SIS Journal of Projective Psychology & Mental Health

Editorial : New Name, Old Game Wilfred A. Cassell and B. L. Dubey SIS Symbols of PTSD & the Need for Empathy in Therapy D. Brock, W. A. Cassell, C. Tyrone, C. Maureen, B. L. Dubey, J. Halia, R. Leigh and S. Laurel Adult Attachment, Personality and Patient-Analyst Communication: A Case Study Nadine J. Kaslow, Nicole L. Fischer, Sara E. Pollard, Abigail Powers and Susan L. Reviere Prasanta Kumar Roy Figure Drawing Techniques with Older Adults : A 30 Year Perspective Paul E. Panek, Bert Hayslip, Jr., Sharon Rae Jenkins and Amanda Kay Moske Cultural Basis of Psychopathology and Modified Therapeutic Stances: Case Illustrations Somdeb Mitra and Nilanjana Sanyal Sensitivity of Exner's Comprehensive Scoring System in Detecting Specific Delusions in Psychotic Patients : Preliminary Observations Satya Dhar Dwivedi Metacognition-Based Cognitive Therapy in Social Phobia- A Case Study Kasturi Thakur and Prasanta Kumar Roy A Study on Social Desirability Biasness in Rorschach Inkblot Test Roshan Lal Dewangan and Volume 22 Number 1 ISSN 0971-6610 Journal of Projective Psychology & Mental Health Jan. 2015 Official Publication of the Somatic Inkblot Society 1-2 3-8 9-23 24-29 30-47 48-57 58-61 62-71 SIS

Somatic Inkblot Society OFFICE BEARERS President :Bankey L. Dubey, Ph.D. Editor In Chief: Rakesh Pandey,Ph.D. Vice President : Brig. D.Saldanha Gen. Secretary :Nalini Mishra, Ph.D. Joint Secretary: Akansha Dubey, M.A. Treasurer :Padma Dwivedi, M.A. Executive Members : Mike Baker, MBA. Wilfred A Cassell, M.D. Mary Cassell, M.A. Anand Dubey, MBA. Satchit P. Mandal, M.A. Tilottama Mukherjee, Ph.D. Preety Pandey, M.A. Ajay Tiwari, Ph.D. Pragya Tiwari, MBA. SambhuUpadhyay, Ph.D. 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. & Head, 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. 1000, for Indian members. Institutional subscriptions are US $100 for Foreign institutions and Rs.1500 for Indian institutions. Life membership is US $300 for foreign members and Rs. 5000/- for Indian members. Indian institutional life membership is Rs. 10,000/-. Non-members may subscribe for $45 or Rs.600 per issue. Subscription can be made by electronic bank transfer to Punjab National Bank, in the SIS Journal's account given below: Name of Account: SIS Journal of Projective Psychology & Mental Health Bank Name: State Bank of India, Sector- 20, Dwarka, New Delhi-110075 Account No. 32297525238, IFS Code: SBIN0011361 Subscription can also be made thru cheque, payable in favor of “SIS Journal of Projective Psychology & Mental Health” and mail to Prof. Rakesh Pandey, Editor In Chief at Varanasi address. Change of address: Members should inform B.L. Dubey, Ph.D, Editor Emeritus,Email:bldubey@gmail.com OR Prof. Rakesh Pandey, E-Mail: rpan_in@yahoo.com. of any change of mailing address. Copyright @1994. SIS Center, India/Anchorage Website: http://www.somaticinkblots.com SIS

This year in the August issue of the American Journal of Psychiatry, Douglas C. Thomas Ph.D. et al 's most interesting paper entitled “Modifying Resilience Mechanisms in at Risk Individuals: A Controlled Study of Mindfulness Training in Marines Preparing for Deployment” is worthy of serious consideration by readers of our journal. The U S Government financial support enabled the authors to document not only the positive psychological effects of Mindfulness Fitness Training (MMFT), but as well the psychophysiological benefits. Their impressive data reflected this as summarized: “Marines who received MMFT showed greater reactivity (heart rate d=0.43 and enhanced recovery heart rate d=0.67, breathing rate, plasma neuropeptide Y concentration after stressful training d=0.38 and attenuate blood oxygenlevel-dependent signal in the right brain insula and anterior cingulated.” Historically, the technique was originally envisioned by one of the researchers Dr Elizabeth Stanley. MMFT involves training a subject to deliberately focus on and thereby modify one's body's interoceptive functions. The investigators defined it as “A mental mode characterized by full attention to present moment experience without elaboration, judgment, or emotional reactivity. It includes the ability to pay attention to, describe and act with full awareness of sensations, perceptions, thoughts and emotions (Kabat-Zinn J.1990). In recent years it has generated considerable amount of interesting research studies (Blankenship, 2013,Turner,2014, Tomfohr et al, 2014, Turner, 2014). Hopefully this scientific statistically documented study might challenge members of our SIS Society to further advance knowledge regarding the preparation of individuals Editorial New Name, Old Game anticipating future stressful events, by replicating such fundamental research employing the enrichment of SIS projective technology. We know that directing an individual's somatic awareness to focus on inner aspects of the body can be technically achieved by utilizing SIS “Inkblot” visual stimuli. Thesehave the power to drop the away from the external world and focuses on specific internal regions. After all, many of our members in India have long been familiar with Yoga methodology for altering consciousness. Recall that the state of Patanjali's Ashtanga (Eight steps)yoga has been documented by many psychophysiologic studies(Gruzelier, 2005,Kriyananda, 2014, Revonsuo, et al,2009) and Like MMFT, such yoga involves a subject focusing awareness on sensory feedback from internal sources. With training, the individual acquirespowers to alter the physiological process under consideration. It may be recalled that the expert yoga meditation such as “Pranayam, Dhyan and Samadhi” significantly altersill understood mind-body processes otherwise beyond conscious control. The significant state of Dhyana (meditation) is the most powerful stage before Samadhi. It helps in realization of actual situation under meditation/deep concentration. The mind helps in selecting best alternatives out of many workable solutions under this state. By yogic practices, we can increase the power of our mind and ultimately can reach to the blissful state which reduces tension, anxiety and many psychological problems. Moreover, there are considerable research studies suggesting that it also helps in promoting healthy body functions (Kriyananda, 2014, Manickam, 2010, Shamasunder, 2008). While Dr.Johnson's group has done excellent work, what is the advantage of coining a new

name like “Mindfulness” without mentioning the rich historical yoga meditation? We now ask some of the younger members of SIS to take up the psychophysiologic challenge and move ahead. It is an old game. We predict that your yoga background will enable you to play the game better! Reference: Blankenship, A. E. (2013) A prospective examination of Mindfulness training on the mitigation of post-traumatic stress symptoms, a dissertation submitted to the Graduate College, Dept of Psy, Western Michigan University, for Ph.D. Johnson, D.C., Thom, N.J., Stanley, E.A., Haase, L., Simmons,A.N. et al (2014) Modifying resilience mechanisms in at risk individuals: A controlled study of mindfulness training in marines preparing for deployment, American Journal of Psychiatry, 171:844- 853. Kabat-Zinn J.: Full catastrophic Living: The Program of the Stress Reduction Clinic at the University of Massachusetts Medical Center, New York, Delta, 1990 Kriyananda, S. (2014) Patanjali's Ashtanga Yoga: The Eightfold Path from Raja Yoga: The Science of Self- Realization, 2171 El Camino Real, Palo Alto, CA 94306, Revonsuo, A., Kallio, S. and Sikka, P. (2009) What is an altered state of consciousness? Philosophical Psychology, 22:187–204. Gruzelier, J. (2005) Altered states of consciousness and hypnosis in the twenty first century. Contemporary Hypnosis, 22:1–7. Shamasundar, C. (2008) Relevance of ancient Indian wisdom to modern mental health-A few examples. Indian J Psychiatry, 50:138–43. Manickam, L.S. (2010) Psychotherapy in India. Indian J Psychiatry, 52:366–70. Tomfohr, L. M., Pung, M.A., Mills, P.J. and Edwards, K.(2014) Trait mindfulness is associated with blood pressure and interleukin-6: exploring interactions among subscales of the Five Facet Mindfulness Questionnaire to better understand relationships between mindfulness and health, Journal of Behavioral Medicine, 10.1007/s10865-014-9575-4 Turner, K. (2014) Mindfulness skills training: a pilot study of changes in mindfulness, emotion regulation and selferceptionof aging in older participants, Activities, Adaptation and ing, 38; 156-167 Van Dam, N.T., Hobkirk, A.L., Sheppard, S.C., Andrews, R.A. and Earleywine, M. (2014) How does mindfulness reduce anxiety, depression and stress? An exploratory examination of change processes in wait list controlled mindfulness meditation training, Mindfulness, 5:574-588 Ph.D., D.M.&S.P siswilfredacassell@yahoo.com, 4406, Forrest Road, Anchorage, AK 99517 Wilfred A Cassell, M.D., FAPA, & Bankey L. Dubey, Editor Emeritus, SIS J. of Proj. Psy.& Mental Health, E-mail: E-mail: bldubey@gmail.com 2 Cassell & Dubey

SIS Symbols of PTSD & the Need for Empathy in Therapy D. B. L. Dubey, J. Halia, R. Leigh and S. Laurel Brock, W. A. Cassell, C. Tyrone, C. Maureen, This Somatic Inkblot Series (SIS) clinical case history utilized the SIS- II Booklet version. (In psychologically unstable victims of severe stress, it is prudent to begin assessment with the Booklet projective procedure before introducing the more powerful peering electronic versions.) It involves an intelligent African American middle aged woman who was employed as a medical technician. Her formal diagnostic conditions involved Bipolar Affective Disorder Type II and Posttraumatic Stress Disorder. Her personal problems as subjectively perceived, labeled in the “Brief Health History” form follow: “Weight”, “Depression”, “Hyperactivity”, “Paranoia” and Bulimia”. Her medical outpatient pharmacologic treatment plan involved initiating a therapeutic trial of Lithium to which she responded with mood stabilization. This was supplemented by SIS guided Cognitive -Spiritual Psychotherapy. The latter was empathetically provided by a mature married mature African male. He was selected because of being clinically familiar with “Pandemic” stressful socioeconomic conditions rampart in inner urban areas in too many American cities. He provided personal empathetic support when therapeutically processing emotionally painful PTSD memories. Moreover at critical times of such memory activated suffering he encouraged her to recall religious supportive spiritual images acquired early in life from an empathetic supportive maternal grandmother. Case History Summary: Because of her technical training the suffering woman was familiar with medical history formats. Regarding her genetic background, she indicated that her mother had been diagnosed with Bipolar Affective Disorder. Apparently during either manic periods, or when under the influence of street drugs (i.e. Cocaine, Crack etc.), this parent was both emotionally and physically abusive. According to her grandmother, her mother had repeatedly knocked her unconscious. Moreover she was sexually abused in childhood and adolescence by male cousins. When such traumatic sexual events were reported to her mother, she was ignored. She had no protection from her drug addict father. With this stressful psychologically impoverished developmental background, as a girl she A major underlying aspect of all medical therapies involves the degree of positive empathetic linkage extending from the clinician to the sufferer. This is especially applies for those tormented by recurrent intrusive childhood traumatic memories - the basis of (PTSD). In such situations, the clinician created supportive empathic bond provides an essential foundation of psychotherapy. Moreover when the treatment plan encompasses “Body-Mind-Spirit” theoretical principles, the resultant empathetic bridge optimizes the prognosis. Yet such occupational exposure over time, in vulnerable care providers may induce empathetic “Secondary Traumatization”. This article illustrates typical professional risk factors by presenting a case history study of a victim of PTSD who was traumatized by severe stress throughout childhood and adolescence. ……………………………………………………………………………………………………………… D. Brock, W.A. Cassell, C. Tyrone, C. Maureen, B.L. Dubey, J. Halia, R. Leigh and S. Laurel, (Corresponding Author e- mail : siswilfredacassell@yahoo.com) SIS Center, Anchorage, Alaska. Key words: SIS Symbols of PTSD

grew up tending to be moody and socially isolated. When stressed, she would shave her head to make herself emotionally “Feel Better”. Consistent with this as an adult, she habitually had trouble interacting with people in social situations and at work. During initial therapy, she was under scrutiny in her employment for conflict with other staff. Outside of work, the central positive focus of her personal life was her eighteen old daughter. A few months before evaluation this girl had departed Alaska to attend college. Her loss had provided a major stress for this socially isolated lonely woman. Stressful Dreams Reported Early in Treatment: The following are examples of her adult PTSD dreams. Such historical material shaped both the reality imagery content, as well the emotionally disturbing affect linkage of her later life SIS Responses. 1. “I was hiking with a couple from work and they became angry with me and pushed me down into a snow bank!” Here the dream captured her ongoing stressful situation at work. 2. “I was with my daughter who was drinking alcohol and became intoxicated”. This reflected her concerns about her daughter's drinking”. 3. “My mother called me mentally retarded and stabbed me!” This portrayed both psychological and childhood physical abuse perpetrated by her mother”. 4. “In the nightmare my mother put her hands down inside my pants and it was disgusting!” Here PTSD memories of childhood sexual abuse surfaced in a PTSD affect charged dream. 5. “I was terrified because rats kept nibbling at my toes!” The place that she lived in as a child was “rat infected”. At night she was terrified that she would be bitten in while sleeping. 6. “My mother kept telling me to kill myself!” Her mother's suicidal suggestions constantly plagued her “Nightmares”. Content Analysis of SIS Projective Assessment: In assessing the projective SIS data, initial attention will be given to the three responses labeled in the Answer sheet as “Liked Most”. (The affect linkage associated with what was seen follows in capital letters enclosed by brackets). B27:“Two embryos one is stronger and bound to survive…the other will die”. (“SAD”) Later after responding to the entire 62 “Inkblots”, she elaborated further on her selection by writing “I FEEL LIKE THAT A LOT” (especially after her daughter left for college). Here the symbolism gives projective awareness to her deep seated depressive feelings involving preoccupation with death and recurrent suicidal impulses. Here the projective data suggested that she was episodically attracted to death as a way of ending her recurrent suffering. This SIS symbolism served as a signal for her psychotherapist to closely monitor the possible need for psychiatric inpatient care. B15:Her preoccupation with death surfaced symbolically again with SIS structure as follows: “Knives with a herd mentality attacking the loner…I am the loner”. At the end of the viewing procedure, she rationalized her entering therapy as follows: “I want to work on this loner mentality”. Such projected imageryy is consistent with the time persistence of her “SIS Revealed Inner World” by contemplating suicide to escape psychic pain. B29:“A male shadow in the doorway seen through squinted eyes”. (“FEAR”) Subsequently she indicated both that both originally as child, and later in her long term 4 Brock et al

feelings”. This represented a very direct projection of her affect inhibition as a child for repressing distressing PTSD feelings. Later when elaborating on this response at the end of the viewing, she added the comment “I learned (i.e. as an adult) more facial expression”. A18:“Labia and vaginal opening”. She immediately wrote “No feelings” and then crossed this statement out. Then she substituted the negative emotional description linkage as “GROSS”. Subsequently at the end of the viewing procedure she wrote “I feel very unattractive down below…NERVOUS about what it says about me”. This negative view of her body's sexual structures was consistent with her past abusive history Next her clinically significant responses to the projective viewing procedure will be presented in order of their presentation as follows: A1: “An angry rabbit…it reminds me of a movie Danny Darko…no feeling at all”. This symbolized, in the angry animal image, her long standing repressed rage, which consciously she denied. As a child, as noted with A30, she wore a non-expressive facial “Mask” as her symbolic defense object. A2: “A dancing juggling hippo…amused”. Here a psychologically safer movement animal response was projected as a defensive strategy over the human figure structure inherent in the stimulus array. A3:“A person wearing a hat with a gun…menacing…reminds me of Oakland”. Here affect charged childhood stressful traumatic memories from California flooded projective awareness. Her psychotherapist had learned that initially prior to therapy, she had reported experiencing angry “Violent impulses”. Fortunately with therapy she learned some effective techniques for “Nightmares”, she would close her eyes tightly pretend to be sleeping”. Paradoxically, she rated this as “Liked” because it was “Visually accurate”. However, in reality it brought into mental focus “negative” charged affect emotionally painful PTSD memories activated in SIS projective consciousness reminiscent of childhood sexual abuse. Ironically enough, she rationalized these in a denial type mental defense mechanism as a “positive” emotional event! Next a review will be given of those three SIS scenes, which she considered to be “Least liked”. In rating order these were as follows: B28: “Child hugging mother…mother trying to be reciprocal”. She indicated that in spite of its favorite first rank position, looking at it made her feel “SAD”. She explained that she liked the scene liked because it reminded her of her love for her daughter who had just departed to attend university. Although they remained in telephonic and e-mail contact, to this lonely woman, this loss represented a severe stressor. This symbolism supported her psychotherapist's original impression regarding the role of her daughter's moving as a major determinant of her seeking treatment. The reader might note the direct emotional Content Validity of this projected symbolism response sequence and the reported clinical history. It is suggested that “The child hugging the mother” signifies her daughter sadly saying goodbye at the Anchorage airport. The “mother trying to be reciprocal” symbolizes herself as a lonely, emotionally distant mother struggling to express love back in return. Later she indicated further the following: “I wish that I had demonstrated my love daughter via hugs more often”. A30: “A child wearing a mask to appear void of SIS Symbols of PTSD & the Need for Empathy in Therapy 5

highly threatening. Such a response might forewarn her therapist to expect her be e s p e c i a l l y a f r a i d o f e m p a t h e t i c pychotherapeutic intimacy. A10:“An image of a partial face, nose and above mouth hidden behind paper so I cannot read the entire expression”. (“FEAR”)The fearful imagery brought to the surface of her conscious awareness was symbolized suspicious and paranoid like social fears. Now several responses will be given for the reader to interpret independently: A11: “Front of a car or a nose”. A12: “An ear or an embryo”. A13: “A hand coming out of fire…overheated (“I HATE”). A14: “An embryo holding a chess piece or a seal under a buoy”. (“AMUSED”) A17: “Someone's chest cavity partially skinned to reveal the heart under the ribs…other organs have been removed…interested”. A21:“An animal smashed by a car on the road…no feelings” or “Such is life or death”. A24: “Two men wrestling”. (“INTERESTED”) A25: “Another vagina”. (“NOT INTERESTED”) A26:“An embryo 8 months??? Malformed or hog tied…my interpretation BOTHERS me”. This once again brings to her conscious awareness the issue of “Deformed” noted earlier regarding her own Body Image. The fact that she became “Bothered” by her projection reflected appropriate awareness of its symbolic connotation. A27:“Female breast…jealousy because I am flat chested”. Here she revealed previously unexpressed concerns about her feminine Body Image. A28:“A muscular deformed left leg…or a parasite on someone's leg”. (“I AM UNSURE dealing with anger. A4: “A deformed butterfly” (“NO FEELINGS AT ALL”). The symbolic imagery here directly in a symbolic projects her own “Body Image”. Her Mental Defense Mechanism involved affect driven perceptual inhibition. Apart from sexual abuse, recall her history as a child, of having been repeatedly knocked unconscious by her mother. A5:“A child wanting a hug or an angry clown…UNCOMFORTABLE with both”. Here the stimulus array initially triggered childhood unmet needs for positive emotional support from her mother. As indicated, her frustration in not receiving this left her with memories of frustration and symbolically disguised ANGER. A6: “Someone kicking a Teddy bear”. (“NO FEELINGS”).This again reflected her life style defensive position of blocking affect. Here the symbolism disguised PTSD memories of her mother kicking her. A7:“A dancing lady wearing a mask under an apple…it is an illusion…she is a lot further back than she appears…my mother …Distance…but appears closer”. Here again the SIS structure triggered long standing memories of her mentally ill mother “Distant” lacking emotional nurturing. A8:“A happy person”. (“JEALOUSY”)This response reflected her nonpsychotic (and therefore accurate) reality testing perceptual ability. Here her feelings of “Jealousy” of “Happy” people in social situations spontaneously emerged. A9:“Love and communication between two adults”. (“FEAR”). Here she correctly recognized the loving positive potential in this SIS scene. Since she is a tragic victim of multiple early life human stressors, such close interpersonal activity was perceived as 6 Brock et al

OF FEELINGS”). Since she feels psychologically damaged from childhood abuse, she projected this onto her own Body Image. The symbol chosen reflects her past childhood horror. A29: “A crime in progress…stay inside to avoid crime”. Her stressful memories from her childhood living in a poor area of Oakland California shape and negatively distort her perception. A31:“One person comforting another or predator feeding on another…my preference over my reality”. This sequence reflects both her intelligence and insight into her PTSD projected responses. Words like “Predator” here and “Parasite” graphically symbolize her imagery. B2: “A frog ready for dissection…I wish that I were back in school with the knowledge I have today”. This is a positive wish. It opens opportunities for her psychotherapist to empathetically explore more hopeful future life pathways. B3: “A giant bird with an incredible wing span” (“AWESTRUCK”). Her interest in Nature and Animals represented a psychologically positive trait. B4: “Adult secrets to a child” (“inappropriate”. Once again her childhood traumatic memories shaped her resent day perception. B5: “Communication” (“ENVIOUS”). The issue of jealousy of those who are able to socially communicate emerges again like it previously did with A9. B6: “A crime where only the lower body is found” (“INTERESTED”). Once again her growing up in an inner city violent area shapes her present day perception. B10: “Mean angry Panda bear distorted”. Here she initially wrote “No feelings” then crossed this out and inserted the word “FEAR”. Not only did this response reflect her long standing rage, it touched upon her episodic anxiety episodes. B12: “A seahorse with wings (“INTERESTED. Here her mental defense mechanism of perceptual inhibition protected her from recognizing the SIS embedded figure more suggestive of a man's angry face. B13: “A house in the shadows…isolation”. This response symbolized her own sense of social isolation. B17: “I don't know”. She had previously demonstrated a perceptual diathesis to recognize embedded anatomical SIS content. However, here she avoided reference to the heart because of its close linkage to intimate emotions. B18: “A penis or a crab claw inside of something”. (“NO FEELINGS”). Here she consciously denied any emotional feelings viewing a penis. Yet in view of being the victim of past rapes, her psychological defense mechanisms created the penetrating symbolism projected onto thesis anatomical structure. B19: “Beginning of a Zygote I assume after love making but the ovum looks sick”. (“UNKNOWN FEELINGS”). Like her ability to recognize embedded SIS anatomical structure, she projected the response “Zygote”. However, the recurrent theme of “Sickness” or distortion of the Body Image surfaced once more in projective awareness. B22: “A dead person on an autopsy table”. This reflected her past medical training. B23: “A tic or a spider”. B24: “Immature lungs”. B25:“Womb that is glowing…the dark area is the beginning of life”. (“THIS IS SAD”). The symbolism superimposed on the SIS SIS Symbols of PTSD & the Need for Empathy in Therapy 7

anatomical structure is strongly colored by her “SAD” view of reproduction and ultimately human life. B26: Here she wrote labels on the SIS structure as follows: “ovaries, vagina, and uterus” and then in psychological denial wrote (“NO FEELINGS”) B31: Present Photograph Most individuals imagine seeing here a family of two adults and two children. Normally, many responders add the descriptive emotional content “HAPPY”. Reflecting her past history of severe abuse and long standing suffering, she wrote “A family of four…SUSPICIOUS…are they happy?” Discussion: While empathetic interaction with a suffering person may optimize SIS diagnostic/ therapeutic procedures, over time it may expose the clinician to “Secondary Traumatization”. This occupational stressor may be particularly experienced by those treating traumatized children or for adults previously abused in childhood suffering from PTSD. Such SIS psychotherapists are very vulnerable. Repetitive occupational exposure over time may eventually prove “Toxic”. This is due the immense penetrating power of SIS stimulated visual imagery to transmit emotionally charged traumatic memories. The accumulation involves both reality based stressful scenes and by affect reduced disguised defensive symbols. Over time, the accumulation in the SIS clinician's memory neurons of such empathetically transmitted suffering may negatively distort the care provider's selfperception of “Body-Mind-Spirit” phenomenon. There may be a tendency for the care provider, to partially react in an analogous fashion to the PTSD victim by Dissociation or “Defensively splitting off awareness from the mind to the body”. When severe, the resulting symptom syndrome may mimic many of the formal diagnostic classification criteria of PTSD. One example, involves cognitive changes related to trust, intimacy and emotional sensitivity. Such a chronically exposed clinician may during the day experience intrusive thoughts linked to the empathetically transmitted memories. These may then stimulate emotionally disturbing autonomic nervous system arousal. At night during sleep such intrusive material may be incorporated into disturbing dreams. This occupational hazard also applies for therapists lacking SIS projective technology but who do habitually work in psychotherapy by analyzing PTSD dreams. These professionals are also vulnerable to having their memory systems “infected” with a victim's daytime “Flashbacks” and sleep disturbing “Nightmares”. While the scientific literature is still lacking on this occupational hazard for mental health care providers, one older comprehensive article (Fothergill, A. & Burnard, P., 2004) reviewing the effects of “Compassion Fatigue” in psychiatrists will be briefly summarized. In the United Kingdom, of surveyed psychiatrists 25% reported significant psychological morbidity. Women, who traditionally tend to be more empathetic than men, were more likely to have suffering. The suicide rate was greatest for their medical specialty. Severe stressors involved attempting to care for violent individuals and those suicidal. The authors reported that on an “Impact of Life Scale” the suicidal death of a person under their care was “Equivalent to the death of a parent”. Finally, it might be noted that the authors in the above review article outlined effective techniques for coping with such stress. These may be professionally relevant for clinicians exposed to SIS magnified Empathic Trauma! References : Fothergill A. & Burnard P. (2004) Stress, burnout, coping and stress management in psychiatrists: findings from a systematic review. Int. J. Social Psychiatry 50: 54. Norfolk, T., Birdi, K., & Walsh, D. (2007). The role of empathy in establishing rapport in the consultation: A new model. Medical Education, 41(7), 690-697. doi:10.1111/j.1365-2923.2007.02789.x 8 Brock et al

patient-analyst communication over the course of psychoanalysis. The patient was a participant in a long-term research study investigating outcome and process issues associated with psychoanalyses provided to selected artists with a background in creative writing. Attachment: The attachment field has its origins in the work of Bowlby, who focused on mother-infant interactions and the emotional bonds between the two . There is an association between the quality of mothers' relationships with their children, children's attachment patterns, and mothers' own adult attachment patterns . These patterns theoretically influence children's patterns of attachment throughout their lifespan, including with partners, friends, their children, and their therapists . The mother-child attachment field was advanced by the work of Ainsworth, who examined infants' responses to maternal separation. Indeed, a major methodological breakthrough was the development of empirical means for determining working models of attachment in infants using the Strange Situation experiment by Ainsworth and colleagues. This experiment gave way to the designation of four attachment styles, according to children's responses to separation from and reunion with primary caregivers: secure, avoidant, resistantambivalent, and disorganized/disoriented . Two dominant lines of work have extended attachment research to adults. The personality line of attachment research focuses on the attachment relationship between romantic This longitudinal case study examines the association between a patient's attachment style and personality characteristics and communication between the patient and analyst. The measures used for this case analysis of a creative writer include the Adult Attachment Interview (AAI), the Minnesota Multiphasic Personality Inventory – version II (MMPI-II), and the Mergenthaler qualitative data scoring system for patient-therapist communication using the Therapeutic Cycles Model (TCM). Results revealed that level of the patient's security of attachment improved over the course of the psychoanalysis, although not to the extent that would be optimal. Moreover, he became significantly more coherent in his attachment narratives. His personality profile suggested that he is often socially isolated, and that his creative tendencies may make him feel like an outcast. MMPI results also suggested a mild-to-moderate level of psychological distress and that he may have difficulty engaging in treatment. However, the patient showed marked communication improvements with the analyst over the course of 18 months with regard to reflecting behavior, perceptions of depth of the treatment, feelings of connection with the analyst and a greater sense of security in the relationship, and writing experience. However, there was decline in some of these reports near the end of treatment, which might have been reflective of negative feelings toward termination. Overall, the patient showed significant benefit from the psychoanalysis as evidenced by increased attachment security, more coherent narrative descriptions, and more positive writing behavior.

vis-à-vis attachment. It includes four principle adult attachment classifications (i.e., states of mind): secure-autonomous, insecure-dismissing, and insecure-preoccupied, as well as an unresolved category to capture unresolved loss and healing from a traumatic event. These classifications parallel the child classifications in the following ways: secure-autonomous (adult) and secure (child); insecure-dismissing (adult) and avoidant (child); insecurepreoccupied (adult) and resistant-ambivalent (child); and unresolved /disorganized (adult) and diso-rganized/ disoriented (child) . Personality Functioning: There is a literature examining the link between adult attachment variables, based upon findings from different measures of this construct, and personality functioning. In general, the secure-autonomous classification is linked to extraversion, agreeableness, selfconfidence, and effective interpersonal functioning. The insecure classifications (i.e., dismissing and preoccupied) are associated with lower levels of extraversion and agreeableness and higher levels of anxiety and neuroticism. Moreover, the unresolved/ disorganized classification has a strong connection with multiple forms of personality pathology among adolescents and to schizotypal and borderline personality disorder in adults. Further, the unresolved/disorganized classification has a strong link with borderline personality disorder among adult and adolescent clinical samples. One measure of personality traits used in connection with attachment styles is the highly regarded Minnesota Multiphasic Personality Inventory – 2 (MMPI-2) . An investigation of selfreported psychiatric symptoms on the MMPI-2 found that adult women with insecuredismissing attachments reported less partners. According to this perspective, the same biological system influences the emotional and behavioral characteristics of the relationships between both children and caregivers and between adult romantic partners. In keeping with this tradition, Bartholomew and colleagues described four prototypic attachment patterns based upon the individual's internal working model of self and of others as either positive or negative. These patterns tend to be relatively stable over time and correlate with interpersonal problems . The second line of work is consistent with the developmental tradition, which focuses on the links between adult mental representations of childhood attachment relationships and parentinfant attachments. This emerged through the recognition that adults' experiences of their significant relationships during childhood influence their adult relationships and become organized into a “state of mind” with regard to attachments that is relatively stable. There are parallels between the individual differences observed in child-caregiver and adult attachment relationships. Differences evident in adult attachment behaviors result from the expectations and beliefs (i.e., working models) that individuals have developed about themselves and their intimate relationships based on their attachment histories dating back to their relationships with their primary caregivers. Adult attachment classifications, which are associated with their internal working models of relationships, influence individuals' histories of engagement in psychotherapy. The focus on adult attachment was enhanced by the development of the Adult Attachment Interview (AAI). The AAI is a qualitative measure used to gather retrospective reports about childhood relationships with primary caregivers to determine adults' state of mind 10 Kaslow, et al

psychiatric stress and anxiety and higher levels of independence compared to those with insecure-preoccupied or secure-autonomous attachments. The insecure-preoccupied attachment group reported the greatest number of psychiatric symptoms related to distress and relationship problems and the secureautonomous attachment group reported a moderate frequency of symptoms among all categories. Initially it appears counterintuitive that those with secure attachments reported more symptoms than those with insecuredismissing attachment. However, this finding is in keeping with other studies, and reflects the fact that adults with secure attachments are more comfortable acknowledging their difficulties whereas those with insecuredismissing attachments tend to minimize their emotional distress and paint an inaccurate picture of their mental health . Patient-Therapist Communication: Another projective-based strategy for understanding the link between attachment classifications and behavioral manifestations of personality styles pertains to the relational behaviors that take place in the therapistpatient relationship. The Therapeutic Cycles Model (TCM) is a computer-assisted coding system and language measure that captures patient-therapist interactions, therapist interventions, and changes in emotionabstraction patterns. It is a useful approach for understanding process and outcome in single cases. Content analysis factors, known as “emotional tone” and “abstraction,” describe therapeutic cycles including key moments during psychotherapy sessions. Emotional tone refers to verbalization of emotion, particularly negative emotion, whereas abstraction is the term used to reflect cognitive mastery. The TCM recognizes relevant themes in the discourse between patient and therapist. It identifies clinically important moments during psychoanalytic sessions based upon significant turning points, breakthroughs, or acquired levels of insight. In addition, it offers valuable information with regard to the way in which therapist-patient interactions facilitate therapeutic change. Several studies have shown how the TCM and emotional abstraction patterns accurately describe emotional-cognitive regulation in therapy sessions and other forms of dialogue and processes of insight. Throughout the course of psychoanalytically-informed treatments there is a shift from low-emotion and low-abstraction to high emotion and abstraction. This occurs in part through the process of referential activity, which is defined as the capacity to connect non-verbal experience with language. High referential activity is associated with expression of transference themes in psychotherapy sessions, resolution of problematic situations in therapy, and better therapeutic outcomes. Although no studies have linked personality traits and the TCM, the TCM objective text analytic approach is useful in differentiating between attachment categories based on both the two dimensions (emotional tone, abstraction) and the four emotion-abstraction patterns (Pattern A- Relaxing, Pattern B- Reflecting, Pattern C- Experiencing, Pattern D – Connecting). In these studies, the insecurepreoccupied individuals showed significantly more emotional tone and abstraction than did insecure-dismissing individuals, with the secure-autonomous group falling in the middle reflecting their more flexible approach. The insecure-dismissing group had the lowest text scores consistent with their tendency to depersonality measures and then postulate how responses on these measures interrelate. Methods: Patient and Examined Psychoanalysis: This case report is drawn from one of the eight analysands who were provided free psychoanalysis in return for participating in a comprehensive, longitudinal research project. All eight patients in the research project were selected for being creative writers experiencing psychological difficulties (broadly defined) who expressed interest in engaging in psychoanalysis. Daily psychoanalytic sessions and administration of assessments were paid for by the funding agency. The patient that is the focus of this report is an adult male who was selected because he had successfully completed all of the designated measures associated with the pertinent constructs in this case report. Due to the confidentiality of the study, no additional identifying information, besides gender, is known about the participant. This individual's psychoanalysis was comprised of four to five analytic sessions per week for a period of approximately 3½ years. The participant discussed in this manuscript underwent 708 sessions of psychoanalysis. Procedure: As described previously , to be included in the research study and have one's psychoanalysis paid for by the Lucy Daniels Foundation, the following factors were considered in screening potential participants for inclusion in the study: need and suitability for psychoanalytic treatment, creative accomplishments and potential, and openness to engaging in a longitudinal empirical investigation. After completing a detailed application form and sharing personal historical information inactivate attachment-relevant information, whereas the insecure-preoccupied group had the highest scores in keeping with their propensity to hyperactivate attachmentrelevant information. In terms of the emotionabstraction patterns, insecure-dismissing individuals more often were classified in Pattern A on the TCM, which underscores the fact that they are low on both emotional tone and abstraction and less likely to be engaged in therapy, whereas the insecure-preoccupied group were highest for Pattern D, which highlights their having high levels of negative emotional tone and abstraction. This latter finding is likely attributable to their pseudoanalytical style. AAI and TCM data both involve close analysis and focus on metacognitive monitoring and an individual's ability to spontaneously account for childhood history in a coherent manner, based upon retrospective thoughts and feelings. Level of attachment security is influenced by cognitive processes, representation of childhood experiences, and the degree to which thoughts related to childhood experiences are coherently organized. In addition, any display of defenses or incongruence between affect and behavior are noted on both the measures. Purpose: The purpose of this case study is to understand the ways in which a patient's state of mind with regard to attachment (AAI) and personality characteristics (MMPI-2) influence the patientanalyst relationship (TCM). Thorough assessment of these aspects of the patient and his interactions with the analyst can shed light on the ways attachment classification and personality characteristics influence the analytic relationship. More specifically, in the current case study, we examine the patient's scores on these three projective and 12 Kaslow, et al

parental figures. Information is gathered according to a structured interview that includes eighteen questions related to childhood and child-rearing experiences and that lasts approximately 60-90 minutes. During the interview, participants are asked about current and past relationships with salient attachment figures, memories of separation and loss, past trauma, the impact of these experiences on their current lives, and experiences with own children (if applicable). Interviews are transcribed, retaining all dysfluencies, grammar and pronunciation errors, and pauses. The scoring system includes rating scales to code three types of variables that combine to create a classification: (1) childhood attachment experiences with each parent (i.e., loving, rejecting, role reversing, involving, pressuring, and neglecting), (2) states of mind with respect to the attachment to each parent in terms of how they are represented in the present discourse (idealization, involved/ involving anger, lack of memory, metacognitive monitoring, derogation, fear of loss, passivity of thought); and (3) overall coherence of the narrative (coherence of transcript, coherence of mind). Scales range from 1-9, with 9 representing high levels of the variable. Scale scores are used to derive three main attachment classifications:secure-auton omous, insecure-dismissing, and inse curepreoccupied. Unresolved/ disorga-nized may be assigned in conjunction with one of the three primary classifications to further classify people who have failed to resolve losses of an attachment figure or traumatic events, evidenced by disorganization or disorientation when discussing these events. Secureautonomous participants talk freely and provide a narrative that is coherent and relevant. Insecure-dismissing participants avoid talking depth, potential participants were invited to submit both their published and unpublished writings. Subsequently, the Clinical Coordinator met with them for an interview, during which time they gathered more information about the individual and responded to their inquiries about the project. Then, potential participants had one to two interviews of approximately one hour in duration with a psychoanalyst at the Foundation's expense. This was followed by participation in a comprehensive psychodiagnostic assessment protocol. To determine appropriateness for inclusion in the project, the clinical review team examined all of the abovenoted data in order to ascertain suitability. Creative writers accepted into this clinicalresearch project understood the general exploratory purpose of the research. The following is the procedure for the measures used in this study. Measures, such as the MMPI-2, were collected at the outset of the psychoanalysis. In the current study, once participants were accepted into the study but prior to initiating treatment, AAI interviews were recorded, transcribed, and coded for attachment classification. Coding of the AAIs was conducted by two individuals trained for reliability with the scoring and classification schema. Disagreements between coders were resolved by conferencing. All sessions were recorded on audio cassette tapes and later transcribed. The sessions were analyzed with Mergenthaler's cauterized text analysis program for psychotherapy sessions, yielding scores of the affective and cognitive processing evident in the sessions. Instruments: Adult Attachment Interview(AAI) . The AAI, a semi-structured interview, allows for classifying an adult's state of mind with regard to significant attachment relationships with parents or

Minnesota Multiphasic Personality Inventory-2 (MMPI-2) : The MMPI-2 is a 567-item, true/false, selfreport inventory assessing social, behavioral, and emotional functioning. The assessment is a well-validated personality test for individuals aged eighteen and older with a sixth-grade reading level. The assessment includes three validity scales and ten clinical scales; as well as restructured clinical, supplementary, content, psy-5, Harris-Lingoes, and Content Component scales . Although the MMPI-2 includes validity scales, the inherent nature of self-report scales compromises the accuracy of reported symptoms. The mean T score is 50, with a standard deviation of 10. T scores above 65 most likely suggest clinically significant problem areas or dysfunctions. Therapeutic Cycles Model(TCM) : The TCM is a computer-assisted program that analyzes transcripts of psychotherapy process at the level of the patient and therapist emotional and cognitive dialogue. For example, insight appears to occur during the sessions in which the patient combines a high level of emotional and abstract processing when addressing important personal issues. This model is applicable to all types of psychotherapy, and is not based on any particular theory or therapeutic orientation. Instead, this model is based on a theory of how improvement occurs throughout therapy sessions via interaction between the therapist and patient measured in their verbalizations. The TCM has demonstrated sensitivity to outcome and reliability in the identification of key moments during psychotherapy sessions. In addition, the TCM has shown to be able to identify emotion-abstraction patterns (i.e. about emotional experiences and exhibit incoherent and contradictory accounts, lack of recall, and either idealization or devaluation of attachment figures. Insecure-preoccupied participants provide incoherent, inconsistent, and endless accounts of childhood memories, with emotional over-involvement in past conflicts and pseudo-analytic jargon. The Cannot Classify (CC) category is used when the pattern of responses do not fit into one of the three main categories. The psychometric properties of the AAI have been well-established. Scores on the AAI have been found to be stable over time. Classifications have been found to be unaffected by verbal and performance intelligence, social desirability, and nonattachment related memory. In addition, classifications on the AAI are predictive of a mother's responsiveness to her child . The distribution of AAI classifications in nonclinical samples is approximately 55% secureautonomous, 16% insecure-dismissing, 9% insecure- preoccupied, and 19% unresolved/ disorganized. When collateral information is collected from peers and family members, a more accurate description of symptoms is likely to be represented. An analysis of the first 10,000 AAIs revealed that AAI distributions were relatively comparable across gender, language and country of origin. As expected, individuals in clinical samples exhibited more insecure and unresolved classifications than those in nonclinical groups. Moreover, the nature of personality pathology was linked to the type of attachment difficulty manifested. In the current sample, inter-rater agreement on overall fourway attachment classification was 91% (ê = .71). 14 Kaslow, et al

relaxing, reflecting experiences, and connecting) that correspond to different therapeutic phases based on the predominant language used within the session. Several studies have shown the TCM and emotionabstraction patterns are suitable for describing emotional-cognitive regulation in therapy sessions as well as in other examples of dialogues and monologues, or identifying key moments of emotional insight in the form of connecting with others among individual or group therapy settings. Results: AAI: Over the course of the psychoanalysis, the patient's AAI scores revealed that he had greater coherence of his narrative was evidenced in terms of more coherence within transcript and in state of mind. The change in coherence suggests that the patient's ability to provide a coherent story during the interview and present and assess past experiences and beliefs in a consistent and clear manner increased over time. In terms of his relationship with his father, the patient generally demonstrated an insecurepreoccupied attachment at the outset of treatment and a secure-autonomous attachment when the psychoanalysis terminated. Consistent with this, he showed movement in the positive direction on one aspect of his perception of his childhood experiences with his father. Namely, his level of role reversing decreased, suggesting that his pre-psychoanalysis AAI transcript reflected problematic childhood experiences of being made to meet his father's needs for caregiving whereas his post-psychoanalysis AAI did not. He evidenced, however, two shifts in his state of mind vis-à-vis his relationship with his father. More specifically, over the course of the psychoanalysis, he became less angry and less derogatory of the relationship. Furthermore, this patient evidenced low idealization scores both pre- and post-psychoanalysis that did not change significantly as a result of the psychoanalysis. Unfortunately, the remainder of his scores remained consistent with an insecure-preoccupied attachment throughout the treatment. For example, he showed very low loving scores and very high rejecting and neglecting scores for the duration. Of note, he had a secure-autonomous attachment to his mother at both time points. There were changes in the positive direction with regard to his attachment to his mother in terms of his perception of his childhood experiences, as observed in the reduction of his description of problematic parent-child role reversal over time. In addition, there were improvements in his state of mind in terms of his mother as reflected in lower levels of anger and derogation over the 3½ year psychoanalysis. No other improvements were evident in his AAI scores. MMPI -2: The full 567-item MMPI-2 was completed by the patient. Regarding the validity scales, he scored low on the L scale (T = 43) and K scale (T = 39) and high on the F scale (T = 85), which may be indicative of an exaggeration of symptoms and a plea for help. Individuals who score low on the K scale also are often self-dissatisfied, have limited insight into behavior and motives, are socially conforming and awkward, and may be skeptical or suspicious regarding the motivations of others. Despite this pattern on the validity scales, the profile appears valid. Clinical Scale Scores were as follows: Scale 1 (Hypochondriasis), T = 45, Scale 2 (Depression), T = 61, Scale 3 (Hysteria), T = 47,

Scale 4 (Psychopathic Deviate), T = 69, Scale 5 (Masculinity-Femininity), T = 70, Scale 6 (Paranoia), T = 35, Scale 7 (Psychasthenia), T = 64, Scale 8 (Schizophrenia), T = 67, Scale 9 (Hypomania), T = 53, Scale 0 (Social Introversion), T = 55. Elevations appeared on scales 4, 5, and 8. Overall, this MMPI profile suggests an individual that is experiencing a mild-moderate level of psychological distress, but may have difficulty expressing that distress adaptively. TCM: Analysis of TCM data revealed that the patient's reflecting behavior increased over time, with data recorded every six months for the duration of treatment. The patient's self-reports of overall quality of treatment slowly increased over time, peaking at 36 months, and then declining slightly in the last six months of psychoanalysis. His experience of connecting with the analyst in therapy increased sharply in the first six months of treatment, then remained stable and positive over the next 12 months, and peaked at 18 months of treatment. The experience of feeling connected with the analyst declined during the 18-30 month period, sharply increased from the 30 to 36 month period, and then decreased slightly in the final six months of psychoanalysis. By termination, the patient's report of feeling connected to the analyst was at a positive, high level. Experience feeling secure in the relationship with the analyst followed a very similar pattern as the experience of feeling connected with analyst. Behavior patterns for overall motivation to write, as well as writing for self were very similar to one another. There was an increase from the outset of treatment to 6 months and another increase from 6-12 months, finally peaking at 12-18 months for both variables. A significant decline occurred for both assessments during the 18-24 month period. However, between months 24 and 30, he showed another significant increase in both. The 30 month time period was his highest peak in motivation, at which time he returned to the same level as was noted at month 18 for his writing for self. Behavior patterns for working through problems while writing and positive feelings experienced while writing had a similar pattern as well. For working through problems while writing, the self-reports remained the same for 1-6 months and 6-12 months. Afterward, reports peaked at 12-18 months. Afterward, reports declined after 18-24 months. For positive feelings experienced while writing, self-reports gradually increased between 1-6 months and 6- 12 months. Afterward, self-reports peaked at 12-18 months. Finally, reports significantly declined after 18-24 months. However, again between 24 and 30 months, he showed a sharp increase in his behavioral pattern of working through problems while writing and positive feelings experienced while writing. These levels again decreased between 30 and 36 months, and remained low until termination. Discussion: In reviewing the patient's scores on projective and personality measures, it appears that he found significant benefit from the psycho - analysis. This is reflected in improved attachment style, a greater ability to connect with his analyst and more perceived improvement from sessions, as well as shown gains in his writing behaviors. The results of the AAI scores showed that the patient had greater coherence of narrative by the end of treatment, which suggests that he was better able to present and assess past experiences and beliefs clearly and consistently. He also demonstrated a significant change in his attachment relationship toward 16 Kaslow, et al

his father from the outset of treatment to termination, moving from insecure-preoccupied to secure-autonomous attachment. Individuals who are preoccupied in their attachment experience often exhibit anger or passivity toward the attachment figure or when discussing childhood experiences, whereas a secure-autonomous attachment reflects an individual who can openly explore past experiences whether positive or negative . The finding of improved father attachment suggest that this change may have, in part, resulted from a shift in his state of mind regarding his relationship with his father through reduced anger and derogation, as well as reduced levels of reported role reversing in childhood (i.e., being made to meet father's needs for caregiving as a child). Despite this positive attachment style shift, a number of his scores on the AAI reflecting his relationship with his father were not ideal and reflected very low loving and very high rejecting and neglecting feelings toward his father even at termination. His attachment toward his mother remained secure-autonomous throughout the psychoanalysis, with some positive shifts in his state of mind toward his mother, including reported lower levels of anger and derogation by termination. Of note, it is not surprising that the patient's low idealization scores both pre- and post-psychoanalysis did not change significantly as a result of psychoanalysis since they were at an adaptive level to begin with. The patient showed elevations on Scales 4 (Psychopathic Deviate), 5 (Masculinity- Femininity), and 8 (Schizophrenia) on the MMPI-2. Individuals who score highly on Scale 4 tend to have difficulty with authority figures, stormy and superficial relationships with loved ones, and trouble maintaining a job. High scorers on this scale tend to be outgoing and extroverted, but also often demonstrate impulsivity, hostility, and narcissism. These individuals may report feeling sad at times, but do not usually experience deep emotional responses or strong emotional turmoil. They tend to blame others for their difficulties and intellectualize problems in treatment, making it difficult to see change or successful treatment. In addition, high scores on Scale 5 are often indicative of an absence of stereotypic masculine interests and these individuals tend to have artistic interests. Individuals who score high on Scale 8 often demonstrate an isolated lifestyle, feeling unaccepted and misunderstood by peers. High scorers may experience generalized anxiety, feel hostile or aggressive, and feel insecure. Sexual role confusion is common in those that score high on Scale 8 and their behavior is often seen as nonconforming or eccentric. This might include highly creative or artistic behavior or skills. Again, individuals with high scores on Scale 8 often have a poor prognosis due to an inability to relate meaningfully to a therapist. Overall, this individual is likely creative and may be nonconforming to societal norms, while also remaining isolated and feeling unaccepted socially. Aggression or hostility may be a common way this individual expresses himself and may be one reason that relationship difficulties occur for the individual. His self-report of overall quality of treatment and feeling of connectedness and security to the analyst increased over the course of psychoanalysis, peaking at 36 months. It is unclear exactly why there was a decrease in perceived treatment quality and relationship with the analyst in the last six months of treatment, but it is likely that the patient was aware of the approaching termination which may have affected his ability to engage in treatment as he had previously. Regarding his behavioral patterns related to writing, he

showed greater variability. In looking from the outset of treatment to month 30, there were significant gains in overall motivation to write, writing for self, positive feelings experienced, and using writing to help work through problems. Based on the results of the TCM, it appears that the patient did achieve a number of gains in his writing motivation and positive use of writing for his psychological benefit; however, those gains fluctuated greatly during treatment and did not appear to hold peak levels by the end of treatment. Anger, derogation, and hostility appeared very high across both his personality profile and attachment style at the outset of treatment. It appears that this approach to expressing himself spanned not only the way that he described his relationships with his parents growing up, but also carries over into other aspects of his life and may be contributing to a more socially-isolated lifestyle. Although we did not obtain a personality profile via the MMPI at termination, is it possible that his use of anger or aggression as a reflexive strategy may have been reduced, since he did express less anger and derogation in his attachment narratives by the end of psychoanalysis. It is also important to keep in mind that his creative tendency and writing behaviors might have come across as non-conforming to societal norms and may have affected his attachment relationships, particularly with his father, although it is impossible to know based on the data gathered for the present case study. The patient's improvements in attachment security and narrative may have been related to his ongoing benefit from psychoanalysis and feelings of security and connectedness to the analyst. These gains both in his attachment narratives as well as perceived benefits of treatment appear to also have been evident from his improvements in writing behavior. These findings may be interpreted in light of prior work exploring the influence of attachment on psychotherapy process and on psychoanalytically-informed treatment on attachment security. These studies tend to find that attachment security is associated with more commitment to psychotherapy, more helpseeking behavior, more self-disclosure, and more compliance with therapy—in other words, behaviors that would make them more likely to obtain the full benefits of therapy--compared to those with insecure attachments. In terms of therapeutic alliance, secure-autonomous and insecure-preoccupied each show a U-shaped distribution in the therapeutic alliance over time, with the slope of the decline steeper for the insecure-preoccupied. The pattern for preoccupied patients may be understood in light of their tendency toward more emotional extremes, both positive and negative, and it has been thought that work with preoccupied patients may involve more fluctuations in the alliance and more rupture and repair work. In another study of in-session discourse as a function of AAI state of mind, preoccupied patients were found to show more narrative initiative and talk more often and in longer spurts than dismissing patients, who themselves paused more often . Differences in verbal productivity may be more or less adaptive, with sufficient speech being necessary for the therapist to understand the patient's experience but excessive verbosity risking overwhelming the therapist. Of note, findings linking attachment to psychotherapy outcome have been mixed, likely due to methodological differences. One study found a link between AAI status and treatment effects; almost 93% of dismissive patients improved their Global Assessment of Functioning (GAF) scores over the course of treatment, compared to 41% of the preoccupied group and 33% of the secure-autonomou-sgroup, and attachment 18 Kaslow, et al

status was a significant predictor of final GAF score. Another investigation found that preoccupied AAI status predicted relatively poorer treatment outcomes and that the later stage of treatment may prove more difficult for preoccupied individuals, as it may activate fears of separation from and abandonment by the clinician. Keeping these studies in mind, although the patient showed movement from a preoccupied attachment style to secure-autonomous, it is possible that the decrease in perceived benefit of psychoanalysis and his relationship with the analyst near the end of treatment was a result of difficulty with separation from the analyst. The move from a more insecure to a more secure attachment status exhibited by the patient in this study is consistent with attachment theory and some prior research findings using selfreported attachment style and the AAI. In terms of change in attachment over the course of therapy, early results of one on-going study have shown complex findings on the AAI, with three of ten patients changing from an insecure to a secure classification, four exhibiting no change, and three changing from insecure classifications to cannot classify (perhaps indicating re-organization in progress) over one year of psychotherapy. Measures of reflective functioning more consistently improved over the course of treatment. Levy and colleagues have produced findings of significant improvements in AAI attachment security in psychodynamic but not DBT or supportive therapy. These findings are consistent with data from a randomized controlled trial (RCT) with adults with borderline personality disorder that found greater movement toward secure attachments in individuals receiving transference-focused psychotherapy than dialectical behavior therapy or dynamically-informed supportive therapy. The finding of a positive shift over the course of treatment with regard to self-reflection is in keeping with RCT data showing similar improvements with psychotherapy, particularly more intensive-dynamically oriented treatments. In closing, this is the first study to examine the associations between these three projective constructs, as well as between the MMPI and TCM. Moreover, it is only the second study to examine the relations between the AAI and MMPI and only the third to examine the relations between the AAI and the TCM. While the findings are interesting and lend credence to the view that adults can use their therapists/analysts to serve key attachment functions for them, the results need to be considered in light of key study limitations, most notably the single case design format and the lack of attention to other related unconscious processes, the analyst's attachment security, and the patient's attachment relationships outside the analytic relationship. It is recommended therefore that future research include both a larger sample size and a control group to address causal questions related to the short- and long-term benefits of psychoanalysis. To more fully appreciate the links between the patient's attachment patterns, personality functioning, and patient-therapist communication patterns, responses to additional projective measures (e.g., Rorschach) should be examined. Moreover, given that attachment style is known to influence caregivers' ability to provide a secure attachment relationship and some emerging findings on its impact on therapy outcomes, the impact of the intersection of the therapist/ analyst's own attachment and the patient's is

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Social desirability bias represents tendency to present oneself in a socially desirable or positive manner to others. As there is high possibility of faking good or bad in objective psychological tools many psychologists rely more on projective psychological assessment to identify any personality pathology or clinical symptoms with the believe that projective tools are protected from social desirability biasness, but there is lack of research to pin point this belief. In the present study authors tried to examine whether more 'socially accepted role- response' can affect subject's responsiveness to Rorschach cards. 60 college students were divided equally in 3 different instructional groups randomly and were presented with same set of Rorschach responses to identify. Three groups were informed that responses were given by a convicted criminal, a talented student and a severe mental patient respectively. Responses included contents like popular, sexual, aggression, anatomical, isolate etc. Comparison of three instructions failed to find any significant association of instructional set and identification of Rorschach response to suggest minimum possibility of social desirability biasness in Rorschach. Prasanta Kumar Roy Over reporting, under reporting or rejection of particular response in psychological assessment have been discussed (Neeley and Cronley, 2004) as result of social desirability bias or conscious; unconscious censorship. Social desirability bias represents tendency to present oneself in a socially desirable or positive manner to others. Research designs that use a self-report format and measure constructs having high social influence appear to foster problems with socialdesirability bias (Neeley and Cronley, 2004). This is the reason different objective psychological tests (for example, Minnesota Multiphasic Personality Inventory, Multiphasic Socially desirable responding (SDR) is most likely to occur in responses to socially sensitive questions (King and Brunner 2000). Psychologists have developed and validated scales to detect SDR. The most widely used example is the33-item Marlowe-Crowne Social Desirability Scale (MCSDS) (King and Brunner 2000; Crown and Marlowe, 1960). Questionnaire; Eysenck Personality Questionnaire etc.) have incorporated reliability and validity checkups for examinee given responses to screen out desirable response pattern in test taking approach. But these tests are not free from its pitfall. As there is high possibility of faking good or bad in these tools many psychologists rely more on projective psychological assessment to identify any personality pathology or clinical symptoms. This is even truer in forensic psychological evaluation. Though For example, Kroger (1967) and Kroger and Turnbull (1970) manipulated social expectancies to indirectly induce college students to respond to several personality tests as either a military officer or artist might, and found that highly reliable, rolespecific responses occurred. Grossman, et al, (2002) proposed that the Rorschach is resilient to attempts at faking good, and should be considered an especially powerful tool in forensic settings in which clients are likely to purposely distort their symptomatology. But does it mean Rorschach is free from social desirability biasness?

it was believed that projective tools were protected from social desirability biasness, but there is lack of research to pin point this belief. As Rorschach test elicits both primary process (bewildered or irrational) and secondary process thought (rational, abstract) as theorized by Freud (1900/1965); there is high possibility of getting Defense Demand responses like libidinal, aggressive etc., as well as Defense Effectiveness responses like movement response (Holt, 1956). Research has identified that Schizophrenics rely more on primitive or primary process thoughts and thus show less social maturity in giving Rorschach responses (Hersch, 1962; In an experiment Exner and Laura (1976) took 30-30 male and female non-patient volunteers randomly divided in two groups to check the ease of different responses in different Rorschach cards. Each subject was given a list of 50 responses, 5 responses for each card, a group of responses for each card consisted a popular response; two commonly given responses and two other that are not given commonly. Among five responses, responses taken as target response consisted content of sexuality, injury or violence. Subjects In an experiment Exner and Laura (1976) took 30-30 male and female non-patient volunteers Harrow, et al, 1976). Similar is true for sexual offenders. Many researchers (Holt and Havel, 1960; Exner, 1986) have proposed that preoccupation with sexual content on the Rorschach might suggest sexual disturbances as sexual preoccupation is part of primary process thought. Exner (1986) has reviewed and demonstrated that concerns for social approval filter out many sexual references and external social taboos might inhibit the verbalization of sexual material. He further mentioned that even instructional set can influence responses, particularly content of the responses. randomly divided in two groups to check the ease of different responses in different Rorschach cards. Each subject was given a list of 50 responses, 5 responses for each card, a group of responses for each card consisted of a popular response; two commonly given responses and two other that are not given commonly. Among five responses, responses taken as target response consisted of content of sexuality, injury or violence. Subjects were exposed to the cards in screen for 165 seconds and were asked to give the rank according to ease they would perceive the responses in cards. Difference in two groups was that, one group was said that the responses they would rank were those of given by normal people and other group was said that the responses they would rank were those of given by severely disturbed psychiatric patients. It was found that both groups significantly differed for target responses and common responses. In a similar study Thomas, Exner and Laura (1977) found significant differences in two groups (a group which ranked the responses, responses given by very successful businessman and another group who ranked the responses given by inpatient schizophrenic). Both groups were observed to differ significantly for target responses (especially for sexual responses). In above discussed studies as subject was asked to rank the responses as their 'ease' of perception, and they were also provided location chart indicating responses, there might be two important issues: first, subject might feel forced to rank the responses, even they did not want to disclose their perception of blot in particular response way; second, as the response location was provided to the participants there was a high possibility that they might have got suggested. In this present study the authors have tried to

overcome some of the methodological issues and also wanted to check effect of social desirability in response censorship on Rorschach Inkblot Test. Q Rorschach Inkblot Test (RIT): All RIT response checklist: Quality Methods: Sample: Sixty postgraduate college going healthy (as screened by General Health uestionnaire -5, Shamsunder, et al, 1986) male students were selected for the study after getting their consent. Mean age of the students was 23.13±1.11 years with 22-26 years range. All the students were then randomly recruited equally in one of the three groups. Measures: 10 figures or cards by Herman Rorschach (1942) were used as stimulus. As a test these stimulus cards prompt a complex set of psychological features. The coding of responses provides indirect information about those psychological features that can be used to describe the psychology of an individual. A check list of responses was prepared for all the ten cards following Form Table of th The Rorschach: A Comprehensive System, 4 Edition (Exner, 2003). For each card 8 responses were selected. Responses for each card consisted of at least one sex response (except in card VIII), one animal or human aggressive response, one anatomical response, one isolate response (e.g. nature or cloud or geography or botany) and one popular response. Responses were selected from common detail areas (D Location) with ordinary (o) form quality so that responses can be easily seen without much scanning. Responses were selected maintaining similarity of response patterns used by Exner and Laura (1976) with minor modifications. The response set was then given to 20 post graduate psychology students who were well versed with Rorschach Test, to rate the responses with respect to their easy identification in the cards. This was done to minimize cultural interference in seeing responses. 5 most easily identifiable responses in a card as rated by them were retained for final experiment. Procedure: The subjects were randomly recruited in one of three groups, group-1, group-2 and goup-3; thus there were 20 subjects in each group. All of them were administered the Rorschach Inkblot Test response checklist with Rorschach cards individually, and was asked if they could see the given responses on a particular card. Three groups only differed by the content of instruction before introducing the checklist. Group-1 was told that the given response checklist they would identify was given by a young male criminal who was charged for rape and murder. Group-2 was told that the given response checklist was given by a brilliant Indian Institute Technology student and group-3 was informed that the responses were given by a severely disturbed young male mental patient who was roaming naked on the road and was picked up by police. After these instructions all of them were read the responses one by one after giving the respective Rorschach Card and were asked if they were able to see that particular response in the blot. Results: As homogeneity of variances was observed between three comparative groups an Analysis of Variances (ANOVA) was computed using General Linear Model to see if the groups differed significantly considering confidence of 26 Dewangan and Roy

popular response suggests individuals ability to identify with most others in the society, thus indicates high social desirability (Exner, 2003). It was hypothesized that students who received criminal/ sex offender and mental illness limit as 95%. There were nine types of responses as seen in the Rorschach Cards by the respondents with three different instructions. These responses included Popular content, Sexual content, Animal content in Aggressive activity, Human Content in Aggressive activity, Anatomical content, Part of Animal or Animal detail content, Parenthesize (Mythological or Imaginary) Animal content, Parenthesize Human content and Isolate content (includes botany, cloud, nature and geographical content). The F-Ratios ranged from 0.03 to 1.38 across the variables and the p- values of all these scores were found to be much higher than the p-value of 0.05 to this study failed to find any significant association of instructional set and identification of Rorschach response. The observed power estimations were calculated as from 0.05 to 0.28 across the variables with trivial to small suggest that effect size following Cohen's criteria (R-squared or Eta squared values ranged from 0.001 to 0.046). This indicates only 0.1 to 4.6% of the variance in the test performance was explained by Instructional variation. However, when total number of Rorschach content variables was compared across the three groups qualitatively, it was observed that the group-1 (Antisocial Response Instruction) had recognized approximately 14% less sexual response, 16% less human response, 16 % less anatomical response, 22% more animal detail response and 14% more mythological (parenthesized) nd animal response in comparison to the 2 group (Bright student response instruction). In rd contrary, the 3 Group (Mental Illness Response Instruction) had identified 11% less Animal response, 14 % less Human, 27% less nd Anatomical responses to the 2 Group. Table1 Comparison of three instruction groups to identify specific response content Responses Group -1 Mean±SD Group-2 Mean±SD Group- 3 Mean±SD F-ratio p-value Popular 8.00±1.49 7.75±2. 15 7. 10±2. 13 1. 14 0.327 Sexual Content 4.85±2.52 5.65±2. 13 5.50±2.33 0.67 0.518 Animal Aggressive Content 8. 15±1.69 8. 15±1.90 7.25±2.29 1.38 0.260 Human Aggressive Content 2.70±1.56 3.20±1.32 2.75±1.21 0. 81 0.451 Anatomical (An) 1.90±1.45 2.25±1.02 1.65±1.35 1. 10 0.340 Animal Detail (Ad) 1.95±0.94 1.60±1. 19 1.70±1.03 0.58 0.564 (A) 1.25±0.79 1. 10±0.79 1.20±0.77 0. 19 0.826 (H) 1.00±0.92 1.00±0.73 1.05±0.76 0.03 0.975 Isolate 7.35±2.54 7.85±2.37 7.50±2.72 0.20 0.820 (Group 1: Criminal Response Group 2: Brilliant Student Response Group, Group 3: Mental Patient Response Group) Discussion: Except the popular content other responses are relatively undesirable in a protocol and hence they represent poor social desirability. High

response instructions might refuse to identify many undesirable responses to show themselves as sane. However, this study failed to identify if social desirability has any significant impact on identifying Rorschach responses and thereby contradicts with the findings of previous similar studies (Exner and Laura, 1976; Thomas, Exner and Laura, 1977). Projective Techniques became popular with the understanding that source content of projective is unconscious and hence the projections themselves are not subject to manipulation; thus are more appropriate tool to identify psychopathology even under defensive conditions. However, this hypothesis could not be demonstrated empirically (Holmes, 1968), rather evidence suggests individual can control their projection consciously and thus can be manipulated too (Holmes, 1974; Sewell, 2008). This assumption was reflected in the study by Thomas, Exner and Laura (1977) to establish social desirability biasness in projective assessment. But the study by the present authors indicates social desirability biasness did not lead to the conscious or unconscious manipulation of data set as seen in the Rorschach cards and thus questions how much it affects the response pattern. There may be many methodological reasons for this opposite finding. Authors conducted this study among the urban male students of similar age and education. The responses were taken by the first author who is male, thus minimizes any possibility of defensiveness due to gender. As students were administered the test, they hardly represent the general population at large, rather represent young adult male students of a metropolitan city of Eastern India where social desirability factor may not interfere with the response process to an extent to that of rural or less educated group. The stimulus responses as identified/ prepared by the authors might be another factor that might have lessened the perceptual difficulties to identify responses. As popular responses are the most obvious response in terms of location and form quality, all three groups identified almost equally and thus minimizing social desirability biasness. Other responses were also chosen from the frequent response table with good form quality to decrease the probability of denial. Above all responses were finalized only after getting the rating of easy identifiability from psychology students who were well versed with Rorschach to minimize the impact of more organizing/ cognitive effort of the study subjects. Previous studies did not try to control these factors that might interfere with the test taking approach. Another possibility is, obviousness of the responses might have made the task easier for the current study to minimize any associated anxiety and thus motivating the subjects to given responses freely. There are researches to point out that induced mood during psychological test might change the approach to form impression about others (Bless, et al, 1992), information processing (Isen and Daubman; 1984) and also response pattern (Isen, et al, 1985). By providing different sets of instructions to induce positive or negative mood also might had some impact on identifying different response set in the previous studies rather than the social desirability biasness alone. The present authors have tried their best to negate the factors associated with the stimulus demands by considering responses from major detail area with good form quality and thus minimizing the effect of anxiety to scan a particular response. As test taking anxiety was minimal that might have motivated the subjects to find responses without much social biasness. Despite these a trend was observed though not significant that students have tried to avoid undesirable responses specifically where they were informed that the responses were from a sex offender. Though the current study contradicts with the previous findings but this is not free of limitations. The study was only conducted on male college students with a total 60 subjects. Small sample size might have limited the statistical power of the findings and it just represents a small section of the population. 28 Dewangan and Roy

The similar work may be replicated taking various strata of the population with representative sample size. The obviousness of the responses in a card also might need some manipulation with emphasis on both ordinary and unusual form quality so that some responses demand more processing effort to identify. Reaction time to identify a response also may be incorporated to identify the speed of processing or if any hesitant process is working underneath. More studies will clarify the confusion about if at all we need to bother about social desirability biasness to form Rorschach responses. References: Bless, H., Hamilton, D. L., and Mackie, D. M. (1992). Mood e f f e c t s o n t h e o r g a n i z a t i o n o f p e r s o n information.European Journal of Social Psychology, 22, 497-509. Crowne, D. and Marlowe, D. (1960). A new scale of social desirability independent of Psychopathology. Journal of Consulting Psychology, 24(4):349-354. Exner, J. E. and Laura, A. V. (1976).Variation in ranking Rorschach responses as a function of situational set. Rorschach Workshop (Study no. 221, unpublished). Exner, J. E. (1986). The Rorschach: A comprehensive system(Vol. 1,2nd ed.) New York: Wiley. Freud, S. (1965). The interpretation of dreams (J. Strachey, Trans.).NewYorK: Avon Book. Grossman, L. S., Wasyliw, O. E., Benn, A. F., and Gyoerkoe, K. L. (2002) Can sex offenders who minimize on the MMPI conceal psychopathology on the Rorschach? Journal of Personality Assessment, 78(3), 484-501. Harrow, M., Quinlan, D., Vallington, S. and Pickett, L., Jr. (1976) Primitive drive-dominated thinking: Relationships to acute schizophrenia and sociopathy, Journal of Personality assessment, 40, 31-41. Hersch, C. (I962) The cognitive functioning of the creative person: A developmental analysis. J. Projective Techniques, 26, 193-200. Holmes, D. S. (1968) Dimensions of projection. Psychological Bulletin, 69: 248-268. Holmes, D. S. (1974)The conscious control of thematic perception. Journal of Consulting and Clinical Psychology, 42:323-329. Holt, R. R. (1956)Gauging primary and secondary processes in Rorschach responses. Journal of Projective Techniques, 20, 14-25. Holt, R., and Havel, J. (1960)A method for assessing primary and secondary process in the Rorschach.In M. A. Richers-Ovsiankina (Ed.), Rorschach psychology(pp. 263-315) New York: Wiley. Isen, A. M., and Daubman, K. A. (1984)The influence of affect on categorization, Journal of Personality and Social Psychology, 47, 1206–1217. Isen, A. M., Johnson, M. M. S., Mertz, E., and Robinson, G. F. (1985)The influence of positive affect on the unusualness of word association.Journal of Personality and Social Psychology, 48, 1413-1426. King, M. and Bruner, G. (2000) Social desirability bias: a neglected aspect of validity testing. Psychology and Marketing, 17(2):79–103. Kroger, R. (1967). Effects of role demands and test cue properties upon personality test performance. Journal of Consulting Psychology, 31: 304-312. Kroger, R. and IV.Tumbull (1970) Effects of role demands and test-cue properties on personality test performance: Replication and extension. Journal of Consulting and Clinical Psychology, 35:381-387. Neeley, S. M., andCronley, M. L. (2004) When Research Participants Don't Tell It Like It Is: Pinpointing the Effects of Social Desirability Bias Using Self vs. Indirect- Questioning. Advances in Consumer Research, Vol 31.( ABSTRACT) Robinette, R. L. (1991) The Relationship between the Marlowe-Crowne Form C and the Validity Scales of the MMPI, Journal of Clinical Psychology, 47 (May), 396- 399. Sewell, K. W. (2008) Dissimulation on projective measures. In Clinical assessment of malingering and deception (3rd ed.). (pp. 207-217). New York, NY US: Guilford Press. Shamsunder, C., Sriram, T. C., Murliraj, S. G. and Shanmughan, V. (1986)Validity of a short 5-items version of the General Health Questionnaire. Indian Journal of Psychiatry, 28: 217-219. Thomas, E. A., Exner, J. E. and Laura, A.V. (1977)Differences in ranking responses by two groups of non- patient adults as a function of set concerning the origins of the responses.Rorschach Workshop (Study no. 225, unpublished).

Note: This paper is dedicated to the first author, Prof. Paul E. Panek, Dept. of Psychology, The Ohio State University- Newark, who died on December 28, 2007. Figure Drawing Techniques with Older Adults: A 30 Year Perspective Paul E. Panek, Bert Hayslip, Jr., Sharon Rae Jenkins and Amanda Kay Moske Panek, Wagner and Kennedy-Zwergel (1983) and Hayslip and Lowman (1986) have reviewed the use of expressive personality tests with older adults. In this context, the present review presents and discusses the research on human figure drawing techniques (HFD) with older adults during the past 30 years since those reviews. Findings are presented for age differences, and the differentiation of diagnostic groups.These are discussed in the context of the assessment referral questions most common with older adults and the challenges of geriatric assessment for which HFDs are suitable tools. Conclusions and recommendations regarding the use of HFD with older adults are presented, as are the implications for future research using HFD with older persons. Psychologists have recognized the importance of becoming skilled in working with older persons, especially those with some form of dementia (Abeles et al, 1998; APA Monitor, 2008; Panek, 2006). However, many clinicians have little professional training in working with such persons (see Knight, 2004), for whom certain referral questions, differential diagnoses, and appropriate assessment tools may differ from younger populations. Psychological assessment instruments are available to assess diagnosis, levels of impairment, personality, and social functioning, as well as to distinguish premorbid personality and normative age differences from psychopathology and responses to situational stress. Such assessment information is needed to inform decisions affecting older adults and their families, for example the wisdom of independent living versus an assisted situation versus admission to a long-term care facility, level of care needed, the older person's capacity to cope with the emotional byproducts of physical or cognitive deficits, or the implementation of treatment plans and other interventions, including the likelihood of treatment adherence. However, these instruments do not necessarily address these most common referral questions for this population, and they are not always suitable for older adults for reasons discussed below. We present here a review and evaluation of the empirical and clinical literature regarding the status of human figure drawing (HFD) techniques with older adults over the past 30 years since the reviews by Panek, Wagner and Kennedy-Zwergel (1983) and Hayslip and Lowman (1986). These are classified as constructive techniques (see Meyer & Kurtz, 2006 and Radika & Hayslip, 2002). We hope to provide an objective basis for clinicians' decision-making regarding whether to utilize HFD techniques either formally or informally in their evaluation of older clients. We begin by presenting the major clinical referral questions for which HFDs may be uniquely useful with older persons, then we discuss broadly the suitability of HFD for addressing those questions in this population. The major portion of the paper reviews the past three decades of literature on HDFs with older adults, and is followed by our synthesis, conclusions, and recommendations.

Common Assessment Referral Questions with Older Adults: As the proportion of older persons in our population increases, the likelihood of such persons experiencing certain forms of mental illness also increases (Hayslip, Patrick, and Panek, 2011; Koenig, George, & Schneider, 1994). Depressive symptoms, anxiety, and dementia are the most likely forms of psychopathology that clinicians are likely to confront, wherein the incidence of subclinical depressive symptoms and dementia are not uncommon in later life (see Segal, Qualls, & Smyer, 2011; Zarit & Zarit, 2008). Certain subtypes of non-melancholic depression may be secondary to some older adults' living situations (e.g., in nursing homes, socially isolated, physically inactive) and/or their anticipation of resource depletion, decline, and death; consequently, they may go unrecognized and underdiagnosed (see Blazer, 2002; Zarit & Zarit, 2008). Whether or not these symptoms reach the threshhold required for formal diagnosis, they may exacerbate social isolation and inactivity, contributing eventually to physical decline. Confronting and coping with such mental health challenges is essential to older persons' and their families' quality of life. Routine stressors associated with aging include age-related sensory losses, losses of close others as family and friends die, losses of functionality, and eventually loss of self. Anticipating and experiencing these demands may elicit depressive reactions and anxiety about the future (see Ruth & Coleman, 1996; Segal,et al, 2011; Zarit & Zarit, 2008). Older adults may be coping with the physical and cognitive changes associated with aging as well as changes in family relationships growing out of such changes (see Blieszner & Bedord, 2012). Some older persons experience significant difficulties in dealing with the normal physical changes accompanying the aging process, i.e. sagging and wrinkling of skin, loss of height, redistribution of fat from the extremities to the torso, which impact persons' assessment of their physical attractiveness as well as their physical competence (Whitbourne & Skultety, 2002). These changes may require identity assimilation or identity accommodation as an aspect of coping to retain a coherent sense of the self despite physical change. Many older persons (and their families) must face the ultimate loss of the self that is associated with Alzheimer's disease, stroke, or other forms of dementia (Feil, 2002; Taylor, 2007). Declines in one's physical or cognitive functioning may have a unique psychosocial impact on older persons' personality and behavior secondary to the actual functional losses. For example, illnesses such as osteoporosis, arthritis, or cancer (see Fiedler, 2012; White, 2002) as well as the effects of cancer treatments themselves (Pruzinsky, 2002) may impact physical competence, undermining older persons' self-efficacy. This may impede older adults' efforts to engage actively in their prevention, maintenance, and/or treatment regimens to prevent or remediate the effects of normal and pathological aging changes (e.g. the use of sunscreen, diet, exercise; Whitbourne & Skultety). Psychometrically measured changes in one's functioning may be a byproduct of the older person's reaction to the loss of his/her skills (e.g., depression symptoms, feelings of inadequacy, sense of losing oneself, impaired relationships with others, withdrawal from others, anger, changes in sleep or patterns of eating), which tends to lower a person's scores on timed tests. Constructive test performance is not a direct alternative to psychometric measures of cognitive functioning, but with expert interpretation, it may assist in diagnosis by providing evidence for or against specific DSM criteria, or appraising the client's status on rule-out criteria (see Segal, Qualls, &Smyer, 2011; Zarit & Zarit, 2008).

make some resistant to clinicians' efforts at diagnosis by explicit self-report, structured interview, or psychometric methods. On the other hand, some isolated, lonely older adults who are anxious about their health status may overengage with clinical interviews and other less structured self-reports, having learned to use elaborate symptom disclosures as a form of social discourse. Either orientation is likely to give misleading results. Memory impairments may make self-report findings questionable. Physical impairments might make some assessment methods too fatiguing to yield accurate results, leading to overpathologizing the client. Subclinical depression symptoms may slow performance on timed tests, yielding underestimates of functional capacity. Wordfinding problems may constrain scores on verbal expressive tasks, leading to underestimates of language comprehension. Reliance on DSM diagnosis (except in extreme cases) tells the clinician little about the client's ability to sustain independent living and does not address explicitly the kinds of referral questions for which older adults are often referred for psychological assessment. Human Figure Drawing (HFD) techniques are sensitive to subtle personality changes that often precede the diagnosable symptoms of the Alzheimer's form of dementia, i.e. Mild Cognitive Impairment (Peterson et al., 2001). HFD techniques may provide us with valuable information about how the older person is coping with either alterations to their bodies via aging or disease, or normal or pathological cognitive decline, emphasizing their strengths in doing so (see Kahana, 1978). Moreover, for some older persons, they can be less threatening than clinical interviews, more acceptable and engaging and less fatiguing than are lengthy personality inventories, and may allow for the detection of subtle response patterns that more structured and self-report measures obscure. We note eight key points briefly. First, HFD One's reactions to the immediate life context (e.g., chronic health difficulties and resulting treatment burden, social isolation, an understimulating nursing home environment, exposure to ageism in everyday interactions, difficulties in everyday decision-making) may present additional stresses and/or deprivations that tempt misattribution of situational stress effects to psychopathology. Reichlin (1984) notes that ignorance of the impact of situationrelated moderating factors on the test performance of older persons may lead to their being overpathologized by the clinician. Complicating matters is the increased range of individual differences in functionality with aging (see Nelson & Dannefer, 1992), associated psychosocial and health problems, and psychological responses to these that may interfere with treatment adherence or result in older adults requiring a variety of support services, adding to the range of referral questions and recommendations. Like verbal expressive techniques (see Panek, Jenkins, Hayslip, & Moske, 2013), constructive techniques to assess personality such as the HFD techniques can play a unique role in informing these recommendations in the context of multimodal assessment. Why Use HFD Techniques for Assessing Older Adults? Psychological assessment with older adults faces unique challenges related to American cultural expectations regarding aging and its consequences, and the familial, social, and institutional structures that define and shape the aging process. The co-morbidity of either cognitive or physical change and personality difficulties, along with situational stressors, complicates the usual purposes of assessment and adds a cascade of new ones that are less typical of younger individuals. In addition to the stressors described above, older adults may fear losing the ability to live independently if impairments are discovered. This fear may 32 Panek, et al

techniques are routinely used by practitioners as clinical tools, although their perceived utility covaries with the skills and experience of the clinician utilizing it (Anastasi & Urbina, 1997; Handler & Thomas, 2014; Qualls & Knight, 2006; Segal, Qualls, &Smyer, 2011). Second, techniques such as HFDs do not require verbal skills or insight, and are easily adapted to assess older persons who are embarrassed or guarded about what they might reveal about themselves in the process of being evaluated (Anastasi & Urbina; Kane & Kane, 2000; Segal et al.). Third, HFDs may help in the establishment of rapport and easily engage older persons (Radika & Hayslip). Fourth, HFDs may provide data that may be more intuitively obvious to older patients and their caregivers than psychometric scores when used with collaborative (Fischer, 1994) or therapeutic (Finn, 2007) assessment approaches. Fifth, HFDs are faster and easier to administer and score than comprehensive structured interviews and personality inventories, and thus may be useful for screening (REF). Sixth, it could be argued that HFD techniques are best suited to be used as an adjunct to either structured or unstructured interviews and other assessment tools, key to the broadband assessment of older persons (see Anastasi & Urbina, 1997). Seventh, process information gained from qualitative clinical tools such as HFD techniques at times can be more important that quantitative data in the wholistic assessment of the older person (Abeles et al., 1998). Finally, they may indeed be valuable in generating hypotheses about the client, based upon the characteristics of the drawings themselves and an inquiry following the drawing task, which must be interpreted in the context of other information about the individual (Anastasi & Urbina; Zarit, Eiler, &Hassingher, 1985). Edelstein and Segal (2011) echo this preference for multimethod assessment in discussing the shortcomings of relying solely on self-report data and suggesting that the shortcomings of one method can be avoided to an extent by relying upon multiple methods of assessment and triangulating the evidence. A last key consideration is that the utility of the criteria by which constructive techniques are evaluated is a function of whether or not they are considered tests, and thus subject to the psychometric criteria used to judge structured self-report scales and performance measures. Alternatively, they may be used and interpreted as process-based measures, as is done by most clinicians (see Jenkins, 2008a). In this respect, Hooker and McAdams (2003) and Bornstein (2009) stress the unique value of a process approach for assessing not only personality traits, but also goals, motivations, self-regulatory processes, expectations, and the construction of life stories. Anastasi and Urbina (1997) observed, regarding “projective” techniques, that “attempts to evaluate them in terms of the usual psychometric procedures may be inappropriate” (p. 441). In a similar vein, Neugarten (1977), in discussing late life personality, questioned whether personality can be meaningfully understood in solely scientific terms. On the other hand, Zarit, Eiler, and Hassinger (1985, pp. 736-737), in discussing the “projective” assessment of personality in later life, note that “at the heart of the matter is the extent to which untested and inferred propositions are appropriate in assessment …….Inference, intuition, and creativity all have an important place in assessment as well as other clinical activities, and they are useful for generating hypotheses to account to account for the apparent diversity or order in human phenomena, and it is often necessary to go beyond the data, if only because adequate explanations are lacking. At the same time, inferences that are supported only by other inferences can be misleading”. Thus, the use of scoring manuals that are sufficiently detailed to allow for appraisal of interscorer reliability is the most important indicator of objectivity. We argue that at the minimum, HFDs should be

viewed as an adjunct to other sources of information the clinician has at his/her disposal regarding the older client. Interestingly, in a study of 158 British clinical psychologists, while most did not utilize figure drawings as a formal component in their assessment, half reported using drawings as an informal aid in assessing persons (Bekhit, Thomas, & Jolley, 2010). Purpose and Structure of the Present Review : The present review, like its predecessors, discusses the research with HFD techniques with older adults during the past 30 years, organizing the review by 1) the extent of age differences in performance and 2) diagnostic group comparisons. While too few studies address similar questions with the same outcome measures to allow for a meta-analysis, in discussing this work, we provide relevant sample characteristic data and information pertinent to effect sizes (e.g., Cohen's d, effect size r between the independent and dependent variable, r ) where provided and/or where sufficient information was provided by a study's author(s) enabling us to compute effect sizes. Where work has been replicated or cross validated, we note this as well. Where group comparisons were conducted, we note whether they were systematically matched to control extraneous variables, and if they were not explicitly matched, whether their demographics were comparable, or whether the comparability of groups was unclear. Overview of the HFD Research Literature over 30 Years: Since the earlier reviews by the first and second authors, drawing techniques have become the most researched expressive personality tests with older adults (see Radika & Hayslip, 2002). The main foci of these studies have been to establish normative age differences, to differentiate Alzhiemer's disease and other dementia patients from normal controls, and/or to identify levels of personality that may parallel different levels of cognitive impairment. HFD techniques are also a prime source of data in the study of body image, but this research has largely neglected older adults, as noted by Peat, Peyerl, and Muehlenkamp (2008). Since the previous reviews, no new work regarding either individual differences or drawing techniques' normative characteristics with older persons has been published, so these sections from the earlier reviews are not presented here. Age Differences: In a study by Ericsson, Hilleräs, Holmén and Winblad (1996), using a freehand HFD technique (FFD, where persons were simply instructed to draw a human figure) in a sample of 668 persons aged 75 and older, the authors found that age had a significant influence on HFDs after age 90, wherein most HFD variables showed regressive changes; this was true as well for persons suffering from dementia (see below). A reduction of essential bodily details with increasing age (and level of impairment), based upon a cross sectional (10 groups of 10 five-year cohorts) comparison of persons aged 35-80, has been observed by Ericsson, Winblad and Nilsson (2001).These authors argue the human figure drawings are as good a predictor of cognitive declines in older persons as is episodic memory performance, and consequently can be used with confidence to screen older persons for cognitive decline; among the oldest aged persons, this may be especially valuable (Ericsson et al.). Ericsson, Hilleräs, Sundell and Winblad (1997) examined HFDs in a) 716 children/adolescents who were enrolled in a longitudinal study; b) school pupils (n = 143) between the ages of 10 and 15, c) nursing students (n = 71) aged 20 to 35, d) 936 healthy adults aged 35-80, e) 371 elderly living in the community, and f) 94 cognitively impaired elderly, as determined by mental status exam scores and clinical dementia rating scale performance. Figure drawings were evaluated for essential body details (e.g. facial features, hands, legs), 34 Panek, et al

hierarchical level (objectively scaled childlike qualities or not, e.g. drawing stick figures or just a head and feet), and structural characteristics (centeredness regarding placement on the paper). One-way ANOVAs suggested no age differences between the ages of 10 and 80 years for the presence of essential details, while hierarchical levels (drawings that were more technically correct, i.e. body parts are not just present, but are drawn in correct proportions relative to one another) of the HFD decreased with increasing age. That is, in the youngest (4 to 5 years of age), drawings changed from being defined by essential details to correct proportions. At 70 years of age, drawings continued to reflect correct proportions, while from 75 to 90 years of age, figures were drawn in two dimensions. Thus, few age differences were observed, except between the very young and the very old. Regarding the two older adult groups, impaired aged persons (age > 75) as a whole group showed, like the 4-year old group, a large range in drawing essential details. Of the structural characteristics, centeredness varied in all groups except nursing students and impaired older persons. This study's principle strength is the diversity of the samples varying in age. Yet, it is cross sectional in nature, and consequently cannot speak to intraindividual change over time. It is also to be noted that many of the age effects, while reliable, are nevertheless small in magnitude. In a study by Hayslip, Cooper, Doughtery, and Cook (1997), human figure drawing scores were reliably derived according to the system developed by Doughtery and Cook (1991), and broken down into general characteristics, e.g. figure size, line quality, and specific characteristics, e.g. eyes, ears, arms, feet. Such scores favored young adults (ES rs> . 14). Thus, figure drawing scores converged with Holtzman Inkblot Technique (Holtzman, Thorpe, Swartz, & Herron, 1961) scores in suggesting that older persons exhibited a more negative body concept at both a global and a specific level than middle-aged and younger individuals, and indicate that body image issues may indeed exist for middle-aged and older adults, not just younger adults (Hayslip et al.). Silver (1987) investigated the effects of gender and age on the expression of emotions using the Stimulus Drawing Task (Silver, 1986), comparing third graders, high school seniors, adults (between the ages of 20-30 years), and older adults (total N = 326). Silver found gender differences in the emotional content of the drawings across the four age groups (F = 4.15, p< .05, ES r= .22). To the extent that the principal subject of a drawing reflects the selfimage of the person who draws it and the environment reflects the way that person perceives the world, these findings suggested that men and boys tend to see themselves as fighting in a dangerous world, while women and girls tend to see themselves as part of the world rather than opposing it (Silver). Given the limited demographic information regarding participants' age and health in this study, it is difficult to assess the significance of the lack of age and presence of gender differences found by Silver here. Silver (1993a) explicitly examined age and gender differences in attitudes toward solitary subjects and relationships expressed in response to the Stimulus Drawing Task (Silver, 1991). Participants were 531 respondents in five age groups: children (7-10 years), younger adolescents (13-16 years), older adolescents (17-19 years), younger adults, (20-50 years), older adults (65+ years). Results indicated: a) respondents tended to choose and draw subjects of the same gender as themselves, ÷² = 145.84, p< .001, ö = .66; b) boys and men expressed positive attitudes toward solitary subjects, negative attitudes toward relationships, ÷² = 46.97, p< .001, ö = .47; c) girls and women expressed positive attitudes toward solitary subjects, both positive and negative attitudes toward relationships, ÷² = 25.32, p< .001, ö = .33; and d) boys and men showed higher frequency than girls and women in drawing about assaultive relationships, ÷² =

9.38, p< .01, ö = .21. However, age and gender interacted resulting in a significant age variability in assaultiveness for females (÷² = 11.89, p < .05, ö = .24) but not for males. The proportion of older women who drew pictures about assaultive fantasies (27%) somewhat exceeded both the proportion of older men who did so (21%), and the proportion of all other female age groups. An inverse age by gender interaction was also found for caring relationships (÷² = 12.52, p< .05, ö = .25), where males showed significant age variability (÷² = 13.10, p < .05, ö = .25), while females had a significant commonality of caring relationships across all age groups. The proportion of younger men who drew pictures about caring relationships (46%) exceeded both the proportion of younger women who did so (10%) and the proportion of all other male age groups (Silver). Silver suggested that drawings can identify age and gender differences in attitudes, and if expanded, they may eventually provide norms upon which to base more accurate expectations as well as provide information about emotional needs. Silver (1993b) expanded on Silver (1987) by more closely investigating attitudes toward self and others. One group of participants was 59 adults over the age of 65 who lived independently in their communities in New York City and who varied in socioeconomic status (moderate to low SES versus high SES) who responded to the Stimulus Drawing Test (Silver, 1991). The second group consisted of 22 older adults from moderate to high socioeconomic neighborhoods in a Florida city, responding to the Drawing from Imagination subtest of The Silver Drawing Test of Cognitive Skills and Adjustment (SDT). Despite the fact that samples were too small for statistical analysis, the authors nevertheless claimed that among older adults there was expressed pessimism in the subjects they chose to draw and the relationships they portrayed. Silver infers that these findings are consistent with the idea that depression may be widespread among older men and women in our society; this is indeed true regarding depressive symptoms but not major depressive disorders (see Segal, Qualls, & Smyer, 2011; Zarit & Zarit, 2008). Morin and Bensalah (1998) found in persons aged 30-85 that self-portraits differed with regard to the representation of the hands and face, where among persons younger than 65, no one failed to represent facial features, while 17% of persons aged 65 and older were unable to produce self portraits with facial details; this was interpreted by the authors as reflecting the inability to face the losses accompanied aging, given that the drawn real mouth and eyes are both symbolic body orifices and imaginary in nature. In a sample of 225 persons aged 3-80 who completed a drawing completion task where instructions were to draw simple lines suggesting 2 figures facing one another, Spaniol (1992) found the lines of older adults to be more likely to draw broken lines, with less differentiation and fewer boundaries; this might suggest the perception of less clearly defined relationships and more dependency in later late. Pruis and Janowsky(2010) presented younger and older women (ns = 19 in each case) with morphed images of their own bodies (ranging from 35% thinner to 35% fatter than each woman's actual size). Such ratings did not differentiate younger and older women, suggesting equal degrees of body satisfaction with age. Comparing Diagnostic Groups : Relative to other expressive techniques, much HFD work has appeared regarding the comparison of diagnostic groups, especially cognitive impairment and dementia, suggesting that older persons can be successfully differentiated in this respect utilizing HFDs. To explore figure drawings' ability to differentiate older persons on the basis of cognitive impairment, Ericsson, Forssell, Amberla, Holmen, Viitanen and Winblad (1991) administered several drawing/graphic tasks (free-hand figure drawing, FFD), and the three- 36 Panek, et al

dimensional Cube Test to 250 older (aged 75 and older) persons with cognitive deficiency (according to mental status exam scores) who were matched on age and gender with unimpaired individuals. Scoring of the FFD reflected the presence of eight critical details (i.e., main details such as two-dimensionality of arms and legs, clothing, body proportion, shoulders, ears, movement and eyes turned in same direction). The number of main details disappeared in fixed order with decreasing cognitive function. The authors observed that the order of loss of these details was the inverse of that observed during the development of the child. Overall, declines with greater cognitive impairment were observed for all variables (p< .01 for ears and life-like movements, p< .001 for clothing, arms and legs in two dimensions, body proportions and shoulders; no F values were reported) with the exception of directed glance. The authors suggest a subset of the different tasks of copying geometrical figures, writing sentences, FFD, and writing a signature can be used to evaluate an individual's state of cognitive functioning. Knapp (1994), using modifications (M) of the House-Tree-Person (H-T-P-M) and the Kinetic Family Drawing (K-F-D-M), compared early stage Alzheimer's disease patients (n = 25, aged 51-89) and an age-gender matched healthy control group (n =25, aged 45-83) . These drawing tests differentiated persons by group (t = 11.45, p < .0001, d = 1.64), though the most substantial difference in this respect was in H-T-P-M scores (t = 12.57, p< .0001, d = 1.80). Knapp suggested these results demonstrated the effectiveness of expressive drawing tests in differentiating pathological and normal aging processes. It is of note that groups were matched on age and gender here, but the samples of normal and impaired persons were small, and no controls for drawing competence were implemented. Ericsson, Hilleräs, Sundell and Winblad (1996) examined freehand figure drawings (FFDs) in 465 elderly people aged 75 and older, 94 of whom were cognitively impaired. They were matched on the basis of age with a control group of 371 cognitively healthy elderly living in the community. Figure drawings were evaluated for essential body details, hierarchical level (e.g. non-response, scribbles, circle, headfooter, stick figure), and structural characteristics (e.g. ratio of head size to figure height, centeredness of the figure on the page). Findings indicated that the number of body details and figure height decreased with decreasing cognitive function, whereas centeredness increased with decreasing cognitive function. However, the FFD did not discriminate between individuals with Alzheimer's disease and persons with vascular dementia. While no effect sizes could be derived from this study, Ericsson et al. suggested that the FFD can help differentiate elderly persons with and without dementia as well as differentiating persons with dementias of varying severity. It is to be noted that some, but not all of the effects found in this study were small, though reliable, a likely artifact of the increased power associated with large samples. This study's principle strength is its large and representative sample and the differentiation of essential body details, attention to developmentally relevant drawing characteristics, and structural characteristics. Ericsson et al. (1994) compared the free-hand human figure drawings (FFD) of mild dementia patients (n = 11), those with moderate dementia (n = 22), and those with severe dementia (n = 27); all groups averaged between 78 and 82 years of age. Of the dementia patients, 36 were diagnosed with Alzheimer's disease (AD) and 24 diagnosed with Vascular Dementia (VD). The FFD was scored for 53 body details according to Goodenough's Draw-A-Man test, but modified for older persons (Ericsson et al., 1991). A short scale of 15 details was developed by selecting body details with high item-total correlations (SHFD). The SHFD had high interscorer (r = .96) and test-retest reliability (r =

.85) and high concurrent validity in that the SHFD was highly correlated with the MMSE scores (r = .78) and the Clinical Rating Dementia Scale (CDR) (r = .82). A one-way ANOVA indicated that the SHFD discriminated demented and non-demented patients and different levels of dementia severity (F = 82.6, p< .0001, ES r = .80); no differences were observed between AD and VD patients. Ericsson et al. suggested that the HFD is a valid instrument for assessing cognitive dysfunction in old age. While their two studies suggest that the HFD can differentiate older persons by level of impairment, their samples are very small. A similar degree of impairment (spontaneous drawing and copying a figure) among 15 dementia patients versus 15 age and gender matched healthy controls was found by Moore and Wyke (1984), though no information of the strength of these differences was provided by the authors. Ericsson, Hilleräs, Holmén and Winblad (1996) studied the effectiveness of freehand humanfigure drawings (FFD) (persons were simply instructed to draw a human figure) in a sample of 668 persons aged 75 and older to differentiate elderly people with dementia (n = 444) and healthy elderly controls (n = 224). Figure drawings were analyzed via the content of body details and structural characteristics of the drawings; findings indicated that the body details and the height decreased with decreasing cognitive function, whereas the centeredness increased with decreasing cognitive function. However, the FFD did not discriminate between individuals with Alzheimer's disease and persons with vascular dementia. While no effect sizes could be derived from this study, Ericsson et al. suggested that the FFD can help differentiate elderly persons with and without dementia as well as differentiating persons with dementias of varying severity. Wang, Ericsson, Winblad and Fratiglioni (1998) explored whether the screening capacity of the MMSE (both sensitivity and specificity; see Kane & Kane, 2000) could be increased by adding the HFD test, comparing data from 95 older persons who were affected by dementia and 366 who were non-demented. Controlling for HFD scores, MMSE scores were found to be significantly lower in the groups with different severities of dementia (p< .001) versus the nondemented group. Moreover, scores from a short version (29 HFD body details, HFD29) and seven HFD essential body details (HFDess) were significantly decreased in the demented as compared to the non-demented group (p< .01, d = 1.29). Wang et al. found that sensitivity increased by 4.2% when HFD and HFDess were added to the MMSE, compared to MMSE scores alone, concluding that the HFD29 can complement information gathered from the MMSE, especially in the relatively early stages of dementia (corresponding to Mild Cognitive Impairment, MCI; Peterson et al., 2001). To explore visuoconstructive deficits in impaired versus unimpaired older adults, Freeman et al. (2000) asked 63 older adults suffering from either Alzheimer's disease (AD), vascular dementia, or Parkinson's disease (versus normal controls, n = 20) to copy a modified version of the Rey-Osterrieth Complex Figure (a figure similar to two superimposed pentagons derived from the Bender-Gestalt test). As might be expected, normals outperformed all dementia patients; and the drawings of AD patients were of higher quality (less fragmented, fewer omissions and perseverations) than those of the other demented groups; this finding was quite robust (d = 1.9). Similarly, Fan, He, Xiao and Jia (2002) found that the HFD performance of persons with mild Alzheimer's disease exceeded (p < .05) that of persons with moderate AD, and that all persons with AD performed more poorly than normal; body details differentiated persons with different degrees of cognitive impairment as measured by the Clinical Dementia Rating Scale. However, these authors found no HFD differences in comparing AD and vascular 38 Panek, et al

dementia patients, using the Draw-A-Man test. Helmes (2012) found a similar difference in comparing older persons who were unimpaired, suffering from dementia, or presenting with some cognitive impairment, but without dementia in terms of their ability to copy the intersecting pentagons from the Bender- Gestalt (rated along a 10-point scale). As did Freeman et al., Helmes found those who were unimpaired to outperform those without dementia, who in turn, outperformed those with dementia (R = .26, d = .90). In contrast, (Jungwirth et al., 2009) found that when combined with purely cognitive measures (verbal fluency, episodic memory), figure drawing performance did not adequately predict the incidence of late stage Alzheimer's disease (AD) in a longitudinal study of older adults (average age = 78, n = 478), suggesting that, non surprisingly, such measures better reflect deterioration per se characteristic of AD, wherein many cognitive measures are sensitive to such declines (see e.g., Potter & Attix, 2006). A major problem in the clinical diagnosis of older adults is to differentiate depression and dementia, since many of the symptoms of depression mimic dementia (Wells, 1979). Thus, Clément et al. (1996) assessed the quantitative and qualitative differences characterizing human figure drawings and comparing depressed, demented, and healthy elderly persons in two studies. In the first study, the DAP was given to 39 dementia patients and a matched (gender, age, education) control group of 41 older adults. Mann-Whitney U rank tests indicated group differences in DAP scores (U = 237, p< .001), as well as for the MMSE (U = 57, p< .001). Subsequent analyses indicated good inter-rater reliability for the 20 scored items (Kappa > .65, p< .05). These 20 items made up a second (new) quantitative scale with an internal consistency of .95 (Cronbach's alpha). In Study Two, Clément et al. (1996) administered the new 20-item DAP and added a qualitative assessment (DAP 50 - based on five components from examination of the drawings; each component has a 10-point value). Participants were members of one of three groups: Dementia (n = 51) at three levels of severity; Depression (n = 70), and Controls (n = 39). Participants were similarly aged, but were not matched by gender. However, DAP scores were not related to gender, education, or age (p = .14). Mann-Whitney U rank tests indicated that DAP scores of individuals with dementia differed from those of both controls (U = 460, p < .0001, ES r= .50) and those with depression (U = 1,057, p< .0001, ES r= .36). However, there were no differences in DAP scores between controls and those with depression (p = .19). Subsequent analysis indicated that four items demonstrated good sensitivity in discriminating normals from those with dementia: presence of: eyes, nose, arms, and the connection of the arms to the trunk (p< .001). The presence of arms, the connection of the arms to the trunk, and the presence of nose, hair, ears and the trunk length discriminated between dementia and depression patients. Only one item, eyes present, discriminated between the controls and depression patients (p = .007). Clément et al. (1996) suggest that the drawings of older adults are often characterized by incompleteness, a lack of integration, flatness, a lack of proportion, bizarreness, evidence of inadequate motor coordination, and also make it difficult to identify the gender of the figure. These authors recommend caution in the use of the DAP with older adults due to a problem with inter-scorer reliability, particularly regarding the qualitative aspects of such assessment. Despite this drawback, the Clement et al. study is a fine example of needed expressive test research conducted to explicitly replicate findings, in this case regarding differential diagnosis with older persons. In the Clement et al. work, attention to matching participants across diagnostic groups is also a strength. Such work underscores the importance of expressive personality research with both intact

and cognitively/physically impaired older persons (e.g., those suffering from dementia or cognitive impairment) to more fully understand the extent of age-relatedness in expressive personality test performance. Indeed, Wang, Ericsson, Winblad and Fratiglioni (1998) observed that among persons with both cognitive impairment and severe dementia, mental, visual, and physical problems often compromise persons' ability to draw. Still, even if these other problems are considered, figure drawings can apparently still differentiate older persons with varying degrees of cognitive impairment. This is especially important when cognitive declines are mild, perhaps as a precursor to full-blown diagnosable dementia. Discussion: The Utility of Human Figure Drawing Techniques with Older Adults 30 Years On: The primary effectiveness of drawing techniques seems to be in differentiating persons with dementia/Alzheimer's disease from normal (nonpatient) older adults, and in this respect, the above findings are quite impressive, and consistently robust across studies. We note that the vast majority of effect sizes (Cohen's d, r) reported here are of at least moderate strength (d = .50, r = .30). Although some samples are small, these often use matching designs and/or statistical controls of at least some extraneous variables, and some of the sample sizes are in the hundreds, quite large by clinical research standards. Moreover, the work reviewed here reflects a serious attempt at replication/cross validation of findings, based upon the studies by Clement et al., Silver, and Ericsson and his colleagues. Still, stronger research designs are needed that consistently utilize larger, more representative samples, analyze and report cultural differences, and match groups on moderator variables (e.g., level of education, gender, health status, psychomotor skill, physical decline, sensory impairments, both premorbid and disease-related drawing competence) that would otherwise confound group comparisons. Controls for drawing competence per se and a lack of confidence in one's drawing skills, as well as for age-related or disease-specific (e.g., arthritis) shifts in drawing ability remain relatively lacking in the HFD literature with older adults. This is an especially noteworthy limitation in that Ericsson et al. (1996) indeed found small but reliable age declines in the ability to copy geometric figures among nondemented persons aged 75-90+. Thus, the systematic impact (if any) of such factors on drawing techniques' sensitivity to detect dementia at the individual level remains to be established. Though older adults were not their focus, Gardner and Brown (2010) have considered possible methodological confounds in HFD research: the presence/absence of clothing or body details and whether stimulus figures being judged for participants' body shape and size preferences are presented in an orderly or disorderly fashion (and subject to spatial bias effects). These issues have yet to be explored in such research with older adults. Given these common confounds, we were surprised that such techniques continue to be used as frequently as they are and that studies produced such large effect sizes. However, that HFD techniques do differentiate diagnostic groups (both in small scale and large scale studies) is a testament to the development and reliable application of scoring criteria that identify objective features which are not dependent upon drawing ability, artistic training, talent, self-confidence, and other extraneous individual differences. Future research should flesh out the two areas we found most lacking compared with the previous reviews: age-normative data and psychometric information about the scoring systems used. As recent normative data for both normal and clinical samples of older adults are unavailable, this deficit needs to be rectified, and should include differentiation by 40 Panek, et al

depression and/or self-destructive thinking (Hayslip, Hicks-Patrick, &Panek, 2011; Miller, 1979). In this respect, a significant deficit in the HFD older adult literature is a lack of longitudinal studies assessing age changes; we found but one exception to this void in this review (Jungwirth et al., 2009). As most studies to date are cross-sectional and often based upon small, non-representative samples, large-scale longitudinal studies are sorely needed to assess individual differences in intraindividual changes over time. Longitudinal work might inform us more clearly about whether personality does or does not change with age, depending in part upon the level (i.e. intrapsychic versus socioadaptational) at which personality is assessed (see Hayslip, et al., 2011; Mroczek, Spiro, & Griffen, 2006; Neugarten, 1976, 1977). This lack of longitudinal work is particularly unfortunate given that one easily implemented application of HFDs is to elicit HFDs from individuals at admission to a residential situation or facility as part of routine intake procedures. If change in functioning over time is suspected, new HFDs can then be compared with the intake baseline to evaluate change, much as a baseline mammogram is used to detect developing pathology. Such a strategy controls for many of the individual differences (e.g., premorbid drawing ability) that contribute to error variance in HFD scores. The specific features that differ between the first and second administration may help to differentiate economically among possible causes of change. An additional direction in accurately assessing age effects in HFD performance is the differentiation of age effects from cohort effects (see Baltes, Reese, &Nesselroade, 1988), and thus, there is a lack of work exploring potential cohort/historical influences on HFD performance. This is important given the the moderator and control variables listed above. However, this is only important to the extent that HFD scores are used nomothetically - in making comparisons of persons with regard to the normative tables of scores for their reference group. As with other expressive techniques (Panek et al., 2013), psychometric work is needed to develop a psychometric theory appropriate to these less structured measures in which the data are free-response behavior samples that are scored using a descriptive manual that quantifies certain features of the behavior sample. Psychometric standards, chiefly interscorer reliability, may then be applied to the results produced by the manual, rather than to the behavior samples. The movement in both the aging and personality literatures toward thinking about personality processes (Bornstein, 2007, 2009, 2011; Hooker & McAdams, 2003), as well as greater emphasis upon interindividual variability in personality (Mroczek, Spiro, & Griffin, 2006), may offer a promising new psychometric paradigm for evaluating HFD techniques. Age Differences: It is clear that HFD techniques are agesensitive, in contrast to other expressive techniques (see Panek et al., 2013) which are not. Indeed, many age-related findings are consistent with a pattern of increasing personality constriction with increased age, perhaps in response to declines in physical health, cognitive capacity, everyday functionality, or lack of environmental stimulation. Interpretatively, we note that such findings may reflect one's reaction to cognitive and other impairments. Persons may be differentially sensitive to the age or diseaserelated loss of their decision-making and everyday functional skills and ultimately the loss of the self as an organized entity. Each of these changes is likely to lead to increased isolation from others and/or unwanted dependence upon them, and consequently predispose one to

suffering from dementia or mental retardation) to more fully understand the extent of agerelatedness in expressive personality test performance; intact and impaired persons are likely to age differently. Comparing Diagnostic Groups: The literature reviewed here clearly indicates that HFD techniques are being used by clinicians and researchers to assess older persons reliably. While the effectiveness and appropriateness of any measure in screening for dementia and/or evaluating persons' responses to aging-related change does vary by the purpose for which a specific test is utilized, the evidence shows that HFD techniques can indeed differentiate older persons with varying degrees of cognitive impairment. Importantly, such techniques may be valuable as well in uncovering the elder's response to the loss of cognitive skills. For these specific purposes, the weight of the evidence favors these constructive approaches over verbal expressive techniques (see Panek et al., 2013). Indeed, subtle personality shifts prior to the formal diagnosis of Alzheimer's disease which are characteristic of Mild Cognitive Impairment (Peterson et al., 2001; Shigeta& Homma, 2007) may be especially susceptible to detection via HFD techniques, as may one's reaction to normal age-associated memory impairments (see Crook, Bartus, et al., 1986). Such information may be predictive of adherence to treatment as well as treatment response among those who are adherent. With a few exceptions, however, this work rests upon one-shot studies in dire need of replication, and in a few cases, the samples employed are quite small, underpowering findings. This remains true since it was observed by Kahill (1984) in her evaluation of HFD techniques (irrespective of age), based upon the literature from 1967-1982. Yet, we find here that there is substantial consistency in the question of differential diagnosis across studies utilizing samples of varying sizes using different steadily rising average level of education in successive American cohorts. Prospective studies differentiating the personality process antecedents of cognitive or functional ability changes and/or terminal drop (nearness to death) from their consequences would also be quite valuable (see Mroczek et al). It should be noted that in cases where the impact of age on HFD performance is of interest, the data must be considered correlational, wherein that age-related change is a dependent variable (see Baltes, Reese, & Nesselroade, 1988). Thus, dependent upon the acknowledgement and influence of moderating variables, findings regarding age differences may or may not replicate across studies. Consequently, the many studies that have examined age effects may only be partially consistent with those of Neugarten (1976, 1977) suggesting increased interiority with age at the intrapsychic level of personality functioning. Findings speaking to the possibility of cohort-related shifts in HFD performance could easily help to explain the failure to replicate earlier work. Bearing on the replication of age differences, we also note the need for cross-cultural research investigating age differences in other cultures/countries utilizing HFD techniques, allowing us to evaluate the generalizability and/or cultural specificity of what we know about personality processes and aging in the U.S. (Panek, 2006). This is important in light of the increasing attention to minority aging and to health disparities among minority older persons (Yee & Chiriboga, 2007). At the minimum, it is important to develop norms for ethnic groups within a particular country or culture (Panek, 2001). Considering the question of differential diagnosis as well as developmental change, our review underscores the importance of HFD research with both intact and cognitively /physically impaired older persons (e.g., those 42 Panek, et al

scoring approaches, and the effect sizes for many studies' findings are impressive enough to be taken seriously. The pattern of these findings across conceptual replications or nearreplications suggests that they do indeed reflect real phenomena that may be of clinical importance to those working with older persons. Given this body of evidence, we nevertheless argue that further HFD research is needed in the differential diagnosis of older adults, substantiating degrees of personality deterioration in such persons as well as among those whose physical health has worsened due to normal aging-related changes or due to pathological processes, i.e., illness. For example, as we have noted above, what may be operating in finding a decline in both cognitive and physical function is that we are assessing the older person's reaction to the loss of his/her skills. This contrasts with an older view of constructive test performance as a direct measure of cognitive functioning, a conclusion reached with regard to the use of HFD with children (reference). Importantly, the literature lacks studies in which HFD techniques and self-report inventories are jointly administered to clinical and non-clinical samples of older adults. This would enable one to triangulate the strengths and weaknesses for each test (Ganellen, 1996; Meyer, 1997). Future Research Needed: Extraneous Individual Differences: We found no studies focused on non-agerelated, non-diagnostic individual differences since the previous reviews. In light of the potential confounding of age effects and extraneous influences on HFD performance, there is a continued need for research to determine the effects of extraneous factors (as mediator or moderator variables) such as sensorimotor impairment, health conditions, and psychosocial problems (e.g., isolation, loneliness, discrimination) on the HFD protocols of older adults. Generally speaking, some work with HFDs reflects these ends, important in that such factors can be impediments to the use of such techniques in both research and clinical contexts (Anastasi & Urbina, 1997). However, in light of the current review, we advocate their exploration as important sources of useful information about interindividual variability among older adults (Nelson & Dannefer, 1992) that might require intervention or predict everyday functionality, and thus, would be important guides and caveats for treatment planning. Moreover, by controlling for the effects of such variables, triangulating by the use of multi-modal assessment, and/or observing their impact on expressive test responses, age differences/age changes in characteristic responses to such expressive techniques (see above) can be accurately assessed. Since the mid-1980s, researchers have moved away from simply investigating “typical” or “characteristic” response patterns of older adults on many verbal expressive personality tests (see Panek et al., 2013) to evaluating the effects of potential moderator variables on the responses of older adults. An issue not unique to expressive assessment but a risk in the assessment of older persons that might be overlooked in clinical training is the possible misinterpretation of findings. Some of the moderator variables discussed above are far more common among older adults than in the general population, and failure to differentiate their effects from age-related change, cognitive debilitation, or emotional functioning in older persons may result in misdiagnosis, inappropriate treatment, or a failure to treat. Future research studies should either build such variables into their designs, control for them as confounds, or consider them in the interpretation, as appropriate to the sample and the study's purpose. Future Research Needed: Normative Data: Although dated norms for normal and clinical samples of older adults exist for human figure drawing techniques (see Hayslip & Lowman,

1986; Panek et al., 1983), to the extent that normative comparisons are desired, new norms for current cohorts are needed. Indeed, norms may be unnecessary when interpretation is process-oriented, content-based, ipsative, or idiographic. Concluding Remarks and Recommendations: Given the difficulties in assessing impaired older persons with self-report methods, and the strength of the findings gathered here, we advocate the use of HFD techniques in tapping personality processes, i.e. transient states, self-regulation, that covary with situational/ contextual demands (see Hooker & McAdams, 2003), thus marrying non-trait-like views of personality to HFD research. As HFD scores may represent older persons' emotional responses to cognitive decline/impairment, such work would be quite valuable in assessing the functioning of persons with dementia who cannot or will not submit to being assessed more traditionally or to being extensively interviewed. Thus, in our opinion HFD techniques, have unique value for older adults, whether used alone or as an element of multimodal assessment (see Edelstein & Segal, 2011). Good assessment data are valuable when decisions affecting older adults and their families need to be made regarding a) the wisdom of admission to a long-term care facility, b) the level of care one might need, c) one's capacity to cope with and/or represent physical or cognitive deficits, or d) the implementation and evaluation of treatment plans and interventions. HFD techniques may play a valuable role in these aspects of patient care and allow the clinician to generate a hypothesis regarding the patient's functioning which can be investigated, monitored and modified with additional data as required. The course of an older person's emotional reactions to a loss of intellect or memory over time, for which HFD techniques might be quite important (e.g. see the above discussed work by Silver and Ericsson and his colleagues, Morin & Benshalah, 1998). Such changes reflects altered views of the self, dimishedoptimisim about life, and changes in one's relationships to others; these are likely to be of central interest to the clinician, as might aspects of one's physical identity/body image representing how one appears to self and others as well as reflecting one's physical competence. It ihas been pointed out that how older persons cope with such challenges also has important implications for not only their own health and well-being, but also for that of their caregivers (Knight, Kaskie, Shurgot, & Dave, 2006; Knight & Losada, 2011). Although the technology of manualized scoring systems and training manual development is less mature for HFDs than for other expressive techniques (e.g., Rorschach comprehensive system, Exner, 2001; thematic apperceptive techniques, Jenkins, 2008a, 2008b), the need for systematic, objective scoring procedures for HFDs was recognized half a century ago, and some early manuals for the general population are still in use (Goodenough, 1962; Jones & Rich, 1957; Hammer, 1997; Machover, 1949). The forthcoming volume edited by Handler and Thomas (2014) includes chapters that present scoring manuals by Naglieri and by Crisi, among others, that should be studied with older adult samples. However, many manuals, especially the earlier ones, are dependent for accurate scoring on the interpreter's clinical experience and/or grasp of theory that give different clinicians a similar set of working assumptions for scoring. In the present clinical environment of theoretical diversity (indeed differential emphasis on theory) and demand for convergent empirical evidence, training materials and methods must become more efficient and less subject to divergent interpretation. Explicit manuals with many concrete examples and rationales for scoring are needed to make accurate use of these techniques accessible to students, practicing 44 Panek, et al

clinicians, and researchers, as well as defensible to critics. A helpful clinical strategy while we wait for the necessary science, and a good strategy for producing that science, is the joint use of tests and assessment procedures that are sensitive to the same diagnostic targets but are susceptible to different sources of systematic method error variance. Apparently “conflicting” findings among methods can reveal a need for the careful differential diagnosis of agenormative, pathological, and situational influences. The best example of this strategy, i.e., reviewing the combined use of the Rorschach and MMPI-2, given their different response style biases, is work reviewed by Ganellen (1996) (see also Clemence& Handler, 2001). An important emerging strategy is an increasing focus on the elements of the response process, for example their sequencing or overall integration, relative to a single quantitative score (Bornstein, 2011). Such integration has long been an important implicit element of most of the extant HFD scoring systems; it remains only to make the scoring criteria explicit and the manuals and training materials widely available. As 1) the above cited work could easily be seen as an underestimate of the true worth of HFD methods with older adults, 2) such persons are increasingly more likely to be seen in clinical settings and 3) the need to assess them becomes more imperative, further appreciation of the unique value of HFD techniques with older persons will hopefully increase. Their ease and efficiency of administration, engaging and less demanding assessment process, nonthreatening indirectness, ambiguity to the client, and subtle data yielded recommend them for this population. HFDs indeed merit much more research attention regarding the study of personality and aging. References: Abeles, N. (1997). What practitioners should know about working with older adults.APA. Washington, DC. th Anastasi, A., & Urbina, S. (1997). Psychological testing (7 Ed.). Upper Saddle River, NJ: Prentice Hall. APA Monitor. Psychology's growth careers, April 2008, pp. 64-65. Baltes, P., Reese, H., &Nesselroade, J. (1988). Life span developmental psychology: Introduction to research methods. Hillsdale, NJ: Earlbaum. Blazer, D. (2002).Depression in late life.New York: Springer. Bornstein, R.F. (2007). Toward a process-based framework for classifying personality tests: Comment on Meyer and Kurtz (2006). Journal of Personality Assessment, 89, 202-207. Bornstein, R. F. (2009). Heisenberg, Kandinsky, and the heteromethod convergence problem:Lessons from within and beyond psychology. Journal of Personality Assessment, 91, 1-8. Bornstein, R. F. (2011). Toward a process-focused model of test score validity: Improving psychological assessment in science and practice. Psychological Assessment, 23, 532-544. Clemence, A. J., & Handler, L. (2001). Psychological assessment on internship: A survey o f t r a i n i n g directors and their expectations for students. Journal of Personality Assessment, 76, 18-47. Clément, J.-P., Marchan, F., Boyon, D., Monti, P., Léger, J.- M., & Derouesné, C. (1996). Utilization of the Draw a Person Test in the elderly. International Psychogeriatrics, 8, 349-364. Crook, T.H., Bartus, R.T. et al. (1986). Age-associated memory impairment: Proposed diagnostic criteria and measures of clinical change. Developmental Neuropsychology, 2.261-276. D o u g h e r t y, L . M . , & C o o k , D . B . ( 1 9 9 1 , November).Development of a geriatric draw-a-person scoring system. Paper presented at the Annual Scientific Meeting of the Gerontological Society of America. San Francisco, CA. Ericsson, K., Forssell, K., Amberla, K., Holmén, K., Viitanen, M., &Winblad, B. (1991). Graphic skills used as an instrument for detecting higher cortical dysfunctions in old age.Human Movement Science, 10, 335-349.Ericsson, K., Hilleräs, P., Holmén, K., Jorm, A., et al. (1994).The short human figure drawing scale for evaluation of suspect cognitive dysfunction in old age. Archives of Gerontology and Geriatrics, 19, 243-251. Ericsson, K., Hilleräs, P., Holmén, K., & Winblad, B. (1996).Human-figure drawing (HFD) in screening of cognitive impairment in old age. Journal of Medical

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Culture is the lens or template we use in perceiving, constructing, defining and interpreting reality. People from different cultural contexts are expected to define and experience reality in different ways. The views of therapies developed in the western individualistic culture and Indian collectivistic culture are strikingly different. Therefore, to successfully treat the patients reared up in Indian culture, the therapist – mostly trained in therapies developed in the west – must remain aware of these influences and approach them in a way that is congruent to their belief system. The case presentations illustrate religious and cultural factors markedly influenced the therapeutic intervention. The first case illustrates the psychopathology of a Schizotypal patient and the second one presents with features of Hypochondriacs – following the ICD 10 (WHO 2006). An attempt is made to formulate the psychopathology following the western models and illustrate how the cultural factors influence the presentation. Furthermore, attempts have made by the therapist to tailor the interventions developed in the west in accordance with the Indian philosophical and cultural modes. It is argued that, until empirically validated Indian psychotherapies are developed and therapists are trained well enough to utilise the Indian methods of therapy, such attempts towards integration can be beneficial. Utilisation of such an approach is likely to reduce resistance in the patients and enhance compliance, and thus have widespread clinical significance. Culture can be understood a learned system of values, beliefs, meanings, rules and practices that are passed from one generation to the next in patterned ways. Culture provides a way of looking at the world and of experiencing it. Bakhtin (1981) defined culture as “all the ways of life including arts, beliefs and institutions of a population that are passed down from generation to generation.” The civilisation in India dates back to thousands of years before the dawn of civilisation in the western European nations. From the prehistoric ages, the fertile land of India has been home to civilised human beings who lived in towns and villages. Persons of several communities from the various parts of the world have come into the Indian subcontinent and vastly influenced the life and livelihood of the natives. In turn they have been so greatly influenced by the ways of life of the natives that in course of time, it became impossible to ascertain their separate identity.The seeds of the latest impact of the western world were sown by the British who influenced the socio-political as well as the educational system. A large section of the population accepted their patterns of thought and philosophy. Since independence, in the pursuit to become a developed nation, the policy makers have followed the British tradition. However, the vast land of India has not been equally moulded by the influences across the ages. Even within a geographical region, certain groups have held on to their beliefs and customs. As a result, different persons in India have completely different, at times contradictory – psychological templates of worldview. It is not easy to point out a single Unitarian Indian culture, though various similarities are shared by a vast majority. Indian civilisation is historically a collectivistic culture and religious and philosophical beliefs are ingrained in the

explanations and guidance for the patients who cling on to their faulty, pseudo-philosophical ideas and thereby cause suffering to themselves and others. Attempts towards directly confronting these defences are likely to cause therapeutic rupture and weaken therapeutic alliance. On the other hand no empirically validated Indian methods are available and the therapist has to depend on the western models. It becomes essential to understand and formulate the psychopathology along the lines of western treatment paradigms available. Among the several treatment paradigms developed in the west, the psychoanalytic perspective, provides the most intellectually satisfying view of mind (Kendell, 2005). Moreover, this depth-psychology approach provides the scope of an in-depth exploration of the person's psyche. Furthermore, attempts have been made by this school of thought to understand and explain religion and culture (Freud, 1953-1974). While this school of thought has the rich heritage of in-depth exploration of different aspects of human life, it also enjoys the status as a scientific treatment procedure in several countries for different mental illness (Charman, 2004). Moreover, it is asserted by the Indian school of thought, that the process of knowing cannot be separated from the knower and instructed from the outside. Similarly, in psychodynamically oriented therapies, the analysts (or therapists) are specially trained to be able to monitor their subjectivity while dealing with the patient. Thereby the therapist provides the interpretation when the patient is ready to accept it. However, interpretations are only hypotheses that the patient has the right to accept or refute (Saddockand Saddock, 2000). However, the radical biological and interpersonally based psychodynamic model roots of it. Although the western education has flourished here, many persons – including those having exposure to western culture and education – still are ardent believers of the Indian religious and philosophical thoughts. As a part of culture, religion is entwined deeply in their belief systems. Authentic understanding of religion acts as a buffer to stress and enhances the quality of life. It provides the cushion to tolerate the pains of materialistic living. However, our clinical experience suggests that erroneous use of religious concepts can prevent a person from attaining mental health. The symptom manifestations of the mentally ill are often largely coloured by their half-cooked religious ideas. Their apparent search for salvation through religious practices reflects their inauthentic, defensive manoeuvres which contribute to their immaturity and lack of scientific knowledge. The richness of Indian culture is acclaimed around the world. However, the major weaknesses of the Indian systems of education and science lie in the lack of documentation and scarcity of controlled scientific research. This leads to lack of empirically validated treatment procedures to deal with mental illnesses. As a result, the clinicians currently practising in India face several difficulties. There is scarcity of Indian psychological texts and teaching methods. Therefore, the training provided to them is developed in the west. The western culture is different from that of India. It is largelyindividualistic, has an outlook of consumerism and has a bio-centric bias (Rao, 2008). In contrast, the Indian culture is collectivistic; its philosophical and psychological stance is largely based on consciousness and salvationfrom suffering, and mostly preaches the values of self-control and TYAG (giving up) (Rao 2008).Therefore, most of the western schools of thought fail to provide sufficient

has little space for philosophical and religious ideas. If used in a crude fashion, it can be detrimental for the person's psychological wellbeing too. The Cognitive Behavioural model as well as the Rational Emotive Behaviour Therapy models relies heavily on rational thinking and objective empiricism. CBT emphasises on the cognitions and their errors leading to maladaptive emotional reactions and behaviour (Wells, 1997). REBT on the other hand, focuses on the belief system of the individual which lead to maladaptive response patterns (Dryden, 2001). These schools believe in objective demonstration and measurement of the problem and their modification. Thus they minimise the scope for the scope of subjective bias in therapy. In the current paper, an attempt is made to present two case illustrations where the therapist attempted to formulate the psychopathology of the patients following the psychodynamic model while taking the cultural aspects into consideration. Moreover, the communication with the patients was specifically moulded by keeping them congruent with cultural beliefs. Case Vignettes: Case 1: The indexed patient N.D. was a 42 years old Hindu male hailing from sub-urban region around Kolkata, belonging to low socioeconomic background and presented with the complaints of burning sensations inside his head and aches inside his stomach for the past 3 years. Further questioning revealed his odd belief that as if some tortoise-like creature is sitting inside his stomach. He reported that a 'tantric' was trying to cause harm to him. Gradually it was revealed that in childhood his family was very poor and his father, at the age of 45 years, had left them to attain sainthood. Neither the patient nor any of his family members know anything regarding his whereabouts. His elder sister required psychiatric treatment for disorganized behaviour and uncontrolled aggression. Later on she committed suicide by jumping in front of a train. The patient was very unruly as a child and did not comply with authority. He had a stormy relationship with his mother. Around the age of 17 years after a quarrel, he left his family and went away to Assam and started worshipping the goddess “Kamakhya”. He roamed around in several places and lived like a beggar. Thereafter he met a tantric (spiritual practitioner)who showed some magic which stunned the patient and he was led to believe that the tantric had special powers. He became disciple of that tantric and believed that he had learned certain ways of Yoga that could lead to unison with God and Moksha. One day the tantric asked the patient to marry his daughter, who was a divorcee. The patient refused to do so and the tantric became angry with him and swore to cause harm to the patient through his special powers. The patient left that place and started working as a plumberand got married. One day there was a quarrel in his neighbourhood and someone shouted at him without any fault on his part. Thereafter his psychological health deteriorated. He started believing that others are trying to harm him and the tantric is plotting behind. He believed that some odd creatures had entered his body and this is leading to his symptoms of burning sensations all over, especially in the head. He started to display disorganised behaviour and was treated by using ayurvedic as well as antipsychotic medications. Although he improved, the symptoms persisted. Every night when he sat for meditation (Tantrasadhana) of 'Ma Tara' or 'Baba Tarakeshwar' (a famous Goddess and 50 Mitra and Sanyal

so weak that he failed to save his daughter's marriage and could not even convince the patient to marry her. Rather the patient was powerful enough to withstand his witch-craft for ten years. Moreover, the world also consists of good persons too – the doctors – who have been largely successful to help him by their medication, which is their 'sadhana'. Finally he was explained the concepts of different ways of religious practices. The saints have also accepted 'family life” as a way of worshipping God and reaching 'moksha'(salvation) through selfless service. He was thus persuaded within the realms of Indian tradition to give more attention to his family and work. He reported of improvement and was able to provide better support to his family members, while continuing medication. However, he was depressed regarding his tantric guru being so evil. Therapist remained supportive throughout the sessions. After 8 therapeutic sessions, once the patient came 3 hours late and the clinic got closed. Thereafter, he did not come for further therapy sessions, but he was visiting the psychiatrist regularly for medication. He reported improvement even after 6 months of follow-up. Case 2: The indexed patient K.P., 27 years old Hindu male, belonging to middle socio-economic status of suburban area adjacent to Kolkata. He presented with the complaint of a fear that he would get infected by rabies, for the past 10 years. He reported that he was bitten by a dog around the age of 13 years. However, he did not take the vaccinations to prevent rabies, nor did he observe whether the dog died within a few days after biting him. Around the age of 17 years, when he was preparing for his higher secondary examinations he overheard that rabies could occur long after a dog-bite (5- 7years). Following this, he became anxious, God in that area), he reported that he was distracted by evil spirits screaming like Hyenas and Foxes. However, he was adamant that he would achieve moksha (salvation) by such religious and spiritual practices. It was understood that the patient was suffering from an ongoing psychotic process and required anti-psychotic medication. Clinically, he had features of delusions of reference and persecution, fleeting hallucinations and his somatic complaints reflected abnormalities in perceptual and thought processes. However, his religious beliefs actually stood against his treatment process. He firmly held on to his beliefs of tantric rites which are largely culturally sanctioned, but his thought process marked the bearings of psychopathology. He believed that the tantric had fed him such things which caused his physical discomforts and fear. With the object of psychiatric treatment compliance, the therapist argued that if the poisons of the tantric are stored in his stomach and spread through blood – so would the medicines do. These medicines prescribed by physician are chemical agents that would counter-act those harmful chemicals. Moreover, as the patient mentioned being afraid and psychologically weak, therapist argued that if the medicines of the evil tantric can weaken him and medicines given by doctors could cause improvement (as his past experience with doctors suggest) then these medicines too can strengthen his mental state. It was further suggested that if he remained more stable, he would be able to practise yoga even more effectively. These words could persuade him and he agreed to visit a psychiatrist. Later also he was persuaded similarly to continue medications and he reported of further improvement. As medical compliance was achieved, the next step focused his cognitive structures. He was persuaded to accept that his tantric was actually

could not study and suffered from anxiety and headache. Thereafter he took vaccination and his anxiety was reduced. Although he was apparently symptom free, one day he came to know that the vaccine is ineffective as he had not taken it within the medically stipulated period after dog bite. Following this, his worries, palpitation, headache, weakness returned. His appetite and libido decreased but he remained energetic in his work and performed well as an LIC agent. His seniors were impressed by his work. Thus, although he was able to function well apparently, he was periodically tormented by the fears of death. As a child he was very unruly and undisciplined. He was never regular in school and bunked classes. His father stayed away on Job. His mother used to beat him up to make him disciplined though no change in his behavior. He was a very energetic sports-person, and used to play in the club. At age 16 he viewed Blue movie along with his friends in Club. He was advised by elders that sex is condemnable and can cause weakness. Thereafter, although he liked blue movies, he withdrew himself. He was doing very well in studies while in class XII and liked by girls. He also developed liking towards a girl. He viewed physical relationship is acceptable only after marriage. During this period, his fear of death due to rabies emerged prominently. After this, he became disciple of a religious guru following Lord Krishna. He was taken to a Psychiatrist who referred him after medication to a female psychotherapist who administered 20 sessions of CBT. Initial improvement was followed by stagnation as the patient got stuck with the fear of being alone after the therapy ends. At this stage, he was referred to one of the authors practicing psychoanalysis. After certain clarifications about the illness, therapist tried to understand the underlying unconscious dynamics of the patient. Mr. K.P.had desire to make love with a girl while studying in class XII, but could not express to her. He condemned such feelings as he was a bachelor, led to guilt regarding sexuality. He was given sex-education, and explained how sexual desires are inevitable after a certain age. Though his attempts to worship Lord Krishna hold on to the religious chanting prescribed by the guru helped him to suppress the sexual desires. The “pranayama” (breathing exercises) helped to calm down his anxieties. However, he was still tormented by the fear of dying due to rabies. In Hindu Shastra, death is often seen as “Nirvana” freedom from life. The soul is indestructible and only changes forms. Thus, the therapist confronted his idea of religion within the paradigms of religious philosophy. He was moved by this argument, and agreed that the real Yogis do not bother about death. The therapist re-educated him to understand the meaning of religion and its practices with correct interpretation. The patient agreed, and in the next session, he was able to see the opposite forces at work within his psyche – one side wants to obey the moral values whereas the other side wants to defy it and seek pleasure of primitive impulses. The point of psychological vulnerability and discomfort was clear to the patient. He was also on the verge of realizing that he was actually afraid of some form of punishment, as he secretly enjoyed sexual fantasies. Mr. K.P. reported quite stable and relieved after therapeutic interventions. His denial of sexual desires gradually decreased after psycho-dynamic psychotherapy. Later sessions revealed his ability to realize his own conflict of autonomy versus compliance regarding authority that led to passive aggression. His escalated fear of snakes during 52 Mitra and Sanyal

this period was carefully interpreted. He gradually realised that, his attempt to be a disciple of a guru was flight from the conflicts of everyday life. After therapeutic intervention, he agreed to get married and gradually psychotherapy was terminated. Discussion: It is evident in the above case illustrations that the symptom manifestations of the patients were largely mediated by cultural influences. It is not unlikely that if the therapist questioned their beliefs and tried to show the fallacies being adhered to in the name of culturally sanctioned practises, a lot of resistance would have resulted. The chances of drop-out and avoidance of such interventions in future could also result. On the other hand, scarcity of empirically validated eastern psychological treatment paradigms, and lack of training in the available material made it impossible for the therapist to follow indigenous methods. Therefore, the therapist decided to strictly adhere to western methods – in which he is trained – but have respect for the cultural issues, tolerate them and fit them within the western treatment paradigm. It was done in five phases. First, arriving at a diagnosis; second, formulation of psychopathology; third, psychoeducation; and fourth, rationally questioning the frames of thought of the patient and finally guiding the path of intervention along the lines of psychodynamics. Case 1: First stage: Arriving at a Diagnosis: Arriving at a diagnosis can be considered as the first step as it guides the treatment process, and also helps in communication across clinicians. The features of fearfulness in case 1 reflected his paranoid delusions. These were considered to be delusions not only because of its contents (which are not completely out of keeping with the client's background as many people in our culture do believe in witchcraft) but primarily due to its logical fallacies and over-abstraction. His odd-eccentric beliefs regarding his somatic preoccupations reflected either his delusional misinterpretation of bodily sensations or were hallucinatory experiences. The sounds of animals he perceived during his yoga or religious prayers in night reflected his fleeting hallucinatory experiences. As no informant was available to elaborate on case history, it could not be ascertained whether he ever had a psychotic breakdown. On the basis of above information, he was provisionally diagnosed as having Schizotypal Disorder with a differential diagnosis of Undifferentiated Schizophrenia. Second stage: Psychopathology Formulation: Case 1 reveals significant family history of psychotic illness in his elder sister. His father could also be suffering from psychotic condition.Thus, the patient might have been genetically vulnerable. Due to prevailing mental illness in family and poverty, his early childhood is likely to have been stressful. These could lead to poor object relations and fixations of the personality in the level of psychotic personality organization which is dominated by immature defences such as delusional projection and splitting – as mentioned by psychoanalytic theorists such as Melanie Klein (Segal 1975). As the child reached adolescence, due to biological factors as well as psychosocial stressors (including the suicide by elder sister and taking up responsibility of adult life), he found himself inadequate. This could have led to desires to regress back to infantile stage of life where the child idealises his parents as omnipotent and desires to share their power by

being in complete unison with them – as mentioned in the concept of fixation and regression in the works of Sigmund Freud (Hall et. al. 2000). The desire of the patient to achieve moksha, is actually the psychotic's rejection of reality and fantasy to be ideally loved and united with the good mother – here being expressed as “ma tara” due to cultural influence on perception. The tantric and the evil forces can represent the projection of hisown evil and painful aggressive desires, which threaten to overpower the conception of good self-image holding on to the good mother. Moreover, the procedure of 'Sadhana' followed by him is same as that of his father. This could also indicate identification with the father which would lead to conquering the mother (fantasised by male child in Oedipal stage) – through religious and tantric practices. These conceptualisations owe a lot to the theories of Klein (Segal 1975). Third stage: Psycho-education: It was necessary to put the client under proper medication. Hence, he was given the right information regarding the utility of drug compliance. However, the language was tailored to match his belief system. It was accepted that he might be imbalanced by certain harmful chemical compounds, and the effects of those needs to be expelled from his body. It was suggested that the chemicals of the medicines could help to heal those negative effects. Thus, the aspect of neuro-transmitters was simply used and it helped to improve compliance. The patient visited the psychiatry department of a government hospital, collected the medicines and regularly started taking them. While answering his question 'why am I suffering?' therapist remained supportive and said 'actually you have undergone a lot of hardships since childhood days and also were deeply hurt by the behaviour of the tantric who was your guru. Thus you became fragile psychologically and are suffering.' Thus, the interaction of vulnerability with stress and its role in development of psychopathology was explained in simple terms to him. Fourth stage: Rational Analysis of Thought Process: He was encouraged to ask question about the belief that would harm him. Gradually it got elicited through 'Socratic Questioning' (Beck, 1976) that his tantric guru is not omnipotent, rather has no power. He has improved economically and is presently supporting his wife and two schools going sons. Moreover, he questioned his negative automatic thoughts of being vulnerable and harmed and could refute them. Furthermore, his belief regarding the world as an evil place was challenged and it was shown that the good also exists in this world. The doctors have been largely successful in treating him. This he interpreted as the blessings of 'ma tara'. This led him to believe non-directlythat the world is a safe place. At large, the therapist was actually following the path of supportive psychotherapy and acting as an auxiliary ego of the client (Saddock and Saddock 2000) at one hand and using the concepts of cognitive behaviour therapy on the other (Beck, 1976). Final stage: Guidance along Psychodynamic lines: From the psychodynamic point of view, it was a form of supportive therapy where therapist at times was available as the auxiliary-ego. However, when the therapist was trying to show the presence of both good and bad in the world, he was actually reducing the patient's reliance on splitting. By using empirical logic, attempts were made to reduce the level of delusional projection. The supportive attitude of the 54 Mitra and Sanyal

therapist was essential in strengthening the client's fragile ego. Finally, it was understood that as the patient has poor object relations, he cannot be expected to form a strong therapeutic alliance. Hence, confrontations on the points of logical errors and defensive use of religion were circumscribed. As he had poor object relations, and his apparently heightened religious practices weakened his interpersonal relatedness, he was shown the option of 'Family life' and 'karmayoga (duties)' as a medium of attaining moksha (salvation). In this way he was being discouraged from secluded meditation, and encouraged to enhance his inter-personal relatedness. Thus, though the language was in keeping with the culture, the interventions were strongly rooted in the empirical and theoretical works documented in the west(statement not needed). CASE 2: First stage: Arriving at a Diagnosis: Case 2 revealed the primary feature of fear of being infected by dog bite leading to “Rabies” which may lead to death. This long-standing preoccupation leads to the features which mark the arousal of sympathetic nervous system. This stress in turn led to complaints of headache and depressive symptoms. He was provisionally diagnosed as a case of Hypochondriasis with Mild Depressive Episode. Second stage: Psychopathology Formulation: The case history indicates that the patient was very energetic and unruly in childhood. Since his father stayed away from home, it is likely that he got more attached with his mother. This dyadic relationship was based on ambivalence and the client himself reported that after being beaten up by his mother he felt as if the scores were settled. Due to this enmeshed bond with mother-figure and a strong id (reflected by his unruliness) he probably developed a strong Oedipus complex. However, to balance this, a strong superego (symbolically the watchdog which induced fear of punishment in him) also emerged – probably from the same disciplinarian and at times aggressive mother. This strong superego kept the id under check. However, in due course of development and maturation his sexuality emerged in adolescence along with romantic interest in a girl. This rejuvenated the earlier conflict of the oedipal stage in the unconscious level. The symbolic expression of his desires was probably threatening to the ego. He apprehended punishment from outside as he projected his feelings of conscience – probably directed towards the mother as the source of external superego. Even this could give rise to intense tensions and hence displaced the idea of punishment that could even cause death onto dog-bite and fear of rabies. As he was suffering from intense guilt and anxiety, the ego opposed the id and took the side of the ego ideal to satisfy the feelings of conscience. This projected egoideal is the religious practises he is following. These rituals helped him to suppress his sexual drive and the breathing exercises and meditation helped him to control his anxiety. However, they failed to provide full remission as these behaviours were actually defensive manoeuvres, in the pattern of reaction formation. Hence they failed to give complete satisfaction as unconsciously the id desires threatened to break through. The client was actually dependent on his mother and this was transferred on to the earlier therapist leading to complications in reaching effective cure. He was unconsciously seeking approval from the mother-figure, the therapist, as he feared separation that meant withdrawal of love and thus punishment – the same cycle of

psychopathology that caused his neurosis. The above formulation of psychopathology seemed to be explicitly along the psychodynamic lines (Hall et al 2000, SaddockandSaddock 2000). Third stage: Psycho-education: Client was given psycho-education regarding hypochondriasis and neurotic anxiety spectrum of disorders, and how it was related to inner psychological weakness which can be treated by psychotherapy. As the patient's problem could clearly be seen as centring on sexuality, sex education was provided including the understanding regarding the lower brain that humans share with lower animals. Specifically this was done to reduce his guardedness and bypass the influence of culture. This was expected to open up the road for further discussion and deeper exploration. Fourth stage: Rational Analysis of Thought Process: As the patient had received interventions along the lines of CBT, causing improvement in the initial stages but then leading to stagnation, the present therapist did not work much on this line. However, through Socratic Questioning he revealed that it was likely that many others too suffer from dog-bites but do not develop such intense fears. Thus he could accept the likelihood of psychological weakness and the operation of other psychological factors. Moreover, rational analysis of his understanding of religion helped him realise that if he could truly appreciate the religious views, he would not have been so much bothered by death anxiety – as death is inevitable and also a In addition to background information about the diagnosis and symptoms, clients are presented with a cognitivebehavioral model to provide a framework for understanding their symptoms and anxious experience in this model. form of getting freedom from limited worldly life filled with sufferings according to many schools of Indian philosophy. This paved the way for agreement by the patient to discuss other, apparently unrelated areas of his personality. Final stage: Guidance along Psychodynamic lines: The initial sessions were aimed to strengthen the patient's ego through rational analysis, while the therapeutic alliance gradually became strengthened – which could tolerate the upcoming stressful issues more openly. Thereafter, he was inquired regarding his adolescence phase to uncover his romantic fantasies. The probable links between his romantic interest and onset of neurosis was clear to the therapist, but the interpretation was avoided. Rather the session focussed on the presence of conflicting opposing wishes for pleasure and morality, and its resultant psychological stress was dealt. Thus, the conflicts between superego and id was gradually emerging which overwhelmed the weak ego earlier, and led to symptom formation. The ego-ideal was represented in this case by religious institutions. Moreover, the client's character pattern was a reaction formation as well as expression of passive aggression. Working through those conflicts led to acknowledgement of libidinal and aggressive desires which led to improved adjustments and expression of willingness to get married and accept responsibilities. The above discussion thus reveals that the models of western school of thought can be useful while treating Indian clients. However, if the clinician attempts to directly confront their defences which are masked by apparently normal and useful cultural practices, it can lead to rigidity in the patients by strengthening of the 56 Mitra and Sanyal

defences and viewing the clinician as biased against the patient's cultural mores and beliefs. On the other hand, if the clinician is aware of the cultural background, shows patience and carefully examines the thought process of the patient – he is bound to find the discrepancies and also guide the patient to discover them and motivate them for change. The western models are indeed developed to treat human beings, and the human race does share characteristics which are basically common but often culturally variegated. Therefore, the importance of understanding and having a thorough knowledge regarding the cultural background can never be undermined (not true). In conclusion, it can be said that the approach mentioned above, is completely based on clinical insights and judgement of the clinician. Acceptance or rejection of this approach awaits the test of empirical validation through controlled scientific research. Several ideas and clinical insights pertaining to psychoanalysis lack empirical support (Hall et al 2000). Therefore, more scientific research with stringent methodologies while allowing the scope of consideration of the cultural nuances can be useful. However, until empirically validated techniques of completely indigenous psychotherapy for different psychiatric disorders are developed, the approach mentioned above is likely to reduce resistance and enhance compliance while using a scientific paradigm. References: Arnold, M. (2006).Culture and Anarchy. NY: Macmillan. Bakhtin, M. M. (1981). The dialogic imagination: Form essays, Holquist,M. (Ed.). Trans. Caryl Press. Beck, A.T. (1976).Cognitive Therapy and the Emotional Disorders. New York: International Universities Press. Charman D.P. (2004), (Ed.) Core Processes in Brief Psychodynamic Psychotherapy – Advancing Effective Practice, New Jersey; Lawrence Erlbaum Associates. Dryden, W. (2001).Reason to change: A rational emotive behaviour therapy (REBT) workbook. Hove: Brunner- Routledge. Freud, S. (1953-1974). The Standard Edition of the complete psychological works, J. Strachey (Ed.). London: Hogarth. Kendel, E. (2005) Psychiatry Psychoanalysis and the New Biology of Mind. Washington DC: American Psychiatric Publishing. Rao R.K. and Dalal A.K. (2008) Sadock B. J. & Sadock V. A.(Eds.)(2000) Kaplan & Sadock's Comprehensive Textbook of Psychiatry(7th ed.) NewYork: Lippincott Williams & Wilkins. Wells A.(1997), Cognitive Therapy of Anxiety Disorders – A Practice Manual and Conceptual Guide. New York: J. Wiley & Sons. Handbook of Indian Psychology. New Delhi: Cambridge University Press. Segal H. (1975). Introduction to the work of Melanie Klein. Ed. Khan M. S. London: Hogarth Press.

The present study was an attempt to gather preliminary observations to explore if Exner's Comprehensive Scoring System is sensitive enough to tap and discriminate various kinds of disorders of content of thought, specifically, delusion of infidelity in persons with psychotic illness. The sample comprised of 5 patients having delusion of infidelity and 5 patients having other delusions drawn from inpatients of Institute of Mental Health and Hospital, Agra. Psychotic Symptom Rating Scale (Haddock et al. 1999) was used for understanding of severity of delusions. Rorschach Inkblot Test was administered and scored in accordance with the Exner's Scoring System. The findings revealed that none of the scoring variables of Exner scoring system could differentiate the groups. Schizophrenia is a clinical syndrome of variable, but profoundly disruptive, psychopathology that involves cognition, emotion, perception, and other aspects of behavior. The expression of these manifestations varies across patients and over time, but the effect of the illness is always severe and is usually long-lasting. The disorder usually begins before age 25, persists throughout life, and affects persons of all social classes. The life time prevalence of schizophrenia is about 1 percent, which means that about 1 person in 100 will develop schizophrenia during their lifetime. Schizo-phrenia is equally prevalent in men and women. The two genders differ, however, in the onset and course of illness. Onset is earlier in men than women (Kaplan & Sadock, 2007) (p.467) Disorder of content of thought: It is customary to define a delusion as a false unshakeable belief that is out of keeping with the patient's social and cultural background. The content of delusions in schizophrenia is dependent, to a greater or lesser extent, on the social and cultural background of the patient. Common general themes include persecution, jealousy, love, grandiosity, ill health, guilt, nihilism and poverty. The commonly used term 'delusion of jealousy' is generally a misnomer as patients tend to have morbid jealousy with delusions of infidelity, rather than delusions of jealousy (Munro, 1999). Delusions of infidelity may occur in both organic and functional disorders. Often the patient has been suspicious, sensitive and mildly jealous before the onset of the illness. Delusions of marital infidelity are not uncommon in individuals with schizophrenia and have been reported in many different varieties of organic brain disorders, but are especially associated with alcohol dependency syndrome. Delusions of infidelity are also seen in the affective psychosis, where they may again represent a morbid exaggeration of a premorbid mildly jealous attitude (Casey and Kelly 1978) (p.44) The Rorschach Inkblot Test assesses broad personality characteristics and their behaviour proclivities (Blatt, 1990; Exner,1988; Weiner, 1997) by evaluating cognitive processing via the examination of what the individual has

assigned to his perceptual experiences (Exner et al,1978; Weiner, 1997). The perceptual cognitive processes that invoke subjects in formulating and articulating their responses provide clues to their characteristic ways of dealing with life experiences and their psychological state and traits. It also helps to understand how they process information and how they prefer to cope with problem solving situation (Weiner, 1997). According to Garber and Kaminski (2002), the responses on the Rorschach protocol conceptualize different types of shortcoming in individual cognitive perceptual processing. Kleinger (1999) has pointed out that delusional disorder and obsessional thinking share some important structural features. Auslander et al, (2002) compared 27 medically stable out patients with paranoid schizophrenia to 17 outpatients with non-paranoid schizophrenia and 45 normal comparison participants. The paranoid patients showed significantly less impairment on Rorschach measures of perceptual inaccuracy and cognitive slippage. Belyi (1991) found that the responses on Rorschach protocols of patients with systematized delusions were similar to those of normal controls and were distinguished only by greater attention to detail. Kleinger (1991) reported a case of frankly delusional woman whose Rorschach protocol had no indication of perceptual inaccuracy or cognitive distortion. The present study was an attempt to gather preliminary observations to explore if Exner's Comprehensive Scoring System is sensitive enough to tap and discriminate various kinds of disorders of content of thought specifically, delusion of infidelity, in persons with psychotic illness? Method: The sample was collected from the Inpatient Department (IPD) of the Institute of Mental Health and Hospital, Agra. 10 persons with psychotic illness were taken for the study. Five of them had a prominent delusion of infidelity and the other five had delusions other than infidelity. Following tools were administered – (a) Psychotic Symptom Rating Scale (Haddock et al. 1999) for mapping severity levels of psychotic symptoms. (b) Rorschach Inkblot Test as per Exner Scoring System. 83 variables were scored in each Rorschach Protocol and processed through Kolmogrove-Smirnov Test for group comparisons to identify the scoring variables that could discriminate the groups. Exner’s Scoring System: 59 Table 1 Scoring Variables and Kolmogrove-Smirnov Test Values Z .000 .000 -1.000 -1.000 .000 .000 -.106 .000 .000 .000 -.434 -1.170 -.319 -.449 -.671 .000 -1.491 Z -.419 -.106 -1.054 -1.396 -1.088 -.943 .000 -1.017 -.529 -.110 .000 -.876 -1.000 -.655 .000 .000 .000 VARIABLE psyrate W D Dd S DQO DQVPLUS DQV F M FM m C CF FC Cn C' C'F VARIABLE FT VISTA VF FV Y FY PAIR rF Fr FQPLUS FQO FQU FQMINUS H Hd (H) (Hd) H VARIABLE (Ad) An Art T Ay Bt Cg Cl Ex Fi FOOD GEO Hh Na Sc Xy Ls S Z -1.000 -.386 -1.000 .000 .000 -.904 -1.000 -1.000 .000 .000 -1.000 -1.000 .000 -.775 -1.500 .000 -.643 1 000

system for assessing the presence of thought disorders in the subjects. The present study is one step ahead in its approach with a specific focus on assessing the power of Rorschach quantitative variables if any of the variables is sensitive enough to detect the presence of specific type of disorder in the content of thinking. The quantitative data generated in this pilot study did not support the idea of specificity of Rorschach variables for the detection of delusion of infidelity. Similarly, it may be the case for other delusions too which need to be investigated specifically. There could be a multitude of reasons that can account for this failure of Exner system in detecting specific delusions. Firstly, inherently it may not be possible for Rorschach's quantitative system to tap specific kind of delusions. Secondly, the sample size is too small to permit inductive logic. A study done by Belyi (1991) found that Discussion: The Rorschach Inkblot Test is one of the most frequently used test for making diagnosis in clinical setting. The present study was conducted to gather preliminary observations regarding whether Exner's Comprehensive Scoring System is sensitive enough to tap and discriminate various kinds of disorders of content of thought, specifically, delusion of infidelity in persons with psychotic illness. 93 scored variables according to Exner system were processed for non-parametric analysis and none of the variables of Rorschach protocol differed significantly in groups of psychotic patients with delusion of infidelity and without delusion of infidelity. The literature on Rorschach Inkblot Test does exist which attempt to detect thought disorders on Rorschach Inkblot Test through Exner system. In fact, a Perceptual-Thought Disorder Index has been formulated in the scoring There is no significant difference between both the groups on their Z scores. None of the variables of Exner Scoring System could discriminate the groups. -1.000 -1.000 .000 .000 -.106 .000 .000 .000 -.434 -1.170 -.319 -.449 -.671 .000 -1.491 -.149 -.740 -1.063 -.629 .000 .000 -1.000 .000 -1.000 -1.000 -1.000 -1.054 -1.396 -1.088 -.943 .000 -1.017 -.529 -.110 .000 -.876 -1.000 -.655 .000 .000 .000 .000 .000 -.894 -.430 .000 .000 -1.000 .000 -.149 .000 .000 D Dd S DQO DQVPLUS DQV F M FM m C CF FC Cn C' C'F FC' FD Zest DV1 DV2 DR1 DR2 INCOM1 INCOM2 FABCOM1 VF FV Y FY PAIR rF Fr FQPLUS FQO FQU FQMINUS H Hd (H) (Hd) Hx A Ad Zsum FABCOM2 PSV AB PSV AB AG COP Art T Ay Bt Cg Cl Ex Fi FOOD GEO Hh Na Sc Xy Ls Sx Idio ZF P MOR PER GHR PHR CP BLENDS TOTAL R -1.000 .000 .000 -.904 -1.000 -1.000 .000 .000 -1.000 -1.000 .000 -.775 -1.500 .000 -.643 -1.000 .000 -.430 -.671 -1.671 -1.423 -.149 -.212 -1.000 -.693 -.958 60 Dwivedi

responses on Rorschach Inkblot Test of patients with systematized delusions were similar to those of normal controls and were distinguished only by greater attention to detail. Kleinger (1991) reported a case of frankly delusional woman whose Rorschach protocol had no indication of perceptual inaccuracy or cognitive distortion. The quest for delineating Rorschach variables associated with specific delusions may not come to an end with this preliminary observation. The other option for such an attempt could be to do a qualitative analysis of the content of responses and enquiry which may give clues to the presence of specific delusions. The delusions may get reflected in the themes of the responses. In future, an attempt will be made to present qualitative data relevant to the delusions. The system of content based analysis has already been standardized and well researched in the context of Somatic Inkblot Series. Other projective techniques like TAT, SIS may also be explored to see whether they permit the detection of specific delusions. Conclusion: The quantitative analysis through Exner's comprehensive scoring system does not seem to be sensitive enough to detect specific disorder of content of thinking. A quantitative or content based analysis may provide clues to the theme of delusions which need be explored empirically through future studies. References: Auslander, L. A., Perry,W. and Jeste, D. V.(2002). Assessing disturbed thinking and cognition using the ego impairment index in older schizophrenia patients: Paranoid Vs. Non Paranoid Distinction. Schizophrenia Research, 53(3),199-207. Belyi, B. I. (1991). Interpretation of Rorschach inkblots by patients with delusion forms of schizophrenia. ZhurnalNeuropatologii I Psikhiatrii, 91(7), 97-104. Blatt, S.J.(1990). The Rorschach: A Test of Perception or an evaluation of representation. Journal of Personality, 55, 394-416. Casey P. & Kelly B.(1978). Fish's clinical psychopathology. Third edition. Bombay. Varghese Publishing House. (P.44). Exner, J. E. Armbuster, G. L., & Vigilone, D. (1978). The Temporal Stability of Some Rorschach Features. Journal of Personality Assessment, 42, 474-482. Exner, J. E. (1988). Problem with brief Rorschach protocols. Journal of Personality Assessment, 52, 640-647. Exner, J. E.(2003) the Rorschach: A comprehensive system: Vol. 1.Basic Foundation (4 th ed.). New York : Wiley. Garber, J. and Kaminski, K. M. (2002). Laboratory and performance- based measures of depression in children and adolescents. Journal of Clinical Child Psychology, 29(4), 509-525. Kaplan and Sadock's (2007) Synopsis of psychiatry. New Delhi: Wolters Kluwer (India). (p.467) Kleinger, J. H.(1991). Disordered thinking and the Rorschach: Theory, Research, and Differential Diagnosis. Hillsdale, NJ: Analytic press. Munro, A. (1999) Delusional Disorder: Paranoia and Related Illnesses. Cambridge: Cambridge University Press. Weiner, I. B. (1997). Current status of the Rorschach inkblot method. Journal of Personality Assessment, 68, 5-19. Exner’s Scoring System : 61

Metacognition-Based Cognitive Therapy in Social Phobia- A Case Study Kasturi Thakur and Prasanta Kumar Roy The new era is the witness of an emerging concept - Metacognition, and this perspective is contributing towards the effective understanding and treatment of psychopathology. This Case study investigated the role of metacognition and focused on the changes resulting from the use of Metacognition based Cognitive Therapy in a case of Social Phobia. Studies from the west had laid down not only the framework of metacognition but had delineated its importance in anxiety disorders as well but, there is a dearth of research in the Indian context. An attempt was made to explore the concept with respect to anxiety disorder with the help of a case study diagnosed with social phobia Social communication leads one to be under the continuous attention of friends, colleagues and strangers. For some people this results in extreme social discomfort and they try to avert social gaze. The consequences of this social discomfort is the excessive and persistent fear that a performance or social interaction will be inadequate, humiliating resulting in negative evaluation and hence either lead to the avoidance of social settings or enduring it with extreme distress. People affected with such problems and difficulties are called social phobics or diagnosed with social anxiety disorder. Social phobia is the third most common psychiatric disorder with a lifetime prevalence varying greatly and range from 0.4 to 20.4% as depicted in different studies (Sareen and Steen 2000; Heimberg et al., 1995; Crozier et al., 2001; Lepine and Lellouch, 1995; Wittchen et al., 1999; Furmark et al., 1999; Weissman et al., 1996). The symptoms of social phobia are highly distressing and often produce severe functional impairment on areas like employment, family relationships, marriage, friendships and other areas of interest (Simon et al., 2002; Stein and Kean, 2000). A number of effective treatments are available for this debilitating disorder including cognitive techniques, exposure treatments and social skills training (e.g., Heimberg et al., 1990; Heimberg, et.al., 1993; Mattickand Peters, 1988; Turner, Beidel, et.al., 1994; Turner, Beidel, and Cooley-Quille, 1995). A study by Heimberg& Becker (2002) indicated that Cognitive Behavioral Therapy (CBT) is an effective short-and long-term intervention for social phobia. The psychopharmacological treatment has also been established with selective serotonin reuptake inhibitor (SSRI) being the treatment of choice (Ballenger et al., 1998). Clark et al (2003) compared CBT with SSRI and found CBT to be superior to fluoxetine. According to International Classification of Diseases (ICD) -10, the criteria for social phobia include: A) the psychological behavioral or autonomic symptoms must be primarily manifestation of anxiety and not secondary to other symptoms such as delusions or obsessional thoughts. B) The anxiety must be restricted to or predominate in particular social situations. C) The phobic situation is avoided whenever possible. ------------------------------------------------------------------------------------------------------------ Kasturi Thakur, Research Scholar, Department of Psychology, University of Calcutta, Email: kasturi_thakur2005@yahoo.co.in and Prasanta Kumar Roy, Assistant Professor, Department of Clinical Psychology, Institute of Psychiatry, Kolkata Key words: Social phobia, metacognition, cognitive therapy.

culminating into perseverative ruminative thinking styles and inflexible self-focused attention which all pose disadvantageous to the disconfirmation of dysfunctional thoughts and beliefs. Case History: The patient was a 21 year old male, pursuing graduation, hailing from a middle socio economic status of urban background, with contributory family history of mental retardation in distant relative,with no past history of psychiatric illness The patient was average in academic performance and premorbid personality revealed him as an individual characterized by less self-confidence, timid and shy nature with minimum social participation, rarely vested with responsibilities and was also less able to adjust himself to changing life circumstances, presented himself with the complains of fear of speaking with known and unknown people resulting in nervousness, fear of not being able to speak and interact properly in social situations associated with trembling of limbs, palpitation, sweating, breathlessness and avoidance of social situations and interactions with people. The patient's father had always allowed him to shoulder minimum responsibilities, even if it was the patient's own chore of work, emphasizing the crucial timings to be spent in studies only. This has resulted in restricted social interaction. His symptoms started for the past three years when he performed poorly in standard eleven and twelfth along with his failure to secure good grades in the engineering entrance examinations. This resulted in frustration and feelings of inferiority and for one year he confined himself at home not interacting with friends and relatives. His symptoms has exacerbated for the past one year, after which he is under pharmacological treatment for the same period, with improvement in the physiological manifestations of the . , Role of Cognition and Metacognition in Social Phobia: Western studies have documented the importance of metacognition and the changes brought about by psychotherapies specially related to anxiety disorders (e.g. Wells and Papageorgiou, 1998; Wells and Carter, 2001; Roussis and Wells, 2006; Wells, 2000; Wells and Sembi, 2004; Wells and King, 2006;Wells, 2007; Wells, 2009; Simons et al., 2006), however, in the Indian context there is a paucity of such researches. Indian studies have depicted importance of cognitive factors like negative automatic thoughts, schemas and dysfunctional assumptions, however, the arena of metacognition need more to be explored in the field of psychological research. This study made an attempt to focus on the metacognitive changes in social anxiety and highlight the significant changes resulting from it. The prominent cognition prevalent in social phobia is the danger of behaving in an inept and unacceptable fashion and that such behavior would have disastrous consequences in terms of loss of worth and status, following negative evaluation and rejection. This perceived negative evaluation by others of revealing a flaw or unacceptable behavior is referred to as 'external shame' (Veale, 2003). Also the failure to achieve the set standard, bring forth assumptions that others will find them inferior, imperfect which they also tend to agree with. This is referred as 'internal shame' (Veale, 2003). Wells (2004) defined metacognition as the “cognitive processes, strategies and knowledge that are involved in the regulation and appraisal of thinking itself” (p.167). Metacognitive beliefs in social phobia tend to center around certain worry based thinking later Adopted Treatment Procedure: The treatment plan involved using

symptoms. However his cognitions (e.g. “I will sound stupid if I am not able to speak properly”, “others will think I am foolish and asocial”) were still distancing himself from pursuing interactions in social situations which increased his anxiety even more. On Mental Status Examination (MSE) it was revealed that the patient maintained partial eye contact, his speech was soft, affect was anxious with appropriateness and commun-icability, phobia of social interaction revealed in thought content with emotional insight to the problem. He was diagnosed with Social Phobia as per ICD-10. Adopted Treatment Procedure: The treatment plan involved using Metacognition based Cognitive Therapy (Wells, 1997). Metacognitive model of anxiety disorder predicts that metacognitions must change to bring about effective psychological treatment. The self-regulatory executive function theory proposed by Wells delineated that Cognitive Attentional Syndrome (CAS) results due to the activation of cognitive dysfunctional patterns (Wells & Matthews, 1996). This pattern of thinking in the form of inflexible self-focused attention was prominent in the patient. The patient's belief was found to center on metacognitive notions regarding the usefulness of certain worry-based thinking styles such as being conscious of the facial tremor and by hiding his face, he will be successful in avoiding attention to himself. Understanding the dysfunctional belief system based on the psychopathology formulation and targeting the modification of these beliefs, is likely to help preventing future relapse, leading the therapist toward the application of Metacognition based Cognitive Therapy. Treatment Goals: The goal of the therapy aimed at intervention of the information processing functions like metacognition and its modes of processing, attentional processes and self-regulatory goal states. The treatment targeted to restructure maladaptive metacognitions, while disconfirming the existing knowledge and construction of replacement self-knowledge. The short-term goals of the therapy included enabling the patient to start interaction instead of avoiding social situations, focusing attention on external aspects and minimizing the use of safety behaviors. The long term goals were focused on bringing a change in his negative selfevaluation, and de-focusing of selfpreoccupation, enabling him to restore selfworth and changing the dysfunctional cognitions related to social performance and relating to self as a result. Figure 1: Cognitive Model of Social Phobia(Clark & Wells, 1995; Wells & Clark, 1997) Situation M y friend is visiting me

N egative autom a tic Thoughts I will not b e ab le to speak p ro perly Everyone will think I am a stupid

S elf-Conscious

Ima ge of facia l tre mor and no t be ing able to sp eak prop erly

Sa fe ty Beha vior Anxiety 1 . A voiding e ye contact 1.Breathlessness 2 . Talking less and listening m ore 2. P alpitation 3 . Reh earse sente nce be fore sayin g 3. Swe ating 4 . Not drawing a ttention to self. 4 . Tremb ling

64 Thakur and Roy

Initial Phase: The initial phase of the therapy consisted of three sessions with the goal towards assessing present state of metacognitive functioning (using Meta-Cognitions Questionnaire (MCQ), Cartwright-Hatton & Wells, 1997), the worrying thoughts (using Anxious Thought Inventory (AnTI), Wells, 1997 ), level of fear with respect to social situations (using Social Phobia Rating Scale (SPRS), Wells, 1997). The findings as revealed are presented in Table 1, 2 & 3 respectively. Table 1 Scores on Meta-Cognitions Questionnaire as measured in the second session Subscales Positive worry beliefs Beliefs about uncontrollability and danger of thoughts Cognitive confidence General negative beliefs Cognitive selfconsciousness

Scores

Table 2 Scores on Anxious Thought Inventory as measured in the second session. Subscales Social Worry Health Worry Meta Worry

Scores

Table 3: Scores on Social Phobia Rating Scale as measured in the second session. Subscales Distress Avoidance Self- Consciousness Frequency of seeking safety behaviors Negative Beliefs

Scores

The second step included in helping the patient to understand the structure of therapy, which consisted of sessions being conducted once a week for aduration of 45 minutes to one hour. It was also pointed out that the termination phase would begin once changes in the cognitive, emotive and behavioral cycle were established. This phase was also directed in educating, developing awareness toward his problems through case conceptualization, engagement and socialization. Recent social anxiety episodes (as shown in Figure 1) were elicited and analogue phobic situation was created enabling in conceptualization and socialization

within the context of the model (Clark & Wells, 1995; Wells & Clark, 1997). With this a step was taken forward to establish the metacognitive mode by sharing with the patient a cognitive behavioral conceptualization of the presenting problem. The model was also used to highlight the role of social self-processing through behavioral experiments to bring forth the knowledge that self-focused attention increases awareness of feelings and the mistaken attribution that such feelings must be attracting attention. In-session experiments were also carried out to demonstrate the effect of attentional focus on physical symptoms, social performance and self-consciousness under two contrasting conditions -- practicing all safety behaviors in one situation and dropping of safety behaviors in another situation. As the patient compared his performance in the two conditions, he discovered that with the use of increased safety behaviors, conversation was difficult in terms of keeping track of people's comment and at the same time to think and speak, as he was more self-conscious of his facial tremor being conspicuous resulting in people staring at him. The belief that he would be unable to speak decreased little from 80% to 70%. While in the reversed safety behavior situation, he dropped all safety behaviors, and focused only on the conversation and made statements without rehearsing. This was less difficult for him and his belief fell to 20%. Performing this behavioral experiment the patient was enquired about his knowledge of being at the center of everyone's attention when he attempted to avoid eye contact and was focused on his facial tremor being visible to others. Thus contrary to his prediction of not being able to speak properly and everyone looking at him he discovered that there was barely any evidence of people looking at him and of his inadequate performance. The patient's ability to introspect, to change his style of processing and motivational priorities helped in enhancing the metacognitive awareness. However, he still believed that at times he was conscious of his facial tremor being visible to others and so he resorted to use some of his safety behaviors although minimally. The testing of negative automatic thoughts was started. Homework included maintaining the record of automatic thoughts, specific exposure to external situations with dropping of safety behaviors and external focusing. Middle Phase: The middle phase consisted of nine sessions held once a week for duration of 45 to 60 minutes with sessional assessments through Social Phobia Rating Scale, Anxious Thought Inventory and Metacognition Questionnaire. The middle phase of the therapy aimed at shifting the attentional focus from the self to the external environment, challenging the negative thoughts and modifying assumptions and dysfunctional beliefs.Subsequent sessions revealed patient's understanding of the model, his apprehensions regarding the fearful consequences that might result in any social setting, leading him to generate numerous negative thoughts and how his behavior was posing an obstruction in the way of disconfirming those negative thoughts. During this phase testing of specific negative automatic thoughts and identification of cognitive errors continued, where the negative self-appraisals, negative thoughts concerning the reaction and thoughts of others were targeted through verbal reattribution as well as through behavioral experiments (interrogating the environment) that became possible with the help of guided discovery. Negative automatic 66 Thakur and Roy

thoughts such as “friends will find me foolish”, “I will sound stupid”, and “others will think I am asocial” were targeted for verbal reattribution followed by repetition of new propositions or rational self-statements that helped to strengthen replacement knowledge. Practicing behavioral activities in-situation to anchor attention externally and the processing of new information was conceptualized as a means of acquiring new skills for metacognitive control. Situational Attention Refocusing (SAR) was practiced, as the patient tended to shift attention inward onto processing of the self as a social object, imagining his facial tremor would be conspicuous to others. SAR helped him to shift to external attention which interfered with his in-situation coping behaviors and the nonoccurrence of catastrophe was then no longer attributed to the use of coping strategies. Interrogating the environment was practiced with the aim of introducing shame-attacking exercises and bandwidth experiments. Also the P-E-T-S (Preparation, Exposure, Test, and Summarize) protocol (Wells, 1997) was used for conducting behavioral experiments. As the focus of treatment was on modifying the style of processing before, during and after attending social situations the introduction of the social balance sheet helped in the processing of evidences capable of disconfirming belief in the negative automatic thoughts. Initially the patient was extremely scared with the idea of behavioral experiments, but as he continued to perform it, helped him discover that the negative thoughts with which he encountered the situations were disconfirmed as he gathered counter evidences for those thoughts, that enhanced his self - confidence also. This also provided a means of enhancing patient's metacognitive monitoring skills. it Bandwidth experiments helped modify long standing restricted social patterns, the associated negative automatic thoughts and rigid rules like “I should always be able to carry on any type of conversation”, “I must not make others inconvenient”, and “I mustn't draw attention to myself”. These experiments included disagreeing with people, making complaints, requesting tuition teacher to reexplain topics. With this homework, the client in the subsequent sessions pointed out that although he initially felt hesitated in facing social situation but thereafter had taken a step forward and found that his teacher's attitude and friends attitude towards him remained unchanged despite the type of social interactions he maintained with them .The patient also had apprehension centered on how he would present himself and what he should say, made him frightened regarding the situation and as a result he would attempt to rehearse social coping strategies. At this point the role of anticipation, which often leads to inaccurate results, was once again emphasized and with it the role of post-mortem was also explained. Anticipatory processing and post mortem was introduced as examples of selffocused attention. The therapist proceeded by eliciting the advantages of anticipatory processing which helped in the identification of positive metacognitive beliefs and thereby challenging those metacognitions. Similarly the advantages of postmortem were elicited and thereupon challenged, with the reviewing of advantages and disadvantages and reinforcing the latter. With in-session experiments the patient was successful in reducing anticipatory processing and post-mortem. The next part of the middle phase emphasized modifying conditional assumptions and dysfunctional beliefs. “I should always be able to speak clearly and properly else people will ,

think I am asocial and foolish”- in this conditional assumption the meaning of speaking clearly and properly as well as the meaning of asocial and foolish was elicited from the patient, which allowed operationalization of the assumptions in a manner that became testable. It was found that the sign of asocial and foolish would be people staring at him and finding him stupid. Thus at this stage he was equipped to conduct some behavioral experiments in which he said more and made deliberate errors in speech, and thereafter was made to ask the interaction partners to comment on the patient's behavior. The beliefs of the patient centered on “I am inept”, “I am stupid and asocial”, “I cannot interact therefore I should not interact”—these were challenged through methods like positive data logs, interpersonal strategies and flash cards. As a homework assignment he was asked to complete a daily log of different types of interaction that he attempted and the types of attention he received from others including verbal greeting, compliments, nonverbal gestures, smiles and so on. After a week he felt that his beliefs were not true. As a result his replaced self- knowledge like “I am capable of interacting in social situations” was introduced. Termination Phase: The various assessments carried out during the middle phase across the sessions revealed significant changes in different aspects of functioning of the patient from metacognitive aspect to the sphere of social functioning as well as reduction in social anxiety. The patient's ability to function in the metacognitive mode, effective use of attentional resources and coping strategies resulting in reduced selfconsciousness, enabled him to disconfirm negative thoughts and dysfunctional beliefs. The changes brought about in the therapeutic treatment as depicted through figures 2, 3 and 4 along with the prominent behavioral changes, led the therapist plan for the termination phase. This phase was planned to be conducted twice in a month and thereafter once a month for a consecutive three month period. However the patient did not continue the monthly follow up as his board examinations had started. Relapse prevention was elaborated during this phase. It consisted of generating a summary of the patient's understanding of the nature of social phobia and a description of effective strategies for dealing with social situations. The patient's summary constituted a therapy blueprint, comprising of an example of idiosyncratic formulation, examples of key metacognitions, reviewing situational attentional strategies which consisted of focusing attention on other people and on the environment and summaries of data that disconfirm maladaptive metacognitive beliefs. Residual negative beliefs were assessed and challenged and avoidance of situations that would trigger social fear was eliminated by continued exposure. Discussion: Wells and Matthews (1994) pointed out that people seem to construct and revise beliefs based on internal rules. Hence it is necessary to put together the internal cognitive processes, rules and mechanisms that lead patients to develop maladaptive beliefs and interpretations. A cognitive framework representing the interactions between self-knowledge and emotional disturbances helps to achieve this. With the view that the mind is conceptualized as a dynamic self-regulatory system, Wells and Matthews (1994, 1996) advanced the Self- Regulatory Executive Function (S-REF) model. According to them the model delineated the 68 Thakur and Roy

reciprocal causal interplay between multiple components of cognition including beliefs, metacognition, attentional control, online processing and self-regulation. The model also pointed out that the occurrence of disconfirmatory processing (that helps in modifying beliefs) depends on certain internal factors like attentional capacity, and flexibility of control over processing. Case history, MSE and test findings revealed that the patient was operating in the object mode, where his beliefs and negative thoughts offered true reflections of threat. This led him to escape as well as avoid social situations which posed a threat towards his social performance. Functioning in this mode had made the patient invest his attentional resources and coping efforts directed toward monitoring, evaluating and preventing threats to the self. The acquisition of metacognitive mode which aimed at examining and modifying thinking and beliefs were facilitated through the techniques of Cognitive Therapy like verbal reattribution achieved through “metacognitive profiling (Wells & Matthews, 1994).This helped him to appraise his thoughts and beliefs in a detached way, treating them as events that should be evaluated and not merely as depictions of reality but also to process new information. The patient also manifested an overload of attention which hindered in the process of changing his beliefs, his proneness toward high self-focused attention made him more vulnerable. Socializing the patient with the cognitive model by tracing recent episodes of social anxiety helped in emphasizing the role of self-focused attention. This was also illustrated through behavioral experiments like (SAR) i.e. shifting to external attention, interfered with in-situation coping behaviors that required high levels of self-monitoring. Disrupting of such monitoring responses increased the propensity for belief change since the non-occurrence of social catastrophe could not be attributed to the use of coping behaviors. This also had a positive impact on his metacognitive efficiency as evidenced from the Metacognitions Questionnaire. Moreover the patient's use of worry and rumination, viewed as coping strategies were found as unhelpful in the restructuring of self–knowledge and as impediments to developing new plans for processing in therapy. These were explored and as a measure of the role of anticipatory processing and post-mortem was brought into focus that helped in active problem solving and developing alternative and adaptive routines for handling social situations. Thus rumination or positive beliefs about worry which were prevalent in the patient were gradually found to decrease as revealed through Metacognitions Question-naire. Sessions with the patient also brought to light the use of controlled processing or the dependence on specific coping strategies. For instance the patient's attempt to articulate his words in a careful and controlled way, his belief that his facial tremor will be visible to others and consequently repeated attempts to cover his face, all the more interfered with his verbal fluency, thus strengthening negative selfbeliefs. However, practicing behavioral experiments under typical threat conditions enabled him to override dysfunctional processing and acquire new skills for metacognitive control over cognition and behavior as also evident by his reducing disconfirmatory belief that worries are uncontrollable and dangerous. These set the stage for procedural learning which was achieved through repeated practice of new combinations of attention, behavior and thinking, leading to the strengthening of new metacognitive procedural knowledge.

With the continued emphasis on verbal reattribution, in-session experiments and homework exercises the restructuring of selfknowledge was gradually achieved. This was also evident through the behavioral responses, implementation of plans for guiding attention, emotion and behavior during the treatment phase. The outcome as also evident through the changes in test findings (Social Phobia Rating Scale, Anxious Thought Inventory, and Metacognition Questionnaire) brought about change in beliefs, metacognitive plans and new coping strategies along with a workable level of affective experience. Conclusion: Wells and Matthews (1994) suggested that the locus of dysfunctional processing in some disorders may be more explicitly metacognitive, as it was also true for the present case. Metacognition based Cognitive Therapy provided a new emphasis on conceptualizing and modifying metacognitive factors. The outcome of the treatment established changes in cognitive processes, particularly those involving excessive self- focused attention, attentional monitoring of threat and active worry. Emphasizing on the modification of metacognitive beliefs as well as general non metacognitive beliefs helped to enhance the therapeutic change by facilitating disconfirmation and replacement of self-knowledge. Thus the systematic single case evaluation indicated the effective changes brought out in the sphere of metacognition. Reference: Ballenger, J.C., Davidson, J.R., Lecrubier, Y., Nutt, D.J., Bobes, J., Beidel, D.C., Ono, Y., & Westenberg, H.G. (1998). Consensus statement on social anxiety disorder from the International Consensus Group on Depression and Anxiety. Journal of Clinical Psychiatry, 59(17), 54- 60. Cartwright-Hatton, S., & Wells, A. (1997). Beliefs about worry and intrusions: The Meta-Cognitions Questionnaire and its correlates. Journal of Anxiety Disorders, 11(3), 279-296. Clark, D.M., & Wells, A. (1995). A cognitive model of social phobia. In R. Heimberg, M. Liebowitz, D.A. Hope, & F.R. Schneier (Eds.), Social Phobia: Diagnosis, Assessment and Treatment. New York: Guilford Press. Clark, D.M., Ehlers, A., McManus, F., Hackmann, A., Fennell, M.J.V., Campbell, H., Flower, T., Davenport, C., & Louis, B. (2003). Cognitive therapy versus fluoxetine plus self exposure in the treatment of generalized social phobia (social anxiety disorder): A randomized controlled trial. Journal of Consulting and Clinical Psychology, 71, 1058-1068. Crozier, Ray, W., & Alden, Lynn, E. (2001). International Handbook of Social Anxiety: Concepts, Research and Interventions Relating to the Self and Shyness. New York: John Wiley. Furmark, T., Tillfors, M., & Everz, P.O. (1999). Social phobia in the general population: Prevalence and sociodemographic profile. Social Psychiatry and Psychiatric Epidemiology, 34 (8), 416-424. Heimberg, R.G., & Becker, R.E. (2002). Cognitivebehavioral group therapy for social phobia: Basic mechanisms and clinical strategies. New York: Guilford Press. Heimberg, R.G., Dodge, C.S., Hope, D.A., Kennedy, C.R., Zollo, L., & Becker, R.E. (1990). Cognitive behavioral treatment for social phobia: Comparison with credible placebo control. Cognitive Therapy and Research, 14, 1-23. Heimberg, R.G., Liebowitz, M.R., Hope, D.A., & Schneier, F. (1995). Social Phobia: Diagnosis, Assessment and Treatment. New York: Guilford Press. Heimberg, R.G., Salzman, D., Holt, C.S., & Blendell, K. (1993). Cognitive-behavioral group treatment for social phobia: Effectiveness at five-year follow up. Cognitive Therapy and Research, 17, 325-340. Lepine, J.P., & Lellouch, J. (1995).Classification and epidemiology of social phobia. European Archive Psychiatry Clinical Neuroscience, 244 (6), 290-296. Mattick, R.P., & Peters, L. (1988). Treatment of severe social phobia: Effects of guided exposure with and without cognitive restructuring. Journal of Consulting and Clinical Psychology, 56, 251-260. Roussis, P., & Wells, A. (2006). Posttraumatic stress symptoms: tests of relationships with thought control strategies and beliefs as predicted by the metacognitive model. Personality and Individual Differences, 40, 111- 70 Thakur and Roy

122. Sareen, L., & Stein, M. (2000).A review of the epidemiology and approaches to the treatment of social anxiety disorder.Drugs, 59 (3), 497-509. Simon, N.M., Otto, M.W., Korbly, N.B., Peters, P.M., Nicolaou, D,C., & Pollack, M.H. (2002). Quality of life in social anxiety disorder compared with panic disorder and the general population. Psychiatric Services, 53 (6), 714-718. Simons, M., Schnieder, S., & Herpetz-Dahlmann, B. (2006). Metacognitive therapy versus exposure and response prevention for pediatric obsessive-compulsive disorder. Psychotherapy and Psychosomatics, 75, 257-264. Stein, M.B., & Kean, Y.M. (2000). Disability and quality of life in social phobia: Epidemiologic findings. American Journal of Psychiatry, 157 (1), 1606-1613. Turner, S.M., Beidel, D.C., & Cooley-Quille, M.R. (1995). Two year follow-up of social phobics treated with Social Effectiveness Therapy. Behavior Research and Therapy, 33 (5), 553-555. Turner, S.M., Beidel, D.C., Cooley, M.R., Woody, S.R., & Messer, S.C. (1994). A multicomponent behavioral treatment of social phobia: Social Effectiveness Therapy. Behavior Research and Therapy, 32 (4), 381- 390. Weissman, M.M., Bland, R.C., Canino, G.J., Greenwald, S., Lee, C.K., & Newman, S.C. (1996). The cross-national epidemiology of social phobia: a preliminary report.International Clinical Psychopharmacology, 11 (3), 9-14. Wells, A. (1997). Cognitive therapy of anxiety disorders: A practice manual and conceptual guide. Chichester, UK: Wiley. Wells, A. (2000). Emotional disorders and metacognition: Innovative cognitive therapy. Chichester, UK: Wiley. Wells, A. (2004). A cognitive model of GAD: Metacognitions and pathological worry. In R.G. Heimberg, C.L. Turk, & D.S. Mennin (Eds.), Generalized anxiety disorder: Advances in research and practice (pp.164-186). New York: The Guilford Press. Wells, A. (2007). Cognition about cognition: Metacognitive therapy and change in generalized anxiety disorder and social phobia. Cognitive and Behavioral Practice, 14 (1), 18-25. Wells, A. (2009). Metacognitive therapy for anxiety and depression.New York, NY: The Guilford Press. Wells, A., & Carter, K. (2001). Further tests of a cognitive model of generalized anxiety disorder: Metacognitions and worry in GAD, panic disorder, social phobia, depression, and non patients. Behavior Therapy, 32 (1), 85-102. Wells, A., & Clark, D.M. (1997). Social Phobia: A cognitive approach. In D.C.L. Davey (Eds.), Phobias: A Handbook of Description, Treatment and Theory. Chichester: Wiley. Wells, A., & King, P. (2006). Metacognitive therapy for generalized anxiety disorder: An open trial. Journal of Behavior Therapy and Experimental Psychiatry, 37 (3), 206-212. Wells, A., & Matthews, G. (1994). Attention and Emotion. A Clinical Perspective.Hove, UK: Erlbaum. Wells, A., & Matthews, G. (1996).Modeling cognition in emotional disorder: The S-REF model. Behavior Research and Therapy, 32, 867-870. Wells, A., & Papageorgiou, C. (1998).Relationships between worry, obsessive –compulsive symptoms and meta-cognitive beliefs. Behavior Research and Therapy, 36 (9), 899-913. Wells, A., &Sembi, S. (2004). Metacognitive therapy for PTSD: a preliminary investigation of new brief treatment. Journal of Behavior Therapy and Experimental Psychiatry, 35 (4), 307-318. Wittchen, H.U., Stein, M.B., & Kessler, R.C. (1999). Social fears and social phobia in a community sample of adolescents and young adults: Prevalence, risk factors and co-morbidity. Psychological Medicine, 29 (2), 309- 323.

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Regd. No. 71632/99, RNI Delhi SIS JOURNAL OF PROJECTIVE PSYCHOLOGY & MENTAL HEALTH Volume 22 Number 1 January 2015 EDITORS EMERITUS : Wilfred A. Cassell, MD, Director, SIS Center, 4501E,104th Avenue, Anchorage, AK.99516 (USA). E-Mail: siswilfredacassell@yahoo.com Bankey L. Dubey, Ph.D., Director,4406 Forest Rd, Anchorage, AK 99517, E-mail: bldubey@gmail.com Amool R. Singh, Ph.D., Prof., RINPAS, Kanke, Ranchi-834006 E-mail:sisamool@yahoo.com EDITOR-IN-CHIEF : Rakesh Pandey, Ph.D. Professor, Dept. of Psychology, BHU, Varanasi-221005 E-Mail: rpan_in@yahoo.com EDITORS : , Anand Dubey, MBA, 4406 Forrest Road,Anchorage, AK 99517(USA) 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 NilanjanaSanyal, Ph.D., Prof. Dept. of Psy, University of Calcutta, 92 A. P. C Road, Kolkata-700009 Email: sanyal_nilanjana2004@rediffmai.com M. P. Singh, Ph.D. 1329, Sec.70,Guru TegBahadur Complex, SAS Nagar (Punjab) Email: mpsingh1329@gmail.com EDITORIAL CONSULTANTS : Yogesh K. Arya, Ph.D., India Jayanti Basu, Ph.D. India Antonio Cervigni, M.A.., Italy Suprakash Chaudhury, M.D., Ph.D. Carina Coulacoglou, Ph.D., Greece Manisha Dasgupta, Ph.D. India Padma Dwivedi, M.A., USA R. P. Gupta, M. Phil. India Anatoly B. Khromov. Ph.D., Russia H. Kumar, Ph.D., USA Rakesh Kumar, Ph.D., India Ranjeet Kumar, Ph.D., India Lisa Milne, Ph.D., Australia Nalini Mishra, Ph.D., India Tilottama Mukharjee, Ph.D., India Arvind K. 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 Radhe Shyam, Ph.D.India Umed Singh, Ph.D. India Ajay Tiwari, Ph.D., India Ailo Uhinki, Ps.D., Finland Yasho V. Verma, Ph.D., India Robert B. Williams, Ph.D., Canada