when they are empowered with hypnotic trance, either with traditional induction procedures or the electronic mesmerizing floral scenes in the electronic forms of the SIS, then resistances tend to melt away. The reader will learn about how this second level of enquiry can technically facilitate exploring the depths of body-mind-spirit functioning to open innovative paths to treatment. Such new “Inkblot” therapies now demand more attention. In many clients/patients suffering from the less severe mental disorders, the emerging scientific literature indicates that side effect prone psychopharmacological interventions are not much better than placebo. Providing a technical based memory releasing aide to psychotherapy, the imagery projected onto inkblots enable the examiner to view stressful events from the subject’s past life. The critical images that are projected may reflect, either directly or in disguised symbolic form, real life historical events. Interpreting these is much more challenging task, than faced by an astronomer whose concepts relate to time, space and energy. In addition to the above, the projected symbolism may be traceable to highly subjective body mind-spirit phenomena such as body imagery, dreams, visual hallucinations etc. Just as it has taken modern telescopic technology to enable astronomers to conceptualize invisible “Black hole” cosmic conditions, there are instances of perceptual blindness, or not seeing the obvious suggestive structure in SIS inkblots. Their theories predict an ultimate dire ending. For example, they inform us that the source of energy in our solar system will ultimately blow up in a massive ball of fire, destroying all life on our planet. Yet there are unanswered philosophical/religious questions that go unanswered. One critical one is that astronomers cannot conceive of what preceded the “Big Bang” origin of the universe. This philosophical void in introspective individuals can trigger various mood disorders such as “existential anxiety.” In combination with real life socioeconomic stressors, genetically susceptible individuals may experience stressful somatic symptoms, such as, “chest pain”, palpitations” etc. Such susceptible people are more likely to project heart responses or perceptually inhibit cardiac like inkblot structure. Alternatively, like those mentally threatened by Darwinian evolution theory, Cosmic theory can cognitively force others into the comforting balm of explicit, yet irrational, religious dogma as well as mind altering street drugs. Characteristically, such individuals are open to exploitation by authoritarian leaders, as intellectually restricted or “brain washed” victims. During much of their lives they function in society in a trance like mental state. Dictators who repress the free flow of information in a culture can seize upon such the immaturity of such individuals to exert dictatorial control. Now in the 21st century many countries have societies that are not open to uncovering the depths of suffering and releasing the “inner cry.”

Spiritual Warfare and SIS Spiritual Symbols 89 In these, professionals tend to be restricted who utilize the mind-spirit enhancing aspects of poetry, dream analysis and projective testing. Fortunately this journal was able to be published, since it emerged from the democratic aspects of Indian culture. In general, political/religiously repressed people are unlikely to be open in psychometric testing - especially projective inkblot assessment. If they do participate, they will give responses denoting religious symbols (e.g. “angels,” the devil” etc.) Defensive symbolism may be projected onto SIS somatic structure suggesting sexuality, death, etc. Those preoccupied with modern warfare tend to project images depicting “nuclear destruction.” Likewise, those clinically obsessed with threatening astronomical theory are more likely to visualize space hazards (e.g. “planets colliding,” “dark hole phenomenon.” etc. Inkblot evoked images can highlight otherwise hidden aspects of the inner emotional world of humans. These may reveal to the professional, past traumatic events and unexpressed distressing emotions which might, otherwise, only surface in disguised symbolic dreams. A clinically effective variation of the SIS procedures involves administering these, at bedtime, to stimulate dreams revealing material otherwise unreported in traditional clinical interviews. Other innovative approaches involve viewing inkblots during the memory enhancing aspect of hypnotic trance. Thankfully, such innovative work has flourished in India. This country has long been revered for its rich contributions to depth psychology, meditation and healing. People from around the world have traditionally traveled there to acquire skills as practitioners of Yoga. Image focusing exercises have long been effectively taught by the Indian experts. Practicing the traditional techniques eventually can lead to positive health effects. Those planning to acquire SIS aided Yoga skills; in association with efficacious psychological techniques require courage for “SPIRITUAL BATTLES”. Footnote : Before the Christian missionaries came to southeast Alaska, the Tsimshian Indians in Metlkatia neither had written language, nor did the clan’s young males have high suicide rates. Traditionally the elders preserved their stories and legends by carving on totem poles symbols depicting past significant events. On special cultural occasions, an elder would repeat such historical stories while translating the religious symbolism. These served to link the participants to higher creative spirits of Nature as well as the mystical Cosmos beyond. Apparently the early missionaries failed to appreciate the identity positive symbolic significance of such carvings. Consequently they ordered their converts to terminate the carving tradition. Sometimes they moved from “Spiritual Warfare” into the physically destructive realm by destroying their totems citing passages in the Bible “Not to worship Idles”. A few years ago, I attended a lecture by Rev. David K. Fison who had served as a United Methodist minister in Tsimshian. He outlined his artistically creative attempts to convert Indians to Christianity. He cited his original inspiration on how to design totem poles with embedded symbols portraying Bible stories. Afterwards, he proudly reported that an Alaskan Roman Catholic bishop had purchased two miniature replicas of the two totems to take to Italy as a present for the Pope. However, few religious leaders have been willing to publically consider that such “treatment” of the Indian cultural heritage might have potentially “toxic side effects”. Yet to be objective, the supportive empathetic bonding of his caring personality to the clan seemed to have outweighed such “toxicity” Apparently the elders felt this as well. In 2001

90 Cassell and Dubey he was adopted into the Killer whale Clan with the name “NADAAM NLOMSK” meaning Carver of Sacred Things. Conclusion : The Somatic inkblots procedure has been found to release long forgotten memories and brings on surface painful materials needs processing. The symbolic spiritual interpretation further helps during therapeutic intervention. The yoga practices and meditation work as further aide to therapy. The paper has emphasized the power of SIS inkblots imagery, spiritual and symbolic interpretation during therapeutic intervention. References: Cassell, W. A. (1979) Anatomical Rorschach Responses and Death Symbolism. British Journal of Projective Technique and Personality Study, 24: 7-16. Cassell, W.A. (2011a) Editorial: Dissolving Death Anxiety with Yoga Empowered. SIS Journal of Projective Psychology & Mental Health, 18: 123-128. Cassell, W.A. and Dubey, B.L.(2003) Interpreting Inner World Through Somatic Imagery, SIS Center, Anchorage, Alaska(USA). Cassell, W. A., Dubey, B.L.and Roth, G.J. (1997) Medical, Psychological and Spiritual Application of the SIS Inkblots SIS Journal of Projective Psychology & Mental Health, 4, 89-112. Cassell, W.A., Ilardi, F.J., Collins, A., Mishra M. and Dubey B.L. (2001) Optimizing Spiritual Healing by assessing Dream and SIS Imagery, SIS Journal of Projective Psychology & Mental Health, 8: 75-94. Cassell, W. A., Dubey, B.L. E Molchanov and L. Routhul (1999) Stimulating Beacon images for meditation and projective psychotherapy, SIS Journal of Projective Psychology & Mental Health, 6:7-30. Chatters L.M. (2000) Religion and Health: Public Health Research and Practice. [Review][185 refs] Annual Review of Public Health. 21: 335-67.

indeed to have been one of the causes of the collapse of the Roman Empire. The adverse effects of chronic abuse of wine were well known to the physicians in that era. It is said that as Christianity spread in Europe so did wine drinking. For some, drinking alcohol is a pleasure. In China, where rice was one of the cereals used to make alcohol, there was a common saying: ‘First the man takes a glass, then the glass takes a glass and finally the glass takes the man (Sournia, 2009). Sweden’s Magnus Huss had first coined the word “alcoholism”. The pattern of alcohol abuse has changed over the years. In a systematic web based review by Murthy et al (Murthy, 2010), out of 25 major regional Indian studies from 1968 to 2007, 23 were on alcohol alone. The terms “Abuse, Harmful use, and Dependence” have different meanings. Abuse refers to adaptive patterns of use leading to harmful consequences not amounting to dependence and harmful use of alcohol refers to any mental, physical or social harm resulting out of excessive use. The term alcohol dependence can be used when additional criteria of 3 or more out of 6 as per ICD10/ DSM-IV for a dependence syndrome are met (WHO 2004, APA 2000). A central descriptive How Common is Alcohol Induced Psychosis in a Suburban Part of India? D. Saldanha, K. Anuja, P. Vishal, B.Sumit, K.Arpita, G.Ambarish and V.Patel The effects of alcohol on human mind and body are a fascinating subject since times immemorial. 200 cases (Non Alcoholic, Mean Age 41.32 years) and 50 patients (Alcoholic, Mean Age 42.96 Years) admitted in a Medical College Hospital, Pune (situated in a semi urban area) were taken for the study. The incidence of alcohol abuse in the study sample was 20 percent and Alcohol induced psychosis was 3.2 percent .The importance of group psychotherapy towards prevention of alcohol abuse in the young adults is highlighted in the paper. characteristic of dependence is the desire (often strong, sometimes overpowering) to take alcohol. Tyndel (1974) found e0 that return to take alcohol after a period of abstinence leads to a more rapid reappearance of other features of syndrome than that occurs with nondependent individuals. Alcohol dependence often has a familial pattern, and it is estimated that 40 to 60 percent of the variance is explained by genetic influences. The risk of alcohol dependence is 3 to 4 times higher in close relatives of people with alcohol dependence (Benjamin 2007). Craving, one of the foremost criteria’s for a dependence syndrome plays an important role in persistence of its use and relapse. In the first National Household Survey of drug use in India, Ray (2004) observed Alcohol abuse as high as 21.4 percent. Alcohol use is highly prevalent in most western countries. The lifetime risk of alcohol dependence is approximately 10 to 15 percent for men and 3 to 5 percent for women with 1 year prevalence rates of about 6 percent. About 90 percent of Americans have at some time consumed alcohol, with most beginning in their middle teens. The peak age of onset of dependence is as early as 20 years and often going on to the age 40 years. (Benjamin 2007) Life time risk of alcohol dependence is approximately 15 percent in general population. Alcohol related disorders affect 5 to10 percent people world vide..

92 Saldanha, et al Prevalence of psychiatric disorders in alcohol dependents is a matter of concern. Ray and Chandrasekhar (1982) in their review articles mentioned, that the prevalence of alcohol in epidemiological studies done in India range from 58.3 percent to 74.1 percent, above the age of 15 years, and alcohol dependence is approximately seen in 4 percent of the population. Effects of alcohol on individual may include mental and physical illness, family disruption and even death. The pathological relationship with alcohol increases with quantity and frequency of its use and the side effects on different organ systems. Consuming more than 3 drinks a day increases low density lipoprotein, cholesterol, triglycerides and blood pressure which has direct bearing on heart, GI system, Liver and pancreas. Early stage of cirrhosis is approximately seen in 15 percent of alcoholics, acute pancreatitis (10 percent) that can present as an abdominal emergency. Consumption of 4 to 8 drinks per day decreases the production of WBCs and impairs ability to migrate to sites of infection. Essentially high doses of alcohol adversely affect almost all body systems, cutting a decade or more off a lifespan even for people with higher socioeconomic and educational status. Prolonged excessive drinking can give rise to serious and sometimes irreversible psychotic conditions. Psychotic disorders occurring during or immediately after use (usually within 48 hours) are included provided it is not a manifestation of alcohol withdrawal state with delirium (ICD 10 WHO 2004). Alcohol related psychosis is defined as a cluster of phenomenon that occur immediately or during alcohol use and are characterized by vivid hallucinations (typically auditory, but often in more than one modality), misidentifications, delusions and/or ideas of reference (often of paranoid or persecutory nature), psychomotor disturbance, excitement or stupor, and an abnormal affect, which may range from intense ecstasy to fear .The sensorium is usually clear but some degree of clouding of consciousness may be present. This disorder typically resolves at least partially within a month and finally within 6 months. Induced psychotic states are of short duration provided that no further amount is consumed. Alcohol related psychoses includes alcoholic hallucinosis, alcoholic jealousy, alcoholic paranoia and alcoholic psychosis not otherwise specified (NOS). In residual or late onset, alcohol induced psychotic disorder changes in personality or behavior persist beyond the period during which a direct alcohol related effect might reasonably be assumed to be operating. The occurrence of Psychosis on prolonged and continuous use is well known. However, there is a wide variation in the reported incidence and prevalence rates of alcohol induced Psychosis. Tyndel (1974) reported 6 percent among 100 hospitalized cases of alcoholism.Vohra et al (2003) reported 21.7 percent in 30 consecutive admissions for alcohol dependence in a tertiary care center in Northern India. Weaver et al (2003) in a large community based study in UK reported 8 percent among 124 patients of drug abuse and harmful alcohol use. Soyka (2008) reported a prevalence of 0.4% among alcoholic inpatients in a University Hospital. Keeping in view of the wide variation in the reported incidence and prevalence of alcohol induced psychotic disorder a study was planned in a semi urban industrial setting to know the incidence of the alcohol induced psychosis. Objectives: The present study was conducted with the following objectives: a) To find out the incidence of Alcohol induced Psychosis in patients admitted in a semi urban population. b) To initiate therapeutic intervention to reduce alcohol dependence through education, information and communication.

Alcohol induced psychosis in a suburban Part of India? 93 Material and Methods: 250 consecutive admissions in male medical and psychiatric wards, over two and a half month period from June 15 to August 30, 2011, in a semi urban area of a Medical College Hospital, near Pune. The study was sponsored by ICMR to a short period of time with no follow up involved and was more a survey of alcohol abuse. Inclusion criteria: 1) All first time male admissions in medical and psychiatric wards were taken. Female patients were not included in the study because there were hardly any female admissions in the ward. 2) Only those above the age of 16 years with clear history of alcohol abuse and admitted in Psychiatry ward through direct admissions. A comprehensive demographic profile was taken on a proforma which included age, sex, economic and marital status, duration of use and co morbidity. Alcohol use Disorders identification Test (AUDIT) was used as the screening instrument to identify problem drinkers. (Saunders 1993).The AUDIT was developed by World Health Organization (WHO) to identify persons with consumption of alcohol that is harmful to their health (Babor, 1992). It is a 10 item questionnaire with 3 questions on the amount and frequency of drinking, 3 questions on alcohol dependence and 4 on problems caused by alcohol. The minimum score is O (non-drinkers) and the maximum possible score is 40. A score of 8 or more indicates likelihood of harmful alcohol consumption to dependence. The patients were further examined by a psychiatrist to arrive at a diagnosis as per ICD10 criteria. Results: A total of 250 consecutive admissions in male Medical and Psychiatric wards were analyzed using statistical software EPI info and SPSS. The mean age of Non-alcohol and alcohol patients were 41.32 and 42.86 with a SD 16.04. The breakdown of age is shown in Table 1. Table 1 Age Wise Admission Pattern Age Non-Alcohol Admissions Alcohol Abuse <20 yrs 21-30 31-40 41-50 51-60 61-70 >71 Total Mean 41.32 Mean 42.96 SD 16.04 X2 (3) = 1.22; P > 0.75 (Rows 1& 2, and 5, 6, 7 clubbed for statistical analysis) Table 1 indicates that 76 percent of the patients in the alcohol group are in the age of 21-50 years and nearly 56 percent are below 40 years. The two groups differed significantly as far as the Education and Socioeconomic levels were concerned. Table 2 and 3 further indicates that 67 percent non-alcoholic patients as compared to 84 percent of alcoholic group were educated SSC and less and majority was doing menial jobs / daily wagers. 69 percent of non-alcoholic group as compared to 52 percent in alcoholic group have an income of less than Rs. 3000 and consume the locally brewed alcohol. Marriage seems to play no role in the consumption of alcohol in this study. 88 percent non-alcoholic and 84 percent alcoholic were married, remaining unmarried in both the groups (Table 4).

94 Saldanha, et al Table 2 Education of Both the Groups Education Std/Gradu-ation Non-Alcohol Admissions Alcohol Abuse <5 Std 5<SSC SSC Grad Post Grad Total X2 (3) = 34.07; P < 0.0001 Table 3 Socioeconomic Status as per Income /Month Class (income in Rs) Non Alcohol Admissions Alcohol Abuse 0 to 1000 1001-3000 3001-5000 5001-7000 Total X2 (3) = 8.37; P <0.039 Table 3 reveals that 69 percent of non-alcoholic group as compared to 52 percent of alcoholic group have an income of less than Rs. 3000 per month and, consume locally brewed alcohol. It is also observed that most of the patients admitted to this hospital for alcohol related problems consume locally brewed alcohol. As far as marital status was concerned both the groups were evenly matched. The pattern of alcohol abuse in the three groups (Table 5) is statistically significant. 58 percent of the total cases in the three groups drink 180 ml or more of alcohol daily. The amount of alcohol varies as it is directly proportional to the individual’s paying capacity to buy the drink. Table 4 Marital Status Groups Married Unmarried Non Alcohol Admissions 176(88%) 24(12%) Alcohol Admissions 42 (84%) 08(16%) Total 218(87.2%) 32 (12.8%) Table 5 Alcohol Abuse (AUDIT) VS Alcohol Consumption Types AUDIT 120>180ml >180ml Total Harmful use Upto <7 Alcohol dependence 8-13 Alcohol Psychoses 14-27 Total X2 (3) = 1 9.82; p< 0.0001 Therapeutic Intervention: The patients were managed as per the conventional methods by detoxification and pharmacotherapy and counseling. Group therapy sessions were held to rehabilitate the patients with a view that once they are discharged from the hospital they remain abstinent. The gains of therapy were highlighted during therapy sessions. The need for abstinence was impressed upon the patients during the group discussions which were attended by the psychiatric staff consisting of a Psychiatrist, Residents in Psychiatry, Clinical Psychologist, Psychosocial worker and the patients in groups of 8-10 per session. Three to four sessions were held regularly every week. Each patient was asked to elaborate their drinking profile and asked to describe how much damage it has caused to their lives. They were monitored by the psychosocial workers through individual interviews and day and night observations. They were asked to report if they feel craving and alcohol seeking behaviour. Group therapy

Alcohol induced psychosis in a suburban Part of India? 95 sessions helped each of the patients in overcoming their initial resistance to discuss their alcohol abuse problem. A few of them were keen to discuss and share their anguish of domestic problems including financial mess. Listening to each patient in the group and showing them the ill effects that one can experience paved the way for their confidence to get well. This therapeutic approach following the deaddiction phase helped them to enhance their self respect and motivational skills. The harmful effects of alcohol on various internal organs were highlighted through video projections. The progress of each one attending the group therapy session was monitored. At the end of the therapy almost 90 percent of the patients could state their motivation to give up alcohol totally and remain abstinent. Those who envisaged problems after discharge were asked to come for therapy sessions. Discussion: 250 admitted patients in the male medical and psychiatric ward constituted the sample. Out of these 20 percent alcohol abuse cases were analyzed after screening them by AUDIT and were being treated in male psychiatric ward. About 31 percent of patients admitted in Male Medical ward for various medical illnesses, had doubtful history of alcohol abuse were not included in the study. AUDIT was selected as a tool for screening to identify problem drinkers. Srinivasan and Augustine (2000) studied the prevalence of alcohol dependence and alcohol related diseases in 297 newly admitted patients in a general hospital and used AUDIT as a screening tool. The study revealed that 186 patients (62.6 percent scored 0) never drank alcohol 93 (31.3 percent) patients had positive score suggesting alcohol abuse. 61 (20.54percent) patients had a score of 8 and above on Audit. As compared, 31 percent patients in the non-alcoholic group had a doubtful history as they were admitted for various medical disorders like hypertension, diabetes, anemia etc in the present study, were not subjected to screening. Those who undergone AUDIT in the alcoholic group 66 percent had scored 8 and above (likelihood of harmful alcohol consumption to dependence). The percentage of alcohol dependence and psychosis (with score 8 and above) is 13.2 percent which is similar to the findings of 12.8 percent of Pala et al (1997). However, it is much lower than 20.54 percent reported by Srinivasan and Augustine (2000) and 23.3 percent reported by Savithri et al (Savithri1997) in their study on problem drinkers admitted to a general hospital in Bangalore. Though 66 percent patients in the alcoholic group in present study were consuming harmful amount of alcohol, there was no empirical relation between their alcohol consumption and verifiable medical co-morbid diagnoses. Although Alcohol dependence syndrome is conceptually different from alcohol related problems, they are not mutually exclusive (Edwards and Gross 1976). It is relevant here to note that harmful consumption of alcohol is associated with common illnesses such as diabetes mellitus and hypertension. Physicians usually do not consider alcoholism often enough as a differential diagnosis and consequently miss out the alcoholic problem altogether. While considering the age of Alcohol abuse group, 26 percent were in the age range of 20- 30 yrs, 28 percent in the age range of 31-40 yrs. Alcohol abuse in such young age is detrimental not only to your own health but also ruins the family structure, shatters the peace of family and leads to early death due to added medical problems. 64 percent of them studied high school and below and more than 50 percent earned less than Rs. 3000/pm. The finding was similar to the study carried out in an urban area by Meena (2002) in Haryana. They also found most of the abusers belonged to High School category. 58 percent of alcoholics took more than three large (180 ml) each day. The number of years of using alcohol ranged from 3- 37 years. Alcohol induced psychotic states was observed in 16 percent of the alcohol group and 3.2 percent in both the groups combined.

96 Saldanha, et al These were the cases abusing alcohol excessively over the years. They were brought by their family members and admitted directly in the Psychiatric ward. The predominant finding in these cases was auditory hallucinations which were derogatory type. Three of the 8 such cases had visual hallucinations. These were managed by antipsychotic drugs and Benzodiazepines. Upon complete recovery they were subjected to counseling and group therapy sessions. 90 percent patients who attended the group therapy session reported not only improvement but were self confident to remain abstinent from alcohol abuse. Conclusion: It is evident that indulgence in alcohol at a young age is consistent with the severity of alcohol abuse and its resultant complications like alcohol induced psychotic behavior which in the present study is 16 percent in alcoholic group and 3.2 percent in non alcoholic group. The spread of alcohol abuse in the young, however, can be tackled through information, group discussion and education about the ill effects of alcohol abuse. References: American Psychiatric Association. Diagnostic and Statistical Manual of mental Disorders (4th Edition) DSM-IV TR. (2000). Washington DC; APA. Babor, T. F., Fuente de la, J.R., Saunders, J. R and Grant, M. (1992).The alcohol use disorders identification test. Guidelines for use in primary health care. World health Organization Geneva: Switzerland. Benjamin, J. S., and Virginia, A.S. In Kaplan & Sadock’s Synopsis of Psychiatry 10th ed. (2007).Chapter 12.2 Alcohol Related Disorders pp 390-407.Indian reprint.ISBN-13:978-81- 89960-37-7.Published by Wolters Kluwer (India) Pvt ltd, New Delhi. Edward, G and Gross, M. M. (1976). Alcohol dependence: provisional description of a clinical syndrome. British Med. Journal, 1058-1061. Meena, K., Vohra, P and Rajput R. (2002). Prevalence and Pattern of alcohol and substance abuse in urban areas of Rohtak City. Indian J Psychiatry, 44(4), 348-352 Murthy, P., Manjunatha, N., Subodh, B.N., Chand, P.K. and Benegal, V. (2010). Substance use and addiction research in India .Indian J Psychiatry, 52:2, 89-99 Pala, I., Patel, K., Tilwani, M., Sha, R and Vankar, G. (1997) Alcohol use disorders among general hospital patients. Indian J Psychiatry, 39.44 Ray, R. (2004) The Extent, Pattern and Trends of Drug abuse in India. National Survey, Ministry of Social Justice and Empowerment, Government of India and United Nations office on Drugs and Crime, Regional Office for South Asia. Ray, R. and Chandrasekhar, K.(1982). Detection of alcoholism among psychiatric inpatients. Indian J Psychiatry, 24 (4), 389-393. Saunders, J.B., Aasland, O. G., Babor, T. F., Fuente de la, J. R and Grant M. (1993). Development of Alcohol Use Disorders screening Test (AUDIT) WHO Collaborative project on early detection of persons with harmful alcohol Consumption. Addiction, 88,791-804 Savitha, S. Raguram, R and Srivastava, M. (1997) Alcohol problems in a general hospital- A preventive study. Journal of Indian Medical Association, 95.506-506 Sournia, J.C. (2009) A History of Alcoholism last modified September 7th,.http://www.hoboes.com/Politics/ Prohibition/ Notes/Alcoholism History [Context Link], Pp 5- 137. Soyka, M. (2008). Prevalence of alcohol induced psychotic disorder.Eur Arch Psychiatry Clin Neursci, 258:317-318. Srinivasan, K and Augustine, M. K. (2000) A study of alcohol related physical diseases in General Hospital patients, Indian J. Psychiatry.42(3), 247-252 Tyndel, M. (1974). Psychiatric study of 100 alcoholic patients. Can J Psychiatry, 19:21-4. Vohra, A. K., Yadav, B. S. and Khurana, H. (2003).A Study of Psychiatric Co morbidity in Alcohol Dependence. Indian J. of Psych.45 (IV), 247-250 Weaver, T., Madden, P., Charles, V., Stimson, G and Renton, A.(2003). Co morbidity of substance misuse and mental Illness. Community mental health and substance misuse services. British Journal of Psychiatry, 183,304-313 WHO, Geneva. (2004). The ICD-10 Classification of Mental and Behavioral Disorders, 1993. AITBS, Publishers, Delhi, 70-83.

The present century is characterized by “head-on collisions” to be “achievers” in the competition so as to attain cherished targets in life, with least considerations to everything around. Such impulsivity gets manifested in behavior, owing to the presence of minimal frustration-tolerance of individuals. It is an irony that improved science and technology in the present day have brought forth more accidents, be it in industry, in war or on the road. The resultant is rash driving, which is rampant at top gear. Road accidents act as true menace to civilians and society at large. Repeated bouts of road-rage over a prolonged period of time jeopardizes the very physical as well as emotional safety of the pedestrian (Basu, 2006; Sanyal and Dasgupta, 2007). In fact, approximately 230,000 people worldwide die on the roads each year (Brom et al., 1993), and one in four people will experience a serious motor vehicle accident at some point in their lives (Norris et al, 2000). In developing countries like India and China, the trend has essentially been on the rise, registering an increase of road accidents by about 30-100% (Basu, 2006). Hence is the need to bring about a check to the wide-spreading “disorder on Aggression and Related Psychosocial Correlates among Offending and Nonoffending Drivers: A Therapeutic Intervention Nilanjana Sanyal, Sayantani Chatterjee, Manisha Dasgupta and Sraboni Chatterjee Driver-violence has been essentially on the rise, taking toll of many innocent lives. The present study probes into the personality profiles of rash driving drivers, from the perspectives of mental health, in a comparative parlance with non-offending counterparts. The sample consisted of 168 drivers (99 offending and 69 non-offending drivers) who were matched with respect to age, sex, education and socio-economic status. Standardized questionnaires were administered to assess selected personality variables. Offending drivers were found to have significantly impaired controllability awareness in all the dimensions, mood states in addition to higher indirect form of expressed aggression than normal counterparts. Besides, significant profile differences were also observed with regard to morbid and morbidity-free drivers along with intra-group findings. Specific strategies for therapeutic interventions for promoting road safety have also been implicated. the roads” (Raghavan, 2005). The present research endeavor delves into such an attempt to understand the psychosocial perspective of offending drivers to pinpoint their vulnerabilities, if any, so that remedial measures in terms of therapeutic interventions may be provided in future to ensure safety. Driver-violence has been found to be closely associated with driver’s aggression, which is defined as any behavior intended to physically, emotionally or psychologically harm another within the driving environment (Hauber, 1980; Hennessy and Wiesenthal, 2001). Following the horrendous trend, the number of major injury cases in Kolkata over the years is essentially on the rise (Kolkata Traffic Police, 2006). According to conservative estimates, rash driving accounts for about 50% of all road deaths in India (estimated annually to be about 80,000) while the remainder is the fault of pedestrians and all other factors combined including natural hazards (Basu, 2006). Keeping the increasing death data in mind, there is need to study the personality profiles of offending drivers so as to enable unfurling the etiologies of aggressivedriving from mental-health perspective to offer Nilanjana Sanyal, Ph.D., Professor, ManishaDasgupta, Ph.D. Asst Professor, Dept. of Psychology, University of Calcutta, 92 A.P.C Road, Kolkata-700009 (Correspondance: sanyal_nilanjana2004@rediffmail.com). Sayantani Chatterjee, Ph.D., Asst. Prof, Loreto College, 7 Middleton Row, Kolkata-700071 and Sraboni Chatterjee, Lecturer, Muralidhar Girls’ College, P4/124 Gariahat Road, Kolkata – 700029 Key words: Offending drivers, aggression, mood states, controllability awareness, narcissism

98 Sanyal, et al them with therapeutic interventions in the long run. Under conditions of stress, drivers are more likely to exhibit mild forms of driver aggression, including horn honking, swearing and yelling at other drivers (Shinar and Crompton, 2004). For many, the inability to deal effectively with stressful driving demands contributes to feelings of frustration, irritation and anger, which can subsequently enhance the potential for driver aggression (Deffenbacher,et bal., 2000, Vanlaar, et al, 2008; Shaikh, et al, 2008; Bjorklund, 2008; Esiyok, et al, 2007). A heightened loading of aggression among offending drivers seems to be intimately associated with their relative inability to distinguish between controllable and uncontrollable aspects of their potential outcomes. Controllability awareness describes the extent to which a person’s outcomes reflect distinctions between controllable and uncontrollable aspects of potential outcomes (Heth and Somer, 2002). Offending drivers appear to have deficits in controllability awareness, resulting in low stress-tolerance and proneness to develop aggressive orientation that gets manifested through “rash driving” (Sanyal and Dasgupta, 2007). Mood states appear to be yet another important personality variable, influencing one’s emotional platter and thereby lead to rash driving. A number of researches have acknowledged high anger drivers to have problems in driving who tend to report more aggressive and less adaptive/ constructive forms of expressing anger while driving, engage in more aggressive and risky behaviour on the road, and experience more of accident-related outcomes than lowanger drivers (Deffenbacher et al., 2003; Biggs et al., 2009; Machin and Hoare, 2008; Vanlaar et al., 2008). Fatigue, depression and negative affect was also found to have some bearing on reckless driving on the road, resulting in fatal accidents (Brookings, DeRoo and Grimone, 2008; Lajunen and Parker, 2001). Besides, psychiatric morbidity also appears to be a vulnerable personality factor paving the way for aggressive driving among offending drivers (Malta et al., 2005; Kanaan et al, 2009; Dumais et al, 2005). Narcissism refers to a “pervasive pattern of grandiosity” that is characterized by arrogant behaviors, feelings of entitlement, superiority and lack of concern or empathy for others (A.P.A., 1994). Extremely high levels of narcissism are considered pathological, though narcissism is a normally distributed personality trait (Raskin and Hall, 1979) that has been characterized as a system of inter-personal and intra-personal strategies devoted to maximizing and protecting selfesteem (Morf and Rhodewalt, 1993). As such, a profile high in self-love among drivers is likely to be coupled by high authority, superiority, and self-sufficiency feelings that may get manifested through rash driving. The present study is guided by the following objectives: • To find out whether offending and nonoffending drivers differ with respect to controllability awareness and its different dimensions, aggression-strategies, mood states and dimensions of narcissism; • To determine whether morbid and morbidity-free drivers differ with respect to the selected variables and their respective dimensions; • To reveal whether intra-group differences exist with respect to the selected variables and their respective dimensions. Method: Sample: The sample consisted 168 drivers, of whom 99 had committed some offence (people died in the accident), were referred to as ‘offending’ drivers, had their driving-license seized temporarily and had attended a three-day refresher training course at the Traffic Training School (TTS),

Aggression and Related Psychosocial Correlates among Offending and Non-offending Drivers 99 Kolkata and 69 subjects had safe records and were referred to as ‘non-offending’ drivers. The non-offending drivers also attended the three-day refresher course at TTS, Kolkata and were selected by matching each of them to their offending counterparts with respect to age, educational level, socio-economic level, and the number of hours expended in driving per day. All the subjects belonged to lower socioeconomic status (SES), in the age range from 20-55 years and did not attain any formal education. They were administered the 28 item version of the General Health Questionnaire (GHQ-28) (Goldberg and Hiller, 1979) and were also divided into two further groups, namely, morbid and morbidity-free groups (based on their respective scores of 4 and above on GHQ to belong to morbid group and below 4, to belong to morbidity-free group). As such, the sample consisted of 121 morbidity-free and 47 morbid drivers. Tools : The following tools were used in the present study: 1. Information Schedule: The information schedule, constructed by the researchers themselves, aimed at eliciting certain basic information like age, sex, education, occupation, duration of service, number of hours expended in driving per day, reason(s) for opting driving as an occupation, whether used seat-belt or not, how long they had been holding their driving license, the number of accidents they encountered in their driving-lives and the like. The items of this schedule were prepared in advance and were approved by experts of the field. 2.Controllability Awareness Inventory (CAI): It was developed by Heth and Somer (2002) and used to assess controllability awareness as a characteristic of stress tolerance. The inventory consists of 20 simple statements, they being clustered into four groups, each comprising of five statements and thereby assessing four different aspects of controllability awareness, namely, personal control, shared control, others in control and no one in control. Each of the statements is scored on a 5-point scale from 1=‘disagree strongly’ to 5=‘agree strongly’. Anti-trait items are reversed and the responses are summed to produce a score between 20 and 100. Similarly, scores for each of the different dimensions of controllability awareness is also found out, which is found to have a range between 5 and 25. High score in a domain indicates high level of controllability with respect to that dimension. 3. Aggression Orientation Scale (A.O.S.): This scale was developed by Basu (2001). It consists of two major parts, namely, Readiness for Aggression and Expression of Aggression. The Readiness part has five sub-scales, namely, hostility, anger, positive attitude to aggressive expression, externalizing tendency, internalizing tendency. The expression part has three sub-scales – verbal, physical and indirect aggression. The respondent answers in a Yes/ No format. The entire scale has 76 items. The affirmative responses were scored 1 and the negative ones 0. Only two of the items in the domain of predisposition were reverse scored. The higher the score, the greater is the aggression. 4. Profile of Mood States: It has been developed by McNair, Lorr and Droppleman (1971). It consists of 37 items measuring mood disturbance. Items on the scale are rated using a 5-point Likert scale from 0 (not at all) to 4 (extremely). Participants are asked to rate how they have been feeling during the past one week. The scale consists of 6 mood factors: :Tension-anxiety, Depressiondejection, • Anger-hostility, Vigour-activity, Fatigue-inertia, and Confusion-bewilderment.

100 Sanyal, et al 5. Narcissistic Personality Inventory (NPI): It was developed by Raskin and Hall (1979). It is a 40-items measure that assesses narcissism as a normally distributed personality trait (Raskin and Hall, 1979). The NPI distinguishes seven different aspects of narcissism, namely: Authority, Self-suffeciency, superiority, Entitlement, Exhibitionism, Exployoitativeness and Vanity. 6. General Health Questionnaire (GHQ): It was developed by Goldberg and Hiller (1979) as a self-administering screening test aimed at detecting psychiatric disorders among respondents. Each item of GHQ-28 has four response alternatives. GHQ-28 has been adapted for Bengali population by Basu and Dasgupta (1996). The scoring was done by G.H.Q. method (0-0-1-1) as suggested by Goldberg & Williams (1988). Total score ranges from 0 to 28. In this study, cut-off point for psychiatric morbidity was considered as 4 and above (Basu & Dasgupta, 1996; Goldberg and Hiller,1979) Procedure: All the questionnaires were translated into Bengali version and checked by five raters for their approval to be used as standardized tools for the present study. The participants were administered with the questionnaires by reading aloud for them by the 2nd, 3rd and 4th investigators one at a time, for their completion in a single session, as the participants had not received any formal education. The sequence of the administration followed as Information Schedule, General Health Questionnaire, Controllability Awareness Inventory (CAI), Profile of Mood States (POMS), Narcissistic Personality Inventory (NPI), and Aggression Orientation Scale (AOS). Results: The data obtained were analyzed to see the significance of difference between the means of offending and non-offending drivers for each of the variables under consideration. Besides, it was also examined whether there was any difference with respect to the type of group (morbid vs. morbidity-free) for the respective variables, for which two-way analysis of variance (ANOVA) {2(offender groups) X 2(morbidity groups) ANOVA} was computed. Student’s t-test was computed so as to ascertain the general trend of the significance of difference between the different groups. The obtained results have been briefly described below. Table 1 Summary of 2 Offender Group (offending vs. non-offending) X 2 Morbidity Group (morbid vs. morbidity-free) ANOVA Variables Sources of variance F-values Controllability awareness Between groups Between type Interaction 34.06** 11.85** 0.66 Aggression Predisposition Between groups Between type Interaction 2.07 21.66** 4.62* Externalizing tendency Between groups Between type Interaction 0.26 9.67** 1.98 Internalizing tendency Between groups Between type Interaction 2.65 12.14** 0.006 Expressed aggression (verbal) Between groups Between type Interaction 0.96 8.82** 1.12 Expressed aggression (physical) Between groups Between type Interaction 0.25 13.10** 2.16 Expressed aggression (indirect) Between groups Between type Interaction 8.01** 4.00* 0.61 Mood states (total) Between groups Between type Interaction 17.04** 48.04** 0.51 Narcissism Between groups Between type Interaction 1.61 0.09 1.01 *p<0.05, **p<0.01

Aggression and Related Psychosocial Correlates among Offending and Non-offending Drivers 101 Table 2 Means (M), Standard Deviations (S.D.) and T-Values Showing the Significance of the Difference Between the Means of the Scores of Offending and non-offending Drivers for Selected Variables Variables Offending drivers Non-offending drivers t-value 1. Controlla-bility aware-ness a. Personal control 17.10 3.78 20.17 3.58 5.30** b. Shared control 15.86 4.25 19.10 4.30 4.84** c. Others in control 16.45 3.82 17.87 3.52 2.44* d. Uncontrollable 13.19 4.28 15.80 3.35 4.23** 2. Aggression a. Expressed (indirect) 10.55 2.35 9.26 2.69 3.28** 3. Mood states a. Tension-Anxiety 1.74 0.68 1.35 0.69 3.62** b. Depression-Dejection 1.93 0.73 1.37 0.92 4.35** c. Anger-hostility 1.57 0.51 1.40 0.66 1.89 d. Vigour-Activity 2.43 0.94 3.39 0.80 6.89** e. Fatigue-Inertia 1.58 0.62 1.45 0.57 1.37 f. Confusion-bewilderment 1.69 0.61 1.22 0.32 5.91** *p<0.05; **p<0.01 The results suggest that offending drivers have significantly lower personal control, shared control, others in control and uncontrollable aspects of controllability awareness along with vigor-activity and significantly higher expressed aggression (indirect), tensionanxiety, depression-dejection and confusionbewilderment aspects of mood states in comparison to their non-offending counterparts Besides, morbid drivers, on the whole, have significantly lower personal control, others in control dimensions of controllability awareness and vigor-activity along with significantly higher predisposition, externalizing tendency, internalizing tendency, verbal aggression, physical aggression, tension-anxiety, depression-dejection, anger-hostility, fatigueinertia and confusion-bewilderment than morbidity-free partners. Non-offending morbid drivers have significantly higher predisposition of aggression compared to non-offending morbidity-free counterparts. Discussion: Inter-group analyses of findings: The present study focuses on probing into the personality profiles of offending drivers against a comparative platform of non-offending drivers. As expected, offending drivers have been found to be significantly lower in all the dimensions of controllability awareness in comparison to their non-offending counterparts (Table 1, 2). This indicates that offending drivers are either unaware of or are unable to distinguish between those aspects of situations which are controllable and those which are not and are more likely to appraise environmental demands as threatening, rather than challenging (Heth and Somer, 2002; Sanyal and Dasgupta, 2007). Besides, offending drivers tend to have poor confidence, low self-esteem, poor concentration, depressed mood (Narang et al, 2000; Sathyawathi and Murti, 1961); have impairments in shared control, others in control

102 Sanyal, et al Table 3 Means, S.D. and T-Values Showing the Significance of the Difference between the Means of the Scores of Morbid and Morbidity-free Drivers for Selected Variables Variables Morbid drivers Morbidity-free drivers t-value Mean S.D. Mean S.D. 1. Controllability awareness a. Personal control 16.78 3.89 19.04 3.87 3.37** b. Shared control 16.24 5.32 17.63 4.26 1.75 c. Others in control 16.04 3.59 17.41 3.74 2.14* d. Uncontrollable 13.41 4.76 14.72 3.78 1.85 2. Aggression a. Predisposition 9.93 5.07 6.93 4.07 3.98** b. Externalizing tendency 1.83 1.29 1.29 0.97 2.91** c. Internalizing tendency 2.87 1.02 2.31 0.90 3.47** d. Verbal aggression 3.11 1.93 2.16 1.83 2.96** e. Physical aggression 1.85 1.95 0.97 1.32 3.34** f. Indirect aggression 10.50 2.97 9.78 2.41 1.62 3. Mood states a. Tension-anxiety 2.01 0.84 1.40 0.57 5.38** b. Depression-dejection 2.11 0.75 1.54 0.85 4.04** c. Anger-hostility 1.82 0.50 1.37 0.56 4.71** d. Vigour-activity 2.45 0.84 2.97 1.02 3.14** e. Fatigue-inertia 1.97 0.74 1.34 0.42 6.91** f. Confusion-bewilderment 1.78 0.61 1.38 0.51 4.25**

*p<0.05; **p<0.01 Table 4(a) Significance of the Difference between the Mean Aggression Scores of Offending Morbid and Morbidity-free Drivers Variables Offending morbid drivers Offending morbidity-free drivers t-value Mean S.D. Mean S.D. Aggression a) Predisposition 9.77 4.77 7.99 4.12 1.81 *p<0.05; **p<0.01 and unpredictable dimensions of controllability awareness (Gupta and Singh, 1981). As such, offending drivers tend to be more susceptible to experience stress than their non-offending counterparts.

Aggression and Related Psychosocial Correlates among Offending and Non-offending Drivers 103 Besides, offending drivers have been found to exhibit significantly higher indirect forms of expressed aggression than their non-offending partners (Tables 1, 2). This hints at the fact that such drivers tend to vent out their aggression through indirect means, perhaps one of them being aggressive and reckless driving. The findings of present study have been supported by Roberts and Indermaur (2008), Bjorklund (2008), Smith et al, (2006). Other studies have also claimed that aggressive forms of angerexpression correlate positively with driverrelated anger, aggression and risky behavior (Deffenbacher et al, 2002; Deffenbacher et al,, 2003; Hennessy and Wiesenthal, 2001). Further, offending drivers were found to show impairments in their mood states in contrast to non-offending counterparts (Tables1, 2). In fact, the former group was found to show significantly higher scores on tension-anxiety, depressiondejection, fatigue-inertia, and confusionbewilderment and significantly lower vigoractivity. This pinpoints the presence of negative loadings of affect among offending drivers that probably result in “emotional blockage”, making them more vulnerable to risky driving (Deffenbacher et al, 2003; Sagaspe et al, 2008; Smith et al, Waterman and Ward, 2006). Analyses of findings on the basis of psychiatric morbidity: Significant profile differences among morbid vs. morbidity-free drivers were found with respect to almost all the dimensions of controllability awareness (Tables 1 & 3). Morbid drivers showed significantly impaired personal control and others in control. This is probably because of the presence of psychiatric morbidity that deters such drivers to have a sound grip of controllability and appraise environment adaptively (Malta et al, 2005). Moreover, morbid drivers showed significantly higher aggression in the dimensions of predisposition, externalizing and internalizing tendencies, verbal, physical and indirect aggression in comparison to their morbidityfree counterparts (Tables 1& 3). This can be attributed to the presence of emotional vulnerability among morbid drivers that make them to be frustrated easily resulting in aggressive outbursts (Kanaan et al, 2009). Furthermore, morbid drivers were also found to have significantly higher levels of tensionanxiety, depression-dejection, anger-hostility, fatigue-inertia, confusion-bewilderment and lower vigor-activity in contrast to morbidity-free counterparts (Tables 1 & 3). This highlights their emotional distress which gets its outlet through aggressive routes owing to the impairment of controllability awareness among such drivers (Lajunen and Parker, 2001). Intra-group analyses of findings: Non-offending morbid drivers showed significantly higher predisposition of aggression than their morbidity-free counterparts of the same group (Table 1 & 4b). This perhaps indicates the role of psychiatric morbidity in Table 4(b) Significance of the Difference between the Mean Aggression Scores of non-offending Morbid and Morbidity-free Drivers Variables Non-offending morbid drivers Non-offending morbidity-free drivers t-value Mean S.D. Mean S.D. Aggression a) Predisposition 10.15 5.55 5.37 3.48 4.32** *p<0.05; **p<0.01

104 Sanyal, et al catering to the predisposition of aggression as a trait among such drivers (Deffenbacher et al, 2005). Specific Interventions for offending drivers: Drivers throughout India are low paid and in Kolkata their earning is still low which may be due to downfall of industrial growth of West Bengal State. Because of poor economic conditions, Indian drivers are unable to provide good education to their children and even proper care of the family. These poor conditions create tension and stress which disturbs them while on job. No drivers generally run away after the accident in USA or other developed countries. In Kolkata, however, most drivers run away after accident for the fear of being killed by the public. Because of this attitude, instead of saving the victim and taking him to hospital, they often feel tensed and run away from the scene. To ease their stresses of various kinds, at times, they try to take refuge to drugs or other addictive components that worsens the situation further. It is easy to tell them “be stress free while driving” and “do not think about your home and family while driving”, but practically it does not work. Taking these background psychological accounts of their lives, the alternative to change their day-to-day orientation can be formulated as follows. i. It is possible to change their mind by therapeutic intervention. ii. It is also feasible to help them to improve their financial condition by providing opportunities to their wives and family members. It can be in the form of some financial assistance given to develop means of earnings by their wives/family members at home. On the contrary, drivers working in western countries particularly in the United States, earn good money. Those working in hard weather conditions (icy road, Tundra and Siberian region) earn almost 2 to 3 times more than average truck drivers. They work only for 4 to 5 months and are able to support their family the whole year. Hence there is necessity of specific therapeutic interventions among drivers, for promoting road safety from mental-health perspective. Some of these are as follows: l Individual counseling services needs to be provided to help understand and correlate their personality factors. This will enhance their morale and ego strength to face similar intervening situation in future. l Group therapy (discussion in a small group of 8-12 offenders) to discuss what happened and what precautions might be taken in future) might further enhance their level of confidence. l Attempts to educate drivers to decide “Drink or Drive” and not the both together. It is rule in USA and the license is revoked if caught DUI (Driving under the influence) for 6 months to 3 years. In Kolkata drivers are poor and they can learn if the DUI is followed by Kolkata Police l Services may be provided to reorient offending drivers to a domain of cognitive and affective equilibrium by personal counseling. l To reinstate perceived sense of controllability leading to high self-esteem among offending drivers by dint of grouptherapeutic programs. l To enable drivers to be aware of venting out their excessive aggression through constructive sublimated forms as per their opportunity-frames in life. l Attempts may be taken to enable drivers to experience positive affect to a greater extent, enjoy life gracefully and involve themselves in a realm of satisfaction and responsibility with one’s job.

Aggression and Related Psychosocial Correlates among Offending and Non-offending Drivers 105 l Clippings of outcomes of casualties and their family members may be projected to increase the availability of information regarding motor vehicle accidents and to systematically and effectively manipulate the effect of trauma to make offending drivers more aware of the core problem, be more sensitive and encourage them to adopt safer means of driving. l Vulnerable factors in one’s personality may be identified so as to help predict the accident record of drivers with a greater degree of accuracy through psychometric testing procedures. Conclusion: Offending drivers have the hallmark traits of personality in terms of significantly impaired controllability awareness in all the dimensions, significantly impaired mood states (higher tension-anxiety, depression-dejection, fatigueinertia, confusion-bewilderment and lower vigour-activity), and significantly higher indirect form of expressed aggression than nonoffending counterparts. Morbid drivers have constituent significantly impaired personal control and others in control dimensions of controllability awareness, significantly higher aggression (predisposition, externalizing and internalizing tendencies, verbal and physical aggression) and significantly impaired mood states with respect to all dimensions than morbidity-free drivers. Non-offending morbid drivers have higher predisposition of aggression that can cause blunder at any moment. Before issuing licenses to people, a check-up process of personality profile of “would-be” drivers can help prevent significant number of road accidents in our social context. Even if the driving experiences are there for a significant length, in between assessment of personality, therapeutic interventions to keep them properly oriented to their task and if and where needed, one-to-one counseling sessions to help these people can really change the road-rage scenario of this state. The present project needs to be taken as an eye-opener. References: A.P.A. (1994) Diagnostic and Statistical Manual of Mental Disorders (4th ed). Washington (DC): APA. Basu, B. (2006) Road accidents and drivers’ psychology: Some policy implications. The Indian police Journal, Vol. LIII, No.1, 12-16. Basu, J. (2001). Aggression Orientation Scale (AOS) Department of Applied Psychology, University of Calcutta. Basu, S. and Dasgupta, S.K. (1996) Bengali version of General Health Questionnaire-28, Calcutta: Department of Applied Psychology, Calcutta University. Biggs, H., Dingsdag, D., and Stenson, N. (2009) Fatigue factors affecting metropolitan bus drivers: A qualitative investigation. Work (Reading, Mass), 32(1):5-10. Bjorklund, G.M. (2008) Driver irritation and aggressive behaviour. Accidents: Analysis and Prevention. 40(3), 1069-1077. Brom, D., Kleber, R.J. and Hofman, M.C. (1993) Victims of traffic accidents: Incidence and prevention of posttraumatic stress disorder. Journal of Clinical Psychology, 49, 131-140. Brookings, J.B., DeRoo, H., and Grimone, J. (2008) Predicting driving anger from trait aggression and selfcontrol. Psychological Reports, 103(2), 622-624. Deffenbacher, J. L., Huff, M. E., Lynch, R. S., Oetting, E. R., & Salvatore, N. F. (2000) Characteristics and treatment of high anger drivers.Journal of Counseling Psychology, 47, 5-17. Deffenbacher, J.L., Deffenbacher, D.M., Lynch, R.S. and Richards, T.L. (2003) Anger, aggression and risky behaviour: a comparison of high and low anger drivers. Behaviour Research and Therapy, 41(6) : 701-718. Deffenbacher, J.L., Lynch, R.S., Filetti, L.B., Dahlen, E.R., and Oetting, E.R. (2003)Anger, aggression, risky behaviour, and crash-related outcomes in three groups of drivers.Behav Res Ther., 41(3), 333-49. Deffenbacher, J.L., Lynch, R.S., Oetting, E.R. and Swaim, R.C. (2002) The driving anger expression inventory: a measure of how people express their anger on the road. Behaviour Research and Therapy, 40(6): 717-737. Deffenbacher, J.L., Richards, T.L., Filetti, L.B., and Lynch, R.S (2005) Angry drivers: A test of state-trait theory. Violence and Victims, 20(4):455-69. Dumais, A., Lesage, A.D., Boyer, R., Lalovic, A., Chawky, N., Menard-Buteau, C., Kim, C., and Turecki, G. (2005) Psychiatric risk factors for motor vehicle fatalities in young men.Canadian Journal of Psychiatry, 50(13), 838- Esiyok, B., Yasak, Y., and Korkusuz, I. (2007) Anger expression on the road: Validity and reliability of the

106 Sanyal, et al driving anger expression inventory. Turkish Journal of Psychiatry, 18(3):231-43 Goldberg, D.P. and Hiller, V.E. (1979)A scaled version of the General Health Questionnaire. Psychological Medicine, 9: 136-146. Goldberg, H. and Williams, P. (1988) The user’s guide to the general health questionnaire, Windsor : NFER- Nelson Publishing Co. Gupta, S.C., and Singh, H. (1981)Psychiatric illness in suicide attempters. Indian Journal of Psychiatry, 23, 69- 74. Hauber, A. R.(1980) The social psychology of driving behaviour and the traffic environment: research on aggressive behaviour in traffic, International Review of Applied Psychology, Vol. 29, pp. 461-474. Hennessy D. A., Wiesenthal, D. L. (2001) Further Validation of the Driving Vengeance Questionnaire. Violence and Victims, Vol. 16, pp. 565-573. Heth, J.T. and Somer, E. (2002) Characterizing stress tolerance: “Controllability awareness” and its relationship to perceived stress and reported health. Personality and Individual Differences, 33: 883-895. Kanaan, A., Huertas, P., Santiago, A., Sanchez, A., and Martinez, P. (2009) Incidence of different health factors and their influence on traffic accidents in the province of Madrid, Spain.Legal Medicine (Tokyo, Japan); [Epub ahead of print] Kolkata Traffic Police (2006) Review for the year 2006: Managing the ever growing traffic of a resurgent cosmopolis. Kolkata Traffic Police, Thomson Press. Lajunen, T. and Parker, D. (2001) Are aggressive people aggressive drivers? A study of the relationship between self-reported general aggressiveness driver anger and aggressive driving. Accident Analysis and Prevention, 33(2): 243-255. Lajunen, T., and Parker, D. (2001) Are aggressive people aggressive drivers? A study of the relationship between self-reported general aggressiveness, driver anger and aggressive driving.Accid Anal Prev., 33(2), 243-55 Machin, M.A., and Hoare, P.N. (2008)The role of workload and driving coping styles in predicting bus drivers’ need for recovery, positive and negative affect, and physical symptoms.Anxiety, Stress, and Coping, 21(4, 359-75. Malta, L.S., Blanchard, E.B., and Friedenberg, B.M. (2005) Psychiatric and behavioural problems in aggressive drivers.Behaviour Research and Therapy; 43(11):1467- 84. McNair, D., Lorr, M., and Droppleman, L. (1971)POMS manual for the Profile of Mood States. San Diego: Educational and Industrial Testing Service. Morf, C. C., and Rhodewalt, F. (1993) Narcissism and selfevaluation maintenance: Explorations in object relations. Personality and Social Psychology Bulletin, 82, 668–676. Morf, C. C., and Rhodewalt, F. (2001) unraveling the paradoxes of narcissism: A dynamic self-regulatory processing model. Psychological Inquiry, 12, 177-196. Narang, R.L., Mishra, B.P., and Mohan, N. (2000) Attempted suicide in Ludhiana. Indian Journal of Psychiatry, 42: 83- 87. Norris, F. H., Matthews, B. A., and Riad, J. K. (2000) Characterological, situational, and behavioural risk factors for motor vehicle accidents: A prospective examination. Accident Analysis and Prevention. 32, 505 – 515. Raghavan, R.K.(2005) Disorder on the roads. India’s National Magazine, The Hindu, Volume 22, Issue 04, Feb. 12 – 25. Raskin, R. and Hall, C.S. (1979) A Narcissistic Personality Inventory.Psychological Reports, 45, 590. Roberts,L.D., and Indermaur, D.W. (2008) The “homogamy” of road rage revisited. Violence and Victims, 23(6), 758- 772. Sagaspe, P. Taillard, J., Akerstedt, T., Bavon, V., Espie, S., Chaumet, G., Bioulac, B., and Philip, P. (2008) Extended driving impairs nocturnal driving performance. PLoS ONE, 3(10): 3493. Epub 2008 Oct 22 Sanyal, N. and Dasgupta, M. (2007) Offending and nonoffending drivers in Kolkata metropolis: A comparative psychosocial perspective. Indian Journal of Social Psychiatry, Vol. 22(1-2), 2006, 44-51. Sathyawathi, K., and Murti, R.(1961) A study of suicide in Bangalore. Tran AIIMH, Bangalore,2, 1. Shaikh, I.A., Shaikh, M.A., and Siddiqui, Z. (2008) Road rage behaviour and experiences of bus and wagon drivers in Islamabad and Rawalpundi.TheJournal of Pakistan Medical Association, 58(4):220-1. Shinar, D. and Crompton, R. (2004) Aggressive driving: an observational study of driver, vehicle, and situational variables. Accident Analysis and Prevention, 36(3) : 429- 437. Smith, P., Waterman, M., and Ward, N. (2006) Driving aggression in forensic and non-forensic populations: Relationships to self-reported levels of aggression, anger and impulsivity.British Journal of Psychology (London, England: 1953). 97(Pt 3):387-403 Vanlaar, W., Simpson, H., Mayhew, D. and Robertson, R. (2008) Aggressive driving: A survey of attitudes, opinions and behaviours, Journal of Safety Research, 39(4):375-81. Vanlaar, W., Simpson, H., Mayhew, D., and Robertson, R. (2008) Aggressive driving: A survey of attitudes, opinions and behaviours.Journal of Safety Research, 39(4), 375- 81.

Forensic psychological evaluations require the multiple sources of data for formulating opinions and drawing conclusions. Projective tests are one of the sources which truly provide a window into an individual’s hidden or implicit personality that would be of en ormous value in forensic setting (Skeem et al., 2009). The Human Figure Drawing Test (HFDT) is the pioneering work of Karen Machover and others during 1940s. The HFDT is based on deep rooted projective analytic theory. Projective analytic theory is based on the assumption that deep and often unconscious feelings and motives may be accessed through various means of self-exploration (Machover, 1949). The HFDT involves both qualitative as well as quantitative analysis to interpret which provides information about individual’s cognitions, feelings, and emotions expressed in a subtle manner. The administration, scoring, and norms of Human Figure drawings are already been established by Mitchell et al. (1993) and have been used on different clinical population. Permissibility of HFDT in forensic setting is evaluated in crime investigations for understanding and analyzing the suspected person’s behavior. Analysis revealed that there is considerable diversity in the standardization of administration and scoring of human figure drawings (Lally, 2001). However, there is dearth Human Figure Drawing Test in Forensic Investigation: A Case Study Nilesh B. Wagh, Jay Kumar Ranjan and Shivarathna L.Vaya Human Figure Drawing Test (HFDT) is a reliable and valid projective assessment tool; has potential to elicit information regarding cognition, feelings and overall personality of an individual. There is considerable diversity in the standardization of HFDT in forensic setting, and also absence of Indian study in this context. This paper intends to highlight the applicability of the test in forensic setting. Mr. A, 25 yrs old male, working as domestic help, was arrested for murder of his landlady and five children. He was referred for forensic psychological evaluation as he confessed the crime. The projective profile of HFDT on cognition, feeling and personality are discussed in the context of forensic investigation. of Indian studies on the utility of this test in forensic investigation. Keeping the above facts in view, the present case study is a sincere attempt to see the power of this test. Case Report: The case Mr. A, 25 yrs old male, working as a domestic servant, was arrested for brutally killing his 35 yrs old landlady and five children at a night. He confessed that he entered in the house during night with an iron rod and killed his landlady, her two children and one nephew with the iron rod. Later he killed another nephew by strangulating and hitting on chest while he was sleeping. Next he went to the servant’s room and hit another servant with the rod and dragged his body where others were killed. He set the bedroom on fire with dining chairs, clothes and papers. During the interrogation, he confessed that he alone had killed all five members by using the iron rod and burnt the dead bodies by setting the house in fire. He revealed that he killed them due to maltreatment, abuses, rebukes, and threats to throw him out of the house by the deceased landlady. He also revealed that after killing them, he committed suicide by jumping in a well but did not die. He vehemently denied the involvements of any other person associated with him in committing the crime. Nilesh B. Wagh, Lecturer, Jay Kumar Ranjan, Lecturer and Shivarathna L. Vaya, Director, Institute of Behavioural Science (IBS), Gujarat Forensic Sciences University, Gandhinagar, Gujarat. (Correspondence to J.K. Ranjan, email: jaykumarranjan@gmail.com) Key Words: Human Figure Drawing Test, Crime Investigation, Forensic Psychology

108 Sanyal, et al During forensic psychological investigation on Brain Electrical Oscillation Signature (BEOS) profiling, findings suggested that he had unusual experiential knowledge of most of the things he had committed on that night. However, data did not support all the descriptions that were given in the First Investigation Report (FIR). It appeared that he was trying to logically fill up some of the blanks rather than having true memory of actions. Behavior during testing : He appeared calm, willingly answered all the questions asked. He was neither apprehensive nor emotionally disturbed. He voluntarily showed his willingness to undergo all the tests without any hesitation. However, he expressed his failure to understand as to why tests are required as he has already confessed his crime and nothing to hide or prevent him from his confession. He was told about the need of the test and the reasons for not believing his confessions, as he is unable to account for certain lose ends in his narration. He got convinced and agreed to undergo all the tests willingly. Cognition, Emotions and Personality : Human figure drawing test was administered as adjunct to establishing rapport in crime investigation. It is generally administered in forensic psychology division when a suspect is referred for any kind of investigation. The basic aim is to make the person feel relaxed, cooperative, and spontaneous to undergo psychological assessments before taking structured tests which have specific and direct questions related to crime. It also helps to assess accuser’s cognition, primary intentions and motivations, unconscious feelings and overall personality. In legal context, drawings reflect that person was not coerced to undergo psychological assessments in a forensic setting, which is considered a valid reflection during trials. He was asked to draw a human figure in which first, he drew face of the female Goddess. When asked he said he has drawn Goddess Durga’s face (Figure-I). In second figure he drew a twodimensional man’s figure using appropriate proportion of the page at the centre; figure is in movement reflecting action, with wide open arms and legs, with aggressive facial expression (Figure-II). Scores on cognitive indices of impairment (scaled score ≥ 46), distortion (scaled score ≥ 46) and simplification (scaled score ≥ 50) indicates his normal cognition functioning. Organic factor index score was ‘0’ which also indicates absence of any organic condition. His first female dominant figure of ‘Goddess Durga’ reflected his striving for masculine needs such as dominance, power and authoritativeness. Second picture of man indicates sophistication in behavior. It also suggests evasiveness, angry and withdrawn behavior. At times he shows oppositional tendency to his surroundings as a result of his inner drives and needs. Size of the drawing was large which reflects that he is confident, and having courage and capacity to handle the environment on his way. Dark shading and sketches in the drawing indicates feelings of insecurity and uncertainty.

Fig 1.

Fig 2. Discussion: Profile drawing and Organic factor indices indicate that the accused is intelligent and does not have any cognitive dysfunction (Buck, 1966; Mitchell et al., 1993). He drew first figure of dominant female of goddess ‘Durga’ which indicates striving of his masculine needs (Machover, 1949; Gurvitz, 1951; McElhaney, 1969) as reported that he was working

Aggression and Related Psychosocial Correlates among Offending and Non-offending Drivers 109 submissively under a dominant landlady for last ten years. The findings of present study are similar to that of Blazina and Watkins (1996) who have also reported that there is significant relationship between masculinity role conflict and psychological well-being, including scores for trait anger, and the angry temperament. Similarly, Biron (2000) has also documented that male murders to women can be a result of undermine hegemonic, or obligation to submit masculine institutional authority or act of phallic privilege. Persistent striving of masculine need, maltreatment, abuses, rebukes, and threats may further lead to accuser’s passivity and withdrawal, which were expressed in form of shading (Levy, 1958; McElhaney, 1969) and profile picture drawing (Jolles, 1971). He has also shown oppositional tendency. Persistent passivity, withdrawn and oppositional tendency may further lead him to indulge in aggressive criminal act. Findings of the present case study is similar to that of Heilbrun (1996) who reported that such criminal act will occur due to limited skills in social interaction, socially withdrawn and interpersonally inept. Sheldon and Glueck (1959) and Tiwari et al. (2004) have also noted those delinquents’ showing neurotic needs are more impulsive, hostile and destructive. The size of the drawing reflects that accused is confident, stable, has courage and capacity to handle the environment (Ottenbacher, 1981). It seems that he is capable of doing such aggressive criminal act. The drawing itself is an indication of voluntariness, willingness reflected in the form of drawing in a forensic investigative setup. Conclusion : On the basis of above case description, it indicates that HFDT provides comprehensive means information about the individual, which provides a useful data and have immense worth in forensic investigation. Scientifically, it also has properties to elicit primary intentions and motivations, as well as unconscious feelings and desires behind criminal act. It can be concluded that HFDT provides personality characteristics of an individual, which are helpful in understanding possibilities of his/her involvement in crime. References : Biron, R. E. (2000) Murder and masculinity: violent fictions of twentieth-century, Latin America: Vanderbilt University Press, USA. Blazina, C., and Watkins, C. E., Jr. (1996). Masculine gender role conflict: Effects on college men’s psychological wellbeing, chemical substance usage, and attitudes towards help-seeking. Journal of Counseling Psychology, 43, 461-465. Buck, J. N. (1966) The house-tree-person (H.T.P.) Revised Manual, Los Angeles: Western Psychological Services. Gurvitz, M. (1951) The dynamics of psychological testing, New York: Grune & Stratton. Heilbrun, A. B. (1996). Criminal dangerousness and the risk of violence. University Press of America, Maryland, USA. Jolles, I. (1971) A catalogue for the qualitative interpretation of the H.T.P. (Revised). Los Angeles: Western Psychological Services. Lally, S. J. (2001) Should human figure drawings be admitted into court? Journal of Personality Assessment, 76 (1), 135-149. Levy, S. (1958) Projective figure drawing. In E. Hammer (ed.) The Clinical Application of Projective Drawings, New York, IL: Thomas. Machover, K. (1949). Personality projection in the drawing of the human figure: A method of personality investigation, Springfield, IL: Thomas. McEthaney, M (1969). Clinical psychological interpretation of the human figure drawing, Springfield, IL: Thomas. Mitchell, J., Trent, R. and McAruthur, R. (1993) Human Figure Drawing Test: An illustrated handbook for clinical interpretation and standardized assessment of cognitive impairment, Los Angeles: Western Psychological Services. Ottenbacher, K. (1981) An investigation of self concept and body image. Journal of Clinical Psychology, 37, 415-418. Sheldon, W. H. and Glueck, E. (1959) Mental Pathology and Delinquency: the problem of delinquency. Baton: Houghton Mobbin Co., the riverside press, Cambridge, Mass. Skeem, J. L., Douglas, K. S. and Lilienfeld, S. O. (2009) Psychological science in the courtroom: consensus and controversy, The Guilford Press, New York, USA. Tiwari, S. C., Gupta, S. C., Shukla, S., Srivastava, S., Pandey, M., Maurya, A. and Kumar, A. (2004) A Study of Risk Factors in Recidivistic Criminals, Indian Journal of Psychiatry, 46 (2), 156-165. Urban, W. H. (1963) The draw-a-person catalogue for interpretative analysis, Los Angeles: Western Psychological Services.

“Alcoholism is a primary, chronic disease with genetic, psychosocial, and environmental factors influencing its development and manifestations. The disease is often progressive and fatal. It is characterized by impaired control over drinking, preoccupation with the alcohol, use of alcohol despite adverse consequences, and distortions in thinking, most notably denial. Each of these symptoms may be continuous or periodic” (Morse and Flavin, 1992). This definition recognizes alcohol dependence as a disease, i.e., as an involuntary disability. It accepts a genetic vulnerability in some people and identifies the phenomenon of denial as both a psychological defence mechanism and a physiological outcome of alcohol’s effect on the memory. Grover et al. (2007) reported the Indian scenario where 34 to 42 percent of adult Indian population report of having used alcohol in their lifetime. 5 to 7 percent has been estimated to be abusers of alcohol and 10 to 20 percent million people have been estimated to be in need of treatment for alcohol dependence. There is a steady rise in per capita alcohol consumption every year. The influence of family, social support system and marital relationship is considered to be the most important factors which contribute in maintaining alcohol dependence. Marital relationship and social support system are also acts as predictors of treatment outcome. (Billings et al.,1979 ). In alcohol dependence family relationships are often characterized by struggle for power. Alcohol dependent are dependent only upon the substance, thus their dependence upon relation is less and they tend to exert power and dominance over their partner. These characteristics of alcohol dependent individual hamper their marital quality of life to a great extent. In a review paper of marital and family processes in the context of alcohol use and alcohol disorders, Leonard et al., (2006) stated that alcohol use is often part of the fabric of marriage and family life, alcohol disorders can exert a negative effect on marital development and on the development of children in the context of the family. This review considers evidence that alcohol influences and is influenced by marital/family processes, including transitions into marriage Alcohol Dependence: Personality and Interpersonal Perspectives Arundhati Biswas, Tilottama Mukherjee and Saugata Basu The present study aims to explore how the three groups of subjects, alcohol dependents not attending any self help group (NON-AA), Alcohol dependents attending self help groups (Alcoholic Anonymous) and normal control differ with respect to the personality variables namely, “Assured– Dominant”, “Arrogant-Calculating”, “Cold hearted”, “Aloof-Introverted”, “Unassured-Submissive”, “Unassuming-Ingenious”, “Warm-Agreeable” and “Gregarious-Extraverted”, measured in terms of interpersonal relationship, by Interpersonal Adjective Scale (Wiggins, 1995).Marital Quality of the subjects under study was assessed by MQ Scale (Shah, 1995). The sample consisted of 90 male subjects divided equally into three groups, age ranging from 30-50 years. The obtained results were analysed by using ANOVA followed by ‘Duncan’s Multiple Range Test’. Results revealed significant differences amongst three groups with respect to personality characteristics and marital quality. The study indicates that attending self help support group (Alcoholic Anonymous) brings about changes both in personality characteristics and marital quality of life. Arundhati Biswas, Consultant Clinical Psychologist, Apollo Gleneagles Hospital, 58, Canal Circular Road, Kolkata-700054, Tilottama Mukherjee, Ph.D. Asst. Professor, and Saugata Basu, Ph.D. Asso. Professor, Dept. of Psychology, University of Calcutta, 92, A.P.C. Road, Kolkata 700009 (Correspondance: Tilottama Mukherjee: Email: tilottamamukherjee3@gmail.com) Key words: Alcoholic Anonymous; Personality, Interpersonal Perspectives, Marital Quality

Alcohol Dependence: Personality and Interpersonal Perspectives 111 and parenthood, marital satisfaction, marital violence, parenting, and child development. Peer influence is another important causative factor in alcohol dependence. Studies have shown how the adolescents are at high risk for the development of alcohol dependence due to peer pressure (Kendel et al., 1978). Peer group influence also helps to prevent and reduce alcoholism. One of such peer group of alcohol dependent person individual is Alcoholic Anonymous (AA). AA is a fellowship of men and women who share their experience, strength, and hope with each other so that they may solve their common problems and help others to recover from alcohol dependence. It is a self-help group and offers a kind of friendship, understanding and/or opportunity for empathetic mutual discussions with other members, thereby helping to relieve the burden and complexes of alcoholics. Research indicates that participation in Alcoholic Anonymous and in 12-step treatment is associated with significant reductions in substance abuse and psychiatric problems. Further, such interventions, it has been found, reduce health care costs over time in naturalistic, quasi-experimental, and experimental studies. Evaluation studies have also begun to illuminate the processes through which self-help groups and 12-step treatment programs exert their effects (Humphreys, 2002) in terms of personality, Anderson et al., (2005) found that Personality and alcohol expectancies as risk factors for the initiation and maintenance of alcohol use in adolescents and young adults and extraverted youths reported more positive alcohol expectancies. Scoufis and Walker (1982) found that heavy drinking was associated with high power needs but not with low activity inhibition. Thus, environmental facilitation alone does not explain the genesis of alcohol dependence in specific individuals. Mulder (2002) conducted a study to search alcoholics’ personality traits. The Cross sectional studies have suggested that two broad bands of personality, impulsivity/ novelty seeking and neuroticism/negative emotionality, are associated with alcohol dependence. The most vulnerable to alcoholism may be those with both high impulsivity/ high novelty seeking and high neuroticism/ negative emotionality Furthermore their longitudinal studies have consistently reported that antisocial behaviour and hyperactivity are related to later alcoholism. These research shows that alcohol dependence can be best understood as the result of social prompting, individual vulnerabilities and predisposition like personality factors. “Personality is the relatively enduring patterns of recurrent interpersonal situation which characterise human life” (Sullivan, 1953). As the present research emphasizes the interpersonal perspective of alcohol dependence, this approach seems to be especially fruitful for understanding how the interpersonal domains of personality influence addictive behaviours. In sum, it can be said that different aspect aspects of personality as well as interpersonal relationships affect alcohol dependency to a great extent. However, fewer studies were conducted on the line of exploring the fact that how addicts receiving help and support differ from those addicts who didn’t have that opportunity; Furthermore, no Indian studies are available on how they differ from non alcohol dependent person counterpart with respect to personality traits when measured in terms of interpersonal relationships. As such the present research endeavour attempt to find out how the alcohol dependent individuals differ from nonalcohol dependent with respect to personality variable, measured in terms of interpersonal relationship and another relationship aspects, namely marital quality. Objectives: 1. To find out difference among alcohol dependent persons not attending self help support group (non AA) ( Group-I), alcohol dependent persons attending self help group support group(AA) (Group-

112 Biswas, et al II) and non-alcoholics (Normal Controls) (Group-III) in the different domains of Personality (namely, Assured- Dominant, Arrogant-Calculating, Cold hearted, Aloof- Introverted, Unassured-Submissive, Unassuming-Ingenuous, Warm- Agreeable, Gregarious-Extraverted), measured in terms of interpersonal relationship. 2. To find out difference among these three groups, alcohol dependent persons not attending AA, alcohol dependent persons attending self help group support (AA) and non-alcoholics ( Normal Control) differ with respect to marital quality of life . Method: Sample: The sample comprised of 90 married males in the age range of 30-50 years, equally divided into 3 groups- Alcohol dependent persons not attending any self help group (NON- AA)(Group-I), Alcohol dependent persons attending self help support group (AA)(Group- II), Non alcoholics (Normal Control)(Group-III). Subjects’ formal education is up to at least the higher secondary level and all of them were conversant in English. Subjects of both AA and NON-AA groups have been taking alcohol for at least 10 years, subjects attending selfhelp group support for at least 5 years and diagnosed of having alcohol dependence by psychiatrist (according to ICD-10 criteria ) were included in the clinical group. For normal control group screening was done with General Health Questionnaire-28 (score 4 or below) (Goldberg and Hiller, 1979). Subjects who were physically handicapped, presently suffering from any other psychiatric and major physical illness or those who have past history suggestive of psychiatric and/or significant physical illness and subjects who had the habit of taking other substances except nicotine through smoking were excluded from the study. Measures: In addition to a personal information schedule the following measures were used: Interpersonal Adjective Scale: Personality variables were measured by Interpersonal Adjective Scale, developed by Wiggins (1995). This scale contains 64 items, i.e., 64 words. It provides a brief comprehensive measure of 8 domains of personality namely Assured-Dominant, Arrogant-Calculating, Cold hearted, Aloof-Introverted, Unassured- Submissive, Unassuming-Ingenuous, Warm- Agreeable, Gregarious-Extraverted. Each of these domains contains 8 items. These 8 variables are interpersonal in nature as they reflect “dyadic interactions that have relatively clear cut social (status) and emotional (love) consequences” (Wiggins, 1979). Marital Quality Scale: It is a multidimensional scale developed by Shah (1995). It assesses the qualities of marital life in Indian context. Procedure: The study was cross sectional in nature. The data were collected between December 2007 and September 2008. English version of the tools was administered individually in a single session to all respondents after obtaining their informed consent. At the end of the session the researcher clarified ambiguities, if any. On completion of the study, the researcher provided further information about the study to the respondents on request. Data were analysed using One-Way Analysis of Variances (ANOVA) and Duncan’s Multiple Range Test to find out whether the 3 groups of subject differ significantly in terms of personality and marital quality.

Alcohol Dependence: Personality and Interpersonal Perspectives 113 Results and Discussion: Table 1 represent the Mean and Standard Deviation and F Values of 8 Variables Namely, Assured -Dominant, Arrogant–Calculating, Cold hearted, Aloof, Introverted, Unassuming– Ingenuous, Unassured-Submissive, Warm-Agreeable, Gregarious- Extraverted and Marital Quality for 3 Groups of Subjects. Table 1 Significance of Difference Among the Three Groups on Various Dependent Measures Variables NON-AA (Group I) AA (Group-II) Normal Control (Gr- III) F-value Mean S.D. Mean S.D. Mean S.D. Personality: Assured- Dominant 51.67 4.10 48.9 3.92 43.8 4.60 26.97* Personality :Arrogant – Calculating 54.57 4.19 43.4 4.46 33.13 4.44 180.89* Personality: Cold-hearted 39.5 4.99 29.30 5.27 30.10 4.62 39.12* Personality: Aloof – Introverted 35.27 7.78 33.9 6.79 29.93 3.81 5.7* Personality:Unassured– Submissive 29.30 5.39 38.27 6.19 38.33 4.29 28.36* Personality:Unassuming- Ingenuous 28.8 4.55 40.97 5.2 38.67 5.25 49.83* Personality: Warm -Agreeable 38.23 4.72 43.87 3.78 52.63 3.76 93.38* Personality:Gregarious- Extraverted 46.60 7.735 44.90 5.77 42.58 6.98 3.07 Marital Quality (MQ) 102.4 18.82 83.00 8.13 64.13 4.26 75.26* *p<0.05, ** NON AA: Alcohol dependent, not attending self help group support, AA: Alcohol dependent attending self – help group support, Normal Control: Non Dependent F-values obtained from One-Way Analysis of Variance (ANOVA) suggests that there exist significant differences among 3 groups of subjects, (1) Alcohol dependent, not attending self help group support (NON-AA) [Group –I] (2) Alcohol dependent, attending self help support group (AA) [Group–II] and (3) Normal Control [Group-III] with respect to personality variables, namely Assured Dominant, Arrogant–Calculating, Cold hearted, Aloof-Introverted, Unassured-Submissive, Unassuming–Ingenuous, Warm-Agreeable and also with respect to Marital Quality. There does not exists and difference as far as the “Gregarious-Extraverted” domain is concerned.

114 Biswas, et al Table 2 Range Values Obtained from Duncan’s Multiple Range Test between Group I and Group II Groups Compared Variable Mean Difference Alcohol dependent Not-Attending AA and Alcohol dependent Attending AA Personality : Assured- Dominant 2.7 * Personality :Arrogant -Calculating 11.17** Personality :Cold hearted 10.2** Personality :Aloof - Introverted 1.47 Personality :Unassured –Submissive 8.97** Personality :Unassuming-Ingenious 12.17** (Group-I & Group-II) Personality :Warm- Agreeable 5.64** Marital Quality 19.4** * p<0.05, ** p<0.01 Table 3 Range Values Obtained from Duncan’s Multiple Range Test between Group II and Group III Groups Compared Variable Mean Difference Alcohol dependent Attending AA and Normal Control (Group-II & Group-III (GroupI & Group-II) Personality : Assured-Dominant 5.12* Personality : Arrogant -Calculating 10.27 Personality : Cold hearted .8 Personality : Aloof - Introverted 3.97* Personality : Unassured - Submissive .06 Personality : Unassuming-Ingenious 2.3 Personality : Warm- agreeable 8.67** Marital Quality 18.9** * p<0.05, ** p<0.01 Table 4 Range Values Obtained from Duncan’s Multiple Range Test between Group I and Group III Groups Compared Variable Mean Difference Alcohol dependent not Attending AA (Group-I) and Normal Control (Group-III) Personality : Assured-Dominant 7.87* Personality : Arrogant -Calculating 21. 44* Personality : Cold hearted 9.4* Personality : Aloof - Introverted 5.34* Personality : Unassured - Submissive 9.03* Personality : Unassuming-Ingenious 9.87* Personality : Warm- agreeable 14.4* Marital Quality 38.3* * p<0.05,

Alcohol Dependence: Personality and Interpersonal Perspectives 115 Range values in table 2 suggests that significant differences exists between the means of Group-I and Group-II with regard to personality variables like – Assured-Dominant, Arrogant- Calculating, Cold hearted, Unassured- Submissive, Unassuming-Ingenious, Warm- Agreeable and Marital Quality. No significant differences exist between two groups in terms of Aloof-Introvertedness. Range values in table 3 suggests that significant differences exists between the means of Group-II and Group-II with regard to personality variables like – Assured-Dominant, Arrogant –Calculating, Warm-Agreeable and Marital Quality. No significant differences exist between two groups in terms of Cold heartedness, Unassured-Submissiveness and Unassuming- Ingeniousness. Range values in table 4 suggests that significant differences exists between the means of Group-I and Group-III with regard to personality variables like – Assured-Dominant, Arrogant–Calculating, Cold hearted, Aloof– Introvertedness, Unassured-Submissiveness, Unassuming- Ingeniousness, Warm-Agreeable and Marital Quality. From the above findings it can be said that alcohol dependent persons are more forceful, assertive, dominant and like to win arguments. They have a strong need for dominance and aggression (Wiggins, 1995). Heavy drinking is associated with high power needs (Scoufis and Walker , 1982). Markowitz (1984) has shown that perceived lack of power is present among alcohol dependent and because of inability to feel competent and self-determining, they use alcohol as a defense to protect their selves, and thus perceive themselves as Assured- Dominant. Their need for dominance (Murray, 1938) gets fulfilled by over compensating their emotional void inside. Furthermore, it can be said that alcohol dependent who receive selfhelp group support may have comparatively greater insight about their problems as they share their problems with other sober peers, and as such, they probably acquire greater understanding about their problem-behaviours, resulting themselves to differ significantly from their alcohol dependent person counterpart. In Unassured-Submissive domain, alcohol dependent attending AA obtained higher score in comparison to alcohol-dependent persons not attending AA, which indicates that AA members perceive themselves a more submissive and unassured than non AA members. On the contrary, alcohol dependent, not attending AA perceive themselves least submissive and unassured than both of the other two groups. It can be said that an air of perceived assuredness which is covering a realm of emotional void make them secured and not shy, owing to the play of over compensation defense (Fenichel, 1945). They do not acknowledge their fear regarding social situations and cover up their low self-esteem, through the defence. Alcohol dependent individuals who have lesser insight upon their problems are found to be more dominant and emotionally vulnerable. In this context, it can be highlighted that the developmental fold of the superego formation of the Indian child becomes dictated more by “do’s and don’ts” “should or should not” and the like. As such moral conscience is correlated to the conservativeness and the authoritativeness of the Indian society, which has a significant impact on the process of development (Sanyal, 2001). The findings of the present study, however, does not tally with the findings of Korneich et al. (2002), who have found alcohol dependent persons have submissive disposition than non-alcoholics. The probable reason, perhaps is due to the play of compensatory mechanism of dominance among Indian alcohol dependent persons which serves as a cultural factor, explain the discrepancy (Pattel, 2005; Kapur, 1995). As such Individuals who later on acquired the habit of alcohol consumption and finally becomes addict tend to be posses a

116 Biswas, et al “dominating air”, shielding a void of emotions; thereby manifesting their immaturity. On the other hand, AA members have received self help support, which in turn has a therapeutic effect, which would in turn help them to realize their problems and vulnerabilities. This self realisation is prompted by the psycho-education and sharing of feelings that the AA members received from their sober peer in the self-help group. Alcohol dependent persons attending AA and the normal group did not differ significantly in the present personality domain. This octant of personality is positively correlated with need for succorance (Gough and Heibrun, 1980). Thus, people who constantly receive support from their peer group and families acknowledge their need and the same are being fulfilled. Alcohol dependent persons attending AA and non-alcoholics both perceive themselves more deferent, obliging, modest and straight forward in social transactions (Wiggins, 1995), than alcohol dependent not attending AA. These individuals tend to describe themselves as non-argumentative and admit mistakes easily (Wiggins, 1995). Thus, alcohol dependent persons who did not attend self-help group support (Non AA) perceive themselves as less timid, less dependent than normal group which is again in support of the proven findings as revealed in “Assured- Dominant” and “Unassured -Submissive” octant. Arrogant-Calculating persons express anger and ir ritation towards others in the form of humiliation and exploitation. They describe themselves as egoistical, cunning and exploitative. They “put others in their place” wrong, and criticize them publicly. Their world view is a cynical one in which competition and exploitation are means of survival (Wiggins, 1995). It is correlated with classical ‘psychopathic factor’ (Harpur et al., 1989). In the present domain, alcohol dependent persons (Non AA) has obtained highest score on the arrogant-calculating domain followed by alcohol dependent persons attending AA and normal control respectively. It can be thus inferred that alcohol dependent persons have low conscientiousness and higher aggressiveness and thus, they exploit and manipulate other individuals to a greater extent than their normal counterparts. Their world view is a cynical one in which competition and exploitations are the means of getting alcohol as their life centres around that object (Accocella et al., 1992). Merenakk et al. (2003), in their study, found that aggression and lower score in conscientiousness were the significant predictors of alcohol use in adolescence. Amongst alcohol dependents, those attending AA are less arrogant, aggressive and manipulative. This might be due to the fact that as they are associated with a sober peer group, learn that it is possible to participate in social function without drinking, and are given a model of recovery by observing the accomplishment of sober members of the group (Sadock and Sadock, 2007). They have a better kind of mental health as well as interpersonal relationships and thus they show less arrogance and manipulativeness in their interpersonal domains. Cold hearted persons are person are not warm, cooperative, or nurturing when such behaviours would be appropriate. They describe themselves as not warm, kind, sympathetic or understanding. It can be said that alcohol dependents who are receiving self-help support are relatively more warm, cooperative and less distant in interpersonal relationships than alcohol dependent not receiving any such self-help support. It may be due the fact that they receive constant support of their peer groups, feel accepted and thus, can learn to value relationship at least in their peer-circle. This perhaps lessens their score as far as coldhearted octant of personality is concerned. Present study shows that Aloof-Introvertedness is unique characteristics of alcoholics as they (both attending AA and Non-AA) scored significantly higher in the present domain. On

Alcohol Dependence: Personality and Interpersonal Perspectives 117 the contrary the 2 alcohol dependent groups didn’t differ significantly in this domain. It may be because of the homogeneity among each other as far as endogenous factors are concerned. In support of this findings it can be highlighted that maladaptive personality traits and familial risk for characters for the development of substance dependence revealed that people with substance use disorders scored higher on alienation and negative emotionality than did people without substance use disorder (Sweden et al., 2002). It can be said that as alcohol - dependents have a greater Reward-Seeking Personality than normal control (Brunelle et al., 2006), they often seek situations where they can be rewarded. If people surrounding them are unable to gratify this need of alcohol dependent individuals, they may perceive an extreme rejection. This perceived rejection in turn, makes them introverted, aloof, distant and unsociable. In fact, “Aloof-Introverted” trait is positively correlated with social anxiety (Fenigstein et al., 1975), social avoidance and distress (Watson and Friend, 1969). As negative emotionality like anxiety and depression are more common features of alcoholics (Cox, 1979, Lang, 1983). The degree of self reported anxiety and depression are found to be directly related to the degree of alcohol dependence (Skinner and Allen, 1982). It can be concluded that, these kinds of emotional experiences restrict them to come forward and engage in social interactions thereby making them more aloof and introverted. Warm-Agreeable individuals have a disposition to be warm, nurturant, sympathetic, caring in social transaction. High scoring individuals on these domains are sympathetic, forgiving, kind and soft hearted. Alcohol dependents, not attending AA, scored significantly lower in ‘warm agreeable’ domain, followed by alcohol dependent person attending AA and normal control respectively. Group-III people nurture other people, provide emotional benefits and they are well adjusted (Plutchik and Platman, 1977). Whereas alcohol dependents often demand that other people must nurture them as they have insatiable need for dependency. They want to be cared for by others. If this need is not satisfied, they do not show warmth to others. Furthermore, alcohol dependents who attend self help group receive supports from their peer, which in turn have a therapeutic effect and make them more hopeful regarding their life. It helps them to build more positive attitude towards life and thus, they are relatively more adjusted than their counterparts who are not receiving any kind of support. There does not exists any significance difference amongst the 3 groups of subjects as far as Gregarious-Extraverted and Unassuming-Ingeniousness is concerned. The present domain is concerned. However, different studies revealed a contradictory results. A study by Flory et al., (2002), revealed that alcohol dependent have high extraversion and Merenakk et al. (2003) revealed that higher score of extraversion and aggression as significant predictors of alcoholism. The present finding is not supported by these studies. It may be due to cultural factor as these studies were done in a different cultural background. From the above discussion it can be said that Alchololic Anonymous (AA), i.e., self help group has a therapeutic effect upon personality changes of alcohol dependent persons. Evidence indicates that Alcoholics Anonymous (AA) participation has some therapeutic effect (Kelly et al., 2012). Self-efficacy, negative affect, adaptive social networks and spiritual practices are mediators of this effect AA members follow 12 step programme. They admit that they are powerless over alcohol and need help from “higher power”. They seek guidance through prayer and meditation and they become ready to remove their deficits. A more experienced member (sponsor) in recovery guides less experienced aspirant by sharing his own experiences, strength and hope with new

118 Biswas, et al members. Sponsor is simply another addict in recovery who is willing to share his own journey through 12 steps. Thus, the effect of AA attendance on alcohol dependence can be primarily explained by adaptive social network changes. Kelly et al. (2011) found that AA lead to better outcomes by reducing negative affect and facilitated recovery by mobilizing several processes simultaneously, it is the change in social factors which appear to be of primary importance. Blonigen et al. (2011) found that attendance in AA decreases impulsivity, increases social support and self efficacy. Thus, the 12 step of AA provides the structure for which a person with alcohol dependence may turn for an answer to his problem of alcohol use (Detar, 2011) which would in turn improve physical psychosocial and emotional stability. It is believed that though personality characteristics are relatively enduring, therapy does change them. However, studies suggest therapy does change personality characteristics. Biswas (1998) found that external locus of control has been partially changed to internal locus of control after Cognitive Behaviour Therapy in group of patients with anxiety disorder. Roper et al., (2009) in their study with alcohol dependents found out significant improvements in relation to depression, anxiety, and maladaptive schemas after a period of abstinence and psychoeducational programme. Thus, maladaptive schema can be changed with psychosocial support and therapeutic impact which may in turn lead to personality changes, at least from interpersonal perspective. It further suggests that greater social support has a therapeutic effect which improves mental health of the alcohol dependent person. Alcohol dependence decreases marital satisfaction as it decreases spouse ability to participate in everyday activities (O’Neill and Bornstein 2001). Thus, marital relationship of an alcohol dependent person is characterised by the presence of less warmth, greater aggression towards their wives and impulsivity which further affect communication, affection and understanding, trust, decision making, and role functioning of marital life. Spouses often feel rejected and devaluated which in turn leads to poor marital quality. As marital satisfaction gets hampered, it further gives rise to frustration and aggression among alcohol dependents and a vicious cycle results. Thus, alcohol dependence exerts a negative effect on marital relationship. Alcohol influences family and relation and in turn, it is influenced by marital process, marital satisfaction, marital violence and parenting (Leonard et al., 2006). Alcohol dependents, attending AA receive support from other members. They often start enjoying the beauty of relationship, often get deeper insight to their pathology, owing to the supportive therapeutic intervention that they obtain. Thus, they can understand their fault to a relatively greater extent, compared to those alcohol dependents who do not receive any support. Furthermore, like alcohol dependents who attending AA, their spouses also get support from the ‘Al anon’ – which is a self-help support group of alcohol dependents’ spouses (Sadock and Sadock, 2007). Thus, their wives also can understand them better and have better understanding of the nature of the problem they are suffering from. For this, these spouses also provide more support and companionship to them. It can be said that due to these two factors, alcohol dependent, attending AA have better marital quality of life compared to the other group-alcohol dependent person who are not receiving support from self-help group. Some limitations in the design of the study place constraints on the generalisability of the findings to a larger population. The sample size was small and the information gathered primarily through the use of self report measures which are inherently susceptible to social desirability biases. Different domains of marital quality are not explored in the present study. The cross sectional nature of the study do not allow for conclusion regarding cause effect relationship

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The most common terms for homosexual people are lesbian for women and gay for men, though gay is also used to refer generally to homosexual men and women. The number of people who identify as gay or lesbian—and the proportion of people who have samesex sexual experiences - are difficult for researchers to estimate reliably for a variety of reasons. (LeVay, Simon (1996). In the modern West, according to major studies, 2% to 13% of the population is homosexual or has had some form of same-sex sexual contact within his or her lifetime (Billy et al, 1993, Binson et al, 1995, Bogaert 2004, Sell, et al, 1995). Many gay and lesbian people are in committed same-sex relationships, though the political conditions and acceptability of the culture facilitated their visibility and enumeration. The 2010 Census indicates increase among samesex homeowners in Oklahoma, USA. These relationships are equivalent to heterosexual relationships in essential psychological respects. The Homosexual relationships and acts have been admired, as well as condemned, throughout recorded history, depending on the form they took and the culture in which they occurred. Since the end of the 19th century, there has been a movement towards increased visibility, recognition and legal rights for homosexual people, including the rights to marriage and civil unions, adoption and parenting, employment, military service, Assessing Sexuality “Homosexuality” Bankey L.Dubey, Preeti Pandey, Ajay Tiwari and Nalini Mishra Somatic Inkblot Series Booklet version was administered to a 19 years old girl, student of 12th grade with decent family background. She always liked and adopted the life style of a boy used to dress up like boys and drive motorbike. She had emotional attachment and physical relationship with her classmate like lesbians. She had a history of sexual abuse by her cousin at age 13 which she did not inform to anyone in the family. She became aggressive towards boys and wanted to punish her cousin. Her responses on the SIS images revealed her aggressive attitude towards males and sexual inclination as revenge against the perpetuator. The responses on SIS are discussed in the paper. and equal access to health care. The scenario in 21st century is very different and same sex marriage has been legalized in different countries. Many one-dimensional thinkers historically have emphasized in their etiological speculations that so-called Homosexuality is a “condition” solely due to genetic factors. However their arguments have been undermined by investigators studying the sexual behavior of mono psychotic twins since not all such twins share a common sexual preference. Ongoing international researchers are attempting to sort out multidimensional determinants such as intrauterine hormonal factors, early family structure, as well as a variety of social influences. Consequently any proposed scales purported to quantify scientifically dimensions of sexuality must be viewed with a considerable degree of skepticism regarding validity issues. Clinical case work supports the contention, that SIS studies can open up deeper aspects of human sexual experience, otherwise hidden from scientific study. With regard to quantifying SIS-I a responder’s relative of sexual content Wilfred Cassell outlined in Body Symbolism (1980) a scoring system for sexually specific responses which may signify opposite sex attraction (OT), same Bankey L. Dubey, Ph.D., DMSP, 4406 Forest Road, Anchorage, AK 99517, Email: bldubey@gmail.com Preeti Pandey, M.A., Counselor and Ajay Tiwari, Ph.D.,Director, Nai Subah Counseling center, Jawahar Bhavan, Sankat Mochan (Turn), Lanka Area, Varanasi-221005 , Email: naisubahvaranasi@yahoo.com, and Nalini Mishra, Ph.D. Principal, Dhirendra Mahila P.G.College, Sunderpur, Varanas-221005 Key Words: SIS in homosexual, SIS in Lesbian

122 Dubey, et al sex attraction (SS) or indeterminate (I):Score 1 for “sexy” appearance, foreplay such as kissing, petting, fondling etc. Score 2 for responses visualizing the genitalia Score 3 for visions of active sexual relations. The following case history illustrates both the scoring system and the psychosocial stressors of a nineteen year old female student who scored high on the same sex scale. She had sought psychotherapy with a female SIS psychologist depressed in emotional turmoil. In reviewing her developmental history, her therapist noted that in early adolescence her client had adopted a masculine appearance / style. Apparently she became overtly disturbed in college after another girl discovered her kissing her female lover. The observer then reported this culturally/religiously sanctioned behavior to authorities, who in turn informed her parents. Apparently they came to class and her enraged father beat her publically. Afterwards was then forced to attend another school and terminate all contact with her former lover. A case history of a lesbian girl and her illustrative responses to the Booklet version of SIS-II follow: Case History: She is a 19 years girl who always liked and adopted the life style of a boy. She used to dress up like boys and used to drive motorbike. She had emotional attachment and physical relationship with her classmate who was also of her age. Both loved each other and always enjoyed each other’s company. They used to participate as each other’s couple on college functions at various occasions. They never informed about their growing relationship to their family members and had physical relations like lesbians. She had history of sexual abuse by her cousin at age 13 and he threatened her not to inform this to anyone in the family. She dressed up nicely that day and was attending a family marriage party. She was feeling ashamed after the incidence and she did not tell anyone about this. She developed hatred against female dress and thought that girls are weak and they can be used by boys. She became aggressive towards boys and started using dress like boys and wanted to punish her cousin. One day, they were seen by their classmates while kissing each other in the class room and brought in the notice of the Principal. The incidence was reported to their parents and they were asked to leave the college. Client’s father could not control his anger and slapped her in front of others. Both the girls were withdrawn from the college and admitted to different colleges. They were asked not to contact or meet to each other. This incident disturbed her emotionally and she developed various symptoms such as headache, disturbed sleep and social withdrawal. The SIS Booklet form (Cassell and Dubey, 1990,2003) was administered to find out the underlying psychopathology and personality factors. Significant responses on SIS images follow: Image A1: She perceived it as “Two girls doing oral sex”. This may indicate her fantasy as she is unable to seek other kind of erotic pleasure with her female partner. (Sex Score 3) Image A7: She viewed it as “A dancing woman looking very sexy and an apple” is a common response, perceived by majority of people. However “looking sexy” may indicate lesbian inclination. (SS1). Image A9: “Two women doing sex” may again indicate her sexual fantasy and wishful thinking to have sex with her female lover. She further described her role as a male and treats her lover as female. (SS 3) Image A10: “Two sad girls separated by social customs and social boundaries”

Assessing Sexuality “Homosexuality” 123 may indicate her own suffering and non-acceptance in the society for lesbians. Image A18: “Vagina and Hymen of a girl” may indicate sexual pre-occupation, though heart is the common response on this image. (SS 2) Image A25: “Vagina” This is normal response on this image (SS2) Image A31: Face of two girls touching each other, may indicate homosexual tendency. (SS1) Image B5: “Two close friends separated by customs of society” may indicate her feelings against significant others particularly her parents who has stopped her relationship with her friend. Image B6: “Sexy waist of a girl” indicates homosexual inclination. (SS1) Image B7: “A girl getting pregnant after marrying another girl” suggest her wishful thinking to have her children with this relationship though she is fleeing from reality. (SS3) Image B15: “A girl breaking all the social boundaries and customs with the help of a knife” suggest her aggression and revolt against her family and significant others. Image B22: A girl having menstruation (SS1) Image B25: “Two loving hearts separated by a boulder” Theme of separation and her inner cry has been brought on this image and Image B5. Her therapist should take this issue to reeducate her and counsel about the appropriate physical relationship. Image B31: “A happy family of two lesbian girls” A happy family is very healthy concept but of two lesbians indicates her preoccupation with living relationship with her female friend. Her therapist should also explore if she is developing some psychotic features. The total summation of same sex score of 17 may be scored as a projective measure of Same Sex attraction. In interpreting the clinical significance of such numerical data, it is suggested that present conceptual models only partially explain the complexities of the underling ill understood phenomenology. While the same sex sexual content index of 17 falls well beyond normative data, there is no solid statistical theory concerning its significance. For example, questions could be raised by researchers whether or not these data might represent a variant of “healthy sexuality or exactly the opposite as signifying “clinical pathology”. Fundamental questions may be raised regarding the nature of her propensity in recognizing/ projecting same sex scenes. Perhaps what she imagined to see in the SIS Booklet may have been partially influenced by one or more time references of memory. For example, might possibly her response sequence related to recollection of pornographic lesbian art or erotic photographs? Perhaps alternatively, did it reflect memories of past fantasies and/or same sex activity with her lost friend, or even long term deep seated memories of childhood abuse? A final consideration for exploring her sexual puzzle pertains to excluding medical conditions. An adolescent with such SIS-I same sex saturation might well benefit from referral for diagnostic workup including hormonal studies. In such cases there is some practical reality testing value for her psychologist to have SIS projective test data to supplement subjective interview reports of a troubled adolescent. Hopefully such data might provide a basis as well for parental education and defusing the father’s rage in family counseling. In any case, those related to stressful cultural/religious issues and loss, such as portrayed in her responses to A10, B5, and B15 etc. may assist her psychotherapist in more empathetically processing her issues therapeutically. Sexual Abuse and Rape Trauma : If the clinical history is consistent with a recent rape, diagnostic assessment issues

124 Dubey, et al have less clinical relevance than therapeutic considerations. Consequently, the treatment team needs to consider the appropriate SIS system to employ as an adjunct to therapy. For a female, than a logical decision would be to choose a woman as test administrator and therapist. Then the recommended SIS order would be first “Living Images”. At an appropriate later date SIS-II might be added as a way to assess subsequent distortion of men (e.g. phallic sexual imagery). Forgotten, Perceptually Inhibited or “Repressed” Sexual stress: In such situations, the test administrator may have no clinical clues regarding such trauma. Therefore, SIS-II should be selected since much more normative data is available for diagnostic administration. Conceptual Model : When a client/patient views the robotic artificial intelligence mesmerizing versions of SIS-II or “Living images”, the scientifically ill understood, but clinically potent powers of hypnosis become electronically activated. Unlike the vast multitude of sexual questionnaires, these projective procedures readily access the inner world of previously amnesic psychologically “blind” sufferers. Amnesic victims whose psychological defenses systems have split off from conscious awareness traumatic sexual memories may be identified The self-administered viewing administration method provides introspectively intelligent victims, a unique subjective opportunity to cognitively correct and reprocess emotionally long forgotten events. In addition, the electronic technology can amplify therapeutic flushing out of negative affect linkage to such PTSD imagery by activating the release of neurotransmitter chemicals reconditioning memory neurons. While this form of robotic Behavioral Therapy in repeated viewing sessions may be partially efficacious in itself, ordinarily it needs reinforcement from a SIS trained psychotherapist. The latter requirement is due to the fact that scientific studies indicate that while the traumatic events are vividly recorded in “Flashbulb” fashion. However, the actual details of the recollections with the passage of time are subjected to considerable neurochemical distortion secondary to the coloring effect of affect linkage. From a conceptual standpoint, it is hypothesized that during a severely stressful situation, sensations from various trauma specific somatic sources are transmitted by multiple sensory modalities. With regard to vision, a recording of events on the retina is transmitted by the optic nerves to the victim’s brain centers for neurochemical storage. This memory embedding process may take a period of time ranging from hours to sometimes months. Medications such as propranolol have been tried to block the recording process with only partial success. Yet some such investigators suggest that this strategy is worthy of further pharmacological trials. In this conceptual model of sexual trauma, the sensory input both from the perpetrator’s body, as well as that of the victims is considered to follow nerve pathways centrally. At first the flood of sensations arouses the amygdala neurons on its right side to stimulate them to link affect to the memories. This natural reaction to psychological stress is duplicated with SIS viewing. By immediately reacting to SIS structure imagined to be reminiscent of past stressful life experiences, the amygdala serve as a sentry. It accomplishes this by arousing the cortex to increase “perception” and vigilantly focus on the details of the threating or “disliked” inkblot. Concomitantly, it triggers the release stress neurochemicals exciting the autonomic nervous system (e.g. causing tachycardia, pupil dilations etc.) as well as the hippocampus establishing neurochemical based memory records. Rarely, during projective assessment extreme arousal may transiently occur. This phenomenon has been referred to as “Color Shock” with both the Rorschach and Holtzman series. With the SIS, such an extreme physiologic process has also been labeled “Somatic Shock”. An

Assessing Sexuality “Homosexuality” 125 example flows: in responding to SIS-I, a young adult single female medical student appeared emotionally stable until viewing Card XVII. At that moment her previously relaxed easy delivery changed dramatically. She gasped, stared at the card and then was speechless. After a lengthy pause she whispered “It looks like a penis”. Her blood pressure fell precipitously to the point of vasomotor shock and the testing was terminated. Such an extreme reaction is analogous to subjects fainting at the sight of blood and the bizarre body reactions reported by the early 20th century European clinicians treating so-called “Hysterics”. In view of such situations, it is recommended that the test administrator, or a trained clinical associate of the same sex, always be available nearby in the SIS viewing room to provide traditional supportive/cognitive psychotherapeutic care. This is particularly important in the clinical management of recent rape victims. These distraught individuals may immediacy become terrified by visualizing see the perpetrator. Such projected imagery then may serve to release a torrent of detailed affect charged PTSD memories (Cassell et al,1996,1999,2000). In our futurist conceptual model, these are hypothesized to be linked as a neurochemical pathological memory package. It is envisioned that in the future, immediately after severe stress, emergency room treatment teams will be able to combine memory altering medications and state of the art psychological therapies. In any case, at the present state of the art, when SIS “Somatic Shock” is observed, it is recommended that the viewing procedure be terminated. Sometimes then the victim may be encouraged to “Abreact” cathartically since there can be a benefit from tears and crying out anger. In selected cases, these may be supplemented with an innovative approach such as “Cognitive Reappraisal” whereby the professional not only explains the irrationality of abused victim’s guilt, but also points out any positive learning aspects of the trauma. It is hoped that in the future, all such therapeutic approaches will be scientifically examined with objective data based SIS research. Conclusion : The SIS responses helped in understanding her inner cry and aggressive attitude towards male figure leading her to adopt a male life style and sexual role like male partner. She attended ten therapeutic sessions which helped her to understand the role and acceptability in Indian society. The patient has shown improvement and changing her behavior pattern. References: Cassell, W.A. (1990). Somatic Inkblot Series Manual. Anchorage: Alaska. 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, M. A., Cassell, W. A. Dubey, B. L., Dwivedi, P., Molchanov, E, O’Roark, A.M. and Routh, L.C. (1999) A Video Projective Technique for PTSD in Women. SIS Journal of Projective Psychology & Mental Health, 6:3- 28. Cassell, W. A., Dubey, Asheem and Dubey, B. L. (2000) SIS Projective Responses in PTSD and Dissociative Disorder. SIS Journal of Projective Psychology & Mental Health, 7: -93-108. Cassell, W.A. and Dubey, B.L. (2003) Interpreting inner world through somatic imagery: Manual of the Somatic Inkblot Series. Anchorage: Somatic Inkblot Centre. Billy JO, Tanfer K, Grady WR, Klepinger DH (1993). “The sexual behavior of men in the United States”. Family Planning Perspectives 25 (2): 52–60. Binson, Diane; Michaels, Stuart; Stall, Ron; Coates, Thomas J.; Gagnon, John H.; Catania, Joseph A. (1995). “Prevalence and Social Distribution of Men Who Have Sex with Men: United States and Its Urban Centers”. The Journal of Sex Research 32 (3): 245–54. Bogaert AF (September 2004). “The prevalence of male homosexuality: the effect of fraternal birth order and variations in family size”. Journal of Theoretical Biology 230 (1): 33. LeVay, Simon (1996). Queer Science: The Use and Abuse of Research into Homosexuality. Cambridge: The MIT Press ISBN 0-262-12199-9 Sell, R.L, Wells, J.A, and Wypij , D. (June 1995). “The prevalence of homosexual behavior and attraction in the United States, the United Kingdom and France: results of national population-based samples”. Archives of Sexual Behavior 24 (3): 235–48.

The somatization disorder has been attracted clinicians over a century and remained the subject of debate. Still there is uncertainty and varying opinions regarding its psychopathology. However, most current explanations focus on the concept of a misconnection between mind and body. The common theories dealing this disorder fit into three categories. The first theory is that the symptoms of somatization disorder represent the body’s own defense against psychological stress. This theory states that the mind has a finite capacity to cope with stress and strain. Therefore, increasing social or emotional stresses beyond a certain point are experienced as physical symptoms, principally affecting the digestive, nervous, and reproductive systems. Researchers in this area have also connections between the brain, immune system, and digestive system which may be the reason why somatization affects those systems and that people with irritable bowel syndrome are more likely to get somatization disorder (APA 2000) This theory also helps to understand the relationship between depression and somatization. It is also observed in greater frequency in women with a history of physical, emotional or sexual abuse (Pribor, 1993) The second theory explains that the somatization disorder is caused by one’s own negative thoughts and overemphasized fears. SIS in a Case of Somatised Pain Atri Sengupta, Nalini Mishra and Padma Dwivedi Somatic Inkblot Series-II Video version was administered to a 35 years old female executive. She got married 6 years before with her childhood friend with whom she had love relations for almost 15 years. She feels neglected by her husband who is short tempered, demanding and hostile. Even the personal relation has got deteriorated with depressed mood and insecurity towards future. The SIS images brought her unprocessed unconscious material on surface and helped her in processing. She started feeling better after therapeutic intervention. The case study is discussed in the paper. Their catastrophic thinking about the slightest ailments such as pain in stomach is an ulcer or shortness of breath is due to asthma, could lead those who have somatization disorder to actually worsen their symptoms. This then causes them to feel more pain for a simple ailment like a headache. Often the patients feel like they have a rare disease, because their physicians may not be able to have a medical explanation for their unconsciously exaggerated pain. With the fear that the routine work will exaggerate their pain, they slowly stop doing activities one by one until they practically shut themselves from a normal life. With nothing else to do, they always think about their problems and develop more stress and disability (Somatization Disorder, 2008). Freud (1917) and early psychoanalytic theorists have emphasized the role of defense mechanism in protecting the ego and helping the person from breakdown. The projective techniques are known for their sensitivity in tapping unconscious mental processes reflected in responses to unstructured / semistructured stimuli. The SIS can help the therapists more sensitively ‘hear’ a suffering individual’s cry for help, the inner cry that is not only hidden from others, but often hidden from one’s own conscious awareness as well (Cassell and Dubey, Atri Sengupta, Ph.D., 68 Sevadal Road, Udaypur, P.O.: Nimta, Kolkata—700049, Nalini Mishra, Ph.D. Principal, Dhirendra Mahila P.G.College, Karmajitpur, Sunderpur, Varanas-221005 and Padma Dwivedi, M.A., 4406 Forest Road, Anchorage, AK 99517, Email: bldubey@gmail.com Key Words: SIS in somatic disorder

SIS in a Case of Somatised Pain 127 Case Description: A 35 years old female executive with doctoral degree has been working since 14 years in the management cadre. She is professionally successful and earns a handsome package. Her creativity, ability to learn new things with high adaptability has brought her closer to top management. She has been found responsible and dependable at work as well as home frontiers. She is a caring person. She has grown up with strong value systems. She has an older sister along with parents and all are close to each other. They used to live together happily. Her personality is highly influenced by her mother who is emotional and less assertive. She got married at age 29 with her childhood friend with whom she has affair for almost 15 years. Though she had problems with her husband’s family initially but soon she got adjusted with them. After marriage she noticed that her husband was pessimistic, opinionated, and blaming to her for every problem. She realized her life has become miserable and she has lost peace and happiness. During last 6 years of her married life, she has no emotional or financial support. She is dissatisfied with her personal life. As she remembers they meet once in 4 to 6 weeks like wife and husband. She never conceived and consulted to a physician who found no physical deficiency in both of them. The physician advised them to live happily and have regular coitus. Still she is blamed for not getting the child. By using self-healing techniques she copes with the stress of life. She feels lonely and gets depressed at times. She gets headache and body pain off and on. She feels deprived sexually and emotionally. She doesn’t get anybody to share her feelings. She feels happiness disappeared from her life. She consulted a Clinical Psychologist who administered somatic Inkblot Series-II (DVD) along with psychotherapy. Significant responses are analyzed by using content/ psychoanalytic interpretation as follows: Three Images liked Most: A26: “Baby in mother’s womb – safe and secured” may indicate her desire to become mother which she wanted since last 5 years. It may also indicate her regression to childhood when she was more secure while living with her mother. A21: “A big bird trying to give protection to the small birds” Maternal instinct is brought on the surface with the help of this imagery where bird with two children is the common response. B28: “A mother is hugging her child” may indicate her affection and good interpersonal relationship with her mother whom she admires and considers her ideals. Three images you liked least : B14: “Some people are closed in a bottle” may indicate her aggressive attitude/ wishful thinking to see the significant family members tied and overpowered so that they may not create any problem in future. A17: Two bad spirits doing foul play with ‘love’. This may project the imagery of her husband and his cousin who are creating problems in her life. B12: Rejected. Normally people perceive human face on this image and it may remind her face of her husband. Other significant Response : A1: “Two Zebras are in the control of one person who is in the middle”. A person in the center may reflect her own imagery and two zebra (animals) are the two persons (her husband and his cousin) who are behaving like animals. This is an aggressive response which was

128 Sengupta, el at dealt during psychotherapy session. She described how she feels deprived sexually and emotionally. Similar theme is reflected in Image A17. A2: “A child is in the lap of a mother” is a good response may again indicate her wishful thinking to have a child. A3: “A beautiful lady with color of happiness or colorful” is a good response may suggest his elated mood and desire to live happily. A4: “Mouth of a horse” may indicate her insecurity and anxious mood. A5: “A man sending his love message to someone” may again indicate her desire to have love relations in her personal life. A6: “Two legs of a female” is sexual connotation depicting femininity and her desire to have love relations. A7: “A lady with smiling face and showing an apple” is a beautiful response indicating her intact ego strength, and positive attitude towards life. A8: “A smiling lady”. Normally people see female genitalia on this image and the smiling lady may have sexual expression which might be the desire of the patient. A9: “Two females are sharing their feelings” may indicate her inner cry which she wanted to share with someone. Her therapist should take note of this and help her to come out during therapy session. A10: 1. “A sad lady is crying” suggest her depressive mood and inner cry. A11: “A ship in dangerous sea” indicates her anxiety and insecurity towards her future. The dangerous sea represents her “outer circle/family” where she is trying to adjust. A12: 1. “Ear” is a normal response. 2. “Baby in mother’s womb” is a normal response.

3. “A man is in danger” represents her insecurity for her husband who is not able to look after himself and the family. A13: 1. “A man asking for help” may indicate her own projection to get help to resolve her problems.

2. “A frightened man” may symbolically represent her husband who might be afraid that the client may get separated one day if the situation remains unchanged. A14: “A baby from mother’s womb sending message to her mother” This may be the projection of support which she feels that her child (wishful thinking) might have helped her in such situation. This may also indicate the kind of support she is expecting from her therapist. Her therapist must take note of such situation which leads to positive transference. A15: “A baby in mother’s womb” is a normal response. A16: “Two birds loving each other” is a healthy projection and wishful thinking to have loving relations with her husband. A18: “Face of a lion” Normally a heart - a sign of love - is seen on this image. The face of lion may indicate her fear, cruelty and insecurity, a kind of projection of her husband. A19: “A mother holding her baby in lap” may indicate her desire and wishful thinking to become mother. A20: “Human body organ – Kidney” is a normal response. A22: 1. “Male sex organ” may indicate her frustrated erotic desire.

2. “Flower vase” is a normal response on this image. A23: ”A tree standing alone” projects depressive contents and feeling of being alone in real life situation. A24: “A mother full of emotions” might project the imagery of her mother who provides emotional support to her.

SIS in a Case of Somatised Pain 129 A25: “Female sex organ – fully stimulated” indicates her desire to have love relations, which she is not able to satisfy with her husband. Such situation may create hostile behavior which must be tackled by her therapist during psychotherapy session. A27: “Left breast of a female to feed her baby” is a healthy normal response. It also indicates her close relationship with her mother. A28: “A naked lady dancing” projects her desire to have love relations. Naked lady may further symbolize to cross over the social boundary and have full freedom to enjoy life. A30: “Skull” is a normal response. A31: “A man is talking to a lady who is in serious mood” may project her own serious mood and depressive contents. B1: “A hand is ready for punch” indicates her fear to get physical assault from her husband. B2: 1. “Lord Ganesh” is spiritual symbol helping her to manage the odd situations spiritually.

2. “A giant” may again represent her cruel husband. B3: “A man is proposing a lady” This image has taken her back in time when she had loving relationship before marriage. She might be still expecting the old days may be back and she may have better life. B4: A mother hugging her child is a normal response. B5: “A man and woman sharing their viewpoints” may indicate that she wanted to resolve the issues with discussion and sharing of views. B8: “Baby in mother’s womb” is a normal response. B9: “Kidney” is a normal response. B11: “A man is kissing a lady” may project her wishful thinking to have loving relations with her husband. B15: “Bum of a lady – an artist’s picture” may project her exhibitionistic desire to attract. It may also represent her body imagery. B16: “An well-dressed lady” indicates her desire to look decent and beautiful. B17: “Sign of love” is a normal response. B18: “Male sex organ” is a normal response on this image. B19: “Young people are enjoying and dancing” is again indicating her wishful thinking to enjoy like young people. B20: “Human brain” is a normal response. B21: “Display of food” may indicate her insecurity and frustration. B22: 1. A man is sleeping and his energy is spreading” is a normal response. It also indicates her spirituality which is helping her to manage the painful situation. 2. “Spirit of a man is moving to heaven” is a normal response on this image. B23: 1. “Goddesses Durga” may again bring the spiritual theme and taking shelter of GOD when most of the alternatives fail to work. B24: ”Kidney of human body” is a normal response on this image. B25: “Virat swarup of God Vishnu” may bring back the spiritual theme of Image B24. The spirituality, meditation and yoga practices help in releasing the tension and stress. B27: “Two kids are playing with each other” is a normal response on this image. B29: “A boy is running/ playing” is a normal response on this image. B30: “Twin-baby in mother’s womb” is a normal response. B31: “Two children with their parents who are kissing each other” is a normal response and desirev to have loving family.

130 Sengupta, el at Conclusion: The present case study has highlighted the efficacy of SIS-II Video Form in a case of 35 years old female. She feels neglected by her husband and has dissatisfied relationship. She feels lonely and gets depressed at times. Consequently she developed headache and body pain.. She feels deprived sexually and emotionally. She doesn’t get anybody to share her feelings. The SIS images brought her unprocessed painful unconscious material on surface and helped in processing. She started feeling better after therapeutic intervention. References : American Psychiatric Association (2004). Diagnostic and Statistical Manual of Mental Disorders, 4th Edition , Text Revision (DSM-IV-R), Washington D.C. American Psychiatric Association. pp. 486–490. ISBN 0-89042- 025-4. Cassell, W. A. and Dubey, B. L. (1996) The Use of the Rorschach and SIS in Releasing Somatised Grief. SIS J. Proj. Psy. & Mental Health, 3 : 3 -32. Cassell, W. A. and Dubey, B. L .(1996) Efficacy of the Booklet and Monochromatic Version of the SIS in a Case of Repeated Miscarriages. SIS J. Proj. Psy. & Mental Health, 3 : 131-145. Cassell, W. A. and Dubey, B. L. (1997) Therapeutic Dream Stimulation with SIS- Video. SIS J. Proj. Psy.& Mental Health, 4 : 3-23. Cassell, W. A. and Dubey, B. L. (2000) Inkblot Responses as an Aid to Therapy. SIS Journal of Projective Psy. & Mental. Health,7:3-10. Cassell, W.A., Dubey, A. and Dubey, B.L. (2000) SIS Projective Responses in PTSD and Disociative Disorder SIS J. of Proj. Psy & Mental Health, 7:93-108 Cassell, W, A. and Dubey, B. L. (2003) Interpreting Inner World through Somatic Imagery: Manual of Somatic Inkblot Series. Anchorage (USA): SIS Center. Cassell, W. A. and Dubey, B. L. (2007) Restructuring Rorschach Pathological Body Symbolism in the Somatoform Disorders with Truth Serum Behaviour Therapy SIS J. Proj. Psy. & Mental Health, 1: 20-29. Cassell,W. A. and Dubey, B.L. (2009) SIS and Sand Tray Psychotherapy of Suicidal adolescents. SIS J. Proj. Psy. & Mental Health,14:2, 87-97 Cassell, W.A. and Dubey, B.L. (2010) Infectious Suicidal Imagery in Combat PTSD, SIS J. Proj. Psy. & Mental Health, 17: 27-37. Cassell, W. A., Dubey, B. L., Molchanov,E. and Routh,L.C. (1999) Stimulating Beacon images for meditation and projective psychotherapy. SIS J.Proj Psy. & Ment. Health, 6:7-30. Cassell, W. A., Illardei,F.J., Collins, A., Mishra, M. and Dubey, B.L. (2001) Optimizing Spiritual Healing by Assessing Dream and SIS Imagery. SIS J. Proj. Psy. & Mental Health,8, 75-94. Freud, S. (1917) Mourning and melancholia. In Standard edition of the Complete Psychological Works, Vol. 14, 243 – 258. The Hogarth Press Ltd., London, 1963. Pribor, E. F., Yutzy, S. H., Dean, J. T., Wetzel, R. D. (1993) Briquet’s Syndrome, dissociation and abuse. american Journal of Psychiatry, 150, 1507-1511.9 Somatization Disorder (2008) www.minddisorders.com/ Py-Z/Somatization-disorder.html. Oct. 10, 2008 Gordon, G.H. (1987) “Treating somatizing patients,” Western Journal of Medicine, 147, 88-91.

Several studies have investigated the association between psychiatric disorders, particularly anxiety and mood disorders, and various headache forms. A review underlined that the frequency of depression and anxiety disorders in migraine is greater than that expected by a chance association (Scher, et al. 2005). The mechanisms linking psychiatric disorders to the natural history of migraine remain controversial. Genetic and/ or environmental etiologies and psychological vulnerability have been proposed to be implicated in the psychological problems and psychiatric disorders of migraine (Lipton and Silberstein 1994, Sheftell and Atlas 2002). Depression is a frequent finding, especially in patients with frequent attacks (Breslau et al., 1994). Behavioral and somatic symptoms commonly observed in subjects with chronic headache are also found in patients with anxiety, mood, or somatoform disorders (Mongini et al., 1994). However, there are exceptions, at least for some disorders, like depression, which seems to be more specifically linked to migraine (Breslau et al, 2003). Cognitive Behavior Therapy and Relaxation in Chronic Migraine Patients M. G. Sharma and Vandana Sharma The present study attempts to examine the effect of cognitive behavior therapy and relaxation practices on chronic migraine patients. 50 treated and 50 non-treated patients were evaluated at SIMPHS Varanasi (India). The two groups were matched on age range from 20 to 55 years with a mean age of 38.4 years and mean length of intolerable pain of 6.8 years. Indian adaptation of T.A.T. (Seven cards: 1, 3B, 4, 6BM, 7BM, 13MF, and 16), Defense Mechanism Inventory and Questionnaire for Dependency were administered to ascertain personality, defense mechanism and dependency characteristics on eleven selected dimensions viz: need, press, interpersonal relations, outcome, reversal, principalization, turning against self, projection, turning against object, internal dependency and external dependency. Mean scores obtained on different variables were analyzed using t-test of significance. Results indicated that the characteristics associated with treated chronic migraine patients were cognizance, dominance, autonomy, achievement, counteraction, affiliation, sex capacity, interpersonal relations, outcome, projection turning against object and internal dependency whereas the characteristics associated with non-treated chronic migraine patients were aggression, rejection, passivity, acquisition, anxiety, , reversal, principalization, turning against self, internal dependency, external dependency and press. A diagnosis of depression or anxiety carries an indication for treatment irrespective of the presence of migraine or other headache disorders (Blier and Abbott 2001). On the other hand, the presence of an abnormal psychological profile has less obvious clinical implications and is less easily detected. Few studies have investigated the association between different types of headache and personality profiles. The results have not fully clarified the clinical implications and significance of the relationship between headache and psychological characteristics. Cao and coworkers (2002) found that patients with migraine as well as those with episodic and chronic tension type headache showed traits of neuroticism-anxiety and depression, but that no abnormal personality traits were present in migraine with aura. With regard to the potential of personality profile to determine the evolution of migraine, Mongini et.al.,(2000) administered the MMPI- 2 tool to a relatively small number of patients and frequently found a conversion profile that became more pronounced (neurotic or M. G. Sharma, Asstt. Professor, Dept. of Psychology, Sri Agrasen Kanya P. G. College, Varanasi-221002 (India) 09415448519, Email:gopal.simphs@gmail.com and Vandana Sharma, Ph.D. Psychologist, SIMPHS, C33/204-1-B-1, Chandua Chhittupur, Varanasi 221002 (India). 08004314101. Email: vns.simphs@gmail.com

132 Sharma & Sharma emotionally over whelmed) with the episodic chronic form of migraine. It remains to be determined whether such a personality style predisposes to chronic headache or merely reflects the stresses and difficulties associated with it. Mongini et al. (2003) further examined the association between personality traits, depression, and migraine. The findings suggested that the co-occurrence of depression and personality changes did not appear to influence the short-term treatment outcome in women patients with migraine; rather it increased the frequency of headache on long term treatment. The present study of a subgroup of chronic headache patients without psychiatric disorders aimed at exploring the influence of personality profile on disease prognosis. Diagnosis of migraine was made according to the widely accepted criteria of International Headache Society (1988) based on a validated semistructured interview. Patients with full details were included in the study. The frequency of migraine attacks fifteen times in a month was used to define chronic migraine. Since the new International Headache Society classification (2004) was not officially available at the time of our investigation, patients not entirely fulfilling the new criteria for chronic migraine might have been included in this study. Moreover, the characteristics of most of our patients seem to fulfill the criteria for chronic migraine without aura as defined by the proposed revision of the International Headache Society classification (Manzoni et. al, 2006). In a study on migraine patients, behavioral disturbances were successfully managed, and anxiety symptoms were reduced, using different psychological interventions (Fan and Zhou, 1999). The Jacobson Relaxation Technique is described in brief ahead. Jacobson Relaxation Technique: The techniques were developed by Edmund Jacobson in the early 1920s. Jacobson (1938) argued that since muscle tension accompanies anxiety, one can reduce anxiety by learning how to relax the muscular tension. The physical component involves the tensing and relaxing of muscle groups over the legs, abdomen, chest, arms and face. With the eyes closed and in a sequential pattern, a tension in a given muscle group is purposefully created for approximately 10 seconds and then released for 20 seconds before continuing with the next muscle group. The mental component focuses on the difference between the feelings of the tension and relaxation. Because the eyes are closed, one is forced to concentrate on the sensation of tension and relaxation. In patients with anxiety, the mind often wanders with thoughts such as “I don’t know if this will work” or “Am I feeling it yet.” If such is the case, the patient is told to simply focus on the feelings of the tensed muscle. Because of the feelings of warmth and heaviness, in the relaxed muscle after it is tensed, a mental relaxation is felt as a result. With practice, the patient learns how to effectively relax and deter anxiety when it becomes at an unhealthy level where an anxiety attack would otherwise occur (Craske and Barlow, 2006). Jacobson trained his patients to voluntarily relax certain muscles in their body in order to reduce anxiety symptoms. He also found that the relaxation procedure is effective against ulcers, insomnia, and hypertension. There are many parallels with autogenic training, which was developed independently. The technique has also proven effective in reducing acute anxiety in schizophrenics (Chen et al, 2009). Jacobson’s Progressive Relaxation is very popular with modern physical therapists. Procedure of Relaxation Practices: Wolpe and Lazarus (1966) told that progressive relaxation involves alternately tensing and relaxing the muscles. A person using progressive muscle relaxation may start by sitting or lying down in a comfortable position. With the eyes closed, the muscles are tensed (10 seconds) and relaxed (20 seconds)

Cognitive Behavior Therapy and Relaxation in Chronic Migraine Patients 133 sequentially through various parts of the body. The whole progressive muscle relaxation session takes approximately 30 minutes. As this is a technique, practice with progressive muscle relaxation does make perfect and will usually not work effectively as it should the first couple of times. Patients with generalized anxiety disorder who first try progressive muscle relaxation with anxiety may become frustrated, feel rushed, or feel an increase in anxiety for various reasons such as being afraid to “let your guard down.” As with doing anything new, this is to be expected and simply practiced again once or twice a day (Craske and Barlow 2006). The, purpose of the present study was to see the management of chronic migraine patients by administering Cognitive Behavior Therapy and Relaxation practices and find out the personality factors with the help of T A T, D M I and Q D. Materials and Method: The study was carried out at S.I. Mental and Physical Health Society (SIMPHS), Varanasi (India). The sample consisted of 50 treated and 50 non-treated chronic migraine patient between the age ranges 20 to 55 years with a mean age of 38.4 years. Both the groups were matched on socio- economic status. All the subjects had experienced chronic pain for several years with the frequency of attacks not less than fifteen times in a month. After individual counseling they were administered cognitive behavior therapy and relaxation practices each with 45- 60 minutes for 6 months. Both therapies were administered 4 times weekly in first month, 3 times weekly in 2nd month, 2 times weekly in 3rd month, once weekly in 4th months, once in 10 days in 5th months and once in 2 weeks in 6th months. Tools: TAT (Chowdhury, 1967). Defense Mechanism Inventory (Mrinal and Mrinal, 1997) and Questionnaire for Dependency (Sharma and Sharma, 2012) were administered to ascertain personality characteristics, defense mechanism and dependency of treated and non-treated chronic migraine patients. Statistical Analysis: The data thus obtained were analyzed using Mean, S.D. and‘t’- test. Results and Discussion: The mean scores of treated and non-treated chronic migraine patients were compared on need, press, interpersonal relations, outcome, reversal, principalization, turning against self, projection, turning against object, internal dependency and external dependency using the ‘t’-test of significance. Results are shown in Table 1 to 4. Table 1 compares the treated and nontreated chronic migraine patients on need variables. It was found that the two groups differ significantly on cognizance, aggression, dominance, rejection, autonomy, achievement, passivity, counteraction, affiliation, acquisition, and sex. The treated chronic migraine patients obtained higher mean scores on harmavoidance needs of which treated chronic migraine patients do have higher mean scores on cognizance, dominance, autonomy, achievement, counteraction, and sex needs, and lower on aggression, rejection, passivity, and acquisition. The treated chronic migraine patients have higher harm-avoidance. It indicates that treated chronic migraine patients had better cognizance, dominance in nature, and autonomy in behavior. They think about their achievement; counteraction, affiliation, and sex needs. Un-treated chronic migraine patients were more aggressive, rejecting reality with low passivity. The two groups were compared on press, interpersonal relations and outcome variables using the ‘t’-test of significance and the results are given in Table 2.

134 Sharma & Sharma Table 1 Comparison of Treated and Non--treated Chronic Migraine Patients on Need Variable. Variables Treated Chronic Migraine Patients Non-treated Chronic Migraine Patients ‘t’ value df. p M SD M SD Cognizance 3.84 1.98 2.99 2.06 4.42 .01 Aggression 6.98 2.01 5.89 2.38 1.14 NS Dominance 9.13 2.98 7.28 1.99 5.96 .01 Rejection 2.70 1.04 3.99 1.79 4.45 .01 Autonomy 5.97 2.47 3.89 1.54 5.07 .01 Achievement 8.87 2.06 5.73 2.53 5.70 .01 Passivity 2.31 1.62 3.58 1.74 3.84 .01 Harm- avoidance 3.05 1.98 2.02 1.37 2.97 .01 Counteraction 4.03 1.67 2.86 1.75 3.44 .01 Affiliation 6.67 2.08 4.85 2.05 4.41 .01 Acquisition 4.62 1.95 6.00 2.68 2.94 .01 Sex 7.36 2.07 5.48 2.03 4.67 .01 Table 2 Comparison of Treated and Non-treated Chronic Migraine Patients on Press, Interpersonal Relations and Outcome Variables Scores obtained by the two groups on reversal, principalization, turning against self, projection, and turning against object, variables were analyzed using ‘t’-test of significance and results are presented in Table 3. It is clear from table 2 that the press, interpersonal relations and outcome, in the treated and nontreated chronic migraine patients do differ significantly on press, interpersonal relations and outcome variables. The treated group of chronic migraine patients shows higher mean values on interpersonal relations and outcome, and lower on press variables. The means indicate that the treated patients have better interpersonal relations and better adjustment in social situation.

Cognitive Behavior Therapy and Relaxation in Chronic Migraine Patients 135 Table 3 Comparison of Treated and Non-treated Chronic Migraine Patients on D.M I. Table 3 indicates that the two groups did differ significantly on reversal, principalization,, projection, and turning against object. The nontreated chronic migraine patients’ shows higher mean scores on reversal, principalization, and turning against self. It indicates that they used major defense mechanism in comparison to the chronic migraine patients. This means reversal dimension of defense mechanism deals that with conflict by responding in a position or natural fashion to a frustrating object, which might be expected to evoke a negative reaction. Defenses such as negation, denial, reaction formation, and repression are subsumed under this category. The principalization has also higher mean scores which indicate that nontreated chronic migraine patients deals with conflict through invoking a general principle that “splits off” affect from content and represses the former. Defenses such as intellectualization, isolation, and rationalization fall into this category. The highest score on turning against self indicates that non-treated chronic migraine patients handle conflict through directing aggressive behavior towards self. Masochism and auto sadism are examples of defensive solutions in this category. The treated group of chronic migraine patients has higher scores on projection suggests that they justify the expression of aggression towards an external object through first attributing to it, without unequivocal evidence, negative intent, or characteristics. Experimental group of chronic migraine patients has also higher mean scores on turning against object which indicates that defenses deals with conflict through attacking a real or presumed external frustrating object. Such classical defenses as identification with the aggressor and displacement can be placed in this category. The two groups were also compared on internal dependency and external dependency variables using‘t’-test of significance and the results are given in Table 4. Table 4 Comparison of Treated and Non--treated Chronic Migraine Patients on Q. D. It is apparent from Table 4 that the two groups differed significantly on internal dependency and external dependency. The non-treated chronic migraine patients showed significantly higher scores on internal dependency as well as external dependency. Results further indicate that both type of dependency is found due to long period of chronic pain which was in

136 Sharma & Sharma their life and after treatment it reduced in both type of dependency. Conclusion: The present finding of the study has shown that the characteristics associated with chronic migraine patients are cognizance, dominance, autonomy, achievement, harm-avoidance, counteraction, affiliation, sex, interpersonal relations, outcome, projection, and turning against self; and characteristics associated with non-treated chronic migraine patients are rejection, passivity, acquisition, press, reversal, principalization, turning against object, internal dependency and external dependency. References: Blier, P. and Abbott, F.V. (2001).Putative mechanisms of action of antidepressant drugs in affective and anxiety disorders and pain. Journal of Psychiatry Neuroscience 26:37 43. Breslau, N., Davis, G.C., Schultz, L.R. and Peterson, E.L. (1994). Migraine and major depression: A longitudinal study. Headache. (34)387-393. Breslau, N., Lipton, R.B., Stewart, W.F., Schultz, L.R. and Welch K.M.A. (2003) Comorbidity of migraine and depression investigating potential etiology and prognosis. Neurology. (60)1308-1312. Cao, M., Zhang, S., Wang, K., Wang, Y. and Wang, W. (2002). Personality traits in migraine and tension-type headaches: A five factors model study. Psychopathology. (35)254-258. Chowdhuri, Uma (1967). Manual of the Indian adaptation of the T.A.T. Publisher: Janaki Nath Basu, 1 Sanker Ghose Lane, Calcutta-6. Craske and Barlow (2006), Worry, Oxford University Press, Inc., p. 53, ISBN 0-19-530001-7. Chen, W.C; Chu, H; Lu, R.B; Chou, Y.H; Chen, C.H; Chang, Y.C; O’Brien, A.P. and Chou, K.R.(Aug 2009).Efficacy of progressive muscle relaxation training in reducing anxiety in patients with acute schizophrenia”, Journal of Clinical Nursing 18,87–96, Fan, A.Y. and Zhou, A.N. (1999). MMPI changes associated with therapeutic intervention: A migraine control study. Headache. (39)581-585. Headache Classification Committee of the International Headache Society. (1988).Classification and diagnostic criteria for headache disorders, cranial neuralgias and facial pain. Cephalalgia; 8 (suppl. 7):1-96. Headache Classification Committee of the International Diagnostic Criteria of Headache Disorders. (2004). Cranial neuralgias and facial pain. Cephalalgia.; 1(suppl 1):1-96. Jacobson, E. (1938) Progressive relaxation. Chicago: University of Chicago Press Lipton, R.B.and Silberstein, S.D.(1994). Why study the comorbidity of migraine? Neurology. 44(suppl 7):4-5. Manzoni, G.C., Lambru, G. and Torelli,P .(2006). Chronically evolvine headaches: Classification and terminology. Neurology Science. (27)S164-S167. Mongini, F., Ibertis, F., Ferla, E. (1994). Personality characteristics before and after treatment of different head pain syndromes. Cephalalgia.; (14)368-73. Mongini, F., Ibertis F. Barbalonga, E. and Raviola, F. (2000). MMPI-2 profiles in chronic daily headache and their relationship to anxiety levels and accompanying symptoms. Headache. (40)466-472. Mongini, F., Keller. R., Deregibus, A, Raviola, E., Mongini, I.and Sancarlo, M. (2003). Personality traits, depression and migraine in women: A longitudinal study. Cephalalgia. (23)186-192. Mrinal, N. R. and Mrinal, U. (1997). Manual for Defense Mechanism Inventory , National Psychological Corporation, Agra. Sharma, M. G. and Singh, S. (2012). A study of personality characteristics of migraine patients. Unpublished P.hD. thesis , Varanasi. Scher, A, I., Bigal, E.M. and Lipton, R.B. (2005). Comorbidity of migraine. Curr Opin Neurol. (18)305-310. Sheftell, F.D. and Atlas, S.J. (2002). Migraine and psychiatric comorbidity: From theory and hypotheses to clinical application. Headache. (42)934-944. Wolpe, J. and Lazarus, A.A. (1966) Behavior therapy technique. New York. Pergamon Press.

of Mental Disorders of APA, and such conditions are still recognized in the latest edition of the DSM. However, the name psychosomatic disorder is no longer used in the DSM scheme of classifying mental disorders. Among the so called psychosomatic disorders, the coronary artery disease (CAD) and diabetes have emerged as major health hazards in the contemporary world and are associated with a very high rate of morbidity and mortality. Traditionally, these diseases were classified as psychosomatic disorders in which chronic stress and negative emotional experiences are considered to play important role in their genesis. Among the various psychosomatic disorders such as peptic ulcers, asthama, hypertension, eczema, and other skin diseases like psoriasis etc., the diabetes and CAD have received greater attention of researchers in the recent years. Differential Affective Profile of Patients with Diabetes and Coronary Artery Disease Prachi Saxena, Tulika Pandey, Akanksha Dubey, Sujeet Pratap, and Rakesh Pandey The present paper attempts to explore the profile of affect related traits and abilities that may potentially discriminate the patient suffering from diabetes from those having Coronary Artery Disease (CAD) apart from discovering the specific set of affect related traits/abilities that differentiate the said patients groups from healthy controls. Patients with diabetes, CAD and a group of matched control participants (N = 15 in each) were assessed on the measures of alexithymia, emotional intelligence, style of emotional expressions and perceived autonomic arousal associated with emotions. A multiple discriminant function analysis was conducted to uncover the affective profile that maximally discriminated the two patient groups from the matched controls as well as the two patient groups themselves. The findings yielded two discriminant functions – ‘emotional inability’ and ‘emotional expression’. The plot of the centroids of the three groups on both the functions revealed the ‘emotional expression’ function differentiated the two patient groups (diabetes and CAD) from each other while the ‘emotional inability’ differentiated the patient groups from the matched controls. The classification matrix revealed that the discriminant functions classified the diabetics with 73.3% accuracy, CAD patients with 66.7% accuracy, and the matched controls with 80% accuracy. The findings of analysis of variance revealed that the patient groups were significantly more alexithymic, less emotional intelligent and less emotionally expressive than the matched control group. However, the post-hoc comparison revealed that higher level of alexithymia and poor emotional intelligence differentiate the two patient groups from health controls. Further, the patients with diabetes and CAD were found to have a specific affective profile that differentiated them from each other. The patients with diabetes were characterized by an affective profile defined by relatively higher level of emotional intelligence (as compared to CAD) associated with difficulty in expressing positive emotions and a strong belief for non-expression of emotions. On the other hand, the patients with CAD were characterized by a relatively poor emotional intelligence but better expression of positive emotions and lower score on belief for non-expression of emotions. The findings imply that a difficulty in identifying verbalizing emotions (i.e., alexithymia) and poor emotional intelligence differentiate the two patient groups from healthy controls while higher emotional intelligence associated with poor emotional expression (or vice-versa) differentiate the patients with diabetes from the CAD.The results have been discussed in the light of available empirical findings.

138 Saxena, et al The conception of diabetes mellitus (DM) as a psychosomatic diseases sprouts from the school of psychoanalysis (Wasserman and Trifonova, 2006). DM is one of those disorders that Alexander (1939) initially described as psychosomatic. According to him, emotions can play a causative role in diabetes because of its significant influence upon carbohydrate metabolism. The link between negative emotional experiences and development of diabetes was also noted down by British physician and anatomist Rubin and Peyrot (2002). Diabetes is a serious, lifelong condition that can cause heart disease, kidney failure and blindness and often leads to disability and death. Diabetes Mellitus results in complex course and outcome, physical and dietary restrictions, and life-threatening risks of hypo- and hyperglycaemia. It also worsens the patient’s social functioning, contributes to stigmatization and disruption of significant relations (Luminet et al, 2006). Similar to Diabetes, in terms of its emotional causes and social consequences, is CAD. Cardiovascular diseases are the leading causes of death and disability in almost every society around the world. CAD is characterized by hardening and narrowing of blood vessels due to cholesterol. This can lead to chest pain or a heart attack. Rozanski et al (1999) have described CAD as the hyper-responsivity of the sympathetic nervous system, manifested by exaggerated heart rate and blood pressure responses to psychological stimuli. In the classical psychosomatic paradigm chronic stress and emotional conflicts have been considered to cause persistent fluctuations of the blood pressure resulting in the overtaxing of the vascular system (Alexander, 1939). According to Miles and associates (Miles et al,1954), for instance, severity of angina pain may be considerably influenced by emotional state of the patient and acute coronary occlusion with myocardial infarction can be precipitated by a severe emotional crisis. The idea that emotions are linked with the health of an individual has been fundamental to the psychosomatic medicine right from its inception. Alexander (1939) emphasized upon the mind body relationship and the ways in which an individual’s emotions can impact his physical health. According to Alexander (1939) suppression or non-expression of emotions is the root cause of various psychosomatic conditions including diabetes and CAD. Whenever emotions are not expressed and relieved from conventional channels then they lead to chronic autonomic arousal which in turn develops the vulnerability for the development of physical disorders and diseases. According to psychosomatic paradigm suppression of negative affect is the central element leading to the development or expression of a physical illness. Continuous fears, aggression, wishes, if repressed results in persistent emotional tensions which disturb the bodily functioning and results in chronic physical illness. After a few decades of the Alexander’s psychosomatic paradigm, Sifneos (1973) introduced the construct of alexithymia that emerged as an alternative to classical psychosomatic paradigm for linking emotions with health. Alexithymia is characterized by difficulties in identifying and communicating emotions and feelings (Taylor, 1984). Like the traditional psychosomatic medicine paradigm, the alexithymia construct links susceptibility to disease with prolonged states of emotional arousal which seek expression through bodily channels (Pandey, 1995). The significance of alexithymia in explaining physical illness has been highlighted by others also (Lumley et al, 2008). The alexithymia construct focuses attention on deficits in the cognitive processing of emotions, which remain undifferentiated and poorly regulated (Taylor et al, 1991). Because of the underlying difficulty in understanding and expressing emotions in alexithymia (Taylor, 1984), the ultimate outcome of this behavioural disposition is equivalent to emotional suppression. Apart from alexithymia, several other emotion related variables have been identified that may play significant role in predicting the physical

Differential affective profile of patients with diabetes and coronary artery disease 139 health of an individual. For example, emotion regulation (ability to cognitively or behaviourally influence the occurrence, intensity, duration and expression of emotions; Gross and Thompson, 2007), emotional intelligence (the ability to perceive, express, understand, monitor and manage emotions; Salovey and Mayer, 1990), affect intensity (the disposition to experience extreme of emotional states irrespective of emotional valence; Larsen and Diener, 1987), positive and negative affect (the affective disposition to experience positive or negative emotions) and emotional suppression ( the inability to express and share emotional experience, especially negative emotions) are some of the emotion related constructs that might influence the physical health of an individual (see Pandey and Choubey,2010 for a review). The present study focuses on the role of alexithymia, emotional intelligence, style of emotional expression and perceived autonomic arousal associated with emotions in differentiating the patients with diabetes and CAD. The following section presents a brief review of empirical studies relating the said constructs with diabetes and CAD. The construct of alexithymia as a personality trait was initially proposed by Sifneos in 1973 for explaining psychosomatic disorders. It is considered as a disturbance of affect and cognition and is reflected in a difficulty in describing or recognizing emotions and a reduced affective and fantasy life (Taylor and Bagby, 2000). Alexithymia is a complex mixture of personality traits which remains stable over time, even after distress or depression have diminished (Taylor and Bagby, 2000). Though alexithymia was initially observed in psychosomatic patients, the alexithymic personality trait has been found in a wide variety of medical and psychiatric patients, and diabetes and the CAD are not exception to it. A number of researchers have studied diabetes in relation to alexithymia and noted that diabetic patients often reflect a unique personality or cognitive style, including disorders of affect regulation such as alexithymia (Taylor, 1997). The prevalence of alexithymia was found to be 22.2% in diabetes patients and 7.6% in controls, even after adjusting for confounding depressive symptoms and it was found to be positively related with diabetes duration and negatively with treatment intensifications (e.g., Chatzi et al., 2009). The presence of alexithymia in diabetic patients is also associated with more difficulties in taking care of oneself (Abramson et al, 1991) in addition to worse glycaemic control (Luminet et al, 2005; Topsever et al, 2006). Similarly, alexithymia has also been found to be associated with various cardiovascular disorders including coronary artery disease. For example, Todarello et al, (1995) found a high prevalence of alexithymia in hypertensive patients (55.3%) as compared to normal control (16.2%). While explaining the link between alexithymia and cardiovascular disorders, researchers have argued that a deficit in the cognitive processing and modulation of emotions may leave such individuals prone to states of heightened sympathetic arousal that are conducive to the development of essential hypertension. Jula et al, (1999) observed that alexithymia is associated with elevated blood pressure independent of sodium and alcohol intake, body mass index, and physical fitness. Similarly, grabe et al., (2010) found that alexithymia may represent a relevant and independent risk factor for hypertension even after adjusting for socio-demographic factors and classical risk factors for cardiovascular diseases and mental distress. The aforesaid studies suggest that alexithymia is more prevalent among patients with diabetes and CAD as compared to normal healthy controls. Another emotion related construct that has been studied in relation to health is emotional intelligence (EI). Salovey and Mayer (1990) coined the term emotional intelligence and defined it as a form of intelligence that involves the ability to monitor one’s own and others feelings and emotions, to discriminate among them and to use this information to guide one’s thinking and action. Later, this definition was revised by the same authors only to make it more accepted and EI was conceptualized

140 Saxena, et al as the ability to perceive emotion, integrate emotion to facilitate thought, understand emotion, and to regulate emotions to promote personal growth (Mayer and Salovey, 1997). According to Mayer and Salovey, (1997) the ability to understand and modulate one’s emotional states should facilitate more effective coping responses to stress, which would in turn diminish the adverse impact of prolonged distress on the body and reduce the likelihood of developing a disease. Similarly, ability of self-insight and self-regulation would prevent the use of maladaptive coping strategies and instead promote a more positive lifestyle that increases longevity and physical wellbeing (Keefer et al, 2009). Emotional intelligence has been studied in relation to diabetes as well as CAD. For instance, Samar (2001) reported that emotion intelligence is significantly related with type 1 diabetes, self-management practices and glycemic control. Yalcin et al, (2008) have found that diabetic patients showed significant improvement in quality of life and well-being following a twelve week emotion intelligence workshop. Researchers have found facets of trait emotional intelligence such as decreased ability to use and regulate emotions as well as frequency of negative expressiveness to be associated with incidence of coronary heart disease (Kravvariti, Maridaki-Kassotaki, 2010). Similarly researchers have found trait emotional intelligence to be negatively associated with occurrence of coronary artery disease in Greek urban population while taking into account already identified highly significant risk factors for the disease, namely, age, gender, cigarette smoking, presence of hypertension, obesity and family history of coronary artery disease (Panagiotakos, et al., 2002; O’Donnell and Elosua, 2008). These researchers argued that perceived ability to use, regulate and express emotions as well as frequent expression of positive emotions would be associated with decreased incidence of coronary heart disease. To sum up, the aforesaind studiess suggest that patients with coronary artery disease and diabetes are significantly low on trait emotional intelligence than the normal controls and these deficits may be associated with development as well as poor outcomes in the disease. Another emotional variable frequently associated with physical health is style of emotional expression. Style of emotional expression is related with how and to what extent people express positive and negative emotions in different social context. It also includes the belief about expression or nonexpression (or social sharing) of emotions. Emotional expression may include observable verbal and/or non-verbal behaviour. In the present study the identified components of style of emotional expression include- Inhibited social sharing and expression of emotion, Control over expression of negative emotions, Difficulties in expressing positive emotions, Belief about non-expression of emotions and Inhibited non-verbal expression of emotion (Pandey, 2001). The style of emotional expression has been found to be associated with coronary artery disease (Friedman and Booth-Kewley, 1987). For example, Rosenberg and associates (Rosenberg et al., 2001) found that ischemic patients showed significantly more anger expression and non-enjoyment smiles than non-patients. According to Mendes et al, (2003) the context and content of emotional expression influences the cardiovascular functioning. Similarly, Johan and associates (Denollet et al, 2010) found that patients with coronary artery disease who suppress their anger were at increased risk of adverse cardiac events, after controlling for decreased systolic function, poor exercise tolerance, extent of CAD, and revascularization. Similarly high score on both negative affectivity and social inhibition is related with coronary artery disease (Denollet, 1998). Studies dealing with the role of style of emotional expression in diabetes have observed that expressed emotion is a significant predictor of glucose control in diabetes (Koenigsberg et al, 1993). From the preceding review it is evident that various emotions related traits and abilities are strongly associated with course

Differential affective profile of patients with diabetes and coronary artery disease 141 and development of diabetes and CAD. Here it is worth mentioning that both the classical psychosomatic as well as the alexithymic paradigms link the emotional variable to the physical health status through autonomic arousal. According to the classical psychosomatic paradigm persistent emotional stress results in arousal of the autonomic nervous system and this continuous arousal results in the overtaxing of the organ system leading to physical illness (Alexander, 1939). Similarly, according to the alexithymic paradigm, when an individual is faced with excessive stress he/she fails to understand and express them because of their affective deficit. Thus, the alexithymic’s difficulty in understanding and describing emotions amounts to suppressed emotions which results in increased sympathetic arousal that (Taylor, 1984). Researchers have also noted that individuals with high levels of alexithymia manifest high tonic levels of autonomic arousal activity (Pandey and Mandal, 1996). Though, these theoretical paradigms have emphasized upon the role of autonomic arousal in linking emotions to somatic complaints, empirical studies to test the role of actual and/or perceived autonomic arousal in psychosomatic disorders are scant. Few researches have indirectly related autonomic arousal to health problems. The loneliness and boredom are the common features associated with chronic patients. Researchers have found boredom to be associated with increased the autonomic arousal (London, Schubert and Washburn 1972). Perceived autonomic arousal also correlates positively with the measure of anxiety (Mandler et al, 1958). Sympathetic nervous system (SNS) arousal is associated with anxiety, neuroticism, the Type A personality, cardiovascular disease, and immune system suppression (Dienstbier, 1989 ). Studies also suggest that such patients manifest unique style of expressing emotions especially the negative emotions which is associated with high autonomic arousal (Rosenberg et al., 2001, Kravvariti, Maridaki-Kassotaki, 2010) that may make them prone to develop further complications. The aforesaid review indicates that both diabetes and CAD is associated with a variety of emotional deficits such as difficulty in identifying and describing feeling, poor emotional intelligence and enhanced sensitivity to autonomic arousal. Further it is also evident from the preceding review that the patients of diabetes and coronary artery disease differ from the normal control in terms of their emotional profile. However, how and to what extent the said affect related variables differentiate the two patient groups from each other has not been explored much. In other words, despite the evidences that patients with diabetes and CAD differ from their healthy counterparts in terms of their poor emotional abilities, there is dearth of studies to demonstrate that these two disease states are associated with different types of emotional difficulties or affective profile. Thus the present study aims to study the emotional profile of diabetic and cardiac patients and explores how and to what extent the said emotional deficits can be used to differentiate between patients of diabetes from that of coronary artery disease. Otherwise stated, the present study is an attempt to examine disease-specific affective profile for patients with diabetes and CAD. Such attempt would help to develop suitable psychotherapeutic interventions for management of psychosomatic disorders in general and the said diseases in particular. Method: Sample: The sample included three groups of participants- those suffering from diabetes, coronary artery disease and an age, gender matched normal healthy control group. Each group consisted of 15 participants (male = 8, female = 7). The age range of the participants was between 40-60 years (mean age = 50 years). The education level of participants ranged from high school to graduation. All the participants belonged to middle class socioeconomic status. Further, only those patients were allowed to participate in the present study

142 Saxena, et al who was suffering from either diabetes or CAD only. Those patients were excluded from the study who reported other comorbid medical conditions. Measures: The Hindi version of 20 item Toronto Alexithymia Scale (TAS-20-H) (Pandey, Mandal, Taylor, and Parker, 1996) was used to assess the level of alexithymia of the participants. The TAS-20-H consists of 20 items that assesse three dimensions- difficulties in describing feelings, difficulties in identifying emotions and externally oriented thinking. Items are scored on a five point likert scale. Higher score on this scale indicates higher levels of alexithymia Hindi version of Emotional Intelligence Scale (EIS) of Schute et al (1998) developed by Pandey (2001, 2002) was used in the present study to assess emotional intelligence. The scale consist of 26 items, scored on a five point likert scale. The scale assess two dimensions of emotional intelligence namely, Ability to appraise, express, regulate and utilize one’s own emotions and Ability to appraise and regulate emotions in others. The reliability and validity of EIS scale was found satisfactory in several studies (Pandey2002; Sharma, 2001; Srivastava2001). Style of Emotional Expression Questionnaire (SEEQ) (Pandey, 2001), consists of 80 items which are related to the nature and style of expressing emotions. The scale assesses six types or styles of emotional expression and a brief description of each is given below. Dimension 1- Inhibited social sharing and expression of emotion. Individuals who score high on this dimension are unable to share their emotions with other people, friends or even family members. Their emotions often get expressed in form of high anger and rage. Dimension 2- Control over expression of negative emotions. High scorers on this dimension try to control or restrict the expression of negative emotions. They believe that expressing negative emotions is not a good thing and make a conscious effort to regulate their negative emotions and control their behaviour. Dimension 3 – Difficulties in expressing positive emotions. Individuals who have a high score on the dimension ‘difficulties in expressing positive emotions’ are reluctant to express their positive emotions. They are unable to express their happiness freely and feel that it is better to be sober than to show off their joy. Dimension 4 – Belief about non-expression of emotions. This dimension tries to measure an individual’s beliefs about emotion expressions and not his actual behaviour. Individuals who score high on this dimension believe that there is no need for sharing their emotions with others. They have a negative view about expressing emotions (both positive and negative) infront of others. Dimension 5- Inhibited non-verbal expression of emotion. High scorers on this dimension do not express their emotions verbally and try to control their emotional expression but their emotions get expressed through their nonverbal channels. They show spontaneously non-verbal expression of emotions even when they try to control it. Dimension 6 – Non - acceptance and suppression of emotions. High scorers on this dimension do not accept their emotions and try to suppress them. They employ cognitive strategies such as denial and ignore to suppress the expression of their negative emotions. Hindi version of Autonomic Perception Questionnaire (HAPQ-R; Pandey, 1993) is a revised version of Autonomic Perception Questionnaire (APQ – Mandler, Mandler and Uviller, 1958). The questionnaire includes 30 items, rated on a seven point scale ranging from ‘not at all true’ to ‘very true about me’. The total score ranges from 30 to 210. High

Differential affective profile of patients with diabetes and coronary artery disease 143 score indicates hypervigilance for autonomic activation. Procedure: The participants of the present study were contacted individually. Before the administration of the questionnaires the participants were briefed about the purpose of the study and their task. After getting the consent of the participants the aforesaid questionnaires were administered as per the standard instructions of each questionnaire. All participants were requested to ensure that they have responded to each items of every questionnaire/scale. Results and Discussion: To examine and identify the affective profile that maximally differentiated the two patient groups from each other as well as the two patient groups from the matched control group; a discriminant function analysis was conducted. Since there were three groups of subjects the analysis yielded two functions. The observed structure matrix is presented in Table – 1.The table shows that the first function loaded significantly and positively on alexithymia and negatively on emotional intelligence. This pattern of loading suggests that this function may be labelled as ‘emotional inability’ characterized by difficulty in identifying, understanding and describing emotions and poor emotional intelligence. The second function loaded significantly and positively on ‘belief about non-expression of emotions’ and ‘difficulties in expressing positive emotions’. This pattern of loading suggests that the second discriminant function may be labelled as ‘emotional expression’. Table 1 Discriminant Function Structure Matrix To explore how and to what extent the said functions differentiate the two patient groups from each other and the patients from healthy controls, the centroid of the three groups were plotted ( Fig. 1). It is evident from the plot that ‘emotional expression’ differentiated the two patient groups (diabetes and CAD) from each other while the ‘emotional inability’ differentiated the patient groups from the matched controls. Further, this function (emotional inability) does not differentiate the two patient groups, as it is evident from the plot that the centroids of the two patient groups are approximately on the same position.

144 Saxena, et al The classification results (Table-2) revealed that the two discriminant functions (emotional inability and emotional expression) correctly classified the original diabetes patients, CAD patients and the matched controls with 73.3%, 66.7% and 80% accuracy respectively. However, 13.3% of CAD patients healthymatched controls were misclassified as diabetes patients, 20% of diabetic patients and 6.7% of matched controls were misclassified as CAD patients and 6.7% of diabetic patients and 20% of CAD patients were misclassified as matched controls. Table 2 Classification Results of Discriminant Function Analysis To explore the disease specific affective profile the extent and direction of difference among the three groups in terms of the four affect related variables that defined the said discriminant functions was examined using one way analysis of variance followed by post-hoc comparisons. The mean scores of the three groups on the on various affect related variables along with the test of significance have been presented in Table-3. The findings of ANOVA revealed a significant difference among the three groups in terms of alexithymia [F(2,42) = 3.45,P<0.05], emotional intelligence [F(2,42) = 9.61,P<0.001], difficulties in expressing positive emotions [F(2,42) = 4.903,P<0.01] as well as belief about non-expression of emotions [F(2,42) = 3.36,P<0.05].

Differential affective profile of patients with diabetes and coronary artery disease 145 Table 3 Between Group Differences among Diabetes Patients, CAD Patients and the Matched Controls. It is evident from the Table-3 that the mean alexithymia score of patients with diabetes (mean = 57.00 ) and CAD (mean = 53.80) is greater than the mean score of matched controls (mean =46.33). The post hoc-comparison, however, revealed that difference in terms of alexithymia was found significant only between diabetics and the matched controls [ t (28) = 2.46, P<0.05]. The difference between CAD and matched controls was marginally significant [ t (28) = 1.83, P=0.07]. This pattern of findings suggests that alexithymia differentiate between the patients and health controls but not between the two patient groups. Both, patients with diabetes and CAD were found to be significantly more alexithymic as compared to normal controls. A reverse pattern was observed in terms of the level of emotional intelligence. The mean emotional intelligence of patients with diabetes (mean=96.60) and CAD (mean = 88.53) was considerable lower than that of the matched controls (mean=103.67). Post-hoc comparisotn revealed that both patient groups differed significantly [t (28) = 2.44, P<0.05] and there was a significant difference between CAD and the matched controls [t (28) = 1.86, P<0.05] but the diabetics and the matched controls didn’t differ significantly [ t (28) = 1.93, P>0.05] in terms of emotional intelligence. This finding implies that as compared to healthy individuals CAD patients are emotionally less intelligent but the same is not true for diabetes. The diabetics showed a level of emotional intelligence comparable to healthy individuals. Further, it also implies that as compared to CAD the diabetics are emotionally more intelligent. Putting it in other way, the patients with CAD were found to be emotionally less intelligent as compared to patients with diabetes. The comparison of the mean scores on difficulties in expressing positive emotions revealed that diabetes patients (mean = 42.47) scored higher than the CAD patients (mean = 37.80) who in turn scored higher that the matched controls (mean = 35.60). The posthoc between group comparisons revealed that on this affective domian a significant difference was found between the diabetes and the CAD patients [t (28) = 2.24, P<0.05] as well as between patients with diabetes and matched controls [t (28) = 2.68, P<0.02]. The CAD and

146 Saxena, et al matched controls did not differ significantly on this dimension. This pattern of mean difference implies that a difficulty in expressing positive emotion is important in differentiating patients with diabetes from patients with CAD as well as healthy controls. In other words, diabetes is characterized by difficulties in expressing positive emotions but the patients with CAD do not have such difficulties. A slightly different pattern was noted for beliefs about non-expression of emotions. The patients with diabetes (mean = 37.13) scored higher than the matched controls (35.33) who in turn scored higher than the CAD patients (mean = 32.27). However, the post hoc comparison revealed that the belief about non-expression of emotions is one such affective domain that differentiate the patients with diabetes with the CAD as indicated by a significant difference between these patient groups on this affective domain [t (28) = 2.54, P<0.05]. The difference between diabetics and healthy controls as well as that between CAD and controls was not found to be statistically significant. Thus, the findings imply that a strong belief about nonexpression of emotions is characteristics of the diabetics and not of the CAD. Taken together, the findings of the discriminant function analysis followed by ANOVA and post-hoc between group mean comparisons suggest that higher level of alexithymia (i.e., difficulty in identifying and describing feelings associated with externally oriented thinking) and poor emotional intelligence form a cluster of affective deficit (emotional inability) that differentiate both the patient groups from healthy individuals. On the other hand, difficulty in expressing positive emotions and a strong belief about non-expression of emotions form a profile of affective deficit that is characteristics of patients with diabetes and which differentiate them from CAD score lower on such affective domains. However, the observed lower level of emotional intelligence among CAD patients as compared to diabetics helps to define a more specific affective profile for differentiating the patients with diabetes from CAD. The affective profile that differentiates the two patient groups may, thus, be defined by emotional intelligence as well as emotional expression. The affective profile of patients with diabetes is defined by better emotional intelligence (as compared to CAD patients) but poor emotional expression- difficulty in expression of positive emotions and a strong belief to hold the expression of emotions in general. On the other hand, the affective profile of the patients with CAD is just opposite of the diabetics. Though, the patients with CAD have a lower level of emotional intelligence (as compared to the diabetic patients) but they do not hold a belief for non-expression of emotions in general and are better than the diabetics in expressing the positive emotions. The finding that patients with CAD are more expressive of emotions as compared to diabetics is corroborated by some earlier empirical evidences. For example, Kravvariti and Maridaki-Kassotaki (2010 ) found that patients with CAD seem to perceive themselves as less able to use and regulate their emotions than individuals without CAD and they also express negative emotions more frequently than those who do not have CAD. Similarly, a recent study of patients treated with percutaneous coronary intervention (PCI) shows that positive affect is an independent predictor of adverse clinical events, with increased positive affect exerting a strong protective effect (Denollet et al., 2008). Similarly, higher levels of alexithymia among the two patients group is also in accordance with several earlier observations (e.g., Abramson, McClleland etal.1991). Similarly, as discussed in the introduction section of this article a number of studies have demonstrated that both diabetics and the CAD patients show lower levels of emotional intelligence. However, what is innovative and the significant contribution of the present study is the observation that the CAD patients have even more low level of emotional intelligence as compared to diabetics but the CAD patients show better capacity and a belief for

Differential affective profile of patients with diabetes and coronary artery disease 147 expression of emotions in general and positive emotions in particular. Since decreased trait emotional intelligence and higher frequency of negative expressiveness have been found to be associated with CAD in the present study as well as in some earlier studies ( Evrydiki, et al, 2010), an active social life may be recommended for such patients to prevent the occurrence of CAD. Such recommendation is based on earlier observation that suppression of anger is associated with the increased risk of cardiac events (Denollet et al, 2010) and therefore the active social life accompanied by better interpersonal relationship may help to reduce such tendencies. The observation that both diabetics and the CAD patients have significant difficulty in identifying and expressing emotions (alexithymic tendency) and show a lower level of emotional intelligence as compared to their healthy counterparts is theoretically congruent with both the classical psychosomatic paradigm (Alexander, 1939) as well as the alexithymia paradigm (see Pandey, 1995; Taylor, 1984) of explaining psychosomatic disorders. However, the observation that despite better levels of emotional intelligence observed in diabetics they face difficulty in expressing positive emotions and hold a belief that emotions should not be expressed and shared rather kept to oneself need further explanation. Similarly, the observation that the CAD patients have a poor level of emotional intelligence (as compared to diabetics as well as healthy controls) but they are more expressive of their positive emotions and a belief towards sharing and expression of emotions in general also need to be further explored. This unique and paradoxical type of affective profile (paradoxical in the sense, that who are less emotionally intelligent are emotionally more expressive and who are emotionally less expressive are emotionally more intelligent) which differentiate diabetics from the CAD, however, may be interpreted in speculative termsFor instance, better emotional expression observed in the CAD patients having poor emotional intelligence may be a reflection of their tendency to use emotional expression (particularly of positive emotions) as a compensatory mechanism to camouflage their emotional deficits (higher level of alexithymia and poor emotional intelligence). This may also be a reflection of the psychosocial defence mechanism to protect against and neutralize the adverse effect of their emotional deficits. Similarly, the observation of emotional nonexpression among diabetics despite their better level of emotional intelligence may also be explained in speculative terms. For instance, because of their better emotional intelligence level the diabetics are expected to be better at estimating the consequences of social sharing and expression of emotions as well as better at regulating and controlling their emotions. As a result, it is likely that diabetics might have developed a tendency to over-regulate (control) their emotions which is reflected in the present observation that they hold a belief of emotional non-expression. Thus, the emotional nonexpression may be a deliberate attempt of the diabetics who are having the capacity to do so because of their better emotional intelligence level. The aforesaid explanations, however, suffer from the risk of overgeneralization and need to be tested in future research before accepting them. Conclusion: The findings of the present study suggest that though, psychosomatic disorders are often linked with emotions and emotional deficits, such emotional deficits or factors are not generalized rather disorder specifics. In the present study two specific psychosomatic disorders, viz., diabetes and CAD were found to be associated with specific types of emotional deficits. The patients with diabetes are characterized by relatively higher level of emotional intelligence but poor capacity for expression of positive emotions and a strong belief for non-expression and non-sharing of

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interest of researchers to explore modifiable psychosocial factors that promote optimal mental health and well-being of an individual. Researches on well-being have produced a plethora of scientific literatures on different correlates and mechanisms of overall health and well-being. But as far as the modern wellbeing research trend is concerned, researchers focus more on those correlates which can be modified and/or developed within an individual through practices and efforts. The construct of mindfulness is of great interest in this regard, because oriental meditation practices particularly Buddhism provides methods of cultivating it, which are now being adopted in the western research world also in order to elevate health and well-being. Mindfulness connotes non-judgmental and nonreactive acceptance of emotional states. According to Ellen Langer (1989), it refers to “a flexible state of mind, openness to novelty, a process of actively drawing novel distinctions.” It plays a big role in making human being free from automatic thoughts, habits and unhealthy behaviors and enhances self-regulated behavior which is related to enhancement of well-being (Ryan and Deci, 2001). The psychometric approach to study mindfulness as a trait has resulted in better operationalization and psychometric measures of the construct and one of the most widely studies and validated operationalization and measure of mindfulness and its mechanism has been given by Baer et al (2006). They proposed a five element structure of mindfulness namely observing, describing, acting with awareness, non-judgment of inner experiences and nonreactivity to inner experiences. Mental Health and Mindfulness: Mediational Role of Positive and Negative Affect Sachit Prasun Mandal, Yogesh Kumar Arya and Rakesh Pandey A consensus is emerging among the researchers that mindfulness is associated with better physical health and psychological well-being. The present study attempts to explore the posstible role of positive and negative affectivity in explaining the relationship between mindfulness and health. One hundred undergraduate and post-graduate students (52 male and 48 female) were assessed on selfreport measures of mindfulness, positive/negative affectivity and mental illness/distress. Analysis revealed that most of the dimensions of mindfulness as well as the total score of mindfulness were correlated positively with positive affect and negatively with different dimensions of mental illness/ distress and negative affect. Further, positive affect correlated significantly and negatively with the dimensions mental illness/distress whereas negative affect correlated positively with the same. Though, most of the dimensions of mindfulness correlated significantly with mental illness/distress as well as positive/negative affect, the findings of stepwise multiple regression analysis revealed that ‘acting with awareness’ dimension of mindfulness emerged as the best predictor of mental illness/distress. Further, in predicting negative affect ‘describe’ dimension of mindfulness emerged as best predictor followed by non-judgment of inner experiences. Positive affect was best predicted by ‘describe’ dimension of mindfulness followed by reactivity to inner experiences. To examine the mediational role of positive/negative affect in mindfulness-mental illness relationship a mediation analysis was carried out. Findings revealed that the negative affect and not the positive affect significantly mediated the relationship between mindfulness and mental illness/distress. The results have been discussed in the light of available empirical researches.

Mental Health and Mindfulness: Mediational role of Positive and Negative Affect 151 According to Baer and colleagues (2006), observing refers to flexible awareness over internal and external experiences, such as sensations, cognitions, emotions, sights, sounds, and smells. Describing refers to labeling internal experiences with words. Acting with awareness denotes doing activities of the present moment with being conscious of them. Non-judging of inner experience refers to the attitude of not evaluating the emotions and thoughts. Non-reactivity to inner experience is the tendency to take a detached position towards cognitive and affective experiences without getting involved in them and exerting any responses. ‘Based on the aforesaid operationalization of the construct of mindfulness and its various domains they developed the Five Facet Mindfulness Questionnaire (FFMQ) that has been widely used in the area of health research. The effectiveness of mindfulness in reducing negative health outcomes and a wide range of mental and physical health symptoms has been observed in serveral studies. For instance, Speca, et al. (2000) observed that a mindfulness-based stress reduction program on mood disturbance and symptoms of stress in Cancer patients resulted in reduced mood disturbances and stress symptoms in both male and female patients with a wide variety of cancer diagnoses. Similar effectiveness of mindfulness based stress reduction program in reducing symptoms associated with physical, psychosomatic and psychiatric disorders has been reported (Grossman, et al. 2004). Several other studies demonstrate that mindfulness trait as well as training programs have been found to be very successful in the reduction of symptoms related to chronic pain (Kabat-Zinn, 1982; Kabat-Zinn et al, 1985), generalized anxiety and panic disorders (Kabat-Zinn and Massion, 1992), fibromyalgia (Kaplan et al 1993), and cancer (Speca and Carlson, 2000). Apart from reduction of symptoms and distress, the mindfulness trait and related practices have also been found to be associated with positive mental health, positive affect and life satisfaction (Micheal and Graham, 2010). The foregoing studies, though, suggest that mindfulness as a trait as well as a practice is associated with better mental health and wellbeing, the exact mechanism through which it brings beneficial health effect is little known. Several potential mediating mechanisms may be put forward to explain the mindfulnesshealth relationship. For instance, it is likely that mindfulness increases positive affective experiences and also decreases negative affective experiences which in turn exert a long term beneficial effects on human health and well-being. Interestingly, existing literature follows this theoretical lining as mindfulness indeed positively relates with positive affect and negatively with negative affect. Brown and Ryan (2003) in an experience-sampling study found that mindfulness induces self-regulatory behaviors and frequent experiences of positive emotional states. Cherie and Dianne (2010) demonstrated that mindfulness increases positive affectivity and life satisfaction. Jacob, et al, (2004) conducted a survey on mindfulness, spirituality and subjective wellbeing and observed that mindfulness leads to pro-social values, decreases negative affective experiences, increases positive affective experiences and life satisfaction. The trait positive affect (PA) has been found to be related with low rates of stroke among non-institutionalized elderly (Ostir et al 2001), low rates of hospitalization for coronary problems (Middleton and Byrd, 1996), fewer injuries (Koivumaa-Honkanen et al., 2000) and improved pregnancy outcomes among women undergoing assisted fertilization (Klonoff- Cohen et al 2001). On the other hand, negative affect has been found to be inversely related with health and wellness. Numerous studies suggest that prevalence of negative affect leads to high greater levels of stress, depression, poor psychological health, well-being and low self-esteem (Cohen et al, 2003). It is evident from the review that mindfulness is associated with enhanced positive emotions and reduced negative emotions and greater positive and lower negative affect is linked with better health and well-being. This observation lends indirect support to our speculation that the beneficial health effect of mindfulness

152 Mandal, et al may be mediated by the positive/negative emotional experiences. However, there is dearth of literature in this area and most of the earlier studies on mindfulness-mental illness were conducted on clinical population that presents a lot of confound difficulty to control experimentally. The present study is a modest attempt to reexamines the mindfulness-mental illness/ distress relationship in general population using psychometric measure of mental health and explores the relative significance of various domains of mindfulness in predicting mental health. It will also explore the potential mediating role of positive/negative affectivity in mindfulness-mental health relationship. Method: Sample: The present study was conducted on a sample of 100 adult students belonging to different colleges and universities of the Varanasi city. They ranged from 20 to 33 years (mean age = 23.54 years and S.D= 2.84 years) and all of them belonged to middle class. It was an incidental sampling with almost equal number of both sexes (Males = 52, Females = 48). None had reported any history of chronic illness. Tools: The Hindi adaptation of Five Facet Mindfulness Questionnaire (FFMQ; Baer, et al., 2004) made by Mandal, Arya and Pandey, 2011 was used to assess the trait mindfulness of the participants. It consists of 39 items and assesses five facets of mindfulness viz., observing (8 items), describing (8 items), acting with awareness (8 items), non-judgment of inner experiences (8 items) and non-reactivity to inner experiences (7 items). It has demonstrated good internal consistency with alpha coefficients ranging from .75 to .91 and satisfactory validity of the factor structure (Baer et al., 2004). Positive and negative affectivity was assessed using the Hindi adaptation of Positive Negative Affect Schedule (PANAS; Watson, Clark and Tellegan, 1988) developed by Pandey and Srivastava (2008). It consists of 20 mood related adjectives (10 positive and 10 negative) that assesses two global dimensions of affect: positive and negative (Watson et al, 1988). Respondents are required to mark the level to which these moods were experienced by them during a specified period on a 5-point scale. The Hindi adaptation of the Ninety-item Revised Symptom Checklist (SCL-90-R; Derogatis, 1973) adopted by Dubey and Pandey (2011) was used to assess mental health and general level of mental distress. It is designed to evaluate a broad range of psychological problems and nine primary symptom dimensions viz., Somatization, Obsessive-compulsive, Interpersonal sensitivity, Depression, Anxiety, Hostility, Phobic anxiety, Paranoid ideation, Psychoticism and three global indices of distress. It also indicates three global indices viz: 1) Global Severity Index (GSI) (which reflects the average score of the 90 items of the questionnaire), 2) Positive Symptom Distress Index (PSDI) (refers to the mean score of the items scored above zero) and 3) Positive Symptoms Total (PST) (is simply the number of items scored above zero) (Derogatis, 1983). According to Holi (1999) “The global indices provide a means of communicating an individual’s pathology with a single number”. Procedure: The participants were contacted either individually or in small groups consisting of 3 to 4 persons and explained the purpose of study. After getting their consent of the participants the aforesaid questionnaires were administered as per the standard instructions of each questionnaire. All participants were requested to ensure that they have responded to each items of every questionnaire/scale. The obtained data were analysed by using bivariate correlation, stepwise regression analyses and mediation analysis. Results and Discussion: To examine the relationship of mindfulness with mental health bivariate correlations were computed and the obtained results have been displayed in Table 1.

Mental Health and Mindfulness: Mediational role of Positive and Negative Affect 153 Table1 Correlation of Various Dimensions of Mindfulness with Various Symptom Dimensions of SCL-90 R ** p < 0.01; ** p < 0.05 It is evident from Table 1 that mindfulness total score as well as all the dimensions of mindfulness except observing and nonreactivity to inner experience correlated negatively and significantly with all the symptom dimensions of mental health as assessed by the SCL-90-R. The observing dimension of mindfulness correlated positively to only two symptom dimensions viz., hostility and paranoid ideation and the non-reactivity to inner experience failed to correlate with any symptom dimension of mental health. Only two significant correlations (with mild effect size) obtained between observing dimension of mindfulness and nine dimensions of mental health suggest that the association of this dimension of mindfulness with mental health is statistically unreliable if family-wise type-I error is taken into account. In fact, this speculation is supported by its non-significant correlations observed with the various global indices of the SCL-90-R (Table 2). Table 2 Correlation of Different Dimensions of Mindfulness with Three Global Distress Indices ** p < 0.01 , * p < 0.05

154 Mandal, et al It is evident from Table 2 that a similar pattern of correlations was also obtained between various dimensions of mindfulness and three global indices of distress namely positive symptom total, positive distress index, global severity index. Again only the aforesaid 3 dimensions of mindfulness correlated significantly and negatively with the three global indices of mental distress and psychopathology and the two dimensions viz. observing and non-reactivity to inner experiences failed to correlate with any of the said indices. The observed pattern of correlation between mindfulness and mental health and general mental distress suggests that higher level of mindfulness trait is associated with fewer symptoms of various types of mental health problems as well as global mental distress. Further, it also suggests that though, total score of mindfulness correlated significantly with all the symptom dimensions of mental health and various global indices of psychopathology and mental distress, only three dimensions of mindfulness (Describing, Acting with awareness and Non-judgment of inner experience) significantly contribute to the observed association between mindfulness and mental health. However, as relative significance of various dimensions of mindfulness in predicting mental health cannot be determined by simple bivariate correlation, a series of stepwise regression analyses was conducted using different dimensions of mindfulness as predictors and various symptom dimensions of SCL 90 R as criterion variables. The result has been shown in Table 3. Table 3 Results of Step Wise Multiple Regression Analysis using Dimensions of Mindfulness as Predictor Variables and Symptom Dimensions of SCL 90 R as Criterion

Mental Health and Mindfulness: Mediational role of Positive and Negative Affect 155 The results revealed that acting with awareness emerged as the best predictor of all dimensions of mental illness except depression. It also emerged as the single best predictor of global mental distress or level of psychopathology. This dimension of mindfulness explained approximately 12.4% to 24.6% of the total variance of the various symptom domains of mental illness/distress. Depression was best predicted by describing and observing dimensions of mindfulness and these predictors explained 10.3 and 4.6 percent of the total variance in depression. The describing dimension of mindfulness was found to be the second best predictor of obsessive compulsive and phobic anxiety symptoms. The nonjudgment of inner experience was the second best predictor of paranoid ideation, positive symptom total and interpersonal sensitivity and the observing dimension of mindfulness was the second best predictor of symptoms of hostility and depression. Overall, the findings suggests that acting with awareness is such dimension of mindfulness that plays important role in ameliorating mental health and alleviating various symptoms of mental illness and global mental distress. However, for alleviation of symptoms of depression the describing and observing dimensions of mindfulness play a pivotal role. This finding corroborates the earlier observations that mindfulness is associated with reduction in the symptoms of psychopathology (Kingston, et al., 2007), mood disturbances and stress (Brown and Ryan, 2003). The relationship of mindfulness with positive and negative emotional experiences was also examined and the obtained pattern of correlation between the two constructs (Table 4) indicates that though, mindfulness total score correlated significantly and positively with positive affect and negatively with negative affect, not all dimensions of mindfulness correlate significantly with positive/negative affect. It is evident that describing, acting with awareness and non-judgment to inner experiences correlated significantly and negatively with negative affect. However, the positive affect was found to be positively correlated with only two dimensions of mindfulness- describing and non-reactivity to inner experiences. Table 4 Correlation of Various Dimensions of Mindfulness with Positive/Negative Affectivity ** p < 0.01 , * p < 0.05 Overall, the obtained pattern of correlation between mindfulness and its various dimensions on one hand and positive/negative affect on the other suggest that higher level of mindfulness trait is associated with reduced negative emotional experiences and enhanced positive experiences. However, in reduction of negativity and enhancement of positivity different aspects of mindfulness have been found to be significant. In reduction of negative emotions the same three dimensions of mindfulness (Describing, Acting with awareness, Non-judgment of inner experience) were found significant that were found to be important in reduction of symptoms of psychopathology and general mental distress. However, for enhancement of happiness and positive affect non-reactivity to inner experience was found significant in addition to the describing dimension of mindfulness. The present observation provide additional support to the earlier observations that selfreported mindfulness is positively related to positive affect and negatively related to negative affect and that mindfulness training leads to increase in positive affect as well

156 Mandal, et al as decrease in negative affect (Schroevers and Brandsma, 2010). The present findings point out the possibility that not all domains of mindfulness are equally important in predicting level of positive and negative affect. To test this speculation we conducted two sets of stepwise regression analyses using different dimensions of mindfulness as predictors and positive/negative affect as criterion variables. The results are shown in Table 5. Table 5 Results of Step wise Multiple Regression Analysis using Dimensions of Mindfulness as Predictor Variables and Positive/Negative Affect as Criterion It is evident from Table 5 that the describing dimension of mindfulness emerged as the best predictor of both positive and negative affect and accounts for around 16.6 and 20.8 percent of the total variance in these constructs, respectively. However, the second best predictor for positive affect was nonreactivity to inner experience and for negative affect it was non-judgment of inner experience. Thus, the findings imply that though, describing is such a dimension of mindfulness that is common to both enhancement of positive affect and reduction of negative affect, the nonjudgment of inner experience is a factor that helps in reduction of negative affect but not in the enhancement of positive affect. Similarly, non-reactivity to inner experience leads to enhancement of positive affect but it has not been found important in reducing negative affect. The finding that non-reactivity to inner experience leads to reduction in negative affect is theoretically congruent with conceptual definition of this dimension of mindfulness. This dimension of mindfulness reflects an individual’s ability to stay back and watch the emotions including the negative ones without reacting to them. Some example items of this dimensions are, “When I have distressing thoughts or images, I just notice them and let them go” and “When I have distressing thoughts or images, I feel calm soon after.” Thus, just noticing the negative emotions and letting it go or feeling calm soon after reflects such traits and behavior pattern that will gradually reduce the potential of negative events/thoughts to further generate negativity and thereby reducing the overall negative affect. On the other hand, the non-judgment of inner experience domain of mindfulness reflect such behavioral tendencies as to not to disapprove oneself in presence of irrational ideas, not evaluating one’s emotions or thoughts as bad. It is apparent from the description of this domain of mindfulness that it emphasizes acceptance of self and negative events and not giving a value judgment of ‘bad’ to such events and thoughts. Naturally, such tendency will enhance positive affect even in face of negative and/or adverse situations of the life. Further, the finding that describing dimension of mindfulness is associated with enhanced positive affect and reduced negative affect also appears to be theoretically congruent with description of this dimension of mindfulness. The describing domain of

Mental Health and Mindfulness: Mediational role of Positive and Negative Affect 157 mindfulness is defined by the ability to notice and verbally describe the emotions or putting the emotional experiences into words and thus it is not only likely to facilitate emotional catharsis but also social sharing of emotions. And a bulk of researches evidences available, which demonstrate that social sharing of emotions not only reduce negative emotions but may also enhance positive ones (Pandey and Choubey, 2010). The foregoing findings suggest that mindfulness and some of its dimensions do not only help to reduce symptoms of mental ill-health and general mental distress but it also help to reduce negative emotions in one’s life and to enhance the positive affects such as happiness and joy. However, before testing this mediated effect of mindfulness on mental health through positive/negative affect, it is essential to establish that a relationship exists between mental health and positive/negative affect. Thus, bivariate correlation was computed between the measures of positive/negative affect and mental health and the findings have been presented in Table 6. Table 6 Correlation of Dimensions and Mental Illness/Distress Indices of SCL-90 R with Positive/Negative Affectivity.

** p < 0.01 , * p < 0.05 It is evident from the table that positive affect correlated significantly and negatively with all the symptom domains of mental health (except hostility) and the negative affect correlated positively with various symptom domains of psychopathology. This pattern of correlation suggests that positive affect is associated with fewer symptoms of psychopathology and general mental distress whereas the negative affect is associated with more symptoms of psychopathology. This finding is congruent with the findings of various earlier studies (e.g., Gruber and Hu, 2008; Salovey and Birnbaum, 1989). Taken together, the preceding findings of the present study suggest that mindfulness is associated with fewer symptoms of mental illness and general mental distress as well as with a higher level of positive affective experience and lower level of negative affective experience. Further, it is also evident from the findings of the present study that higher level of positive affect is associated with fewer symptoms of psychopathology or mental illness and higher negative emotional experience is linked with more symptoms of mental illness and general mental distress. This pattern of relationship among mindfulness, mental health and positive/negative affect clearly support our speculation that the beneficial health effect of mindfulness is likely to be mediated by the resulting positive and negative affect. However, we have tried to empirically test this positive/ negative affect mediated relationship between mindfulness and mental health. The mediation analysis was conducted by running a series of hierarchical regression analyses using the SPSS script developed by Hayes (2009) the mediational effect of positive and negative affect was tested independently. For this analysis the total score on mindfulness questionnaire was considered as predictor and the global distress index SCL-90-R was taken as criterion variable. The mediated relationship of mindfulness and mental health via positive affect has been presented in Fig. 1 along with the path coefficients.

158 Mandal, et al Fig. 1: The meditational effect of positive affect on mindfulness-mental illness relationship It is evident from the above figure that the total effect of mindfulness on mental illness/distress represented by path C = -.0136 and the total effect of mindfulness on positive affect represented by path a= .1384. The effect of positive affect on Mental illness/distress represented by path b= –.0165. The dashed line (path C’) between mindfulness and mental illness/distress represents the direct effect of mindfulness on mental illness/distress. The direct effect is the effect of predictor on criterion after controlling the effects of mediator. Here it can be seen that the direct effect of mindfulness on mental illness/distress is C` = -.0113, which is smaller in magnitude than the total effect. Any mediator can be declared as a significant mediator only when the indirect effect of predictor through the mediating variable on criterion is found to be statistically significant. Indirect effect is the product of path coefficients a and b (.1384 and -.0165 respectively) which is -.0023. However, the conventional test of significance as well as the Sobel test both indicated that this indirect effect of mindfulness through positive affect is non-significant (P>.05). This finding suggests that positive affect does not mediate the relationship of mindfulness and mental illness/ distress. A similar test of mediational effect of negative affect on mindfulness – mental health relationship was also conducted. The path diagram and path coefficients of direct and total effects have been displayed in Fig. 2. Fig. 2.: The meditational effects of negative effect on mindfulness-mental illness relationship It is evident from Fig. 2 that the total effect of mindfulness on mental illness/distress (path coefficient C = -.0136) reduced substantially after controlling the indirect (mediated) effect of negative affect resulting in a nonsignificant direct effect of mindfulness on mental health (direct effect is represented by path C’ = -.0037). The product of the effect of mindfulness on negative affect (path a= -.2037) and effect of negative affect on mental illness/ distress (path b = .0486) was computed to determine the mediated (indirect) effect of mindfulness on mental illness/distress through negative affect. The indirect effect was found to be -.0099 which was statistically significant (z = -4.1844, p<.05, Confidence interval of Sobel test ranged from -.014 to -.005). The observed significant mediational effect of mindfulness through negative affect implies that mindfulness promotes mental health by reducing negative emotional experiences. Conclusion: The findings of the present study suggest that mindfulness in general and three of its components in particular (viz. verbally describing emotions, acting with awareness, and non-judgment of inner experience) are not only helpful in reducing the symptoms of mental illness and thereby promoting mental health but also in reducing the negative affect and enhancing positive emotional experience. The results also indicate that mindfulness exerts its beneficial mental health effect largely by reducing the negative affect and not by its positive emotion enhancing effect. Thus, it can be concluded that mindfulness alleviates symptoms of mental illness and distress by regulating the emotional balance of an individual. However, it will be premature to generalize such conclusions before rigorous experimental verification on larger group.in future. References: Baer, R. A., Smith, G. T., Hopkins, J., Krietemeyer, J. and Toney, L. (2006).Using self-report assessment methods

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FORTHCOMING BOOK Hand Book of Inkblot Technique: Rorschach, Holtzman and Somatic Inkblots Series (SIS) Bankey L. Dubey, Ph.D., Wilfred A.Cassell,M.D.,Amool R. Singh, Ph.D., Anand Dubey, B.E., MBA, FSIS. And Rakesh Pandey,Ph.D,FSIS

Foreword The authors have compiled a comprehensive, up-to-date handbook on inkblot tests as the most important projective techniques for assessing personality. Three inkblot tests are featured, the Rorschach, the Holtzman Inkblot Technique, and the Somatic Inkblot Series. A novel highlight in the Preface is the imaginary conversation between Wilfred Cassell and Hermann Rorschach, a fantasy that ends with “assurances” from Rorschach that the current direction of studies by mostly Indian psychologists under the authors’ guidance are worthy advances Rorschach would like. Part I in the book begins with an excellent, detailed history of Hermann Rorschach and his early experiments with inkblots in the diagnosis of mentally ill patients. The final set of ten inkblots has been used extensively throughout the world, resulting in thousands of publications that still continue to grow in number. Special attention is given to the administration and scoring of the Rorschach with special sections detailing with the systems developed by Klopfer and Exner. The Holtzman Inkblot Technique (HIT) is reviewed in detail, emphasizing its excellent psychometric qualities resulting from two parallel forms, each containing 45 rich, colorful inkblots selected from thousands of inkblots originally produced by Holtzman and his colleagues. Unlike the Rorschach with only 10 inkblots, the HIT has 22 scores for which the reliability and validity for personality assessment have been more easily determined. In addition to the HIT’s psychometric value when administered in a standard manner, a wealth of information is available on responses to each of the 90 inkblots from the original standardization on several thousand individuals. Special subsets of inkblots that elicit body image or sexual ideation can be assembled for experimental studies of a qualitative nature involving free associations much like those described in detail in the 31 case studies based mainly on the Rorschach and the Somatic Inkblot Series in Part II of this book. Future research involving the HIT inkblots will probably go in three directions: (1) computer-based testing and analysis using configural scoring for efficient, valid psychodiagnosis of mental disorders and personality, (2) special subsets of HIT inkblots for which two responses are requested rather than just one, and (3) qualitative use of selected subsets for free association and therapist-patient interaction much like the interesting and informative case studies presented in Chapter 11. The Somatic Inkblot Series I and II are reviewed in great detail that will be of special interest to western clinicians who have not had a chance to learn much about the test. Many of the most recent SIS studies have been published in the SIS Journal of Projective Psychology and Mental Health or in Indian journals, neither of which has had wide circulation in western countries, unfortunately. The SIS deserves much greater attention from clinicians and researchers everywhere, and this handbook will help to acquaint them with the attractive features and both research and clinical possibilities of the Somatic Inkblot Series I and II. I am greatly impressed by the extent to which psychology has matured in India during the past several decades, much of it under the leadership of Bankey Dubey and his colleagues in clinical psychology, with strong guidance from Wilfred Cassell. The current book is much overdue as a significant contribution to the study of personality, psychodiagnosis, and mental health. It certainly should stimulate new research throughout the world. Wayne H. Holtzman, PhD Hogg Professor Emeritus of Psychology Past President, Hogg Foundation for Mental Health The University of Texas, Austin

Book Summary Chapter one has emphasized the conceptual frame work and achievement of HERMANN RORSCHACH- Father of Inkblots testing. All the achievements what Hermann is credited was in very short period of 11 years. His untimely death created a vacuum which led many future Rorschachians to develop new scoring systems. Chapter Two describes the historical roots of the three major projective Inkblots measure: Rorschach, Holtzman and Somatic Inkblot Series. Chapter three reviews the theoretical postulates underlying these techniques in a fashion readily comprehensible regardless of the reader’s background. Chapter four presents the overview of extensive work on this projective procedure done in India. These should be of particular interest of international students and professionals in the field. The material is all encompassing involving normative data and applications in Industry. In addition with regard to clinical conditions information is both comprehensive in India and extending into international studies. Chapter five details the administration techniques historically based on the Rorschach system. This overview begins with the original work of Hermann Rorschach. Next it details the contributions of the recognized authority figure in the field: Bruno Klopfer, Samuel Beck and John Exner Jr. Chapter Six and Seven takes the readers further on the intellectual voyage to HIT and SIS technique. For professional in the field, the information provided is highly detailed. Moreover it is in a form that should be straight forward for most clinicians and researchers to apply. Chapter Eight expands on the previous information by providing quantitative indices to facilitate statistically based interpretation. Chapter 9 presents normative data on various Indian populations and as well illustrative groups related to specific diagnostic categories. Chapter 10 highlights the effectiveness of the reality based Color- Form- Movement visualizations as well as the projected images evoked by the Somatic Inkblots test for personality assessment during selection procedure in Indian Industry. Chapter 11 illustrates Rorschach and SIS Content Analysis. This illustration encompasses the assessment/ treatment using across a wide spectrum of clinical cases.

CONTENTS Foreword

Preface

10-22 Acknowledgments List of Tables

CHAPTER 1 : Hermann Rorschach an Introduction: 25-26 CHAPTER 2 : Historical Development of Inkblots Techniques: 27-39

History of Inkblot Procedure

Features of Inkblot Tests:

Rorschach

Holtzman Inkblot Test

Somatic Inkblot Series CHAPTER 3: Theoretical Postulates of Inkblot Tests: 40-50

The Theory of Percept Analysis:

Somatic Imagery Theory:

Theory of Body Symbolism:

The Inner Cry for Help: CHAPTER 4: Studies on Rorschach/ Holtzman and SIS in India: 51-83 CHAPTER 5: Administration and Scoring of Rorschach: 84-103

Administration

Scoring Systems in India:

Klopfer’s Method:

Beck’s Method:

Exner’s Method CHAPTER 6: Administration, Scoring and Interpretation of HIT: 104-112 CHAPTER 7: Administration and Scoring of Somatic Inkblot Series: 113-126

Definitions of Scoring Indices

Total number of Responses

Human Responses

Animal Responses

Anatomical Responses

Sex Responses

Movement Responses

Most Typical Responses

Typical Responses

Atypical Responses

Typical and Atypical Responses (SIS II A)

Typical and Atypical Responses (SIS II B)

Rejection of Images

Pathological Scales CHAPTER 8: Quantitative and Indices based Interpretation: 127-137

Klopfer’s Method

CHAPTER 9: Indian Norms and Diagnostic Indicators: 138-150

Indian Norms on Rorschach, SIS-I and SIS-II

Clinical Indices CHAPTER 10: Application of SIS in Business Organization: 151-154 CHAPTER 11: Interpretation: Clinical Applications of Content Analysis: 155-436

Case 1. Past Pain and Migraine.

Case 2. The Use of the Rorschach, SIS-I and SIS-II in Releasing Somatic Grief.

Case 3. Body Consciousness in Exhibitionism through Somatic Imagery.

Case 4. Desensitization Therapy for Body Image Anxiety.

Case 5. Unmasking the Devil with Projective Technique: Rorschach and SIS.

Case 6. The Adjunctive Use of SIS with Hypnotherapy (three Case studies).

Case 7. The SIS in Treating a Child with Panic Attacks during the Post-Divorce Period.

Case 8. A Case of Alopecia Areata.

Case 9. Rorschach and SIS in the Somatoform Disorders with Truth Serum Behavior Therapy.

Case 10. Inkblot Responses as an Aide to Therapy: Longitudinal Case Study.

Case 11. Therapeutic Dream Stimulation through Inkblots Imagery.

Case 12. SIS –I in a case of Obesity.

Case 13. SIS -II in a Case of Sex Abuse and Somatic Pain.

Case 14. SIS Living Images in a case of PTSD in Women.

Case 15. Symbolism in Violent Hallucination and Somatic Inkblots Imagery.

Case 16. Releasing Trauma of Repeated Miscarriage through SIS Imagery.

Case 17. SIS Detection of Invisible Imagery in Bipolar Affected Disorder

Case 18. Therapeutic Processing of PTSD (Road Accident).

Case 19. Intervention with Projective Procedures (SIS, Art and Sand Tray Psychotherapy).

Case 20. Optimizing Spiritual Healing by Assessing Dream and SIS Imagery.

Case 21. SIS Cognitive Psychotherapy for Spouse Induced PTSD.

Case 22. Cognitive-Behavior Therapy with the SIS in Body Phobia.

Case 23. Tracing the Roots of Violence by associating Dream and SIS Images: A Vicarious Visit to an Adolescent’s Birthday Party.

Case 24. Assessing Suicidal/Homicidal Impulses with the Somatic Inkblot Imagery.

Case 25. SIS Assessment of Somatic Conversion Symptoms.

Case 26. Infectious Suicidal Imagery in Combat PTSD.

Case 27. SIS Imagery in Depression with Somatization – Therapeutic Intervention.

Case 28. Dissociative Convulsion Disorder: A Case Study.

Case 29. SIS II-Video and Treatment of Alcoholism.

Case 30. Childhood PTSD Roots of Borderline Personality Disorder (EUPD) (ICU-10)

Case 31. Dissociative Convulsion Disorder: A Case Study.

Case 32. SIS Screening for Dangerous Impulses.

Case 33. Somatic Inkblots imagery in Transsexual: A Case study. CHAPTER 12: Bibliography: 437-471

What others say: The authors have compiled a comprehensive, up-to-date handbook on inkblot tests as the most important projective techniques for assessing personality. I am greatly impressed by the extent to which psychology has matured in India during the past several decades; the current book is much overdue as a significant contribution to the study of personality, psychodiagnosis, and mental health. It certainly should stimulate new research throughout the world. Wayne H. Holtzman, PhD Hogg Professor Emeritus of Psychology Past President, Hogg Foundation for Mental Health The University of Texas, Austin “Readers of the Handbook of Inkblot Technique: Rorschach, Holtzman and Somatic Inkblot Series will gain a meaningful classical perspective and understanding of the three clinical instruments of projective psychology that have benefitted many mental health and psychotherapy practitioners and clients.” Robert B. Williams, PhD, MA CPsychol CSci NCSP Dept. of Psychology, Crandall University,Box 6004 (333 Gorge Road) Moncton, NB, Canada E1C 9L7 Email: robert.williams@crandallu.ca The book is like a good workshop explaining the history, development and the progress in the field of projective techniques.It should be of great interest not only to the scholars, researchers & teachers of psychology but even more useful to clinical psychologists as well, due to its application in diagnosing and treating the patients.I believe the reader will find the Handbook as a valuable companion to the DSM-IV because of vignettes, easy to understand language and its clinical application to develop a road map for navigating thru the differential diagnosis and formulating treatment plans.Handbook’s conciseness and excellent organization and yet sufficiently broad in its coverage will have special appeal to the psychology students. This is the kind of textbook that will find a place on the clinicians’ desk rather than on a bookshelf. Greesh C. Sharma, Ph. D., Founder, Director & Clinical Psychologist Lower Bucks Institute of Behavior Modification, 699 W.Trenton Ave. Morrisville PA 19067. Email: Drgreesh@yahoo.com “For the authors Projective Psychology is not just a science and a theoretical framework for psychological assessment, but is always a way of live, a true philosophy and a mean to and end: to know and reach the most in-depth self. Responses to inkblot projective methods can in fact be seen ‘as a mirror of inner world’. These methods are solid and well validated forms of assessment. A useful tool for clinicians and researchers, this book presents historical, theoretical, empirical and clinical information about the three inkblot projective methods, Rorschach, Holtzman Inkblot Technique and Somatic Inkblot Series. Let the deepest memories, fantasies and feelings emerge, of our patients and clients, as well as our own…” Rui C. Campos, Ph.D., Professor of Psychological Assessment, University of Évora, Portugal. “This book gives me an excellent overview of three important projective psychological techniques and their theoretical backgrounds. As an European psychologist I gladly learn about the SIS, originated in USA and

widely used in India. I found it helpful to have a comparison of the SIS with the other two methods, all this in a single book. Correspondingly, I warmly recommend the book not only to researchers and professionals in India, but to psychologists internationally. So the book also contributes to for common concept system between clinicians. – I have listened to Dr. Professor Dubey on several congresses in the U.S.A. and India, and I am sure that his presence as one of the authors of this book is a guarantee of its high quality. Ailo Uhinki, PhD, Finland” Psykologitoimisto, Synteesi,Linnankatu-37a A 9, Fin-20100 Turku, Finland, EMail: a.uhinki@synteesi.inet.fi The authors of this manual must be congratulated for the production of a manual of the Somatic Inkblot Series all be it that this book is long overdue. The handbook of Inkblot Technique is one of those manuals every clinician should have on their bookshelf. It covers the area of projective testing in a very comprehensive, clear crisp and readable way. One of the most valuable sections of the manual is the one that deals with the administration, scoring and interpretation of the Somatic Inkblot Series (SIS). This section is dealt with in great detail yet so easily to understand that any clinician with just a rudimentary knowledge of the use of projective tests will be able to administer, score and interpret the series with great confidence. As an adjunct to therapy this tool is second to none. Every therapist knows the frustration when they are confronted with a block of information knowing that there is something somewhere in the client’s mind but being unable to tap it. This is where this manual comes into its own giving the therapist all the skills and methodology to deal with just that kind of situation. This manual and series can be recommended with the greatest of confidence. George Savage. M.Sc. (Clini. Psycho.), D.Tech (Edu). Clinical Psychologist in Private Practice. 8 Schoon Street, Ladysmith. 3370 South Africa E-Mail : gsav@worldonline.co.za This is one of the few books that examines and evaluates in great detail three major associative projective techniques. For this reason, it can be considered as a valuable contribution to the field of psychological assessment, and in particular projective assessment. More particularly, it presents the reader with extensive information on the theoretical and historical background the administration, scoring and evaluation principles of the Rorschach, the Holtzman and the Somatic Inkblot Series instruments. Evaluation is enriched by numerous examples of clinical cases. A particularly interesting feature of the book is the application of the Holtzman and the SIS in India. The uniqueness of the Indian culture, affects the personality and the psychopathology of its people in such a way that makes the application of projective techniques particularly useful and offers the opportunity for interesting cross-cultural comparisons. Carina Coulacoglou, Ph. D. Director Fairy Tale Test Psychologist, University of La Verne,40E, Esperou Str. Kifissia, Athens 14561 (Greece), E-mail : carina@fairytaletest.com A compendium, I shall recommend it to everyone who is involved in teaching, research and application of inkblot techniques. It should stimulate more and more application of inkblot techniques in pinpointing underlying issues and their effective handling in psychotherapy. Rakesh Kumar, Ph. D. Co-ordinator, Dept. of Clinical Psychology, Institute of Mental Health and Hospital, Agra (India) Email: jain.imhh@gmail.com

About Authors Bankey L. Dubey, Ph.D. Bankey L. Dubey is a clinical psychologist and Management consultant. He completed his Ph.D. in 1978 on the Rorschach test and had undergone 2 years internship in clinical psychology. He has also done Post Graduate Diploma in Personnel Management. He was trained by Dr. Wilfred Cassell in the application of Somatic Inkblot Series at SIS Center, Anchorage (USA) He has been the Editor in Chief of the SIS Journal of Projective Psychology and Mental Health from 1994-2006 and continuing as Editor Emeritus since 2006. He is President of the Somatic Inkblot Society from 2008-todate. He is also heading the SIS Internet Therapy Division. He has been the President of Clinical Psychology for the year 1984 and 1985. Dr. Dubey has published 3 books and about 160 research papers. He has received 5 awards for best research papers in the USA for the years 1991, 1992, 1993, 1996 and 2000. He started his career as Clinical Psychologist in T.N. Medical College Bombay in 1969 and served Ministry of Defense (Command Hospital Chandigarh) for 8 years before shifting to Panjab University, Chandigarh in 1980 from where he retired as Professor of Psychology in 2005. He is associated with the Dept of Psychology, University of Alaska, Anchorage as Adjunct Faculty and teaches Personality Psychology. He has been the visiting faculty in Post Graduate Medical Institute and Research, Chandigarh for 15 years. He helps people in understanding the personality through SIS tests and practices hypnotic relaxation therapy. SIS is the major therapeutic tools which he uses during relaxation therapy. He is widely travelled and conducted workshops in various international meetings in Anchorage,AK, New London CT, Boston, MA., San Francisco, CA., Columbia, SC., Geneva, Amsterdam, Brussels, Madrid, Singapore, Sydney, Hobart, Philadelphia, Chicago and several cities in India. Wilfred A. Cassell, M.D. Like Hermann Rorschach,Wilfred Cassell was impressed with the phenomenon of projective testing, that innermost thoughts and feelings can be accessed by ambiguous and semi-ambiguous inkblots. He studied under Dr. Seymour Fisher, an international authority on somatic technique. Dr. Cassell has devoted about forty years to the development of the somatic inkblot series (SIS). During this time he has personally administered the series, exploring firsthand its usefulness and potential and improving its scope and depth. His mentor Seymour Fisher described the Series as “maximizing the projection of body imagery in general and also feelings about specific sectors to one’s body.” The late Walter G. Klopfer, renowned Roschach expert, considered it “worthwhile to add to the techniques currently in the marketplace” and its manual “full of clinical wisdom” and “a summary of much valuable theoretical and practical value.” Wayne Holtzman, Ph.D., developer of the Holtzman Inkblot Series (Holtzman et al, 1956), had this to say about Dr. Cassell’s new procedure: “Dr. Cassell takes full advantage of new video technology in developing his interesting inkblot technique, the Somatic Inkblot Series. Considerable effort and artistic talent has gone into the development of this method which clearly deserves further research. In the hands of an experienced clinician, particularly after receiving competent

training and supervision from Dr. Cassell or one of his colleagues, the Somatic Inkblot Series is a most welcome new projective technique for the assessment of personality and psychopathology. Unlike many other methods, it is particularly appealing when used by the clinician and subject as an interactive, interpretive mode as a part of the total diagnostic and treatment process. The dynamic nature of the stimulus, when presented by video in full color reaches well beyond the limitations of traditional projective techniques. Amool R.Singh, P.D. Professor Amool R. Singh is the Director of Ranchi Institute of Neuro-Psychiatry and Allied Sciences (RINPAS), Ranchi (India) and heading the Departments of Clinical Psychology and Psychiatric Social Work. He started his career as Clinical Psychologist in VIMHANS, New Delhi in 1990 and shifted to RINPAS in the year 1997. RINPAS is a large 500 beds mental hospital with facilities of Doctoral and Post Graduate program in the areas of Clinical Psychology, Psychiatry and Psychiatric Social Work. Prof. Singh has completed his Ph.D. in 1991 and had undergone 2 years internship in clinical psychology. He was trained by Maj.Gen. K. R. Banerjee, in the application of hypnosis and psychotherapy to psychiatric patients, substance and alcohol dependents. . He had also undergone advance training in the application of Somatic Inkblot Series, Content Analysis and Hypnotic Relaxation under the guidance of Prof. B. L. Dubey. Dr. Singh was honored by best paper research award from SIS Center, Anchorage, Alaska (USA) in the year 2008. He is the Editor-in-chief of the SIS Journal of Projective Psychology and Mental Health since 2006 and had been the Editor of Indian Journal of Clinical Psychology for 4 years (2002-2006). Dr. Singh is also Consulting Editor of the Contemporary Who’s Who, American Biographic Institute, USA. Dr. Singh has published about 125 research papers in National and International Journals. He is Member of various National Committees on Health, Education and Research. Anand Dubey, BE, MBA. Anand Dubey is an experience business leader & entrepreneur. He started his career in the field of technology & engineering in 1994. At present he is the Director of Enterprise Technology Services, State of Alaska (USA) and his prime interest is service management in the field of technology services and development of the human potential of the people, process and technology trade. He has been working with SIS since 1990 and currently provides direction to the marketing SIS products and technology support for SIS research. He helped in preparing the “Somatic Inkblot Series-II/Video Manual” in 1997 and book “Interpreting Inner World through Somatic Imagery” in 2003. He is Editor of the SIS Journal of Projective Psychology and Mental Health since 1994. He completed his MBA in telecommunication in 2000 and had undergone advance training in the application of Somatic Inkblot Series. He has developed different software programs for the application of SIS in Business organization and made SIS System popular internationally. He has been the coauthors with Dr Wilfred A .Cassell and Dr.B.L.Dubey on SIS publications.

Rakesh Pandey, Ph.D. FSIS, Rakesh Pandey is Professor in the Dept of Psychology, Banaras Hindu University, Varanasi. Presently he is the coordinator of the UGC-SAP-DRS-I, Department of Psychology, Banaras Hindu University and the former founder coordinator of PG Diploma in Counselling and Psychotherapy. He completed his Ph.D. in Psychology in 1993 on Alexithymia from BHU. He is trained in Meditation and Indian Yoga system. He was trained by Dr. Wilfred Cassell and Dr. B. L. Dubey in the application of Somatic Inkblot Series. He is Executive Editor of SIS Journal of Projective Psychology and Mental Health. He is also the Editor in Chief of Indian Journal of Scocial Science Researches. Dr. Pandey has published numerous research papers in national and international journals of repute and contributed chapters to several books. He has also published/developed several psychometric tests that have been widely used by Indian researchers. He has made extensive efforts, in collaboration with international researchers, to adapt several Western psychological tests and scales for Hindi speaking Indians. His current focus of research is to understand the psychological dynamics of human health. His research team is focusing on role of such affect related traits and abilities as emotional intelligence, emotion regulation, alexithymia, emotional processing, affect intensity, positive/negative affect and other affect related traits and beliefs in understanding human health. Dr. Pandey is a recipient of the Young Scientist Award of the Indian Academy of Applied Psychology and the SIS Award. The expertise of Dr. Pandey has been utilized by several National level organizations such as NCERT, New Delhi and the National Testing Services, CIIL, Mysore. Dr. Pandey started his career as Lecturer in Bihar Yoga Bharti in 1997 where he practiced Yoga , meditation, Hypnosis and Relaxation along with teaching yoga Psychology to Graduate and Postgraduate students. Later he moved to Department of psychology, DDU Gorakhpur University, Gorakhpur as lecturer in 1998. After serving for around five years he was appointed as Reader in the Department of Psychology, M.G. Kashi Vidyapith in the year 2003 and after three years in the year 2006 he joined Banaras Hindu University as Reader and promoted to the position of Professor in 2009. His area of teaching interest includes Personality assessment, Research Methodology, Statistical Analysis and Projective Psychology and Clinical Psychology. He helps students in learning the therapeutic interventions and hypnotic relaxation.

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 38 issues in 19 years. The Journal is available on Society’s Web Site at http: //www.somaticinkblots.com The Journal from Volume 1-19 is available in C D(Acrobat ) 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, DM&SP, Editor Emeritus, SIS J. of Proj. Psy. & Mental Health, E-mail : bldubey@gmail.com Web Site at http: //www.somaticinkblots.com OR Prof. Amool R. Singh, Ph.D.,DM & SP, Director, RINPAS, Ranchi, Editor in Chief, SIS J. of Proj. Psy. & Mental Health, Email:sisamool@yahoo.com OR Rakesh Pandey, Ph.D.,FSIS, Prof. Dept of Psychology, BHU, Varanasi Editor, SIS J. of Proj. Psy. & Mental Health E-Mail: rpan_in@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 : ______________________________________________________________ E-mail________________________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 Varanasi. 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. 2,500/- Institutional Membership Rs. 1000/- Institutional Life Membership Rs. 10,000/- Total Cheque $/Rs.________________________ Drawn at_________________ Signature of applicant : __________________________ Date : ________________ PLEASE RETURN with your cheque to : Dr. Rakesh Pandey, Ph.D., Professor, Dept. of Psychology, B.H.U., Varanasi-221 005. 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 throughout station cheque.

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-34006. 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 Gautam Printers, Jagatganj, Varanasi, M. 09415201718 Editor-in-Chief : Amool Ranjan Singh