SIS Journal of Projective Psychology & Mental Health

ISSN 0971-6610 SIS Journal of Projective Psychology & Mental Health Volume 20 Number 1 January, 2013 Official Publication of the Somatic Inkblot Society Editorial: SIS Psychotherapeutic Applications Wilfred A Cassell 1-2 Perceiving One's Own Dead Body and Death Anxiety Dissolving SIS Spiritual Symbols Wilfred A. Cassell, Bankey L. Dubey, Tyrone Charlesand, Padma Dwivedi 3-17 Integrated Intervention in Psychiatry of Urgency: The Role of the Projective Space in the Psychotherapeutic Interview S. Daini, B. Grasso and L. Bernardini 18-35 Effect of Psychotherapy in Phobic Patients and Their Follow-up M. G. Sharma, Vandana Sharma and Awadhesh Upadhyay 36-41 Unravelling the Roots of Personality Disorganization through Psychodynamic Lens: A Case Study Somdeb Mitra, Saugata Basu and Nilanjana Sanyal 42-48 SIS Guided Therapy for an Adolescent Girl's Tension Headaches Wilfred A. Cassell, Preeti Pandey, Ajay Tiwari, Nalini Mishra and B. L .Dubey 49-54 Effect of Therapeutic Intervention in a Case of Schizophrenia Through SIS-II and Rorschach Daniel Saldanha, Preethi Menon, Sameer Guliani, Vivek Goyal, Madhav Garg, Abhinav Tewari and Madalsa Agrawal 55-61 Consistency of Response Pattern on Rorschach after an Interval of 14 Years : A Case Report L.S.S. Manickam 62-67 Dichotic Listening Asynimetry : A Potential Neuro-behavioural Marker of Depression Rakesh Pandey and I. L. Singh 68-73

Somatic Inkblot Society OFFICE BEARERS President : B. L. Dubey (USA) Vice President : Brig. D.Saldanha (India) Gen. Secretary : Nalini Mishra, Ph.D. Joint Secretary : Akanksha Dubey, Ph.D. Treasurer : Padma Dwivedi (USA) Executive Members : Anand Dubey, MBA, Editor Wilfred A. Cassell (USA) Mary Cassell (USA) Satchit Mandal, M.A. Tilottama Mukherjee, Ph.D. Preeti Pandey, M.A. Ajay Tiwari, Ph.D. Shambhu Upadhyay, Ph.D. Pragya Tiwari, MBA (President Nominee) MIke Baker, MBA (President Nominee) SIS SIS JOURNAL OF PROJECTIVE PSYCHOLOGY AND MENTAL HEALTH is an International refereed journal and published twice a year (January & July) by the SOMATIC INKBLOT SOCIETY and is devoted to the advancement of research in the areas of projective psychology, personality assessment, psychotherapy and mental health. The journal is broadly concerned with the development of inkblot tests and personality assessment in clinical, counseling, cross cultural, organizational and health psychology settings. It aims to reach clinical psychologists, psychotherapists, psychiatrists, social workers, medical professionals and professional managers interested in the understanding and modification of human behavior. The journal includes (a) research articles (b) book reviews (c) brief reports (d) news about conferences and letters to the editor. MANUSCRIPTS PREPARATION : Manuscripts should be typewritten (single-spaced throughout) submitted through E-mail to B.L. Dubey. Ph.D. Editor Emeritus, E- mail:bldubey@gmail.com with a copy to Rakesh Pandey, Ph.D. Editor-in-Chief, & Prof. Dept of Psychology, BHU, Varanasi-221005 Email: rpan_in@yahoo.com.Cell: 91-9415812329. The Editors reserve the right to refuse manuscript submitted and to make minor additions / deletions. Authors should prepare their manuscripts according to the Journal of Personality Assessment / SIS Journal of Projective Psychology & Mental Health. SUBSCRIPTION: The journal is free to members of the Society, Annual membership fees are US $50 for foreign members and Rs. 300, for Indian members, Institutional subscriptions are US $100. for Foreign institutions and Rs. 1000 for Indian institutions. Life membership is US $400 for foreign members and Rs. 2500/- for Indian members. Indian institutional life membership is Rs. 10,000/-. Non-members may subscribe for $60 or Rs. 250 per issue. Cheques should be made payable to "SIS Journal of Projective Psychology and Mental Health" at Varanasi and should reach Rakesh Pandey, Ph.D., Professor, Department of Psychology, Banaras Hindu University, Varanasi- 221005. Members in foreign countries should send the cheque to B.L. Dubey, Ph.D. Editor Emeritus, 4406 Forest Road, Anchorage, AK- 99517 (USA) Please add $10IRs.501- if you are sending subscription through cheque. CHANGE OF ADDRESS: Members should inform BL. Dubey, Ph.D, Director SIS Centre, Email: bldubey@gmail.com of any change of mailing address. Copyright@1994.SISCenter , lndia/Anchorage Website: http://www.somaticinkblots.com ONLINE TESTING: http://psyche.dubay.bz http://122,160.96,85:1001/SISTest

Editorial SIS Psychotherapeutic Applications I invite readers to consider the 21st century human's precarious state and our transient existence on the planet earth. Visualize our planet's journey, spinning in the vast Cosmos prior to the anticipated annihilation the sun. Recall that the earth, the fragile human body pulsates in a time limited fashion. All SIS professionals need to carefully plan and prioritize the relative importance of future projects. Because my wife, Mary, continues to suffer the consequences of her aortic dissection and stroke suffered years ago in India, I cannot be with you physically. Yet, please understand that I am with you in a supportive spiritual fashion. Since I am now 78 years old, many of my colleagues have died. Their loss reminds me of my own mortality. Our society now needs more objective evidence documenting the therapeutic efficacy of SIS technology. I respectfully request that all so motivated SIS society members envision futuristic statistically controlled clinical therapeutic trials. In order to more deeply consider this challenge, I now invite you to take a few moments for SIS image guided Yoga meditation. For trance induction, activate your most effective personal subjective steps for body-mind-spirit relaxation. Then imagine what your spiritual soul is currently experiencing within your pulsating body. Focus on the professional goals that you have with specific reference to SIS research and clinical applications that you may have completed. For psychic time travel, imagine the morbid symbolism of your body's demise by conjuring up an image of death symbolized in SIS-II B22. Recall that this portrays your soul exciting your dying body. If you have previously benefited from the use of culture sanctioned spiritual symbols associated with your religion, enrich the meditation by recalling these from memory neural records in your brain's visual cortex. Concurrently bring into cognitive consideration what you hope to accomplish both personally and professionally prior to that ultimate fate. Consider repeating this near death psychic voyage on days that you have set aside for religious activities. To further enrich this subjective mystical journey, occasionally repeat this meditation exercise at bedtime. Use as dream programming visual input, either the Booklet version of B22 or the more powerful video/computer monitor electronic selfadministered systems. Such supplemental exercise should provide a much stronger subjective modality for futuristic SIS planning. Since even professionals trained in dream interpretation are, because of their own mental defense mechanisms, necessarily partially blind to the symbolic significance of their own sleep imagery/affect, consider consulting colleagues trained in SIS evoked dream stimulation. Through internet communication I would be pleased to assist members of our SIS society in this regard (siscassell2@ yahoo.com). At the present stage of scientific knowledge, clinical investigators need more statistical research data concerning differentiating "Placebo" effects of treatment for the various Mental Disorders, from truly efficacious modalities. Internationally, there currently appear to be two opposing viewpoints. One school of thought contends that "Medications are more effective than psychological treatment". Those in the opposite camp argue that "Psychological treatments such as Cognitive Behavioral Therapy are just as effective, but unlike pharmacotherapy, have long lasting effects, some of which may prevent recurring illness. What seems to be most fascinating conceptual background is that thanks to research using neuroimaging techniques, such as positron emission tomography (PET), single-photo emission computerized tomography (SPECT) and functional MRI indicate that both psychotherapy and medication change the brain. My personal bias regarding treatment is traceable to my 1960's psychiatric research in Canada's providence of Saskatchewan. Then because of socialized medicine government funded computer based total population medical/psychiatric care utilization statistics, supplemented by community surveys of psychiatric morbidity,

meaningful epidemiological studies were possible. These suggested that consideration of socioeconomic conditions regarding prevention and early detection of preventable conditions was the most humane and cost effective approach for government funding. After preliminary case history diagnostic work I realized that the SIS could aide in such endeavors. Now years later, I challenge members of our society to scientifically study the potential efficacy of SIS technology as an aide to therapy! 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

hallucinated seeing his own dead body in a mass grave along with those of deceased loved ones. The unique case enables the reader to graphically understand the clinical concomitants of severe Death Anxiety. In addition, it demonstrates the healing power of spiritual symbols. "This is the paradox: man is out of nature and hopelessly in it; he is dual, up in the stars and yet housed in a heart-pumping, breath-gasping body that once belonged to a fish and still carries the gill marks to prove it. His body is a material fleshy casing that is alien to him in many ways- the strongest and most repugnant way being that it aches and bleeds and will decay and die. Man is literally split in two: he has an awareness of his own splendid uniqueness in that he sticks out of nature with a towering majesty and yet he goes back into the ground a few feet in order blindly and dumbly to rot and disappear forever. It is a terrifying dilemma to be in and to have to live with" According to the cultural anthropologist Ernest Becker in his Pulitzer Prize winning book entitled "Denial of Death" (Becker, E., 1997), there is a universal tendency for ego based defense mental systems, when so threatened, to trigger the psychological mechanism of Denial. Throughout human history, various cultures have created religious rituals/symbols in response to this ultimate, unavoidable fate. Many religious people believe that "Death Anxiety" is a universal affective response, when individuals philosophically contemplate the existence of the soul within a body destined to die. Many theoretical views on the clinical relevance of this fate were outlined in the book "Body Symbolism" (Cassell, W.A., 1980). Later the Medical, Psychological and Spiritual Applications of the SIS were reviewed in the July 1997 is of this journal (Cassell, et al, 1997). This has proven to be a central theme over the subsequent years (Cassell, 1979, 2005; Cassell et al, 1999, 2002; Cassell and Dubey, 2003). Historically, intense philosophical conflict between ancient cultural groups has provided various rationalizations for war. The nickname for modern mental health practitioners "Shrinks" arose from the role of "Medicine Men" as magical healers in primitive societies. Victors sometimes shrunk the heads of their defeated enemies for future symbolic use in ritualistic spiritual ceremonies. Religious dogma, seemingly rational to believers in one group, but appearing irrational to another group's religious belief, continues into the modern world sowing seeds of warfare. When planted on the soil of divergent economic interests, in our biological-chemical -nuclear weapon age, these threaten all life on our planet. Scientists have only begun to penetrate the intellectually opaque veil surrounding the symbols and sacred rituals of organized religion for dissolving Death Anxiety. Apart from unmasking the negative aspects of religious dogma conflict, this highly complex field of enquiry now warrants exploration for medical reasons. A modern scientific literature has begun to statistically document the positive health benefits of certain measureable religious activities. In this issue's editorial, Somatic Inkblot Series (SIS) based imagery techniques were outlined. These enable the Yoga practitioner to conjure up in body-mind-spiritual awareness soul futuristic trips (Cassell, 2011). By practicing such travel to the imaginary destination of Death, under conditions of low psychophysiological arousal-anxiety, the voyager can, with less cognitive numbing anxiety, philosophically reexamine basic life

goals. In this article, another practical SIS application will be outlined relevant to the therapeutic management of Mental Disorders. Clinical case history data will be presented to illustrate how the (SIS) projective power can stimulate long standing, seemingly indelible, combat induced memories linked with intense Death Anxiety. This study symbolically examines long term traumatic memories of an American soldier of Korean ancestry suffering from Vietnam War induced combat Posttraumatic Stress Disorder (PTSD) and concurrent Chronic Recurrent Major Depression. Like many such soldiers during combat, as an occupational injury, his brain's visual memory system had become saturated with scenes of Death. This flooding of consciousness was extreme during viewing a grave estimated to be full of 400 or more Asian bodies. The stressful imagery caused him to visualize in the grave, his own dead body, as well as bodies of long deceased loved ones. Most modern diagnosticians would label this apparent break with reality a psychotic phenomenon. Those with a religious orientation might consider possibly in addition, his vision as a transient mystical voyage into the spiritual "Afterlife". In the western countries, most such combat veterans are treated with psychopharmacological medications supplemented by psychotherapy. Yet often, in spite of such therapeutic trials, the suffering may persist for years. Moreover many avoid emotionally painful counseling, and selfmedicate with alcohol or drugs. More ominously, significant numbers in America act on suicidal impulses. A few act out homicidal rage through "Copycat murders. Fortunately a few research centers are exploring innovative therapies. "Exposure therapy" is one promising example. Essentially this involves professionally supervised sessions analogous to those constructed in Psychodrama therapy. These establish affect controlled exposure to environmental stimuli designed to recapitulate the specific stressful combat events. It is suggested, that projective memory evoking SIS stimuli can operate in an analogous fashion. The inkblot stimuli can bring into conscious awareness or "Expose" the victim, throwing therapeutic light on the underlying symbolism, inherent in recurrent PTSD visual "Flashbacks", and dreams (Cassell et al, 2001, 2010, 2012). Moreover, with the electronic versions of the SIS, the hypnotic like floral stimuli and relaxing nature scenes can simultaneously, in a deconditioning fashion "Desensitize" the linked dysphoric affect. All such conceptual models warrant therapeutic trials since such traumatic combat events are recorded in the brain more indelibly embedded, than less stressful situations. As indicated, the illustrative case involved an elderly American veteran, of Korean genetic descent. He was never under treatment with any of the authors. In 2011, Wilfred A. Cassell and his wife Mary, met the veteran and his Caucasian wife at dinner in an American retirement residence. Prior to dining, the he prayed a Christian prayer indicating that both he and his wife were deeply devoted to Christianity. After learning that Wilfred Cassell was a psychiatrist, he spontaneously spoke about his stressful experiences related to death during Vietnam War combat. Eventually he reported that his PTSD symptoms had become dramatically reduced after his 1980 religious conversion to Christianity, and his Christian wife concurred. Afterwards, it seemed that assessing the healing impact of his dramatic spiritual change might provide a useful SIS educational program. When asked, he agreed to have a recorded educational SIS interview the following day. The SIS structured interview utilized visual stimuli from the SIS-II Booklet. The training transcript follows: Dr: Can you tell me what you see there please? (A1) JR: What I see there, are two things…the shape of the pelvic area…I also see the shape of the Ram's head…that is one of the Satanic symbols I believe… the Ram's head…it also looks like x-rays of someone's insides. (The order of his associations may be interpreted to reflect a three step mental mechanism response pattern: 4 Cassell et al

Step one: What first entered projective awareness was imagery with reference to the human body, specifically the pelvis. This focus of attention might be considered within normal content limits. However, immediately afterwards he associated the SIS stimulus with long standing PTSD memories of combat violence, suffering and death. Step two: Perhaps this step may be more graphically explained, if the defense mechanisms are conceptually portrayed by the psychological mechanism of Personification. Imagine that regions of his brain were talking to each other, out of his range of hearing and awareness. Such is observed clinically with the Dissociative Disorders (e.g. "Multiple Personality Disorder". To protect him from consciously recalling threatening Death related "Evil" content related to Combat PTSD imagery/affect, consider that an imaginary inner world neural "voice" called out an alarm from a SIS symbolic recognition brain center saying: "Bring on the visual defensive spiritual symbols!" Then postulate that neurochemical electronic impulses loaded with codified signals denoting combat memories transmitted the signals through the optic nerves to the central nervous system. Next postulate that the resultant content was cognitively assessed as threatening. It was then linked with dysphoric affect traceable to old PTSD memory centers recording the original combat stressors. In Vietnam these ha triggered perceptional inhibition, transient amnesia, and autonomic nervous system based vasomotor shock (i.e. Fainting). Many years later, in viewing the first SIS-II inkblot stimulus, these former indelible processes were reactivated. This resulted in a negative spiritual connotation being linked to the stimulus assessed as "Satanic". The symbolism reflected his moral Christian religious evaluation of the evil aspects of his long standing war induced inner rage. Step Three: The third response immediately returned to internal body imagery. This association was related to his persistent long term traumatic memories of bodies mutilated by war related events. It immediately enabled the interviewer to question him more specifically regarding his seemingly indelible memories of combat stressors. Moreover, as will be shown, when the SIS is used primarily to structure an interview for recollection purposes, often only a few key releasing "inkblots" need to be administered. Dr: In the war did you see many people cut up and all that? JR: Yes sir, I did. Dr: How did you feel about that? JR: Sick…you want to do something but there is nothing you can do… because it is already sick feeling. Dr: What kind of sickness? JR: Depression…I see a bit of depression… from another angle…I see that the person's insides look like an autopsy had been made…if you look at a person's parts… especially the internal parts… usually that person is dead. WC: Okay…does it bring anything else to mind? JR: It has a lot of negative feelings… I was part of a detail in Vietnam…a detail in which we buried more than 400 enemy dead in a mass burial…I was the only Asian on that detail…there was only one other non-white person there and that was a black person walking across the hall from me…we were encamped on top of a Vietcong hospital because we were building an eleven mile road from Bedcamp to Phopin …or near Phopin…but we were building an eleven mile road…we were a company of engineers…we had the support of an artillery unit, a couple of infantry units… including an Australian infantry unit to our right…by the way…when I was digging a fox holes the first day we were in Kampin…the rubber tree plantation…I took my shirt off…and I took the rest of my gear off…including my weapons and laid them up against the tree and I dug a fox hole…and there was a person behind me…I turned around to see that GR saved my life…GR Mills…he knocked a gun out of the hands of an Australian soldier…this Australian thought I was a Vietcong(Recall Death anxiety dissolving SIS spiritual symbols 5

his Korean ancestry)…I thanked GR but I gave the Australian a negative look…because I thought to myself.. "How could he not realize that if I am the enemy? What would I be doing in the middle of an American unit with my shirt off, digging a fox hole?" Dr: It wasn't very smart! JR: So then I realized how close to death I was…I want to go through this whole thing…we were not aware that we were encamped on top of a Vietcong hospital…at about 1:00 am in the morning the Vietcong started coming out from under us and they emerged in front of the infantry unit that was in front of us…there was a battle between the infantry unit in front of us…the artillery unit commander behind us told our captain…Jeff Johnson… to keep all of us troops down in the hole…that they would provide the fire power…and they did…they fired over our heads as we were in the bunkers built over the fox holes…they also fired over the infantry unit in front of us…but I did see rounds go flying by…especially tracers…so we stayed down in the fox holes until around 5:00 in the morning when the firing stopped…it was still dark…we waited until 7…or 7:30 …until it was daylight…we were given the all clear…Sgt. Pete Johnson…when down the line in front of our perimeter, not the infantry perimeter, but our perimeter in front of the bunkers…he said: "You, you, you, you, you, you, come with me." Now somebody in our unit had a little Chihuahua, and the Chihuahua was making a lot of noise…so Sgt. Pete Johnson gave the order for someone to hold the dog down while he took a sledge hammer to the dog's head…I didn't like watching that anyway! …from thereon…we went about several hundred meters in front of the infantry unit that was in front of us…there was somebody with a pick and shovel…there was a bucket there…they dug a hole by 6 feet by 6 feet by 8 feet deep…we threw in 8 bodies in there…I can never forget that! Dr: Were they the bodies of the Vietcong? (His visual memories were flooded with graphic images of DEATH.) Dr: Were they the bodies of the Vietcong? JR: We believe so…it was hard to tell between the Vietcong and the Cambodian mercenaries and the North Vietnam regulars…the Cambodian mercenaries fought on both sides…whichever side paid them more…sometimes they fought for us…sometimes they fought for the enemy…or sometimes they fought for the North Vietnamese regulars…but anyway…we were put on the backs of five ton dump trucks…there were bodies that were picked up and loaded onto the back of the trucks…I remember going up the road about 3 miles and every time we passed the Vietnamese peasant people would shriek at the horrible sight of what was passing in front of them…we went about three miles up the road then we went off the road and went about 400 or 500 meters to what was an old LZ…a helicopter landing zone…there was a bulldozer and a bucket loader that had been used to dig a crater and the crater was about the size of a typical volcano crater, about 50 yards across or so…these trucks were backed up…we could back in facing the rim…two men on the back of each truck…with fatigue pant legs tied around their arms… and we swung bodies into the pit…there was a man from the Pacific Stars and Stripes… basically two military newspapers in Vietnam…there was All the Army times and the other was the Pacific Stars and Stripes…I think it was the Pacific Stars and Stripes…but there was a man counting the bodies…and you could hear him counting…after one hundred…he would call "one hundred… stop!" The bulldozer was sent in to level dirt over that layer of the first one hundred…once the bulldozer came back out…throw in another hundred…the bulldozer goes back in and levels another layer of dirt…comes back out…another 6 Cassell et al

hundred…he stopped counting at 350 and we were still throwing in bodies…I think we threw in more than 400…after that I remember looking down in the crater… I took pictures…after that I didn't want to see them…I destroyed some of the pictures…I came down from the back of the truck and I stood on the right side running board of this five ton dump truck and talked with the driver whose back was facing the back…he was looking straight ahead because he didn't want to see anything else…I told him: "I don't want to go back to my unit, on this truck or on any vehicle that brought bodies out here!" And without looking at me he said: "I understand." He didn't even look at me… he didn't want to look at anything else…the next thing I know…I'm back in my tent…in the rubber tree plantation…in the pup tent…I crawled out of my tent…I wandered around in a daze…I saw Staff Sgt.…I asked him: "I remember being on the burial detail, but I don't remember how I got back here?" He claimed that he saw somebody carry me and put me on a jeep…I don't recall that…that was emotionally the most horrifying experience that I had in Vietnam! (Here he described how the accumulation of highly stressful combat experiences totally overwhelmed his psychological defenses. Concomitantly the brain's visual centers, as a blinding defense, activated total perceptual inhibition of all PTSD input. Then as indicated earlier, in addition to blindness he became amnesic and fainted.) ("Flashbacks"). Dr: It was horrible! Did you have that in your dreams ever? JR: No…I would have flashbacks.… yes! Dr: During the daytime…what would a flashback look like? (Recall that his body was also Asian and like certain spiritual dreams, "visions" may transmit spiritual communications.) JR: When I was on the detail…I felt like I threw all my family members in there…I felt like my ancestors were thrown in there…I felt like my father…my mother…my brother…my sisters…(He describe a transient "psychotic" like break with reality. If analyzed from a religious frame of reference, it could be interpreted as a "Vision" in which he peered into the afterlife glimpsing images of long deceased relatives, Perhaps if he had not been concurrently subjected to the reality of combat stressors, his psychic voyage might have been more spiritually positive in the reunion) I was throwing in there…and everybody that looked like me…everybody that looked like me was dead and in that crater…I could not relate with them because they were dead…but neither could I relate with the living because they did not look like me…they were all Caucasians except for one black man working across the hall from me…so where did I belong? I did not know where I belonged. DR: You were really confused? JR: I did not know if I was supposed to be dead or alive! (In spite of long term psychiatric care with psychotherapy and antidepressant medication, his PTSD "Flashbacks", dreams and depressive episodes recurred intermittently until 1980 when he adopted Christianity and they became less frequent.) JR: But I came to Christ in 1980…I slowly…slowly…over a period of time grew from that and came to a point where I now realize that we all have one father and that is my creator…and it is my creator who created all peoples…so my creator is my father and he is the father of all people's…so that is where my consolation lies…and to prove that…there is the fact of Jesus Christ…he sent his son to die for all of us…no matter what our ethnic heritage may be…no matter what we look like…no matter what our experiences are…no matter what language we speak…no matter Death anxiety dissolving SIS spiritual symbols 7

what country we live in…He died for all…and our creator sent his son to do that for us…and so I have found that there are a lot of Caucasian people who love me…a lot of Black's who love me…I have a wife who loves me. Dr: And God wanted you to realize that, that love. (The interviewer adopted his spiritual frame of reference). JR: In 1980…I came to Christ…but even four years later…after having submitted myself to Christ…after having been rid of my addiction to smoking, drinking and doing dope…(Here he reported how his conversion and participation in Christianity assisted him in giving up chemical addictions. However, he never had received adequate spiritual treatment for his "Inner World" SIS recalled Combat PTSD suffering and intense Death Anxiety.) I still had the inkling for suicide…I still think, at that time…I had what I believe was the tail end of the temptation to suicide.( In moments of deep despondency, in spite of his positive Christian support system and antidepressant medication, he was still occasionally transiently attracted to death to escape his psychic suffering.) Dr: Previously it was with you all the time, very strong. JR: Then I came to realize that suicide is selfish…and selfish is miserable…and I didn't want to be miserable anymore…I have come to learn that as I learn to love people more…and as I learn to reach out to people more…I am reaching out to myself. Dr: When we give, we receive. JR: Yes. A few years ago I volunteered my time and my services as a DVA (Department of Veteran Affairs) van driver, picking up people and bringing them to the VA hospitals, especially these people who lived in areas that were not serviced by the bus…one of those persons was a man who was beaten up by a platoon of guys (civilian)…so he had a fear of people…he had a fear of going into buildings because he was beaten up in a building. Dr: By the Vietcong? JR: No, this was State side (in California)…So he lived in a tent in the forest. Dr: They knew he was a veteran and gave him a hard time? JR: They thought he was preaching about Jesus…and he wouldn't shut up…he was…he lived in the forest in a pup tent…he did his own cooking…he ate a lot of canned goods…if he went into a store to go and buy something it was usually a small store…not a super market…he would go in and buy a few canned goods and then come out…that was his living. Dr: Can we go to this next inkblot. What do you see there? (A2) JR: I can't make anything about this, except this might look like somebody riding on a rocker. This one looks like someone holding on to something. (Initially in projective awareness there emerge an image of an adult person "holding on to a rocker". This was a direct projection of his inner instability.) Dr: Someone on a rocker? JR: Rocking…emotions. Dr: Okay. And the third one, someone what JR: It looks like a child holding onto something. Dr: How do you feel looking at that? JR: I don't know…if this is a child holding onto something…it looks like the way the head is designed…it looks like there is an anger…there seems to be what appears to be steam above the head…but he is holding onto something…could that something be anger??? I don't know…it looks like a child holding onto something here…this is the arm…this might be his head…but his head is frazzled… seemed to be mixed up…seems to be anger here…I see something like steam here. (As his turbulent hostile emotions were brought to the surface of consciousness, stress induced 8 Cassell et al

psychological regression transformed his projected own self-image into that of "an angry mixed up child".) JR: We have done three of them, here is the fourth one. Does that remind you of anything here…or look like anything? JR: This reminds me of a boot…and this reminds me of a bird standing on its leg here…what I see and what I perceive of that is maybe there is some sort of a healing here. Dr: Tell me about the healing you sense? JR: The boot is not on the bird, the bird is on the boot. The bird seems to be indicating, "Hey I have authority over the boot." I have a freedom. I have mastered the thing that could stop me. Dr: How does that relate to your life…do you think…in terms of Jesus? Jr: In terms of Christ…all things are possible. ..no problem…the boot is a problem…but no problem is too great as to conquer me. Dr: That is very…very good. (the interviewer supported his positive religious mental defense system.) What about this one here? (A5) JR: I see this as a bird…the bird appears to be standing…the leg is here…not really flying…but standing…there might be a cushion here of air…but on top of here…there is a load of grief… darkness, like a dark cloud here…it is saying, it seems that the bird is carrying a load…but the load is lightened by a cushion of air…so there seems to be an ease of the load…I think that is a transition that a person has to go through…maybe that is a healing process right here… sometimes the loads are not taken off quickly but the load becomes gradually lighter or easier to bear…a lot of times when you are carrying a load…if you don't have a cushion on the top of your back to support the load…it becomes harder for you to bear it. Dr: How does that relate to you, do you think? JR: To me? It makes me think of my growth. (Here he again refers to his positive Christian spirituality.) Now this one here is the best one, down here. Dr: That is number A6…and it is the best one in what way? JR: I'm free…like this…like this…I'm free! (Free of Death Anxiety). Dr: You are…it is good that you are free. JR: I have a video at home, on the computer…it shows a 40 to 50 ton humpback whale that was not moving…so a group of people went up there on the boat and they were wondering why the whale was not moving…yet it struggles to breath…so they pulled up to about 10 feet from the whale and one of the guys dove in to assess the situation…found that fishing lines bound the whale…the fins and floats were wrapped around this whale…so he swam over to the whales and there seemed to be an understanding that he was there to help…so then he swam back to the boat and with his knife his boat…and he radio for helped and he was told it would probably be an hour before help could get out there…he thought…the whale might be dead by then…anyway what these guys did…was they pulled on the line…thereby drawing the boat closer to the whale…they only had one knife but they were cutting and cutting…and it took them over an hour to cut all the lines…the whale even turned upside down…they did everything they could to free the whale…the whale came under the boat and up the other side…and the whale eventually took them about a half mile ride…and they again pulled themselves up to the whale and they were able to free it…and the whale swam out about 4 to 500 meters and put on a show…it did tale slaps…it did breechings for about an hour…I was able to freeze this one shot…where the whale came straight up out of the water and the only thing that was underwater was the fluke… this is an underside belly shot…the whale appears to Death anxiety dissolving SIS spiritual symbols 9

be standing in jubilation…the title of that video was "Whale Put on a Show after being Saved." This is a beautiful picture (Showing the photo)…this was a shot that was taken of the whale's underside as the whale was nearly standing on its tale with fluke underwater…you can see everything else…what a jubilation…and the thought that came to me; "you know what…this whale had a jubilation because it got saved." Why don't we Christians put on jubilation like that…after we are saved…I can provide you that picture…print it out. Dr: If we can spread the word more…I think there will be more…thank you for sharing that…that is a wonderfully exciting story…wonder! (It is important for the interviewer to support the healing power of the sufferer's religious symbols.) Let's do some more images. How about this one? (A7) You can be a role model…a mentor…because when we give…we receive. What do you see there? JR: I see someone under this dark mole…or something that looks like a dark apple…it is a sizeable thing…this darkness…but underneath it …and unattached to it…is this dancing person, appears to be happy ...appears to be free of the load that once controlled him or her…but now is able to kick it around…push it around…he is in control of it…or he is free of it…there seems to be a joy here in this person just dancing around…this might be a dark beach ball…for all I know… but he is hitting it…he is not really affected by the load…or whatever it is. Dr: He is in control and not being compressed? JR: He is control…yes. Dr: What does that make you think of? JR: It makes me feel that I have a freedom to be happy…freedom to be happy about it. Dr: Let's do A8…what do you see there? JR: A situation here…I don't know what this figure is…it might be a funnel cloud or something, but this is a person here…and this is a world of gloom…it is dark here…he is going like this… inside that person there is a joy…we live in a world of turmoil…we live in a world of wars…we live in a world of all kinds of troubles…but we can have a peace and a joy that passes all understanding. Dr: What do we have to do to do that? JR: Keep relating to God through Christ and to relate with one another…to try to relate. Dr: Like you are doing now…you are giving. JR: Sometimes we are not able to relate with that person, because that person is either not able to understand us…or not wanting to understand us. Dr: They have a different appearance or different voice or something like that. JR: It is very possible for a person to choose to not understand…whenever that happens…we are not able to relate…but on our part…we feel the joy and comfort because we know what it is like…I see life in this physical realm is…is a battle…when I look at things from that aspect…I am reminded of the words that somebody found in the Marine Base Camp at Ksom, Vietnam in 1968…these words were scrawled on a seed ration box: "For those who fought for it, freedom has a special flavor that protect that, shall never know." For us…as Christians…the freedom that we have…has a special flavor that the unredeemed shall never know…if they remain unredeemed? Dr: When we had supper last night…you talked about some very meaningful dreams…do any dreams come to mind as you are looking at these? JR: The experiences I had…I saw Christ in that vision that I had. Dr: Tell me about that vision…when was that? (Positive religious spiritual symbols may appear as "visions". Sometimes these are better considered as such -not "diagnosed" as pathological visual hallucinations.) 10 Cassell et al

JR: That vision was when Christ asked me: "are you a dragon?" We were on a 20 minute break…I was working at a plant in which I did countersinking for rivets…I did countersink drilling for the rivets…that is all I did…not the riveting…daily we had two 20 minute breaks…one in the morning and one in the afternoon…we were on a 20 minute break on the afternoon and I was seated on a green steel stool…there was a long table…like a series of tables with a covering on top…I had a stand with a Winslow Double Countersink drill…and you had to mount it in the stand and operate the stand…as if it were an old Singer sewing machine…you had to use the peddle…as we were on the 20 minute break my friend was seated about 20 feet away from me, Larry Owen…he was reading the newspaper…and I looked down like this…and I could see the green stool that I was seated on. I had my jeans…I had my flannel t-shirt and saw the concrete floor…then I couldn't see anything but white light…that is where I saw the vision of Jesus Christ…it was so bright that I was not able to see his features…his facial features…I was not able to size him…I was not able to tell how far away he was from me, the only thing that I could see was his outline in the light. Dr: How did you feel inside? JR: I felt somewhat comforted…but I could not understand the question that he asked me at that moment: "Are you a dragon?" I knew that he knew that I was wondering what he meant by that question "Are you a dragon?" Was he talking about a dinosaur???was he talking about a lizard, was he talking about the kind of a dragon that one would see painted on the walls of a Chinese restaurant…or painted on the chinaware?

If he was talking literally…then my answer was, and I did answer him…I said…"No." And he said: "Why is it that I sometimes see smoke coming out of your nostrils?" Oh…I knew what that was about…it was a convicting question…I could not answer him. So he asked me "do you want to quit?" I said, "Yes." "Turn to me." Those words were very stern. "Turn to me." I thought I was in direct alignment as I am facing that chair that is opposite me right now. No, I was not in direct alignment because the vices that I had kept me from having a meaningful relationship with him…so I can be physically aligned with him…but not mentally, spiritually, emotionally aligned with him. So I felt, within me the desire to be rid of those things. In a split second, or fraction of time, I saw very quickly, I half a whiskey barrel upon which I stood on explode. I heard an explosion. I saw a black ball and chain go flying. Then I realize that I had made myself number 1. It wasn't Christ who was number 1 in my life, it was me who was number 1 and I had placed myself on that half whiskey barrel because I was the main guy. The 5 main man". Me. I was my own god. I was trying to control everything in my life. No wonder I felt miserable. No wonder I had a low selfesteem. No wonder. A couple of months later and I did not share with you at any time, I was transferred to Plant 2, which was the plant in which we built containers for the life support system for 747 that were going to be placed on oversea routes. We built the containers for the life rafts. And there my job was riveting. It was in 1980 when I was working there. During the lunch time we went downstairs to a cafeteria. I bought a hamburger on a paper plate, and I bought myself, I believe a large cup of pepsi cola, and put some gravy on the hamburger. I went through the line and paid for it at the cashier and sat at the booth. The booth had a wooden partition with slats in it. As I sat in the booth, I was about to give thanks. I prayed. I had a plastic fork hanging, the plate in front of me, with the drink to my right. I was tired, and I gave thanks. (His vision incorporated Christian religious symbols from the Bible). Death anxiety dissolving SIS spiritual symbols 11

What I saw was Abraham in the book of Genesis. I was about six inches above the platform and I saw old man Abraham come up the steps and come towards me. About half way over the platform, he turned to his left, took two steps and he addressed the crowd. He was speaking in a language which I wasn't very clear about, but I knew in my mind that he was speaking to them about their violation of God in worshiping idols, false gods. Then in a very short, short, short span of time, I had drifted from the time of Abraham which was about, maybe 2000 years BC, to the time of Paul in the streets of Corinth. (Here he documents spiritual time travel consistent with that outlined in this journal's editorial.) I saw this apostle wearing a green outfit, talking with a shop keeper…he was standing on the sidewalk about this large, and about as cobbled with stones as the street was…the street was at a lower level…I heard him say to the shop keeper, "I'm going to go to Rome, but I will be right back."…he turned as if to just cross the street…and he said either "I am going to go to Rome" or "I just came from Rome."…but he turned to go across the street…when I saw him, I saw the left side of him…the left side of his profile…as he started to go across the street, I came back to myself, in this position, looking at my hamburger. (Here he returns to reality on the planet earth.)… I looked up and I saw these people looking at me, these people sitting in the booth adjacent to me. And I saw people on the other side. I could see through the slats, people sitting in the next booth beside me, on the other side of the partition, were looking at me…they were giving me strange looks. ..now I saw my friend Steven who was also a Christian and he worked alongside me, in the very next shop…in the place upstairs where I worked at there were lines on the floor, if you crossed a line you were in a different shop. Steven worked on the other side of the line…so after lunch when I went back to my respective place of work, I talked with Steven, and I asked him, "You saw me there in the cafeteria didn't you?"…he said: "Yes I did."… "And I noticed that you were looking at me and so were a lot of other people, tell me what was going on? Why were people looking at me?"…well Steven said, "I want you to tell me what was happening to you?" So I did. I told Steven what I just shared with you… Steven told me, "you were speaking in an unknown language." I told Steven, "I don't know anything about that…was I talking?" He said, "Yes, you were. But you were speaking in a language. ..we know it wasn't mumbo jumbo because the words you were speaking were not repetitive…you were speaking in an unknown language and nobody knew what you were talking about."…so I don't fully, fully understand what that vision was all about. WC: A mystery…but you have an idea? JR: I believe, at least the idea as you say, leads me to believe that the triune God is much more concrete than I ever imagined him to be…there is substance to that…the experience that I had was so real is that there is emotional substance to that. WC: And that changed you in what way? JR: It gave me a maturity. It gave me the ability to realize that God is more real than we think he is. We tend to put God in a box, but yet we can't. (He appreciated the spiritual power in such a vision.) WC: As far as your addictions? JR: I don't have any. I don't have the addiction to smoking. WC: He said that you would be smoking the day? Do you remember you told me last night? JR: That was Ken Smith (Carl La viola)…that was Carl…he asked me why did I throw away my cigarettes? Why did I put all my matches out? Why did I throw away my lighter? I said to Carl, "I quit." He said: "No you won't."…and I asked him, "what do you mean?"…he said, "You have been smoking too long. ..you will be back here tomorrow smoking?" That was Carl…the next day he came and many, many, many days and years he came and I'm still not smoking. I don't miss it. (His religious conversion assisted him in stopping a very addictive chemical substance.) 12 Cassell et al

WC: It is not all you…you had some help from above? (Reinforcing the spiritual component of his healing.) MA: He had a lot of help.(his wife commenting.) WC: I think that is very helpful…that is going to be very helpful. Is there anything more you would like to say? JR: When I was at the burial detail I was not aware of it, as I was not a Christian at that time. I remember when I was a child, my mother would tell me about Jesus, but she never explained to me, how or why Jesus was a purification for our sins, so I did not know why God sent his son Jesus to die for me. In fact, I did not know that Jesus died for us. All I knew was that there was God who was the father, and there was the son, and the Holy Spirit. I knew nothing about the Holy Spirit. But since I came to the Lord in 1980, I was able to go back in time and realize that the Triune God was there with me at the burial. And it is only through my relationship with the Triune God that I am able to understand that it is not important where I came from, or who my ancestors are, or what my ancestry is, or was, or what I look like. What is important is where I am going. WC: And you had a dream with the seven people, how does that fit in? Do you remember? JR: That was not a dream. Okay. Okay. Initially it wasn't a dream, but I was able to tell her about a dream that I had. It was when Mary (his wife) asked me. We have all had some good and some bad moments in life, some moments when we were happy and some moments when we were sad. Now, if you relive your happy moments, which one would it be?...any one of your happy moments?... I thought for a moment and I said, "Not a single one." Then she questioned me about that. "Why?" I told her. This was several years ago. "Right now I am closer to going to heaven than any time before. So I am willing to compromise on that." "Can you explain that?" So I explained it. I told her about a dream that I had. WC: When did you have that dream? JR: I don't recall exactly when. ..Possibly in the 1980s… I dreamed one night as I was asleep of a time, back in the late 1950s, early 1960s when I was going to high school. I depended upon public bus transportation. I had to walk about a quarter of a mile down Vineyard Street (later Vineyard Boulevard) to the corner of Vineyard and Lilly Han. I got to the bus stop. No one else was there. I was the first one. I waited. I waited and waited and waited. Pretty soon there were two of us, then six of us, then eight of us. I remember there were eight. Still, no bus. I got a little impatient. I went around the corner to a mom and pop store and bought a candy bar. And when I came back to the bus stop just around the corner, the seven people that were with me were gone. I missed the bus. I panicked because I knew I was going to be late. Well when I panicked I woke up. WC: Your heart was pounding and you were panicked? JR: Well, maybe not to that extent, but I panicked enough to the point where I woke up and I realized it was a dream. This is a dream in which somebody is trying to tell me something. WC: And what do you think that was? JR: Don't let things distract you. That candy bar was not as important as a trip to the school, as my transportation to the school. My transportation to heaven will be by my relationship with God through Christ. So I should never fall back to a scene that can snare me from having an everlasting relationship with God, through Christ. (Here he summarized how his religious conversion had reduced his pathologically intense Death Anxiety. WC: That was an important milestone dream. I think maturity never stops, it keeps on going. We learn. Our bodies don't keep up Death anxiety dissolving SIS spiritual symbols 13

with us, they sort of fade, but you are much more of a man now… as a spiritual entity… than you were then. Don't you feel that? JR: Yes! Yes! WC: Can you put that in words please? JR: There are times when you can bury a hatchet. Once you bury it you leave it there. Do you know what happens when you bury a hatchet? You can have a tree. You bury an axe which has a longer handle than a hatchet, you leave it in there, and eventually a tree can come out of that. But if you carry that hatchet or that axe with you, that is not going to happen. I don't want to carry load that God does not intend me to have. WC: The other thing that I thought was so important that you spoke about last night, biting on the pit. Do you remember the analogy that you had? JR: We were sitting with a lady during dinner time yesterday and she mentioned something to the effect that sometimes life really throws her the pits. And the thought that came to my mind was, "well, no pits, no fruit." I love fruits. But without the pits you can never have the fruit. WC: And specifically what symbolized. JR: The pit has at least two meanings. One is a hole, one is a seed. You can put the seed into the hole and eventually you will have a fruit, or fruits. The thought that I had many years ago was, what if someone gave you a can of worms, opens for you a can of worms, what do you do with it. Go fishing. Go fishing (laughter). Have fun! JR. s wife M.R. who was listening to the recorded SIS interview and had formally agreed to participate at the ending: That is so obvious that some people wouldn't get it. (After his conversion to Christianity he married his second wife who supported him in his spiritual internalization of Christian dogma, rituals and symbols.) JR: Go fishing. Be fisherman… Be a fisher of human beings… Be a fisher of women… You can always share what you believe in and have a joy in it. WC: You are a wonderful survivor and that "Experience with All the Bodies"… I am glad that you worked that through! You wouldn't have done that alone! (Without positive spirituality) JR: (laughter). I can laugh! WC: And you can be an inspiration model for other veterans…not just veterans…but people who have been traumatized…other forms of abuse… because you are a model and I really thank you for your time! JR: God has given us a sense of humor… I like to tell people: "take a look at my family tree, it is full of nuts." MR: That is how Howard got his post-traumatic stress disorder. Here she validated the direct relationship between his viewing of the grave full of bodies resembling his own as well as those of his Asian family members as a central stressor of his combat PTSD.) JR: I'm under medication for PTSD. WC: Can you tell us what you are taking? (JR names a common antidepressant drug) then added: Another great medication that I use is laughter. WC: It is the best kind. JR: It is good to be able to laugh at myself. WC: Life is somewhat of a tragic comedy. (At times when appropriate it may be helpful to counteract PTSD psychic pain in a psychotherapeutic SIS session with humor.) JR: This is another thing that I really think about…when I get to the final moment of life. (The SIS session ends with his facing his own mortality.) WC: Which we all will be there! (See editorial) JR: When I get to that door, what kind of a rating can I give my life? I see my life from my earliest recollection, up until now, and even until the time I get there, as a movie. As a lifelong movie. What kind of a rating when my time ends here on earth, in this physical body, what kind of rating will I be able to 14 Cassell et al

give it? A1 star rating or an all-star rating. My pitfalls and everything else. My up and downs. The tears, the joys and everything that has happened! Discussion: Clinicians who dare to explore the spiritual realms to uncover the active healing components of a particular religion are likely to threaten those who need to brace their inner world with rigid definitions of spirituality. These may include powerful dogmatic literally bound authoritarian leaders. For example, one of these was an American evangelistic speaker, who prior to death chose to interpret the Bible literally. He once exclaimed in regard to the Biblical story of "Jonah and the whale", that since it was written in the Bible it "must be literally true". He was a powerful speaker who once, when living also exclaimed, that even if the Bible indicated that "Jonah swallowed the whale", that his faith would enable him to consider it true. He was sought out by media manipulating politicians hoping to obtain votes from narrow minded citizens. Even in so-called democracies many voters prefer surrendering their judgment so as not to psychically suffer the ambivalent anguish always associated with in independent analytic cognition. Unfortunately too many modern citizens, who label themselves as "Christians" while reading the Bible, fail to take into intellectual consideration that it was originally translated from Hebrew descriptions of the inner spiritual world. Biblical scholars suggest that many of the stories in the Old Testament represent translations of earlier civilizations tales which symbolically portray semi disguised lessons for a positive life. Yet there are many Biblical passages for readers capable of study beyond literal interpretation. For example in Romans, the apostle Paul raised a universal inner world question asking essentially "Why God do I often do things that I know in my heart are wrong?" It can be helpful for a spiritual oriented therapist to acknowledge this dilemma suffered by free thinking humans. All people have been given internal freedom by God to make life choices between immediate gratifications versus longer term reality based wise choices. Such psychic ambivalence may sometimes pertain to the inner world struggle a religious introspective person frequently faces between "Good versus Extreme Evil". Many fundamental Christians personify the latter component of their inner life by envisioning an evil, threatening figure. Such concrete thinking subjects in SIS guided spiritual counseling may be given enlightment into the reality based true source of their deeper darker forces, which Jung referred to as their inner "Shadow". Here the goal of the therapist is to provide insight so that negative spirituality may be controlled and then properly channeled - not projected onto others. Recall that in the case presented, the veteran projected the response "Satanic" as a second visualization of the first SIS stimulus. This facilitated his speaking about his inner rage. If the interview had not been simply for educational purposes, interpretative comments might have therapeutically enriched the discourse. A SIS projective-cognitive-behavioral-spiritual therapist might have redirected his responses from affect release of his "inner cry", to guiding the session to one also involving cognitive correction. Perhaps it might be relevant to note that historically it was a surprise for Wilfred A. Cassell to observe in clinical case studies that the original SIS stimuli evoked spiritual symbols ranging from the positive to the negative depending on the individual's religion. In this sense the projected symbols of the SIS are not religiously/culturally free of influence. Certain stimulus designs were specifically created religious for uncovering negative spirituality. Such symbolic stimuli can more powerfully bring to the surface socially unacceptable impulses for assessment and modification. These more effectively can identify self-worshiping sociopathic individuals. Now the minds of many fanatical war mongering international religious/political leaders ominously appear to have more "Shadow" than "Light". One can only hope that at some far distant future time SIS validity studies will justify public laws requiring the routine screening of all candidates for public office. Death anxiety dissolving SIS spiritual symbols 15

There is another benefit for a therapist to incorporate in treatment, the belief in a mystical higher spiritual power described nominally as "GOD" in English and many other names. This concerns the inherent value for the professional to be able to empathize, yet establish appropriate boundaries in the therapeutic relationship. Empathizing with suffering souls can expose one to Secondary Empathetic Trauma. This occupational hazard may partially account for the high rate of suicide in the mental health professions. Consequently SIS clinicians are advised to meditate daily on the fact that we are only merely professional "aides". All ultimate responsibility for spiritual healing is GOD's! Readers are challenged to replicate the SIS technology to spiritually dissolve Death Anxiety utilizing the symbols of the major world religions. A recent Hindu example of this was published in the 2012 issue of our SIS journal by Atri Sangupta, Nalini Mishra and Padma Dwivedi. They described a clinical case history study involving a Hindu woman suffering from Somatized Pain. It illustrated how her psychotherapy was enriched, when supplemented with spiritual therapy. This occurred when the SIS-II stimulated spiritually symbolic healing imagery in her viewing B2 ("Lord Ganesh") and B23 ("Goddesses Durga"). Finally, it might be recalled that several promising theoretical systems relate to SIS theory. One example of these is "Mindfulness". Technique based upon this has been shown to leads to be help victims of PTSD experiencing cognitive dissonance. It enables a sufferer in a positive way to rethink by become aware of their thoughts, moment to moment, including those debilitating thoughts that occur during "Flashbacks". Another conceptual model related to that underling SIS theory involves "Eye Movement Desensitization & Reprocessing" or "EMDR". Hopefully SIS workers may expand upon both existing SIS theory and technology. Relative to this case history report, one challenging direction involves the need to design more religion specific spiritual symbolic stimuli. Such work should enable future therapists to supplement traditional therapies by focusing on the healing light of positive spirituality. Footnote: At the beginning of this article, a quotation from Ernest Becker's book entitled "Denial of Death" declared that knowing the body's ultimate fate "is a terrifying dilemma to be in and have to live with." Now deceased, he was a former professor and then a college of mine in the department of psychiatry, at the Upstate Medical Center in Syracuse, New York. He ignored the carcinogenic effects of smoking and consequently died at an early age of cancer. As an atheist, throughout life, in retrospect, it seemed as though he had been tormented by severe Death Anxiety. His Pulitzer Prize winning 1973 book described this in a vivid fashion. Although brilliant, he often seemed to be suffering from Dysphoria. While I was conducting my initial trials with inkblots, he once stormed uninvited into my office. He was angry with me because of my pilot projective SIS studies. He insisted that such projective methodology was totally invalid and even fraudulent scientifically. He based his criticism on his own past personal history. He claimed that he had almost been eliminated from entering graduate school, because of his preadmission Rorschach test. Prior to this case history with the veteran, I recalled this stressful encounter, when rereading his book. Like all humans, my aging body is destined to die. His view of the body's demise contrasts dramatically with the world's great religions. Many of these dissolve fears of dying by doctrines of the soul uniting with deceased loved ones in a harmonious "Afterlife". Such positive soul mystical travel may be suggested in the following song entitled "I'll Fly Away": "Some glad morning when life is o'er, I'll fly away to a home in GOD's celestial shore…when I die halleluiah!" It may be expressed as well as prose such as expresses succinctly by Ramana Maharshi: "Deathlessness is our real nature. The real "I" exists here and now." References: Becker, E. (1997) The Denial of Death, Simon and Schuster Publisher.(Google E Book). Cassell, W. A. (1979) Anatomical Rorschach Responses and Death Symbolism. British Journal of Projective Technique and Personality Study, 24: 7-16. Cassell,W.A.(1980) Body Symbolism and the Somatic Inkblot Series. SIS Center, Anchorage(USA) Cassell, W. A (2005) Assessing Suicidal/Homicidal Impulses with the SIS, SIS Journal of Projective Psychology & Mental Health, 12: 2, 99-106. Cassell, W.A. (2011) 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). 16 Cassell et al

Cassell, W.A. and Dubey, B.L. (2010) Infectious Suicidal Imagery in Combat PTSD, SIS Journal of Projective Psychology & Mental Health, 17: 27-37. Cassell, W. A. and Dubey, B.L (2012) Spiritual Warfare and SIS Spiritual Symbols, SIS Journal of Projective Psychology & Mental Health, 19: 2, 80-90. 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. Death anxiety dissolving SIS spiritual symbols 17 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., Illardi, 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., Schaeck, A.M. and Mohn, D. (2002) Symbolism in Violent Hallucinations. SIS Journal of Projective Psychology & Mental Health, 9: 81-92.

suggested an admission in a Psychiatric Hospital. The method followed has led to a series of diagnostic and emergency psychotherapy interviews and to the implementation of a psycho-diagnosis, in particular with the use of projective tests, during the immediate post-critical period. The treatment plans paid particular attention to the need of patients for care continuity. Clinical examples are presented in the context of attempted suicide, personality disorder psychotic crisis and psychosomatic disabling disorder. The intervention model proposed is compared with other western psychoanalytic models and allows an alternative reading of the crisis moment, the preservation of a patient-centred intervention and continuity with subsequent phases of psychoanalytic therapy. The focus of western culture on mental health services and their historic and imperishable contribution to contemporary psychiatry lies in the fact to have set with strength the need to put in connection the individual therapeutic relationship, with therapist-patient dyad, and the group therapeutic relationship, intending for group also the institution as a whole. It's a care culture that measures and articulates various moments, a care crossed by a non-confusing plurality. Since the Forties we can observe innovative experiences in an institutional context, thanks to psychoanalysts and psychiatrists who have helped to promote an on-going and deep transformation of therapeutic methods from traditional psychiatry to the acceptance of a psychoanalytic perspective. At the same time, there has been an extension of the investigation object, from the individual and from the classic dual setting of the origins' psychoanalysis, to the group and the family, especially for those serious or critical illnesses that may require an extended setting. This experience of multiplicity and plurality qualifies the institution field as a therapeutic laboratory, the proper one for accepting new study and care objects, especially the kind of diseases called "serious", often inaccessible to classical setting tools. These patients differ significantly because their disease appears to invest the whole personality structure and because of the strong entanglement between intra-psychic and environmental field (family microcosm, social network, the institutions they belong to) (Correale A., 1991). They show so powerful and pervasive psychotic components that to strongly invade the therapeutic team activity, which may experience an elaborative deadlock, resulting in a sort of lack of setting. As for the psychosis, a key issue is the dialectic ability between a catastrophic moment of crisis, with alienation and loss of meaning, and a chronic moment, when the avoidance of stimuli threatens to perpetuate psychotic symptoms, leading to a progressive isolation from social world and affections. The question arises between considering psychotic patients exclusively as chronic or as acute, in a permanent emergency, abandoning them during the interval phases. It's not enough, therefore, that the crisis is analysed and treated individually, in a customized privileged and continuous basis therapeutic relationship, but you also need an anti-chronic theatre of operations beyond that single cognitive representative instance. Historically, since the forties, pioneering institutional psychoanalysis therapeutic laboratories were:

Integrated intervention and the projective space 19 "Northfield experiments" at Hollymoor Hospital, a major psychiatric hospital for military veterans at Birmingham, with the work of Bion on groups, of Foulkes on group analysis and the work of Tom Main, founder of the residential care model known as "Therapeutic Community"; the experience of "Operating Groups" started by Pichon Rivier and Jorge Garcia Badaracco multifamily therapeutic community in Argentina; "Chestnut Lodge and Menninger Foundation" theoretical and clinical experience in the United States; "Sector psychoanalysis" in France, with Racamier and Sassolas; "Zapparoli functional integration intervention model and De Martis and Petrella theories" in Italy (Vigorelli, 2005). In the 70's first attempts of innovative experiences within the asylum system are made in Italy and then they flow into Basaglia Reformation movement, carrying a first impact of the psychosocial model and the territorial organization on psychoanalysis: both of them force the analyst to go out of the private-room setting and to deal with group team work complexity, with techniques and professional skills diversity, with severe psychopathologies requiring a complete care of patients, not only as individuals, but also of their family and social microcosm. In view of this , several working groups interest has developed trying to exploit the potential of this personal history critical phase (the psychosis or anyway the mental crisis) implementing a clinical approach that values the encounter, the acceptance and a common search for the sense of "crisis" experience. The crisis intervention is conceived as a way to earn a space-time to meet the patient: the crisis is not conceived as an already given fact to evaluate at the time of the meeting, but rather as a flow of experiences and emotions that can give rise to a meaning and to a construction in the therapeutic interaction. Indeed it's the notion of crisis as a break that emerges here dramatically: a break with the world out there, with family and social entourage, which comes along with an upheaval of the subject usual points of reference and that is frequently felt as a faltering and sometimes as a "loss" of identity. Accepting a person in crisis means to recognize that instability and despair, whose origin is multifactorial, means to encourage the possibility of an encounter and the establishment of a relationship of trust with a therapist's team. On the quality of this encounter depends the immediate evolution of the situation and the patient's history development (Marcel and Goudal, 1990). Intervention Models: The reflection that gave birth to this work is based on the clinical experience of a hospital psychiatric service (at Policlinico Gemelli in Rome) where psychiatrists and psychologists, besides their outpatient and day hospital performances, work as consultants in the wards and at the Emergency Room. Among its primary objectives the work on patients in crisis had care continuity, in an environment where different skills professionals work, often not prepared to deal with a patient, physical and mental pain at the same time. So the beginning of the intervention can take place in condition of urgency and with an "open" setting" as may be the Emergency or a ward, while the final aim is to build a psychotherapeutic setting where the patient can be cured in the short or in the long term. The key points of the intervention can be summarized as follows: a) Flexibility and Customization of Intervention ways: The first approach with the patient is not therefore intended to control the psychic crisis by drugs (that may still be needed if the patient's condition must be eased) but to an understanding and interpretation of the meaning of the crisis, which may occur from the first moment or become possible later. The psychopharmacological intervention may be experienced by the patient as a moment of closure, sometimes potentially final, regarding the reading of the meaning of the crisis. The patient itself or his/her relatives may indeed

20 Daini et al reduce the moment of crisis to the biological meaning, thus strengthening exactly the denial and projection mechanisms involved in maintaining the active psychic issue. So the ability to differentiate the basic care mode in a careful listening from the first contact with the patient allows to personalize the work and to leave at least an open door to the understanding of the dynamic meaning. Building a first prospect of work is part of this approach, which puts the patients not in a rigidly determined treatment schedule but in a path where they can gradually take up again their ability to plan a later work and to participate in decisions about therapy. The supportive attitude required in the first approach is not therefore its only feature. The patient has to be able to understand that the psychological situation can be explored more closely and that there will be the chance to further understand and resolve it. b) Psychotherapeutic Intervention and Team Intervention (container and background): The psychiatrist in collaboration with clinical psychologists can therefore already joint the intervention on two levels, trying to make crucial and privileged the dual patient-therapist communication, while through the involvement of the team, family members can be supported, exploring their dynamics and the role they may play in the present situation. This intervention, however, is the background of the psychotherapeutic one, as well as interactions with other doctors constituted a background or an environment where psychotherapy takes place. This delicate work is focused on the individual, which has within her/himself the possibility to resume her/his own identity and to play the main role in the crisis moment solution. The objective is to outline from the very beginning a differentiation, with the intent to establishing a dual relationship and create a field of action where there is a primary care provider and the person who leads the dialogue. The purpose of this arrangement is, therefore, to assist the patient in containing the crisis through the cooperation of both doctors and family members, not leaving her/him though as a passive element but allowing her/him to resume an active role and to maintain skills and roles already present in her/his history and that the crisis could lead to lose. So, the changeover we try to obtain in the shortest possible time is that from an external to an internal containment. An example may be what can happen with suicide attempts, when in the crisis immediacy the external containment can work, that is the hospital environment with the doctors and the presence or supervision by family members, where the desirable change is that the patient her/himself is able to contain her/his own suicide motions or thoughts, and can find her/his own motivations to go on and live. In this situation, analyzing transfert and countertransfert experiences becomes important from the very beginning, not only as present elements but also on a perspective level. The critical and tragic situation leads indeed to the emergence of fusional dynamics, and raises a break of borders and an increase in permeability. The patient may show the tendency to establish these fusional ties towards any doctor, but also towards the institutional environment. These or the institution itself could become targets of intense projections, often without the possibility to elaborate them. A fortiori, to receive these projections is the abstract institution by which the patient may initially get a very intense welcome and reassurance that could then become, in front of a too intense and prolonged need from the patient, an exclusion or expulsion response, even for purely organizational reasons, a response that would have a reactivating impact on the crisis. In this context, it is really important to identify a therapist as a central figure who can leave a certain room for a fusional relationship being able, thanks to her/his own psychotherapeutic training, to both modulate the intensity of the relationship itself and to allow its gradual evolution towards more advanced and less fusional modes. This implies, therefore, that the initial moment is modulated according to a perspective of care continuity, where the psychotherapeutic relationship can

become long term, since a fusional transfer must be able to count on a therapeutic continuity permitting its working-through. For all more "serious" cases, therefore, and all the times when organizationally possible, the therapeutic continuity should be understood in the strict sense and should involve an alliance with a single psychotherapist, during the transition from the urgency phase to the subsequent ones. For all those cases in which instead this arrangement is not possible, the urgency treatment should be conducted with less intensity, exactly considering the switch to another therapeutic relationship. Meetings with the patient are arranged according to the possibilities and to the perspective of care, and deciding the frequency if daily or every other day c) Elements of the Setting: The elements of the setting are often initially framed in a confused and confusing situation, and the fragmentation experienced by the patient is reflected in a chaotic environment, non-open to communication: an example could be the beginning of a consultation in the Emergency, an open environment, characterized by continuous comings and goings, with people in need to carry out their care activities as soon as possible; or another example could be the resuscitation room care, characterized by the artificiality of the place, a place detached from the surrounding environment and from normal circadian rhythms and marked by a strong emphasis on the patient corporeality his passiveness. In such circumstances, it's obviously very difficult even just a psychological interview, also when the patient is capable enough to cooperate. In these cases, the setting must be therefore flexible, according to the situation, without sacrificing the progressive construction of a proper psychotherapy setting. If the patient is bedridden and we don't have a room where to examine him, we should try and establish a framework similar to the psychotherapy's one, then try to get a quiet space where a dialogue between two people can be sufficiently confidential. This can help to offer and create the necessary mental space for the reacquisition of thought. The first interviews, when necessary, can be performed on the patient. As soon as physical conditions allow him, the patient can continue the meetings in a room of the ward or of Psychiatry ward. In fact, getting out of bed can be a first step in the autonomy reconstruction process. And conducting psychological interviews can be a motivating factor for the patient even with regard to regaining a physical self-sufficiency. The duration of the interview is also modulated on patient's condition, with a tendency to a day-byday increasing up to a psychotherapy session standard length and giving the patient the opportunity to gradually disengage from a concrete plan and from a focus on physical health, to gain access to a psychological plan. The decision of visits schedule assumes moreover importance. The patient, despite being bedridden with a daily life marked by the ward routine, should be free to be unavailable for a visit or for a certain time, not having the feeling of being at the therapist disposal but on the contrary feeling that he's able to arrange the visit with him. It is important also for the psychological intervention a professional interpersonal distance, meaning the acknowledgment of patient's body and mind identity often violated by emergency medical procedures (eg both invasive medical procedures needed in the first moments of aid, and the praxis of an excessive psychological proximity in the emergency moments, such as calling the patient by name). This way of maintaining a professional psychological distance also constitutes a step in reconstructing interpersonal boundaries and in individualizing the patient. We see how the 'identity' theme is predominant, as the whole patient's history that has been interrupted by the crisis. . Addressing space and time factor in a dialoguing relationship, progressively rediscovering elements of previous history and identity, we try to redefine the coordinates explosively skipped in the crisis. Here then the relationship sets out in its uniqueness and acquires in some situations the added value of being the force that encourages us to get out of a passivity condition that often colludes with the family environment, which is also looking for meaning and containment. Integrated intervention and the projective space 21

After the crisis, the transition, the jump into the abyss or the fall, the possibility comes of a lucid and lived awareness: a world appears to repair, to give the subject back, a subject willing to take back the road. The ability to find some coordinates, some landmarks and the constancy of object investment enable the thought, the construction of a representation of sense and the patient regaining possession of that shattered road. d) Tolerance of Anxiety: In these situations the therapist has to work out de-structuring and helplessness feelings, not only from the patient but also from the family members and the doctors, thus becoming himself screen of many projective processes. Compared to other doctors and medical staff position, the psychotherapist's one has the privilege of a wide-range observation and of an apparent lower degree of responsibility, as the immediately required element in emergency situations is the physical health and the suitable care activities to restore it in a short time (eg treating the physical consequences of an attempted suicide or restoring the physical conditions for the survival of an anorexic patient). The care environment hyperactivity may look inconsistent with a psychotherapeutic listening attitude that also substantially operates on a plan of non-action since its functions are related to thinking and communication. In high-risk situations, however, moments of reflection and thinking are considered virtually absent or may be considered unnecessary, with a focus on activities aimed at the care of the body and postponing to a hypothetical "second half" the re-emergence of the patient's mental activity which is likely to face alone the anguish of the moment. The therapist has to work with partial images attributed to the patient by other medical staff or by the same family, originating from denial, rationalization and isolation processes. The patient is in turn regarded as a subject that has a body, that has emotional experiences, positive or negative affections, but hardly as a person who thinks, that is in possession of a psychic function of mediation and integration of these various instances. Under these circumstances it is difficult for both the patient and the medical staff to form and maintain an integrated identity representation, because it is more painful and dangerous to the balance of the medical staff themselves. Just think how it is more painful to look at an anorexic subject, for example, as a desperate person tending to suicide through fasting rather than as a subject suffering from an unexplained psychiatric illness. Here then turning to action is likely to be the most immediate solution to this state of distress and helplessness, since also in the medical staff a reification process takes place that is just the same the patient unconsciously represents in his psychopathology. e) Integration into the Social: Think the crisis has led us then to face the issues that concern the timing, the history of the subject, the somatic and psychic causality, his identity. The patient brings us something that is not organized in a sense of continuity. It is essential then to try and work on an articulated and differentiated containment, in order not to go back and rebuild the fracture lines present in more crystallized aspects, the ones over which the individual has opened a confusing and catastrophic picture. It is also vital to encourage a prompt social reintegration of the patient, in order to prevent that the crisis results in disabling the patient's social skills; a disability predictably much more difficult to treat in the long-term. This is in line with rehabilitation theories saying that the first form of rehabilitation begins in the critical phase and consists in supporting the patient and preventing him from losing his existing skills. Therefore, allowing the patient a certain decision-making margin with regard to his family and social environment, allowing him a resumption of his activities and projects in the shortest possible time, means to acknowledge his identity and the necessary development to prevent a progressive social exclusion. An example can be the fact of allowing and encouraging the completion of studies in adolescents and young adults, as well as the resumption of work as soon as the patient is able to do it. 22 Daini et al

Integrated intervention and the projective space 23 The aim is to avoid crystallization also in the outside, so that the new balance and the new economy are not based on a static and immobile diagnosis of psychosis or chronic disorder, which could lead to a gradual withdrawal from the social and the "refuge" in a progressive handicap situation. Through the work of containment and autonomy and with the family in the background, we try to avoid the exclusion of the patient from his social context, encouraging the contact, the sharing, the resumption of a project, so that his regained limits and the small resumptions of himself help him to live that unfinished future, but a future that can be lived. Some Clinical Experiences: Patient A: We meet the young 21 years Claudio at the Emergency Room where we are called for urgent advice. The patient has come for a suicide attempt, after having crashed through the window from the third floor of his house. The energy he put in the jump led him to fall onto a dirt road that partly cushioned the fall. The young man was with his mother, alert, partly oriented from painkillers and very cooperative, as if to implicitly deny the seriousness of the fact. The mother, who runs to the bedside of his son from outside Rome, seemed not to realize what happened, because she never thought that his son could do such an act. The denial of both the mother and the son unconsciously would leave space for a deep anguish, expressed in the difficulty to assign a medical role to the psychiatrist. At the first interview, the patient describes himself as a student who came to Rome to begin his studies at the Academy of Fine Arts, willing to work to support his studies and engaged in a love affair with a student. The mother then refers to this relationship as an engagement in crisis. After the trauma, the young man seems to have regained a kind of balance held by a vaguely smiling mask, a symptom of strong denial processes. It is not possible to sustain a long conversation, with the patient fatigue. The medical history is completed by the mother that alone makes a portrait of Claudio as an active and committed guy, with good prospects and with a friendly attitude towards others; no communication by the boy would have made the distant parents assume that he could commit a suicide attempt. The distressed communication from his girlfriend, present at the gesture, came to them as a bolt from the blue. The young man is admitted for reported fractures in Orthopaedics, where he is followed, by a psychiatric point of view, with meetings every other day until the time of orthopaedic surgery. In the first interview carried out at Orthopaedics, the patient is forced to immobility as a form of therapy for some of his fractures. The guy gladly welcomes the talks, almost as a way to overcome the hospital monotony and they also seem to have a tone of a friendly conversation. Claudio tells about the pains that he had during the night and of trauma-related nightmares. After remaining silent for a while, he mentions critically of the gesture he has made. Specifically he recalls the girl's screams as he was falling to the ground. He then goes on talking about himself as a very selfless person, to the point of being scolded by his parents. He is happy if others are happy and he's wondering, now, if this is normal. He adds that he never had disappointments from friends and even family, keeping a good relationship with everyone, "after the fights, back then as before." He says "I feel fragile in love" telling how unique his girlfriend is, his thought is addressed only to her. When she wanted to leave him, he felt alone and tried to die. Now he would not do it, even if he had to face a bad week, a bad month. From the hospital, he is hearing from the girl again by phone: they send messages to one another. Claudio then tells an episode in which he made a long journey to his girlfriend's house to bring her a bracelet he had bought and that she so desired. The girl's parents, however, do not approve of the relationship and they don't want they see each other. What he wants, at the end of this first interview, is "to go back doing the things he used to do before".

24 Daini et al The reason for the suicidal act is clear in the mind of the young man, but he already implicitly questions about his own mode of object relationship which, in a psychodynamic perspective, seems to be too much shifted on the anaclitic so as to completely depend for his happiness and his own existence on the other's approval and on being emotionally reciprocated. In the second interview the young man says that his family was very close to him and that he understood that he was lucky because it could be much worse. He reflected in those days on the severity of crises; for him there shouldn't be moments of crisis, which would lead to such acts, people should not suffer. His mother told him she knows he won't do it again. He adds that now, in the worst moment of pain, at the thought that he wanted to d... (He's no longer able to pronounce the word 'die', now that he has been able to give a concrete meaning to it), all the people who love him line up in front of him as Saints. He says that people should not feel so bad, and that hospitals should not even exist. He's confident that he became friends with his neighbor, and says he realized suffering seeing pain in others. He talks a lot of pain and the fear of pain after surgery. Pain gets worse at night because there's no distraction. He thinks about physical and mental pain. He tells us he has many nightmares, not only now but since he was a child. He reports about a recurring childhood dream, where he used to dream of a monster that killed his parents while he was quiet in the kitchen. He pauses and says that he got a screw loose for the girl. In the next meeting he says he's much better and can't wait to have surgery; he received several visits over the weekend and this helped him to get distracted. The only sad moments are when he sees others sad, when others suffer for what he did. He tells himself these are things you get past and he almost doesn't think about it anymore. He has to go through surgery, but hardly thinks that is for that gesture. Even if it was over with his girlfriend, even if they were not to come back together, he wouldn't do it again, he would suffer by himself, in silence, or he would let off steam with someone else. During the meeting, he talks again both about his childhood and his recent history. After a brief silence, he speaks to the psychiatrist about that 'thing' that was born to him, the thing that he wanted to do that gesture, "it died from the moment I felt I was still breathing," he confesses. He had this idea two days before, now he feels he has the same personality as before and he speaks as if there weren't that thing anymore. Going back to the first session, we see how Claudio immediately presents a question of a psychological nature "I'm happy if others are happy, is this normal?" showing an object relationship of an anaclitic type; sensing this about himself, he seems almost surprised that this kind of object relationship has so deeply swallowed him. Similarly, the possibility of a repair within the relationship assumes a strong psychological priority. In the background, the suicidal act meaning unconsciously emerges: to restore, repair the object relationship with the beloved girl at risk of his own life. The affair takes on a fusional tone in him, depending on her to continue his studies (it was the girl who convinced him to continue them) and in moving to Rome. The same fusion brings the young couple to create a strong psychological barrier towards parents, especially her parents, which did not approve of their union. The episode of the bracelet suggests that the patient's happiness is related to his ability to give. As soon as he earns some money he spend it on a gift to his girlfriend and cannot wait and see her, but he runs away to where she lives with her parents in order to give it to her immediately: a way of unconditionally giving and without limitations, an inability of waiting and maintaining a position where you wait for the other one, revealing a strong impulsiveness. Claudio then begins to talk about the suicidal act from which, however, a spirit of survival seems to be emerged against the pain of separation.

Confusingly, then, his attitude of denial with respect to the gesture is beginning to soften already, even if on the basis of another denial, that the girl may abandon him for good. From the beginning the patient seems to refer to a friendly and non-professional dimension of the interview, he's happy to talk to a young psychiatrist as if that meant to confide in a peer. Nevertheless, the dynamic movements emerge spontaneously and the patient begins to have some access to his own consciousness in relation to the situation reality. In the second interview Claudio talks without communicating about a conversation he had with his mother and soon the association between love and death emerges again, with the patient describing strong difficulties in the affective expression but even more so in the thought of death. After the conversation with his mother, dying has become an unthinkable word. The first defenses against depressive ideas seem completely archaic: an absolute superego ban resulting in images of people who love him "as saints lined up" that do not allow him any suicide thoughts anymore. Seeing pain in others, family and friends, leads him to neglect his own, if it wasn't for the constant physical pain that, however, at some point he differs from the mental pain he recognizes in others and he's able to perceive as his own as well. Physical pain itself allows him to deny and project the split mental pain up on family. He focuses on remote anguish moments. The current trauma attracts traumatic moments in the mental sense, which occurred in the past, in a dynamic call of events. The recurrent nightmares he tells suggest splitting processes widely present in the patient psychology, particularly a spin-off of aggressive components, which the patient still seems not to realize. In this context, the dream is only upheld, having regard to the patient fragility. Within the session processes of denial prevail again, the patient talks about his friends and about the bond that is paradoxically reconstituted with the girl. Only at the end an awareness of the irrationality of falling in love comes out. The girl's attitude seems ambiguous between a friendship and a bond of love. The treating psychiatrist maintains on this issue an attitude of abstention than a clarification; with the orthopedic surgery approaching, the patient's concentration moves totally on this event, which, almost cathartic, according to him will bring to a disorder global solution, in a scotomization of the psychological sphere and the suicidal gesture. So at the end of the session he thinks back of the suicide attempt, making an elementary description of it, which lets out obsessive defenses: the patient indeed emphasizes his own breathing's perception after the fall, the search for the extreme limit, he underlines he determined being alive for a 'fundamental element", he still was breathing, the soul was there, as if to represent an atonement element. The young man seems to close the gesture in a bubble as to be able to control it. The self-concept emerges again; the suicide attempt is isolated and he would like to cancel it through the notation that everything is back to normal. The session, however, leaves out a very fragile balance, full of post-critical swings. Immediately after surgery, in fact, Claudio will not want to continue the talks. Visits by the psychiatrist, however, will not stop: in agreement with the patient the psychiatrist will continue to go and ask about his health. The containment function, at this stage, makes it possible to allow the projection of the refusal of the sessions: the origin of the suicidal act was, in fact, the girl's refusal to continue the relationship and in the transference this is projected onto the psychiatrist. Not to enact an aggressive countertransference (refusing or prescribing unwanted talks) seems particularly important to the treating team, because this way they allow the identification of the patient with the psychiatrist, which he refused, maintaining the relationship in the following short visits. The patient is not aware, but the team is, of another aspect of transference countertransference which appears concretely in this sentence of the patient: "the mother that lets her- Integrated intervention and the projective space 25

self to be rejected without rejecting in turn"; it's certainly a psychic image of containment that encourages a new integration of the young man archaic instances. He is allowed to find an identification pole in the therapist, who let herself to be abandoned without denying the relationship, without dying, you can be abandoned without losing your mind. With identity support function, he can survive even if he is abandoned. Besides, the patient would have continued treatment once in Naples, and it was therefore important not to compromise a subsequent report. A further consideration, that the patient would continue treatment in another city encouraged this therapists choice: it was important also not to jeopardize a subsequent psychotherapeutic relationship with an excessive in-depth of a relationship that would last a short time necessarily. The emotional bond created between us will be eventually expressed in the final salute, when the patient embraces me saying "thank you" before going away to another hospital, manifesting the emotional part, left unexpressed during the sessions. The treating team follows in the same time the parental couple. Part of the job is to make them aware of a beginning psychiatric disorder hypothesis and recognize the psychological question. They shows a tendency to deny what happened and the possibility of a psychological problem more deeply rooted, in addition to the will to take the guy home with them, in her attempt to restore the fusional tie between him and herself. The re-establishment of an immature bond with her could be rationalized and justified by the patient's physical condition, by his need to do rehab and be assisted; against the crystallization of this pathological bond, the work done wanted to ensure a care continuity in their place of origin, exactly in an attempt to nurture a space of thought and wait, against the patient disruptive impulsiveness. Patient B: The patient arrives at the Day Hospital of Psychiatry sent by a fellow psychiatrist for a further differential diagnosis in a protected environment. The current crisis has shown, in fact, psychotic symptoms, but since the onset of symptoms both the family and the psychiatrist preferred not to take the young man to an Emergency, trying to prevent hospitalization in a psychiatric ward, which could be dramatic for the patient. When we meet Stefano, the guy is 23 years old, the eldest of three children; he has a few years younger sister and a brother 11 years old. Some psychological problem has been present for several years. Stefano indeed has a long history of psychotherapeutic interventions started at the age of 6 and continued up to 10, due to language difficulties. He will resume psychological consultations in high school years, along with an anxiolytic pharmacological therapy, because of severe relational difficulties and introversion that will even lead him to change Institute. He enrols at the University, the Faculty of Letters and Philosophy that he will leave, however, after 3 months. At the time of the visit the boy, even if emotionally disconcerted by his own symptoms, is cooperative and oriented along the three axes; he reports a body and senses dysperceptive framework, he feels the body very heavy, as if it were detached from him, a lot of pressure in the head and some liquid in the brain. This body identity issue and its experience motivate a progressive social isolation with a marked increase in anxiety towards external relations. Stefano tried to find a job after leaving university, but after several attempts, the current situation is a total lockdown of his activities. The mood is markedly depressed. The body identity problem had been complicated by a physical problem of obesity, which had led him to follow a diet. Just before the crisis moment, he had come to lose more than 44 pounds, paradoxically; however, this was not accompanied by a better body experience, but rather by an increase in anxiety and by a loss of control over the self-perception. The patient is offered an outpatient setting intervention with a first phase of infusion therapy where Stefano on a daily basis will be following in the context psychological support sessions. A 26 Daini et al

new delusional component will come out: a female voice insulting and despising him. The patient himself will ponder over it, associating it to his mother's voice. However, he will not be able, at this stage, to analyse the dynamics of the relationship with his mom, because he's too involved in the crisis concrete elements. After the infusion therapy period (approximately ten days) Stefano's condition seems improved: the patient is less anguished and less in need of constant attention from family members. He can even think of moving temporarily to his grandparents, with whom he has a more serene relationship anyway, and trying to help his grandfather in his work, just to start doing something instead of staying all day closed at home. His parents were present in this first period and markedly anxious, living with difficulty the detachment of their son and his greater autonomy. Both accompany him, walking on either side of the boy, while Stefano, perhaps rationalizing about the hot season, returns to wear shorts, completing a picture that evokes childhood. The affection of his parents is full of anguish and led them to call different institutions to come up with an immediate solution to the problem. After the day hospital period, they suggest a community for young psychotics where Stefano doesn't want to go. Psychodiagnosis: While Stefano continues treatment with antipsychotics and antidepressants on an outpatient basis, he begins a psychodiagnosis path with projective tests, which willingly consents to and progressively he even comes to meetings alone. Draw a Person Test: The subject draws first the female figure, just slightly shifted to the left of the sheet; it has good proportions and is characterized, as well as the male figure, by significant stroke rigidity. The type of design is childish for the big head, the feet facing in opposite directions, some inconsistencies in clothing. The same method is found in the male figure, indicating a rigid rationalizing personality, with a strong immaturity on body image. In this regard it is useful to recall that the young man critical moment happened after a weight loss that is precisely when interpersonal relations instances were not placed in the background or "covered" by the prevailing obesity problem. Both figures have a thick dark hair surrounding their faces to indicate a strong anxiety and a significant mistrust. Very large eyes indicate, however, curiosity and desire for knowledge. While commenting the drawing, the patient denies that the female figure represents his mother and about the male figure, that represents a man of his family: since the first test, the issue concerning the conflict with the mother figure seems obvious, as well as the difficulties in his own identification, coming from the relationship with his father. Baum Test: In the drawing of the Tree the great defences that the subject is using to overcome the crisis emerge; the tree indeed takes up almost the entire sheet surface and comes up with a sturdy and straightforward trunk to confirm a good subject's ego strength. Both the roots and the branches, parallel at times, confirm the patient obsessive tendencies. Compared to all of these Tree figure elements, the hair appears relatively constricted and without leaves or fruits representations, suggesting both a tendency to hide his own imaginative life and to limit it for defensive reasons. Family Drawing: The patient draws a family whose identity he doesn't know how to define, at first saying "imaginary people", then "my sister and I, younger". The characters are holding hands to express a desire for relationship within the family and of the patient himself, especially with her mother and sister. The representation expresses a repressive desire; in fact, the patient is at the age of ten and all family members are younger than they really are: "and it was nice at the time to be together". The younger brother does not appear in the drawing, to declare an unconscious conflict. The father figure that is enhanced appears, however, distant and not in contact with the patient. Integrated intervention and the projective space 27

Wartegg: The subject shows permeability to external stimuli, adhesions to the collective thinking with adaptive capacity and resulting inclinations to social relationships. The affective component, though, especially with regard to the subject potential disposal and his harmony degree in the relations with the environment, looks tending to the depressive side. At the moment, the subject doesn't seem very interested in interpersonal relationships and, where present, the affective component looks removed. The relationship between emotional and formal quality (the latter appears much higher) confirms the presence of feelings and emotions control and of a constricted personality, blocked in its operations by depressive inhibitions. Furthermore, the presence of an experienced symptomatic apprehension is largely confirmed by the anxiety index that also indicates a poor ability to control it. The Sequence Analysis reveals that the relationship with the mother figure is consciously confrontational, while the one with the father figure is only unconsciously confrontational, even though it is completely conditioning in a underlying way the subject behaviour in the relationship with the authority. In previous years, indeed, the young man had taken different types of jobs, never able to keep them for a mismatch with the work environment. Rorschach test: The test shows a normal psychic productivity (R = 23), with more prolonged reaction to coloured plates. The percentage of form responses is also standard, while a reality index of 4 lies in a neurotic range. This was just a few weeks after a period of crisis with transient psychotic symptoms. The percentage of global responses expresses, however, regressive tendencies of oral type, and the small number of well-liked responses shows a tendency to move away from collective thinking. Psychotic imbalance traces are also reflected in the high frequency of "blood" responses that indicate the subject's tendency to lose control on his emotional response, as indeed it frequently happens in a post critical period. The primary reaction formula shows an intratensive personality, while the secondary formula expresses an unconscious tendency to be mainly stimulated by the external environment. This inconsistency seems therefore; indicate that the subject is at a time of major change in his personal tendencies. The relationship between global and movement responses is strongly skewed in favour of the former, indicating a disproportion between ambition and inner resources. The relationship between human and animal movement suggests, also in this projective test, a tendency to instinctual tension control, while the absence of perspective/diffusion responses expresses the patient difficulty to physically experience the anguish. This, as indicated by the contents, is revealed by persistent sexual and "blood" content and then it can express dissociative personality components. As for dependence feelings, the subject partly consciously accepts these, but they are mostly unconscious, as not structured and not accepted tendencies to dependence. The relationship between structured and unstructured coloured responses shows a trend, this mostly unconscious too, to lose control on emotional responses. The relationship with the paternal figure seems characterized by dependency feelings investing also the patient sexuality sphere. The maternal figure seems related to an emotional response against dependence correlated to unconscious and not very structured dependence emotions and instances. All this puts the patient in anxiety over the female world and exposes him to a progressive loss of emotional control. Treatment: After the diagnostic process, Stefano continues with psychological support talks until he chooses to start a speech therapy. As a matter of fact, the work of psycho-diagnosis shows a phase of transition in the subject who seems to be in a time when change is now seen as inevitable, especially in the relational sphere, while the previous rigid defences had prevented a more gradual maturation. An evident search for affection joins the need of independence, and both the issues are centred 28 Daini et al

on his personal insecurity and impulses inhibition. These have brought the subject to express schizoid traits such as social withdrawal and a tendency to obsessive-phobic control that he only partially manages to contain. These more de-structured nuclei are contained by drug therapy and by those personality traits of inhibitory type that in the subject come with depressive experiences. In this case, the activity carried out in Day Hospital has created an environment where, through various figures, the patient has been able to reconstruct his identity and to return and see a line of development, shifting the over-concern for body issues to a boost towards social inclusion. The strong weight loss had contributed to the dissociative process on a psychotic break side. The psychological diagnosis process, in particular with the contribution of projective tests, has suggested two main directions. The first one was to seek clarification on the meaning of crisis in the patient life, using a method of his choice, on the opposite side to drug therapy, where the patient might feel passive. The psycho-diagnosis, having been proposed as not essential but as the result of a patient's choice, gave him back a freedom margin (the freedom to reflect on meanings) that the crisis moment seemed to have taken off from him, and this even in the immediate post critical period. The second line is represented by the description and recovery of identity that projective tests allow: the diagnosis results communication and the same patient resulting reflections let him take back his own psychological identity that seemed initially overshadowed by the crisis. In addition to psychological support, some talks with his family members help find a solution that the young man agrees with, also supported by his grandparents. In the family he feels too anxious and locked, but he manages to partly come off by going to live with them temporarily; a relative detachment accepted by both parents and son and that allows Stefano to think more calmly in a neutral environment. Grandparents played a role of transitional space which made possible for him having access to a social plan until then feared, that used to relegate and fold him within the family. So as the figures met in Day Hospital, whom he easily related to, were somehow testing grounds for an external communication. To rise from depression he started working at his grandparents' warehouse. In a short time the psychotic symptoms will resolve with an atypical antipsychotics pharmacological treatment. Stefano, therefore, will no longer have to depend on his family to find a job; later he will work in temporary jobs at the municipality of residence, taking up that activity which was completely blocked in the crisis moment. In this phase, the patient starts the speech therapy with a male psychotherapist whom he will choose, seeking support for his own identity. Maybe the day hospital team, which also carried a new contact with the female figure, was still too dangerous, leading him to choose an outside male psychotherapist. The patient will continue to come in day hospital for less frequent meetings with also a pharmacological control function. The following summer, in a wider separation attempt, Stefano decides to temporarily move to England. During the trip, from which he will come back after a short time not having found a job, he sees an older girl, thus establishing a bond that goes in the direction of a progressive attempt at autonomy and disengagement. In addition to the transitional function carried out by grandparents, also the day hospital's one, in this case, can be defined a transitional function, i.e. to allow a gradual detachment from parental figures. The transference of parental meanings on the day hospital team mediated this process. May be in the patient's mind, the real parents, and especially his mother, were psychological objects from which he couldn't initially come off, while the patient as much possible, experienced the detachment from the day hospital medical staff figures. The relationship with them had plenty of room for flexibility; in fact, the therapy carried out at those meetings has not exhausted or completed in the same circle the patient's evolutions and reflections, but has allowed a number Integrated intervention and the projective space 29

of subsequent detachments, which have not, however, deleted the relationship with the first medical staff members. The resolution of his crisis picture has gone through successive evolutionary self-assertions: saying no to residential treatment, choosing a psychotherapist by himself, making autonomous decisions which have not been perceived as dangerous for his integrity and which began to plot a new course that Stefano is now living. He is facing the "process" that triggered his crisis, because a process is something in motion and, as such, is full of critical points. Choices allow evolution, transition and growth. Separation, tearing in front of us and that we have to deal with, without the possibility to ignore it (at least in the acute phase), may lead us to a decisive transformation and to a deep change. Patient C: Mrs. Paola, 42 years old, comes at the ER for pain and stiff neck accompanied by anxious crisis and crying, and there she meets the psychiatrist. For about ten years she has been living with a form of stiff neck that occurs with repeated accesses and which so far has been treated just as a somatic disorder; in fact, the woman is being treated by a neurologist and she draws relief from a botulin toxin therapy that relaxes muscles: nothing psychological seems to have showed up until the moment we meet her. From the first interview in the ER, a state of depression, never adequately treated, that occurred before pregnancy and by pregnancy was exacerbated, emerges. In the postpartum period, a fleeting contact with a psychiatrist translates into a solely pharmacologic therapy, subsequently suspended. As a matter of facts, from childhood, Paola is accustomed to face alone her own difficulties, which she reacts to without resolving them. Now that her daughter is almost eight years old, however, the woman's ability to face difficulties by herself seems to have dramatically decreased. Paola welcomes the interview and begins to tell her story. The apparent psychosomatic involvement leads the psychiatrist to indicate a psychodiagnostic and psychotherapeutic path alongside a bland pharmacotherapy. Psychodiagnosis: Before starting the psychotherapy, the patient performs a psychodiagnosis with Projective Tests. She approaches to such Tests performance, showing collaborative, even though there is some apparent embarrassment and fear towards the assessment and the results that, as she reported, may emerge. In all the Graphic Tests, style, pressure and strong stretch express the presence of anxiety, emotional instability, as well as a not very elaborated instinctually and aggressiveness. Draw a Person Test: The body concept looks primitive with childish and disguised strokes and expressionless figures that suggest introversion and communication difficulties. The male figure, drawn first, suggests conflict and a possible tendency to identify with the aggressor. As a matter of facts, the interviews express a current couple conflict, rooted however in much more remote experiences. The male subject devaluation is expressed by the imbalance and instability of the figure, drawn on a horizontal sheet, and by her own comment 'looks like a 15-16 years child'. The female figure, larger and vertically oriented on the sheet, expresses a desire to dominate and, in the emphasized hips, interest in motherhood. Baum Test: The same stiffness is reflected in the drawing of the Tree which, she describes "a green tree full of leaves and fruits" reveals sensitivity and a fertility desire. The absence of roots in the Tree, indicating strong removal processes of the unconscious parts of her-self, suggests that the somatic symptom is an expression of those meanings and can be improved by psychotherapy. Several holes in the trunk, unusual in adults, suggest the presence of trauma of which, for now, the patient does not speak. Family Drawing: Again indirectly, again with rational and schematic connotations, the Test represents a patient unfulfilled need of help and support to her emo- 30 Daini et al

tional life. The ideal of having another child confirms what emerged in the other Tests ("I wish I had a baby boy too"), even though this desire doesn't seem to translate into a real project. But now she is once again a victim of stiff neck as before and during pregnancy. Wartegg: The Test shows a subject with a fair adjustment to common thinking and a good reality testing, even if a certain amount of anxiety and inner tension comes out. Affectivity is inhibited, while practical skills and realistic attitudes are heightened. Also in the affectivity sphere, a marked conflict concerns the relationship with authority and the one with the father. Less conscious but equally confrontational is the relationship with the female figure in a deep sense, which can evoke a child identification but also motherhood fantasies. One aspect which the patient removes, but that influences her behaviour appears to be the expression of aggressive dynamics, which are not constructively addressed to overcome an obstacle, but lived in a intra-punitive way. Rorschach test: From the Test the productivity appears quantitatively small (R = 13) and poor in quality. The global responses high percentage and an enhanced observation of small details indicate that the woman is oriented towards a cognitive attitude that is not supported by her own abilities, coerced due to a severe emotional inhibition. Moreover, the attention to details and a prevalence of global amputated responses seem to be, rather than an interest in what is uncommon or unusual, more a tendency to seek in details something to criticize. The low number of formal responses reports a lack of self-control, which pushes the patient to have too personal reactions in front of the dynamics that surround her. The Ego resources appear poor, and she has a hard time to recognize and accept her own fantasies; her impulses and object relations, where present, are shallow and discontinuous. The affective sphere seems to be at the mercy of anguish; her instincts prevail and find their way to expression without going through reason. Chiaroscuro also confirms that colours urge the patient. The reaction time, significantly longer in the achromatic tables, indicates that the patient appears disturbed when environment stimuli affect the emotional needs sphere (almost totally Plate VI, whose latency time was the highest, indicating a sexual shock, has contributed to such a high value). With respect to relations with the environment, however, the woman tends to draw more from the outside than from her own inner world. The apparent contradiction actually clarifies how her pulsional dimension is unapproachable. So the environment becomes vital yet unapproachable because it awakens anxiety and pain. The reality index indeed is equal to 2 and ranks under psychosis, unlike in Wartegg Test where reality testing is much more appropriate, probably because the semi-projective Test allows a greater environmental containment which can reassure Paola on a both emotional and concrete level. The identity problem emerges, however, more clearly in this test, where the patient sees herself as a butterfly (answer to I Plate) but an ugly butterfly. The centrality and beauty desire expressed in the response to the performance turns in the examination into a devaluation of her own image. The same happens for the III Plate where not human figures are perceived but again a big insect, ugly and bad. The male images (responses to IV and VI Plates) appear monstrous and VI Plate investigation reveals a strong aggressiveness ('a smashed, crushed dragon'). The Latency time to VI also suggests a shock related to sexual issues. Female images appear at VII Plate ('two children ranging in Carousel') to suggest a fairly emotional relationship with her sisters, while the maternal unconscious image (as opposed to conscious representations) is monstrous again ('It seems to me the x-ray of a monster, these are the tentacles'). The response to II Plate is coming late and expresses a shock towards red ("this part below seems to me like blood ..."). The female part puts even additional emphasis on the patient difficulties about sexuality. To this shock the patient reacts then distancing herself and rationalizing ('everything else seems to me like an x-ray'). Integrated intervention and the projective space 31

The entire Test is dotted with aggressive contents suggesting in the foreground this dynamics and its containment attempt. Treatment: After the psychological diagnosis, Paola begins a weekly psychotherapy that has been in progress for about two years now. What emerged from the tests battery has been confirmed since the first sessions which showed an introverted and inhibited personality, with a tendency to depression and anxiety. Her fragility and her mental weakness on one side make her in need of support and safety, but at the same time lead her to take an avoiding attitude towards the environment to prevent the strong sense of personal inadequacy. The relationships with her origin family are in the foreground, especially the one with her father figure that for every year of her childhood seems to have perpetrated not only against her, but also against her seven sisters and her only brother, repeated physical abuses and any kind of negligence. Of all this, Paola has only fragments of memories that emerge in the early months of sessions, while clearer and sharper episodes are the ones told by her older sisters. The patient expresses bewilderment and anger also against her mother, towards whom she shows her disbelief at the fact that her husband's numerous extramarital affairs were denied or passively accepted by her, even against the evidence. Now their grown up daughters finally urge the parents for separation after they found out that the father has a son from outside relationship Her mother issues invest Paola heavily: the absence of any form of protection for herself and her own children, who were submitted to constant harassment by their father, translates in the fact that the relationship with her mother is undermined in terms of confidence and emotional expression. So it looks obvious that the patient takes primitive defensive mechanisms in response to her emotional needs frustration, and so they can push her to a strong somatizations: the symptom as an expression of discomfort, inability of expression and representation into words. However, the high subjective sensitivity and the need for containment, even just from the simple symptomatic relief, allow the woman to use the same anxiety as a signal of a recurrent conflict leading to introspection and to a further understanding of her own emotional needs as time go by. Because of her inability to consider legitimate emotional needs (also her mother in the end was a mistreated person) Paola's couple bond is affected by her difficulty to communicate and assert them, making her assume an attitude of excessive tolerance and appeasement towards her partner. As a matter of facts, she undertakes a cohabitation following the man's preferences, and she agrees to have a baby daughter with him outside of marriage, despite having the unexpressed desire to legitimize their couple union. Also a second son desire, which looks like one of the relevant reasons of patient's discomfort since the first sessions, is restrained and postponed according to her partner's will. These latent conflicts make the couple life unsatisfactory also in terms of sexuality. Neck muscles dystonia had become apparent during her pregnancy, complicated by a stiff neck rather than by explicit psychological conflicts: the patient seems to unconsciously represent the Latin expression "obtorto collo" (literally: "with a crooked neck") which was used to describe the need to obey against one's own will and desires. Paola was indeed tolerating at the time a lack of recognition of her wife and mother role by her husband and his family. The connection between emotions and muscle symptoms awareness emerges very slowly in the patient, even if anxiety containment makes improve her symptoms at times. The uncertainty about her own situation also affects in a serious way the subsequent relationship with her baby daughter: the woman tends to establish and maintain with her a fusional relationship, unconsciously attacking the bond between father and child. When the woman undertakes psychotherapy, her daughter is already seven years old, but she still sleeps in the bed with her mother and still wears diapers at night, despite being an apparently adapted little 32 Daini et al

girl during the day. As a matter of facts, she attends elementary school with a great success, also supported by her mother's perfectionism, and she shows a good trend to social relationships at school, while looking a little shy. The woman inability to put some distance between herself and her little girl meets the father's collusion, which resigns to usually sleep on the couch. Part of the first months therapeutic work is therefore aimed also to create situations allowing a better development of the patient's daughter: the woman can rationally understand her daughter's need to have greater autonomy and this translates into the little girl's psychological evolution improvement and a physiological functions better control. For the woman, this relative detachment involves a strong subjective suffering, compensated however, by the fact that her daughter is calmer and that her couple relationship has enhanced. An important element at this stage of psychotherapy is the persistence of elements of external and concrete conflict representation (the muscular symptoms, the concrete place where the little girl sleeps, the concrete place where her partner sleeps) where the first awareness elements are still on an intellectual level and not yet responding to a greater fluidity between the patient personality structures (Ed-Ego-Super Ego). If on a family plan the situation concretely reflects the patient's problems, socially the consequences of her feelings of shame, passivity and retained anger are still there. Apparently, Paola is efficient at work, very loyal to duty, very quiet to the point not to present any complaints, despite being hypersensitive to any injustice or discrimination towards her. Generally, anyway, also on this level the situation is of deep mistrust and difficulty in spontaneous communication. After a year of therapy it is the working environment to trigger another stiff neck crisis in the patient. This time she was forced to do extra hours because a colleague of hers found a way to escape additional work commitments. Paola meets the specified requirements without protesting by the employer. After this event, she imagines with the Psychotherapist to take refuge in a 'false disease', but right away a new stiff neck crisis intervenes to force her to bed. This time it is easier for the patient to grasp the connection between her own repressed aggressiveness and dystonia symptoms. At the same time, Paula realizes that botulin toxin may not achieve the desired effects (the patient had performed the treatment shortly before). A joint consultation with the Psychiatrist and the Neurologist leads then to the decision, welcomed by Paola, not to repeat the infiltrations and rather run an antidepressant and anti-anxiety therapy completed with Psychotherapy. In relation to this episode, a more interpretative Psychotherapist's attitude becomes possible to clarify the relationship between anger feelings and somatic symptoms. The problem at work makes somehow easier, and shifted compared to the family more deeply engaging environment, acquiring awareness for the patient. This awareness, however, puts in motion also remote unconscious logs, missing until now in psychotherapy sessions. A few months after the episode at work, indeed, the woman begins to talk about childhood episodes that definitely upset her and that made her feel powerless to react. A first memory of sexual abuse is related to her paternal grandfather figure and is recalled also thanks to the conversation with her sisters, also abused. A patient strong removal had prevented these not worked out memories from coming to the surface. Equally covered by removal are the reminiscences of a possible sexual abuse committed by a cousin of hers when Paola was already 9. Of this episode, where her sisters were not witnesses, the woman only recalls uncoordinated flashes, not centred on sex acts, but the memories she has, particularly the ones relating to the emotion of wanting to go home, arouse intense emotional reactions in the patient. Some sessions have an important cathartic function anyway; Paola won't come back on the subject to work it out any more, but the abuses revelation will lead her to a greater peace of mind attitude and to the ability to communicate more openly both within the family and at work. The tendency to an over-compensatory attitude towards her daughter loses intensity. As a matter of facts, the patient had both been trying to spare Integrated intervention and the projective space 33

the little girl any frustration through an unconditional satisfaction of her desires, including the one of maintaining a physical contact with her, and through an unconsciously deeply scarred attitude, which had led the woman to tighten her daughter to herself in order to avoid her any possible trauma. As a matter of facts, the girl can for the first time get away from home and be entrusted to a school friend's mother for a few days, following a little car accident happened to the same patient. The girl can live with joy this little detachment and this environment change granted by her parents. The therapy is still going on after two years but it can now proceed on a more expressive and interpretive plan, a plan detached from the somatic symptom, almost completely overcome. Starting a psychotherapy first supportive and then individual expressive has thus allowed us to investigate the level of the socio-affective dimension impairment, with its current and past experiences, exploring the object relationship, the relationships with her most significant reference figures, the primary and secondary socialization process. It has appeared crucial to understand which parts of the Self have been experienced as inadequate and therefore a source of shame, identifying the image that the subject has of herself, of the other, of the relationship and related fears, and exploring the feelings of shame, presumably derived from unexpressed and not accepted anger, which therefore has been reworked over time. Discussion: The experiences here presented show how it is possible to integrate in critical and post critical states treatment an individual intervention, both at a psychodiagnostic level and at emergency psychotherapy level with global psychiatric intervention. It is necessary for this type of model to choose a primary therapist, dedicated to the relationship with the patient and to his re-identification after the crisis moment. The rest of the staff performs the function of environment in support of the main therapeutic relationship, the function of contacts with family members, whenever required, and the function of indicating and monitoring drug therapy. This differentiation of roles allows us to observe not only the group dynamics raised by the psychic crisis, but also to take back to the patient's individual mental space those dynamics that often in crisis are indirectly expressed or are overly specific and therefore cannot be analysed. This makes possible to deal with various clinical states, as shown by the examples, especially when patients age and previous psychic resources suggest from the beginning the presence of a strong enough Ego, prospectively capable of certain flexibility. Compared to mentioned models, which mainly refer to psychiatric wards, the setting of this experience is motivated by the performance in an "open" institutional environment, it took place indeed among a General Hospital ER, a psychiatric Day Hospital and a Psychiatry and Psychology clinic of the same hospital. So the aspect of external institutional containment typical of a psychiatric ward was not present, and the medical staff had directly to aim to and restore an "internal containment" by the patient with the psychological support of family members and medical staff, replacing from the very beginning the crisis containment provided by doors and windows shut or by the permanent presence of nursing staff. This made also possible to highlight the presence in critically ill patients of abilities that can still be encouraged when one might suppose they are already lost. In this context, conventional methods such as psychodiagnosis may find space in an immediately post-critical context, unlike traditionally planned times. The personality framework emerging during the post critical period is obviously less crystallized (solid? Stable?) then in greater balance phases, but it lets us bring back the patient's narcissistic interest to self-knowledge (and indeed it is constantly accepted by subjects) and it also makes possible a first decoding of the crisis meaning, placing the foundations, both to the patient himself and to therapists, of clarification of therapeutic goals to be pursued over time. 34 Daini et al

Conclusions: The therapeutic continuum between acute care and post-acute care is proposed anyway as one of the fundamental objective of care process, allowing therapeutic changes in the patient. The presented cases have followed different treatment plans: the first one for contingent needs related to the place where the patient would continue the treatment, the second one to allow the patient to be somehow free to choose, while the third one continued at the institution with a more frequent continuity. However, they have in common the fact that during the initial intervention the foundations for a psychodynamic look and for an interpretation of the crisis meaning were laid, making possible a subsequent action where the patient's role could be of active awareness and positive hope for change. References: Castellazzi, V. L. (2010) Il Test del disegno della Figura Umana. Roma: Las Castellazzi, V. L. (2006) Il Test del disegno della Famiglia. Roma: Las Correale, A. (1991) Il campo istituzionale. Roma: Borla Crisi, A. (2007) Manuale Test di Wartegg. Roma: Magi Daini, S. (1994) Concretizzazioni, estratto da Minerva Psichiatrica. Torino: Minerva Medica Klopfer, B., McGlashan Kelley, D., Davidson, H.H. (1946) The Rorschach Technique: a Manual for a Projective Method of Personality Diagnosis. World Book Co. Klopfer, B., Davidson , H. H.(1994) La tecnica Rorschach. Firenze: Giunti Organizzazioni Speciali. Marcel J.L, and Goudal, l. P. (1990) Measures de placement en centre d'accueil: la loi di 30 juin 1638 à l'épreuve des nouvelles pratiques. Nervure,3 8; 98-101 (written in French). Vigorelli, M. (2005) Il lavoro della cura nelle Istituzioni. Roma: Franco Angeli Wartegg, E. (1953) Schichtdiagnostik. der Zeichentest (WZT) Einfu?hrung in die experimentelle Graphoskopie. Go?ttingen: Verlag fu?r Psychologie, [Writtten in German] Winnicott, D. W. (1995) Esplorazioni psicoanalitiche. Milano: Corti Integrated intervention and the projective space 35

a person is affected that determines whether that fear has become a phobia. Phobic neurosis, referred to by Freud as anxiety hysteria characterized by anxiety focusing on certain external objects, be they things, persons, or situations. It is essentially a castration anxiety caused by an oedipal scenario (Freud, 1894).Freud gave a fairly clear definition of the phobias, which he connected, in part; to hysteria, and which he distinguished from obsessions. In contrast to the socalled "actual" neuroses, which have a contemporaneous dysfunction in their etiologies, he related obsessions and hysterias to intra-psychic conflict with roots in childhood sexual history. In the case of an obsession, the sexual idea is later divorced from the corresponding affect; in the case of "hysteron phobia," the sexual idea, because of repression, disappears from consciousness only to reappear in the form of anxiety linked to another idea. Freud (1909) analyzed the case of a Phobia in a Five-Year-Old Boy" stated that Little Hans's phobia corresponded to a repressed libidinal longing and emphasized the irreversible character of this transformation. Even if the longing could later be satisfied, it "can no longer be retrained from the libido; there is something that keeps the libido back under repression." In an attempt to clarify this imprecise understanding, Freud (1926) after elaborating the second topography and returning to his reading of the case of little Hans in "Inhibitions, Symptoms, and Anxiety" reversed his earlier formulation: "The anxiety felt in phobias is an ego anxiety and arises in the ego, and it does not proceed out of repression but, on the contrary, sets repression in motion". Melanie Klein further developed this line of thinking in light of the death instinct hypothesized by Freud (1920). As Segal (1979) wrote in, "For her part, Melanie Klein believes that anxiety is a direct response to the internal work of the death instinct." The phobic defenses are erected against unconscious fantasies, which are linked to the death instinct, in an attempt to control the external objects; this attempt is proportional with other attempts to exercise omnipotent obsessive control over internal objects. Even a succinct discussion of the place of these concepts in Klein's meta-psychology would require developing other ideas, notably those connected with the hypothesis of the internalization of an early archaic superego. Klein's case study of "Richard" illustrates this problem. Treatment of Phobia: There are a number of treatment approaches for phobias. The effectiveness of a treatment depends on the individual and the type of phobia. The present study aims to see the effect of systematic desensitization and group therapy on different type of phobic patients viz: hydrophobia, zoophobia, nyctophobia and astraphobia. One hundred and ten (110) phobic patients matched on Socio-economic status, ranging from 12 to 19 years (Mean age of 16.7 years) with mean length of abnormal fear for three years at least. The Rorschach Inkblot Test was administered using Beck's method to ascertain personality characteristics on selected indices viz: R, W, obvious details, rare details, M, C, CF, FC, Vista, Shading, Affective ratio, H, Hd, Anatomy, Good form, Animal, Popular, Lambda, White space, T/IR and Rejection of cards. The Mean scores obtained on different variables were analyzed using Chi Square test. The patients were evaluated at S. I. Mental and Physical Health Society (SIMPHS) Varanasi (India). Results indicated that the two groups differ significantly on total Responses, Whole responses, obvious details, rare details, Movement, CSum, Vista, Human, Human detail, Good form, Animal, Popular, Lambda, T/IR and Rejection of cards. After 7 months of psychotherapy most of the patients became symptom free. The findings of Rorschach test and efficacy of Psychotherapy is discussed in the paper.

There are just a few potential Phobia treatments. In exposure treatments, the patient is exposed to the fear object in order to help them overcome their fear. One type of exposure treatment is flooding, in which the patient is confronted by the fear object for an extended length of time without the opportunity to escape. The goal of this method is to help the individual face their fear and realize that the fear object will not harm them. Another method often used in the treatment of phobia is counter-conditioning. In this method, the patient is taught a new response to the fear object. Rather than having panic in the face of the feared object or situation, the client learns relaxation techniques to replace anxiety and fear. This new behavior is incompatible with the previous panicked response, so the phobic response gradually fades. Counter-conditioning is often used with patients who are unable to handle exposure treatments. Helping those who suffer from phobias is thought to be most effective when psychotherapy and medications that are specific to the treatment of phobia are both used. One form of psychotherapy involves the supportive and gradual exposure of the individual with phobias to circumstances that are increasingly close to the one they are phobic about (desensitization). These situations can either consist of actual or computer-generated anxiety-provoking stimuli. Systematic desensitization technique: This technique is used to help the client cope with phobias and other fears, and to induce relaxation. In progressive relaxation, one first tightens and then relaxes various muscle groups in the body. During the alternating clenching and relaxing, the client should be focusing on the contrast between the initial tension and the subsequent feelings of relaxation and softening that develop once the tightened muscles are released. After discovering how muscles feel when they are deeply relaxed, repeated practice enables a person to recreate the relaxed sensation intentionally in a variety of situations. After learning relaxation skills, the client and therapist create an "anxiety hierarchy." The hierarchy is a catalogue of anxiety-provoking situations or stimuli arranged in order from least to most distressing. For a person who is frightened by snakes, the anxiety hierarchy might start with seeing a picture of a snake, eventually move to viewing a caged snake from a distance, and culminate in actually handling a snake. With the therapist's support and assistance, the client proceeds through the anxiety hierarchy, responding to the presentation of each fearful image or act by producing the state of relaxation. The person undergoing treatment stays with each step until a relaxed state is reliably produced when faced with each item. As tolerance develops for each identified item in the series, the client moves on to the next. In facing more menacing situations progressively, and developing a consistent pairing of relaxation with the feared object, relaxation rather than anxiety becomes associated with the source of their anxiety. Thus, a gradual desensitization occurs, with relaxation replacing the anxiety. This behavior modification technique, which is founded on the principles of classical conditioning, was developed by Wolpe (1950). Some of the most common fears treated with desensitization include fear of public speaking, fear of flying, stage fright, elevator phobias, driving phobias and animal phobias. Relaxation responses are trained to occur through progressive relaxation training, a technique initially perfected by Edmund Jacobson during the 1930s. Group therapy: Group therapy is a type of psychotherapy that involves one or more therapists working with several people at the same time. In Theory and Practice of Group Psychotherapy, Irvin D. Yalom outlines the key therapeutic principles that have been derived from self-reports of patient involved in the group therapy process (Yalom and Lesczc 2005). How Does Group Therapy Work? Groups can be as small as three or four people, but group therapy sessions generally involve around 7-12 individuals. The group typically meets once or twice each week for an hour or two. The minimum number of group therapy sessions is usually around six, may continue for a Psychotherapy in phobic patients 37

38 Sharma et al year (Manor, 1994). Manor also notes that these sessions may either be open or closed. In open sessions, new participants are welcome to join at any time. In a closed group, only a core group of members are invited to participate. In many cases, the group will meet in a room where the chairs are arranged in a large circle so that each member can see every other person in the group (Manor, 1994). A session might begin with each member of the group introducing themselves and sharing why they are in group therapy, or members might share their experiences and progress since the last meeting. The specific manner in which the session is conducted depends largely on the goals of the group and the style of the therapist. Some therapists might encourage a more free-form style of dialogue, where each member participates as he or she sees it. Other therapists might have a specific plan for each session that might include having clients practice new skills with other members of the group. Materials and Method: One hundred and ten phobic patients (55 treated and 55 un-treated) in the age range of 12 to 19 years with a mean age of 16.7years, matched on socio-economic status were taken for the study. All the patients were treated at S.I. Mental and Physical Health Society (SIMPHS), Varanasi (India). They had history of phobic fear for at least 3 years. After individual counseling, 55 patients were treated with systematic desensitization technique and group therapy. Each therapy session lasted about 45 to 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. After treatment they were requested for follow-up by personal visit or telephonic follow-up. All the patients were administered the Rorschach Inkblot Test following Beck's procedure (Beck et al, 1961). The data thus obtained were analyzed using Chi-Square test. Results and Discussion: An attempt was made to compare mean scores of treated and un-treated phobic patients on Rorschach Indices using Chi-square. Results are given in Table1. Table1 shows that the two groups differ significantly on total Responses, Whole responses, obvious details, rare details, Movement, CSum, Vista, Human, Human detail, Good form, Animal, Popular, Lambda, T/IR and Rejection of cards. The treated phobic patients obtained higher mean scores on total Responses, Whole responses, obvious details, Movement, Affective ratio, Human,Good form, Animal, Popular, Lambda andT/IRand lower on rare details, Csum, Color, Color-form, Form-color, Vista, Shading, Human details, Anatomy, White space, and Rejection of cards. Treated phobic patients have obtained significantly higher total Responses which indicate their higher productivity and maturity. This further indicates that treated phobic patients have shown maturity in comparison to the non-treated patients. The Treated group had significantly higher score on W responses and also had higher frequency on cards I, IV, and VI, further indicating their maturity and high productivity with organizational ability. The R and W responses' variation were also found able to discriminate between the two groups and serves as diagnostic indicator According to Rorschach (1942), obvious details indicate an ability to perceive and react to clear and distinct characteristics of world. It's somewhat easier to give D responses because they represent the easiest perceptual cognitive mode to act when faced with ambiguity. High D responses in treated patients show better control during stressful situations compared to the nontreated group. The D was also able to discriminate the groups significantly. Higher Human Movement responses in treated group of phobic patients indicate their involvement, reactivity towards the external world and emotional conflict, which could not get obvious expression in the world of reality (Beck et al, 1961). Higher C and CF responses in Non-treated phobic patients may indicate their impulsivity and serves as diagnostic indicator. Rorschach (1942) reported that chromatic colour responses indicate affectivity or emotional excitability. Beck and

Psychotherapy in phobic patients 39 Table 1 Mean and Chi-square between Treated and Un-treated Phobic Patients with p Value Rorschach Indices Treated Phobic Patients Un-treated Phobic Patients p Total Responses (R) 22.21 19.16 <0.05 Whole Responses (W) 12.98 10.92 <0.05 Obvious Details (D) 71.99 68.65 <0.05 Rare Details (Dd) 9.00 11.68 <0.05 Movement (M) 6.89 3.81 <0.05 Csum 4.99 7.97 <0.05 Color (C) 2.09 3..00 N.S. Color-Form (CF) 1.97 3.10 N.S. Form-Color (FC) 1.58 3.62 N.S. Vista (V) 2.01 3.01 .<0.05 Shading (Y) 3.36 4.00 N.S. Texture (T) Affective Ratio (Afr) 3.37 2.17 N.S. Human (H) 13.99 9.31 <0.05 Human Detail (Hd) 2.12 3.80 <0.05 Anatomy (At) 3.43 4.86 N.S. Good Form (F+ %) 39.71 33.25 0.05 Animal (%) 48.03 41.13 <0.05 Popular (P) 12.08 8.74 0.05 Lambda (L) 22.01 16.48 0.05 White Space (S %) 2.08 2.97 N.S. T/IR 296.67 258.55 0.05 Rejection of Cards 1.13 3.20 <0.05 Molish (1967) reported that the sum of colour responses is an index of affective energy available for responding to the environment. The manner in which this energy expanded is a function of the total ego structure and of the inward balance afforded by M. In healthy person, Csum projects the energy and drive available for coping with adversities and in order to manipulate the environment, adjusts to change and react to stress. The lower csum is indicative of a more rigid effort at coping with the demands of the environment. The treated phobic patients obtained lower mean scores on Vista responses may indicate better control over exciting events but no difference was noticed on Shading, Texture and Affective Ratios between the groups. A high number of animal responses may indicate that the person has stereotype manner of approaching the world, immature thinking and aggressive attitude. Individuals who lack closeness to other people may either reject blots or may perceive more of animal contents. The treated patients obtained comparatively more Animal responses than the non- treated patients still indicate their immaturity and aggressive attitude. They need to continue psychotherapy to control their aggressive attitude (Wedemeyer, 1954, Neff and Glasser, 1954 and Beck and Molish, 1967). Non treated group of phobic patients have ob-

40 Sharma et al tained higher Anatomical responses than the treated group, which indicates their preoccupation with bodily concerns, though the difference was non-significant. Philips and Smith (1953) reported that anatomical responses also indicate concern with destructive impulses. A high number of popular responses may indicate popular view of world with social standards. Often such individuals may have conventional way of thinking and associated with human relationships. A low number of P responses may indicate that the person has non conformity of social norms, is away from reality and has signs of psychosis. The treated phobic patients have shown significantly higher popular responses than nontreated patients, which may suggest the efficacy of therapeutic intervention (Cassell and Dubey, 2003, Dubey, 1981, 1982, Hertz, 1946 and Piotrowski, 1950). When a person is unable to perceive images in a concrete form, it can be taken as rejection. It has been noticed that people reject images, which depict certain precept related to their traumatized experience or underlying painful memory (Cassell and Dubey, 2003) and in most cases it may be an index of neurosis (Bohm,1958). In present study, non-treated group of phobic patients have significantly higher mean value on this indices as compared to the treated group of phobic patients. Table 2 Follow-up Profile of phobic patients Phobic Patients N Symptom free Patients Treated Phobic patients Reporting after 1st months Reporting after 2nd months Reporting after 3rd months Reporting after 4th months Reporting after 5th months Reporting after 6th months Reporting after 7th months Table 2 indicates the efficacy of psychotherapy. The improvement started after one month of psychotherapy, but most of the patients improved after seven months. Only 44 patients continued follow up and 43 of them were reported to be symptom free. The efficacy of systematic desensitization and group therapy is evident for the treatment of phobic patients. Conclusion: The present study aims to see the effect of systematic desensitization and group therapy on different types of phobic patients. One hundred and ten phobic patients matched on Socio-economic status, in the range of 12 to 19 years were administered the Rorschach Inkblot Test using Beck's method. The Mean scores obtained on different variables were analyzed using Chi Square test. Results indicated that the two groups differ significantly on R, W, D, rare details, Movement, CSum, Vista, Human, Human detail, Good form, Animal, Popular, Lambda, T/IR and Rejection of cards. Only 44 patients continued follow up and 43 of them reported to be symptom free after 7 months of Psychotherapy. The systematic desensitization and group therapy was found to be very effective in treating Phobic patients. References: American Psychiatric Association.(1994). Diagnostic and statistical manual of mental disorders (4th Ed.). Washington, DC: Author. Beck, S. J., Beck, A. G., Levit, E. E.andMolish, H. B. (1061) Rorschach's Test Basic Processes. New York: Gume&Strattons. Beck, S. J. and Molish, H. B. (1067) Rorschach's Test Vol. II.A Variety of Personality Pictures. New York: Grune& Stratton. Bhom, E. (1958) A text book in Rorschach test diagnosis (Tr. By A Beck & S. J. Beck) New York: Grune& Stratton. Birraux, Annie. (1994). L'éloge de la phobia. Paris: Presses Universities de France.

Cassell, W, A. and Dubey, B. L. (2003) Interpreting Inner World through Somatic Imagery: Manual of Somatic Inkblot Series. Anchorage (USA): SIS Center. Dubey, B.L. (1981) Rorschach Indicators in Normal and Clinical Groups in Military Population. ISPT J. of Res. 5: 54-56. Dubey, B. L. (1982) A Pragmatic View of Rorschach Ink Blot Technique. National Psychological Corporation, Agra. Freud, S. (1894). The neuro-psychoses of defense. Standard Edition of the Complete Psychological Works of Sigmund Freud, 3: 41-61. Freud, S. (1909). Analysis of a phobia in a five-year-old boy. The Standard Edition of the Complete Psychological Works of Sigmund Freud, Two Case Histories ('Little Hans' and the 'Rat Man'), 10: 1-150. Freud, Sigmund (1925). Inhibitions, symptoms, and anxiety. Standard Edition of the Complete Psychological Works of Sigmund Freud, 20: 75-172. Hertz, M. R. (1946) The scoring of Rorschach inkblot method as developed by the Brush Foundation Rors Res. Exch, 6, 18-22. Klein, Melanie. (1961). Narrative of a child analysis. London: Hogarth. Psychotherapy in phobic patients 41 Manor, O. (1994).Group psychotherapy. In Petr?ska Clarkson & Michael Pokorny (Eds.), The handbook of psychotherapy. New York, NY: Routledge. Neff, W.S. &Glasser, N, M.(1954). Normative data on the Rorschach. Journal of Psychology.37, 95-104. Philips & Smith (1953) Rorschach interpretation advanced technique. New York. Grune& Stratton. Piotrowski, Z. A. (1950). A Rorschach compendium revised and enlarged, Psychiatric Quarterly.4, 543-596. Rorschach, H. (1942). Psycho diagnostic, New York: Grune& Stratton. Segal, Hanna. (1979). Melanie Klein. New York: Viking Press. Wedemeyer, B. (1954). Rorschach statistics on a group of 136 normal men. Journal of Psychology.37, 51-58. Wolpe, Joseph. (1990). The Practice of Behavior Therapy. Tarrytown, NY: Pergamon Press, Yalom, I. D., &Lesczc, M. (2005). The theory and practice of group psychotherapy. New York, NY: Basic Books.

Brief Dynamic Therapy attempts to bring about changes in client's psychopathology by conceptualising it within the frameworks of psychoanalytic thought and actively working out a focal conflict area. The present paper aims to show the understanding of psychopathology, process of psychotherapy, and its outcome on the basis of therapeutic contents in the context of a single case having prominent features of emotional instability. The study attempts to illustrate the utilisation of the techniques as well as the therapeutic relationship, in the framework of psychodynamic psychotherapy. The probable pathways by which these factors bring about the change in the client are discussed. It is suggested that such a work could serve as a pilot study for larger scale research. Brief Dynamic Psychotherapy (BDP) can be defined as a time-limited form of psychoanalytically based therapy, usually lasting between 6 and 40 sessions, characterised by high levels of therapist activity, and the attempt to work with a psychodynamic 'focus' which links presenting problem, past conflict or trauma, and the relationship with the therapist (Holmes 1994). Balint and Balint (1961) introduced the notion of a 'focus' in dynamic therapy, and indeed 'focal therapy' is often used interchangeably with BDP. A focus highlights the contents in the form of: the patient's current problem, past difficulties and the current transferential relationship with the therapist. The focus thus, is a crystallisation of the patient's core or nuclear problem, based in the past, but permeating present difficulties and conflicts. The idea of focus operates at several levels in the course of dynamic therapy. It provides an overall conceptualisation of the problem; ensures that patient and therapist do not get distracted by interesting but irrelevant side issues; and acts as a guide to the therapist's interventions. According to Malan (1963) the case formulation can be done following standard psychoanalytic concepts. However, free association is not utilised. The methods of fostering expression, suggestion, clarification and interpretation are used. This provides the scope for corrective emotional experience as well as new learning. The therapist (T) is more active and does not wait a long time for giving interpretations. Rather T rapidly juxtaposes the present conflict with the past difficulty and aims to bring out the triangles of psychopathology and that of persons (Holmes, 1994). The indications for BDP include high motivation for change, a circumscribed problem, evidence of at least one good relationship in the past, and the capacity for self-reflection or 'psychological mindedness'. Malan (1963, 1979) indicates contra-indications such as:(1) chronic addiction, (2) serious suicide attempts, (3) chronically incapacitating phobic or obsessional symptoms, and (4) evidence of gross destructive or self-destructive 'acting out' behaviours. However, there is clinical evidence (Malan, 1979; Ryle, 1990) that quite disturbed patients with long standing difficulties can, if sufficiently motivated, be helped with BDP. Since Malan's list contains qualifying terms such as 'gross' and 'serious', which are matters of judgement, in the end the 'feel' of the assessment interview remains a critical determinant of whether BDP is likely to be helpful or not. This is consistent with research indicating that a positive therapeutic alliance and the capacity to show affect in the early sessions of therapy are the best predictors of good outcomes in therapy generally (Orlinsky and Howard, 1986). The patients with Borderline Personality Disorder or Borderline Personality Organisation as delineated by Kernberg (1975) are common in the mental health practitioners' offices. Linehan (1993) suggest behaviourally based strategies, whereas Clarkin et al (2002) suggest long term dynamic therapy based on understanding of object relations.

The present study has discussed a single case which has fulfilled the diagnostic criteria of Emotionally Unstable Personality Disorder following ICD-10 (WHO, 2006).The case study attempts to describe the intervention following the principles of BDP, along with the themes emerging from therapeutic sessions. Finally, an understanding of the therapeutic process as well as the outcome has also been discussed. Case History: The indexed patient, K. P. 19 year old female, student of English honours, single, Hindu, hailing from a nuclear family, residing in suburban area, belonging to lower middle class, presented with the complaints of feeling depressed, restless, disturbed sleep, and as if something is moving at a great speed in the spinal cord near the back of her neck. Her mother reported that she was very aggressive and hits elder sister, breaks things, cannot calm down easily. Both reported that these problems started insidiously since last three years with progressive deterioration. She further reported during the psychological testing phase that she had difficulty with loud noises and could not tolerate them. These problems started gradually following financial crisis due to the closer of her fathers' small factory. Her father gradually became more irritable and turned down most of the demands of the client due to financial crisis. She was about 16 at that time and as a result of this refusal she had quarrels with other members of the family. Her father was very critical of the other family members and used to hit his wife. The client's elder sister also lost her job due to recession which further increased the financial crisis of the family. The patient gradually became irritable and started feeling restless, and had no interest in studies. With minor provocations, she used to hit her elder sister and father at times and broke household things. She used to feel restless, had difficulty in getting sleep and felt as if something is moving in her spine. As reported, her father is very dominating person, takes all decisions in the family matters, dislikes any criticism and loses temper very easily. Client's elder sister too loses temper easily, cannot tolerate criticism. She feels that mother always supports the client, remains passive and stays quiet, can do little to handle the situation. The client is very protective about her mother, cannot tolerate any criticism against her. May be due to this, she has a conflicting relationship with father and elder sister. Often the three female members form an alliance against the client's father. There is high expressed emotion - in the form of predominant hostility and critical comments. The client is very energetic since childhood, has aggressive attitude and is generally intolerant to criticism. Her developmental milestones were normal and were rated as a good student. She did not report of having any homosexual or heterosexual experience. On Mental Status Examination she was found to be cooperative, well kempt and tidy, had no abnormality in speech, and perception and she had with average intelligence. She reported suicidal ideations, depressive affect and irritability. The case history and Mental State Examination are indicative of the provisional diagnosis of "Moderate Depressive Episode and Emotionally Unstable Personality Disorder - Impulsive Type". Psychological Assessment: The referral specified the need for psychological evaluation. Among other tests Thematic Apperception Test (Bellack, 1975) was administered which revealed features of anxiety and depression due to conflicting relations with father figure. The major needs identified are need for succorance, achievement, autonomy, dominance and aggression. Mother figure is perceived to be supportive, but passive. Father figure is perceived as dominating, and there exists an intense ambivalence, in which the aggressive part is consciously experienced. Intense disturbance and mistrust in heterosexual relationship is also noticed. Environment is perceived to be stressful. The major defences used are denial and reaction formation. The future is perceived as hopeful. The results of other psychological tests are not mentioned as their findings were not utilised in the process of the study. Unravelling the roots of personality disorganization 43

Excerpts from therapy record: As the therapy progressed, the emergences of discrete phases were observed and are mentioned below in brief. Phase I - The initial phase: Entering the treatment (Session 1-7): In the first session she was introduced to the nature of psychotherapy and its ground-rules, the responsibilities and boundaries to be maintained during the collaborative process. It was decided that the therapy would consist of 30 sessions - fixed on the basis of prior appointment, the frequency being once a week and duration of each session about 45 minutes. Thereafter, the FO- CAL CONFLICT area was decided jointly as her relationship with her father. Her ability to accept interpretations and her psychological minde-- ness was assessed by giving trial interpretations. In the first few sessions, she initially was able to identify her immense hatred and anger towards her father. She was able to ventilate in the sessions and the emotional catharsis seemed to help her to relieve distress. Later on, through clarifications, the emotion of love underlying her hatred for father was evident. The therapeutic alliance had emerged and her dependence and reliance on the therapist paved the way for transference. After a brief period of relief, her symptoms of restlessness increased - indicating the anxiety of the unconscious being revealed. This tension could well be explained as the anxiety resulting from the expression of her impulse, i.e. love for her father. The ego might have identified the signal and was erecting the defences and the anxiety was an expression of this turmoil within her psyche. This was followed by a tendency towards emotional withdrawal and passivity. Thereafter, a strong resistance emerged, which had to be dealt with during the course of therapy. She was able to identify her hatred towards her father as stemming from love, which caused anxiety, paved way for transference and resistance. Thereby, the first repetition compulsion was completed. Phase II: Beginning of middle phase, Emergence and Resolution of Resistance (Session 7 - 19): She again went back to her defensive aggression towards the father, which had to be again clarified after emotional validation. The client was unwilling to undergo therapy session. This could probably be due to the fact that she was habituated in this way and her ego required support prior to moving on. The therapist remained supportive and discussed her issues. Her resistance was also systematically interpreted to her. Catharsis was encouraged and as similar issues of oversensitivity and defensive aggression towards others emerged, they were pointed out to her. The nature of transference in social situations was clarified which she accepted willingly. Thus, several issues on emotional conflict resulting from interpersonal crises were handled. Gradually her hatred towards her father emerged and it was clarified to her that this was due to her over-sensitivity and expectations from a critical father. The difference between her emotional demand and reality was evident. Gradually she revealed her desire to have a peaceful life which she never had. It was only to protect her inner self, she had adopted harsh style in life as defence mechanism. The resolution of resistance was achieved and she could experience other emotions like sorrow, helplessness and despair without being defensive and aggressive and she was able to cry without getting angry. Here it is noteworthy that unlike the suggestions of Davanloo (1980) of head on collision with resistance, it deliberately slowed the pace. It is not easy to induce trust in BPO patients, therefore, if the Therapist wanted to accelerate the process, it is likely that it may increase the defensiveness of the client and weaken the therapeutic alliance and even cause therapeutic rupture. On the other hand, the facilitation of expression provides security to the client as she prepares herself to be able to explore and peep into the inner depth. Phase III: Exploring the inner dynamics to achieve change (Session 20-27): Her dreams in this phase portrayed her inner conflicts centring on aggression. She was also reporting about romantic interests which indicated her progress towards maturity. Her associations indicated her domination upon others and her lack of empathy in general led to interpersonal conflicts. She was somehow identified with the 44 Mitra et al

Unravelling the roots of personality disorganization 45 aggressor and was behaving in the line of her dominating parents. Her defensive over-valuation of self was pointed out as was her low self-esteem. Following this, she could reflect her feelings and also could realize that her inability to open up emotionally was largely due to her mistrust in inter-personal relationships, which contributes to her sufferings. This revelation unearthed her inner helplessness and her fear of abandonment from her father which had been transferred towards the therapist. The transference interpretation could link both the triangles of focal pathology and was easily identified by the client. This was followed by her dreams which clearly indicated her aggression towards her mother. A core conflict with her mother was revealed where she wants to aggress and also was afraid of being aggressed. The nature of aggression is primitive and annihilating. The dreams ultimately indicated that her clinging on to her father was actually a defence against the conflicting relation with the mother figure. It was only when her ego was adequately strong after several therapeutic interventions that she was able to trust the therapist, the core conflict emerged therein. The therapist helped her to check the unrealistic, emotionally charged nature of her fantasies. Her aggression towards her mother was validated and the ambivalence as well as the nature of mature love was discussed. Phase IV: Planning and Handling termination (Session 28-30): The termination was planned after providing support to the client. As per the scheduled intervention, 3 more sessions were left. These were primarily aimed to resolve the transference issues. In these sessions again her defensive aggression for her father emerged. This was probably a displacement of aggression on therapist as she resisted termination and hence the neurotic conflict re-emerged. However, she was able to handle the issues. Her conflict with her mother also reemerged and was interpreted. Finally, therapist discussed the importance of autonomy and development to the client. She was ready for termination. It was decided that if required, she would come back for further help. A follow-up session was planned after 2 months. Follow-up: She reported that her symptoms had not really caused much of disturbance and she has become more composed. She was also able to handle stressful situations on her own. However, she desired a more objective feedback from the Therapist, through reassessment. The follow-up TAT was administered and it revealed that her aggression had decreased markedly. However, a sense of boredom and distance in interpersonal relationships, along with need for achievement - without much realistic planning - was revealed. Thus, the depressive features were evident and these findings were reported to her in simple language. She could gradually identify each of the features in her and realised that she needs to be more active in life. Discussion: As revealed in earlier sections, the client needed to conceptualise that she has deep seated emotional issues which contribute to her distress. Therefore, approaches focusing on cognition and its rationality were unlikely to unravel her inner pain. The psychoanalytic approach focusing on emotion was ideal to uncover the inner conflicts. As the issues centred mostly on her aggression and relation with father, it was easy to locate and work on the focus. As a long term psychodynamic approach would be difficult due to practical constraints of continuation for a long time as well as cost effectiveness, Brief Dynamic Therapy was chosen. The understanding of psychopathology that emerged from the therapeutic dialogues indicates that the client has a desire for peaceful, passive unison with her mother, to be in a quiet and soothing environment. However, it gets disrupted by an aggression laden object-relation pattern with the mother. This is in congruence with the views of Lienehan (1993), Kernberg (1975) and Klein (Segal 1975). The person with BPO is emotionally oversensitive and prone to cling to the primary caregiver for security. They fail to tolerate the frustration of individuation, and are unable to develop a balanced object relation with the primary caregiver. This leads to intense aggression towards the mother to the point of her destruction and mutilation. As a result of splitting, the mother is idealised as goddess and making her almost omnipotent, the other part which is split off from consciousness is laden with violent aggressive impulses. These impulses as well as the defensive manoeuvres indicate her primitive level of ego-functioning. Individuals with Borderline Personality Organisation have a surplus of aggression, either constitutionally or because of frustration of their early needs by insensitive caretakers (Kernberg, 1994). Therefore, in the face of stress due to fixation at more primitive level as indicated by presence of immature defences, identity diffusion occurs and the sets of inner directed values probably breaks down and leads to chaotic relationships, an inability to inhibit the expression of strong affects and impulses etc. The characteristic features of being harmed by own primitive aggressive impulses, splitting it off, projection of the same onto the external reality followed by realisation and mourning - all these phenomena also fit in with the paranoid-schizoid as well as depressive position numerated by Klein (Segal, 1975). These primitive aggression laden object relation pattern is likely to impede the healthy developmental process of the child. The child is also likely to have failed in forming a secured base through identification. These unfulfilled desires are in the latter phase projected on to the opposite sex parent. Therefore, when sexuality evolves during the oedipal stage, the client depends on the opposite sex parent not only for the sexual desires but also for the unresolved issues of security and self-esteem. Fenichel (1945) also mentioned how the depressive fixated at the late oral stage, depends on others for narcissistic supplies, resulting in external regulation of selfesteem, hindering mature object love. As the narcissistic supplies are thwarted in the disturbed family, the ego tries to fixate in the Oedipal phase - relational interplay between the client and her father and somatisation (conversion of psychic anxiety and distress to somatic form) results. However, they are characterized by the earlier hostile object relational pattern as Klein (Segal 1975) mentioned in her theories. Thus, symptoms of both the neurotic level as well as those of borderline personality are manifested, emerging in adolescence when genital sexuality emerges and precipitated by stress on father which had a negative impact on his relation with his family, including the client. Therapeutic Process: The first few sessions comprised of the initial stage, marked by the first repetition compulsion. This was followed by gradual deepening of the emotional exploration and it followed the pattern of exploring the defensive patterns to gradually uncover the impulses or wishes, which leads to anxiety and causes resistance. Her feelings of resistance were frequently hovering around the other emotional conflicts coming repeatedly in sessions. However, gradual explorations led to resolution of the defences and surfacing of the deeper issues. Primarily she reported her deep annoyances with the no-providing father, but slowly the sessions revealed that other emotional underpinnings were equally responsible for her distress and aggressive reactions. With the help of the Therapist she gradually became aware of her transference reactions marked with fears of abandonment and helplessness. Insights regarding the transference helped the client to experience and acknowledge her core fears. This emergence of the core issues in transference can be conceptualised as resulting from insecure attachment, (Bowlby, 1980). These core issues also enabled the client to develop a more realistic appraisal of her fears regarding abandonment and her current position and abilities to handle them. However, when the issue of termination came, the symptoms re-emerged due to incomplete resolution of the transference issues. Yet, the client was encouraged to go ahead. As the follow-up suggests, the therapeutic gains in the client persisted. The above pattern of gradual deepening of exploration, encountering and resolving resistance, manifestation and resolution of transference is widely acknowledged in the process of psychodynamic therapy (Lemma, 2003). The major techniques used were those taken from psychoanalytic therapies. The Therapist attempted to make the client speak freely for the first 25-30 minutes of each session. This not only 46 Mitra et al

gave the chance for abreaction, reflection but as she was a client who was motivated and could verbalise well, it was a means of going deeper into the issues and her feeling of being heard. Apart from active listening and thus fostering expression which helped ventilation, suggestion, clarification, interpretation, and dream analysis were used. Interpretations were given when it was felt that the client was ready and close to reaching the concept. This ensured the minimizing of speculation by therapist as well as the client's ability to relate to and grasp the interpretation. Enough groundwork was done by collecting associations by supportive therapist before leading to the interpretation. Transference interpretations (TI) were deliberately delayed until therapist felt that the relationship was strong enough. Thus, caution was maintained regarding maintenance of the therapeutic alliance. Research on transference interpretations suggests that for patients with low quality of object relations, its use lead to adverse effects. Hence, therapists should consider providing a low number of transference interpretations to low QOR patients (Ogrodniczuk and Piper, 2004). Reflections of Therapist revealed an initial positive counter transference followed by a negative one during her phase of resistance. It probably reflected her testing the patience of Therapist, due to her lack of trust. This emergence of positive and negative counter-transferences was in synchrony with the patient's experiential process. In retrospect, the therapist was able to realise the operation of mechanisms of projective-identification. However, as the therapist was able to control behavioural expressions of the same, the therapeutic relationship survived and helped the client to re-organize her world-view. A therapeutic rupture would have resulted if Therapist lost patience and acted according to the material unconsciously projected by her. For example, by coming late, speaking on the same area and resisting deeper work, she probably tried to make Therapist react in an aggressive way - in accordance with her internalised object-relational pattern and thus re-confirm her world-view marked with mistrust. Moreover, in the end phase the transference was not resolved completely, and a rather positive transference was maintained. This had helped her internalising the Therapist and the therapeutic dialogues, leading to further changes after termination of therapy. This had helped her to return for further sessions, when required. Apart from the above mentioned factors, the client reflected that the calmness and patience of therapist helped her. This was completely opposite to her pattern of experience of inter-personal relationships. As per her, earlier therapists failed to display such qualities. Thus, the feeling of being held not only paved the way for transference but was a way of modelling too for her, which she did not receive adequately in her family. This can also be explained by the concept of 'holding', 'container and contained' concept mentioned by Bion (1962a, 1962b). Moreover, this relation, in its limited time helped her to relate to another person with love - realizing and transcending her aggressive tendencies - and thus altered her dynamics. Regarding termination, the therapist preferred to maintain the initial contract. It was understood that as she had gained some insight into her problems, she should be allowed to handle them independently. Follow-up suggests further development beyond the gains achieved during sessions. Several researchers indicate the same utility of brief therapy and how the gains reduce in successive sessions (Messer and Warren 1995). Reflections regarding the outcome on the above mentioned therapeutic sessions reveal several improvements. First, she was able to acknowledge wide variety of emotions and not only stuck on aggression. Second, her symptoms reduced greatly and on follow up she reported being slightly restless and depressed, but on the whole she was symptom free. Her coping within the family especially to the critical comments of the father, had marked improvement. No incident of hitting elder sister was reported in last 18 sessions of therapy. Thus, she had gained a lot of control over behavioural manifestation and interpersonal relations. The changes in her inner dynamics of personality were evident by the analysis of her TAT stories before and after the therapy. The efficacy of BDP is mentioned earlier too by a large body of outcome research (Levy and Albon, 2009). Unravelling the roots of personality disorganization 47

Conclusion: Though it is a single case study, the authors have tried to mention each session, process of intervention and outcome. This work can serve as a pilot study regarding the use of modified Brief Dynamic Therapy (BDP) approach in clients with deep emotional pathology. Further research in this area needs to explore the qualitative as well as quantitative aspects of process and outcome. References: Balint, M. and Balint, E. (1961) Psychotherapeutic Techniques in Medicine. London: Tavistock. Bellak, L. (1975) The thematic apperception test, the children's apperception test and senior apperception test in clinical use. Grune & Stratton. New York. Bion, W. (1962a) A theory of thinking. International Journal of Psychoanalysis, 43: 306-310. Bion, W. (1962b) Learning from experience. In W.R. Bion (Ed.) Seven Servants: Four Works. New York: Jason Aronson. Bowlby, J. (1980). Attachment and loss.Vol 3.Loss, sadness, and depression. New York: Basic Books. Davanloo, H. (ed.) (1980). Short Term Dynamic Psychotherapy .New York: Aronson. Fenichel, O. (1945). The Psychoanalytic Theory of Neurosis. N.Y. W.W: Norton. Holmes, J. (1994). Brief Dynamic Psychotherapy. Advances in Psychiatric Treatment; vol. I, p. 9-25 Kernberg, O. F. (1994). Aggression, trauma, and hatred in the treatment of borderline patients.Psychiatric Clinics of North America, 17, 701-714. Kernberg, O. F. (1975). Borderline conditions and pathological narcissism.New York: Aronson. Lemma, A. (2003).Introduction to the Practice of Psychoanalytic Psychotherapy. West Sussex: John Wiley & Sons. Levy R.A. and Albon J.S. (2009). (eds.) Handbook of Evidence-Based Psychodynamic Psychotherapy. Boston. Humana Press. Linehan, M.M. (1993) Cognitive-behavioral therapy of borderline personality disorder. New York: Guilford Press. Malan, D. (1963) Study of Brief Psychotherapy. London: Tavistock Malan, D. (1979) Individual Psychotherapy and the Science of Psychodynamics. London: Butterworths. Messer, S. B. and Warren, C. S. (1995). Models of Brief Psychodynamic Therapy : A Comparative Approach. New York: The Guilford Press. Ogrodniczuk, J. and Piper, W. (2004). The evidence: Transference Interpretations and patient outcomes - A comparison of types of patients. In Core Processes in Brief Psychodynamic Psychotherapy: Advancing effective practice ( ed. Charman, D.P.), pp 165 -184. New Jersey: Lawrence Erlbaum Associates. Orlinsky, D. and Howard, K. (1986) Process and outcome in psychotherapy. In Handbook of Psychotherapy and Behaviour Change (eds S. Garfield & A. Bergin), pp. 56- 102. Chichester: Wiley. Ryle, A. (1990) Cognitive Analytic Therapy: Active Participation in Change.Chichester: Wiley. Segal H. (1975). Introduction to the Work of Melanie Klein. Ed. Khan M.S. London: Hogarth Press. World Health Organization (2006) The ICD-10 Classification of Mental and Behavioural Disorders. Geneva. Author. 48 Mitra et al

The Somatic Inkblot series (Cassell, 1990, Cassell and Dubey, 2003) was administered to a 17 years old girl of 12th grade. She was suffering from tension headache for last 2 years. Her other complaints were feeling heaviness and tightness in head, nausea, muscular stress, tingling sensations, numbness, feeling tiredness and physical weakness. She was diagnosed as a case of Tension Headaches by her physician. The SIS responses projected her intra psychic conflict, poor interpersonal relationships, pent up aggression, inferiority complex and disturbed family functioning. The SIS images were used as therapeutic intervention tool with positive outcome. Women are now experiencing greater opportunities to express their unique contributions to 21st century society. Yet for many, optimizing their innate potential has posed a variety of body-mindspirit stressors. International epidemiologic studies have correlated certain dimensions of these, with ill understood, genetic influenced susceptibility to Mental Disorders. Clinically these are characterized by depression, anxiety and concomitant stress induced somatic symptoms (e.g. Women have increased rates of Unipolar Depression by a factor of two). Clinical investigators trace such significant differences in prevalence to the multidimensional interplay between somatic and psychological stressful events. Often, as in the present clinical study, these begin in adolescence. The case involves a seventeen year old Indian girl who was diagnosed by her physician as suffering from "Tension Headaches". It illustrates how such a stress induced spatially focused somatic symptom pattern may be effectively managed with SIS Guided Psychotherapy. Her Indian female psychologist selected the SIS- II Booklet as a visual stimulus series. This projective instrument provided a psychological compass for facilitating symbolic visual image structured psychotherapy. Utilizing a projective instrument capable of stimulating in the Body Gestalt anatomical imagery denoting the "Brain" effectively empowers therapy. This technique is spatially consistent with an established SIS theoretical model of stress induced somatic symptoms. In this case, it is postulated that the suffering girl's mental defense mechanisms converted her psychosocial Dysphoria to excessive psychophysio-lgical arousal. Ultimately these became secondarily subjectively perceived within the Body Gestalt as "Aches in the Head". Here the therapist needs to first demonstrate through SIS symbolic interpretation to the client, the link in time/body space between the external stressors and onset of focal somatic discomfort. Once this association is established, then traditional psychotherapeutic technique may be initiated. This case report will serve to illustrate a basic modification in the detailed enquiry section of assessing SIS evoked responses in a client suffering from localized regional discomfort. Essentially the clinician begins the detailed assessment in the standard way. This involves obtaining associations to first the "Three most liked" inkblots" and those next to the "Three least liked Inkblots". Once these data are obtained, next, attention is directed to obtaining information regarding how the suffering client responds to SIS structure suggestive of the symptomatic body region. In this case, that primarily involved the "Brain". When a client first seeks therapy with presenting regional somatic disturbance, it facilitates confidence by initially focusing attention on the specific anatomical organ system. In addition to the above inkblot order administration innovation, the case will also outline a conceptual model for supplementing SIS Guided "Body-Mind" therapy with SIS Guided Spiritual Therapy.

Clinical Considerations: The client is a 17 years girl studying in 12th grade. Her personality appearance is like tom boy with heavy weight. All of her birth and developmental milestones were normal, with no past history of behavioral, psychological or neurological problems. She was referred to the "Nai Subah psychotherapy and counseling centre" Varanasi, with the chief complaint of severe tension HEAD- ACHES. Other problematic issues involved heaviness, excessive anxiety and general difficulties in controlling her life. She was worried and totally confused about a peer female relationship. She had contradictory thoughts due to her faulty family environment and fear of her elders. Self-Concept of the Client: She described to herself as a very fun loving person who enjoyed company of fun loving peoples. She viewed herself as very soft hearted adolescent who did not want to see any one crying. She said that she is good to those who are good to her and worst to those who are bad to her. She wanted her parents to trust her and allow her to go out with her friends. She related an incident when one day she left home without informing them and came back very late. She said: "I felt regret and sorry but my Dad does not trust me". Responses and interpretation: Three most liked images: A13: "A free man…it shows freedom…I want to be free". This reflected her desire to get free from her parents. This represented a direct projection of her frustrated fantasy of being independent of her dysfunctional family. As will be shown, the frustration of this desire recurs throughout her viewing experience. A6: "Happy boy after getting an appreciation and gift from others". This may indicate her unfulfilled desire to get appreciation and gifts from her parents. A9: "Two girls exchanging their heart". This projected response depicts positive emotional bonds between her and a girlfriend. As will be subsequently shown, this relationship is associated with undercurrents of ambivalent sexuality Three least liked images: A15: "Fetus": She was reluctant to say why this image was so disliked. Yet remarkably enough in viewing A26 she added the descriptive affect linkage as a "sad" fetus. The third instance involved viewing B27 whose inkblot structure depicts "twins in utero", Here she only gave the affect description as "Being apart". Such symbolism reflected her stress induced age regression, and sadness due to her perceived isolation from her family. B5: An elder person giving advice or lecture to their younger. This may represent her poor interpersonal relations with her father. B19: Two hearts getting apart. This card represents the insecurity feeling of client. When her SIS therapist asked her she replied: "My parents do not allow me to meet my best friend with whom I share my problems…and I miss her very much". Chief Presenting Somatic Symptom of Headaches and Brain Responses: In viewing B6, she projected the response "internal parts of the brain which are splitted". This response clearly represents a vivid example of the "Projection of a psychic image whose anatomical content directly depicts the area in her subjective Body Gestalt linked to her presenting somatic symptom pattern of "Headaches". While there is embedded structure purposely designed into the so-called "inkblot" BB, it may be observed that the ambiguous design depicts "the lower abdominal region/pelvis with two upper thighs". Here in her vivid description, she described in symbolic Body Language, her pathologically distorted somatic perception of experiencing "splitting headaches". Next her responses to B20 and B21 will be reviewed. For the former she correctly identified the brain. However, projecting a reference to the "inside" of the brain symbolized the fantasized "inner" deep location of her severe recurrent pain. When moments later in imaging what the following inkblot resembled, in a neurologically perseveration like fashion still resonating in her 50 Cassell et al

A25: "A scary and bad soul leaves his body." Here the psychotherapist needs to clarify why the death scene is so anxiety provoking, as well as whose "bad" soul could this symbolize". A26: "A sad fetus". Here a question might be asked such as "When you are stressed, do you sometimes feel sad, helpless and even childlike?" A29: "A pistol explode and an animal". Since there is no structure consistent what she imagines to see in the inkblot, again her vision is totally shaped and emotionally colored by projection. Here again in the detailed enquiry, questioning concerning the intensity and direction of her hostile/ aggressive impulses need close professional scrutiny. Are they directed towards herself, others or both herself and others?" B13: "An elephant being pushed into a hole". This symbolizes the social pressure that she feels from her punitive parents to conform. B14: "A heart cut by a knife." Like that observed in A29, this is highly serious symbolism. It brings to mind a psychotic adolescent girl whose mother awoke to find her daughter poised over her to stab her with knife in hand. B15: "Pieces of glass and a person being hurted!" B17: "A blurred heart." Here her psychotherapist might further question her regarding disturbances in her cognition as follows: "Do your heart felt emotions and thoughts ever seem confused?" Psychotherapeutic Exploration of Human/ Animal Content: Finally it next becomes helpful to explore through free association those with disturbed human/animal content, not previously assessed in the "Liked" and "Disliked" detailed enquiry. Exiting on this theme, sets the stage for futuristic therapeutic bridging from "soma" to "psychic" to "spiritual" subject matters. visual cortex from B20, she projected the affect loaded image "Exploded granite". Thus her SIS Somatic Symbolism moved symbolically in description from "Splitting" headaches to "Explosive" ones. Empathetic Translation of SIS Somatic Symbolism: Fig 1: Image B6. SIS guided therapy & tension headaches 51 Somatic symbolism provides a unique opportunity for the psychotherapist to enhance empathetic bonding by speaking in feedback language such as "You must suffer a greatly when you are stressed, since somehow, your brain feels like it is going to split, or even explode!" This same linguistic strategy may be used with other Dysphoric affect charged somatic symbolism as follows: A5: "A sad heart which was not happy…after happiness... changed into smoke". Here a therapist might proceed as follows: "Tell me when your "heart last felt happy…and then when did your happiness turn into smoke and you became sad?" A12: "Looks like a hassle ear…it doesn't want to listen to others". Here clarification is required as follows: "Does this represent you in times when you feel hassled and don't want to listen?" Or could this represent your parents not wanting to listen to you?" A21: "A dead bird surrounded by blood." When you feel sad and isolated from your loved ones, do you ever think about death or even contemplate hurting yourself?"

A1: "It seems like two hens with long hair or kissing together." Here a question regarding expressing her relationship with her girlfriend regarding same sex affection/ sexuality might be explored. This issue first surfaced in her visualizing "Two girls etc." A3: "A witch who is dangerous". This symbolized her abusive mother. A4: "A woman hitting with a vacuum cleaner her child". This depicts inappropriate physical abuse. A7: "A dancing snake…an apple". Here she failed to assimilate the separate components into the gestalt response of a "Dancing woman". This may signify problems in accepting a mature feminine Body Gestalt. Her personality presentation and appearance was "Like a Tom Boy with heavy weight." A8: "Fatty figure of a girl and because of her fat body she is not happy." Like with A7, her therapist is alerted to include resolving in the treatment plan stressful issues related to both her feminine obese Body Gestalt. A10: "One boy and one girl between whom one wall is there". Here she avoided reference to the facial structure embedded in the inkblot. Perhaps the "wall" symbolism dividing a symbolic heterosexual social relationship needs to be examined under a psychoanalytic lens. A16: "Two dolphins kissing". It might be relevant to enquire into the sex of the kissing animals. A18: "Two girls are dancing inside a heart shape". Here there is more projective evidence of the homosexuality sexual issues facing adolescents at her stage of psychosexual development. This again appears with A24 below. A24: "Two men are holding each other tightly". A28: "A confused girl." Since there is no human structure in this inkblot resembling the human thigh, her response represents a powerful symbolic description through projection of her own Dysphoric determined cognitive confusion. A31: "Scary mother scolding her child in badly manner". Many viewers visualize a "Happy family" scene. Sadly for her this vision of a dysfunctional mother represents a direct symbolic presentation of her family's need for family therapy. B1: "It seems like a person wants everyone to be like him". Here there is no human structure in the inkblot design to warrant seeing "A person". Moreover, it is significant in regard to her own self- concept that she ascribes masculine identification to the individual. B4: "A mother wants her child to be like her". In view of her earlier statement of wanting "Freedom", this response opens the discussion of her stressful relationship with her mother. The subject continues below for B5. B5: "An elder giving advice to their younger". B8: "A ghosted moon", B10 "vampires…Dracula" and B12 "A witch with a poison bottle" all have in common threatening human like imagery. In regard to the latter denoting death by poisoning, her therapist again was symbolically warned about her experiencing unexpressed dangerous impulses. The ominous theme continues with her visualizing B18 as "A path between which an axe is lying" B27: "Being apart". Here her therapist can empathetically recognize her client's sense of isolation and then provide a socially acceptable feminine object as herself as a surrogate positive maternal figure. B28: "Mother loving her child…not possible". Here her therapist can undermine her hopelessness by educating her on the positive value of family therapy and spiritual acceptance of God's healing power. B29: "A handicap man trying to run fast". Her therapist might make a positive suggest as follows: "In some ways with you family stressors you are like him…trying to run too fast…please realize that there is much 52 Cassell et al

hope for you and your loved ones but in psychotherapy you must be patient and not rush". B31: "A happy family but a girl, apart from them, like me". This provided another opportunity for her therapist to empathize with her adolescent sense of alienation from her family. SIS Spiritual Psychotherapy: It may be recalled that many of the previously reviewed SIS evoked responses symbolized stressors due to her being required (for economic reasons) to reside with her dysfunctional family. Until overall therapeutic change occurs in the immediate psychosocial environment, such an adolescent often may benefit from supplemental SIS Guided Spiritual Therapy. This fundamental principle of supplementing traditional forms of treatment with support in the spiritual dimension may be applied in many Mental Disorders. Sometimes when SIS stimuli evoke visions with spiritual dimensions, these enable a SIS trained therapist to introduce the healing supernatural dimension of positive spirituality into therapeutic sessions. In this SIS training report, the supernatural vision evoked by B25 presented in Figure 2 "HOLDING EARTH IN HIS HAND" serves to illustrate this phenomenon. Fig.2 Image B25 matic-Psychological" to what atheistic critics would label as irrational "Spirituality". There are multiple SIS stimulated psychobiologic pathways to empower therapists for building a bridge from known reality foundations to less tangible spiritual dimensions. When the Booklet version of SIS-II is used as the projective technique, (i.e. not the mesmerizing/hypnotic floral video or computer monitor versions) the therapist might, as a first step, choose to induce a cognitive altering trance state through either hypnosis or Yoga induction procedures. In the case under consideration, the second step would involve instructing the adolescent girl to open her eyes for 10 seconds to view B25. Thirdly, such a subject would be instructed to recall in memory the inkblots "After image" and then actively focus on it. Fourthly the individual would be instructed to visually/emotionally expand on the inkblot structure reminiscent of positive spiritual power. The typical victim should be advised to conjure up in subjective awareness his/her particular religion's sacred Deity symbols. In this case illustration, the adolescent Hindu girl, could create in her imagination a "mental picture" of loving feminine Hindu Deity figure. As she daily practiced this, it would undermine her psychological Dysphoria until more long term psychosocial stressors were resolved by traditional psychotherapy (Cassell, 2011, Cassell, et. al., 1997, 2001, 2012, Dubey, et.al. 2012). Moreover, it would enrich her inner sense of femininity and positive spiritual life. Conclusion: The Somatic Inkblot Series Booklet form was administered to a 17 years old girl, suffering from tension headache for the last 2 years. The SIS responses projected her intra psychic conflict, poor interpersonal relationships, pent up aggression, low self, body anxiety, disturbed family functioning and feeling of alienation from her family. She also projected evidence of the ambivalent sexual identity issues facing adolescents at her stage of psychosexual development. Her traditional psychotherapy was supplemental with SIS Guided Spiritual Therapy. SIS guided therapy & tension headaches 53 To believers in a higher positive plane of psychic existence, only God could symbolically have such immense power. For such therapists, this vision effectively provided an interview bridge for mystically moving conceptually from a reality scientifically based conceptual platform of "So-

References: Cassell, W. A. (1990) Somatic Inkblot Series Manual. SIS Center, Anchorage, Alaska (USA). 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. (2011) Editorial: Dissolving Death Anxiety with Yoga Empowered. SIS Journal of Projective Psychology & Mental Health, 18: 123-128. Cassell, W.A. and Dubey, B.L. (2012) Spiritual Warfare and SIS Spiritual Symbols, SIS Journal of Projective Psychology & Mental Health, 19: 80-90. Cassell, W. A., Illardi, F.J., Collins, A., Mishra, M. and Dubey, B.L. (2001) Optimizing Spiritual Healing by Assessing 54 Cassell et al Dream and SIS Imagery. SIS Journal of Projective Psychology & Mental Health, 8: 75-94. 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 Dubey, B.L., Pandey,P.,Tiwari,A. and Mishra,N. (2012) Assessing Sexuality "Homosexuality", SIS Journal of Projective Psychology & Mental Health, 19:2, 121-125. Web references: www.who.int/mental-health/prevention/ gender/women/en Girlshealth.gov Womenshealth.gov

This is a pilot study to see the effect of medical intervention on the responses of Rorschach Inkblot Test and Somatic Inkblot Series-II in a case of Schizophrenia. The study shows how clinicians can effectively supplement Rorschach data utilizing SIS - II images to monitor the progress of the treatment. In this instance the chief symptoms of hyper sexuality was dramatically reduced. The addition of the SIS data facilitates understanding the significance of hidden desires of the psychotic patient which otherwise would have not been revealed. The success of treatment in any mental disorder lies in its response curve. There are several established ways to measure the efficacy of therapy. Historically, the Rorschach diagnostic test has served as a useful clinical diagnostic projective test. Because of Wilfred Cassell having designed inkblots with more clinically relevant structure, which still have ambiguity, the Somatic Inkblot Series (SIS) (Cassell 1980, 1990) has surpassed Rorschach as a clinical instrument. In his editorial of January 2011(Cassell, 2011) "Changing Personal and Professional SIS Perspectives" he stressed that future claims of success should be based on evidence based scientific studies. In view of this the authors designed a pilot study to follow a patient chronically suffering from Schizophrenia and the impact of electroconvulsive therapy combined with antipsychotic drug. In this instance to reduce the risk of homicidal/suicidal behavior, the electroconvulsive therapy was used in conjunction with anti-psychotic pharmacotherapy. The research design involved assessing baseline Rorschach and SIS data before and after the treatment. The goal of this initial pilot study involving a single case was to set the stage for more formal statistical study using psychometricians blind to the clinical status of the subjects regarding before and after treatment status. Case History: A 40 year old married Hindu male (Mr. X) was admitted to a tertiary care hospital with overdose of antipsychotic drugs Tab Risperidone. He had consumed 15 tablets of Tab Riperidone of 2 mg strength and brought by his wife to the casualty department from where a psychiatric consultation was completed. The patient was conscious at the time of hospitalization. Gastric lavage was carried out. An IV line was set up and he was closely monitored. At the time he was highly suicidal and believed that he will not survive the over dose. Detailed history revealed that he was first diagnosed as severely mentally ill and suffering from Schizophrenia since 2000. When he attempted suicide, he was on maintenance treatment with Tab Risperidone 2mg twice a day. Although he was not completely symptom free, he was well enough to attend his factory job. The Illness had manifested gradually in the form of withdrawal from friends and social circle, tendency to remain aloof, disinterested in work at hand, complaining that his colleagues were plotting his removal from the job, hearing voices of unknown persons, sleeping at odd hours, removing clothes in front of his family members, hyper sexuality, poor selfcare, becoming aggressive for no reason etc. Methodology: The projective tests were administered both before and after treatment. The medication involved an atypical antipsychotic drug (Olanzapine 10 mg once a day) to which he showed good response. Ten electroconvulsive treatments were administered under general anesthesia.

Results: The findings are reflected in the tabular form. The results obtained by these two projective procedures are presented in Table 1. Table 1 Response on Rorschach test before and after Therapeutic Intervention Card No Rorschach Responses on First Assessment Rorschach Responses on Repeat (September 6, 2012) Assessment (October 8, 2012) I Sexual activity Bat II No response No response III No response heart IV No response No response V No response Butterfly VI No response No response VII No response No response VIII No response lungs IX No response Heart X No response No response Although he has given only one response on the Rorschach, this is consistent with his sexual preoccupation and hyper sexuality. The protocol indicated poor productivity, blocked thought processes and psychotic protocol. After treatment he responded to 5 cards and rejected 5 cards. Although clinically, his overall status looked improved, the Rorschach protocol is still relatively restricted and non-conclusive. However, the qualitative analysis suggested improved productivity, withdrawal from reality, impaired emotional control and a schizophrenic protocol. Thus, the data suggests that the treatment as based on the Rorschach was consistent with notion of the improvement for this particular case. Table 2 Response on SIS- II Series-A before and after Treatment Images SIS Responses SIS Responses Scoring Scoring (Pre-treatment) (Post- treatment) Pre ECT Post ECT A1 Breasts of female 1.Butterfly, 2.cloud/Sky A good image makes me to feel happy Sex, AT A, AT, A2 Human Brain, Nice image Brain At, AT, At, AT A 3 Rejected Flash of light/crack in the wall, image can be associated with fear Rej AT, D A 4 Thighs of a man with male genitals Image of trees with shade in surrounding area, a relaxing image Sex, AT AT A 5 Sexual act between a man and a woman. A Cartoon image/Man standing 56 Cassell et al

with arms spread out Sex, H, M, AT H, AT,M A 6 Legs of a female A man standing with a stone kept on the side Sex, H, AT H, AT, P A 7 Body of a female; nude, genital area 1. Body and face of a female. 2. An apple can be seen at the top of the image. Sex, H, T, MT, H, MT A 8 Image of a man; face not clear; legs and penis visible A child standing nude; Might be a male due to the genitals shown Sex, H, T H, M, Sex, T A 9 Breasts of a female Two men standing/or might be two fingers of a man Sex, AT H, M, MT A 10 Chest area of a person; unclear male or female Two eyes, a nose visible; may be a man/a woman looking out of a window H, AT H, M, P A 11 Rejected Ear of a man Rej. H, AT, P A 12 Ear of a man Ear of a man. (Better than the previous image) H, MT H, MT A 13 Image of brain A hand is shown with fire/leaves around the hand At, AT H, MT, (HAS) A 14 Rejected Image of the stomach Rej. At, T A 15 Internal genitalia of female Image of kidneys Sex, H, AT At, T A 16 Image of breast of a female 2 birds kept in a cage ; may be crying to get freedom Sex, AT A, M, T, D A 17 Legs and genital area of a female Below waist area of a man/ woman wearing a sari / dhoti H, Sex, T H, T A 18 Female genitalia with vaginal opening (a very fine picture of the area). 1.Image showing brain of a person 2.face Sex, T At, T, H A 19 Lower limbs/ Female. Pubic region .Female sitting Rejected H, Sex, M, AT Rej A 20 Breasts of a female Kidneys of a dead person Sex, AT At, MT, PAS A 21 Single Breast of a Female A bird flying; Beautiful image Sex, AT A, M, T A 22 Breasts of a female Image showing a tall tree Sex, AT AT A 23 Vertebral column Vertebral column At, T At, T A 24 Rejected Legs of a person with knees shown prominently Rej H, AT A 25 Looks like genitalia of the female 1. Image may represent fish 2. kidney of a person Sex, T A, AT, At, AT Therapeutic intervention in schizophrenia through SIS & Rorschach 57

A 26 A nude female lying on her back and having intercourse. Knees of a person M, Sex, H, AT H, AT A 27 Side view of female breast A beautiful waterfall Sex, MT Good response A 28 A very nice image of hand of a person Hand of a person H,T H, T A 29 Rejected Rejected Rej Rej A 30 Head or skull of a man Skull of a person At, MT At, MT A 31 Image of a man and his wife talking romantically Man and his wife standing together and talking M, H,MT M, H,MT Table 3 Summary of Mr X's SIS Protocol: Pre and Post Treatment Pattern of Pre-ECT Post -ECT Interpretation Responses Total number of responses 33* Increase in the number of responses after ECT indicates significant improvement in productivity and thought processes. Human Responses Post-ECT increased Human responses indicate interest in people, high self-esteem and improved interpersonal skills. Anatomical responses 8* Increase Anatomical content after post ECT may indicate somatic preoccupation, and associated somatic symptoms which he was not aware of because of disturbed thought process, is also an indicator of Schizophrenia (Cassell, 1980). Sex Responses 01* She gave significantly very high Sexual contents amounting to sexual preoccupation an indicator of Schizophrenia which improved after ECT. Movement Responses 07* Patient has become more active and interacting with others (improved H). Most Typical responses 08* Before ECT he gave 4 MT responses which indicate schizophrenic protocol whereas an increased MT (MT 8)after ECT indicate that the person has started seeing the world like others and have contact with reality.. Typical responses No change almost similar. Atypical responses 12* Reduced Atypical responses after ECT and medication indicate better thinking and contact with reality. 58 Cassell et al

Rejection of images Less rejection of images after intervention suggests better perception. Animal responses 04* Not clinically significant. Pathological Anatomy Not clinically significant. Depression Not clinically significant. Hostility Aggression Not clinically significant. Paranoia Heightened paranoid features are indicated by his responses on image A10: Two eyes, a nose visible; may be a man/a woman looking out of a window, and on image A11: Ear of a man(both pre and post ECT) are strong indicator of Schizophrenia with paranoid feature. The comparison between - Pre ECT and Post ECT perception of SIS inkblots indicated increased number of total responses after ECT which indicated significant improvement in productivity. The Post-ECT increased Human responses may indicate higher social interest in people, higher self-esteem and improved interpersonal skills. Increase Post ECT Anatomical content may indicate more accurate somatic preoccupation and awareness of otherwise neglected somatic symptoms which he was not aware of earlier, because of disturbed thought process. Cognitive and perceptual difficulties experienced by schizophrenics along with somatic preoccupation have also been reported by Blatt and Wild (1976). Cassell (1980a) reported that the inkblots make accessible the schizophrenic's tendency to be preoccupied with or cathected to their bodies. And body consciousness is frequently heightened because schizophrenics are flooded with somatic imagery from increased feedback of interoceptive sensations of physiologically aroused organs (e.g. he perceived Brain on image A2 both pre and post-test). Thus he retained, after treatment, the concerns about his brain's psychotic dysfunctions. Chapman (1966) has also found that schizophrenics give emphasis on physical symptoms. Significantly very high Sexual contents before ECT are an indicator of Schizophrenia which improved after treatment even though his subjective insight about his brain's psychotic malfunctioning persisted. He perceived only 4 Most Typical responses which is a strong indicator of Schizophrenia, which increased to 8, almost to normal level after ECT. The average number of Most Typical responses generally found in various studies are more than 13 (7 in Series A and 7 in Series B), which may indicate that the person tends to see the world like others and have adequate contact with reality. The fewer MT may indicate low contact with reality as in Pre ECT protocol. Reduced Atypical responses after treatment indicate better thinking and contact with reality. Less rejection of images after intervention suggests better perception. Heightened paranoid features are indicated by his responses on image A10: "Two eyes, a nose visible, a man/ a woman looking out of a window", and on image A11: "Ear of a man" (both pre and post ECT). Cassell (1980, p 70) has reported "Ear awareness and auditory hallucination" in a case of 20 years old male schizophrenic patient. Such features need to be addressed by the therapist during therapy session. Patient's View about the SIS procedure: It is a test that connects me to the doctor. I feel that the doctors are trying their level best to understand my problem better through this beautiful test. However, he could not recall having taken this test before ECT. Therapeutic intervention in schizophrenia through SIS & Rorschach 59

Discussion: It is always better to exercise caution in a psychotic patient under treatment with various available modalities i.e. psychotropic drugs, Psychotherapy, physical methods like ECT when he is evaluated for response to treatment. A number of investigators have employed the SIS in evaluating the medical and psychiatric patients (Sengupta, et al 2012, Cassell, 1977, 1984, 1996, 2010, Rathee et al 1994, 1995, Gaetani, et al 1995, Mishra, 1996, Saldanha and Dubey, 1995, Singh et al 1996, 1997, Kiranbala, et al 2010, Mishra, et al 2010). The SIS employs quantitative and content analysis to analyze the responses that the individual has given. The increased sexual content on various somatic cards might be because of the clinical nature of schizophrenia as well as use of antipsychotic drugs before the administration of ECT. One of the side effects of the drug being the hyperprolactinemia causing reduced libido which was distressful to the patient hence he somatised his inner craving for sex through increased sexual responses. Soon after the exposure to ECT and reduction in therapeutic levels of the changed atypical antipsychotic drugs, the sexual content decreased significantly and the patient showed marked improvement in his behavior. His wife also remarked that the patient is not having persistent demands for sex as before when he was acutely sick. After the treatment, he is more tolerant and able to understand her sensitivities towards sex. Conclusion: The Rorschach and SIS were administered before and after the treatment to measure the changes in patient's clinical status. Rorschach protocol showed some positive differences, though nonconclusive. However, the SIS-II protocol reinforced, especially in regard to assessing sexuality, the utility of assessing the hidden desires more effectively for treatment and follow up. The patient further felt that he is more able to express his inner feelings. It is hoped that other clinical investigators will pursue the interesting lead of this pilot study. References: Blatt, S.J. and Wild, C.M. (1976) Schizophrenia: a Developmental Approach, New York, Academic Press. Cassell, W.A. (1977) Aggressive Imagery and Clinical Symptoms in Schizophrenia. British Journal of Projective Technique, 16: 21-23. Cassell, W.A. (1980) Body Symbolism and the Somatic Inkblot Series. Alaska, Aurora Publication. Cassell, W. A. (1980a) Body Awareness and Somatic Delusions Involving Sexual Organs. American Journal of Psychoanalysis, 40: 125-135. Cassell, W.A. (1990) Somatic Inkblot Series Manual. SIS Center, Anchorage: Alaska. Cassell, W.A. (2011) Changing Personal and Professional SIS Perspectives: Editorial. SIS Journal of Projective Psychology & Mental Health 18:1, 1-3. Cassell, W.A. (1984) Somatic Inkblot Series Video, SIS Center. Anchorage, Alaska (USA). 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 Journal of Projective Psychology & Mental Health, 3: 2, 131-145. Cassell ,W.A. and Dubey, B.L.(2010) SIS II-Video Treatment of Alcoholism.. SIS Journal of Projective Psychology & Mental Health, 17: 2, 104-119. Chapman, J. (1966) The early symptoms of Schizophrenia, British Journal of Psychiatry,112: 225-251. Miashra, D.K., Alreja, S., Jahan, M. and Singh, A. R. (2010) SIS-II Profile of Epileptic Patients. SIS Journal of Projective Psychology & Mental Health, 17: 2, 187-191. Gaetani,G.Fiorenzo, L. Alfio, L.Giovanni, S.Rosanno,V.and Ferro, R.(1995).Corporal Perception in HIV Positive and Negative Heroin Addicts Assessed with SIS-I. SIS Journal of Projective Psychology & Mental Health, 2:2, 97- 118. Kiran Bala, Mishra, D.K. and Jahan. M. (2010) SIS-II Profile of Patient with Antisocial Personality: A case report SIS Journal of Projective Psychology & Mental Health, 17: 2, 178-179. Mishra,M.(1996) Compatibility of SIS-II and the Rorschach Indices in Normal, Neurotics and Schizophrenics, Ph.D. Thesis. Banaras Hindu University. Varanasi. Rathee, S. P., Goel, D. S., Chawla, M. L. and Saldanha, D. (1994) A Study of Somatic Inkblot Series-I in Coronary Cases, SIS Journal of Projective Psychology & Mental Health, 1: 51-64. Rathee, S. P., Pandey, V. and Singh, A. (1995) Diagnostic Efficacy of Somatic Inkblot Series-II amongst Psychiatric Patents of Armed Forces: A Preliminary Study. SIS Journal of Projective Psychology & Mental Health, 2: 1, 61- 66. Saldanha, D.and Dubey, B. L. (1995) Effect of Sodium Pentothal on SIS Video-A Inkblot Images. SIS Journal of Projective Psychology & Mental Health, 2:1, 19-28. 60 Cassell et al

Sengupta, A. Mishra, N. and Dwivedi, P. (2012). SIS Journal of Projective Psychology & Mental Health, 19: 2, 126- 130. Singh, A. R. and Banerjee, K.R. (1996) Efficacy of SIS-II in Discriminating OCD Patients and Normal. SIS Journal of Projective Psychology & Mental Health, 3: 2, 165-169. Singh, A.R.and Dubey, B. L. (1997) SIS-II Profile of Drug and Alcohol Dependent Cases in Discriminating OCD Patients and Normal. SIS Journal of Projective Psychology & Mental Health, 4: 69-74. Acknowledgement: The authors gratefully acknowledge Dr. Wilfred A.Cassell and Dr Bankey L.Dubey for their valuable contribution; insightful advice and making us understand the value of SIS instrument and Rorschach Projective test in this case. Therapeutic intervention in schizophrenia through SIS & Rorschach 61

population. In the recent period it is primarily used with the clinical population. Different scoring systems are followed in the country. Though research findings showed the usefulness of Rorschach Inkblot Test in diagnosis, understanding psychopathology and in therapy, research interest related to the use of the Rorschach Inkblot Test in India appears to be declining. There is a need to revitalise the training on its use, interpretation and research. The case report of a patient who had not undergone psychotherapy and showed the consistency of the responses even after an interval of fourteen years is presented. Probably there are a group of patients who maintain their perceptual structure, unaffected by ageing and input from environment, in the absence of receiving any form of psychotherapy. The Rorschach Inkblot Test was introduced in India more than half century ago with the pioneering works of Asthana in 1947 (Manickam and Dubey, 2005). In the initial part of the introduction of the test in India, studies were conducted on the general population, especially students, in educational setting (Dosajh, 1956; Raychaudhary and Maitra, 1965). In the clinical setting it gained more acceptance in the later part of the last century (Dubey et.al. 1982, 1991, Mishra and Dwivedi, 1997; Kohli and Kaur, 2002). While its potential with the clinical population was realised, there was decline in the number of studies that used the test in the normal population other than those tested as part of the control group. However there was no major research that evaluated the psychometric properties of the test, either in the form of validation of the test or reliability of the test in recent years. Scoring accuracy is of great concern to clinicians and Guarnaccia et. al., (2001) assessed it using the Comprehensive System (CS) and reported that accuracy scores were better for the code categories of Location, DQ, Pairs, Popular, and Z than for Determinants, FQ, Content, and Special Scores. However based on their study of 20 Rorschach Inkblot Test responses by 21 graduate psychology students and 12 professionals they concluded that there are high levels of scoring errors. On the other hand, Meyer et. al. (2002) described excellent reliability across 8 samples and found 133 to 143 statistically stable CS scores. The authors also demonstrated that the reliability findings from their study closely matched the results derived from prior research. It showed that CS summary scores were more reliable than scores assigned to individual responses. Another important finding was related to sample size of the studies and they observed that small samples are more likely to generate unstable and lower reliability estimates. The clinical utility of the Rorschach Inkblot Test remains unchallenged and still is used with much vigour (Meyer and Archer, 2001; Exner, 2007). Moreover, a later review of the studies confirmed the strong empirical evidence of the inter-rater reliability of this measure when scored by a well-trained and diverse group of researchers and clinicians (Viglione and Taylor, 2003). The authors reported high inter-rater reliability statistics for 70 interpretative Rorschach variables, breaking down interclass correlation statistics by base rate. They also suggested that large samples are needed for stable reliability estimates of low base-rate variables and that estimates of the reliability of low base-rate variables are subject to error. From India, a single case was reported by Dubey et. al., (1994) who administered Rorschach Inkblot Test to one client at an interval of 6 months period and found consistency of 4 responses on two cards, card IV and VI, and slight changes in two other cards. Silverstein (2007) reported a case where the client who was on psychotherapy for 4 years was administered Rorschach after an interval of 2 years and followed up after 30 years and

Consistency of Response Pattern on Rorschach 63 compared it on the basis of structural summary analysis and thematic content analysis. Qualitative analysis of Rorschach Inkblot Test which is equally sound has also gained importance in the recent years. There are also many studies that looked into the qualitative analysis of the test. Aronstam (2004) adopted a method of self-interpretation of Rorschach protocol, integrating gestalt perspectives as part of therapy. In a different context, Lerner (2004) attempted an experimental-relational psychoanalytical approach-using Rorschach Inkblot Test. The present paper aims to describe the profile of the response pattern of a patient who was administered Rorschach Inkblot test at an interval of 14 years. The consistency of the response pattern and its implications are discussed. Case History: Mr. X., a 25-year-old male, consulted the psychological clinic 14 years ago, with the complaints of repeated washing and other compulsive behaviour. At the time of first consultation, in addition to the presenting complaints he had sleep disturbance, loss of appetite, keeping aloof, irritability and loss of interest in personal care. He also had indecisiveness and conflict related to his vocation. His relatives consulted a psychiatrist 5 years before consulting the present investigation and he was put on medication for obsessive and compulsive behaviour. However he discontinued the medication since it did not help him. On psychological evaluation, he did not report any problems related to sexual functions and his sexual history as narrated by him was uneventful. Since his biological functions were significantly affected he was referred to a psychiatrist and asked to continue with psychotherapy. The psychiatrist started antidepressant treatment and his biological symptoms improved and was advised against psychotherapy. But he continued to express one symptom or the other and his relatives consulted different psychiatrists over the past 14 years. He was on different treatments as prescribed by different psychiatrists. However, he got back to the initial psychiatrist to whom he was referred after an interval of 10 years. Four years later Mr. X was referred back to the author. He did not recognise him, though he recollected that he did consult a 'psychologist' 14 years ago. As the patient narrates, his 'present problems' started after he got employment in Dubai (three years after his initial consultation). He worked as an office assistant and got promoted to a supervisory job within a short period of time. He continued to be a loner - but developed infatuation towards Ms. A, a colleague who belonged to a different religion. He reported that Ms. A. showed active interest in him, and she took extra effort to help him at his job. As the relationship developed, she invited him to her house, where she lived with her mother. Because of her concern towards him, he strongly felt that she intended to marry him. Though he had similar feelings, he did not express it to her. He believed both loved each other. He communicated to his siblings who were also living in Dubai, about his liking for Ms. A and they encouraged him to get married to her. However, she refused since he had not communicated his wish to marry her, till date. He returned to India for a vacation after six years. He got married to Ms. B, his cousin sister, who was an engineering student. After marriage he realised that she was not the right girl of choice and went back to Dubai, shortening his stay in India. He told his siblings and their families that he did not like his wife but did not communicate this to her. He did maintain occasional communication with his wife through letters. He indirectly expressed his dislike by not visiting her and India for another 4 years. His wife and her family felt cheated and filed papers for divorce. He got legally separated at the age of 34 after paying compensation. On his return to Dubai, he expressed his desire to marry his colleague Ms. A, which was not accepted by her proposal. She got upset about his marriage and started keeping distance from him. Soon she got married to another person. The patient was convinced that Ms A would have married him, had he told his intention prior to her marriage. He also came to know that Ms. A had an unhappy marriage and therefore continued to persuade her to get divorce and marry him. Due to the unpleasant advances made by the patient, Mrs. A made several complaints against

him to the management at the work place and the management asked him to resign four years ago. He joined another company and continued to work in Dubai. Soon after parting from the earlier company, he got married to another lady in India.It was an arranged marriage. His wife belonged to his home town in India, was of the same religion and spoke the same language. He did not share anything about the previous marriage with her. His wife was well educated, working as a bank manager and was living with her mother. They lived together for seven days after the marriage in India and after that he moved back to Dubai. Contrary to the promise his wife made at the time of marriage that she would join him to Dubai within a short period, she did not do even after many months. He made several attempts to take her to Dubai, which was turned down by her. After a year, during his visit to India, his wife asked him not to meet her and she refused to go to his home. Irrespective of that, he made efforts to contact her and also met her through his relatives, but his wife evaded communicating with him, saying that she is physically indisposed and is not interested in meeting him. At this stage, he decided to consult the doctor for professional help to resolve the conflict between continuing with the second marriage or harbouring the idea of getting married for the third time. He denied having any sexual problems. He also denied having any significant sexual problems at his first contact 14 years ago. He reports that he had adequate satisfaction with his earlier and present wife. Contrary to this, his wife reported that he is not sexually active. During his present consultation, he complained of having an unsuccessful married life. He felt that if the thought of the "woman" is taken away from his memory, he would be able to lead a successful married life. He was not willing to attend psychotherapy session, but since his brother insisted, he came for seven sessions. He was not open during the therapy session and hardly shared any relevant information. In the 7th therapy session, he decided to go against the desire of the family to continue the marriage, and divorce his wife. He also planned for a third marriage and terminated the therapy. Treatment History: He was on antidepressant treatment for two years initially. Since he showed improvement, the drugs were withdrawn. It was restarted when he complained of discomfort in his interpersonal relationships again. However, he had consulted several psychiatrists over the past 10 years and reported no relief of the symptoms. Findings on Rorschach Inkblot Test: The Rorschach test was administered 14 years before and re-administered in September 2012. Rorschach Inkblot Test responses on both administrations were compared and shown in Table 1. Discussion: The Rorschach protocols are restricted in productivity during the first (R 20) and second (R 19) administration. A low number of human responses may indicate low level of empathy and poor interpersonal skills which is obvious from his case history alongwith poor interpersonal relationship with his wife and family members. A low number of popular responses may indicate that he has non-conformity of social norms and keeps away from reality. This is also a strong indication of psychosis. High number of Anatomical contents (10 in first and 8 in second testing) may indicate somatic preoccupation, and associated somatic symptoms (Cassell,1980). Preponderance of sexual responses (7 in first and 6 in second testing) may indicate his sexual conflict and sexual fantasies, which is supported by his conflicting marital relationship.Exner (1993) observed that often subjects do not perceive sexual contents because it is not socially acceptable. However, increased sexual content in the absence of Human responses (one in first testing and zero in 2nd testing) may go in favour of Psychopath. Milne and Greenway (2000) studied female sexual responses of 129 normal adult subjects (61 males and 68 females). Results indicated that males giving more female sexual responses were more satisfied with their level of control over internal states and females giving fewer feminine sexual responses reported more emotional control. 64 Manickam

Table 1 Rorschach Responses on First and Second Administration Card Responses at 1st Administration Responses at 2nd Administration 14 years later I 1. Last Vertebra / Near Anus 1. Dressed chicken, wide open 2. Vagina (supporting, standing) 3. Last bone/vertebra /Near Anus I 1. Uterus 1. Vagina and related uterus III 1. Two people 1. Part below stomach, kidney and hip bone 2. Two kidney 2. Vagina and uterus 3. Uterus Ad/Hip bone IV 1. Backside of skull 1. Skull, Spinal cord (back side) 2. Buttocks 2. Ad/Bear V 1. Vertebra 1. Butterfly 2. Structure of a bone(vertebra, supporting structure VI 1. Back side 1. Portion above Anus, Back side 2. Vertebra column structure from top to bottom 2. Like a bird VII 1. Abdomen 1. Abdomen 2. Anus (Supporting Body) (Included in the above response) VIII 1. Skull 1. Skull (side view) 2. Front view of Skull 2. Kidney 3. Kidney, urinary bladder IX 1. Abdomen 1. Vagina 2. Urinary bladder (supporting structure - bone) 3. Kidney X 1. Skull and different parts 1. Uterus (Vagina) 2. Vagina/Uterus 2. Skull 3. Kidney (Anus) * Those in parentheses were explained during enquiry. ** Ad: Additional response However, increased number of female sexual responses on Rorschach Inkblot Test in the index case, and decreased sexual activities in real life does not go hand to hand. This may also indicate exaggerated sexual fantasies as a defence mechanism to protect his ego.The patient had not acknowledged sexual difficulties with two women, whom he married, but both reported his sexual dysfunctions. He has not given any movement response (Human movement or Animal movement) which may indicate poor ego control, low imaginative ability, passive mood and inactivity. Such ratio is often found in young children, psychopaths, and psychotics. Though at the first contact the client's history showed obsessive and compulsive behaviour, but the Rorschach protocol did not indicate any sign of OCD. Longitudinally there was no persistence of either obsessive or compulsive symptoms as reported by the patient. As a whole, the first and the second testings supported more of "personality disorder", "psychopath" with sexual dysfunction. The indices based quantitative analysis of Rorschach Inkblot Test responses often lead to wrong conclusion. Dubey (1982), in a study on 300 subjects, found that most of the Rorschach Inkblot Test indices are dependent upon the number of responses. When the groups of Normal, Neurotics, and Schizophrenics were divided, on the basis of number of responses, into high productivity and low productivity, many indices, which were found to be significant earlier, lost Consistency of Response Pattern on Rorschach 65

their significance. It further strengthened the findings of Fiske and Baughman (1953) and supported the intention of Holtzman (1956). Many psychologists prefer content analysis and psychoanalysis to avoid confusion caused by the length of the protocol (Cassell and Dubey, 2003). Diagnostic implications: The diagnostic implications of this patient on Rorschach Inkblot Test are suggestive of a psychotic disorder. However, at the time of initial administration, clinical symptoms were more suggestive of depression and OCD. It is difficult to conclude that the patient had an underlying disintegrative process at the time of initial contact. His response to antidepressant treatment augments the clinical diagnosis. It is likely that the increased number of sexual responses might be a manifestation of his sexual problems, which he had consciously denied. The initial testing was done even before his first marriage and it may validate his report and his attitude towards sex. A better modulation and integration of the primary process would have increased the patient's flexibility as well as general coping ability (Weiner, 2004). Therapeutic Intervention: Irrespective of different psychiatric consultations no effort was made to encourage the patient to seek psychotherapeutic help. This may be the reflection of the general trend to overemphasize the psychopharmacological treatment. Many patients due to poor psycho-education, do not believe in therapeutic intervention without medication. In this case, the present client attended only seven sessions of therapy and that too irregularly. Conclusions: The index case described the importance of the Rorschach Inkblot test in India. The use of the test is decreasingday by day. The possible reasons might be the minimal number of clinicians trained in using Rorschach Inkblot Test, lack of training in Comprehensive system, and inadequate exposure of its use in research. The need for training clinicians on Rorschach Inkblot Test appears to be one of the strategies to improve the research. A case report was presented to highlight the importance of content analysis and the penetrative power of sexual and anatomical responses in diagnosis. References: Aronow, E. (2004)The Relationship of Rorschach Determinants to Affective Functioning: Implications for Rorschach Usage. South African Rorschach Journal, 1: 26- 32. Cassell, W. A. (1980) Body Symbolism and the Somatic Inkblot Series. Anchorage, Alaska. Aurora Publishing. Cassell, W, A. and Dubey, B. L. (2003) Interpreting Inner World through Somatic Imagery: SIS Center, Anchorage (USA): SIS Center. Dosajh, N.L. (1956) Imaginationand Maturity as factors indicative of success in teaching. Unpublished Doctoral Thesis in Psychology, Punjab University, and Chandigarh. Dubey, B. L. (1982) A Pragmatic View of Rorschach Ink Blot Technique. National Psychological Corporation, Agra. Dubey, B.L., Mishra, M., Dwivedi, C.B. and Mishra, N. (1994) Diagnosticand Therapeutic Utility of Somatic Inkblot Series - II and Rorschach. SIS Journal of Projective Psychology and Mental Health, 1: 19-26. Dubey, B.L., Pershad, D. and Verma, S.K. (1981)An Evaluation of Rorschach as a Clinical Tool. Indian J.Clin. Psycho, 8: 157-163. Exner, J. E. (1993) The Rorschach: A Comprehensive System Foundation. Vol.1. Basic Foundations (3rd ed.). New York: Wiley. Exner, J. E. (2007) A new U.S. adult non patient sample. Journal of Personality Assessment, 89: (S1), S154- S158. Fiske, D. W. and Baughman, E. E. (1953) Relationships between Rorschach Scoring Categories and the Total Number of Responses. The Journal of Abnormal and Social Psychology, 48:25-32. Guarnaccia, V., Dill, C.A., Sabatino, S and Southwick S. (2001) Scoring Accuracy Using the Comprehensive System for the Rorschach. Journal of Personality Assessment, 77: 464-474. Holtzman, W. H. (1956) Inkblot Perception and Personality. University of Texas Press, Texas. Kohli A., and Kaur, R.P. (2002) Rorschach Profile and its Relationship with PEN Questionnaire in Borderline Psychosis. SIS Journal of Projective Psychology and Mental Health, 9: 109-113. Lerner, P. M. (2004) A Psychoanalytic Approach to the Rorschach. South African Rorschach Journal, 1, 12-25. Manickam, L.S.S. and Dubey, B.L. (2005) Rorschach Inkblot Method in India: Historical Review and Perspectives for Future Action. SIS Journal of Projective Psychology and Mental Health, 12: 61-78. Meyer, G. J. and Archer, R.P. (2001) The Hard Science of Rorschach Research: What Do We Know and Where Do We Go? Psychological Assessment, 13: 486-502. 66 Manickam

Meyer, G. J., Hilsenroth, M. J., Baxter, D., Exner, J. E., Jr., Fowler, J. C., Piers, C. C. and Resnick, J. (2002) An examination of interrater reliability for scoring the Rorschach comprehensive system in eight data sets. Journal of Personality Assessment, 78: 219-274. Milne, L.C., and Greenway, P. (2000) Sexual Content in Rorschach and Perceived Control of Internal States. SIS Journal of Projective Psychology and Mental Health, 7:, 119-126. Mishra, M., and Dwivedi, C.B. (1997) Content Scale Based Diagnostic Compatibility of the SIS - II with Rorschach Test in Normals, Neurotics and Schizophrenics. SIS Journal of Projective Psychology and Mental Health, 4: 121-140. Consistency of Response Pattern on Rorschach 67 Raychaudhuri, M. and Maitra, A.K. (1968) Relationship Between Level of Creativity and Projection of Movement Responses as Measured by Rorschach M. Welsh Mv and a Drawing Completion Task. Indian Journal of Psychology, 43: 30-36. Silverstein, M. L. (2007) Rorschach test findings at the beginning of treatment and 2 years later, with a 30-Year follow-up. Journal of Personality Assessment, 88: 131- 143. Viglione, D. J., and Taylor, N. (2003) Empirical Support for interrater reliability of Rorschach Comprehensive System coding. Journal of Clinical Psychology, 59: 111-121. Weiner, I. B. (2004)On the Future of Rorschach Assessment. South African Rorschach Journal, 1: 3-11.

Dichotic listening asymmetry: A Potential Neuro-Behavioural Marker of Depression Rakesh Pandey and I. L. Singh Depression has often been linked with anomalous pattern of hemispheric asymmetry and recent studies provide support that neuro-behavioural measures of hemispheric asymmetry may potentially be used as a marker of depression. With this background the present study examines the nature of hemispheric asymmetry in depression using dichotic listening test. The rhymed fused alphabets were presented in dichotic listening paradigm to clinically, sub-clinically, previously depressed individuals as well as on age and gender matched healthy controls. The findings revealed that all the four groups showed a significant right ear (i.e., left hemispheric) advantage. However, this left hemispheric advantage was less pronounced in depressed groups (clinically and sub-clinically depressed) as compared to depression free groups (previously depressed and normal controls). The observed gradient in the magnitude of left hemispheric asymmetry from depression to no-depression suggests that with increasing severity of depression the individuals tend to show reduced left hemispheric performance and as the symptoms of depression gradually becomes less severe or disappear the left hemispheric performance tend to recover. The findings imply that reduced left hemispheric asymmetry may serve as a potential neuro-behavioural marker of depression. Rakesh Pandey, Ph.D., Professor, I.L. Singh, Professor, Department of Psychoolgy, Banaras Hindu University, Varanasi (Correspondence: Prof. Rakesh Pandey, email: rpan_in@yahoo.com) Key words: Depression, hemispheric asymmetry, dichotic listening The prevalence of depression is rapidly increasing in the contemporary society. It is considered the single most burdensome disease in the world in terms of total disability-adjusted life years. the fourth leading cause of disability in terms of its physical, social and mental impact (Murray & Lopez, 1996). Combating with depression has become a major concern for clinical psychologists and other health professionals. One major problem in combating with depression is that most cases of depression remain unrecognized and hence underdiagnosed. The issue of underdiagnoses of depression calls for the effort to identify and validate such performance based neuro-behavioural markers depression that does not rely on verbal report and identification of the subjective symptoms. The present paper is an attempt in this direction and examines the potential of dichotic listening asymmetry (an indicator of hemispheric asymmetry) as a marker of depression. Bulk of empirical studies has demonstrated that depression is characterized by anomaly in cerebral asymmetry and lateralization of cognitive functions (Jaeger, Borod, & Peselow, 1987; Liotti, Sava, Rizzolatti, & Caffarra, 1991; Miller, Fujioka, Chapman, & Chapman, 1995; Overby III, Harris, & Leek, 1989). Such abnormalities in cerebral laterality has been assessed using different approaches and methods and the dichotic listening technique is one among them. In dichotic listening paradigm different auditory stimuli (e.g., words or tones) are presented simultaneously to both ears and differences in performance between ears provide a measure of perceptual asymmetry. Unilateral ear advantages on this test are thought to represent the advantage of the contralateral hemisphere for processing of verbal or tonal stimuli (Lezak, 1976). Studies done on depressed people using dichotic listening method have generally reported reduction or absence of left-ear (right-hemisphere - RH) advantage for non-verbal stimuli such as tones (Bruder et al., 1989, 1995; Johnson & Crockett, 1982; Overby, Harris, & Leek, 1989). On the other hand, studies using verbal stimuli have presented inconsistent findings. While majority of the studies have reported abnormally enhanced right ear (left hemisphere - LH) advantage in processing of dichotically presented verbal stimuli (see Bruder, 1988 for a review) few studies have found a normal left-hemisphere advantage in depressed patients for perceiving dichotic consonant-vowel syllables (Hugdahl et al., 2003). Even with verbal stimuli, it has been noted that fused non-sense syllable and dichotic words do not yield the same left hemispheric advantage in depressed patients (Kimura, 1961; Wexler & Halwes, 1983). On dichotic fused word or syllable tests, depressed patients are found to exhibit enhanced right ear (left hemisphere) advantages (G. E. Bruder et al., 1989) particularly when they

are treatment responders (G. E. Bruder et al., 1997). Not all studies using these tests, however, note such differences (Bruder, 1995; Wale & Carr, 1990). For instance, some studies reported that the right ear advantage on dichotic fused words was observed in patients with major depression without anxiety disorder but not in depressed individuals with co-morbid anxiety disorder (Bruder et al., 1999; Pine et al., 2000). Some studies have examined the dichotic listening asymmetry in antidepressant responders and non-responders both before and during treatment and generally observed that responders demonstrated greater right-ear (LH) advantage for dichotic words and less left ear (RH) advantage for complex tones (Bruder et al., 1996, 2001, 2004, 2007; Hugdahl et al., 2003) The foregoing review suggests that clinical depression is associated with LH functioning. The reduced LH functioning (in processing of verbal stimuli) was found to be associated with depression and the recovery from depression was linked with enhanced or better functioning of the LH. On the other hand, studies utilizing complex tones revealed that reduced RH functioning is associated with depression. Further, it also suggests that those depressive patients who do not respond to antidepressant treatment are also characterized by reduced RH functioning. However, several studies have presented contradictory findings. For example, several studies have failed to demonstrate difference between major depressives and controls on verbal dichotic listening task (Wale & Carr, 1990). Similarly, some studies have documented a negative relationship between the left hemisphere dominance for language function and severity of depressive symptoms (Wexler & Heninger, 1979; Yozawitz et al., 1979). Several other studies have also failed to demonstrate left ear advantage (LEA) for non-verbal dichotic tasks in depressed patients (Bruder et al., 1989; Bruder, Sutton, Berger- Gross, Quitkin, & Davies, 1981; Overby, Harris, & Leek, 1989; Yozawitz et al., 1979). The observation of different pattern of findings using non-verbal stimuli in depression further adds to this inconsistency in the reported findings. For example, (Johnson & Crockett, 1982) Johnson and Crockett (1982) failed to find the RH superiority for musical chord processing in depressed patients. Similar failure to observe RH superiority in dichotic pitch discrimination among depressed individuals has been reported by others (e.g., Bruder, 1995). Contrary to the said findings, Yovell et al. (1995) found poorer left ear advantage for pure-tone during the depressed state. A reversal of usual LH advantage for processing of verbal stimuli has also been reported in patients with depression (Bruder et al., 1989). From the preceding review it is evident that dichotic listening asymmetry studies do not provide any conclusive finding regarding the nature of hemispheric functioning in depression. Those study which assessed perceptual asymmetry (using dichotic listening technique) for processing of verbal stimuli (a left hemispheric task), in general, have reported reduced LH functioning in depression with anxiety (Pine et al., 2000). However, those dichotic listening studies that have utilized non-verbal stimuli in general reported reduced RH functioning in depression (Bruder et al., 1996; G. E. Bruder, Stewart, McGrath, Deliyannides, & Quitkin, 2004). Taking a note of the reported inconsistency in the findings, the present study makes an attempt to examine the nature of dichotic listening asymmetry in depression using individuals with clinical and sub-clinical depression as well as those who were previously depressed. Such approach will help to uncover whether the anomaly (if any) in dichotic listening asymmetry is sensitive to the symptoms and risk for depression or not. In other words it would help to identify the potential of such measure as a marker of depression. It is speculated that the extent and pattern of dichotic listening asymmetry would show a gradient- the normal controls and the symptom free previously depressed individuals are likely to show enhanced LH asymmetry as compared to both subclinically and clinically depressed individuals on dichotic listening tests involving verbal material. Method Participants: The present study was carried out on the four groups of participants. The first group comprised of 20 clinically but currently de- Dichotic listening asymmetry & Depression 69

pressed individuals recruited from outpatient psychiatric settings of Varanasi city, meeting the criteria of DSM-IV major depressive disorder (MDD) on the basis of the clinician's diagnostic impression. However those individuals with MDD were not included in the present study who reported any of the following reason such as depression with psychotic symptoms, depressive stupor, difficulty in normal communication, other psychotic disorders, organic mental disorder, history of head trauma, or other neurological disorder, and hearing loss. The second group comprised of 20 sub-clinically depressed individuals identified on the basis of BDI score (score ranged from 19 to 29). The third group comprised of 11 previously depressed individuals who came for the follow-up consultation to the clinic and were free from depressive symptoms for at least one to four months. The fourth group comprised of 20 nondepressed individuals with BDI score less than 9. Those sub-clinically and non-depressed participants were excluded from the present study who showed any history of present or past psychiatric mental illness, present or past history of neurological disorder and/or brain injury and were having hearing problem or loss. The participants in the non-depressed groups were matched in terms of age and gender with that of the depressed of group. Tool The fused rhymed alphabet dichotic listening test is a computerized test. It consists of 10 different single alphabet pairs in which each member of every pair differs from the other. The alphabets are spoken by a male in natural voice and the sound of one alphabet is relayed to left ear and the other to the right ear. The alphabets in each pair are counterbalanced in such a way that each alphabet is presented equally to both ears. When these alphabets are presented dichotically, the members of each pair fuse into a single percept. The participants are required to indicate which alphabet they have heard on each trial by pressing the mouse on that alphabet among six alphabets presented on the computer screen. The aforesaid dichotic listening test is administered through a computer programme written in Java script using a stereo headphone. Procedure Each participant was given practice trials before the actual experimental task. The rhymed alphabets were presented via headphones at a comfortable level of sound. When the participants learned how they have to perform on the dichotic listening task the actual dichotic listening test was administered individually to each participants. The response of each participant is scored and saved in the computer through the same computer programme that was used to administer the dichotic listening test. The scoring was done for each ear separately. Results and Discussion To examine the nature of hemispheric (perceptual) asymmetry on verbal dichotic listening test, the accuracy scores obtained for the two ears were analyzed in a 4 (groups: currently, sub-clinically, previously depressed and non-depressed) X 2 (ears: left and right) ANOVA with repeated measure on the last factor. The main effect of ear [F(3, 67) = 41.288, p = 0.000, p2 = 0.381] as well as the interaction of Group X Visual-Field were found to be significant [F(3, 67) = 3.785, p = 0.014, p2 = 0.120]. The main effect of group, however, was found to be non-significant [F(3, 67) = 0. 133, p = 0. 940]. The comparison of the mean accuracy in identifying dichotic verbal alphabets presented to the left and right ears (LE and RE) revealed that the participants identified alphabets more accurately when presented to RE (mean accuracy =5.71) as compared to LE (mean accuracy =3.545). This pattern of findings suggests that the participants irrespective of their depression level have shown a right ear (LH) advantage in processing of verbal information. This finding attests the validity of the task for assessing perceptual (hemispheric) asymmetry in processing of verbal information, so far as the earlier studies suggest a LH advantage for such tasks. The most important finding of the present study is a significant interaction of Group X Visual-field [F(3, 67) = 3.785, p = 0.014] with an effect size (partial eta square) of 0.145 which implies that the pattern of asymmetry on dichotic listening is not the same for all the groups. Comparison of 70 Pandey & Singh

the mean accuracy scores of the LE and RE for each of the four groups (Figure 1) suggests that though, all the groups have shown a same pattern of RE (left hemispheric) advantage in processing of alphabets, the magnitude of this asymmetry (RE and LE difference) is not the same for individual having symptoms of depression and those free from it. It is evident from the figure that RE advantage (left hemispheric asymmetry) is more pronounced in previously depressed and non-depressed individuals as compared to the other two groups having symptoms of depression (clinically and sub-clinical depressed groups). The simple main effect analysis revealed the right ear advantage (LH) in currently depressed group (mean RE-LE difference = 0.95, F(1, 19) 2.967, p=0.008) was lower as compared to sub-clinically depressed group (mean RE-LE difference = 1.3, F= (1, 19) 2.866, p=0.010) which in turn was lower than the previously depressed group (mean RE-LE difference = 2.909, F= 2.390, p=0.038) who showed even lower RE advantage as compared non-depressed group (mean RE-LE difference = 3.5, F= 4.549, p=0.000. This pattern of interaction and the obtained gradient in the magnitude of left hemispheric asymmetry suggests that with increasing severity of depression the individuals tend to show reduced left hemispheric performance and as the symptoms of depression gradually becomes less severe or disappear the left hemispheric performance tend to recover. Similar to earlier studies the present study also observed an enhanced left hemispheric advantage in depressed individuals for processing of verbal stimuli on a dichotic listening test (Hugdahl et al., 2003; Pine et al., 2000). However, unlike the earlier studies it demonstrate that the magnitude of left hemispheric asymmetry in processing of verbal stimuli is dependent on either the severity of depressive symptoms or the risk for depression. The individuals with risk for depression (previously depressed individuals) are likely to show reduced left hemispheric advantage compared to normal controls. Further, the findings also imply that as the risk or severity of depression increases the magnitude of left hemispheric asymmetry decreases. This inference is based on the observation that sub-clinically depressed individuals who are at risk for developing clinical depression and also having more symptoms of depression showed less left hemispheric asymmetry as compared to previously depressed individuals who are relatively free from symptoms of depression. Further, the aforesaid hypothesis that as severity of depression increases the amount of Dichotic listening asymmetry & Depression 71 Figure 1. The mean performance accuracy across the left and right ear shown by the clinically, sub-clinically, previously depressed and non-depressed participants

left hemispheric advantage decreases is supported by the observation that clinically depressed individuals showed a significantly reduced LH advantage as compared to both subclinically depressed and previously depressed individuals. Conclusions: Overall, the findings of the present study suggest that as individual with depressive symptoms recover the pattern of hemispheric asymmetry return to that of normal individuals free from depressive symptoms. Further, the findings also imply that reduced left hemispheric asymmetry may serve as a neuro-behavioural marker of depression. Such inference is indirectly supported by earlier findings which have demonstrated that depressed patients who responded to fluoxetine had a greater right ear (left hemisphere) advantage for dichotic words compared to non-responders (Bruder et al 1996, 2001, 2004; Sedoruk et al. 2005). However, further large sample based cross-validation studies are required focussing on establishing the sensitivity and specificity of dichotic listening based hemispheric asymmetry measures as marker of depression. References: Bruder, G. E. (1988). Dichotic listening in psychiatric patients. In: K. Hugdahl (Ed). Handbook of Dichotic Listening: Theory, Methods, and Research (pp. 527-563). New York: John Wiley & Sons. Bruder, G. E. (1995). Cerebral laterality and psychopathology: Perceptual and event-related potential asymmetries in affective and schizophrenic disorders. In R. J. Davidson & K. Hugdhal (Eds.), Brain Asymmetry (pp.661-91). Cambridege MA, US: The MIT Press. Bruder, G. E., Fong, R., Tenke, C. E., Leite, P., Towey, J. P., Stewart, J. E., McGrath, P. J., et al. (1997). Regional brain asymmetries in major depression with or without an anxiety disorder: A quantitative electroencephalographic study. Biological Psychiatry, 41(9), 939-948. Bruder, G. E., Fong, R., Tenke, C. E., Leite, P., Towey, J. P., Stewart, J. E., McGrath, P. J., et al. (1997). Regional brain asymmetries in major depression with or without an anxiety disorder: A quantitative electroencephalographic study. Biological Psychiatry, 41(9), 939-948. Bruder, G. E., Otto, M. W., Stewart, J. W., Fava, M., & Quitkin, F. M. (1996). Dichotic listening before and after fluoxetine treatment for major depression: Relations of laterality to therapeutic response. Neuropsychopharmacology, 15(2), 171-179. Bruder, G. E., Quitkin, F. M., Stewart, J. W., Martin, C., Voglmaier, M. M., & Harrison, W. M. (1989). Cerebral laterality and depression: Differences in perceptual asymmetry among diagnostic subtypes. Journal of Abnormal Psychology, 98(2), 177 -186. Bruder, G. E., Stewart, J. W., McGrath, P. J., Deliyannides, D., & Quitkin, F. M. (2004). Dichotic listening tests of functional brain asymmetry predict response to fluoxetine in depressed women and men. Neuropsychopharmacology, 29(9), 1752-1761. Bruder, G. E., Stewart, J. W., Tenke, C. E., McGrath, P. J., Leite, P., Bhattacharya, N., & Quitkin, F. M. (2001). Electroencephalographic and perceptual asymmetry differences between responders and nonresponders to an SSRI antidepressant. Biological Psychiatry, 49(5), 416-425. Bruder, G. E., Sutton, S., Berger-Gross, P., Quitkin, F., & Davies, S. (1981). Lateralized auditory processing in depression: Dichotic click detection. Psychiatry Research, 4(3), 253-266. Bruder, G. E., Sutton, S., Berger-Gross, P., Quitkin, F., & Davies, S. (1981). Lateralized auditory processing in depression: Dichotic click detection. Psychiatry Research, 4(3), 253-266. Bruder, G. E., Tenke, C. E., Warner, V., & Weissman, M. M. (2007). Grandchildren at high and low risk for depression differ in EEG measures of regional brain asymmetry. Biological Psychiatry, 62(11), 1317-1323. Bruder, G. E., Wexler, B. E., Stewart, J. W., Price, L. H., & Quitkin, F. M. (1999). Perceptual asymmetry differences between major depression with or without a comorbid anxiety disorder: A dichotic listening study. Journal of Abnormal Psychology, 108(2), 233-239. Hugdahl, K., Rund, B., Lund, A., Asbjørnsen, A., Egeland, J., Landrø, N. I., Roness, A., et al. (2003). Attentional and executive dysfunctions in schizophrenia and depression: evidence from dichotic listening performance. Biological Psychiatry, 53(7), 609-616. Jaeger, J., Borod, J. C., & Peselow, E. D. (1987). Depressed patients have atypical hemispace biases in the perception of emotional chimeric faces. Journal of Abnormal Psychology, 96(4), 321-324. Johnson, O., & Crockett, D. (1982). Changes in perceptual asymmetries with clinical improvement of depression and schizophrenia. Journal of Abnormal Psychology, 91(1), 45-54. Kessler, R. C., McGonagle, K. A., Zhao, S., Nelson, C. B., Hughes, M., Eshleman, S., Wittchen, H. U., et al. (1994). Lifetime and 12-Month Prevalence of DSM-III-R Psychiatric Disorders in the United States: Results from the National Comorbidity Survey. Archives of General Psychiatry, 51(1), 8-19. doi:10.1001/archpsyc. 1994.03950010008002 72 Pandey & Singh

Kimura, D. (1961). Cerebral dominance and the perception of verbal stimuli. Canadian Journal of Psychology/Revue canadienne de psychologie, 15(3), 166-171. Lezak, M. D. (1976). Neuropsychological Assessment. New York: Oxford University Press. Liotti, M., Sava, D., Rizzolatti, G., & Caffarra, P. (1991). Differential hemispheric asymmetries in depression and anxiety: a reaction-time study. Biological Psychiatry, 29(9), 887-899. Miller, E. N., Fujioka, T. A. T., Chapman, L. J., & Chapman, J. P. (1995). Hemispheric asymmetries of function in patients with major affective disorders. Journal of Psychiatric Research, 29(3), 173-183. Overby, L. A., 3rd, Harris, A. E., & Leek, M. R. (1989). Perceptual asymmetry in schizophrenia and affective disorder: Implications from a right hemisphere task. Neuropsychologia, 27(6), 861-870. Pine, D. S., Kentgen, L. M., Bruder, G. E., Leite, P., Bearman, K., Ma, Y., & Klein, R. G. (2000). Cerebral laterality in adolescent major depression. Psychiatry research, 93(2), 135-144. Wale, J., & Carr, V. (1990). Differences in dichotic listening asymmetries in depression according to symptomatology. Journal of affective disorders, 18(1), 1-9. Wexler, B. E., & Halwes, T. (1983). Increasing the power of dichotic methods: The fused rhymed words test. Neuropsychologia, 21(1), 59-66. Yovell, Y., Sackeim, H. A., Epstein, D. G., Prudic, J., Devanand, D. P., McElhiney, M. C., Settembrino, J. M., et al. (1995). Hearing loss and asymmetry in major depression. The Journal of Neuropsychiatry and Clinical Neurosciences, 7(1), 82-89. Yozawitz, A., Bruder, G., Sutton, S., Sharpe, L., Gurland, B., Fleiss, J., & Costa, L. (1979). Dichotic perception: Evidence for right hemisphere dysfunction in affective psychosis. The British Journal of Psychiatry, 135(3), 224-237. Acknowledgement The authors thankfully acknowledge the financial assistance received from the University Grants Commission under Major Research Project "Identification of Neuro-behavioural Markers of Depression". The present paper is based on the data obtained under this research project. We also thankfully acknowledge the help of Dr. Gaurav Kumar Rai, project follow in collecting the data. Dichotic listening asymmetry & Depression 73

Dear SIS Members and friends, You will be pleased to learn that both SIS-I instrument are available on Website for online assessment. If you want to use these techniques for personality assessment, clinical diagnosis/treatment or research, you are welcome to contact us regarding any help we might be able to provide. You are invited to view these on the following websites: http://psyche.dubay.bz We will welcome comments, suggestions and any constructive criticism about the SIS applications. We also invite your contributions to our SIS Journal, related to projective psychology and mental health. Looking forward to hearing from you! Sincerely Wilfred A. Cassell, Email: siscassell2@yahoo.com Bankey L. Dubey, Email: bldubey@gmail.com Rakesh Pandey, E-Mail: rpan_in@yahoo.com 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 1-18 is available in (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 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 inHard 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 OR RakeshPandey, Ph.D., FSIS, Editor in Chief, Professor, Dept. of Psychology,Banaras Hindu University,Varanasi-221005 Cell:91-9415812329, E-Mail: rpan_in@yahoo.com

THE SOMATIC INKBLOT SOCIETY I wish to be a Life Member __________of the Somatic InkblotSociety. Please submit this request to the Membership Committee. NAME __________________________________________________Birth date _________________ Mailing Address : __________________________________________________________________ _____________________Tel. : (W)__________________________H)_______________________ EDUCATION Degree Year Institution Major Field of Study EMPLOYMENT : Current position, employer, dates (Graduate Students indicate area of study and degree toward which you are working). MEMBERSHIP : _____________________________________________________________________ TRAINING AND EXPERIENCE IN PERSONALITY ASSESSMENT : SPONSOR (S) Name Address Telephone 1.______________________________________________________________________________ 2.______________________________________________________________________________ SIS subscription payable every year in January through Cheque at par/Demand Draft in favor of "SIS Journal ofProj. Psy. & Mental 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 $ 300. For Life Membership in India Rs. 2500/- and InstitutionalAnnual Membership Rs. 1000/-. The Institutional Life Membership is Rs. 10000/- once or in two installments. Total Cheque $/Rs.__________________ Drawn at _______________ Signature of applicant : __________________________ Date : ________________ PLEASE RETURN with your cheque to : Dr. RakeshPandey, Dept. of Psychology, Banaras Hindu University, Varanasi-221005 Foreign members send their subscription cheque to: B.L. Dubey, Ph.D. Editor Emeritus, 4406 Forrest Road, Anchorage, AK-99517 (USA).

STATEMENT SHOWING OWNERSHIP AND OTHER PARTICULARS ABOUT SIS JOURNAL OF PROJECTIVE PSYCHOLOGY AND MENTAL HEALTH PLACE OF PUBLICATION : Dept. of Psychology, Banaras Hindu University, Varanasi-221005 PERIODICITY OF PUBLICATION : Half Yearly EDITOR'S PRINTER'S Name : Rakesh Pandey PUBLISHER'S NATIONALITY : Indian ADDRESS : Dept. of Psychology, Banaras Hindu University Varanasi-221005 OWNER : SOMATIC INKBLOT SOCIETY I, Dr. Rakesh Pandey, hereby declare that the particulars given above are true to the best of my knowledge and belief. Sd/ Dr. Rakesh Pandey, Editor-in-Chief SIS Journal of Projective Psychology and Mental Health Published by Dr. Rakesh Pandey, on behalf of Somatic Inkblot Society at Prabha Press, Chaukaghat, Varanasi. Cell Phone. 09838927095 Editor-in-Chief : RakeshPandey

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

Abstracted in "APA's Psyc INFO" Regd. No. 71632/99, RNI Delhi SIS JOURNAL OF PROJECTIVE PSYCHOLOGY & MENTAL HEALTH EDITORS EMERITUS

Wilfred A. Cassell,

MD,

Director, SIS Center,4501E,104th Avenue,

Anchorage, AK.99516 (USA).

Mail: siscassell2@yahoo.com

Bankey L. Dubey, Ph.D.,

Director SIS Centre,4406 Forest Rd,

Anchorage, AK 99517

Cell: 907 -250 -8834, E -mail: bldubey@gmail.com Amool R.Singh, Ph.D.,

Director, RINPAS and Prof. Clin. Psychology,

Kanke, Ranchi -834006

Cel.: 91 -9431592734,E -mail:sisamool@yahoo.com EDITOR-IN-CHIEF

RakeshPandey, Ph.D.

Professor,Dept. of Psychology,

Banaras Hindu University, Va ranasi-221005

Cell:91 -9415812329,E -Mail:rpan_in@yahoo.com EDITORS: Silvia Daini, M.D.,Instituto di Psichiatria e Psicologia, UniversitàCattolica del SacroCuore,

Roma, Largo Francesco Vito 1, 00168, Rome ( Italy) Email: daini@katamail.com

Anand Dubey , MBA, 4406 Forrest Road,

Anchorage, AK 99517

Mail: anand.dubey@gmail.com

L. Sam S. Manickam , Ph.D.,

Professor Clin.Psych.

Dept of Psychiatry, JSS University, Mysore, 570004, Email: lssmanickam@gmail.com

Nilanjana Sanyal, Ph.D. , Prof. Dept. of Psy , University of Calcutta, 92 A. P. C Road,Kolkata -700009 Email: sanyal_nilanjana2004@rediffmai.com M. P. Singh, Ph.D.1329, Sec.70, Guru TegBahadur Complex, SAS Nagar (Punjab) Email: mpsingh1329@gmail.com EDITORIAL CONSULTANTS Yogesh K. Arya, Ph.D., India JayantiBasu, Ph.D. India

Antonio Cervigni, M.A.., Italy SuprakashChaudhury, M.D. Carina Coulacoglou, Ph.D., Greece ManishaDasgupta, Ph.D. India Akanksha Dubey, M.A., India Padma Dwivedi, M.A., USA R.P. Gupta, M.A., India

M.Jahan, Ph.D., India

Anatoly B. Khromov. Ph.D., Russia H.Kumar, Ph.D., USA

Rakesh

Kumar, Ph.D., India Ranjeet Kumar, Ph.D.,

India A. S. Kundu, Ph.D., India S.P.Mandal,M.Sc., India Lisa Milne, Ph.D., Australia Nalini Mishra, Ph.D., India Tilottama Mukharjee, Ph.D., India Ashok Kumar Nag, M.D., India Paola Nicolini, M.A., Italy Edward M. Petrosky, Ph.D., U.S.A. Jai Prakash, Ph.D.India Stefano Reschini, M.A, Italy Barry A. Ritzier, Ph.D., U.S.A. Brig. D.Saldanha,M.D India RadheShyam, Ph.D.India Umed Singh, Ph.D. India Ajay Tiwari, Ph.D., India AiloUhinki, Ps.D., Finland YashoV. Verma, Ph.D., India Robert B. Williams, Ph.D., Canada