SIS Journal of Projective Psychology & Mental Health

Journal of Projective Psychology & Mental Health Volume 21 Number 1 January, 2014 ISSN 0971-6610 SIS Official Publication of the Somatic Inkblot Society Editorial : A Spiritual “Afterlife” Death Dream Wilfred A. Cassell Dream and SIS Symbolism in Bereavement Wilfred A. Cassell and Bankey L.Dubey Empirically-Supported Case Studies of Creativity in Writers in Psychoanalysis Nadine J. Kaslow, Peggy D. Flanagan, Erica R. Carlin, Rachel Harris, Enith E. Hickman and Susan L. Reviere Psychologists’ Ambivalence toward Ambiguity: Relocating the Projective Test Debate for Multiple Interpretative Hypotheses Jayanti Basu Marital Conflict: An Exploration of Relationship issues in Couples through SIS-II L.S.S. Manickam and B.T. Suhani Rorschach Response in Somatization Problem among College Students Roshan L. Dewangan, Saugata Basu and Prasanta Kumar Roy SIS-II Correlates of Suicide Ideation among Adolescents Umed Singh and Kamlesh Rani SIS-II Profile of patient with Body Dysmorphic Disorder: A Case repor Bhoomika Sachacher and Masroor Jahan Book Review 1-2 3-10 11-24 25-36 37-41 42-48 49-57 59-61 62-64

SIS Somatic Inkblot Society OFFICE BEARERS Executive Members : Mike Baker, MBA. Wilfred A Cassell, M.D. Mary Cassell, M.A. Anand Dubey, MBA. SatchitMandal, M.A. Tilottama Mukherjee, Ph.D. Preety Pandey, M.A. Ajay Tiwari, Ph.D. Pragya Tiwari, MBA. SambhuUpadhyay, Ph.D. President : Bankey L. Dubey, Ph.D. Editor In Chief : RakeshPandey,Ph.D. Vice President : Brig. D.Saldanha Gen. Secretary : Nalini Mishra, Ph.D. Joint Secretary : Akansha Dubey, M.A. Treasurer : Padma Dwivedi, M.A. SIS JOURNAL OF PROJECTIVE PSYCHOLOGY AND MENTAL HEALTH is a refereed journal and published twice a year (January, July) by the SOMATIC INKBLOT SOCIETY and is devoted to the advancement of research in the areas of projective psychology, personality assessment, psychotherapy and mental health. The journal is broadly concerned with the development of inkblot tests and personality assessment in clinical, counseling, cross cultural, organizational and health psychology settings. It aims to reach clinical psychologists, psychotherapists, psychiatrists, social workers, medical professionals and professional managers interested in the understanding and modification of human behavior. The journal includes (a) research articles (b) book reviews (c) brief reports (d) news about conferences 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, SIS Journal, E-mail:bldubey@gmail.com with a copy to Rakesh Pandey, Ph.D.,Editor in Chief, SIS Journal, Prof. Dept of Psychology, BHU, Varanasi-221005, E-Mail: rpan_in@yahoo.com. 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 $300 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.,Editor in Chief, SIS Journal, Prof. Dept of Psychology, BHU, Varanasi-221005, E- Mail: rpan_in@yahoo.com. Members in foreign countries should send the cheque to B.L. Dubey, Ph.D. Editor Emeritus, 4406 Forest Road, Anchorage, AK- 99517 (USA) Please add $10/Rs.50/- if you are sending subscription through cheque. CHANGE OF ADDRESS Members should inform B.L. Dubey, Ph.D, Director SIS Centre, Email:bldubey@gmail.com of any change of mailing address. Copyright @1994. SIS Center, India/Anchorage Website: http://www.somaticinkblots.com

In the July of 2013 issue of the journal my editorial reviewed SIS technology techniques whose validity has been established primarily through phenomenological case history studies. Not only do these have several applications in clinical settings, they also provide illumination for peering deeper into the depths of human consciousness. They can facilitate the inner world exploration of less tangible esoteric philosophical /religious dimensions of a human’s soul. As examples these can enable a trained SIS therapist to reduce Dysphoric Death affects and therapeutically process otherwise unreported suicidal/homicidal ideation. SIS clinical investigators are now challenged to replicate these with more rigorous, “Placebo” controlled, followup statistical studies. My original interest in these seemingly boundary less body-mind spiritual field having Cosmic time, energy and space dimensions has a very long history. Historically, it is traceable to my deceased anthropological professor Ernest Becker theoretical views published in his 1973 Pulitzer Prize winning book “Denial of Death.” He brilliantly described how humans utilize the psychological defense mechanism of denial to avoid such futuristic focused morbid somatic introspection. However, he was not open to the notion that projective techniques, such as original SIS “inkblot “somatic suggestive designs were worthy of scientific investigation. In an angry outburst, he once told me that his own personal undergraduate Rorschach responses had almost excluded him from graduate school. Consistent with his aversion to analyzing symbolic somatic imagery projected onto inkblots, or surfacing in REM sleep, his brilliant book failed to mention Death Dreams. Prior to his premature death from lung cancer related to nicotine addiction based smoking, he remained a dogmatic atheist. After my graduation I taught on the medical school staff with him. At that time in the twentieth century history of medical knowledge, when it was beginning to be clinically documented that spiritually based therapy programs for addiction were Editorial A Spiritual “Afterlife” Death Dream effective. Now year’s later, clinical investigators have provided statistical data supporting the efficacy of various treatment programs having a spiritual/religious foundation. As outlined in the last issue of this journal the evolving SIS technology enables envisioning spiritual life moving beyond the physical boundaries of the dying human body. As a follow-up introspective illustration, in the editorial I will now share a vivid “Death Dream” that strongly suggested to me viewing an “Afterlife” mystical continent. (Before relating it, I must confess that now with my elderly age “Death” has become a fascinating subject, if not a preoccupation. Moreover as illustrated in the subsequent SIS studies published in the journal on “BEREAVEMENT” clinical work frequently exposes me to its dark shadow. Lastly, to facilitate the reader’s independent symbolic interpretation anxiety charged “day residual” affect charged memories, also likely affected the dream. Thus, the visual imagery emerged in nocturnal consciousness just a few days after a personal psychologically stressful and potentially lethal event. This involved my being unrepentantly being caught in some dangerous ALASKA sea conditions, when paddling a kayak on the open ocean. The dream emerged in nocturnal consciousness beginning with the following visual imagery and feelings: My body seemed to be moving magically through the air at a high elevation over an ocean like body of water. I was amazed to observe young people floating in spiritual space above it …then on an emerging island-like configuration below, I witnessed the figures of two adults, as though their bodies we defining a gate-like entrance to the space below… they were observing my floatation through psychic dream space…then a manuscript appeared documenting my many published insights into the clear relationship between nighttime dream imagery and inkblot projective responses… next my theoretical writings in a magical like fashion floated up in psychic space…these appeared to be permanently documented on what resembled an ancient stone tablet form…I held this in my hand to for viewing by onlookers whom I did not see, but somehow sensed to be watching …the words were

clearly written…they documented certain specific projected symbols, that I had previously in the reality of the planet earth had written for SIS scientists to understand my previously published work documenting SIS body-mind-spirit theory. Next my mood changed from positive feelings to one of mild frustration/irritability and sadness… I became saddened observing that most viewers floating by in the dream’s spiritual dimensions seemed somewhat detached and unappreciative of the diagnostic/ healing power of SIS symbolism. After a while of drifting despondently in an aimless psychic dream dimension… I then felt fearful as my aging body was being involuntarily drawn sown towards a dark outline of a continent in an ocean below…however when gradually from a powerful mystical source beyond myself, the spiritual notion entered my mind that this mysterious shape below Wilfred A Cassell, M.D., FAPA, APC. Editor Emeritus, SIS J. of Proj. Psy.& Mental Health, Director, SIS Center, 4501E, 104th Avenue, Anchorage, AK - 99507 (USA) E-Mail: siscassell2@yahoo.com Cassell 2 represented the “Afterlife”, I then felt relief and hope… I realized after my body’s death that SIS Society members and open minded explorers of the spiritual dimensions would carry on refining projective explorations of the inner world of all our planet’s cognitively/emotionally based life, Of course my scientific knowledge and reality testing ability enable me to retain an intellectual position of objectivity. The rigorous anthropological arguments of and atheist such as Ernest Becker in context of his cognitive based contributions to Death psychology are in invaluable. Moreover, I also understand that dropping the “spiritual” dimension from SIS theory does not eliminate all positive clinical applications. Regardless of philosophical/religious considerations, clinical case reviews strongly suggest that the projective technology can enable a so disturbed person “to more calmly look death in the face and not blink!”

Dream and SIS Symbolism in Bereavement Wilfred A. Cassell and Bankey L. Dubey As noted in this month's editorial, introspective humans periodically subjectively in their "Inner World" experience thoughts/emotions concerning their body's ultimate fate. In certain Mental Disorders, stressful ruminations about death or dying may sometimes play a major pathological role. Such flooding of consciousness during the day, as well as during the night in depressive dreams, can provide clinical clues of otherwise unnoted clinical issues demanding diagnostic/treatment emergency attention. Similar symbolic significance may also be assigned to certain morbid SIS evoked somatic responses. For example, this conceptual mode of response interpretation especially applies to the video version of 22B. Clearly it is only an "Inkblot" in nomenclature historical developmental conceptual context. In 1989, I originally designed this particular "Electronic fluctuating light energy source" because of its pattern provides stimulating form and movement clues. To many spiritually/religiously oriented viewers such light patterns are often perceived as highly suggestive of a dying body with the former resident's living "spirit' departing. It is left as an open ended subjective issue what happens next in terms of the responder’s fantasies. An atheistic viewer might contend, in reality based logical argument that: "There is no living spirit leaving a dying body and that such an erroneous projective position only reflects wishful irrational thinking". Alternatively, for those viewers with a hopeful religious foundation, it was created to evoke fantasies regarding a fourth dimension passage leading to a spiritual reunion with deceased loved ones in the "Afterlife". There are many questions surrounding dying that are mysterious and warrant of serious scientific SIS study. For example, why do so many people have visions of deceased loved ones in full conscious daylight awareness? Simply labeling these observations as "Hypnologic Phenomenon" in no way explains their existence. Hopefully investigations might be undertaken by both atheists and those professionals with a more open mind about Death Dogma of the world's great religions. Death Dreams: After her death, several dreams of her daughter enjoyed frequent dream scenes of being with her still living mother. In a similar symbolic fashion, the deceased woman's grieving husband experienced recurrent positive loving images of being with his wife. During these he felt loved and no longer alone. When awakening from such positive sleep enabling dreams for months both felt a return of residual depressive symptoms. Yet each felt subjectively reassured in regard to the spiritual existence of the deceased accident victim “In a happy Afterlife". (More dream data will be provided in the section in association with analyzing the SIS responses). Now the clinical cases of Bereavement will be presented beginning with the accident victim's daughter's clinical history. Up until the early teens, the daughter had enjoyed a positive relationship with her now deceased mother. However subsequently her mother developed a deep depression. During this “terrible" period of her adolescence, her mother regressed, took to bed and became very irritable. Since being the oldest child, she took over the home care of her siblings. She said that during this time "I grew up very fast and independent" Sometimes the body can die before its human resident can cognitively recognize the inevitable, pervasive "shadow of Death”. Such was the accidental death of a healthy elderly married American woman. When a large truck crashed from out of her visual field into her car, her brain was instantaneously crushed. This case history study examines the concomitant protracted Bereavement associated with loss triggered Mental Disorders of her daughter and husband. It reviews both the symbolic imagery in their dreams as well as that reflected in their projective responses to SIS-II Video. Wilfre A. Cassell, M.D., FAPS, APC and Bankey L. Dubey, Ph.D., D.M.S.P., DPM, Director, SIS Center, 4406 Forrest Road, Anchorage, AK 99507(USA), Email: bldubey@gmail.com Key Words: Dream Symbolism, SIS symbolism in Bereavement

often becoming "very angry" with her mother. Later as an adult married woman about a year before her mother's tragic accident she allowed herself to once again emotionally lean on her mother. This began during a highly stressful divorce from a psychologically abusive husband. During this time she suffered from severe depression with suicidal feelings. Then she began treatment for Major Depressive Disorder with a positive response. Months later, shortly after her mother was killed, her depressive symptoms returned. However, this time in ddition she became symptomatic with a clinical picture also involving high anxiety. This was triggered when notified by the police of her mother's death. Then she first responded with panic symptoms as follows: "I could not breathe… I felt quite faint….I felt that it was not happening...thoughts went through my mind like it wasn't happening...it's a mistake...it must not be happening. It isn't real etc.” Soon the reality of her mother's death became apparent to her and she began to weep/grieve profusely. At that time she didn't want other family members to feel such emotional pain. Approximately two weeks after the funeral in a state of significant depression, she experienced her first symptoms of the onset of Panic Disorder. At the time she was working in public relations employment and had organized a reception for an arts center. During the meeting that she was leading, an intoxicated man stood talking loudly in an inappropriate fashion. This severe stress triggered “an extreme anxiety attack” associated with psychophysiology symptoms such as "difficulty breathing", "heart racing” and "dizziness". Subjectively these were interpreted by her as a “heart attack” so she feared that she was about to die. In addition she had severe claustrophobic feelings and panic impulses to run. Mentally she experienced depersonalization and interpreted this as losing her mind. Her second panic attack was triggered by driving by the site of the accident where her mother had instantly been killed. With intensive SIS guided psychotherapy and psychotropic medication her suffering subsided. In a follow-up session two years after her mother's death, she noted that transient recurrence of her symptoms occurred at the following times: "At Christmas when my mother's absence was acutely felt"... "When seeing cloths that reminded me of my mother”… "At the first year anniversary of mother's death" etc. Interpretation of SIS-II Video Responses: The electronic version of the SIS initially present views of mesmerizing flowers followed by a sound tract communicating hypnotic inducing instructions to relax. A response interpreter need to consider in inkblot interpretation, that memories of real events blend in with those more illusive such as dreams and fantasies. Affect events are recorded in the brain uniquely. What is recognized in conscious awareness then flows through a defensive memory filter involving the principle of Sensitization versus Repression. Ill understood brain mechanisms of recognition, such as those based upon Familiarity, and then interact neurophysiologic ally with the brain's abundant inhibitory neurons. Therefore the temporal and affect roots of every SIS responses need to be assessed by the SIS administrator based upon these complex interactions, from a clinical standpoint of determining relevance to symptoms. It has been phenomenological found that that in terms of "Diagnostic/treatment planning time value" focusing in the issues in plan based upon criteria of being affect rated by the viewer as subjectively the “Most liked” and those “Least liked". In contemplating these clinician is well advised to identify their historical time basis and whether what was so rated was based in reality of fantasy (or for psychotics in delusions). Daughter's SIS-Il Video Responses: Her favorite three "Inkblots" were as follows: A7: “A dancing pregnant lady and a floating apple". She rated this as her favorite scene "Because the lady looks natural and happy...the apple is abundance". This symbolized her frustrated desires to have children which were never fulfilled in her past stressful marriage. She was in her late thirties so her biological clock was a concern to her. A5: “A laughing chef...somebody thinking about love". This fantasy life is consistent with her response to A7. At this stage clinically in treatment, her grief symptoms were becoming less intense during SIS viewing. 4 Cassell & Dubey

B22: "Meditating person sending thoughts to God". In the detailed enquiry she spoke about how her female therapist had helped her s to connect with her deceased mother spiritually. Her therapist had supported the daughter's personal religious views that the dreams noted earlier could represent communication with an "Afterlife" positive spiritual dimension. Her three "Least liked" inkblots were as follows: B 15: In this she saw "Flying knives and daggers". She wrote on the SIS Answer sheet that this bothered most because "It made me feel angry because it had such negative energy and bad feelings". In psychotherapy her therapist was able to therapeutically process these in regard to long standing childhood memories of her mother's depressive withdraw al, later life residual traumatic feeling related to her dysfunctional marriage and more recent deeper irrational anger towards her mother for having left her through accidental death. Finally, as might be expected, she still felt hatred to the driver perpetrator of her mother's tragic death. B 24: Here she failed to recognize the embedded anatomical structure of a woman's pelvis. In conscious projective awareness she visualized seeing "Smoke" as a perceptual psychological defense. In spite of this defensive brain mechanism, the discomforting affect linkage to what was suggested out of her awareness by the SIS embedded somatic structure inherent in the inkblot disturbed her. Historically the above process had two time referents. One involves her past traumatic marriage with a sexually abusive man. The other was her mounting pelvic anxiety over not having been unable to get pregnant. A 20: (Many subjects visualize this as "Kidneys and male urogenital system") was the third inkblot rated as "Disliked". Here she responded with defensive non anatomical images "Two beans...alien's face and a" Lamp" (The lower phallic like projection). Here it is relevant that her first Panic attack was triggered by an intoxicated man in a social setting for which she was responsible. Perhaps he triggered the deep seated arousal of unconscious traumatic marital memories. Next a few remaining responses considered to be clinically relevant will be reviewed: A1: "Two twin girls crying" although her bereavement symptoms were fading, at a deeper level of projective memory release she still was grieving. Such a SIS projective sign had clinical relevance in terms of indicating the ongoing need for antidepressant medication. A3: "A twirling flower...it also looks like blood from a bullet hole". Here her first picture association to the stimulus array was clinically unremarkable. However, as observed with A15 it envisioned a very violent scene. This projective response reflected her still unresolved rage of the accident circumstances leading to her mother's death. It also illustrates the memory probing power of SIS trance inducing technology to expose otherwise unreported homicidal impulses. These must always be dealt with therapeutically on an emergency basis by modification with reality testing supplemental Cognitive psychotherapy. A4: “A golf bag...or a mean looking lady with a plum in her mouth". To outward appearances she appeared not to be angry. According to her psychotherapist, in sessions she tended to deny or minimize what she viewed negative feelings. However, as now must be evident to the reader more deep seated hostility and suffering of grief flooded her brain. At this stage of treatment she presented what some clinicians have described as “'A flight into health" state to mask her inner pain and need for more long term therapy. A9: "A husband and wife talking about each other". This portrayed past painful dysfunctional communication in her former marriage. Until the psychological wounds heal in psychotherapy, she would be a poor candidate for a second marriage. Here the SIS scene serves as an index of her slow progress in resolving such past issues. A10: "Eyes staring into the wet windshield of a passing cat". Symbolically this reflects her still uncompleted grieving. The brain's defenses systems defensively after an instant of viewing distanced her from inner pain. Thus what registered in projective awareness was the outer "Wet windshield" rather than a tearful face inside the car. Dream Symbolism 5

A13: "A drowning person's hand reaching for help". This reflected a symbolic projection of herself benefiting from SIS guided psychotherapy". A14: "A baby in the womb talking to its mother without words". This reflected her age regression from the suffering of grief. Physiologically it taps into the same inner neural circuit of her sleep protecting dream imagery where she is spiritually joyful in the presence of her mother. A2l: "A dancing chicken with two chicks...it has an egg in its stomach". This symbolism depicts her frustrated reproductive drives to have a baby". A22: Just as with blots A20 and B24 pathologic affect charged sexual material defensively distorted her perception of the reality somatic structure embedded. Her distorted projection follows: “A lobster claw...a (upper phallic like projection) and "A crab" (lower area of blot)..."screws". A25: “A vagina...or crab or lobster". The latter two secondary level associations are consistent with the pathological Freudian psychoanalytic symbolism referred to in the old literature as a "Dentate Vagina". B2: "Fallopian tubes . . . fireworks". Here she correctly recognized the embedded somatic structure. However, her immediate follow up projected imagery signified that for her such female reproductive anatomy had threatening affect linkage. B8: "Someone who feels terribly sad because they are terribly alone". This clearly portrayed her persistent grief. Even though minimized symptoms and superficially seemed almost recovered, such SIS data indicated that the Bereavement therapy needed to continue. B25: "God's hand creating the ocean...pearl in a shell". The projected imagery here reflected her positive view of God and her appreciation for beauty in Nature. B28: “A mom whose little girl hugs het". This symbolized imagery her dreams and her hope that after her body's death that her loving spirit would reunited with that of her mother's in the "Afterlife"- A second scene portrayed her devout Christian religious faith. This she visualized as spiritually representing "Mary and Jesus". The Victim's Husband's History: When asked in a recorded educational interview, when asked about his Bereavement triggered Mental Disorder, he responded "It is most stressful losing a spouse...nobody knows how much so without going through it...the initial shock is bad but you go carry that for months...You do not know what will happen to you… I felt disoriented...real bad...you feel like melting...All of a sudden bang you know…,it’s hard to believe, then I went into a depression (i.e. Major Depressive Disorder) and became like a zombie....My sleep patterns became all screwed up...I couldn't concentrate and then I became forgetful. When asked if he also had concomitant anger, he responded "I first felt very very sad, and then angry when thinking about the accident...I was angry that she didn't use the other big highway...Its two miles longer...She said...You drive where you want and I will drive where I want...I was angry that she hadn't listened to me". (Here he focused on his frustration from her refusing his driving advice. It was recognized in the proposed treatment plan that eventually in psychotherapy, he would have to become aware that much of his surface anger was related to unprocessed irrational cognitions. Although she was not responsible for her death, part of his mind still irrationally blamed her for leaving him. This insight and affect expression related to loss had yet to be therapeutically processed through SIS guided interpretation. Moreover, the psychological stress of his loss was intensified because he suffered from Dyslexia, although intelligent, essentially he was illiterate. As an operator of a small family business, he had become unduly dependent upon her. Lastly in regard to understanding his earlier life issues that were influencing his present grief, it was noted that his developmental history was psychologically impoverished. He grew up with many siblings and had very "stern" parents who in his words "Didn't know how to show love". 6 Cassell & Dubey

Husband's SIS-II Video Responses: He rated B28 as his favorite .seeing it as "A mother holding her baby". He attributed his selection as follows: "I like closeness and caring...the closeness I didn't get as a child". His associations here are of relevance at two levels historically. The earlier one related to his unmet dependency needs as a child. The later one reflected his frustrated dependency needs not having his wife to assist him emotionally as a person and also in their family business. His second favorite one was B3l "A father and mother and two kids holding hands...I like it because of the togetherness and everybody holding hands". The third favorite "Inkblot" was B29. Here he imagined it to look like "someone running and he has lost his leg and his leg is up in the air...it also could be a little doll that is broken". In the detailed enquiry he later explained "It reminded me of sadness...being where you cannot help yourself like when a child". This sequence illustrates how the SIS electronic technology acted like a type of "Time machine" enabling him to mentally travel into the past recalling significant childhood issues- Next the three "Least favorite" will be reviewed beginning with: B18: "A dildo that did its job". He laughed when responding and spoke about his state of sexual frustration since his wife was killed. This portrayed his sexual frustration in the absence of his wife. Consistent with this in viewing A27 he imagined it to look like "A lady in bed with her legs open". This theme also was projected originally with A8 "It's a person wearing a gown that is partly open showing a penis". The second rated one in the category was A29 seen as "A cloth with a black stain on it". Here he was unable to explain why he disliked it except for the negative feelings associated with the black stain. The third disliked response sequence was triggered by B12 "something torn off a building...cloth and wood...like the response with B29 of "A broken doll" and the “Stain" on A29, the third disliked response sequence symbolically connected emotionally to his broken heart resulting from losing his wife. More directly related to this symbolically was his response to A18 "A heart with the middle missing”. Next the clinically relevant responses will be presented as follows related to his impaired mental state from Dyslexia and Major Depressive Disorder: A1: "Two silk worms and mules sitting on their buts". Here the projected scene of animals inactivity replicates his own depression associated apathy and fatigue. A2: “A monkey hanging onto a rock'. Here the responses depicting a "Monkey" (rather than a human) reflects his insight into his long standing cognitive impairment secondary to his long standing Dyslexia and the loss precipitated Major Depressive Disorder A4: “Part of a face with a distorted nose . . . one eye open and one closed...it looks like a tear in one eye". This responses represent a direct projection of own recent memories from grief associated crying. Next more responses related to his loss of love follow A5: "A person in love and he is having a vision of the person". Here he correctly perceived a Gestalt figure of a "Person". He incorporated the heart like shape as a Valentine. This reflected his daytime fantasies about being with his deceased wife as well a recent recollection of her in loving dream imagery. In SIS directed Bereavement psychotherapy, he was cognitively supported in his religious faith that upon his death he would be with her spiritually in the "Afterlife". A9: “A man and lady exchanging love thoughts with two hearts there". This symbolism again reflects memories from (1) his past marriage (recollections of his daytime fantasies to be reunited with her (3) his spiritual dreams connecting him to her. B15: "A lady walking the kitchen...with several knives and spoons". Here he introduced in the absence of any light patter having human content a reference to his wife in the kitchen. A10: "Rust on white metal". Many viewers correctly Dream Symbolism 7

recognize the electric generated light pattern as a person's facial area, often that of a woman's eyes and nose. Initially and in the subsequent detailed enquiry he failed to recognize this embedded anatomical structure. Here his Somatic Repression" likely related to his incredibly severe stressful traumatic reaction. The police insisted on his identifying her mutilated body after the accident that crushed her head. A11: "Front end of a grasshopper…head between the legs". It is important for the administrator to understand the following theoretical principle underlying" Inkblot" projection involving a particular order of presentation. Sometimes when an emotionally threatening stimulus activates intense neural arousal it may be automatically defended against from registering in fully conscious awareness. Under such automatic conditions, the nervous system's Posttraumatic Memories centers in a reflex manner will continue for a brief time to be aroused - even if the viewer has not cognitively recognized the pattern of the traumatic visual input. This relates to psychophysiologic inhibitory mechanisms underlying Psychological Defense defenses which "Repressed" the symbolic somatic content. Thus in spite of not recognizing the facial structure in A10, due to the perseveration of such-neural excitement moments later in viewing the next video presentation A11, this severely traumatized man projected (disguised in a living creature's body) a "Head" response inviewing A11. This was emotionally safe to be seen, since the defensive imagery was well disguised from a human body because of being portrayed in that of a small bug. A12: "The bowel of a lady with a womb and baby in it”- Here he avoided reference to the ear like content of the electronic stimulus. Here it was most significant that the perseverating image of his wife's crushed body surfaced in conscious projective awareness by his assigning a female sex to the anatomical structure. In regard to his physical health symptoms, after his wife's death his appetite was reduced and he lost weight. T h i s r e s p o n s e s h o w e d h e i g h t e n e d BODYAWARENESS for his bowel. Here the mechanism of somatic "sensitization" was the determinant mechanism. Yet moments later the opposite mechanism of somatic "Repression" became operational in viewing the electronic visual input related to the gastrointestinal tract. Thus A14 having form movement visual connotations suggestive of the upper gastrointestinal tract were avoided in his responding "A kidney hanging down from an artery". Similarly there was such perceptual inhibition with A15 depicting the same region. It was seen as "A stepladder going up and a deer leg". Next examples will be given in regard to responses symbolically capturing his negative reactions to his wife's death, especially his irritability and anger. For A28 depicting a man's thigh, he responded "A cutting from a tree . . . the lower portion of a man's body". Here the initial response of Somatic Repression symbolized his "Cut off marital sexual relationship. Seconds later when the psychological defense failed his frustration and anger surfaced immediately in the interview session exclaiming "I'm getting more pissed off... this is all foreign to me"! This surfaced symbolically soon after in giving a bizarre response to B2 “Lady who got her ass kicked ... and two boobs hanging down all beat up". In subsequent sessions, he was able to express his anger about her death (Apart from being angry at the truck driver) rationalizing his negative critical feelings. Initially he believed that they were due to her having habitually ignored his driving advice prior to the accident. He had habitually advised her to take a safer route. Later with inner world SIS guided psychotherapy, he acquired insight into the more direct irrational source of his anger namely having left him through death. Finally in regard to viewing B2 suggestive of a person body dying with life forces leaving he responded simply "Somebody sleeping or dead...things going up...no idea maybe he is dreaming". Given his previously noted increased SIS-II Video projective awareness of his deceased wife, this seems like a logical inconsistency. I will leave this as a theoretically challenging interpretive exercise for the so interested reader to submit for possible future publication in this journal. Berzoff, et.al. (2011) mentioned that Freud and Loewald have also talked about the ways in which individuals 8 Cassell & Dubey

may be changed by grief, for better and for worse. Mourning may be an occasion for mastery through acts of altruism and may offer new narratives of the self. It may lead to self- hate and to lower self-esteem but it may also lead to new ideals, new capacities, and new kinds of relationships with the dead. d'Epinay, et al. (2009)conducted study on the loss of a spouse, a child, a sibling, or a close friend and found that, the bereaved suffered a marked and lasting increase in depressive symptoms, together with a short-term deterioration in their functional status; those bereft of a spouse or a child saw their functional status worsen and exhibited enduring depressive symptoms but they also benefited from support in the form of increased interaction; those bereft of siblings only suffered from a mild, short-term deterioration in functional status; those who had lost a close friend suffered a very significant increase in depressive symptoms. Kaunonen, et.al. (1999) studied grief and social support after the death of a spouse on a sample of 318 Finnish widows and widowers, in order to investigate the sources of socialsupport, what is the nature of support received, and whether socialsupport is connected with coping with grief. The Hogan Grief Reactions Checklist was used to describe the grief as well as answers to open-ended questions about what helped the widowed persons cope with their grief. Kahn's theory of socialsupport was used as a framework in the content analysis of the open-ended answers. The results showed that Finnish widows and widowers receive socialsupport most often from their own family and friends. They perceived the received support most helpful, but also the support that the grieving person can give to other family members is seen as important. Results suggest that those who had had socialsupport were able to grieve by allowing themselves to disorganize and experience panic behavior. Kaunonen, et.al. (2000) in another study on 242 widows and 76 widowers whose spouse died more than 6 months prior to the data collection, found that widows expressed significantly more intense feelings of panic behavior than widowers. Both widows and widowers grieved about how to survive after the death of their spouse. Both groups found their families and friends to be the most important source of support when trying to cope with their grief.Miller, et.al. (2012) found that a high self-report rating of the importance of religion or spirituality may have protective effect against recurrence of depression, particularly in adults with a history of parental depression. Shear and Skritskaya (2012) stated that Anxiety is a natural response of the attachment system to separation from a loved one, seen in adults as well as children. Confrontation with one's own death is also a natural trigger of anxiety, though we usually protect ourselves from mortality salience using terror management strategies related to cultural values and self-esteem. In addition, loss of a loved one can trigger the onset of anxiety disorder that, when present, can derail the mourning process and prolong acute grief. Conclusion: The death of a loved one is one of life's greatest, universal stressors to most bereaved individuals. For some of bereaved individuals, grief is complicated by superimposed problems, consequently overall healing does not occur. Many such sufferers develop severe depressive symptoms. The present case history has illustrated the effectiveness of therapeutic intervention using as an aide SIS electronic technology. Footnote: At the risk of being criticized for having "Anthropomorphism erroneous thinking", the authors suggest that the open minded spiritual based reader consider contemplating philosophically/religiously the following issue, which cannot be answered scientifically. Consider that any case history study of bereavement for the species Homo Sapiens, in theoretical appraisal, needs to consider the expanding scientific work documenting the emotional life of other higher forms of animal life - perhaps even their "Spirituality? It is historically significant that beginning in the 20th century observers of animal behavior apart from humans have published interested relevant observations on these issues. An example is Jeffrey Masson & Susan McCarthy's book "WHEN ELEPHANTS WEEP, The Emotional Life of Animals" published by Delacorte Press Dell publishing Group, Inc. 1540 Broadway, New York, NY 10036. (Finally, it might be recalled that certain major religious groups, such as members of the Hindu religion have sensed this for centuries.)” References: Berzoff, J. (2011). The transformative nature of grief and bereavement. Clinical Social Work Journal, 39(3), 262-269. doi:10.1007/s10615- 011-0317-6. Dream Symbolism 9

d'Epinay, C. J. L., Cavalli, S., and Guillet, L. A. (2009). Bereavement in very old age: Impact o n h e a l t h a n d relationships of the loss of a spouse, a child, a sibling, or a close friend.Omega, 60(4), 301-325.doi:10.2190 /OM.60.4.a Kaunonen, M., Päivi, Å.,Paunonen, M., and Erjanti, H. (2000). Death in the finnish family: Experiences of spousal bereavement. International Journal of Nursing Practice, 6(3), 127 134.doi:10.1046/j.1440-172x.2000.00189.x Kaunonen, M., Päivi, Å.,Paunonen, M., and Erjanti, H. (2000). Death in the finnish family: Experiences of spousal bereavement. International Journal of Nursing Practice, 6(3), 127- 134.doi:10.1046/j.1440-172x.2000.00189.x Miller, L, Wickramarante, P, Gameroff, M.J., Sage, M, Tenke, C. E, Weissman, M.M. (2012) Religiosity and Major Depression in Adults at High Risk: A Ten-Year Prospective Study. Am j psychiatry 2012; 169:89-94 Shear, M. K., and Skritskaya, N. A. (2012). Bereavement and anxiety. Current Psychiatry Reports, 14(3), 169-175.doi:10.1007/s11920-012- 0270-2 10 Cassell & Dubey "SIS SOCIETY HONOR ROLE" “Throughout history human unbridled aggression worldwide has led to seemingly ceaseless oscillations between peace and war. With the advent of weapons of mass destruction, civilized life on planet earth now exists in an ever more precarious state. It is essential that Society members develop SIS assessment applications for screening all individuals having access to such weapons. Our profession needs to reach out and provide consultative services for the police, military and all government agencies concerned with preventing such aggression. This is a serious problem that seemingly can only be solved by "Preventative Treatment". After the fact of nuclear world war, it is likely that "Treatment" theoretical models would have little relevance. In this issue of the journal a "SIS Honor Role" will be initiated. Its goal will be to recognize as spiritual mentors those who have already played an important preventative role. We are initially focusing on all those brave individuals who prevented Adolph Hitler from accessing Norwegian heavy water supplies produced in an industrial plant at Vermont. This deranged dictator's engineers came very close to successfully assembling nuclear weapons, more so than most people generally recognize. World War II would have ended much differently, if it were not for the efforts of heroic Norwegians who initially destroyed the production facility and then sank a ship transporting the last supply of heavy water. One of the heroic soldiers photograph is shown here.( An interested reader may find related detailed historical data by inserting "The Norwegian Heavy Water Sabotage" into Wikipedia.). All of us can benefit from psychological identification with positive heroic mentors - especially those in training and younger members of our SIS Society In association with the above "SIS HONOR ROLE" the Somatic Inkblot Society will award $500.00 for a leading SIS article on the roots and management of aggression. Wilfred A Cassell, M.D., APC, FAPA, Editor Emeritus SIS J. Proj. Psy & Mental Health

Empirically-Supported Case Studies of Creativity in Writers in Psychoanalysis Nadine J. Kaslow, Peggy D. Flanagan, Erica R. Carlin, Rachel Harris, Enith E. Hickman and Susan L. Reviere This case study provides a structured and qualitative look at changes in Rorschach Inkblot Test responses for two creative writers over the courses of their psychoanalyses. Attention was paid to capacity to preserve transitional space between reality and fantasy using the Reality-Fantasy Scale, which was applied to responses, coded using Exner’s Comprehensive System. Based upon empirically coded responses using the Reality-Fantasy Scale, over the course of their psychoanalyses, they demonstrated greater reliance on fantasy and more extreme reality-fantasy alterations. Psychodynamically-informed clinical interpretations of the Rorschach responses that showed shifts in creativity are offered. Results reveal that the Rorschach is a valuable projective tool for examining creativity in individuals undergoing psychoanalysis, engagement in a psychoanalytic process enables analysands to more readily share their fantasy-based perception, and it is optimal to use both the formal Reality-Fantasy scale and clinical interpretations for garnering a comprehensive understanding of shifts in creative processes secondary to psychoanalysis. Creativity has long been studied as one of the most interesting human traits. It is central to novel problem solving and ingenuity itself, and some would say it is the engine of the human machine. This highly prized characteristic is reflected in all cultures’ love of all forms of artistry. Although there is no agreed upon definition of this multifaceted construct, the production of an idea or product that is novel and useful is generally agreed to be a defining characteristic of creativity (Furnham & Bachtiar, 2008). Creative behavior “may be viewed as an interaction between person and situation …..the criteria for a creative outcome generally include the idea that the production be original, novel, or statistically rare as well as approved, accepted, or socially good” (King & Pope, 1999, p. 200). The creative act is a manifestation of primary process thinking that allows for the generation of a novel idea or insight through loose, illogical and highly subjective thinking when combined with secondary processes that organizes this thinking in a fashion that is socially appropriate and meaningful to other people (Suler, 1980). The processes of creativity and its correlates are largely mysterious. Research has found that creative individuals possess a number of personality characteristics such as intelligence, emotional intelligence, psychological richness and complexity, psychological mindedness, extraversion, autonomy, independence in thought and action combined with a value on cooperation and self-control, flexibility, tolerance, originality, a tendency toward perceiving rather than judging, and an openness to new experiences (Barron, 1990; Feist & Barron, 2003; Furnham & Bachtiar, 2008; Helson & Srivastava, 2002; Ivcevic, Brackett, & Mayer, 2007; King & Pope, 1999; McKinnon, 1965). It is this openness, both to internal and external elements, combined with the tendency to be more expansive in descriptions and understanding, that facilitates the process of one’s own creativity. Studies have revealed that creative individuals rely chiefly on affective processes to integrate their creativity (Russ, 1993). Further, data show that artists, such as writers, are more open to experience than the normal population and thus likely to be creative (Furnham & Bachtiar, 2008). Those with recognized achievements, such as those who publish their writings, demonstrate more creative thinking (Wechsler, 2006). From the start, psychoanalysts have been fascinated by the creative process (Hildebrand, 2006; Rubin, 2004). Both psychoanalysis and creativity offer the promise of personal psychological transformation (Press, 2005). There are a number of reasons that creative people may be particularly good candidates for psychoanalysis. Creative individuals tend to be more capable than their less creative counterparts of tolerating and utilizing the transitional space between internal and external reality (Winnicott, 1958, 1971). This transitional space is an “intermediate area between primary creativity and object perception based upon reality testing” (Winnicott, Nadine J. Kaslow, Ph.D., ABPP, (Corresponding author) Emory University School of Medicine, Department of Psychiatry and Behavioral Sciences, Grady Health System, 80 Jesse Hill JrDr, Atlanta, GA, 30303 (USA), Phone: (404) 616-4757 Fax: (404) 616-2898, Email: nkaslow@emory.edu, Enith E. Hickman and Susan L Reviere, Dept. of Psychiatry and Behavioral Sciences, Emory School of Medicine. Peggy D. Flanagan. Georgia Regional Hospital Atlanta, Erica R. Carlin. Kaiser Permanente and Rachel Harris, Atlanta Veterans Administration Medical Center. Key Words: Creativity on Rorschach, Creativity in writers.

1958, p. 239). In addition, creative people often are capable of adaptive regression or regression in the service of the ego, an altered state of consciousness that is selectively and temporarily used by the individual in order to adapt to changing internal and external conditions. Adaptive regression refers to the process of integrating affectively laden and often illogical cognitive processes with rational and adaptive thought processes. In addition, adaptive regression supports the synthesis of primary and secondary processes in order that objective reality can reflect the subjective experience and socially acceptable outcomes emerge (King & Pope, 1999). The Rorschach Inkblot Test (Rorschach) is a potentially valuable instrument for investigating creativity (Fleenor & Taylor, 2004; King & Pope, 1999). Some efforts have been made to develop scales to assess creativity on this projective instrument (King & Pope, 1999), most notably Holt’s System for Primary Process Responses on the Rorschach (Holt, 1977). There is a small body of research on the responses of creative individuals to the Rorschach. For example, there is some evidence that gifted and creative adolescents and adults have elevated scores on a number of indices associated with the Comprehensive System (Exner, 2003), including the Schizophrenia Index and the Depression Index (Franklin & Cornell, 1997). However, these elevations appear to be related to participants’ motivation to produce original and unusual responses rather than to psychological maladjustment (Franklin & Cornell, 1997). Researchers also have found significant positive correlations between various test measures of creativity and the Adaptive Regression Index of Holt’s Scoring System, a finding that appears to be particularly true for males (Holt, 2002). Creative individuals also have elevations on specific variables, including human movement and total movement (Baker, 1978). In addition, a few studies have examined creativity of writers on the Rorschach. These investigations show that successful writers and painters make more spontaneous affective comments and expressions indicative of a greater capacity for the integration of thoughts and feelings and a wider range of defense mechanisms than do individuals engaged in nonartistically-oriented professions (Dudek, 1968). Compared to non-artists, artists also have more access to libidinal drive energy that is associated with creativity, higher levels of synthetic thinking, greater capacity for adaptive regression, and more interest and skill in offering rationalizations for their unusual responses (Dudek & Hoechstetter, 1995). In recent years, the Reality-Fantasy Scale (RFS) has been proposed as a new Rorschach index (Tibon, 2005) to measure the construct of potential space, which is a spatial metaphor that is informed by a model of intersubjectivity (Winnicott, 1971). This construct refers to the space between self and object and is the intermediate area between reality and fantasy. It is an area that is not challenged, as it is a place that is neither in the realm of reality or fantasy. This intermediate area of potential space can be contrasted with the concepts of the inner world and the actual or external world, which reflect the more extreme ends of the continuum. The capacity to preserve this potential space is considered to be a core factor in healthy and adaptive psychological functioning. The RFS scale is constructed consistent with a paradigm that formulates that Rorschach is a task that invites the participant to enter the intermediate transitional space between inner and outer reality, the space in which creativity takes place. Specifically, the RFS assesses the adaptive use, creation, and preservation of potential or transitional space, the space in which transitional phenomena, playing, cultural experiences, and creativity take place (Ogden, 1989; Pizer, 1996). Since psychoanalysis also takes places in part in this transitional space, it is within this context that artistic involvement can be understood, restricted creative potential can be released, and fertile ground can be laid for people to realize their creative potential (Carson & Becker, 2003; Sternberg, Grigorenko, & Singer, 2004; Turco, 2001). Psychoanalytic treatment can foster the creative process in artists, such as writers, by supporting the construction of the true self, revealing and elucidating the intra-psychic and interpersonal barriers to creative expression, and ameliorating the psychopathology that can inhibit creativity (Parsons, 2000; Rubin, 2004, 2009; Sanville, 1987; Turco, 2001). In addition, the insight one can gain through engagement in a psychoanalytic process is curative in part because it has the potential to facilitate the creative process and to 12 Kaslow et al

affirm the value of creative expression (Blum, 1979). In the context of a psychoanalysis, the patient and the analyst have the opportunity to interpret the relationship between the patient’s creative endeavors and his/her life and psychodynamics (Turco, 2001). Unfortunately, to date, there has been no systematic research to examine whether or not psychoanalysis is associated with enhanced creativity in artists, such as creative writers. The following in-depth empirically-based case studies are designed to examine in two authors the link between creativity, as measured by the capacity to preserve transitional space between reality and fantasy based on their responses on the Rorschach Inkblot Test, and participation in psychoanalysis. At one level, it is reasonable to assume that over the course of psychoanalysis, an individual would be become more organized and reality-based in their perceptions. However, it also is the case that engagement in psychoanalysis, which supports free association, would be associated with greater access to one’s fantasy life, albeit in an adaptive fashion. Such access to fantasy life seems particularly critical for individuals invested in engaging in creative endeavors, such as creative writing. Thus, in keeping with the perspective that participation in psychoanalysis would enable individuals to more comfortably access and share their fantasy-based perceptions, it was hypothesized that over the course of their psychoanalyses the authors would demonstrate: (1) an increased reliance on fantasy (more negative RFS-P) and (2) more extreme alterations between reality and fantasy. Clinical interpretation also will be provided to demonstrate more fantasy-oriented thinking in the Rorschach protocol. Method: Participants: The participants consisted of two Caucasian male creative writers, who were in psychoanalyses funded by the Lucy Daniels Foundation. Analysand A (age 42) underwent 547 sessions of psychoanalysis over a five year time span. His pre-analysis Structured Clinical Interview for Diagnosis (SCID) diagnoses were Dysthymic Disorder, Social Phobia, and Alcohol Dependence. Analysand B (age 35) underwent 837 sessions of psychoanalysis over six years. His preanalysis SCID diagnoses were Major Depressive Disorder and Alcohol Abuse, in Remission. Neither patient met DSM criterion for an Axis II diagnosis. No psychodynamic diagnoses were reported in the research data. The data provided in this report are from their baseline and post-analysis Rorschach. These two analysands were members of a cohort of eight individuals who were included in the research protocol if they were published creative writers. Given the case design nature of the study, we selected these two individuals in a manner that would minimize the differences between the cases examined. Specifically, the two participants worked with the same analyst and also were matched for gender and length of time in psychoanalysis. The analysands were part of a longitudinal research project examining creative writers suffering from psychological distress who wished to undergo psychoanalysis. Analysands who were a part of this research project completed a comprehensive battery of measures pre-analysis and every six months thereafter. Once they completed their psychoanalyses they were re-examined every year on many of the same measures. In addition, the analysands and the analysts completed daily measures on pertinent variables. The one exception to this protocol was the Rorschach, which was only administered at the beginning and end of each psychoanalysis. Thus, this eliminates concerns about practice effects, boredom, or test fatigue with this measure. The study was approved by the relevant university Institutional Review Boards and the participants provided written informed consent. Procedures: Analysands were recruited for this project as follows. In order to be part of the research study and have access to a psychoanalysis paid for by the Lucy Daniels Foundation, potential participants were screened based for their need and suitability for psychoanalytic treatment, their creative productivity and promise, and their willingness to participate in an ongoing research protocol. In addition to completing an application form and providing detailed historical data, they submitted their published and unpublished writings. Following this, they were interviewed by a Clinical Coordinator, who gathered additional data and answered questions. Creativity on Rorschach13

Then, potential participants had one to two interviews, lasting approximately one hour each. These interviews took place with a psychoanalyst at the foundation’s expense. Subsequent to this, they completed a comprehensive psychological testing battery. The clinical review team then utilized all of the aforementioned information to determine whether or not the potential participant would be included in the project. Writers accepted to the program understood the general exploratory purpose of the research. The following are the procedures only for the current measure. The participants were administered the Rorschach according to Exner’s Comprehensive System administration guidelines (Exner, 2001). Multiple psychologists administered this measure at both baseline and the completion of the treatment; sometimes the same psychologist administered the measure to the same patient at the two different time points, but this was not always the case. Unfortunately, some of the psychologists who administered the Rorschach did not adhere completely to the standard administration procedures. We recognize the gravity of non-adherence and its potential to invalidate the outcomes. However, after careful review and having completed the consensus scoring process, we believe the incidents of non-adherence did not alter the outcomes and the protocols can still be considered valid. Three psychology postdoctoral fellows trained extensively in the Rorschach Comprehensive System who had no involvement with the administration of the Rorschach and who were blind to the study hypotheses and order of protocol administration independently scored the participants’ Rorschach responses. There was good inter-rater reliability obtained among these postdoctoral fellows as reflected in a kappa of .86. After the protocols were scored by each fellow, the fellows came together and determined consensus coding for the responses integrating their separate codings. When discrepancies were found among raters, a decision was made after the raters consulted with a licensed senior psychologist. These codlings were then entered into the RFS computerized scoring system by a fourth psychology postdoctoral fellow. Reality-Fantasy Scale (RFS): The RFS (Tibon, Handelzalts, & Weinberger, 2005) was created in an effort to operationalize Winnicott’s construct of potential space (Winnicott, 1971). The RFS captures impaired psychological manifestations using variables derived from Exner’s Comprehensive System (CS) (Exner, 2001). This scoring schema conceptualizes the Rorschach as inviting the respondent to enter the transitional space between reality and fantasy (Smith, 1990). The scale is based on a model of different types of psychopathological manifestations as being revealed by a failure to preserve potential space (Ogden, 1989). There were three phases in which the variables to be incorporated into the RFS were chosen: (1) general theoretical definitions of reality and fantasy were selected, (2) the Rorschach literature was reviewed to ascertain constructs that may have face validity with regard to the concepts of reality and fantasy, and (3) case studies were scanned for the words reality and fantasy to determine which Rorschach variables were used to tap into these constructs (Tibon, Weinberger, Handelzalts, & Porcelli, 2005). This coding schema combines CS variables or combinations of variables (e.g., determinants including form, human movement, and inanimate movement; form quality (unusual, ordinary); contents including whole animal fictional or mythological, animal detail fictional or mythological, whole human fictional or mythological, human detail fictional or mythological, clouds, abstract, ideographic; populars; special scores including deviant response level 2, incongruous combination level 2, fabulized combination levels 1 and 2, contamination, inappropriate logic) and an additional special score of Reality Collapse (RC). The RC score is coded for responses where the blot is experienced as if it were the thing itself. In other words, it is given to responses in which the respondent appears or sounds as if he/she is totally losing distance from the blot and reacting to the blot as if it is the thing itself. The 11-point RC scale ranges from -5, which represents extreme reliance on fantasy (reality collapse into fantasy), to +5 for extreme reliance on reality (fantasy collapse into reality). The RFS-S is a single response score and more fantasy oriented individual responses have elevated RFS-S codings. These will be reported in the clinical interpretation. There are two derivations for interpreting the RFS: RFS- 14 Kaslow et al

P and RFS-S. The RFS-P refers to the mean RFS score of a given protocol and represents the ability to preserve transitional space between reality and fantasy. A score approximating zero (-.65 to + .65) indicates adaptive and functional use of potential space and is found in psychologically healthy individuals, whereas lower or higher scores appear in cases of reality collapse (psychotic spectrum) and fantasy collapse (normotic spectrum, psychosomatic symptoms) respectively. This score is computed by reviewing each Rorschach response according to specific steps delineated in a flow chart. As individuals gain more access to their creative side, it is likely that their RFS-P scores will become more negative, as a reflection of their enhanced access to their fantasy life. The RFS-S refers to the standard deviation of the RFS and represents the fluctuations of the responses between the reality and the fantasy poles through the protocol. An elevated RFS-S (> 2.83) is found in individuals who experience reality and fantasy as two unrelated realms (dissociative states). It is likely that as individuals gain more significant access to the creative realm that their RFS-S scores will increase, as an indication of more fluctuations between reality and fantasy. The scale has been validated in adult patients and nonpatients in different countries (Tibon, 2005, 2007; Tibon, Handelzalts, et al., 2005; Tibon, Porcelli, & Weinberger, 2005; Tibon, Weinberger, et al., 2005). More specifically, the measure has good construct, predictive, and discriminative validity (Tibon, 2005, 2008, 2009; Tibon, Porcelli, et al., 2005; Tibon & Rothschild, 2009; Tibon, Weinberger, et al., 2005). It also can be used for psychoanalytic diagnostic purposes, particularly in conjunction with the Ego Impairment Index (Tibon, 2005; Tibon, Porcelli, et al., 2005). In addition, inter-reliability for coding this measure in other samples has been high (Tibon, 2007; Tibon, Handelzalts, et al., 2005). Results: CS and RFS Scores: Analysand A provided 12 responses at baseline and 14 following the treatment. This is a relatively low number of responses overall and for the CS system, 14 responses is required for a valid protocol. Less than the requisite number of responses may reflect a paucity of internal musings, which likely makes being a creative writer challenging. This relative dearth of internal musings may be found in some creative writers with psychological difficulties, such as those seeking treatment in this study. Alternatively, this low number of responses may raise questions about the validity of Rorschach for tapping the unconscious processes that may be beneficial to creative writers. Analysand B offered 45 responses at baseline and 84 following the psychoanalysis, which yielded considerably more psychological material to interpret. Only the first five responses per card are used to inform the RFS scores. In both cases, the increase in number of responses may be a manifestation of a greater willingness to share unconscious material. Creativity on Rorschach15 Table 1 Creativity Indices for Analysand A and Analysand B at Baseline and End of Treatment Analysand A Analysand B Baseline End of Analysis Baseline End of Analysis RFS-P 0.42 -0.57 0.11 -0.24 RFS-S 1.44 2.82 2.50 2.42 Note. RFS-S = Reality-Fantasy Scale mean score; RFS-S = Reality-Fantasy Scale standard deviation.

Table 1 provides a depiction of the each analysand’s creativity indices at baseline and post-analysis. Both analysand’s findings are consistent with one of the two hypotheses, whereas the responses of one analysand are in keeping with the other hypothesis. Specifically, as predicted their RFS-P scores became more negative and one analysand’s RFS-S became more positive. Thus, over the course of their psychoanalyses, they became more reliant on fantasy and exhibited more extreme alterations between reality and fantasy. It should be noted that increases in creativity were not found for every card for both analysands and the RFS scores reflect an average over the entire protocol. Clinical Interpretation: Although Rorschach responses are most commonly understood using formal quantitative systems, such as the CS and the RFS, in actual practice, particularly analytically-oriented practice, consideration of the content features of the protocol is very valuable (Aronow & Reznikoff, 1976; Lindner, 1950). Such a qualitative approach must be considered in conjunction with the more formal quantitative scoring procedures (Lindner, 1950). The following is a clinical interpretation for each of the analysands based on their Rorschach responses. This clinical interpretation is limited to those Rorschach cards on which they showed RFS scores on one or more responses at the completion of their psychoanalysis that were indicative of high levels of creativity (i.e., RFS score = -5). None of their responses prior to treatment reflected this high degree of creativity. Analysand A: Analysand A gave responses indicative of greater orientation toward fantasy on five cards at the end of the treatment. As examples of changes in the predicted direction, we will discuss Analysand A’s responses on two cards, Card I and Card X. It is interesting to note that marked changes occurred on the sign-in card (Card I) and the sign-out card (Card X), with less change noted on the middle cards. This may suggest that the more indepth dynamic changes are yet to take place. The popular responses for Card I are bat or butterfly for the whole percept. Typically, this card, which has no color on it, offers clues about how individuals respond to novel and stressful tasks. It is considered in a clinical interpretation to be the card that indicates how people first present themselves. Prior to the psychoanalysis, Analysand A gave one response to this card. On free association, he said, “Sort of a Halloween face. Jack-o- lantern, not pleasant, menacing aspect.” On inquiry, he elaborated by saying, “Ears, eyes, mouth.” In response to the query from the examiner, “Halloween?”, the analysand said, “I’ve seen lots of Jack-o-lanterns cut in a similar fashion.” Further in response to the query, “Menacing?”, the analysand stated, “General facial expression.” According to the CS, this response was coded, WSo, Fo, (Hd), 3.5, PER, GHR. In other words, Analysand A gave the response, using the whole card with good form. He incorporated white space (WS) and his special scores are indicative of personalization (PER) and good human response (GHR). His RFS score for this response was a 2, suggesting a slight tendency to rely on reality. A clinical interpretation of Card I prior to treatment would suggest the person has good reality testing, at least when no stress is present. Despite the fact that he has the capacity to perceive and interact with others in a positive fashion (GHR), there is some suggestion of paranoia, with the focus on eyes and on the percept as not pleasant and even menacing. His use of white space (WS) raises the question of his having an oppositional approach to tasks and human interactions. Further, the fact that he personalizes the response may be suggestive of some narcissistic traits. Following the completion of his psychoanalysis, Analysand A once again only provided one response to Card I. His free association was “As I’ll say to all of these, it’s symmetrical. It looks like two identical animals facing each other. Possible pigs holding on to a central object. Possibly dancing or playing. That’s it.” On inquiry, he stated the following, “Looking up. Something holding onto something. About tilt of head. A cartoon quality to it, like they’re playing. Perhaps (pointing to the center), something that can spin so they would be spinning around. Glee, like it looks like bouncy, a lot of fun.” The CS scoring for this response was W+, FMa -, (2), A, Id, COP, FABCOM1. The RFS score for this response was -5, suggesting an extreme reliance on fantasy. 16 Kaslow et al

Thus, the formal coding revealed that although he still used the whole percept and now incorporated active and collaborative animal movement, this was combined with the pigs engaging in unusual activities (e.g., dancing, playing, spinning) and having feelings that are not typically associated with pigs (e.g., gleeful), although these affects are not uncommon in cartoon pigs. On both responses, he failed to receive a popular scoring and on the latter response he failed to see the percept in a fashion commonly viewed by others. His response also indicated some thought disorder in the special scorings, in terms of the unusual pairing of percepts (FABCOM 1). A clinical interpretation suggested that this response was much more elaborated and fantasy-oriented and even child-like in its nature. There was a playfulness and sense of fun reflected in the card, which is in stark contrast to the menacing quality of the response given prior to the psychoanalysis, suggesting that he was less paranoid and more able to experience pleasure and cooperation in relationships. A second card on which Analysand A showed more fantasy oriented responses over the course of treatment was Card X. This card is full of color (i.e., affect) and although it is a pleasant card, there is a lot of concurrent stimuli, which may be challenging for some people who easily become overwhelmed with stimulation, particularly of an affective nature. In addition, because it is the final card in the series, some people’s responses are consistent with a “sign out”, in which they reveal what they believe their situation to be and/or what they are interested in knowing. The popular responses on this are to one particular detail on the card, and are that of a crab or spider. This detail, the same on both sides of the card, appears in blue. Prior to treatment, his response on free association was: “Human anatomy. Physiology. Parts of the spinal column interrupted, not complete.” On inquiry, he noted, “Spinal column, pelvis, continuation up here. Everything else is extraneous. This one looks most abstract of all. Just saw something else (flips card upside down). Heads of seahorses.” This was his only response to Card X. This response was coded according to the CS as follows: Do, Fu, An, 4.5. Thus, he only attended to one detail of the card, using unusual form, and the content was that of anatomy. The RFS score was 2, again suggesting a slight reliance on reality. A content interpretation perspective on this card suggests that he is preoccupied with his insides and his body (anatomy, physiology, pelvis) and does not feel whole or complete (spinal column interrupted). The attention to the interrupted spinal column may suggest some unconscious fears of castration and impotence. This preoccupation with his body and his masculinity, however, makes him uncomfortable and he tries to distance himself by shifting his attention to the abstract nature of the blot and a very superficial and distancing detail, namely seahorses. Because this response was only provided on inquiry, it is not scored. After completing his six and one-half year psychoanalysis, he offered five responses to Card X. Response 1’s free association was, “This is the most elaborate, colorful one of all. Makes me think of modern or postmodern art. Central figures look anatomical or skeletal to me, like top part might be part of the spinal column.” The associated inquiry was as follows: “Here (grey) and this would be supporting bone, doesn’t really look like vertebrae. Response 2’s free association was, “Then big pink structures that are connected by blue could be part of pelvis.” And the inquiry, he elaborated, “pelvis – just the general shape.” Response 3’s free association was, “The very top sorta grayish structures looks like it has a pair of eyes on it staring at me.” Upon inquiry he said, “Top grey is a real long head with two eyes on it. It seems vaguely comical, not threatening or dangerous at all.” The fourth response was, “At bottom of card, there’s a green structure that also appears to have eyes and also ears. Nearly everything else off to the side looks sort of artistic.” On inquiry he said the following, “Unidentified creature with eyes and ears, staring straight at me as if studying me. May be with a look like its sentry and I’m an intruder or potential enemy.” The final response to this card on free association was, “And one more thing, on the left and right side are blue figures that very abstractly look like lobsters holding up one big green claw each. And that’s about it. The colors are very nice.” The inquiry associated with this response was, “These are Maine lobsters, crustaceans, I’m getting hungry. Looks like getting ready to attack or defend itself.” Creativity on Rorschach17

Since only the last three of these five responses received scores indicative of a reliance on fantasy, RFS scores of - 5, -4, and -1, respectively, only these responses will be detailed now in terms of their CS coding and a clinical interpretation. The CS coding for responses 3, 4, and 5 were as follows: Response 3 - Do, Mp-, (Hd); Response 4 - Do, FMp-, (Ad), Ag, DR1; and Response 5 - Ddo, FMa.FC u, (2), A, DR1. Thus, he was more focused on minor details, evidenced a high level of passivity, and struggled more to incorporate affect into his responses (green structure with eyes and ears, lobsters holding up a big green claws). However, how was unable to maintain adequate perceptions of reality and when he did so, became somewhat paranoid (unidentified creature staring straight at me, I’m an intruder or potential enemy), and again personalized the responses in a fashion that reflected a lack of distance from the percept (saw Maine lobsters and noted that this made him hungry). His RFS score of -5 for each of these responses suggested a total reality collapse. Such a collapse occurred after two prior responses to the card in which he became increasingly more paranoid, affectively overwhelmed, and focused on the fantasy rather than the reality aspects of the card. In general, it may be that he is most creative when he has the greatest access to his affect. Analysand B: Analysand B gave responses indicative of greater orientation toward fantasy on five cards at the end of the treatment. Given the large number of responses he gave per card, we will only discuss his responses to two of these cards. We selected cards that are different from those examined with Analysand A. The first card that we will focus on is Card VIII. This is the first multicolored card in the set and the first card that is color only. Because of this, it represents a change of pace. Given that color is believed to represent affect, individuals who find it psychologically challenging and distressing to process complex situations or emotional stimuli often are uncomfortable with this card. Prior to the initiation of the treatment he gave four responses to this card. Response 1 on free association he said “Chameleon, lizards, climbing something.” Upon inquiry he said, “Shape, ridged back, darkening in head area. Color reminded me of a chameleon, usually green, but brightly colored.” It was scored in the CS system, Do, FMa. FCo, (2), A, P, DV1.Response 2 on free association he remarked, “A woman’s sex organ.” On inquiry he stated, “Vulva of a vagina. Pink color and the line down the middle.” This was scored Do, CF-, Hd, Sx, PHR. For his third response to this card, he commented, “A Japanese warrior wearing a helmet.” On inquiry he elaborated as follows, “Helmet, shoulders, nosepiece. White space is eyes. Torso.” When queried by the evaluator, (“Japanese?”), he said, “I’ve seen helmets that look like that.” In the CS system, this was coded as follows: DS+, F-, Hd, Cg, PER. His fourth response to Card VIII was, “A rocket launch at dawn.” Upon inquiry, he said, “Rocket down the middle. Trail of fire.Exhaust. Rosy color is dawn. Blue-grey color is sky that hasn’t turned.” When evaluator says, “Rocket?”,Analaysand B elaborates by saying, “Shape, hard-edged, tube-like.” This answer was coded in the following manner: W+, FCu, Sc, Fi, Na, 4.5. The RFS scores for this card were 1, -3, -3, and 1, suggesting both some reliance on reality and an overreliance on fantasy prior to the initiation of the psychoanalysis, without a total reality collapse on any of his responses. Again, while on the one hand this is suggestive of a reasonably defended individual, which is a positive trait, it may also mean that he has less access to his own creative processes. In general, before starting treatment he gave only one popular response. He used both the entire card and specific aspects of the card. He was very focused on the color and appeared to become overwhelmed affectively, to the extent to which his percepts lacked good reality testing. From a clinical interpretation perspective, many of his responses were sexualized in nature and he even explicitly noted the vulva of a vagina. There were references to many phallic type objects, such as rockets that were hard-edged and tube-like. Of note, this card does not typically draw for highly sexualized responses. He attempted to use intellectualization (e.g., Japanese warrior wearing a helmet) to help him gain distance from his affect, but this defense was not very effective. On Card VIII at termination he provided nine responses. However, given that the RFS scoring only incorporates five responses, we will only comment on his first five responses to this card. His responses were as follows. 18 Kaslow et al

The free association for the first response was “Pair of chameleons.” Upon inquiry, he stated, “Sort of crawling up the page. They are pretty.” The free association for the second response was “A Samurai warrior.” On inquiry he elaborated, “Whole top is helmet, shoulders, armor. White space is shape of shoulders. Face, glowering, out from under the helmet. The rest is robes. The upper half of a warrior. It seems like a costume that I was admiring.” The third response to this card was as follows on free association, “A mountain top.” On inquiry he stated, “The crest of a ridge where mountain top disappears into distance. Both the shape and the green color.” The fourth response was as follows on free association, “Someone diving into a pool.” On inquiry, he further noted, “White space is pool. Person’s arms, body. Seen a person from below.Arrowing down into the water with all the green above.” The fifth response to this card was the following on free association, “A sunset reflected on water.” And on inquiry he said, “Green is water. Color at bottom is sunset. Kind of turned around graphically. But the colors reminded me.” The CS coding was as follows: (1) Response 1 – Do, FMao, (2), A, P; (2) Response 2 – WS+, Ma-, Hd, Cg, Ay, PHR; (3) Do, FCo, Ls, (4) Response 4 - DdS+, FMa.C-, H, Sc, PHR; and (5) Response 5 – Dv/+, C-, Na. On response 2, his RFS score was -5, reflecting a total reality collapse, which we are asserting is suggestive of a potential increase in his access to his own creative processes. In addition, he received a -4 and -3 on his fourth and fifth responses, respectively. The following is a content interpretation of this card. First of all, the fact that he offered nine responses on this card suggests that he became flooded when presented with the intense affect associated with this full color card. His first response is adaptive and suggests positive feelings associated with the change process (i.e., chameleons change). However, he quickly distances himself from these positive feelings, and provides an angry and aggressive response. The rapid shift from positive to negative emotions is indicative of within card splitting and suggests the presence of splitting as a defense to deal with strong feelings. When the distancing fails him in this response, he attempts to defend himself through a greater use of intellectualization and withdraws into the distance. Once again, such withdrawal fails him and he dives head first into his angry feelings (white space represents anger) and evidences his second reality collapse on the same card. Finally, for the third time he tries to have a more positive image, but it makes no sense from a reality perspective, as he sees the sunset at the bottom of the water. Of note, there is much less sexual content in these responses when compared to his answers at the outset of his treatment. The second card we will examine is Card IX. This color card is characterized by its indistinct form and diffuse and vague nature. Problems providing adaptive responses to this card typically reflect difficulties dealing with unstructured situations, particularly those that are affectively charged. The popular response on this card is to one particular area on the card resembling a human or human-like figure and is the least frequently given popular on of all the cards. This detail, the same on both sides of the card, appears in orange. Prior to treatment, Analysand B provided five responses to this card. Response 1’s free association was: “A part of this looks like a fetus with its umbilical cord.” The associated inquiry was as follows: “Shape of head and body…probably twins. Reminds me of pictures I’ve seen of babies in the womb. Eye here.Color.” Response 2’s free association was: “Looks like a clown’s head.” On inquiry, he added: “Painted white, orange, hair puffed out to the side, darkened orange sections would be eye sockets.” Response 3’s free association was: “A skull.” The associated inquiry was as follows: “Same area, paid more attention to eye sockets, nostrils, lighter section defined by the green is cheeks, teeth coming down, top of cranium, orange and green together create 3-dimensional feel.” Response 4’s free association was: “I see two sort of cartoon faces with chins and big noses, starting out in opposite directions.” On inquiry, he elaborated: “Green areas. Outline of green is neck, chin, mouth, big nose, white space is eye with fleck of green as pupil.” Response 5’s free association was: “This one also looks to some extent like a rocket launch, great jets of smoke and fire.” Inquiry is as follows: “Rocket in middle, jets of smoke, fire bouncing up. Green area is smoke. Orange part of the explosion.” The CS coding was as follows: (1) Response 1 – D+, Creativity on Rorschach 19

FC.FYo, (2), H, GHR; Response 2 – DdSo, FC.FY-, Hd, PHR; (3) Response 3 – DSo, FV-, An; (4) Response 4 - DSo, FC’u, (2), (Hd), PHR; and (5) Response 5 – W+, ma.FCu, Sc, Fi, Ex. The RFS scores for this card were 2, -3, -3, -1, and -1, suggesting both a somewhat reasonable reliance on reality and an overreliance on fantasy prior to the initiation of the psychoanalysis, without a total reality collapse on any of his responses. With regard to content interpretation, his first response is suggestive of his wish for a symbiotic partner, whether that be a mother or a twin. He then becomes increasingly paranoid (i.e., focus on eye sockets), in a defensive and hypomanic fashion (i.e., painted clown face, cartoon character faces), as well as in a morbid fashion (i.e., skull). The final response to this card is indicative of an affective explosion (i.e., colorful rocket launch with explosion). Following five years of psychoanalysis, on Card IX at termination he provided eight responses. His responses were as follows. The free association for the first response was “A skull.” Upon inquiry, he stated, “Dome cavity, eye socket, nasal area where teeth should be. Sorta frightening.” The free association for the second response was “Bozo the clown.” At inquiry, he added, “Same shape except orange hair jumping up from white painted head. Sort of disturbing again” Response 3’s free association was: “Two sort of cartoon faces.” Inquiry was as follows: “Green part, white space is eyeballs with a pupil each, staring out back to back. Hooked nose. Smiling chubby, pursed mouth, in a snub and button chin, are funny.” Response 4’s free association was: “A flower.” Upon inquiry, he elaborated, “It’s inverted. Red is flower with leaves below it like somebody holding a flower upside down, maybe a tulip. Pretty.” Finally, Response 5’s free association was: “Pelvis bone.” At inquiry he added, “Orange section. The shape of two sides of a pelvis bone.” The CS coding was as follows: (1) Response 1 – DSo, F- , An; Response 2 – DSo, FC.mao, (Hd); GHR; (3) Response 3 – DdSo, Mp-, (2), Hd, Art, PHR; (4) Response 4 - Ddo, F-, Bt; and (5) Response 5 – Ddo, F-, An. His RFS scores after psychoanalysis were -3, 1, -5, -3, and -3, suggesting even more of a reliance on fantasy than prior to the psychoanalysis, including a complete reality collapse on Response 3. In terms of the content analysis of this card following the treatment, the analysand once again has very morbid and paranoid perceptions, which now frighten him (i.e., skull), which he attempts to defend against once again using hypomanic defenses (i.e., bozo the clown and cartoon faces, flower, all of which were very full of color). These defenses fail, as he continues to perceive these figures as disturbing and returns to his morbid preoccupations, as seen in the pelvis, which is an anatomy response. Discussion: The aim of this in-depth set of case studies was to explore changes in reality-fantasy experiences on the Rorschach as a marker of increases in the creative process in a creative writer in psychoanalysis. Consistent with predictions, on the RFS, both of the analysands become more fantasy-oriented over time and one of the analysands also evidenced more extreme reality-fantasy alterations, suggesting that the RFS is a useful tool for assessing changes in creativity over time according to Rorschach responses. While one might argue that more extreme reality-fantasy alterations are problematic and suggestive of less adaptive defensive processes, it also may be the case that such alterations allow people who are not organized at a psychotic level to have greater access to their creative capacities. There are a number of advantages of using the RFS over isolated Rorschach variables. Specifically, this measure is optimal for capturing the participant’s ability to preserve transitional space, which is the foundation for the creative process (Tibon, Weinberger, et al., 2005). In addition, this scale helps to bridge the gap between the empirical and atheoretical approach of the CS (Exner, 2003) and a psychoanalytically informed approach to Rorschach interpretation. Such integration is consistent with arguments that the CS would be more inclusive if it incorporated a more complex appreciation of the response process that allowed for greater attention to the role of stimuli from the inner world, as well as with recommendations from advocates for a contemporary integration approach to interpreting Rorschach responses (Meloy, Acklin, Gacono, & Peterson, 1997; Willock, 1992). 20 Kaslow et al

Although the standard approach to reporting Rorschach data is via the use of the CS and other formal coding schemas, such as the RFS, these more structured approaches fail to capture the psychodynamic richness often evident in the content of the Rorschach responses. Unfortunately, clinical interpretation increasingly is neglected in psychological practice due to concerns about the validity and reliability of this approach. However, such interpretations are invaluable as they shed light on complex conscious and unconscious psychodynamics that are not captured via more structured approaches (Karon, 2000). In addition, more formal scoring systems often ignore much of the most meaningful data in an effort to have an optimally streamlined and reliable approach. However, it is the rich qualitative data that patients offer through their Rorschach responses that provide an avenue into their internal psychological processes and psychodynamic struggles. Thus, a more structured scoring approach may have a high degree of internal validity, but lack external validity, whereas an approach that incorporates clinical interpretation may be higher on external validity, but lack internal validity. Therefore, utilizing both perspectives may offer the most comprehensive and clinically meaningful understanding of a patient’s dynamics. There are clinical implications of these findings. First, the capacity to produce creative responses, such as on the Rorschach, reflects that the individual has the capacity for working in a transitional space, which is key to positive therapeutic process and outcome (King & Pope, 1999). It is in this shared space that the collaborative therapeutic process can take place, such that narratives can be co-created and feelings, thoughts, and fantasies can be expressed in a safe environment and the patient can gain confidence in reconstructing events. It is in this potential or transitional space that primary process material can be disclosed, understood, and transformed in a fashion that affords the patient the opportunity to gain new insights and develop more adaptive ways of relating to significant people in their environment. This increased capacity for working in a transitional space was not the only positive change evidenced by these analysands. For example, both individuals evidenced less overall psychological distress according to their responses on the Global Severity Index of the Brief Symptom Inventory (Analysand A – 50 at Time 1 and 46 at Time 2; Analysand B - 50 at Time 1 to 40 at Time 2) (Derogatis & Spencer, 1982). Analysand B also endorsed a decrease in depressive symptoms on the Beck Depression Inventory (Time 1 – 22 and Time 2 – 7) (Beck, 1961). Further, both individuals showed reductions in their levels of two dynamically-relevant depressive experiences, dependency (anaclictic depression) and self-criticism (introjective depression) according to their responses on the Depressive Experiences Questionnaire (Blatt, D'Afflitti, & Quinlan, 1976; Zuroff, Moskowitz, Wielgus, Powers, & Franko, 1983). Additionally, the fact that these creative writers provided more creative responses over the course of the psychoanalysis underscores the value of psychoanalytic treatment in offering hope for psychological transformation through creativity (Press, 2005). Some potential limitations of this report should be noted. First, we used a case study methodology with only two analysands and thus to be confident in the findings and to determine if the changes that emerged were statistically significant not just clinically relevant, we need a larger scale study. In a related vein, due to the study methodology and sample size, the generalizability of the findings is an empirical question. Second, as noted above, the construct of creativity is complex and multidimensional and there is no unifying theory of this construct. Moreover, the proxy for creativity in this report is the capacity to utilize transitional space and not only is this a vague construct but its relevance to creativity has not been clearly confirmed. Hopefully, our findings suggest that this may indeed be a fruitful psychodynamic indicator of creativity. However, we recognize that the capacity to utilize transitional space may also be an indicator of other variables that are relevant to positive therapeutic outcome and process, such as a degree of introspection or psychologicalmindedness or attachment style. The possibility that the findings were due to chance cannot be ruled out. Third, there are a number of problems with the Rorschach. Questions have been raised with regard to its validity, including its incremental validity above and beyond other assessment tools, and its relevance for assessing psychological problems other than severe psychopathology and thought disorders (Lilienfeld, Creativity on Rorschach 21

Wood, & Garb, 2000; Mihura, Meyer, Dumitrascu, & Bombel, 2012). In addition, for this project more specifically, some of the administrations of the Rorschach with regard to the questions asked and the presentation of the material on the location sheets were not done in accord with standard operating procedures, including one protocol containing less than the number of valid responses. However, number of responses is less of a concern with a qualitative analysis than a quantitative one. May be most significantly, although the clinical interpretation of the Rorschach revealed some fascinating information, such an approach lacks empirical validation (Lilienfeld et al., 2000). However, some have argued that clinical interpretation, which is based on a content-idiographic approach, rather than the perceptual-nomothetic approach, which characterizes the CS and RFS, is most in keeping with a conceptualization of the Rorschach as a projective technique and as such, is most congruent with the strengths of this assessment tool (Aronow & Moreland, 1995). Fourth, the relevance of the Rorschach data for the analysands actual writings requires future exploration. Fifth, only two data points were available. Thus, it is difficult to determine when changes occurred, whether or not they occurred slowly over time, and if there was an association between the shifts that occurred and the specific working through of core conflicts. Finally, other sources of creative growth (e.g., participation in writers’ workshops or classes) were not accounted for over the course of participants’ psychoanalyses. Independent information demonstrating changes in the quality and quantity of the participants’ writings was unavailable. The findings from this investigation suggest a number of potential avenues for future research. It would be useful to develop a scoring system specifically to assess creativity on the Rorschach (Russ, 1999). Such a system should be based in a comprehensive theory of creativity, which unfortunately has yet to be developed (Russ, 2003). Second, research should address the links between changes in Rorschach responses and other indicators of creativity. Third, attention should be paid to RFS variables in female creative writers and those treated by other analysts. Fourth, future studies should examine the RFS coding system in other groups of creative individuals, to gain a greater appreciation of their response reality-fantasy response patterns on the Rorschach. Finally, the findings would be more compelling if they were linked to material from the actual psychoanalyses and thus, future studies should integrate Rorschach findings with actual analytic material and the analysts’ and analysands’ perceptions of treatment success particularly vis-à-vis improvements in creative writing so that more robust conclusions can be drawn about changes in levels of creativity. Conclusion: To sum up, this case study suggests that over the course of psychoanalysis, writers gain greater access to their fantasy lives, which enables them to be more effective at producing creative written products. The findings from this project add to the growing body of empirical studies to support the value of psychoanalytic treatment. They also support the validity and utility of the Rorschach, consistent with prior reviews and empirical findings (Viglione & Hilsenroth, 2001). The results suggest that the Rorschach is a valuable way of monitoring analytic progress in creative writers. References: Aronow, E., & Moreland, K. L. (1995). The Rorschach: Projective technique or psychometric test? Journal of Personality Assessment, 64, 213-228. doi: 10.1207/s15327752jpa6402_1 Aronow, E., & Reznikoff, M. (1976). Rorschach content interpretation. New York: Grune & Stratton. Baker, M. (1978). The Torrance Tests of Creative Thinking and the Rorschach Inkblot Test: Relationships between two measures occreativity. Perceptual and Motor Skills, 46,539-547. doi: Retrieved from http://www.ammonsscientific.com/AmSci/ Barron, F. X. (1990). Creativity and psychological health: Origins of personal vitality and creative freedom. New York: CEF. Beck, A. T., Ward, C.H., Mendelson, M., Mock, J., & Erbaugh, J. (1961). An inventory for measuring depression. Archives of General Psychiatry,4,561-571.doi: 10.1001/archpsyc.1961.01710120031004 Blatt, S. J., D'Afflitti, J. P., & Quinlan, D. M.(1976). Experiences of depression in normal young adults. Journal of Abnormal Psychology, 85, 383-389. doi: 10.1037/0021- 843X.85.4.383 Blum, H. P. (1979). The curative and creative aspects of insight. Journal of the American Psychoanalytic Association, 27S, 41-70. doi: Retrieved from http://apa.sagepub.com/ 22 Kaslow et al

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Psychologists’ Ambivalence toward Ambiguity: Relocating the Projective Test Debate for Multiple Interpretative Hypotheses Jayanti Basu This article critically relocates the debate concerning the validity and utility of projective tests within multiple interpretative and process oriented approaches. Some scholars opine that there could be alternate ways of looking at projective tests, for example using it as a technique to elicit cognitive and emotional states or as behaviour samples. Supporting, modifying or denigrating the use of projective tests may reflect different underlying attitudes toward ambiguity and multiple interpretation of a situation. Thus it represents either of two different traditions of psychology: one, aspiring to attain a structured and organized view of human behaviour facilitating prediction, and the other, an acceptance and appreciation of idiographic and divergent responses that may not necessarily be predictive, but informative about the multiple possibilities of human thought process. This latter approach would be more concerned with the process of experiencing rather than with obtaining a relatively final and fixed answer to the dilemmas of existential conditions. The possibility of such approach was always present in the history of projective tests, but has been subdued under the hegemonic pressure of diagnostic utility. The present author argues that a process oriented view of responses to ambiguous situations, along with a sensitivity to human diversity and multiple interpretations rather than emphasizing commonality, may open up a fresh relocation of projective technique within psychology. Training of projective technique may incorporate this consideration for future researchers. History of Psychology evinces a wave like movement in the evaluation of projective tests in terms of its validity and utility. Projective testing saw its heyday during and after the Second World War, presumably in response to the need for assessment of personnel for the military purpose. After proliferation of numerous projective tests from 1930 onward in the forms of associations, constructions, completion, ordering or expression (Linzey, 1959), it met with relative disrepute and sharp decline in usage from the late 1950s to 1970s (Pruitt et al, 1985). Since projective testing has always been considered an offshoot of psychoanalysis, its acceptance within the psychological community also depended, at least partially, on the status of the discipline of psychoanalysis within social sciences. In traditional understanding, psychoanalysis locates the current problem within the individual (though its cause can be in the childhood experience), and suggests remedial treatment by dealing with theintra-psychic disturbances. Hence a number of researchers from diverse backgrounds opposed this premise, attributing the source of emotional maladies in the environment and in biology. Conjointly these criticisms made not only projective tests, but testing itself questionable. Such critics included a wide selection of prominent psychologists. Anti-psychiatrists like R. D. Laing (1960, 1964) and Thomas Szasz (1989, 1994, 2002) considered psychiatry and associated techniques as dominance and curtailment of freedom. Humanists Jayanti Basu, Ph.D., Professor, Depat of Applied Psychology, University of Calcutta, 92 A. P. C Road, Kolkata-700009 Email:basumjt@gmail.com Key Words: : Projective technique, Ambiguity, Process approach deemed it unethical to probe individuals for pathology, but suggested an optimistic approach for developing the potential (Roger, 1961, 1969). And behaviourists like Skinner (1972) argued from exactly the opposite pole of humanistic theory, and believed that personality is the product of learning and hence can be unlearned, and therefore unobservable constructs like unconscious and freedom are dispensable. Apart from the general criticism of psychological assessment during this period, the 1960s and 1970s saw the denunciation of projective tests in particular due to their vagueness and questionable reliability and validity (Cohen, 1956; Sarason,1959; YoellandLargen, 1974): a point raised time and again throughout the history of psychological testing (Piotrowski et al, 1993). Those who were still in favour of using some kind of projective test at this period, attempted to quantify them as much as possible, famous examples being in the field of the Rorschach Test by Aaron Beck and his colleagues (Beck et al, 1961) and later by John Exner (1974, 1978). Such efforts also gave rise to the distinction made by some scholars between projective materials used as tests or as techniques (Frick, et al, 2010), depending on the requisites for standardization in a given situation. However, with the cognitive turn in Psychology, and with the renewed interest in psychoanalysis and critiques and revisions thereof among the scholarly communities outside Psychology, including those from philosophy, literature, anthropology, sociology and political sciences

(Barthes, 1968/ 2001; Foucault, 1972, 1976/1978, 1977, 1979; Frankland, 2000; DeleuzeandGuattari, 1983, 1988; Derrida, 1985, 1989, 1999; Lacan, 1998; Smith, 1980 being outstanding examples), concern with the unconscious communication enhanced. Roughly at the same time, within the discipline of psychology, projective tests again attracted attention of the researchers. Millon in his 1984 article called the late 70s and 80s the renaissance of personality assessment and theories. The period from 70s to late 90s was characterized by the vision of using psychoanalytical premises and spirit to explain the confused times within the fold of globalization. During and of course before this period, projective tests have been used to study social and cultural phenomena (Alexander, 1994; Buckham, 1970; Cook, 1942; Post, 2001; Rothman andLichter, 1982). There have also been sporadic efforts on the part of other disciplines like sociology to adopt projective tests (Rose, 1949). However, such efforts rarely ended up being particularly contributory, and ultimately projective tests retained their place within the limited discipline of psychology to assay individual’s personality disposition. Presently, despite many critics, a large number of practicing psychologists all over the world use projective tests occasionally or regularly to ‘understand’ their clients/patients (Watkins et al, 1995). In this context, I would attempt to underscore how the functions of projective tests may be interpreted and employed to herald an alternate dimension in the philosophy and practice of Psychology. Before unfolding such alternate notions, I would briefly present a summary of the major criticisms and defences of projective tests throughout the history of psychology, because the alternate vision has been born out of the same critique. A review of major criticisms and defences of Projective tests: Projective tests, generating one of the biggest controversies in the history of Psychology (Frick, Barry andKamphaus, 2010), have points in favour and points against. Some statements from both camps are quite fervent in nature. Although the purpose here is not to present a full review of this debate, a few salient concerns need to be mentioned. Among the points against, of course the most prominent is the issue of validity: is anything projected systematically enough to formulate hypotheses about underlying personality or is this claim a mere wishful fantasy of the more imaginative brand of psychologists? Indeed, this very claim of systematic projection of unassailable elements of personality is the essence of the ‘projective hypotheses. As Murray (1943) said: ‘There is the tendency for people to interpret an ambiguous human situation in conformity with their past experiences and present wants’ (p. 1). This tendency may be viewed as the personality disposition or trait likely to be unravelled through studying the responses to a given set of stimuli. However, often the predictions from projective tests neither corroborate the empirically formulated clinical diagnosis, nor support the findings from the questionnaires that in turn are more or less supportive of the empirical findings (Spangler, 1992). Some of the prominent critics of projective hypothesis (Anastasi,1988;Gittelman-Klein,1986;Hunsley and Bailey, 2001, Wade and Baker,1977 believe that projective tests are simply waste of time as they lack both reliability and validity, and detract the clinician through generating false expectations (Frick et al, 2010). Murstein (1963) stated that supporters of projective tests have an unwarranted moralistic and romantic tone that perpetuates the use of such tests in an esoteric fashion. Lilienfeld et al, (2000) concluded, from a detailed review of projective tests and a meta-analysis to detect the ability of such tests for child sexual abuse, that although a few indices of the Rorschach and the TAT do have predictive validity, most do not; hence such tests should be used with much caution. They also report that such tests fare worse than other psychometric tests in terms of incremental validity. They, however, recommend a tentative, cautious and well trained use of projective tests in education and forensic sciences. On the whole, these criticisms may be summarized in the words of Gregory (2000)‘The evidence is quite clear that personality inferences drawn from projective tests are often wrong. In the face of negative validation findings, the enduring practitioner acceptance of the tests constitutes… the projective paradox.’ (p. 511). Those who recommend continued application of projective tests in their own merit or in conjunction with self-report and objective tests envision an alternate set of 26 Basu

premises underlying such tests. They believe that despite criticisms, projective tests are particularly multidimensional, useful for their ability to unearth unconscious material, serve as a rich source of data about the propensities of the individual (Lindzey, 1961), especially children (Hughes et al, 2007; Rabin, 1986; Weiner, 1986). Projective tests are considered useful owing to their ability to tap unconscious desires, motives, and impulses, as well as for the scope for employing flexibility and clinician’s insight (Frick et al, 2010). To defend the projective tests against the complaint of low concordance with other tests, and of inadequate reliability and validity, the advocates of projective tests argue that such critics often do not take into account the special nature of validity of projective tests. Their scorn is often based on interpretations by untrained testers, and does not use adequate statistical models (Karon, 1978). Winter et al, (1998) suggest that the low correlation between projective tests and other psychometric tests is an artefact owing to the difference in instruction, and hence of mental set. Koppitz (1982) points out that if a projective test really taps the unconscious processes, it is expected that the findings would not corroborate with self-report measures; they would be substantiated by other tests that reach the implicit or inaccessible domain of the personality. On the whole, it seems that the projective debate remains ever alive without any possibility of termination. Both camps hold their ground with equal conviction and unable to convince the other. Some authors wanted a clear split between the self-report and the projective tests suggesting that these should not be pitted against each other (Levy, 1963). Some were frustrated enough like Kaplan (1964) who suggested that self-report and projective tests suffer respectively from two kinds of fallacy: reductive and seductive. Nevertheless, the debate seemed to prolong over decades, and in response to the criticisms, some projective psychologists resorted to different modes of compromise. Compromises and suggested solutions in response to criticism: After the first bout of enthusiasm over projective tests subsided and criticisms poured in, the test makers tried to introduce new tests and to propose scoring systems that would have adequate reliability and validity. On the one hand some researchers developed semi-projective tests that would have less ambiguity in the stimulus material and hence limited range of responses. Most of such tests do not assess broad personality construct as is claimed by the Rorschach test or the TAT, or even the Draw-a-person test. They often focus on narrower constructs like frustration induced aggression (for example Rosenzweig Picture Frustration Test developed by Saul Rosenzweig et al, (1948), ego strength (as in the Sentence completion test by Loevinger (1998), situational judgment in military set up (like, Pictorial Situation judgment Test by Kaur et al,(2012), attachment (as in Adult Attachment projective picture system by George and West, 2004; 2011), to name a few. Such semi-projective tests are better standardized, and sustain the engagement and interest of the testee. But by virtue of their greater structure, they elicit more surface behavioural rather than motivational information, and remain restricted in scope. Other researchers tried to provide quantitative scoring techniques for the Rorschach and the TAT responses. Percentages have been used by Rorschach (1921) andratios have been proposed by Klopfer (1946). Beck proposed a much tighter quantitative scoring system minimizing the scope for the scorer’s subjective bias (Beck et al, 1961). John Exner’s (Exner, 1974; 1978) comprehensive scoring system of the Rorschach with its detailed quantitative indices is getting popular. For TAT, Murray (1943) proposed ways of quantifying needs. But later authors like Cramer (1996) and Bellak (1996) depended more on qualitative analyses. Later, authors like Garb (1998) also emphasized the need for adhering to quantification of TAT protocol and took to task those psychologists who ignored it. Such compromising attempts in turn have not gone uncontested. For example, Haak (1990) argued that such efforts of standardization of projective tests destroy the essential value of such tests. The projective test was created to provide qualitatively rich and complex information about the personality of the individual. Excessive and mindless statistical rigour in reliability, validity and norms minimize this creative potential embedded in the projective tests. While it is widely acknowledged that Exner’s comprehensive system provides the Rorschach test a never before empirical Projective Technique 27

grounding, its ultimate worth has also been challenged. For example, Auerbach (1999) writes: ‘The chief reason for the success of Exner's system is its empirical basis, yet there is a certain way in which Exner's Comprehensive System has always fallen short - it is almost entirely atheoretical.’ (p. 147). Thus in one sense, many psychologists feel that over-emphasizing quantifying and empirical evidences somehow constrict the very soul of projective tests. Such emphasis may make the tests amenable to undesirable scientism that deprives the discipline from its depth. And, of course there are still researchers who go for hard core projective tests that assay a broad array of components of personality. For example, the Fairy Tale test (Coulacoglou, 2002) or the Somatic Inkblot Test or SIS series (Cassell, 1980, 1990) exemplify relatively recent additions to the repertoire of ambitious projective tests, where responses are evaluated in terms of content and perceptual characteristics and its utility in differential diagnosis is emphasized. Indeed, a number of tests utilize the somatic basis of projection, SIS being one major example, but also others like the Hand test (Wagner, 1962; 1983). The utility of projective tests to break barrier in traumatized persons has been emphasized by recent authors like Capri (2013). Combination of content and sequential analysis from the Rorschach (Lerner, 1998; Schachtel, 1966) and the TAT has been used by Silverstein (1999, 2001) to demonstrate representation of self-status in terms of Kohut’s theory (Kohut, 1977). Current status of projective tests: an alternate to tests: Recent workers in the field of personality assessment are keenly aware of the debate over projective tests, and most users of projective tests make a conscious choice by evaluating their banes and boons. For example, Catterall and Ibbotson (2000) considered the use of projective tests in educational field. They found that such tests were useful so far they are versatile, involving, generate fun, help in overcoming barrier, and assist in idea generation. They are problematic since they involve unsolved ethical issue, difficulty in justifying selection of materials, problems of validity and analysis etc. Most authors recommend an integration of projective and other tests for pragmatic purposes (McGrath et al, 2012; Shemmings, 2004). Others have emphasized need for training and highlight the paucity of such training at Doctoral level (Durand et al, 1988). However, there are also objections regarding the very use of the word ‘projective tests’. Some psychologists opine that confusion is due to the use of these two words - ‘projective’ and ‘test’. The term ‘projective test’ had been launched by L. K. Frank in 1939, and use of such tests was regarded as equivalent to ‘psychological X- rays’. The term projection was specifically meant to connote that subjective idea and contents are projected on a neutral ambiguous stimulus (Dichter, 1960, 1964). McGrath and Carroll (2012) opine that if both of these terms are done away with, and the term ‘projective tests’ can be substituted by other phrases, the problem may be solved. It has been suggested that the phenomenon of projection may be viewed as a technique rather than tests. A second option is to discontinue seeing projective tests as necessarily dealing with unconscious and inaccessible material; Knoff (1983) writes: “A student completes an incomplete sentence blank with ‘I hate myself’ or ‘My father beats me up all the time,’ and these hypotheses are confirmed through self-injurious behaviour or a physically abusive father, is this a hidden aspect of personality? Or how is a student’s response to a thematic approach which uses real photographs depicting significant interpersonal situations (i.e., peer group acceptance, attitudes toward school-work, and reactions to new sibling) different from an interview question asking how she/he is getting along with peers on the playground?” (p. 448). From this perspective, projective tests may be viewed as behaviour sample. It seems, therefore, that the nature of the stimulus material and the interpretation of responses would depend on the mental set or philosophy of the test taker/researcher. When projection is used in tests, there is the need for standardization of stimulus and quantification of responses against a norm. When projection is used as technique, it may serve as a way of deriving psychoanalytically informed propositions from the responses to a specific kind of stimuli. When it is viewed as behaviour sample, it is comparable to observing the spontaneous behaviour of a person and drawing hypotheses from a discourse. 28 Basu

As we move from tests to techniques to behaviour sampling using respondent’s projection on a set of stimuli, the issue of reliability and validity also takes a different turn. In fact, this is a movement from the nomothetic to the idiographic, and therefore, to some extent from quantitative to qualitative, from predictive to experiential. As we use projection as a technique to unfurl individual dynamics from a sample of responses, we become sensitive to the wide range of human variation in experiencing and reacting. We become less sure about the diagnostic labelling to be derived from such endeavours. This last statement makes us re-locate the issue of validity of interpretation of projected behaviour. For example, even if we demonstrate different projected response patterns from differently diagnosed groups, is this piece of datum to be understood as an evidence for criterion validity of a ‘test’ on the basis of the tacit acceptance of rightfulness of diagnostic nomenclature? Or should we simply appreciate that there are multiple patterns of perceptualcognitive gestaltens to be formed from exposure to a stimulus, and this knowledge enriches us about the inner world of the individuals under study by providing instances of variations? The former construal is more structured in organization; the latter is relatively openended in interpretative stance. At best, within the second premise, we could surmise with caution that individuals belonging to groups differentiated on empirical basis might have different perceptual dispositions. This is, indeed, a matter of attitude to the discipline that we study. Are we interested in appreciating the diversity of human responses and construing a qualitative pattern, if any, from the observation enriched with interpretation? Alternatively, do we wish to ignore the variations and focus on the commonalities to chalk out ‘signs’ that may ultimately be quantified? Although, such quantification does not, theoretically speaking, exclude qualitative reading of the individual datum, using hard core qualitative reading to support/nullify the quantitative hypotheses within a triangulation parameter often becomes impractical in actual practice owing to the vast diversification of possible responses by humankind. This requires us to have a fresh look at the interpretation of projected material; perhaps we should opt for a process approach rather than the diagnostic and relatively static orientation to psychological phenomena. The data obtained may reflect the perceptual process at work, an operation of the cognitive flow that may be discerned at different stages of projection in response to ambiguous stimulus - immediate reaction, evidence seeking, elaboration and finalization. Indeed, this is what Hermann Rorschach (1884-1922) implied at the initial stage of his work when he considered the Inkblot test as an experiment and not a test. Unfortunately this process oriented approach was diluted in the diagnostic use of his cards in favour of a more structured interpretation. There have been instances of using projective technique in the spirit of process approach that eschew the need for standardized tools. For example, Vittersø (2003), in an effort to grasp the complicated construct of subjective well-being, used cartoon frames from Donald Duck series to assess positive and negative affect as correlated to life satisfaction and openness to experience. Vittersø used Structural Equation Modeling (SEM) with the participants’ responses to the Donald Duck frames to elicit two different meanings of affect - evaluation (good-bad) and flow (responding to challenges of the environment), associated differentially with life satisfaction as a relatively closed construct of wellbeing, and openness. Since such employment of frames is not standardized, it may be called an example of projective technique, and the responses were analysed in terms of how much evaluation and how much flow was intended, and not the mere content of responses. Indeed projective techniques have long been used to interpret spontaneous creations, and such efforts may be discerned as unlabelled use of projective technique. Freud’s analysis of da Vinci (Freud, 1910/1989), Dostoyevski (1928/1961), Michelangelo’s Moses (1914-1915/1955), and a number of later works of interpretation of creative output, authors and artists indeed indicate the use of the technique in various forms. Rieber (2012) presents an analysis of bookplates by different stalwart thinkers of the 19th century, including Sigmund Freud, Hall, Baldwin and Brill. He interprets these bookplates as symbols of the author’s selfperception. At other times, projective mechanism has been identified in everyday activities. The logic of projective test has been recommended for using affect misattribution procedure as an implicit measure of attitude (Payne et al, 2005). Wood et al, (2010) Projective Technique 29

designated perceiver effect as a projective test; they stated that the way one describes other people in the population is a projection of their personality disposition. If we extend similar use of projection to a certain limit, the entire life of humankind may be contemplated as a result of projection of attitudes and needs: the whole rich domain of psychohistory is indeed replete with instances of projection (deMause, 1980; Erikson, 1958; 1969). But let us not stretch the notion of projection to such extremes, at least for our present discussion, though it may be helpful to formulate our later notions if we keep in mind that projection is actually that common and expansive in the drama of life that human beings play. To remain tied to the pragmatics of practice of psychology in social and clinical fields, we may consider the way people project in response to given ambiguous stimuli within a relatively controlled and artificially constructed and consistently employed situation. The projective debate makes us conscious about the fact that there are at least three attitudes toward interpreting such responses to ambiguity - and these three attitudes themselves may reflect the respective psychologists’ comfort or discomfort with ambiguity. The first attitude is that ambiguous stimuli must be standardized as ‘tests’; so that the ambiguities ultimately yield non-ambiguous and relatively stable categorization of the respondents in clinical terms. This of course requires acceptable level of reliability and validity indices to be reported. Such use of projection also entails an element of power in the test taker: the respondent does not know what is being projected, but the psychologist can see what the respondent does not. The second attitude constitutes presenting ambiguous stimuli as projective techniques and considers the responses as reflecting cognitive tendencies. The resultant tendencies are less certain in nature than clinical categories: tendencies of cognitive and affective responses in ambiguous situation are after all only probabilities, perhaps connected to the degree of ambiguity, but also to the context of occurrence. Here the psychologist is more of an observer of the flow of cognition and affect, rather than a diagnostician. This approach retains the scope of more ‘stories’ of life to be incorporated, and is more open ended in nature. It also retains a doubt as to how much non-ambiguous material can be extracted from ambiguous stimuli. This also entails some degree of power of the psychologist, but that is employed with a reflexive doubt. The third attitude is of rejection of the projective hypothesis - it is believed that ambiguous stimuli would not yield any clear, consistent and non-ambiguous information; hence it is useless. Among these three, I would elaborate the second one, as it entails a scope for a fresh approach to the literature of projective technique. There are two things that might be particularly relevant in this discussion. One is the criteria of interpretation of the responses: content versus formal characteristics. The second is the issue of reliability and validity, about which the researcher must take a clear stand. What is projected in projective tests? Is it the unconscious repressed ‘material’ in the form of wishes, needs, and desires? Is it perceptual-motor and affective tendencies, about which the person may be partially aware? Is it some of each? Initially, Rorschach ignored the content of the protocols, and emphasized a perceptual-cognitive approach for the interpretation of responses. Later on, he introduced the analyses of content as well. However, the formal aspect of Rorschach has kept on coming up as significant (Holt and Havel, 1960). Content has always been the most salient aspect of the TAT protocol. Content has a semantic value and also has symbolic underpinnings special for a culture. Content is also most affected by immediate situation (Bornstein, 2007). Therefore, the more we emphasize content, the more we trade in a complex domain, with the entire gamut of language and its nuances at play. It is also to be remembered that the respondents have the ability to manipulate language to elaborate certain consciously chosen aspects and to suppress others, especially those respondents who are at the high end of functioning. The cognitive-motor tendencies (expressed for example in Rorschach through location and determinant) however are less well understood by the respondent, because such pattern comes out of the habitual immediacy of perception. Also, it is less easy to distort perceptual tendencies. In fact, our challenge is perhaps greater with a content oriented approach, while unfortunately we seem to be more careless with content than with form. When we are trying to interpret a projective protocol, we need to bear 30 Basu

in mind that ambiguous stimuli release a plethora of mechanisms, and it is extremely difficult to standardize and finalize their ‘meaning’. But if we look at the mode of perception and presentation, and scrutinize how its flow changes, we may be in touch with the here and now, the process of construction. Probably something akin to this was attempted by Rapaport, Gill and Schafer (1945- 1946, 1968), who tried to release projective tests from the ordeal of standardization and reinstate its position within psychoanalytical theory, especially ego psychology. Theoretical grounding of the protocol to personality and cognition was deemed to be of importance in this system. Special emphasis was given on the patient’s thought process and cognitive organization - a characteristic of ego psychology. Schafer (1954) furthermore highlighted the determining role of testee-tester relationship in the structure of the elicited responses. Drawing on Schachtel’s work, the role of transference and countertransference was deemed to be important in Schafer’s thesis. In case of TAT, while Murray (1935) and Bellak (1996) emphasized content, the formal aspect was highlighted by Rapaport, Gill and Shafer (1946), so far they focussed on the organization and mode of delivery of the content. Later on, Holt (1958) and Schafer (1958), demonstrated through clinical example, how the organizational pattern of the story helps the clinician to derive meaning. This formal approach to TAT was later reflected in Allison et al, (1968). In line with Knoff(1983) I also find the claim that projective tests reveal the unconscious a bit problematic, and feel the need to illustrate what exactly we mean by unconscious. If the unconscious implies repressed material that requires elaborate effort to unearth, it is unlikely that they would emerge so easily and systematically by mere presentation of ambiguous stimuli. More likely, these are not unconscious, but nonconscious habitual tendencies that are not clearly recognized during everyday transaction by general people, though available to those with an introspective bend of mind. The unconscious, in its classical sense defies mere introspection. So may be, there are many meanings of the unconscious also. However, keeping in mind Freud’s notion of psychopathology of everyday life, we cannot deny that there is a possibility of eruption of unconscious content at any given moment, may be more so when one is forced in an ambiguous situation, but such eruptions are likely to highly idiosyncratic, and less amenable to systematic interpretation. On the basis of the above discussion, we might consider two kinds of projection. One is based on the perceptualmotor tendencies, and belong to a deeper than semantic level of processing, but these are not repressed in the true sense of the word. The other one is content based, and more often tied to less ambiguous stimuli, like TAT or sentence completion. This is potentially complex, but within the discipline of psychology often used rather hurriedly and the impact of language on the responses for such data is not well probed. About reliability and validity of projective techniques, we may draw upon such issues discussed in the context of qualitative research grounded in empiricism. Before taking into account the matter of validity, we must resolve the earlier concern regarding what the projected material represents. In the context of qualitative research, we often talk about triangulation, where measures from different angles collate in support of each other. It is in this sense that the non-corroboration of projective test findings with diagnostic categories posit problem of validation for some critics. But before we agree with this criticism, we must ensure that we choose our measures for triangulation on the basis of what is being measured by the ambiguous stimuli. If we emphasize the formal aspect of perceptual-expressive function, then we should corroborate it with similar functions. For example, in case of the Rorschach, the preponderance of whole perception may be compared with the capacity of analysis and synthesis measured through other kinds of cognitive tasks. The sequential analysis of the Rorschach may be corroborated with longitudinal changes in task orientation. When emphasis is given on content, the productions should be taken as cues to conscious and non-conscious streams of thoughts and therefore may serve as guide to interview. In such cases, it is possible that TAT and also SIS productions may be corroborated for triangulation with interview. Thus, for all projective tests, the same mode of establishing validity may not be useful; we need to be more careful in choosing our ‘criterion’. Reliability of a statistical nature is often eschewed in qualitative research (Guba et al, 1994; Seale, 1999), and Projective Technique 31

may be similarly treated in some uses of projective technique. While some degree of inter-rater reliability with similarly trained raters may occasionally be useful, it needs to be kept in mind that the very nature of projective tests allows multiple response orientations of comparable merit. Test-retest reliability would be inapplicable, as prior exposure should always have impact on the subsequent responses, both in terms of content and formal characteristics, and the direction and degree of change would be unpredictable. Internal consistency of some kind may be considered, although if we emphasize diversity of responses, especially within a creative perspective, internal consistency may have a negative bearing. Thoughts on training and utility of projective techniques: Thus, there may not be only one way to train students in doing and analysing the specific test. Responses to ambiguity are equally ambiguous and posit a challenge to the interpreter for projecting her own bias. Last but not the least; it has been known among clinicians that the nature and amount of output varies with the test taker in case of projective tests. Therefore, even with a standardized instruction, something is not standardized and impacts the response orientation. We should not overlook this aspect but re-search this phenomenon to catch the unique nature of projection, that there is a super-sensitive defensive manoeuvring against what is being projected in a given situation. May be, as in qualitative research, for projective techniques also, we should meticulously describe the situation in terms of things and persons as to where and how it is being employed. We may as well make ourselves comfortable with the ambiguous situation of retaining the ambiguity of interpretation alive within projective psychology. Burstein and Burton (2001) said in the context of evaluating Freud’s contribution, ‘Everyone who reads Freud and is affected by him has his favourite Freud. There is Freud the courageous innovator, Freud the marginalized Jew, Freud the scheming manipulator, Freud the sweeping theorist, Freud the litterateur, and many others, all rooted in the profundity and breadth of his writing’ (p. 159). We may similarly say in relation to projective tests, that those who are fascinated by projective tests have their own idiosyncratic notion of projective test, as revealing a core personality, as corollary of attitudes, as a prelude to scientific testing, as a behaviour sample, or as a guidance to therapeutic planning. One may fear that such multiple interpretations makes projective technique less trustworthy. But a possibility is that projective technique with its multiple usages reflects a kind of attitude to the subject matter of Psychology - the idiographic and qualitative understanding of human beings complete in its uniqueness. In a similar vein, we may not only resign to the fact that there would be no clear answer to the projective debate, but we should welcome the prolonged controversy as it would ultimately reveal the multiple truths of human affairs. Projective tests and techniques may be most credited not because they reveal unacknowledged facts about individuals, but because they reveal unacknowledged facts about the discipline of Psychology. References: Abt, L. E. andBellak, L. (1959). Projective Psychology: Clinical Approaches to the Total Personality. New York: Grove Press. Alexander, S. E. (1994). The Relationship of Projective Test Indices to Proscocial Behaviors, Altruism, and Loneliness.Columbia University Press. Allison, J . , Blatt, S. J ., & Zimet, C. N. (1968).The interpretation of psychological tests. New York: Harper &Row. Allison, J., Blatt, S., &Zimet, C. N. (1968). The Interpretation of Psychological Tests. New York: Harper & Row. Anastasi, A. (1988). Psychological testing. New York: MacMillan. Auerbach, J. S. (1999). Psychoanalysis and Projective Testing:A Review of The Interpretation of Psychological Tests, Journal of Personality Assessment, 72(1), 147-163. Barthes, R. (1968/2001).Trans. Stephen Heath. The Death of the Author, In Vincent B. Leitch (Ed.), The Norton Anthology of Theory and Criticism, (pp. 1322-1326). New York: Norton. Beck, S. J., Beck, A., Levitt, E. and Molish, H . (1961) Rorschach's test: Vol. I .Basic processes (3rd ed.). Grune&Stratton. Bellak, L. (1996) The T.A.T., The C.A.T., and The S.A.T. in Clinical Use(6th Edition) . New York: Allyn& Bacon. Bellak, L. (1992). Projective techniques in the computer age, Journal 32 Basu

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Marital Conflict: An Exploration of Relationship issues in Couples through SIS-II L.S.S. Manickam and B.T. Suhani Persons with marital conflict contact professionals when it goes beyond their control and the problem they present with are usually verbal or physical abuse. Consecutive six couples who were referred for psychological evaluation for marital problem and who had sexual dissatisfaction as reported by the spouses, were taken up for this study. Though the female partners were referred for evaluation, they did not have major psychiatric disorders. However, the female spouses reported that their partners have either low sexual desire or sexual dysfunction. The SIS-II was administered to understand their personality and therapeutic management. The findings showed that there was significant agreement in the scores of the couples except on Sex scores. Analysis of the types of the pattern of responses and its implications are discussed. Couples with marital conflict pose great challenge to psychotherapists. Almost all couples report high relationship satisfaction at the time of marriage and the average satisfaction level decreases after the first decade (Glenn, 1999). However, the nature of stable relationship varies from culture to culture and the partners develop helpful patterns to adjust with each other and manage their conflict. In Indian context, those affected may approach the family members or the village heads or the religious heads for intervention to rectify the conflicts. When the conflicts go beyond control, the affected couple seeks legal help. James (1999) analyzed cases attending family courts in Kerala and opined that the incidence of marital breakdowns is on the increase and the increasing trend is continuing. She observed that the major reasons for marital breakdown included physical and mental cruelty, extra-marital relationship, alcoholism, mental illness, suspicion, mental retardation, and suicidal attempts. Kumar and Dhyani (1994) explored marital adjustment among 240 married women in the age group of 25-50 years, in relation to dual work role and duration of marriage. Examining the extent of relationship between the type of marriage, marital duration and sexual satisfaction with adjustment in marriage, they found that the sexual satisfaction contributed significantly to marital adjustment. The assessments of couples with marital discord serve different functions and several assessment instruments are also available (Sporakowski et al, 2001). However, there is dearth of studies that uses projective tests to assess marital conflicts. Though questions have been raised about the validity of projective tests, irrespective of the practicing clinician’s observations, the projective instruments are useful in clinical work. Different versions of Somatic Inkblot Series test (SIS), including its variants that are technologically advanced have proven its clinical effectiveness as diagnostic as well as therapeutic procedure (Cassell and Dubey, 2010). The SIS test has emerged out of the Somatic Imagery Theory, which postulates that, “…everyone has a unique and highly personalized system of attitudes, both conscious and unconscious, that is projected onto the body concept as a spacial entity” (Cassell, 2000). From psychotherapeutic perspective, SIS provides an opportunity for ‘hearing the inner cry’ and facilitate in bringing out the ‘unprocessed material from the unconscious’ (Cassell and Dubey, 1995). The SIS has been used effectively in unearthing the unconscious conflicts in psychotherapy (Manickam and Suhani, 2003; Manickam et al, 2004; 2013). The studies that have used projective techniques in order to study the inner process, especially SIS are very few (Dwivedi et al, 1998). The present paper is a modest attempt to assess six couples having marital conflict with the help of SIS-II Booklet form of the test. One case study has analyzed SIS responses in details using content analysis for understanding the penetrative power of the SIS procedure. L. S. S. Manickam, Ph.D., DMSP.Professor in Clinical Psychology, Department of Psychiatry,JSS Medical College, JSS University, Mysore 570004 (India) Email: lssmanickam@gmail.com(Corresponding author) and B.T. Suhani, PhD. Psychologist, Dept. of Physical Medicine and Rehabilitation, Christian Medical College, Vellore- 632 002 Key Words: Marital Disharmony, Somatic Inkblot Series, Projective Tests, Sexual Dysfunction

Method: Sample: Six couples who were referred for psychological evaluation for marital problem were taken up for this study. It was a purposive sampling. The duration of marriage ranged from 7 to 33 years and the mean duration of marriage was 16.33 years (Table 1). The mean age of men was 45 years (age ranged from 34 to 60 Yrs.) and the mean age of women was 38 years (age ranged from 25 to 57 yrs.). Four couples were educated up to graduate level, one up to 10th grade and one below Matric. All females were home makers and their spouses were employed except one, who was a retired teacher. The couples were administered SIS-II test individually and their protocols were scored by one of the authors (SBT) who was blind to the conflicts of the couples. Case History: Mrs. D was brought with complaints of being ‘violent’, assaultive and abusive episodically for 2 years duration. She belonged to a high socio-economic family, and was the eldest of two siblings. She reported having sibling rivalry from childhood and was overprotected by her mother, who used to regulate all her activities, including her telephone calls, even after she became an adult. She was looking forward to have freedom and independence after marriage. However, she got married to a family that was very closely knit wherein the ‘mother ruled’ all the children, including her husband’s eldest brother who was 50 years old. As narrated, Mrs. D tolerated her sister’s in law and the ‘mother in law’ for several years and finally they moved out of the joint family to start independent living. Two years ago, she came to know that her husband had a pre-marital relationship and that provoked her. She also found that her husband is keeping regular communication with the other lady. He was too submissive and obedient to his mother, but keeping a short of distance from his wife. She further observed that he stimulates her after engaging her in sexual activities, but sleeps off, before she attains orgasm. She also remembers that her husband did not make any attempt to have sexual relationship with her for about one and half years after marriage. Most often, he also had premature ejaculation. One year ago, he disclosed his sexual dysfunction to his elder brother who advised to take treatment. However, Mrs. D was not keen for any consultation. She also developed dissociative states, seven times, whenever she faced severe stress in the family. She did not want her parents to know about the psychological consultation, because she was afraid that she would be held responsible by her mother for the marital conflict. Finally, she agreed to take treatment but her husband refused to take active part in the treatment. Results and Discussion: The findings of the study suggest that there was agreement in the responses in all the scoring categories of SIS except on Sex responses (Table 2). However, compared to women, the number of sexual responses given by the men was less. This is similar to the other reports, wherein those with sexual problems tend to provide less number of sexual responses either by rejecting the images or by giving less number of responses which might be less threatening (Manickam and Suhani 2003; Manickam et al., 2004). However, it was surprising to observe that none of the men wanted to work through their sexual problems irrespective of the Table 1 Age, Education, Occupation, Duration of Marriage of the Index Patients and their Spouses Subjects A AX B BX C CX D DX E EX F FX Age Education BA B.Com B.Sc. B.Ed BCA BA BA MA Occupation HM Account HM Teacher HM Army HM Lab HM AD HM Teacher Duration of marriage in Yrs 38 Manickam & Suhani

Table 2 SIS-II Scores of the Index Patients, their Spouses and Wilcoxin Sign Test Subjects A AX B BX C CX D DX E EX F FX Mean Women Mean Men Z score SIS Score TR 51.5 54.83 -.105 H 15.67 14.33 -.736 A 5.83 7.67 1.461 At 8.83 6.33 -.934 Sex 0.67 -2.070* M 1.5 -1.069 MT 7.5 5.83 -1.913 T 16.83 14.67 -1.604 AT 33.83 -.943 Rej 17.17 12.5 -.524 PR 2.17 1.5 -.137 PAS 0.83 0.83 -.378 D 0.83 .1.633 HAS 0.5 0.67 -.447 P 0.0 .000 * Significant at .05 level. that the subjects of present study consulted the clinician for marital conflicts and not for sexual problems, could be one of the reasons for the low sexual responses. It could also be that though the SIS images do provide an opportunity for normal individuals to unravel the unconscious process related to sexual functioning, a suppression of the sexual responses can be taken as an indicator of sexual disturbance which can be explored and may lead to success in psychotherapy (Manickam and Suhani, 2003, Manickam et al, 2004,Ghanbary and Kruthi, 2013 ) The number of cases with marital discord is on the increase and they are approaching family courts for resolution. It is a complicating situation where the Marital Disharmony 39 fact that the spouses reported about the sexual dysfunction of their respective partners. It might indicate that unless sexual conflicts are resolved, the men may not be willing for sex therapy and thereby overcoming the marital discord. Contrary to the findings of Dubey et al 2004, the present study found that there is more suppression of sexual responses in the couples. Dubey et al (2004) observed that the persons with psychosexual disorder gave 8.9 responses as compared to the normal subjects who gave 4.12 responses (Cassell and Dubey, 2003). However, the sample of Dubey et al (2004) was those attending Sexually Transmitted Diseases clinics, and was aware of the sexual problems and approached for help. The fact

marital conflicts are manifested in different ways and the core problem is neither identified nor addressed (James, 1999). In that situation, the partners are left with no choice but to live together either sexually dissatisfied or to get separation. However, the findings of the study suggest that irrespective of the years of marriage and age, the problems of the couple could be explored through administering SIS-II and it may help in effectively unearthing the ‘inner cry’ by the clinician. Uhinki, (2001) in Finland, developed a method in order to respond to people who are searching for help in marital interaction problems which were leading to increased number of divorce. Based on the model of “Therapeutic Assessment” initiated by Finn, a technique called “Couples’ Assessment” holds out great hope as a brief marital therapy. It is grounded on the theoretic explanations found in self-psychology, object relations theory and ego psychology. Individual and joint interviews, personality assessment techniques and feedback sessions are the main tools of this approach in which Rorschach Inkblot test, the MMPI and other methods are incorporated. The present findings suggest that SIS could be effectively used as part of the assessment development which may help the clinician to unravel deeper conflicts. Dwivedi et al, (1998) using SIS-Video, conducted a therapeutic assessment in a couple. The SIS responses of a 22 years old young, unmarried, graduate lady who had reported history of rape revealed her traumatic experiences. It worked as a time machine and took her back in time, helped her in processing repressed painful material and she reflected a lot of positive changes in her total outlook following the intervention. Though studies showed that multiple role in women can affect sexual functioning, arguing that work (on the job) and sex could be natural enemies, Hyde et al (1998) found no support for the concern that sexual expression suffers in dual earner couples. In the present study, none of the women were working on job and sexual dysfunction was that of the men and not of the women. However we have not assessed whether the men have predominant femininity dimension in them, which might be causing the sexual problem in men and experienced by the women. Another observation was that one of the couples (Mrs. B & Mr. BX) did not respond to the images they liked best and they liked least. When asked, the husband reported that he liked all the images and therefore did not want to point to any ‘one or two’ in particular. On the other hand, the wife reported that she did not like any of the cards. This might be a reflection of the 33 years long history of marital disharmony from the first day of marriage and the separation in between for 12 years. As suggested by Uhinki, (2001) assessing the couples together may be a better strategy to see how both the husband and wife responded, when they are together. This experiment might be interesting and help understand the dynamics of each one and at the same time the therapist can observe how or whether each one adjusts in agreeing for a single precept or they tend to give different percepts. At the same time, the process would give the clinician the data about the areas of conflict. While discussing about the future direction of psychological assessment, Krishnamurthy et al. (2004) emphasized that there needs to be a shift from the traditional focus on individual assessment to assessing families, couples and groups that form part of the larger systems. And the couples tend to view the assessment positively than therapists (Pittermann and Kubinger, 2011). Therefore, assessment of couples who are well adjusted and comparing their scores on SIS-II with those who have marital discord may be conducted in future to help identify any pattern of the scores and validate the usefulness of SIS-II in helping the couple to develop coping mechanisms. Conclusion: In conclusion, the suppression of sexual responses in the SIS-II may indicate sexual disturbance/ sexual dysfunction or sexual dissatisfaction. The potential of SIS in understanding marital adjustment and unraveling the marital conflicts can be explored by administering SIS and can form part of therapeutic assessment. Experimentation with SIS by administering it to the couples together may be initiated in future research. 40 Manickam & Suhani

References: Cassell, W. & Dubey, B.L. ( 2003). Interpreting inner world through somatic imagery. Alaska: SIS Center. Cassell, W. & Dubey, B.L. (1995). The use of Rorschach and SIS in releasing somatized grief. SIS J. Proj.Psycho.& Mental Health. 3: 3-32. Cassell, W.A.,& Dubey, B.L. (2010). Questionable Validity of Projective Technique and SIS Intervention, SIS Journal of Projective Psychology & Mental Health (2010) 17 : 4-15. Dubey, B.L., Ajith, C., Gupta, S. & Kumar, B. (2004).Role of Somatic Inkblot Series in Psychosexual disorder in India.SIS Journal of Projective Psychology & Mental Health. 11:115-120. Dwivedi, P., Mishra, N., & Mishra, M. (1998). Experiences of the Therapeutic Assessment with Couples.SIS Journal of Projective Psychology & Mental Health. 5:2 151-153. Hyde, J.S., DeLamater, J.D., & Hewitt, E.C. (1998) Sexuality and the dual-earner couple: Multiple roles and sexual functioning. Journal of Family Psychology, 12, 354-368. James, Lizzy (1999). Family Counselling in Family Court: An Analysis of Psycho-social Dynamics of Families of Litigants (Thrissur Family Court). Kerala ResearchProgramme, Discussion Paper Series, 13, 1-40. Thiruvananthapuram: Centre for Development Studies. Kumar, P., &Dhyani, J. (1994).Gender Difference, Wife’s Employment and Marital Duration as Factors in Marital Adjustment, Indian Journal of Clinical Psychology. 23:2 112-116. Krishnamurthy, R., VandeCreek, L., Kaslow, N. J., Tazeau, Y. N., Miville, M. L., Kerns, R.,Stegman, et.al.(2004) Achieving competency in psychological assessment: Directions for education and training. J. of Clin.Psycho. 60(7), 725-739. Manickam, L.S.S. &Suhani B.T. (2003). Psychotherapeutic Usefulness of SIS-II in a Male Client with Somatoform Disorder: Case Illustration. SIS Journal of Projective Psychology and Mental Health, 10, 2, 209-218. M a n i c k a m , L . S . S . , G h a n b a r y, M . & K r u t h i , M . (2013).Therapeutic effectiveness of SIS II in an Afghanistan person with Psychogenic Cough. SIS Journal of Projective Psychology and Mental Health, 20, 91-97. Manickam, L.S.S., Suhani B.T. &Jasseer, J. (2004). Psychotherapy of a Male Patient with Dissociative Convulsive Disorder: SIS Breaks the Resistance. SIS Journal of Projective Psychology and Mental Health, 11,36-44. Pittermann, A. &Kubinger, K. (2011).Co- Existence or Alliance? Psychological Assessment and Its Effects on Therapeutic Process Using Systemic Psychotherapy as an Example. Psychology, 2, 42-48. doi: 10.4236/psych.2011.21007. Sporakowski, M.J., Prouty, A.M. &Habben, C. (2001) Assessment in couple and family counseling.In Mental Health Desk Reference.E. R. Welfel and R.E. Ingersoll (Eds.). New York: John Willey and Sons. Uhinki, A. (2001). Experiences of the Therapeutic Assessment with Couples.SIS J.of Proj. Psychology & Mental Health, 8: 15-18. Marital Disharmony 41

this form of disorder is known as functional somatic syndrome and due to lack of understanding by general physicians about this condition; somatoform is often neglected in terms of treatment. Who so ever could diagnose this condition, the mental health professionals, rarely get the opportunity to see this group of patient. Some important problems with the somatoform disorder is many undiagnosed cases and a high comorbidity with other conditions. For example, somatic symptoms are common with depression, as reported by many researchers, and some studies report that somatic symptoms are the most common manifestation of depression in India (Teja, et.al, 1971; Derasari and Shah, 1988; Sharma and Shah, 2006). The Indian cultural acceptance of problems in somatic form may be one of the important reasons behind it. The definition of somatisation, a type of somatoform disorder based on DSM IV (APA, 1994) is complex. It requires the presence of a cluster of symptoms such as body pain, muscle weakness, memory loss, shortness of breath, and symptoms where organic causes have been ruled out. To make a diagnosis, a history of multiple physical complaints over several years that are severe enough to affect day-to-day functioning is required. Many patients do not meet this stringent condition of the diagnostic criteria (Rief and Isaac, 2007). In a recent primary care study, less than 1% of patients met the DSM-IV criteria for somatization disorder. However, a surprisingly high number of patients, i.e. 79% met the less restrictive criteria for undifferentiated somatoform disorder (Creed, 2006). Identifying a mental health condition is one of the important jobs of a clinical psychologist in a mental health, as well as in general health set up. By understanding the nature of the problem a clinical psychologist will be in a position to make effective decision for suitable intervention to minimize the disease burden. Psychological assessment is a core component of professional training and practice that distinguishes psychologists from other mental health providers (Kleinmuntz, 1967; Handler and Meyer, 1998; Peterson, et.al, 1997, 2006). When used effectively, assessment can establish the foundation for diagnosis and treatment planning (Butcher, 2002; Handler and Meyer, 1998), and may support beneficial psychotherapy outcome (Finn, 1996a, 1996b; Finn and Tonsager, 1992; Fischer, 2000). Three major meta-analyses have examined the psychometric properties of the Rorschach’s test (Hiller, et.al, 1999; Parker, et.al, 1988) which is an important personality assessment tool used by clinical psychologists all over the world. The researchers have found support for the psychometric strength of the Rorschach’s test and have cited its psychometric characteristics are as comparable to the Minnesota Multiphasic Personality Inventory. Several other researchers have used these results as a foundation of

support for the Comprehensive System of Rorschach test and concluded that the Rorschach Inkblot Test is an effective personality instrument which can be reliably used for many psychiatric conditions (Ganellen, 2001; Hibbard, 2003; Meyer, 2001; Society for Personality Assessment, 2005; Viglione, 1999; Viglione and Hilsenroth, 2001; Weiner, 1996, 2005). Despite having a high disease burden and confusion regarding the diagnosis of somatoform disorder, the authors of this present study could not find much research addressing the need for formal psychological evaluation for early identification of the problem so that effective intervention can lead to better prognosis of the disease. The present study was designed to find out the broad Rorschach indicators of somatization problem in college students and also to see the efficacy of Rorschach test to identify somatization syndrome. Method: Study design: The somatization study of the University of Calcutta was designed as a two-stage cross-sectional study. In the initial stage, screening checklist was used to identify high-risk and low-risk cases for somatization (the prevalence is not reported here). In the second stage, selected high-risk and low-risk cases were invited for further assessment with Rorschach Inkblot Test. Sample: Between April 2009 and November 2009 a sample of 400 graduate and post-graduate students (both male and female) from different faculties of University of Calcutta, and Jadavpur University, Kolkata, in the age range of 20-30 years were given the Symptom Assessment-45 (SA-45) Questionnaire. To avoid problem with language, the study was limited to the students who could read, write and understand English language. A total of 303 participants (76%) returned the checklist and indicated that they were willing to participate in the study. On the basis of high and low score respectively on SA-45, 15 subjects were randomly taken for high-risk somatization group and 15 as lowrisk Normal subjects for Rorschach’s test between December 2009 and March 2010. Normal subjects were also screened for absence of significant brain injury, severe medical and mental illness. Measures: 1. Semi-structured Information Sheet (ID): A semi-structured data sheet was used for recording details such as age, sex, education, residence, present and past history of medical and mental illness, habit of smoking and alcohol or other substance. 2. Symptom Assessment-45 (SA-45) Questionnaire: Developed by Strategic Advantage (1998), a 45 item brief version of Symptom Checklist-90 (SCL-90) (Derogatis et al., 1973) was used. It is used as a psychiatric case finding instrument, as a measure of symptom severity in different patient populations (Derogatis and Melisaratos, 1983). It measures symptom intensity in nine different subscales, somatization; obsession-compulsion; interpersonal sensitivity; depression; anxiety; anger-hostility; phobic anxiety; paranoid ideation; and psychoticism. The 45 items of the questionnaire are scored on five-point scale, indicating rate of occurrence of the symptom. Studies have reported high reliability and validity with good Psychometric Properties of the Tool (Maruish et al., 1998; Sandín et al., 2008). Rorschach Inkblot Test: Rorschach Inkblot test was administered and scored following Klopfer’s (Klopfer et al., 1954) method. Procedure: Fifteen subjects for somatization group (who scored above Mean+1SD score on somatization subscale of SA-45) and 15 subjects for normal group (who scored under the range of Mean-1SD score on each subscales of SA-45) were administered Rorschach Inkblot test individually, following Klopfer’s method. The scoring was done by two raters independently and the final scoring was taken after consensus. Statistical Analysis: Student’s t-test was calculated to see if there was any Somatization 43

statistical difference between two groups on Rorschach variables like Location, Determinant, Content and Multiple Linear Regression was calculated to control the effect of gender as confounding considering somatization as predictor variable using SPSS-16 for Windows. A p-value of 0.05 and less was considered as significant value. Results and Discussion: The normal group included 15 subjects (7 male and 8 female), whereas somatization group included (9 male and 6 female, total 15). No significant age difference was found between the two groups (normal 23.33 yrs. ± 1.35 and somatization 22.13 Yrs. ± 11.9). Table 1 Comparison of Somatization and Normal groups on Total number of responses (R) and Popular (P) Indices Somatization Group Normal Group t p-value Mean SD Mean SD R 22.53 12.84 19.40 8.30 0.79 0.43 P 5.00 1.81 4.40 1.72 0.92 0.36 Though somatization group has given higher number of R, but considering α= 0.05 our study did not have the sufficient power to find any significant difference between the groups on R and P. Table 2 Comparison of Somatization and Normal groups on Location and Determinants Indices Somatization Group (N=15) Normal Group (N=15) t p-value Mean SD Mean SD W 9.20 7.67 6.60 2.64 1.24 0.23 D 12.80 7.20 11.67 6.96 .44 0.66 d 0.20 0.41 0.33 0.82 -0.56 0.58 S 0.27 0.46 0.13 0.35 0.89 0.38 F 11.60 6.02 11.53 6.37 0.03 0.98 FM 2.60 1.99 2.13 1.51 0.72 0.48 M 2.87 3.56 1.40 1.80 1.42 0.17 m 1.47 2.50 0.27 0.59 1.81 0.08 FC 2.47 2.64 1.93 1.67 0.66 0.51 CF 1.00 1.46 0.80 1.21 0.41 0.69 C 0.13 0.35 0.20 0.77 -0.30 0.76 FC' 1.13 1.85 0.67 0.90 0.88 0.39 C'F 0.53 1.81 0.13 0.35 0.84 0.41 C' Total 1.67 2.38 0.80 0.86 1.33 0.2 FK 0.33 0.72 1.75 0.09 FK 0.13 0.35 0.20 0.56 -0.39 0.7 44 Dewangan et al.

The study did not find any significant difference between the somatization and normal control groups on any of the location domains; however, somatization group has given relatively more Whole (W )responses. The study group has also given more Space (S) response in comparison to its normal counterpart, but we don’t have sufficient power. The study also did not find any statistically significant difference at 0.05 level between two groups on any determinant variable. If 10% error is allowed then Innanimate movement (m) and Vista response (FK) showed significant difference between the groups where somatization group scored relatively high on both the variables. Somatization group has also given relatively more achromatic colour (C') response though not significant. Table 3 Comparison of Somatization and Normal groups on Rorschach Contents Contents Somatization (N=15) Normal (N=15) t p-value Mean SD Mean SD H 2.53 3.62 1.20 1.21 1.35 0.19 Hd 1.13 1.25 0.93 1.16 0.45 0.65 (H) 1.20 1.90 0.93 0.96 0.49 0.63 A 6.47 3.20 7.13 3.70 -0.53 0.6 Ad 1.40 1.80 0.27 0.59 2.31 0.03 (A) 0.67 0.82 0.27 0.46 1.65 0.11 At 1.60 1.55 1.60 2.10 0.00 A.At 0.27 0.46 0.27 0.59 0.00 X-ray 0.13 0.35 0.00 0.00 1.47 0.15 Object 3.60 4.72 2.47 2.50 0.82 0.42 Smoke 0.07 0.26 0.07 0.26 0.00 Cloud 0.27 0.59 0.07 0.26 1.2 0.24 Geo 0.27 0.80 0.07 0.26 0.92 0.36 Nature 1.40 1.35 0.47 0.83 2.28 0.03 Plant 0.93 1.10 0.93 0.80 0.00 Arch 0.33 0.62 1.27 2.84 -1.24 0.22 Blood 0.27 0.59 0.00 0.00 1.74 0.09 Table 3 shows somatization group has given significantly more Animal Detail (Ad) and Nature (Na) response. Though the power is lacking, but this group has also given more Blood, Pure Human (H), Parenthesezide Animal [(A)], X-ray and cloud response, but less Architectural (Arch) response in comparison to the normal. In the somatization literature, gender has been found to be associated with the diagnosis and some studies (KroenkeandSpitzer, 1998;Waan et al., 2004) report it is more prevalent in female gender. Keeping this in mind, it was hypothesised that gender might contribute as confounding to the present study. Thus, multiple linear regressions were performed by controlling the effect of gender and by taking somatization as predictor variable. Regression analysis could find significant association Somatization 45

between somatization and Ad (p<0.05), Nature (p<0.05) after controlling the effect of gender. Productivity (R): Although there is no significant difference in total number of responses given by both the groups, finding suggests that individuals with somatization tended to give more responses than normal. Though several studies have been done with hysteria but it cannot be compared with somatization due to differences in manifestation. Kumar (1962) and Prabhu (1967) have reported mean R of 22.1 and 28 respectively in their study. Chaudhury et al. (2005) used Klopfer’s method and reported less than 20 responses for normal subjects, but Asthana (1963) reported 33 responses in normal Indians. Popular responses (P): According to Klopfer (1956), average number of popular response in an average record of 20 to 45 responses is five. Dubey, Cassell and Dubey (2004) using Klopfer’s method also found average number of five popular responses on a sample of 75 normal subjects,. Both the groups in this study have obtained average number of popular responses, which might be due to the intact conformity to the society by the somatization group. Location: Klopfer (1956) reported 20-30% of W responses as average; however, in our study the somatization group has around 40% W responses. Klopfer identified this tendency to give more W responses may be pathological if the responses are of simple variety. According to Klopfer, it might be an indication of mental inability to organize the whole card in its subdivisions. As per Exner (2003), higher W indicates an excessive effort to organize the stimulus field may be due to anxiety and it might further lead to an overload state in the individual. This study found an average 57%-59% D response in the somatization as well as normal group respectively which is associated with a ‘common sense’ approach to life as per Klopfer, This finding is close to the Klopfer’s norms (45%-55%). However Chaudhuri et al. (2005) reported 28.3-32.9% D response in army and civilian normal subjects. For d and S average percentage of responses are 1 % (approximately) each, those are again pertinent with Klopfer’s own record for average response. However, a higher tendency to give S response in somatization group may be due to an oppositional tendency or an unreasonable negativism resulting from unbearable external pressure on a deeply insecure individual (Klopfer et al, 1954). Determinant: There is a trend to give high m responses by the somatization group indicates an over-influence of outside forces on the individual that might cause stress or inner conflict. Again there is a tendency of somatization group to give more achromatic colour responses that might indicate a ‘burnt child’ reaction, the reaction of people who are basically responsive to emotional stimulation from outside but have experienced a series of traumatic experiences (Klopfer & Kelley, 1942). This finding is further supported by tendency of high FK indicating affectional anxiety where an individual tries to put the problem at some distance from himself so he can view it more dispassionately (Klopfer et al., 1939). Contents: It is found that somatization group did not differ significantly in most of the Rorschach contents except Animal Detail (Ad) and Nature (Na); however, the study group had given relatively more H, X-ray, Cloud, Blood and (A) responses. Ad has been found to be elevated where individual is having significant adjustment difficulty resulting from poor social skill or suspiciousness (Exner, 2003). A tendency to withdraw from social interaction (Nature and cloud response) and a relatively high willingness to form interpersonal relatedness (Human response) may lead to the conflict. High somatic preoccupation or body concern (x-ray, blood content) is also evident which is typical for somatization. Blood response has been identified as a primitive defence by many Rorschach researchers and both blood and x-ray type responses have been reported to be higher with dissociative patients and people who face trauma, especially sexual trauma (Armstrong and Loewenstein, 1990). 46 Dewangan et al.

Conclusion: Though some of the variables have been identified in association with somatization, but this current study has failed to provide any guideline regarding the use of Rorschach as a test to detect problem of somatization in health set-up. The study had some major limitations that might have affected the finding. This study tried to identify Rorschach variables associated with somatization problem, but only gross Rorschach variables in the domains of Location, Determinant and Content were incorporated. The scoring method also includes basic and supplementary relationships of variables, ratios, sequence analysis, psychogram etc.; but those were not calculated in this current study. Those variables could have been of interest to explore the relationship between somatization and Rorschach test. Another major issue was, somatization was only identified by using a screening checklist among college students; no specific diagnostic interview was carried on. It is also a high possibility that SA-45 somatization subscale might score positive even for people who are having real health problems which could not be ruled out. Small sample size was another major limitation of this study. Sample size was not calculated and proper case control design also could not be followed for equal sample comparison. Though this study could control the effect of gender during calculation, but it would have been better if it could be controlled before. Another important issue is the system of administration and scoring. International literature is currently focusing on highly standardized system of Rorschach, i.e. Comprehensive System by Exner (2003) and Klopfer System is hardly followed in most research works, However, in India many institutes and professionals are using the Klopfer system of Rorschach widely. This study raises pertinent question regarding use of this system to screen neurotic problems like somatization. A comparative study between Klopfer and Exner system as well as Somatic Inkblot Series might help us to deal with the dilemma what to use. References: American Psychiatric Association (1994). Diagnostic and statistical manual of mental health disorders (4th ed). Washington DC: Armstrong, J. G., &Loewenstein, R. J. (1990).Characteristics of patients with multiple personality and dissociative disorders on psychological testing. J.Nerv.Ment. Dis., 178: 448-454. Asthana, H.S. (1963) A Rorschach Study of Indians. Rorschachiana, 45: 283-286. Butcher, J. N. (2002). Clinical Personality Assessment: Practical approaches (2nd Ed.). New York: Oxford University Press. Chaudhury, S., Augistine, M., Saldanha, D., Shrivastav, K., Kundeyawala, S. M., Pawar, A. A. and Ryali, V.S.S.R (2005). Norms of the Rorschach test for Indian subjects. MJFI, 62:153-160. Creed, F. (2006). Should general psychiatry ignore somatization and hypochondriasis? World Psychiatry, 5(3): 146 150. Derasari, S. and Shah, V. C. (1988).Comparison of symptomatology of depression between Indan and USA. Indian J Psychiatry, 30: 129- 134. Derogatis LR, Lipman RS, Covi L. (1973) SCL-90: an outpatient psychiatric rating scale – preliminary report. Psychopharmacol Bull, 9:13–28. Derogatis, L. R. and Melisaratos, N. (1983). The brief symptom inventory: an introduction report. Psychol. Med, 13: 595-605. Dubey, B. L., Cassell, W. A. and Dubey, A.(2004), Impact of number of responses on the interpretation of Rorschach indices. SIS J. Porj.Psy and Ment. Health, 12:27-48. Exner, J.E. (2003) The Rorschach: A Comprehensive System. Vol. 1, ( 4thed). NJ: John Wiley & Sons, Inc. Finn, S. E. (1996a). Assessment feedback integrating MMPI-2 and Rorschach findings. J. of Personality Assessment, 67:543–557. Finn, S. E. (1996b). Manual for using the MMPI-2 as therapeutic intervention.Minneapolis:University of Minnesota Press. Finn, S. E., and Tonsager, M. E. (1992). Therapeutic effects of providing MMPI-2 test feedback to college students awaiting therapy. Psychological Assessment, 4:278–287. Fischer, C. T. (2000). Collaborative, individualized assessment. Journal of Personality Assessment, 74:2–14. Ganellen, R. J. (2001).Weighing evidence for the Rorschach’s validity: A response to Wood et al. (1999). J.Personality Assessment,77:1–15. Handler, L., and Meyer, G. J. (1998).The importance of teaching and learning personality assessment.In I. B. Weiner (Ed.In Chief), L. Handler, & M. J. Hilsenroth (Eds.), Teaching and learning personality assessment, 3–30. Hibbard, S. (2003). A critique of Lilienfeld et al.’s (2000) “The Somatization 47

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including India (WHO, 2012). More than one lakh lives are lost every year due to suicide in India. (Kumar,2010).In the most recent National Crime Records Bureau (NCRB; Ministry of Home Affairs) report, the rate of suicide in 2010 rose to 11.4 per 100,000 populations and this represented an increase of 5.9% in the number of suicides. The rates of suicide have greatly increased among youth and hence are now the group at highest risk all over world (Rajagopal, 2004; Birbal et al., 2009, Patton et. al., 2009). The traditional research on risk factors for suicide has mainly focused either on demographic markers or psychopathological variables; and overlooked personality dispositions (Turecki, 2005; Dogra et al., 2008; Stewart et al., 2008; May et al., 2012; Soltaninejad et al., 2013). Some researchers explored the personality correlates of suicide ideation by using psychometric tests (questionnaires) which suffered frompersonal biases, social desirability and response set etc (Cattell, 1957; Cattelland Warburton, 1967;CattellandDreger, 1977). More so, the genesis of suicide ideation is lying in the unconscious mind, so it is more important to explore the unconscious by using projective techniques. The present study is an empirical endeavour in this direction. The Inkblot techniques have contributed a lot among the projective tests in exploring the unconscious properties for personality assessment, diagnostic evaluation and therapeutic intervention(Cassell, 1980, 1990, 1994, Cassell and Dubey, 2003, Cassell, et.al. 2013). There are three major standardized tests based on inkblots. The first pioneer amongst these is Rorschach Inkblot Test published in 1921 anddominated the field until 1956 when Holtzman developed “Holtzman Inkblot Test” (HIT) to overcome some ofthe limitations of Rorschach by adding psychometric properties. The third is Somatic Inkblot Series (SIS)(Cassell, 1980; Cassell, 1990, Cassell and Dubey, 2003) an extensionand advancement of the traditional inkblot techniques (). It has been developed primarily to understand the manifestation of problems through somatization, and to hear the inner cry of individuals. The exploration of suicide risk through Rorschach test spans more than 50 years (Exner, 1993, Fowler et al., 2001). The earlier research in this regard has been reviewed and criticized (Meyer and Archer, 2001. Blasczyk-Schiep et al., 2011) for focusing on a single test indicators for predicting suicide such as the number of minus form level of human movement responses (M-), colour-shading, transparency in the content analysis of responses or frequency of responses with destructive content (Morbid Imagery; MOR). The drawback of single indicators obtained from Rorschach protocols is their lack of statistical stability. For statistical comparison combined responses by creating composite indicators of a given scale are more stable and more reliable than single indicators (Viglioneand Taylor,

2003; Blasczyk-Schiep et al., 2011). Exner (1993) has developed Suicide Constellation Index (S-Con). The S- con consists of four indicators (MOR > 0, FV + VF + V > 0, colour-shading > 0, and FC < CF + C) and added two more indicators later on (M - > 1 and weighted special score > 9). Holtzman has not suggested such index for suicidal risk.However, the suiciderisk factors have been studied with Somatic Inkblot Series (SIS-I, SIS-II and SIS-Video) by Bellamy (1995), Cassell (2005), Cassell and Dubey (2007, 2010), Dogra et.al. (2008, 2011), Daini et al. (2010), and Paths etal., (2011), but in most of these studies images sensitivities of suicide have been investigated by using case study method. No serious attempts have been made to examine SIS- Constellation Index of suicide. The present study is an empirical endeavour in this regard using multivariate methodology, and is also oriented to explore the gender specific SIS-II correlates of suicide ideation among adolescents. Method: Sample: The sample consisted of 480 school students (186 females and 294 males) drawn from 11th and 12th grade students of various Senior Secondary Schools of Gurgaon and Delhi. The sample was restricted to urban areas. The age of participants in both groups ranged between 15 and 18 years with mean age of 16.5 years. The sample did not include students who have attempted suicide. Measures: (i) SIS-II (Booklet Form; Cassell and Dubey, 1980, 2003): after initial success of SIS-I in 1980; the Booklet Form of SIS-II was developed in 1990. It consists of series A and B, each with 31 images, for a combined series total of 62 images. There is also a sample image in the beginning with instructions for self-administration and a place for a brief health history and personal data. The test can be used as an individual as well as a group test. (ii) Beck Scale for Suicide Ideation(BSS) (Beck, et.al., 1988): is a 21 item self-report instrument that measures the severity of suicidal ideation in adults and adolescents. BSS measures a broad spectrum of attitudes and behavior that clinicians routinely consider when assessing patient’ suicide risk; it also reveals specific suicidal characteristics which require greater clinical scrutiny. The BSS scores are best considered as indicators of suicide risk rather than as predictors of eventual suicide in a given case. Out of 21 items, the first five BSS items serve as a screen for suicide ideation. If a respondent circles the zero statements in both Item 4 (indicating no suicide intention) and Item 5 (indicating avoidance of death if presented with a life threatening situation), then he or she is instructed to skip to the next 14 items which relate to specific information about the respondents plans and attitudes. Any respondent who has previously attempted suicide is requested to rate Item No.21. The severity of suicide ideation is calculated by summing the ratings for first 19 items (items 20 & 21 are not included in the score). The total BSS score can range from 0 to 38. Results and Discussion: Descriptive statistics (Mean, SD) and t-ratios were computed to compare the two groups in terms of significance of mean differences. Perusal of Table 1 reveals that female students have scored significantly high on SIS-II scales of Human, Animal, Movement, and Most Typical Responses; and significantly low on Anatomy than their counterpart males. Here, it is to be mentioned that in case of scales of Total No. of Responses (R) and Rejection (Rej.), the obtained t-ratios are approaching the significance level. The female students scored high on total Responses (R) and Low on Rejection of Images than male students, depicting their intact imaginative capacity and thought processes.Overall, the comparison of female and male students on SIS-II scales depicts that female students tend to be more psychologically mature in interpersonal relationships,appropriate and objective in self-image, high in psychodynamic energy, with imaginative capacity, thought processes and healthy perception. On Beck Scale for suicide Ideation (BSS), female students have scored significantly higher than their counterpart male students depicting high on suicide ideation. This finding supports to earlier studies (Singh, 50 Singh and Rani

Table 1 Comparison of Mean Scores of female and male students on SIS-II and BSS S.No. Variables Females (N=186) Males (N=294) t Sig. R M .608978 SD 1.86150 M 60.4932 SD 3.10866 1.783 NS H M 19.5323 SD 4.71588 M 17.2789 SD 4.74436 5.088 .01 A M 10.4462 SD 3.65836 M 9.2483 SD 3.19923 3.666 .01 At M 10.4624 SD 3.53686 M 11.3741 SD 4.12883 -2.576 .05 Sex M .8656 SD 1.16628 M 0.8259 SD 1.26345 0.351 NS M M 6.7097 SD 4.23009 M 5.0510 SD 3.57668 4.437 .01 MT M 8.9409 SD 2.33695 M 8.1599 SD 2.57149 3.430 .05 T M 11.2043 SD 3.75193 M 10.5850 SD 4.06826 1.705 NS AT M 2.2849 SD 1.71779 M 2.0680 SD 1.44836 1.430 NS Rej M 1.0860 SD 1.84042 M 1.5034 SD 3.17816 -1.820 NS PAS M .7097 SD 1.23096 M 0 .8299 SD 1.22752 -1.044 NS D M 4.7043 SD 2.91570 M 4.4895 SD 2.79899 0.794 NS HAS M 3.1022 SD 2.21672 M 3.0816 SD 2.08852 .101 NS P M .8602 SD 1.2512 M 0.6973 SD 1.01870 1.486 NS SI M 5.8817 SD 3.97927 M 5.0578 SD 3.94589 2.217 .05 2007; WHO, 2012; Kumar, 2004. Mayer andZiaian, 2002; Radhakrishananand Andrade, 2012; Phillips et al., 2004) which have also reported the females to be high on suicide ideation. Inter-correlations: Pearson’s correlations were computed among all the 15 variables (14 of SIS-II and I of BSS) in data from both the groups (Table 2). It may be noted that degree of freedom being 184 (N-2) in female data, correlation coefficients of .13 and .19 are significant at .05 and .01 levels respectively. In case of male data (df =292; N-2), the correlation coefficients of .12 and .15 were found to be significant at .05 and .01 levels of significance respectively. In case of female data, inter-correlations among 15 variables (14 SIS-II and one of BSS) are ranging from .385 to -.991. Twenty seven of 91 correlations are significant, of which 18 are positive and 9 are negative. Significant correlations among some of the scales may be because of their association with some factors at second order level. Correlations between SIS-II scales and Suicide Ideation (BSS) are low. Only three scales of SIS-II viz. Typical Responses, Depression, and Hostility Suicide Ideation 51

Table 2 Correlations between SIS-II Scales and BSS S.No. SIS-II Scales BSS (Female) BSS (Male) Total No. of Response (R) .023 -.107 Human Response (H) -.101 -.016 Animal Response (A) .006 .092 Anatomy Response (At) .077 .023 Sex Response(Sex) .117 -.005 Movement Response (M) -.014 .011 Most Typical Response (MT) .010 -.166** Typical Response (T) .140* -.076 Atypical Response (AT) .047 -.080 Rejection (Rej) -.025 .103 Pathological Anatomy Scale (PAS) -.048 .034 Depression (D) .594** .581** Hostility & Aggression (HAS) .323** .188** Paranoia (P) -.068 -.028 * Significant > p .05, ** Significant > p .01 & Aggression have marked significant relationship with suicide ideation with respective coefficients of .140 (p < .05)’ .594 (p<.01) and .323 (p<.01). In male data, inter-correlations among 14 variables of SIS-II are ranging from .530 to -.969. Only 33 of 91 correlations are significant, of which 22 are positive and 11 are negative. These significant correlations among some of scales may be because of their association with projective factors at second order level. Only three scales of SIS-II i.e. Most Typical, Depression, and Hostility Aggression have marked significant relationship with suicide ideation (coefficients -.166 (p<.01)’ .581(p<.01), and .188 (p<.01). No doubt, bivariate correlations provide significant information about the relationship among variables, but actual overlaps among variables are unveiled by Factor Analysis. Factor Analysis (Female Students Data): Principal Component Analysis was undertaken on the inter-correlations between 14 variables of SIS-II and one of Suicide Ideation, and six factors with eigen values greater than 1.00 were extracted which together accounted for 65.763% of total variance. Extracted factors have been interpreted after varimax rotation (Kaiser, 1950). Varimaxly rotated factors are presented in Table 3. The commonalities (h2) for 15 variables range from .406 to .975. Factor I mainly loads on two scales of SIS-II, namely Total R and Rejection with very high contrasting loadings of .90 and -.98 respectively. Scales of Human, Animal, and Hostility-Aggression responses have also marked some low but considerable loadings which are useful in understanding the structure of this factor. This factor is indicative of “Imaginative Capacity”. It accounts for 13.760% of total variance. Similar structure has also been reported in earlier studies of factor structure of SIS-II (Singh, 2007; Kumar, 2009). Factor II has been defined mainly by two scales of SIS-II namely, Depression (.827) and Hostility & Aggression (.664) combined with Beck Scale for Suicide Ideation (.826). Positive loadings of markers here depict positive association among depression, hostility & aggression, and suicide Ideation. Two other scales of SIS-II i.e. 52 Singh and Rani

Table 3 Rotated Factor Matrix (Females) Variables/ Factors Factors I II III IV V VI h2 R .980 .030 .041 .081 .053 .033 .974 H .178 -.180 -.137 .021 .717 -.179 .629 A .162 .060 -.315 -.042 .087 .595 .492 At -.037 .035 .801 -.032 .100 .263 .724 Sex .039 .079 .594 .193 -.313 -.072 .501 M .070 .195 -.055 .685 .360 .141 .665 MT -.084 .032 .344 -.128 .729 .171 .703 T .102 .048 .688 -.131 .231 -.183 .590 AT -.046 -.083 .236 -.102 -.090 .710 .587 Rej -.983 -.026 -.029 -.059 -.043 -.048 .975 PAS .073 -.020 -.013 .618 -.130 -.034 .406 D .141 .827 -.038 .054 -.114 -.094 .731 HAS -.157 .664 .076 .298 .055 .148 .586 P .005 -.032 .037 .706 -.110 -.209 .556 SI .040 .826 .109 -.207 -.059 -.049 .745 % of variance 13.760 12.688 11.899 10.525 9.367 7.525 Movement and Human Responses have also marked some considerable contrasting loadings helpful in the understanding of the structure of this factor. The obtained structure, hereby, suggests it to be a factor of Suicide Ideation. It has accounted for 12.688% of total variance. The present structure depicts some commonness with Depression Index, and Suicide Constellation (S-Con) reported by Exner (2003), Armstrong (1992), and Blasczyk-Schie et al. (2013). The obtained structure hereby describes that person with depressed mood, preoccupied with hypochondriasis, hostile attitudes & impulses and aggressive conflicts, unexpressed psychodynamic energy, and social isolation tendencies tend to be more prone to have suicide ideation. The present finding also confirms the findings of some other psychometric studies (GieglingJet al., 2009; Soltaninejad et al., 2013) which have established the significant link of suicide ideation with depression, hostility & aggression, and impulsivity. The findings of present finding have provided significant information about the SIS-II correlates of Suicide Ideation. Factor-III has been defined primarily by the SIS-II scales of Anatomy, Typical, Sex, Most Typical, and Animal responses with respective loadings of .801, .688, .594, .344 and -.315. Factorial combination of markers suggests it to be a factor of Self-image. It has accounted for 11.899% of total variance. The obtained structure is indicative of Low self-image, preoccupation with internal body organs, heightened sexual anxiety but realistic and objective perception of the external environment. This structure almost replicates one of the factors obtained in SIS-II protocols of female students by Singh (2007). It is worth mentioning that measure of suicide ideation has not marked significant association with this factor. Factor IV mainly loads on four scales of SIS-II i.e. Paranoia (.706), Movement (.685), Pathological Anatomy (.618), and Hostility & Aggression (.298) Suicide Ideation 53

depicting positive association among them. The obtained structure is indicative of Paranoid Ideation with Hypochondriac Tendency. It has accounted for 10.525% of total variance. It almost resembles with one of the factors obtained in SIS-II protocols by Singh (2007). The obtained structure hereby provides the caricature of a person having paranoid ideation, exaggerated sense of self-consciousness, heightened psychodynamic energy, hypochondriac sensitivity, hostile and aggressive attitudes. Factor V has borne out high positive loadings on scales of Most Typical (.729), Human (.717), Movement (.360) and negative on Sex (-.313) responses. Scale of Typical Response has also marked some considerable positive loading on this factor. Factorial combination of markers suggests it to be a factor of Perceptual Maturity. It has accounted for 9.367% of total variance and almost replicated one of the factors obtained from female students on SIS-II protocols (Singh, 2007). The obtained structure posits that perceptually mat+- ure individuals tend to have coherent and logical thinking, ability to keep up with demands of society, high ego strength, proper interpersonal relationship with others, high level of psychodynamic energy, healthy perception and low level of sexual anxiety. Factor VI mainly loads on Atypical and Animal scales of SIS-II with respective loadings of .717 and .595 depicting positive association between them. Anatomy and Paranoia scales have also marked some considerable loadings on this factor. Factorial combination of markers hereby suggests it to be a factor of Psychosocial Immaturity. It has accounted for 7.525% of total variance and partially replicated one of the factors reported by Singh (2007) and Kumar (2009) on SIS protocols. The obtained structure describes a person’s poor self-image, vague percept and perseveration. Factor Analysis (Male Students Data): The Principal Component Analysis was undertaken on inter-correlations among 15 variables (14 of SIS-II and 1 of BSS), and six factors with Eigen values greater than 1.00 were extracted which together accounted from 67.027% of total variance. Factors have been interpreted after varimax rotation (Table 4). The commonalities (h2) for 15 variables ranged from .247 to .959. Perusal of rotated factor matrix reveals that Factor I has loaded positively on Most Typical, Human, Typical, and Movement responses with respective loadings of .827, .775, .687 and .468; and negatively on Paranoia Scale (- .319) depicting the positive association among the first four, and their negative association with paranoia. Clustering of the above variables suggests it to be a factor of Perceptual Maturity. It has accounted for 14.558% of total variance and almost replicated one of the factors reported from SIS protocols by Singh (2007) and Kumar (2009). Obtained Structure is hereby indicative of coherent and logical thinking, ability to keep up with the demands of society, ego strength, and mature interpersonal relationship with others, reality testing, imaginative and creative thinking, and objective consciousness. Factor II dominantly loads on scales of total number of Responses (R) and Rejection (Rej) with very high contrasting loadings of .968 and -.969. Scale of Paranoia has also marked near significant positive loading 765on this factor. Overall, this factor is indicative of Proper Imaginative Capacity. It has accounted for 13.530% of total variance and replicated one of the factors reported by Singh (2007) and Kumar (2009) from the SIS protocols of adolescents and adults. Factor III has been mainly defined by Depression scale of SIS-II and Suicide Ideation Scale with high positive loadings of .864 and .861 depicting positive association between them. The SIS-II scale of Hostility & Aggression has also marked considerable positive loading on this factor. The obtained structure clearly suggests it to be a factor of Suicide Ideation. It has accounted for 11.204% of total variance; and almost resembles with one of the factors (Suicide Ideation) obtained from the data of female students of the present study. The present structure depicts some overlap with Depression Index and Suicide Constellation (S-Con) reported by Exner (2003), Silberg& Armstrong (1992), and Blasczyk-Schie et al. (2013). The present finding also confirms the findings of some earlier psychometric studies (Giegling et al., 2009; Soltaninejad et al., 2013) depicting the link of suicide ideation with depression, 54 Singh and Rani

Table 4 Rotated Factors Matrix (Males) Variable/ Factors Factors I II III IV V VI h2 R .047 .968 -.036 -.116 .061 .036 .959 H .775 .030 -.005 -.067 -.148 -.159 .653 A .091 .152 .166 -.595 .073 .142 .438 At .161 -.051 .176 .510 -.144 .635 .743 Sex .131 -.017 .092 .674 .170 .036 .510 M .468 .116 .025 .116 .593 -.335 .711 MT .827 .046 -.170 .047 .033 .009 .719 T .687 .018 .020 .234 .022 .380 .672 AT -.043 .069 -.174 -.267 .163 .726 .662 Rej -.046 -.969 .029 .110 -.055 -.032 .958 PAS -.142 .032 -.042 .328 .639 .208 .582 D -.107 .064 .864 .106 .134 -.047 .793 HAS -.124 .080 .248 -.188 .717 .030 .634 P -.319 .284 .018 .199 .105 -.117 .247 SI -.038 -.119 .861 -.119 .042 -.023 .774 % of variance 14.558 13.530 11.204 9.648 9.452 8.634 hostility& aggression, and impulsivity, and provides significant information about SIS-II correlates of suicide ideation among males. The obtained structure describes that a person with depressed mood, preoccupied with hypochondriac thoughts, hostile attitudes tend to have high vulnerability of suicide ideation. Factor IV is a bipolar factor, of which positive pole represents scales of Sex, Anatomy and Pathological Anatomy with respective loadings of .674, .510, and .328; and the negative pole represents Animal (-.595) and Atypical -.267. Responses, representing positive pole are depicting positive association among themselves and inverse with others. Factorial combination of markers suggests it to be a factor of Sexual Anxiety. It has accounted for 9.648% of total variance and resembles with one of the factors obtained in SIS-II protocols by Singh (2007). Obtained structure is indicative of sexual anxiety, psychological immaturity, poor self-image and preoccupation with internal parts of body, hypochondriac ideation and perseveration. Factor V has mainly loaded on three scales of SIS-II, namely, Hostility & Aggression, Pathological Anatomy, and Movement with respective loadings of .717, .639, and .593. Factorial Combination of markers suggests it to be a factor of Inward Fantasized Hostility. It has accounted for 9.452% of total variance. The obtained structure hereby describes a person having hostile attitudes and aggressive conflicts, hypochondriac sensitivity, and unreflected psycho-dynamic energy. Factor VI loads positively on scales of Atypical (.726), Anatomy (.635), Typical (.380) and negatively on Movement responses (.335). The obtained structure is indicative of Poor Self Image. It has accounted for 8.634% of total variance and resembled with one of the factors from SIS-II protocols reported by Singh (2007). Obtained structure is indicative of vague and poor quality of SIS-II precepts, poor self-image and Suicide Ideation 55

preoccupation with internal body organs and unreflected psychodynamic energy. Conclusion: Analysis of significant mean differences (t-ratios) has revealed that the female students scored high on suicide ideation than male students. In case of SIS-II scales, the female students have scored significantly high on Human, Animal, Movement & Most Typical response scales, and low on Anatomy than male students depicting their high psychodynamic energy & imaginative capacity, healthy perception, psychologically mature with objective self-image.The correlational analysis has revealed Sex, Typical, Depression, and Hostility & Aggression scales as significant SIS-II correlates of suicide ideation in females. In case of males, suicide ideation has correlated positively with Depression and Hostility & Aggression Scales and negatively with Most Typical Response Scale. It implies gender differences in the psychodynamics of suicides ideation. Inter-correlations and factor analysis have provided Depression, Hostility & Aggression, and Movement as the most common SIS- II correlates of suicide ideation. The present finding suggests SIS-II Suicide- Constellation Index consisting of M+, D+, and HAS+. For more generalizable findings and examination of SIS-II – Suicide- Constellation Index, further studies on larger samples of suicide attempters and suicide ideators are required. References: Beck, A.T., Steer, R.A., & Ranieri, W.F. (1988). Scale for Suicide Ideation : Psychometric Properties of a Self-Report Version, Journal of Clinical Psychology, 44, 499-505. Bellamy, E.N. (1995). Hospitalised Suicidal Patients and the Somatic Video Procedure: A Descriptive Study. SIS Journal of Projective Psychology & Mental Health, Vol. 2(1), pp. 85-91. Birbal, R., Maharaj, H.d., Clapperton, M., Jarvis, J. Ragoonath, A., Uppalapati, K. (2009). Cyber Suicide and the Adolescent Population: Challenges of the Future? Int.J.Adolesc.Med. Health, 21: 151-159. Blasczyk-Schiep, S., Kazen, M., Kuhl, J., & Grygielski, M. (2011). Appraisal of Suicidal Risk among Adolescents and Young Adults through the Rorschach Test. J of Pers. Assessment, 93:5, 518 526. Cassell, W. A. (1980) Body Symbolism and the Somatic Inkblot Series. Anchorage, Alaska. Aurora Publishing. Cassell, W. A.(1990) Somatic Inkblot Series Manual. SIS Center, Anchorage, Alaska (USA). Cassell, W.A. (1994). The Somatic Inkblot Series; Continuing Rorschach's Conceptualization, SIS J. of Proj.Psy.&Men.Health, 3: 3- 32. Cassell, W.A. (2005). Assessing Suicidal Homicidal Impulses with the SIS. SIS J.of Proj.Psy.& Mental Health, 12(2), 99-106. Cassell, W.A. (2011)Editorial: Dissolving Death Anxiety with Yoga Empowered SIS, SIS J. Proj. Psy. & Men.Health,18:2,123-129 Cassell, W.A. and Dubey, B.L. (1998).Application of Somatic Inkblot Series in Personality Assessment, Diagnosis, Screening and Therapy. SIS J. of Proj.Psy.& Mental Health, Vol. 5(1), 3-32. Cassell, W.A and Dubey, B.L. (2003).Interpreting Inner World through Somatic Imagery: Manual of the Somatic Inkblot Series.Anchorage Somatic Inkblot Centre. Cassell, W.A. and Dubey, B.L. (2007).SIS and Sand Tray Psychotherapy of Suicidal Adolescent.SIS J. Proj.Psy.& Mental Health, 14:2, 87-97. Cassell, W.A., and Dubey B.L. (2010).Infectious Suicidal Imagery in Combat PTSD.SIS J. of Proj.Psy.& Mental Health, 17(1), 27-37. Cassell, W.A., Dubey,B.L., Charles, T. and Dwivedi,P.(2013) Perceiving One's Own Dead Body andDeath Anxiety: Dissolving SIS Spiritual Symbols, SIS J. Proj. Psy., & Mental Health, 20: 1,3-17. Cattell, R.B. (1957). Personality and Motivation: Structure and Measurement. New York: Harcourt. Cattell, R.B., & Warburton, F.W. (1967).Objective Personality and Motivation Tests. A theoretical introduction and practical compendium. Champaign, III: University of Illinois Press. Cattell,R.B. and Dreger, R.M. (1977) Hand book of Modern Personality Theory. John Wiley & Sons.New Personality Theory.John Wiley & Sons.NewYork.London.Sydney.Toronto Daini S., Manzo, A., Pisani, F. and Tanscredi, A., (2010).Attempted Suicide: Psychopathology and Wartegg Test Indicators.SIS J. of Proj.Psy.& Mental Health, vol. 17(2), 171-177. Dogra, A.K., Basu, S. & Das, S. (2008). The Role of Personality ,Stressful Life Events, Meaning in Life, Reason for Living on Suicidal Ideation. A Study in College Students.SIS J. of Proj.Psy.& Mental Health, 15:52-57. 56 Singh and Rani

Dogra, A.K., Basu, S. &Das,S.(2011) Impact of Meaning in Life and Reason for Living to Hope and Suicidal Ideation. A Study among College Students. SIS J. of Proj. Psy. & Men.Health,18:82-102. Exner, J.R. (2003). The Rorschach: A Comprehensive System, Basic Foundations and Principles of Interpretation, Vol.1(4). John Wiley & Sons, Inc. Fowler, J.C., Piers, C., Hilsenroth, M.J., Holdwick, D.J., &Padawer, J.r. (2001).the Rorschach Suicide Constellation: Assessing Various Degrees of Lethality. J.Personality Assesnt,76, 333-351. Giegling, I., Olgiati, P., Hartmann, M., Calali, R., Moller, H.J., Rujescu, D., and Serretti, A. (2009). Personality and Attempted Suicide: Analysis of Anger, Aggression, and Impulsivity. Journal of Psychiatric Research,1262-1271. Kaiser, H.F. (1958). The Varimax Criterion for Analytic Rotation in Factor Analysis: Psychometrika, 23: 187-200. Khromov, A.B., Cassell, W.A. & Dubey B.L. (1999). Some Personality correlates of selected SIS variables: Russian Experience. SIS J. of Proj.Psy.& Mental Health. Vol. 6(1), 35-46. Kumar, R. (2009). Factor Structure of SIS-I in adults, SIS J. Proj.Psy.,& Mental Health, 16: 124-127. Kumar,S.(2004). An Analysis of Suicide Attempters Versus Completers in Kerala. Indian Journal of Psychiatry, 46: 144-9. Kumar,V. (2010). Indian Research on Suicide. Indian J. Psychiatry, 52(1):S291-S296. May, A.M., Klonsky, E.D. & Klein, D.N., (2012).Predicting Future Suicide Attempts among Depressed Suicide Ideators: A 10 Year Longitudinal Study. Journal of Psychiatric Research 46: 946-952. Mayer, P., Ziaian, T. (2002).Suicide, Gender and Age Variations in India. Are women in Indian society protected from suicide? Crisis, 23: 98-103. Meyer, G.J. & Archer, R.P. (2001). The Hard Science of Rorschach Research: What do we know and where do we go? Psychological Assessment, 13, 486-502. Mishra, M. & Dwivedi, C.B. (1997). Content Scale based Diagnostic Compatibility of the SIS-II & Rorschach in Normal, Neurotics and Schizophrenics.SIS J.Proj.Psy.&Men.Health, 4:2,121-140. National Crime Records Bureau (2010). Accidental Deaths and Suicides in India: Ministry of Home Affairs Govt. of India; New Delhi. Paths, R.R. & Daini, S. (2011). Attempted Suicide in Borderline Patients: Projective Suggestions and Clinical. SIS J. of Proj.Psy.& Mental Health, vol. 18(2), 130-146. Patton, G.C., Coffey, C., Sarvyer ,S.M. Viner, R.M., Haller, D.M., &Bose, K. (2009). Global Patterns of Mortality in Young People.A Systematic Analysis of Population Health Data.Lancet. 374:881-92. Phillips, M.R., Yang, G., Li, S.,&Li,Y. (2004). Suicide and the Unique Prevalence Pattern of Schizophrenia in Mainland China: A Retrospective Observational Study. Lavcet; 364:162-8. Radhakrishanan, R. &Andrade,C. (2012). Suicide: An Indian Perspective. Ind.J.Psychiatry, 54:4,304-319. Rajagopal, S. (2004).Suicide Pacts and Internet. BMJ; 329: 1298-9. Silberg, J.L. & Armstrong, J. (1992). The Rorschach Test for Predicting Suicide among Depressed adolescent Impatient. Journal of Personality Assessment, 59,290-303. Singh, U. (2007). Gender Differences in Factor Structures of SIS-II Responses.SIS J. of Proj.Psy.& Mental Health, 14(2), 110-116. Soltaninejad,A., Ashtiani, A.F., Ahmadi, K., Nikmorad, A., etc (2013). Model of Suicidal Ideation among Iranian Soldiers: The Role of Personality Disorder, Emotion Focused Coping Style and Impulsivity. J. of Basic and Applied Scientific Res. 3(2) 832-837. Stewart, M.E., Donaghey, C., Deary, I.J., and Ebmeier, K.P. (2008). Suicidal thoughts in young people: Their Frequency and Relationships with Personality Factors. Personality & Individual Differences, 44, 809-820. Turecki, G.(2005). Dissecting the Suicide Phenotype: The Role of Impulsive-Aggressive Behavior. Journal of Psychiatry and Neuroscience , 30: 398-408. Viglione, D.J. & Taylor, N. (2003).Empirical Support for Interpreter Reliability of Rorschach Comprehensive System Coding. Journal of Clinical Psychology, 59.111-121. W.H.O.(2012). Suicide Rates per 100,000 by Country, Year and Sex (2012 Mar. 27). Suicide Ideation 57

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 40 issues in 20 years. The Journal is available on Society’s Web Site at http: //www.somaticinkblots.com The Journal from Volume 1-21 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 in Hard Copy or through Electronic mail To: Bankey L. Dubey, Ph.D., DPM, DM&SP, Editor Emeritus, SIS J. of Proj. Psy. & Mental Health, E-mail : bldubey@gmail.com

appearance is excessively time-consuming and causes significant distress or impairment in functioning. The most common complaints are about features involving the head and body hair, features, skin blemishes, thighs, stomach, breasts, buttocks, and genitals (Rosen, 1996; Veale, et al., 1996, Oosthuizen and Castle, 1998). Increasing attention has been given to the issue of body image and its relation to BDD. Body image is often conceptualized as having two main components: a perceptual and an attitudinal/affective component. The perceptual Component relates to the accuracy of an individual’s body size estimation whereas the attitudinal component reflects the attitudes/feelings that one has towards his/her own body (Slade, 1994). A perceptual disturbance of body image in BDD is evident by the absence of a real or excessive physical defect. Attitudes and feelings toward one’s body are reflected by the amount of distress and impairment that this disorder causes an individual and encompasses affective, behavioral and cognitive symptoms of BDD. The Rorschach Inkblot test and Somatic Inkblot Series- II were administered to help the patient in understanding his psychopathology and therapeutic intervention. The Rorschach Inkblot Test: The Rorschach Inkblot Test (Rorschach, 1921) is a known projective diagnostic instrument. The utility of the instrument in quantitative research was much improved by the modified scoring system of Exner (1974,1995). The Exner’s system has been utilized in Rorschach studies of diverse disorders such as PTSD (Goldfinger et al., 1998), schizophrenia (Adair and Wagner, 1992), and childhood attention deficit and hyperactivity disorder (Bartell and Solanto, 1995). The Somatic Inkblot Series (SIS): The Somatic Inkblot Series (SIS) (Cassell,1980, Cassell and Dubey, 1990, 2003) is a structured, projective, diagnostic procedure and is an adjunct to psychotherapy. The technique is based on spontaneous, individuallygenerated responses to inkblots, which elicit intrapsychic association’s specific to the person taking the test. These stimuli evoke symbolism and meanings unique to the responding individuals and works as an diagnostic aid. The procedure is an adjunct to therapy because responses can be further explored to create a more effective psychotherapeutic treatment plan. Case Mr. X: Index patient, Mr. X, 30 years old, studied up to 9th class with no past history of physical or mental problem. All of his birth and developmental milestones were normal with no history of any behavioral problems. He was apparently maintaining well until 15 years, and liked his facial appearance. At age 16, he noticed slight defect with his nose while looking at the mirror, but did not pay much attention, though he started comparing his nose with others. Subsequently he appeared in Class X examination and failed. He tried again next year and failed, after which he discontinued studies. He expressed his interest to join the family business. Whenever he looked at the mirror he was upset and started avoiding looking at the mirror after the age of 25. He started applying different types of facial cream without any relief. After a few months, he started working for minimal hours and often stayed at home and avoided meeting others on pretext of not feeling well. He did not enjoy any activities which he enjoyed earlier with his

friends. Often he felt as if he was of no use. Meanwhile he got married and for a brief period of 2 months he worked pretty well, and later started worrying that his wife looks beautiful and someday would even leave him. He used to often seek assurance from his wife that she will not leave him alone and go for another marriage. One day, out of frustration, he tried to end up his life by consuming mosquito repellent liquid and was saved. He still keeps talking having the desire to die. He is on antidepressant drugs. Sleep and appetite pattern have been erratic. Personal hygiene has deteriorated and activities of daily living have been hampered. His present symptoms are excessive concerns about facial features for the last 15 years along with low mood, loss of interest and decreased social interaction for the last 2 and half year. As part of the psychological assessment, he was administered the Rorschach test (Exner, 1995) and Somatic Inkblot (SIS) Series-II (Booklet Version) (Cassell and Dubey, 2003) to understand his personality profile such that unprocessed unconscious material would be brought forth that need to be addressed during psychotherapy. The findings are discussed ahead. Findings on Rorschach test: He took average time to respond the inkblot images. Less number of human responses indicates poor interpersonal relationship. EB ratio indicates extroversive trend of personality. On Afr ratio, his low score indicates his marked tendency to avoid emotional stimuli. He might be quite uncomfortable when dealing with emotions. More anatomical responses might indicate somatic preoccupation. His score on ADj, D and CDI indicate his “Low control capacity” and “Ability to deal with stressful situation”, and “difficulty in adapting to new situation”. Findings on SIS Test: The three most liked images in order: A3: The image is generally perceived as flower which he has viewed as “sign of cross”. The “Cross” is a spiritual symbol of high power and is an ultimate to many individuals in Indian culture, which indicates his attitude towards spirituality as a means to resolve his problems. A7: “Structure of a lady in dancing position” is normal response suggesting her ego strength and positive attitude towards life. The dancing lady may also indicate his wishful thinking to see his wife happy and dancing with happy interpersonal relationship. This is also a positive sign of good prognosis. A25: “A flowers is blooming” has Freudian connotation of happy erotic imagery. This may also indicate his happy relationship with his wife. The three least liked images in order: B31: Instead of seeing a happy family he perceived it “Four persons are standing, in which one person’s arm is not in proper position”. Avoiding seeing a Happy Family, which is the most common response on this image, may indicate his disturbed family relationship including relationship with his parents which should be explored and addressed during therapy session. The arms in improper position may indicate his bodily anxiety. A13: “A hand in flames, helpless” indicates his agony and sufferings and desire to get help from others. A26: “A child’s broken body” indicates his own disliked body part (nose), bodily anxiety and low self. Analysis of other significant responses: A1: “Diseased X-ray” indicates his preoccupation with body imagery and somatic anxiety. A9: “A person is standing alone” may indicate poor interpersonal relationship with his wife and feeling of being alone with depressive content. Generally people perceive two persons male and female on this image which he has avoided due to his poor social interaction and conflict with wife. A10: “Two children’s defected head” again brings the theme of A26 and an indication of preoccupied thought of being ugly. A11: “Wings’ bone, which has been broken” may 60 Sachacher and Jahan

further indicate his anxiety with body imagery. Several imageries of broken body parts may be an indication of severe anxiety and hypochondriacal ideas which may even lead to suicidal ideation. A14: “Kidneys” is a normal response on this image; however, the client appears to be bodily preoccupied due to preponderance of several body responses. A24: “A ghost is fighting with a man” may indicate his aggressive and hostile attitude and an unconscious fear of some miss happenings in future. A30: “A person’s ugly skull” may suggest his fear of poor body image and body anxiety. B4: “Two person’s face in which one person’s face is ugly,” may indicate his anxiety and inferiority complex, which should be addressed during therapy session. Such bodily preoccupation should be taken as an indication of suicidal ideation. B10: “An ugly ear” may bring the theme of Image A30 and B4. B26: “Stomach’s diseased bone” may indicate hypochondriacal ideation and anxiety about body imagery. B27: “A child’s body but his legs and arms are not in proper position” may again indicate his poor body imagery and anxiety. B28: “One person is thinking about his future”. The image indicates “mother - child relationship” which he has avoided due to disturbed interpersonal relationship with his wife. This brings back the uncertainty and fear of future relationship with his wife (also a mother role) and feeling of being left alone. On Rorschach the finding indicates poor interpersonal relationship with somatic preoccupation and having less ability to deal with stressful situations. The Somatic Inkblot Series (SIS) further helped to surface his anxiety and preoccupation with body imagery and poor social interaction. Conclusion: TheSIS-II and Rorschach tests were administered to a 30 years male, who was suffering from “Body Dysmorphic Disorder”. The Images were able to bring on surface his preoccupied thoughts of being ugly, disturbed interpersonal relationship with his wife, depressive mood with suicidal ideation. The SIS further helped in therapeutic intervention with positive outcome. References: Adair, H.E. and Wagner, E.E. (1992).Stability of unusual verbalizations on the Rorschach for outpatients with schizophrenia, Journal of Clinical Psychology, 48 (2), 250–256. American Psychiatric Association (1994). Diagnostic and statistical manual of mental disorders (4th ed.),Washington, DC: American Psychiatric Association. Bartell, S.S. and Solanto, M.V. (1995).Usefulness of the Rorschach inkblot test in assessment of a t t e n t i o n d e f i c i t hyperactivity disorder. Perceptual Motor Skills, 80 (2), 531–541. Cassell , W. A. and Dubey B. L. (2003). Interpreting inner world through Somatic Imagery: Manual of Somatic Inkblot Series, Anchorage (USA): SIS Center. Exner, J. (1974). The Rorschach: A Comprehensive System, Wiley, New York. Exner, J. (1995). A Rorschach Workbook for the Comprehensive System, 4th ed., Rorschach Workbooks, NC. Goldfinger, D., Amdur, R., and Liberzon, I. (1998).Rorschach pattern of response in Vietnam veterans with posttraumatic stress disorder versus combat and normal controls. Depression Anxiety, 8, 104–111. Oosthuizen, P. P. and Castle, D. (1998). Body dysmorphic disorder — a distinct entity? South African Medical Journal, 88, 766–769. Rorschach, H., (1921). Psychodiagnostik, Bircher, Berne. Rosen, J. C. and Reiter, J. (1996).Development of the body dysmorphic disorder examination, Behaviour Research and Therapy, 34, 755–766. Slade, P. D. (1994). What is body image? Behavior Research and Therapy, 5, 497– 502 Veale, D., Boocock, A., Gournay, K., et al, (1996). Body dysmorphic disorder -a survey of 50 cases, British Journal of Psychiatry, 169: 196– 201. Body Dysmorphic Disorder 61

Book Review The book entitled “Re-constructing the Bengal partition: The psyche under a different violence,” by Prof. JayantiBasu, is an exceptional study in the psychopathology of ethnic identities vis-à-vis communalism. Succinct, terse at times, and written in a most informative manner, it portrays the brutal realities of a troubled time from the perspective of a psycho-social ecology. In the portrayal, there is a clear portrayal of the short-term consequences, the sequence of events, various actors, responsibility, and the long-term psycho-political consequences. The reading of the book seems to be a pleasant journey in terms of its linguistic lucidity, pattern of presentation mode, the in-depth content of traumatized human psyche framing the saga of separation, loss, sadness, anger, desperation, and ultimate surrendrance to destiny in relocation after Bengal partition. The book seems to have two strong wings to fly in the freedom of individualistic as well as collectivistic psyche and also helps the reader to take a deep dive into the intricate emotions of partition victims in one hand and to get accustomed with qualitative research methodology on the other hand. The beauty of the book lies in its approach of fathoming the intra-psychic contents of partition victim in a blended methodology of cognitive-humanistic (framing the outer layer) and psychoanalytic (pacing the emotions in inner layer) orientation in a very logistic and balanced manner. The study was based on “narratives”. The descriptions of their life experiences contained their humanistic interpretation of their personal experiences – constituting the exterior of their narrations. Beyond the line meaning contents drawn by the psychoanalyst author from their narratives were totally psychoanalytic. In short, it can be said that the narratives were based on their personal interpretations of the experiential stories that brought out their inner “scripts” of psychoanalytical angle. The author viewed the produced narration as the net expression of the dynamic inter-play between the conscious and the unconscious. Since narratives can be understood as a means of organizing knowledge, both conscious and unconscious. In this book the psychoanalytical model probed the source of schema or scripts, while the cognitive psychological orientation explored how these templates functioned in individual and collective memory. Here the cognitive psychological approach was resorted to understand the nature and stylistic constructions of the narratives and psychoanalysis was undertaken to interpret the underlying motivation of their “declarative memory” process in specific narrative frames. It seemed that their autobiographical narrative had a temporal development. It shared with the cognitive approach the premise of selectivity and distortion of remembered material. Psychoanalysis related the process to defense adoption of displacement, condensation etc. The defenses revealed the coordination and confrontation, between impulses and super-ego. “Truths” were constructed at the moment of narration, the “truth” brought out the underneath “scripts” of the individual that operated without conscious control and thus were “personal facts” rather than being “historical”. Moreover, methodologically narrations had, on the other hand, “listening” as the ability point of the interviewer. In this book, the author, consciously monitoring her counter-transferences at several different junctures seemed well equipped in the process of “inner listening” and “outer listening”. The narrative contents and cues were picked up from expressions as well as from silences. Narrator’s predisposition and personal contingencies to his/ her perception and memory of Partition formed the ultimate mosaics of knowledge in this respect. The significance of “intonations” were accounted for in author’s final “reflecting listening”. The narratives thus became “subjective truth” rather than “objective facts”. In the psychoanalytic fold, another component seems mentionable. The adopted methodology took into account Eriksonian “triple book-keeping” that refers to the three levels of understanding; the level of the body, the level of the ego and the level of the family and society. The interpreter author seemed to be sensitive to all these aspects while listening to the woes of the persons and deciphering the meanings in their narrations. Additionally, the respondents were found to belong to the Eriksonian eighth stage of life that is, they were in the stage of integrating their lifeexperiences in a meaningful whole or struggling with despair. In the interview sessions, the narrations came as “freeassociation” of psychoanalysis having its spontaneous flow without any interruption. Consequently like “patients,” in narration also there was less guardedness in expressing pain and vulnerability. The ultimate attempt of the study was to gain insight into the complex psychosocial processes at individual and cultural levels, generated in relation to the event of Partition. The intention was not to bring out pathogenesis necessarily. The psychoanalytic lens in the book was focused on the emotional contents as effects of Partition. In author’s own language, “Like the ripples of a river, these emotions took different forms: with sunshine and cloud, breeze and storm. Desire, fear, frustration, anger and guilt mellowing into sadness and self-depreciation flowed through the narratives along with an assortment of other, more positive feelings.” Analysis revealed two recurrent themes commonly in their narratives – one was “water” signifying a generated sense of security, the other “the green expanse” – “a carpet of emerald” symbolizing a sense of freedom in the lap of the “mother earth”. Many felt a personal oneness with Nature – the all-encompassing mother’s love and care in life. Proximity with nature seemed to provide a child with a sense of mastery and control in the backdrop of maternal security. The general expression of natural beauty, food, love and family honor in neighborhood – all bore the thread of nourishing factor: the nourishment of soul, mind and body in the care of the mother. Consequently, a common theme was found to emerge, that is, freedom movement, psychoanalytically to save the “mother-land” from predators. The feelings of love and desire for the homeland mingled with more pregnant emotions of fear, anger and guilt over the fact of encountering Partition. Among the visual accompaniments of fear or terror, the sight of the fire was the most prominent. Their accounts related the fact that despite being the experiences of direct brutality, they had lived under the shadow of violence and were the victims of “soft violence.” Anger and guilt took a new platform in post-migration life depicting the struggle of re-adjustment and humiliations of various kinds. Most gave detailed accounts of their education and the nature of jobs they held in West Bengal signifying several defense-adoption in the process. A few reported their participation in rescuing Muslims from Hindu hooligans trying to establish inter-communal harmony. The defenses of “sublimation” and “altruism” were prominent in them. Present author’s surmise was that psychoanalytically, the migration from homeland to foreign country may be compared to the forced weaning of a child carrying two specific messages of growing up.It is only with the acceptance of weaning that the infant enters the fascinating and challenging complexity of the real social world - hence the automatic ambivalence of growing up process in life. With such weaning on the part of the respondents, a plethora of emotions were evidenced like apprehension, frustration, expectation, success, joy, anger and remorse. The associated negative ideations were of failure, loss of self-esteem, feeling lost in the outer world, attribution of blame on to the self and others. The saga of their pathos revealed a blend of positive and negative emotions, and in the process of experiencing this uprooting and persecution, the “other” (the Muslims) were “constructed”. This was the final “reconstruction” of West Bengal Partition. This reflected the love-hate relationship between the communities, as well as the self-contradictions in judging the Muslims in terms of their actions and intentions. The book accounted soft-violence trauma of specific kind. The attachment to their homeland and the pain of lost security were prominent in their descriptions of post-migration adjustment. The realization of loss came late and when it came it was agonizing. Listening to the narrative, the author opined that “the psychological atmosphere” of prepartition Bengal was one of free-floating anxiety in chaotic and confusing context. At a certain point the uncertainty crossed the border of anxiety and converted into panic and flight. For the respondents, there was silence, silence of locus-specific, pertaining only to the period of migration, but not before and after. Their idealized past was a myth they unconsciously chose to retain. A silence it was, a silence called eloquence. The book additionally accounted the ontogenic origins of specific reactions of specific respondents to the basic set of soft violence. The attempt was to show psychoanalytically the core contents in personality being responsible for outer Book Review 63

reactions. The author concluded that the reported emotions and the distortion of the entire memory of Partition, personal or collective, was a kind of attempt to deal with the chaotic feelings, particularly those of aggression and love, generated by the inherent contradiction of the situation. This laid the foundation of generalization from the individual, to the culture to complete the story of “reconstruction” of West Bengal Partition. Contextually, the author used “screen memories” as psychoanalytic tool to fathom the inbuilt trauma of Partition victims. The achievement of the study ultimately could construct two pillars: 1. An improvisation in the methodology for the study of traumatic memory as far as it connected the collective and the personal trajectories with regard to “soft-violence”. 2. The contours of the nature of “self” in Partition, the self in its individual existence as well as in its collective evidence. The reconstructed stories of Pakistan victims all had wrappings of sobs and incessant crying. We, the readers of this book stand as witness there to cry inside automatically. The collective mass psychosis of the oppressor and oppressed are juxtaposed in the narrative, with a clear portrayal of what happened, what may have happened had the psyche differed and the paradigms but shifted a minuscule unit. Yet the portrayals are viewed from an inductive viewpoint, validated by accurate data and supported by incisive arguments not just about the ethos but about the reality in that specific space-time continuum. The communal hysteria that shook the very fabric of human psyche in both communes-the oppressors and oppressed-and the credo of de-humanization which became the order of the day has been qualified and quantified exemplarily in this excellent piece of work, never once veering from the scientific angles. A study in human nature, as well as an excellent evaluation of the transmutation of a community into two, the book offers a par excellence exposition of the social history of an era which changed perspectives universally, and the transformation of the psyche of communities and people that suffered the barrage of brutality which left them homeless. A must read for all intelligent researchers in the fields of history, psychology, sociology as well as all serious readers per se. Nilanjana Sanyal, Ph.D. Prof. Dept. of Psy, University of Calcutta, 92 A. P. C Road, Kolkata-700009, Email: sanyal_nilanjana2004@rediffmai.com 64 Book Review

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Abstracted in “APA's Psyc INFO “ Regd. No. 71632/99, RNI Delhi SIS JOURNAL OF PROJECTIVE PSYCHOLOGY & MENTAL HEALTH Volume 21 Number 1 January, 2014 EDITORS EMERITUS Wilfred A. Cassell, MD, Director, SIS Center, 4501E,104th Avenue, Anchorage, AK.99516 (USA). E-Mail: siscassell2@yahoo.com Bankey L. Dubey, Ph.D., Director SIS Centre,4406 Forest Rd, Anchorage, AK 99517, Cell : 907-250-8834,E-mail: bldubey@gmail.com Amool R. Singh, Ph.D., Director, RINPAS and Prof. Clinical Psychology, RINPAS, Kanke, Ranchi-834006 (India). Cel.:91-9431592734, E-mail:sisamool@yahoo.com EDITOR-IN-CHIEF: Rakesh Pandey, Ph.D. Professor, Dept. of Psychology, Banaras Hindu University,Varanasi-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 E-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 EDITORS CONSULTANT Yogesh K. Arya, Ph.D., India JayantiBasu, Ph.D. India Antonio Cervigni, M.A.., Italy Suprakash Chaudhury, M.D., Ph.D. Carina Coulacoglou, Ph.D., Greece ManishaDasgupta, Ph.D. India Padma Dwivedi, M.A., USA R.P. Gupta, M.A., India Anatoly B. Khromov. Ph.D., Russia H. Kumar, Ph.D., USA Rakesh Kumar, Ph.D., India Ranjeet Kumar, Ph.D., India S.P. Mandal, M.Sc., India Lisa Milne, Ph.D., Australia Nalini Mishra, Ph.D., India TilottamaMukharjee, Ph.D., India ArvindK. Keshary, Ph.D. India Paola Nicolini, M.A., Italy Edward M. Petrosky, Ph.D., U.S.A. 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 Kranti Srivastava, Ph.D. India Ajay Tiwari, Ph.D., India AiloUhinki, Ps.D., Finland Yasho V. Verma, Ph.D., India Robert B. Williams, Ph.D., Canada