SIS Journal of Projective Psychology & Mental Health

Somatic Inkblot Society

OFFICE BEARERS

President: Bankey L.Dubey, Ph.D. Vice President: Brig. D.Saldanha, M.D. Editor-In-Chief: Naveen Gupta, Ph.D. Gen. Secretary: Nalini Mishra, Ph.D. Joint Secretary: Abhilasha Singh, Ph.D. Treasurer: Padma Dwivedi, M.A.

Executive Members : Mary Cassell, M.A. Wilfred A Cassell, M.D. Anand Dubey, MBA. S. D. Dwivedi, M.Phil. M.P.Singh, Ph.D. Greesh Sharma, Ph.D. Riju A Singh, MBA. Ajay K.Srivastava, Ph.D. Ajay Tiwari, Ph.D. Pragya Tiwari, MBA.

Past Editors in Chief:

B.L.Dubey, Ph.D. Director SIS Center, 4406 Forrest Road, Anchorage, AK 99517 (USA) Email: bldubey@gmail.com (1994-2005)

Amool R. Singh, Ph.D., Prof. & Head, Clin.Psychology, RINPAS, Kanke, Ranchi-834006 (India) E-mail:sisamool@yahoo.com (2006-2011)

Rakesh Pandey, Ph.D. Prof. & Head, Dept of Psychology, Banaras Hindu University, Varanasi-221005 Email: rpan_in@yahoo.com (2012-2015)

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 Naveen Gupta, Ph.D., Editor in Chief, SIS Journal, Director. Hindustan Institute of Management and Computer Studies (HIMCS), Farah, Mathura- 281122, U.P. Email: dr_naveengupta@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 transferred to Punjab National Bank, in the SIS Journal’s account given below:

Name of Account: SIS Journal of Projective Psychology & Mental Health Bank Name: Punjab National Bank, Bhikharipur Branch, DLW- Kakarmatta Road, Varanasi -221004 Account No. 4045000102207342, (IFS Code: PUNB0404500) Subscription can be made through cheque, payable to “SIS Journal of Projective Psychology & Mental Health” and mail to Dr. Naveen Gupta, Ph.D., Director, Hindustan Institute of Management and Computer Studies, Farah, Mathura-281122 U.P. (INDIA) dr_naveengupta@yahoo.com, Cell: 91-9627182913 CHANGE OF ADDRESS.

Members should inform to B.L. Dubey, Ph.D, Editor Emeritus,(Email:bldubey@gmail.com) any change of mailing address. Copyright @1994. SIS Center, India/Anchorage Website: http://www.somaticinkblots.com

SIS

Editorial Wilfred A. Cassell In early April of this year my wife and I traveled to Victoria, British Columbia on Vancouver Island in Canada. Here we live in a retirement facility for seniors that have beautiful grounds. Initially for a few evenings this environmental setting enabled a mesmerizing view of a bright full moon. At night the scene stimulated memories from my youth in Ontario. Then my family spent summers living in a cottage overlooking the St Lawrence River. I vividly recalled similar summer spiritual scenes. In these moonlight reflected off the water providing an imaginary pathway for fantasizing travel to explore the moon. Never in my wildest adolescent imagination did I expect that in my lifetime solar system space technology would enable human explorers to safely “walk on the moon”! Now as a senior citizen having my basic “Body Image” identity only temporarily linked to our planet earth, I am amazed that futuristic planning involves an exploratory trip with an estimated two and a half years of travel to Mars. Moreover, ultimate plans are under development to build a permanent space colony there. Exploring deeper reaches of the mysterious Cosmos will dramatically enrich SIS theory as well as concurrently human life “Body-Mind-Spirit” identity. I now invite you for a few moments to imagine that you are listening in the year 1610 to Galileo Galilei lecturing on the value of “scientifically objective” astronomical telescopic observation as opposed to “philosophical’ debate without hard factual data: “The next object which I have observed is the essence or substance of the Milky Way. By the aid of the telescope one behold this in a manner which so distinctly appeals to the senses that all the disputes which have tormented philosophers through so many ages are exploded at once by the irrefragable evidence of our eyes and we are freed from wordy disputes upon the subject, for the Galaxy is nothing more than a mass of innumerable stars planed together in clusters. Upon whatever part of you direct the telescope straight away a vast amount of stars presents itself to view; many of them are tolerably large and extremely, but the number of small ones is beyond determination bright”. Now with this historical background in mind, let us briefly review the manner in which basic principles of “Projection” influence perception from space of our planet. Relevant is the term “Pareidolia”: the phenomenon of perceiving body imagery in clouds, landforms and manmade objects. An example is illustrated in Figure 1.

This is an astronaut’s “Anatomical Projective Response” when circling the earth in the International Space Station while observing the dried up bottom of a lake in Iran. Although he recognized the reality of the Iran scene, his imagination enabled him (In Rorschach language) to secondarily project the Anatomical Response “It also appeared like the surface of a brain” (Hadfield, Chris 2014). Another example of an “Anatomical Response” is illustrated in Figure 2.

Here Hadfield perceived “Labyrinthine stream beds as “running like veins” through the Gibson Desert in the Northern Territory of Australia. Projective Law of Affect Linkage: At this point in theoretical discussion the implication of projected imagery having significant affect linkage to the projected imagery warrants outlining. For example, let us consider the first illustration in which the bottom of the lake in Iran that was seen to resemble the brain. This links whatever positive or negative emotional charges associated with the “Brain” in the responders mind, such as pleasure from intellectual achievement, memory of sex sensations or negative such as headache or psychological distress, binding the feelings both to the original visual geographical content, as well as its secondary projected association in memory storage. This linkage process also applies when viewing cosmic objects and light patterns of objects entering from space. For example, negative affect linked to a Super bolide can make it seem to a paranoid military observer resemble a nuclear missile. The same somatic symbolic projective process influences the naming of structures in the Solar System, as well as light years beyond in the remote Cosmos. Historically, it also has been operating throughout recorded history shaping primitive art. Next for a few moments I invite the reader to meditate for a few moments. When in an altered state of relaxation, fantasize travelling back in time to at least 28,000 years ago. Then awaken your symbolic spiritual self in order to spiritually identify with the Body Images painted (or in SIS language) projected onto the walls of a cave by an early human artist. This is illustrated in Figure 3. In his book “YOU ARE HERE” Hadfield commented on this art in an imaginative theoretical time dimension conceptual model as follows: “Rock paintings in Australia are among the oldest on the planet, with some confirmed to date back at least 28,000 years. Called GwionGwion figures, man mirror the colors and shape of the landscape so closely that they almost seem to have been inspired by an aerial view of the Outback. Perhaps they were: GwionGwion was, according to aboriginal cosmology, a long beaked bird before he morphed into a human artist”. Figure 3. Please seriously contemplate the symbolic material as well as Hadfield’s speculation (i.e. “Perhaps they were”) for a period of time before ending the trance like experience. Afterwards if this psyche trip back in time has proven worthwhile, I suggest that you repeat at bedtime to stimulate spiritual dreaming. If any such GwionGwion programmed dreams prove enriching, please report them to our SIS 76 Wilfred A. Cassell

journal’s editor (bldubey@gmail.com) for future publication and analysis. Hopefully for some readers, such a Body- Mind-Spiritual exercise has been enlightening in preparation for contemplating some of the problems facing mother earth in the 21st century. Many of these relate to the sad state of world affairs regarding national leaders to use scientific psychosocial biological information to either prevent or solve urban problems. Yet in addition, cognitively concerned leaders face both predictable and unpredictable threats from space. While savvy scientists are aware that there are many of the former, only two relevant examples will be mentioned in this discussion: Chelyabinsk- In 2013 on the 15th of February, an unpredicted meteor travelling at high speed entered the earth’s atmosphere and broke up over Russia, becoming what then was called a “Super bolide”. Since the energy released by the intense sound wave was estimated to be comparable to a good sized nuclear bomb, so several building was damaged.

However, the greater danger was that a few members of their military projected paranoid fears onto the sky scene depicted in Figure 4. Apparently they initially misinterpreted it as an American surprise attack. Reportedly they almost launched retaliatory nuclear missiles which might have triggered World War III. I sincerely hope that the Russian psychologists and psychiatrists who are familiar with SIS projective concepts and techniques will develop instructional programs for their military. Moreover, the same suggestion for extreme caution may be applied to those in all nations possessing such powerful weapons. Until the world leaders develop totally effective controls, all life on this planet are at risk from unbridled aggressive drives of power seeking humans, terrorists, suicidal/homicidal psychotics, religious fanatics etc. etc. etc. Figure 4. (2) The so-called Apo phis asteroid named after the Egyptian snake God symbolizing “malevolence”. The last time it approached earth on April 13th 2013, it was sufficiently close that the gravitational pull of our planet’s huge mass attracted it closer in orbit. Astronomers are carefully watching this change in orbit. It is believed that when it approaches next on Friday the 13th of April in 2030, its new path might cause it to endanger all life on earth. If this appears to be a serious risk, plans are under way to employ in order to alter the asteroid’s potentially destructive path. Space scientists now conceptualize employing a “Gravity Tractor” – a theoretical space craft whose gravity would deflect another such threatening objects in space. While the ever growing technology available to protect life on our planet is ever growing in sophistication, human life on earth still remains vulnerable to cosmic events. For example, comets can still sometimes “sneak in from the heavens” at high speeds, before scientists can detect them with present day warning equipment. More funding is required to overcome this vulnerability, not just from governments but from all significant sources. It is suggested that these should include all well-funded religious organizations whose

Death Denying Doctrine postulates after one’s body’s demise on earth a spiritual ongoing survival state exists in a cosmic space “Afterlife” or “Heaven”. An example is the relatively well funded modern Roman Catholic Church. This organization has come a long way educationally since the time when Copernicus was murdered by an earlier Pope for reporting that “The earth is not flat…and dethroned it from the center of the solar system”. In addition, apparently other scientists were threatened by the church not to support Copernicus in his astronomical observations. As an illustration of such intellectually repressive “DENIAL” expressed by Galileo Galilei in the following letter to the Duchess of Christina in 1615: “Therefore I declare (and my sincerity will manifest itself) not only that I manifest to submit myself freely and renounce any errors into which I may fall through ignorance in these matters pertaining to religion, but that I do not desire in these matters to engage in disputes with anyone, even points that are disputable. My goal is this alone; that if, that may abound in these considerations of a subject remote from my profession, there is anything that may be serviceable to the holey Church in making a decision regarding the Copernican system, it may be taken, and utilized as it may seem best to the superiors. And if not, may my book be torn and burnt, as I neither intend nor pretend to gain from any fruit that is not pious and Catholic. And though many of these things I shall reprove have been heard by my own ears, I shall freely grant to those who have spoken them that they never said them, if this is what they wish, and I shall confess myself to have been mistaken. Hence whatever I reply be not addressed to them, but to whoever may have held such opinions”. Reflecting more modern astronomical awareness modern members of the Catholic Church have apologized for their ignorance and persecution of Copernicus. Moreover now the Pope employs an astronomer and funds space viewing equipment. Recently when asked by a news reporter “If an intelligent alien arrived on earth would you Baptize this alien” reportedly he responded taking into consideration the modern world increased social power of women “Only if she requested it”. In spite of more openness, many members of the Catholic clergy are reluctant to publically report there are still limits what can be reveal about the religious deleterious mental health “Side Effects”, of certain of their practices (e.g. celibacy, male domination of the church power structure etc.). Motivated colleagues in our SIS International Society are hereby invited to establish a scientific reality based, cross fertilization theoretical dialogue with scientists exploring the hidden Body-Mind-Spirit dimensions of the mysterious Cosmos. A promising example offering potentially positive joint fruition of concepts for sophisticated SIS explorers is the “Spiritual” one. In the proposed conceptual model of existence, this physically invisible dimension encompasses not just human animals, but other forms of “Intelligent-feelingaware” higher life forms, as outlined within the Hindu faith. In regard to the latter, the loving/playful connection between my-self and our female Golden Retriever Maggie, represents an incredibly joyful, positive healing spiritual force, in my stressful marital care provider existence. As an example of possible cross fertilization of scientific concepts, I now humbly suggest that the historical notion of looking for an “Afterlife” in a real physically structured visual space is 78 Wilfred A. Cassell

likely invalid. I suspect that it needs to be replaced with a new notion comparable to “Dark Energy” – a force that while it is invisible, is powerful. Maybe it’s time to remember that our Homeo Sapiens species evolved “Big Brains” –NOW LET’S USE THEM. Yet in doing so, please be humble, since no mere mortals can ever know the “MIND OF GOD”! Finally, I now invite the open minded reader to consider the extent that Edwin P. Hubble’s 1936 statement in the “Realm of the Nebulae” still somewhat may apply: “From our home on the Earth, we look out at the distances and strive to imagine the sort of world into which we were born. Today we have reached far out into space. Our immediate neighborhood we know rather intimately. But with increasing distance our knowledge fades rapidly, until the last dim horizon we search among ghostly errors of observations for landmarks that are scarcely more substantial”. “THE SEARCH WILL CONTINUE…. THE URGE IS OLDER THAN HISTORY…. IT IS NOT SATTISFIED…. THE SEARCH WILL CONTINUE…. THE URGE IS OLDER THAN HISTORY AND WILL NOT BE SUPPRESSED”. Relative Reading: Cassell, W. A. (1980). BODY SYMBOLISM and the SOMATIC INKBLOT SERIES Published by Northern Lights Publishing Inc., Canada Vancouver B.C. V6G:123 Cassell W. A. and Dubey B.L. (2003). Interpreting Inner World Through Somatic Imagery Published by the Somatic Inkblot Center 4501 East 104th Ave. Anchorage AK 99507 Chaisson, Erick. J. (1994). THE HUBBLE WARS, Astrophysics Meets Astropolitics in the Two- Billion-Dollar Struggle for the Hubble Space Telescope, Harper Collins Publishers, New York, NY Devorkin, D., Smith, R. and Hubble, W. (2014). Imaging Space and Time, Publisher National Geographic Washington DC Hadfield Chris (2014) YOU ARE HERE - Around the World in 92 Minutes Publisher Random House Toronto Canada Limited. Yeomans, D.K. et al (2005) Using a Gravity Tractor to Help Mitigate Asteroid Collisions with Earth (http://www.lpi.usra.edu/meetings/acm2008/pdf/ 8273, pdf) Acknowledgement: I hereby acknowledge the creative contributions of Erik Chaisson and the publisher Random House, Toronto, Canada for giving permission to publish certain of the earth viewing material. In addition, I recognize the value of receiving astronomical insights in Victoria at the senior Center from an amateur astronomer Derick Hirions. Thank you Derick for your contribution in creatively expanding my understanding of cosmic life theory. Like the medieval Pope, I once was trained to believe that “Jesus was the only son of God”. Thank you for informing me that here are many, many planets in the vast cosmos with similar light sources and probably comparable so-called religious hero figures. Now sometime, please tell me what to think about what might be unique, if anything, about my transient human identity on the planet earth. You made me realize why the Pope was so disturbed when Copernicus reported that the earth was spherical and NOT the center of the universe! Wilfred A Cassell, M.D., FAPS, APC. Editor Emeritus, SIS J. of Proj. Psy.& Ment. Health, Director, SIS Center, 4501E, 104th Avenue, Anchorage, AK - 99507 (USA) E-Mail: siswilfredacassell@yahoo.com Email: sis2cassell@outlook.com

What does it Socially Symbolize When a Woman Dreams of Having a Penis? Wilfred A. Cassell, Bankey L. Dubey and Kalyani Menon Dream is the language of unconscious mind. It brings the suppressed unprocessed unconscious material hidden in the store house of unconscious mind. Its symbolic interpretation helps in understanding the inner world of the dreamer. Symbolic interpretation may further help as an aide in therapeutic management of the patients. The present study has interpreted and discussed three dreams in the paper. Dreams may have many references in time and space. They may reflect real life affect charged events as in the case of an individual traumatized by severely stressful life events. Alternatively they are linked in memory storage to earlier daytime thoughts and fantasies. While nonpsychotic dreamers may in the waking state have rational logical cognition, sometimes irrational wishes related to sexuality- aggression may lurk in the deeper aspects of their consciousness. Sometimes symbolic symbolism may relate to the individual’s “Body Image” in a sexually irrational anatomical fashion (Cassell, 1980). When this occurs, the resultant somatic symbols may manifest their presence in semi disguised imagery, partially puzzling to the dreamer. Even if the individual upon awakening is partially insightful regarding interpreting such symbolism, often a professional trained in dream symbolism may provide worthwhile interpretative guides (Cassell and Dubey, 1997, 2003, 2012, 2014). Sometimes sexually structured existing anatomical SIS stimuli may throw interpretative light on penis “Body Image” symbolic content in a woman’s fantasy life/dreams. However this only occurs rarely. Consequently three new SIS “inkblots” were designed with a higher degree of embedded phallic structure to enable clinicians/research projective scientists to focus more specifically on this phenomenon. It might prove intriguing to ascertain if daytime fantasies of having a penis, and such sexual imagery while dreaming, might be related to the increased social power of many modern women. In any case, currently the new projective stimuli under development and standardization will be presented for visual inspection of readers in the next issue of this journal. Three illustrative cases taken from the internet follow: Case 1 is entitled “Decode My Dream: I’m a Woman, but I Have a Penis So this is by far the strangest dream I’ve ever had. I’m going to preface by telling you that I am a female, which is the main reason this dream was so disturbing. In my dream I was in a small bathroom, one I’ve never seen before. I was sitting on the toilet, and when I looked down, much to my shock, I had a penis. I remember being briefly confused, and then amazed as I thought to myself, “Wow for never having a penis before mine is really nice!”. The shock and confusion gave way to a feeling of pride that I needed to put on. I was impressed with my newest body member. Then for some reason I had a condom in my hand that I needed to put on. Not quite sure why, seeing I was alone in the bathroom. I spent the rest of the dream trying to figure out how to “get my penis to work”. Because to my ………………………………………………………………………………………………………………………………………… Wilfred A. Cassell, M.D., FAPS, APC, (Email: sis2cassell@outlook.com), B. L. Dubey, Ph.D., D.M.S.P. (Email: bldubey@gmail.com), and Kalyani Menon (kalyani@mothercomputers.com), SIS Center, Anchorage (USA). Key Words: Dream Symbolism, Dream Interpretation

Dismay I had no idea how to use it or make it function properly. When I woke up I was very perplexed by the dream, I’ m still not sure what it means. “Chick with a Dick”: The following interpretation was given to her by a Jungian analyst: “First let me say that I’m glad that you woke up with all your lady parts in place! Phew! We all have a male and female part of ourselves. Carl Jung often referred to them as the ANIMUS and the ANIMA. The Animus is the masculine part of the female psyche and the Animus is the male part of the feminine psyche. Our eventual goal as healthy and whole human beings is to find an appropriate balance of our masculine and feminine sides. And let me just say… that is not an easy task. The Animus or Anima can show up in our dreams as genitalia that we would not ordinarily have or as someone of the opposite sex who we don’t seem to know in real life. So let’s chat about your Animus (Aka your masculine energy). The fact that you have a penis in your dream let me know that you are probably just getting in touch with the masculine side of your masculine nature. This is really important for women. The Animus represents some male qualities such as self-confidence, creativity, determination, will power, self-control, purposeful action energy and activity. The full development of our masculine side helps us protect ourselves, and go out and get what we want from life. Cultivating these qualities can be challenging, but very necessary to being a strong and well-adjusted woman. In your dream you have this really nice masculine energy that you are starting to appreciate, but you don’t yet know how to make it work in your life. Because your dream takes place in a bathroom, I’m thinkig that the energy that you are thinking about is only done in private; you haven’t really put all your masculine gusto into practice in your life. But being aware of its presence is the first step towards personal growth and balance. A word of advice: It’s time to get to know your man side intimately. Explore it and get familiar with it in your daily life. No need to be scared or confused. You will only learn how to harness your power if you learn how to use it and make it part of your life.” Case 2: One woman responded on the internet a year later after reading Case 1 as follows: however mine was slightly different. My partner (a man) and I were about to have sex when I looked down at my spread my legs and a penis sort of flopped out of my vagina! I would love to know what on earth this could mean. “I had a rather similar dream to this last night and decided to look up what it could mean (which brought me here to the dream interpretation internet program), having read your response to the first (above) dream, I’m seeing that it might have something to do with that, but I still am a little confused because of the way it happened”. Case 3: This involved a middle aged highly successful professional woman who was being treated an Obsessive Compulsive Disorder with mixed anxiety/depressive features. What was sexually remarkable about her clinical case was her preoccupation with irrational fears that her husband might have homosexual tendencies. Although her husband totally denied the accusations, she obsessively requested sexual intercourse “for him to prove that he was not”! In her early childhood, for religious reasons, her parents adopted several younger children.

A male child was mentally retarded and eventually homosexual. After the adoption she felt psychologically displaced from her mother, who had become overwhelmed from having to provide care for so many children. In sharp contrast, she retained an especially close loving relationship with her father. In many ways, she identified with his positive traits. Eventually her symptoms were reduced from the medication and long term psychotherapy. Eventually during her long term treatment, when her father was dying, she experienced a dream in which her pelvic area had “TWO” penises! She said these represented the two psychologically supportive men in life - her father and her mature male psychotherapist. Literature Review: In considering where to begin reviewing the existing literature, a decision was made to insert the Freudian notion of “PENIS ENVY” in an internet search engine. Google had twenty seven references alone. Moreover on Google it was suggested that an interested reviewer might also insert the following related subject names: Female to male transsexuals, Penis Panic, Womb and vagina envy and Castration Anxiety. In contrast to this large volume of related sexual literature, there was little in the way of methodologically valid scientific studies. Hopefully the three new SIS stimuli under development with phallic structure linked to an overall gestalt of the adult female body may open new scientific projective pathways. May be someday there may be solid projective SIS data to better understand a woman’s Body Image physically-psychologically and spiritually, as well as the fact that women are now adopting social power roles traditionally occupied by men. As might be expected there is considerable ongoing controversy regarding both the validity and the social implications of such observations? Two current books warrant brief review: 1. Rosin, H, The End of Men; And the Rise of Women, 9/11/2012 Penguin Publishing Group 2. Coontz, S. A Strange Stirring (Contact her at www.stephaniecoontz.com) Relevant Reading Internet Sources: Cassell, W. A. (1980) Body Symbolism and the Somatic Inkblot Series. Anchorage, Alaska. Aurora Publishing. Cassell, W. A. and Dubey, B. L. (1997) Therapeutic Dream Stimulation with SIS- Video. SIS Journal of Projective Psychology & Mental Health, 4: 3-23. Cassell, W, A. and Dubey, B. L. (2003) Interpreting Inner World through Somatic Imagery: Manual of Somatic Inkblot Series. Anchorage (USA): SIS Center. Cassell, W. A. and Dubey, B. L. (2012) Spiritual Warfare and SIS Spiritual Symbols, SIS Journal of Projective Psychology & Mental Health, 19: 80- 90. Cassell, W. A. and Dubey, B. L. (2014) Dream and SIS Symbolism in Bereavement, SIS Journal of Projective Psychology & Mental Health, 21: 3- 10. https://www1umn.edu/humanrts/edumat/IHRIP/circle/mod ules/module4.htn http://www.google.com/url?sa=t&rtc==j&q en.wikipedia.org/wiki/Women’s rights Also read Women in government, Women rights, Women in the work force) www.encylopedia.com (Read “Women’s movements…social reform) www.un.org 82 Cassell et al

Clinical Instruction on Projective Techniques in the USA: A Review of Academic Training Settings 1995-2014 Chris Piotrowski Academic training with projective methods has been an enduring and enigmatic feature of the assessment curriculum in professional and clinical psychology since the 1940s. However, the past 2 decades have witnessed a steady stream of rather disparaging commentary directed largely on the lack of psychometric credibility of individual projective methods, particularly from the academic community in the USA. The purpose of the current study is to determine whether this collective movement, evident in the scholarly literature, against projective techniques has had a deleterious impact on the extent of graduate-level training and instruction over the past 20 years. To that end, the author identified, through an extensive literature review, published survey research in the USA that reported on training emphasis in projective assessment, from 1995-2014. The 12 identified studies served as the data pool to ascertain the extent of coverage of projective techniques within the context of assessment training, both in academic and internship settings. The analysis showed that: a) there has been diminutive emphasis on projective techniques in academic clinical/professional programs, although some training with projective tests continues in PsyD practitioner programs, and b) expectations of competency with projective assessment during internship training, touted in the past, have largely diminished in recent years. Interestingly, a sizeable minority of graduate students still desire advanced training in projective assessment. Several notable issues in the clinical/professional milieu, in recent years, may account for this decline in interest in projective techniques (see Piotrowski 2015 for further discussion): a) proliferation of graduate–level specialty training has exacerbated ‘inclusion’ (and exclusion) of essential required coursework; b) evidence indicates that instruction in assessment has steadily been reduced, particularly available courses in projective techniques; c) due largely to managed care administrative policies, coverage for comprehensive test batteries, which may include projective tests have been denied and reliance on ‘brief’ assessment instruments has become the standard; d) over time, younger faculty and internship supervisors either hold very negative attitudes toward projective assessment or have sparse training and experience with these techniques; and e) with the retirement of older, more experienced faculty, instruction on projective tests tends to be de-emphasized or unavailable. Thus, it appears that aspiring graduate students and interns, with an interest in projective techniques, either need to pursue external professional training via workshops, individualized supervised instruction, or engage in intensive self-study. These findings have implications for training in projective assessment overseas. Since recent reviews of applied clinical settings show that projective techniques continue to be valued by psychologists worldwide (Piotrowski, 2015), future research should elucidate the status of education, graduate-level instruction, and professional/clinical training with projective techniques in nations outside the USA. Prior to 2000, academic instruction and preparation in various approaches to psychological testing and assessment had always been a hallmark of both graduate-level and internship training in clinical/professional psychology (Butcher, 2006; Craig, 1990; Dana, 2014; Garfield & Kurtz, 1973; Handler & Hilsenroth, 1998; Janda, 1998; Kolbe et al., 1985; Marlowe et al., 1992; McCully, 1965; Newmark, 1996; O’Donohue et al., 1989; Piotrowski & Keller, 1984, 1989, 1992; Russ, 1978; Stout, 1992; Sugarman & Kanner, 2000; Weiner, 1997), including teaching emphasis in projective testing (Dana, 1975; Durand, Blanchard, & Mindell, 1988; Piotrowski, 1984; Pruitt et al., 1985; Ritzler & Alter, 1986; Ritzler & del Gaudio, 1976; Shemberg & Keeley, 1970; Silverstein, 1996; ………………………………………………………………………………………………………………… Chris Piotrowski, University of West Florida, Email: cpiotrowski@uwf.edu Keywords: Projective assessment, Projective technique, Clinical Instruction on Projective Techniques.

84 Chris Piotrowski Stagner, 1984; Thelen et al., 1968). But even during this zenith period of popularity in projective assessment, critical commentary on the nature and efficacy of psychological testing was evident in the literature (e.g., Ivnik, 1977). Thus, it is noteworthy that by the mid-1990s, survey-based data of academic settings indicated a slight decrease in training emphasis in objective testing and a more notable decline in projective tests (see Piotrowski & Zalewski, 1993; Watkins et al., 1990). Moreover, research studies have identified drastic changes in mental health administrative policy, largely due to managed care constraints, as a major reason for this decline (Phelps et al., 1998; Piotrowski, 1999; Youngstrom, 2013). At the same time, these changing trends in emphasis on projective testing may reflect an emerging academic and professional interest on specialty training in applied psychology in such areas like neuropsychological and forensic assessment (e.g., Archer, 2013; Ready & Veague, 2014). During the 1990s, academic psychologists engaged in lively discussion and heated debate about the role of not only psychological testing in the clinical and counseling curriculum but also the efficacy of traditional training models (Craig, 1992; Retzlaff, 1992). In order to obtain an historical perspective on testing trends during this transitional period, several reviews of the extant literature appeared (Evers et al., 2012; Meyer et al., 2001; Piotrowski & Keller, 1992; Watkins, 1991). These extensive examinations of survey-based studies concluded that although enthusiasm for projective techniques was waning somewhat (Garb et al., 2002), instruction on specific projective methods was still considered a valuable, coveted clinical skill by directors of academic clinical training programs (e.g., Durand, Blanchard, & Mindell, 1988; Piotrowski & Zalewski, 1993), directors of internship sites (Stedman and Colleagues, 1997, 2000, 2013), and clinical students in training programs (Stedman, Hatch, & Schoenfeld, 2001b). Interestingly, it was not until the 1990s that an onslaught of hardened opposition to use of most projective techniques emerged from many quarters (Garb 1999; Garb, Wood, Lilienfeld, & Nezworski, 2002; Hunsley & Bailey, 1999; Motta et al., 1993; Smith & Dumont, 1995; Wood, Nezworski, & Stejskal, 1996). In support of these rather disparaging appraisals, extensive reviews of the literature concluded that validity evidence for projective techniques is very limited (see Lilienfeld, Wood, & Garb, 2000; Wood et al., 2000; Ziskin, 1995), including reviews by European researchers (e.g., Wittkowski, 1996). Even proponents of projective assessment questioned the sustainability of academic coverage of projective tests in graduate training (Tuber, 1995). While the status of projective assessment has been threatened over the past 20 years, reviews on recent studies of ‘applied’ settings have indicated that, for the most part, projective techniques continue to be valued and remain a mainstay in the assessment enterprise in practice (see Piotrowski, 2015). But has the role of projective methods in graduate education and training been impacted aversely due to the onslaught of negative criticism directed specifically against this group of tests? Interestingly, recent initiatives and directives toward enhancing competency levels in psychological assessment during academic and internship training (see Belar, 1998; Eyde & Childs, 2000; Krishnamurthy et al., 2004; Stedman et al., 2013), include tests like the Rorschach (Callahan, 2015; Hilsenroth et al., 2007).

Moreover, contemporary reviews and commentaries concerning cross-national factors in education and training in assessment have not excluded projective techniques (e.g., Byrne et al., 2009; Herzberg & Mattar, 2008; Miguel, 2014). Accordingly, clarification on both attitudes and extent of emphasis of projective techniques since 1995, during graduate clinical training, is sorely needed. To that end, it would be of interest to examine the extant literature regarding graduate-level instruction on individual projective techniques, both in academic and internship settings in the USA, over the past 20 years. Current Study: In order to appreciate historical trends on the role of projective testing in training in academic graduate-level programs and internship settings, the author utilized bibliometric analysis of the published literature. To that end, a systematic search of the database PsycINFO (published by the American Psychological Association) was conducted, as this research repository is considered the leading scholarly file of research in the social and behavioral sciences worldwide. Since earlier reviews on assessment training and education have examined studies prior to 1995 (e.g., Piotrowski, 1992; Watkins, 1991), Table 1 summarizes survey findings from key studies of instructional emphasis on projective techniques over the past 20 years. Thus, this analysis includes the (n=12) published survey-type studies of academic and internship programs in the U.S. that appear in peer-reviewed journals. Training Emphasis on Projective Techniques: General Findings: Based on the analysis of these 12 key studies on training emphasis with projective methods, several evolving trends were noted (see Table 1). Interestingly, there seems to be a bifurcation in training emphasis. First, it appears that over the past 20 years there has been a steady decline in academic coverage of projective assessment in graduate-level instruction. This diminutive teaching of projective techniques was most apparent in that: a) coverage of projective tests has been frequently integrated within the general assessment curriculum, b) that offerings of advanced courses on projective tests have continued to decline, and c) individual courses on projective assessment tend not be required. Nevertheless, survey data indicate that many clinical students have expressed an interest in advanced coursework on specific projective techniques. Second, survey data on attitudes of internship training directors (as well as a sizeable minority of interns) confirm that competency in projective assessment has been a desired skill for clinical/professional practice (e.g., Piotrowski & Belter, 1999; Stedman et al., 2001a). Moreover, training opportunities with projective tests have been evident at a sizeable minority of internship settings. Apparently, many interns have obtained supplemental training with projective instruments via workshops and individualized instruction. It must be noted, however, that there has been a sharp decline over the past 5 years in training emphasis with projective tests at internship sites in the USA (personal communication, Dr. James Stedman, 2015). Overall, while there has been diminished interest in techniques like sentence completion and HFDs types of instruments in academic training, the Rorschach and TAT still garner clinical interest of some faculty and

86 Chris Piotrowski students. In fact, the Rorschach remains the most popular projective measure reflected both by the survey data in the current analysis and by the high level of research interest devoted to this specific test (see Hilsenroth et al., 2007; Mihura, Meyer, Dumitrascu, & Bombel, 2013; Piotrowski, 1996). Perhaps as evidence for the high level of clinical interest in select projective measures, research teams continue to explore creative adaptations to the Rorschach method and human figure drawing applications (e.g., Erard & Viglione, 2014; Handler & Thomas, 2014; Kato & Suzuki, 2015; Matto, Naglieri, & Clausen, 2005). Several critical factors have contributed to the de-emphasis in the teaching of projective tests/techniques. The impact of managed care, lack of reimbursement, and shift to alternative professional specialization have already been noted. In addition, perennial concerns on the limitations of psychometric validity regarding projective methods cannot be discounted (Catterall & Ibbotson, 2000; Clark, 1995; Wood et al., 1996, 2000). Another central issue revolves around the level of instructional competency of assessment faculty and disinterest in teaching specific courses on projective methods, particularly younger faculty (e.g., Callahan, 2015; Eyde & Childs, 2000; Krishnamurthy et al., 2004). Finally, I would suggest that as the graduate clinical curriculum has increasing challenges for course inclusion from evolving sub-specialty areas and contemporary psychological approaches, traditional areas such as intellectual/cognitive testing and objective personality assessment might also be deleted from required coursework. Put simply, assessment might cease to be considered a central core competency of professional training; an issue that has confronted the clinical importance of projective testing historically (see Carter, Daniels, & Zickar, 2013; Ivnik, 1977). Thus, the traditional clinical assessment professional may truly be a dying breed, as aptly noted by Ready and Veague (2014), “declining emphasis on projective tests may be due, in part, to retirements of more senior faculty” (p. 281). Conclusions: Projective techniques have had a long but challenging history for nearly a century. Moreover, there has been lively academic and applied interest in projective methods, reflected across copious studies and extensive extant literature on a host of projective instruments (Murstein, 1965; Rabin, 1986). Yet despite the perennial criticism leveled against this unique approach to psychological assessment, particularly in recent years, projective techniques continue to a) garner scholarly interest and b) harbor unique clinical value in clinical practice (e.g.,Basu, 2014; Piotrowski, 2015). In fact, a Keyword search of the recent psychological literature, conducted in the database PsycINFO, reveals a total of 2,943 references on projective techniques, including 1,746 articles in peer-reviewed journals (from 2008- 2012, the range= 18-33). Moreover, coverage of projective techniques remains robust as evident in coverage in many contemporary graduate-level texts on psychological assessment (e.g., Groth-Marnat, 2009; Harwood, Beutler, & Groth-Marnat, 2011; McGrath & Carroll, 2012). Based on the findings of this review, a general conclusion can be confidently offered that there has been a gradual recognized decline in training emphasis with projective tests in graduatelevel clinical psychology training in the USA over the past decade, and a lack of instructional opportunities with these methods in internship settings over the recent past. Although the extant evidence suggests that

instruction on projective measures has been tempered over the past 20 years, it appears that projective techniques, particularly the Rorschach and TAT, continue to be considered a robust assessment tool by a small legion of professional psychology faculty. Indeed, lively discussion on the attributes of the Rorschach continue to appear in the scholarly literature (Bornstein, 1999; Callahan, 2015; Erard & Viglione, 2014; Hilsenroth et al., 2007; McGrath & Carroll, 2012; Meloy et al., 1997; Mihura et al., 2015; Musewicz et al., 2009). Apparently, a select segment of the psychological community value the utility of projective techniques in providing rich clinical data that foster potential working hypotheses in idiographic assessment. Finally, it must be noted that the current review examined survey data based on graduate-level and internship training in the USA. There appears to be a dearth of studies on academic and internship instruction and training on projective assessment from other nations (e.g., Raez de Ramirez, 1999; Rossel et al., 2001; Viljoen et al., 1999). Moreover, research on non-traditional populations should shed some critical light on the importance of competency training in multicultural assessment specific to projective testing approaches (Cheung et al., 2003; Dana, 2002). Thus, country-based studies are needed in order to provide a more comprehensive perspective on the status of projective techniques in graduate-level education and clinical training worldwide. Table 1: Summary and Findings on Instruction with Projective Techniques in the USA (n=12; 1995-2014) Study Sample Major Findings Hilsenroth & Handler (1995) 166 psychology graduate students’ (affiliates of the Society for Personality Assessment) views on Rorschach instruction 50% of these students completed 2 courses on the Rorschach; 32% were required to administer from 5 to 9 protocols; concerns were noted with regard to inadequate coverage of research findings and integration of theory; respondents noted a need for more direction for report writing assessment evaluations Rossini & Moretti (1997) Survey data on 50 directors of APA-accredited clinical training programs regarding didactic instruction on the TAT 22% of this sample indicated no required coursework on the TAT; specific instruction on the TAT was integrated within general assessment courses; 47% offered at least 1 practicum course that involved TAT protocol interpretation Piotrowski & Belter (1999) Extent of graduate-level assessment curriculum was reported by training directors from 84 APAapproved internship settings 67% of directors covered Rorschach & TAT during seminars; 28% provided training on H-F- Ds & SCT; the Rorschach ranked 3rd regarding most important psychological tests for practice; however, 34% of these directors rated a decrease in training emphasis with projective techniques over the prior 5 years Belter & instructors of This sample held moderate views toward

88 Chris Piotrowski Piotrowski (1999) psychological testing coursework in Masters-level clinical/counseling programs projective techniques and predicted a substantial decrease in graduate-level training and emphasis in projective tests Clemence & Handler (2001) Surveyed internship settings on use and training of psychological tests Internship directors supported graduate-level preparation in projective assessment as an important component of professional practice, but admit deficiencies in pre-internship academic instruction on projective methods; 72% value the Rorschach, 56% the TAT, as part of the ‘testing battery’ Stedman et al. (2001a) Assessed internship directors’ evaluation of clinical graduate students’ pre-internship preparation regarding assessment training and competency While all areas of testing (IQ, objective personality, projective techniques, neuropsychological) were deemed important competency areas, projective testing was somewhat less valued than objective measures by internship directors Belter & Piotrowski (2001) Survey data on 82 directors of APA-approved doctoral clinical/professional psychology training programs on assessment curriculum Nearly 60% of the programs required a specific course on projective testing; tests most emphasized, Rorschach 80%/TAT 70%/H-F-Ds 37%/SCT 28%; 27% of respondents view the Rorschach as ‘essential’ for practice; however, about 50% of directors confirm a decrease in emphasis on instruction with projective tests over the prior 5 years Stedman et al. (2002) Based on survey data from psychology interns, determined extent of preinternship assessment report writing experiences Results showed that clinical students met or exceeded most expectations of internship training directors by producing a median of 18 integrated testing reports; however, whereas experience with the Rorschach seemed adequate (4 reports), reports on TAT, H-F-Ds, & SCT were few (M=1.5) Childs & Eyde (2002) Course syllabi data, from 84 APA clinical psychology programs, determined coverage of projective assessment techniques 87% of the programs offer at least 1 graduatelevel course that covers projective tests (79% require this course); the Rorschach (81%) and TAT (71%) were most emphasized; the SCT (29%) and H-F-Ds (24%) less emphasized Mihura & Weinle (2002) Based on data from 254 APA graduate student affiliates, the extent of Rorschach training was investigated While 87% of the respondents reported coursework that included the Rorschach, only 25% were offered an advanced course on this test; Most of the students held very positive views on the Rorschach but desired more advanced training; students from PsyD programs expressed more favorable attitudes than those from clinical

PhD programs Neukrug et al. (2013) Based on survey data from 210 counselor educators across the U.S., this study examined graduate-level coverage of assessment instruments by instructors These instructors provide coverage on a wide range of tests; 95% teach the Rorschach, 93% the TAT, 89% the H-T-P, 71% the CAT, and 70% the Rotter ISB Ready & Veague (2014) Compared training in psychological assessment across 3 training models (Clinical-Science, Scientist- Practitioner, Practitioner- Scholar) in APA-Accredited programs Although the response-rate was rather low (33%), several trends were noted; tests that reflect evidence-based practice standards were emphasized (no projective tests ranked in the top 10); only practitioner-scholar programs offer coverage on projective techniques; younger faculty express little interest or competency in teaching specific projective techniques References: Archer, R.P. (2013). Forensic uses of clinical assessment instruments (2nd ed.). New York: Routledge. Basu, J. (2014). Psychologists’ ambivalence toward ambiguity: Relocating the projective test debate for multiple interpretative hypotheses. SIS Journal of Projective Psychology & Mental Health, 21, 25-36. Belar, C.D. (1998). Graduate education in clinical psychology. American Psychologist, 53, 456- 464. Belter, R.W., & Piotrowski, C. (2001). Current status of doctoral-level training in psychological testing. Journal of Clinical Psychology, 57, 717-726. Belter, R.W., Piotrowski, C. (1999). Current status of master’s-level training in psychological assessment. Journal of Psychological Practice, 5(1), 1-5. Bornstein, R.F. (1999). Criterion validity of objective and projective dependency tests: A meta-analytic assessment of behavioral prediction. Psychological Assessment, 11, 48-57. Butcher, J.N. (2006). Assessment in clinical psychology: A perspective on the past, present challenges, and future prospects. Clinical Psychology: Science and Practice, 13(3), 205-209. Byrne, B.M., Oakland, T., Leong, F.T., van de Vijver, F.J.R., Hambleton, R.K., Cheung, F.M., & Bartram, D. (2009). A critical analysis of crosscultural research and testing practices. Training and Education in Professional Psychology, 3(2), 94-105. Callahan, J.L. (2015). Evidenced-based technical skills training in pre-practicum psychological assessment. Training and Education in Professional Psychology, 9(1), 21-27. Carter, N.T., Daniels, M.A., & Zickar, M.J. (2013). Projective testing: Historical foundations and uses for human resources management. Human Resource Management Review, 23, 205-218. Catterall, M., & Ibbotson, P. (2000). Using projective techniques in education research. British Educational Research Journal, 26(2), 245-256. Cheung, F.M., Leong, F., & Ben-Porath, Y.S. (2003). Psychological assessment in Asia. Psychological Assessment, 15(3), 243-247. Childs, R., & Eyde, L. (2002). Assessment training in clinical psychology doctoral programs: What should we teach? What do we teach? Journal of Personality Assessment, 78, 130-144. Clark, A.J. (1995). Projective techniques in the counseling process. Journal of Counseling and Development, 73(3), 311-316. Clemence, A., & Handler, L. (2001). Psychological assessment on internship: A survey of training directors and their expectations for students. Journal of Personality Assessment, 76, 18-47. Craig, R.J. (1992). On the rocks (Boulder) and under cover (Vail): Models of training and psychodiagnostic assessment. Journal of Training & Practice in Professional Psychology, 6(1), 7-13. Craig, R.J., & Horowitz, M. (1990). Current utilization of psychological tests at diagnostic practicum sites. The Clinical Psychologist, 43, 29-36. Dana, R.H. (2014). Personality tests and psychological science: Instruments, populations, practice. In Leong, F.T. et al. (Eds.), APA handbook of multicultural psychology, Vol. 2: Applications and training (pp. 181-196). Washington, DC: American Psychological Association. Dana, R.H. (2002). Multicultural assessment: Teaching methods and competency evaluations. Journal of Personality Assessment, 79(2), 195-199.

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Children’s Drawings, Thematic Apperceptive Technique Questions, and Memory Robert B. Williams, Joan B. Flagg-Williams, and Laurence A. French The relationship between children’s drawings that serve as thematic picture cards for a clinician’s thematic apperceptive technique (TAT) enquiry format and Tulving’s explanations of memory development are described. Particular attention is given to describing the influences of the procedural, semantic, and episodic aspects of memory. The paper, “In Pursuit of the Aboriginal Child’s Perspective via a Culture-free Task and Clinical Interview,” (Williams, French, Picthall- French, & Flagg-Williams, 2011) reported that French (1993) was seeking “clinical assessments that transcend cultural barriers” (p. 16). His objective was to evaluate potential abuse among children in diverse cultural and socioeconomic contexts who were primarily of Hispanic and American Indian backgrounds in the U.S. state of New Mexico. French (1993) reported that “there are 22 separate tribes located within the state—the Navajo, Jicarilla Apache, Mescalero Apache, and 19 separate Pueblo tribes (the largest being the Zuni)” (p. 15). Regarding evaluation of abuse, Bellak (1990) noted that the Children’s Apperception Test (CAT) was found useful “. . . in the age of child abuse, sexual and aggressive, the stories have to be especially studied from the standpoint of possibly revealing evidence of such abuse” (p. 362). In this context, French considered the three formats of the CAT— animal figures, human figures, and the supplement involving family situations (e.g., physical disability, reactions to mother’s pregnancy) on plates constructed like pieces of a large jig-saw puzzle in irregularly shaped outlines (Bellak & Bellak, 1980). Bellak (1990) did not comment on the issue of adapting the CAT for use with children from a variety of cultural backgrounds. French (1993) determined that none of the CAT formats were appropriate. He settled on an approach that involved integrating Draw-A- Person/Draw-A-Family (DAP/DAF) tasks and thematic apperceptive technique (TAT) questions as least culturally prejudiced for investigating possible child abuse victims from a variety of cultural backgrounds (French, 1993). The children’s drawings became the thematic picture cards that would be the basis of the clinician’s enquiry. Note of selected studies on the influence of children’s drawings on memory: A retrospective survey of clinical assessment procedures that might easily be adapted in a culture-free or culturally appropriate format was completed by Williams et al. (2011). The survey noted, “. . . that children can represent their perspectives through their drawings of what they have been exposed to, what has happened to them and their thoughts and feelings about these experiences” (Williams et al., 2011, p. 24). There have been informative studies on the positive influences of children’s drawings on their memories that also likely influenced the children’s perspectives. In our judgment, these studies support French’s (1993) use of children’s drawings as the format of the thematic picture cards for his clinical enquiry. For example, in contexts where children were being examined regarding abuse, they were asked to draw themselves, family members and, at times, a possible abuser. ………………………………………………………………………………………………………………… Robert B. Williams, Crandall University (Correspondent: Email: robert.williams@crandallu.ca, Joan B. Flagg-Williams, Saint Joseph’s College and Laurence A. French, University of New Hampshire. Key words: children’s drawings, thematic apperceptive technique, memory development

Drawings made it easier for children to review what happened (Jones & McQuiston, 1985). Burgess and Hartman (1993) concluded that, “. . . children’s drawings are useful as an associative tool for assessing and accessing traumatic memories” (p. 161). Ninety percent of forensic mental health professionals surveyed by Oberlander (1995) responded that children’s drawings were useful. Other studies have documented that having children draw improves their memory reports. It must be noted that the studies cited here involve drawing and telling at the same time. This procedure is different than drawing in one context and telling at another time as in French’s (1993) procedure. In Butler, Gross and Hayne’s (1995) study, children participated in unique events and were interviewed one day and one month after the event. Five- to six-year-old children who were asked to draw gave more information about the event than those who were only asked to tell about the event. Drawing did not result in more information from the 3- to 4-year-olds in the study. In another study, it was found that even after 6 months or a year, drawings tended to “. . . facilitate children’s ability to talk about their past experiences in both clinical and legal contexts” (Gross & Hayne, 1999, p. 265). It is noteworthy that children’s drawings also enable them to report emotional experiences in clinical and legal situations (Gross & Hayne, 1998; Patterson & Hayne, 2011). One study also noted the benefits of drawing’s influence on memory in educational contexts (Gross, Hayne, & Drury, 2009). Children’s drawings, TAT questions, and Tulving’s developmental model of memory: Context: Assuming that the origins of children’s perspectives are their memories, this paper focuses on the influences of memory on their drawings and responses to questions about them from the perspective of French’s (1993) study. Consideration of memory and projective tests is not unique as one researcher has proposed that tests of personality such as those based on thematic apperceptive techniques can be linked to aspects of memory (Schultheiss, 2007). What follows are the integrated guidelines for the drawing tasks and the TAT questions based upon French’s (1993) original instructions for sessions with children (see Williams et al., 2011). The drawing tasks and the TAT questions will be especially linked to the developmental aspects of memory— procedural, semantic, and episodic— postulated by Tulving (1985a, 1985b, 1985c, 1987, 1993). Tulving’s explanation of memory development was selected because it is based on extensive research and a synthesis of the memory research of others (see Tulving 1984a, 1984b, 1985a, 1985b, 1985c, 1986, 1987, 1991, 1993, 1995a, 1995b, 1999, 2002, and 2005; Tulving & Schacter, 1990). Session 1- Drawings and memory, especially procedural memory: At an initial session, a child is asked to draw a picture of herself or himself. The child’s response of drawing a picture indicates the attainment of semantic memory (languagebased) for this meaning of the term “draw” and possibly of an episodic (experiential or autobiographical) memory of having drawn a picture in the past. While the child is drawing the picture, there is an ascendance of procedural (doing) memory to complete the drawing task. Thus, the child’s response of drawing indicates competencies in the 94 Williams et al.

semantic, episodic, and procedural aspects of memory. This is in accord with the notion that all tasks will likely involve multiple aspects of the developing systems of memory (Tulving, 1991, 2002). What is most significant in this context is the child’s application of the procedural aspect of memory to the task of drawing. This is noteworthy in that Tulving (1985a) maintains that procedural memory is the first to develop in humans. It is described as “. . . memory for how to do something, including various mental procedures and psychomotor skills” (Martin, 1993, p. 170). Being familiar with Piaget’s (Piaget & Inhelder, 1969) description of the sensorimotor phase from infancy to early childhood helps to understand procedural memory which is also referred to, “. . . as motor memory, body learning, or habit memory” (Jensen, 1998, p.107, 2005, p. 135). It needs to be noted that the procedural, semantic and episodic aspects of memory are hierarchically related to one another (Tulving, 1985a, 1985b, 1985c, 1993). Tulving (1985a) maintains that “at the lowest level . . . , procedural memory, contains semantic memory as its single specialized subsystem and semantic memory, in turn contains episodic memory as its single specialized subsystem” (p. 387). From this perspective, it is understood that semantic memory is dependent upon procedural memory and episodic memory is dependent upon both procedural and semantic memory. In fact, only procedural memory can function without the others. With this perspective in mind it is likely that engaging procedural memory in the drawing task is of benefit for gaining some access to a child’s memory of likely/possible abuse. Regarding episodic memory, Tulving (2002) has noted that achievement of this aspect of memory is uncertain for children under 4 years of age. This was also seen in the study noted above by Butler et.al. (1995) where drawing did not facilitate recall for 3- to 4-year-olds. Session 2- TAT questions and semantic reports of episodic memories: In a second session, which occurs in one to four days after the completion of the drawyourself task, the child is presented with the picture s/he drew and asked to tell the interviewer about the person in the picture. This will likely be an informative experience in that, as psychiatrist Robert Coles (1990) reports, “children are impelled to talk about what they have drawn or painted . . .” (p. 346). Such talk may help to confirm from the child’s perspective the important features of the drawing useful for clinical understanding of the child. Posing the question to tell the interviewer about the person in the picture intends to engage both the semantic and episodic aspects of the child’s memory. The semantic aspect of memory enables the child to retain and internally represent “. . . information learned from words” (Sprenger, 1999, p. 50). According to Tulving (1985), “semantic memory is characterized by the additional capability of internally representing states of the world that are not perceptually present” (p. 387). The dictionary defines semantic as “pertaining to meaning, especially meaning in language” (Morris, 1975, p. 1177). As is noted above, semantic memory is a ‘specialized subsystem’ of procedural memory. It emerges as a form of behavior. The emergence of semantic memory from procedural memory is not difficult to understand. Again, Piaget’s (Piaget & Inhelder, 1969) description of the sensorimotor phase of infancy into early childhood not only helps in understanding the development of procedural memory but also aids in understanding the emergence of

semantic memory. As a child begins to crawl, walk, run, or climb, its parents, siblings and relatives begin labeling or naming the behaviors. This verbal feedback encourages the child to practice the motor skills while at the same time providing verbal stimuli of an initial repertoire for semantic memory. It is the beginning of the wonderful skill of language that allows the child to reflect and relate in words her or his prior experiences or future actions. Developmentally, the semantic labels and words both evoke and limit behaviors that have their origins in procedural memory. There are some interesting examples in research with children that demonstrate how labels or names and words emerge as expressions of and influences on their behavior. Children as young as 17 months of age expressed in verbal behavior the relativity of person-proper names and the specificity of the common names of classes (Katz, Baker, & Macnamara, 1974). Another example of the influence of semantic verbal labelling or naming was seen among 18- to 22-month-old children who were reported to have spent more time playing with toys that were verbally labelled or named than with those that were not (Roberts & Black, 1972). These examples demonstrate the interactive influence of behavior on semantic verbalization and vice versa. It is also noteworthy that they tend to point to the ascendance of the influence of the verbal over behavioral or one might say the semantic over the procedural. The child’s ability to understand the clinician’s enquiry about the person in the picture that the child has drawn represents the mastery of language and applied semantic memory. It is likely that the child’s response will involve episodic memory which is unique in itself from the procedural and semantic aspects of memory. What especially differentiates the procedural and semantic aspects of memory from episodic memory is that they are “. . . a historical, depersonalized, and generally similar in content to the information they represent” (Dretske, 1982 as cited in Martin, 1993, p. 175). Whereas, the episodic aspect of memory is especially unique because it is related to the place and even the time when a person experienced stimuli, learned something or established a memory (cf. Sprenger, 1999). Episodic memory “. . . enables people to remember past happenings. . . . For a rememberer to remember something means that he or she is . . . aware of a past happening in which he or she has participated” (Tulving, 1993, pp. 69-70). It is the memory that people access when they are asked, for example, to recall where they were or what they were doing when they learned about the events on September 11th, 2001. What is striking about the anecdotes is the detail that they contain about where individuals were and what they were doing at the time. This episodic aspect of memory is also an individual’s memory of his or her own behavior and experiences through time. It is also noteworthy that episodic or “autobiographical memories are usually emotional (affect-related), implying that subjects evaluate the emotional significance of the events” (Markowitsch, 2008, p. 278). Also, as noted above, children’s drawings may enable them to report emotional experiences in clinical and legal situations (Gross & Hayne, 1998; Patterson & Hayne, 2011). Sessions 3 and 4: During a third session the child is invited to draw a picture of herself/himself and her/his family. Once again as the child draws there is the engagement of memory as it was 96 Williams et al.

described in session one above. In a fourth session on another day, the child will be presented with the family picture s/he drew and asked to tell a story about the family. The child’s responses will engage the aspects of memory that were involved in responding to the TAT questions as posed during session 2. Conclusion: Learnings from this essay are that 1) children’s retrieval of memories are improved through their drawings and 2) the developmental aspects of memory— procedural, semantic, and episodic—facilitate children doing drawings and explaining their meanings. Finally, Harris (1971) has observed that understanding children via drawings is based upon “the principal assumption . . . in projective theory, of isomorphy between concept or idea in drawing and life experience (or repressed experience, as the case may be)” (pp. 244-245). References: Bellak, L. (1990). The CAT and other projective techniques: 50 years later. Rorschachiana, 17, 361-364. Bellak, L., & Bellak, S. S. (1980). A manual for the Children’s Apperception Test (Animal Figures) (7th and Revised Edition). Larchmont, NY: C.P.S. Inc. Burgess, A. W., & Hartman, C. R. (1993). Children’s drawings. Child Abuse & Neglect, 17, 161-168. Butler, S., Gross, J., & Hayne, H. (1995). The effect of drawing on memory performance in young children. Developmental Psychology, 31, 597- 608. Coles, R. (1990). The spiritual life of children. Boston: Houghton Mifflin Co. French L. A. (1993). Adapting projective tests for minority children. Psychological Reports, 72, 15-18. Gross, H., & Hayne, H. (1998). Drawing facilitates children’s verbal reports of emotionally laden events. Journal of Experimental Psychology: Applied, 4, 163-179. Gross, J., & Hayne, H. (1999). Drawing facilitates children’s verbal reports after long delays.Journal of Experimental Psychology: Applied, 5, 265–283. Gross, J., Hayne, H., & Drury, T. (2009). Drawing facilitates children’s reports of factual and narrative information: Implications for educational contexts. Applied Cognitive Psychology, 23, 953– 971. doi: 10.1002/acp.1518 Harris, D. B. (1971). [Notice of the book Kinetic family drawings (K-F-D): An introduction to understanding children through their drawings, by R. C. Burns & S. H. Kaufman]. Child Development Abstracts and Bibliography, 45, 244-245. Jensen, E. (1998). Teaching with the brain in mind. Alexandria, VA: Association for Supervision and Curriculum Development. Jensen, E. (2005). Teaching with the brain in mind (2nd Ed.). Alexandria, VA: Association for Supervision and Curriculum Development. Jones, D. P. H., & McQuiston, M. G. (1985). Interviewing the sexually abused child. Gaskell: Oxford Katz, N., Baker, E., & Macnamara, J. (1974). What’s a name? A study of how children learn common and proper names. Child Development, 45, 469- 473. Markowitsch, H. J. (2008). Cultural memory and the neurosciences. In A. Erll & A. Nûnning (Eds.), Cultural memory studies: An international and interdisciplinary handbook (pp. 275-283). Berlin: Walter de Gruyter GmbH & Co. Martin, J. (1993). Episodic memory: A neglected phenomenon in the psychology of education. Educational Psychologist, 28, 169-183. Morris, W. (ed.) (1975). The American heritage dictionary of the English language. Boston: American Heritage Publishing Co. / Houghton Mifflin. Oberlander, L. B. (1995). Psychological issues in child sexual abuse evaluations: A survey of forensic mental health professionals. Child Abuse and Neglect, 19, 475–490. Patterson, T., & Hayne, H. (2011). Does drawing facilitate older children’s reports of emotionally laden events? Applied Cognitive Psychology, 25, 119– 126. Piaget, J., & Inhelder, B. (1969). The psychology of the child. New York: Basic Books, Inc. Roberts, G. C., & Black, K. N. (1972). The effect of naming and object permanence on toy preferences. Child Development, 43, 858-868. Schultheiss, O. C. (2007). A memory-system approach to the classification of personality tests: Comment on Meyer and Kurtz (2006). Journal of Personality Assessment, 89, 197-201.

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Therapeutic intervention through SIS in a case of Dissociative Convulsion Disorder Bankey L. Dubey and Padma Dwivedi The Somatic Inkblot Series-II (Cassell and Dubey, 2003) was administered to an 18 years old girl, studying in 12th class with complaints of fits (fainting attacks), headache and nausea. She was diagnosed as a case of “Dissociative Convulsion Disorder” as per ICD-10. The SIS responses projected her poor interpersonal relationship, pent up aggression and abusive childhood. The SIS imagery was used as therapeutic intervention tool with positive results and relief from symptoms. Significant responses are interpreted and discussed in the case study. What is Somatic Inkblot Series? The Somatic Inkblot Series (SIS) is a structured projective diagnostic procedure and an adjunct to psychotherapy. It is the third inkblot test after Rorschach and Holtzman tests. Unlike the earlier two inkblot tests, it is self-administered and can be taken as groupadministered during screening and personality assessment. The series has 5 subtests eg. 20 Cards SIS–I (Like Rorschach), DVD of SIS-I, SIS-II (62 images Booklet), DVD of SIS-II and SIS Living images. The SIS stimuli evoke symbolism and meanings unique to the responding individual such as present in somatic delusions and affect charged dreams. The procedure is an adjunct to therapy because responses can be further explored to create a more effective treatment plan, and can be re-addressed in later discussions, providing opportunities to elicit deeply defended material. During the administration of the SIS procedure, patients may abreact emotional conflict raised to consciousness by the images, which can be a therapeutic experience in itself. The viewer writes responses on an answer sheet. Most of what is included in the ambiguous structure relates to specific life situations and post-traumatic dream content that has been found to have clinical significance. Viewing the SIS has both diagnostic and therapeutic applications that are far reaching. The SIS procedure has been used internationally on different samples. Various researchers have reported high reliability and validity of the test (Cassell and Dubey, 1996, 2000, 2003, Cassell et al, 2013, Cervigni, 2013, Pershad and Dubey, 1994, Pershad and Verma, 1995). As an aide to psychotherapy, the imagery projected onto inkblots enable the therapist to view stressful events from the subject’s past life. The critical images that are projected may reflect, either directly or in disguised symbolic form, real life historical events. In addition to the above, the projected symbolism may be traceable to highly subjective body mind-spirit phenomena such as body imagery, dreams, visual hallucinations etc. By assessing an individual's responses, and associations to them, much can be learned about the person's innermost thoughts and feelings. What is seen or imagined in semi-ambiguous inkblots reveals his deeper layer of self-perception. It is hoped that these evolving technique may be applied by investigators of inner psychic space leading to the creation of new body-mindspiritual theory. ………………………………………………………………………………………………………………… Bankey L.Dubey, Ph.D., DMSP, Director SIS Center and Padma Dwivedi, M.A. Psychotherapist, SIS Center, N8/187-R-1, Newada, (Maa Shitala Road), Sunderpur, Varanasi-221005 (India). Email: bldubey@gmail.com, Key words: SIS Therapeutic intervention

100 Dubey and Dwivedi At its present stage, the various forms of the SIS have been found helpful as an aid to enable professionals to empathize more sensitively with the suffering individual's "inner cry." Previously, their suffering was more likely to be hidden because of defensive mental mechanisms Dubey et al, 2015). Many existing techniques employed today are highly time consuming, not particularly cost-effective. Perhaps most important of all, they do not readily provide a transparent window into the inner world. In an analogous fashion, the imagery projected onto inkblots enables the examiner to view more clearly stressful events from the subject’s past life. The critical images that are projected may reflect, either directly or in disguised symbolic form, real life historical events. Interpreting these is a much more challenging task than faced by an astronomer whose concepts relate to time, space and energy. In addition to the above, the projected symbolism may be traceable to highly subjective phenomena such as inkblot responses, body imagery, dreams, visual hallucinations etc. (Cassell and Dubey, 2012). Case Study: The patient was 18 years girl, studying in 12th class. She had normal milestones with no past history of psychological problems. She had been a good and sincere student, and scored among the top 4 students in the class. Her parents always compelled her to get first position. She tried hard but could not satisfy the desire of her parents and got bad remarks after every examination. She further reported that her father had abusive relationship with her mother and at certain times, ended up with physical assault to the mother and children. Her younger brother always supported her. Her symptoms started when she entered Junior college at age 17. She had fits of unconsciousness with severe headache. On interrogation she narrated her love relationship with a young man who deserted her. Her problem aggravated to the extent that she had pain in fingers while taking examination. At this stage she was referred for therapeutic intervention. She was administered SIS –II Booklet (62 images) and a few clinically significant responses are discussed here to show the penetrative power of the SIS images. SIS Responses: A6: “A sad teddy bear” may indicate her abusive childhood and pensive mood. She feels neglected from parents, particularly father. A7: “A dancing girl” is normal response indicating her desire to live happily and enjoy life with positive attitude. A 9: “A man and a woman seen arguing” may project conflicting relationship between father and mother, who used to quarrel often, ending up in physical abuse of mother. A 10: Face of a sad woman who is crying”. This may reflect her mother’s pensive mood and her own sad face after getting scolding from father. Such responses may be indicative of depressive features and suicidal behavior which must be discussed during therapy sessions. A 13: “hand raised asking for help”. This may project her own or her mother’s cry for help which she has witnessed several times and feels sad. She is looking for help from significant others. The client has concern about her mother and wishes to help her. A 31: “A man and woman in serious discussion. This may project the

disturbed relationship among parents or with her boy-friend. B 4: “Father and son discussing something”. This may indicate her disturbed relationship with her father, who often discussed about her performance in examination and feels he had better suggestions to offer her. B 18: “A snake is swimming into a tunnel”. This may indicate her love relationship and desire for physical contact. Snake and swimming into tunnel has very clear Freudian symbolism which should be addressed during therapeutic intervention sessions. She is a mature person and such response may indicate her normal feeling/desire. B 19: “Two separated heart” may indicate her broken love affairs. The seriousness of such affairs and its impact on her should be discussed during therapy session. Keeping other responses in view, at least this response does not seem to look to have serious impact. B 28: “Woman in sad mood thinking of something”. This may indicate her mother’s sad mood due to broken home environment. Normally people perceive “mother with child” and the avoidance of perceiving child might be her inability to protect her daughter and herself from her husband. B29: “A running boy” looks normal response with positive attitude even in odd situation. Many people perceive handicapped person running on this image. B 31: “Four persons, seems two children and two older people”. This is the last image of the test and the image is created in such a way that people should carry “happy family” perception way back home. She has avoided perceiving happy family because of her disturbed family environment. She has avoided perceiving parents but has seen two children which may indicate her loving relationship with her younger brother. Dream Interpretation: On the following night after viewing SIS images she saw the following dream: “I am walking on the bank of a river and it looks as if I am in my city. It is beautiful weather and I noticed a boat sailing in the river. A young couple is sitting and talking. They look very happy. I am also feeling happy to see them. All of sudden I saw an aged man walking towards me. I did not like his appearance and I woke up”. It looks a wishful dream with lot of pleasant feelings. The young couple may symbolizes “she with her boyfriend”, and “sailing in the river may indicate her erotic desire for physical contact”. “They look very happy” may symbolize her wishful thinking to have pleasant days ahead after marriage, particularly when she departs from her parental home. Such dream may also protect her ego from breakdown. The sudden presence of an aged man may be her father’s image that she does not like. Treatment plan: Initially she was given free verbalization and allowed to express everything she felt bad about during last three years. The significance of SIS responses and its projective interpretation was discussed. She was asked to question anything regarding interpretation. After 3 sessions of initial discussion, she was administered sessions of hypnotic relaxation therapy. She started showing improvement after 5 sessions of therapy. The intensity of headache reduced significantly and she started analyzing the situation around her.

She developed confidence and the frequency of fits reduced. Her relationship with mother improved and she felt cozy to approach her mother. She still hesitates to approach her father and do not like to meet him. She feels everything will be alright in future and she will have a beautiful life. Conclusion: The SIS-II test was administered to an 18 years old girl, studying in class 12th with the main complaints of fainting attacks and headache. The SIS response projected her disturbed relationship with father, broken love affairs and pent up aggression. The SIS imagery was used as therapeutic intervention tool with positive results and provided much relief from her symptoms. She is still under observation and taking therapy. References: Cassell, W. A. and Dubey, B. L. (1996) The Use of the Rorschach and SIS in Releasing Somatised Grief. SIS Journal of Projective Psychology & Mental Health, 3: 3 -32. Cassell, W. A. and Dubey, B. L. (2000) Inkblot Responses as an Aid to Therapy. SIS Journal of Projective Psychology & Mental Health, 7:3-10. Cassell, W.A. and Dubey, B.L.(2003) Interpreting Inner World through Somatic Imagery, SIS Center, 4406, Forest Road, AK 99517(USA). Cassell, W.A. and Dubey, B.L.(2012) Spiritual Warfare and SIS Spiritual Symbols, SIS Journal of Projective Psychology & Mental Health, 19: 80-90. Cassell, W.A., Pandey, P., Tiwari, A., Mishra, N. and Dubey, B.L. (2013) SIS Guided Therapy for an Adolescent Girl’s Tension Headaches, SIS Journal of Projective Psychology & Mental Health, 20:1, 49-54. Cervigni, A. (2013) Therapeutic Intervention through SIS Imagery: Two Case Studies, SIS Journal of Projective Psychology & Mental Health, 20:2, 122-127. Dubey, B.L., Cassell, W.A. and Dubey, A. (2015) Hand Book of Projective Technique (Rorschach, Holtzman and Somatic Inkblot Series), SIS Center, Anchorage, USA.Pershad, D. and Dubey, B.L. (1994) Reliability and Validity of Somatic Inkblot Series in India, SIS Journal of Projective Psychology & Mental Health, 1994 1: 33-38 Pershad, D. and Verma, S. K. (1995) Diagnostic Significance of Content Analysis of SIS-II. SIS Journal of Projective Psychology & Mental Health, 1995, 2: 139-144 PRICE LIST OF SOMATIC INKBLOT SERIES SIS ID SIS Version Indian Users Foreign Users SIS-I: Card Form INR: 12000 US $200 SIS-II: Booklet Form INR: 12000 US $200 SIS-II: Video INR: 18000 US $300 SIS-I Video INR: 18000 US $300 SIS Living Images INR: 18000 US $300 All Versions INR: 60000 US $1000 Place Your Orders: Bankey L. Dubey, Ph.D., Director SIS Centre, 4406 Forest Rd, Anchorage, AK 99517, E-mail: bldubey@gmail.com 102 Dubey and Dwivedi

A Comparative Psychosocial Study of Aggression, Attachment Styles and Personality among Orphans and Normal Children Rajasree Chakraborty, Manisha Dasgupta and Nilanjana Sanyal The nostalgia and mystery of childhood poses to be an eminent question to behavioural scientists. The present investigation attempts to plunge into the intricacies of childhood among a specific sub-section of orphan children across the backdrop of their normal counterparts to probe into their psyche and inner world in terms of shaping of their “selves”. The garden of childhood has thorns for them and offers emotional pains for them in terms of emotional deprivation. The present sample consisted of 60 orphan children and 60 normal children (30 boys and 30 girls in each of the two groups) living with both parents at their residences after matching them with respect to age, sex, intelligence, socio-economic status, education, religion, nationality, location and duration of stay in any institution. Variables studied were aggression, attachment style and personality. Statistics revealed significant group differences, where orphans had significantly higher mean scores in only one dimension of aggression, namely, Anger-Expression Out; certain indices of personality, namely, Total number of Response, Animal responses, and Anatomical Responses. Again, normal children were found to have significantly higher in only one dimension of aggression, namely, Anger-Expression In and certain indices of personality like, Sex responses, and Typical responses. Significant gender differences and interaction effect were also found. The findings have been discussed to unfurl the inner dynamics of orphan children from the psychologist’s desk. Implications of the findings along the provision of psychotherapeutic strategies for shaping their personalities have also been discussed. Childhood is one of the few life experiences that we all share. Childhood plays a crucial role in our development as human beings, for which it deserves to be explored in all its facets: fun, richness, complexity and poignancy. Childhood has been perceived as a necessary stage from which to graduate into adulthood; it has also been regarded as the “golden age” of a person’s life, it does, however, remain a varied experience, and the concept of “childhood” is effectively the product of a constantly changing adult-led society as well as a personal experience. Locke (1963) referred to the child as a tabula rasa, a blank slate, from which they could learn through experience and develop rationally into the adult world. Rousseau (1762) argued that a child should develop in line with nature and self-discovery and learn through the consequences of their actions. Childhood is thus a mystery: the soul is timeless, the body new, and the world complex. It is elusive in us. Childhood is the only time when the mind is so free, when fairies are as real as fires, when fables are true, and reality is constantly invented. The world is a dream. It is the place where many seeds and notions are planted in us, and watered with loving hands of our parents – most generally, our “significant others”. However, this fragile garden of childhood gets scathed and fragmented when the young child suddenly is thrown into a strange world with no biological caregiver to look up to due to myriad reasons. The inner self of the young soul weeps bitterly and searches frantically for a warm hand, a warm touch, a caress… The present researchers attempt to plunge into the inner journey of such children who are orphaned early to understand their shaping of personality in line with certain selected correlates like attachment, aggression and personality. ………………………………………………………………………………………………………………………………………. Rajasree Chakraborty, M.Sc. Research Scholar, Manisha Dasgupta, Ph.D., Asst. Professor (Corresponding author) Email:manisha_peu@rediffmail.com, Nilanjana Sanyal, Ph.D., Professor and Former Head, Dept. of Psychology, University of Calcutta, 92 A.P.C. Road, Kolkata – 700009. Key Words: aggression, attachment style, personality, orphans, normal children

104 Chakraborty et al. Studies of emotional deprivation due to either neglect in the home or due to forced institutionalization have revealed that personality changes are an almost inevitable accompaniment (Coates et.al., 1972; Rutter, 1972). Because young children are more dependent on their parents for feelings of security and for happiness than on anyone else, poor relationship with their parents, especially with the mother have been reported to have a devastating effect on their personality make-up (Hurlock, 1981). Children who are deprived of their parents are likely to experience severe emotional trauma when the basic source of security is removed, either by death or divorce (Hurlock, 1981). Glasner (1961) has reported that the child’s self concept is “formed within the womb of the family relationships”. The dimensions of family interactions that are important for shaping the personality of children include the emotional tone of the family, the responsiveness of the parent to the child, the manner in which control is exercised and the quality and amount of communication (Bee, 1997; Sanyal and Dasgupta, 2008). Bowlby (1979) warned that children whose basic needs have not been met consistently, and who therefore are not securely attached, might respond to the world either by shrinking away from it or by doing battle with it. “Primal wound” in attachment bond with the primary caregiver results in orphaned children because of the loss of the biological parents (Main and Goldwyn, 1985). Attachment begets trust, which is, in turn, necessary for attachment. Verrier (1993) proposed that “the child’s experience of abandonment causes him to mistrust the permanence of the present caretaker and to defend against further loss by distancing himself from her.” Russell (1996) suggested, “If the infant is separated from the only mother it has known for nine months, it will be more difficult for the child to establish trust.” Erikson (1968) himself characterized the development of trust as a crucial foundation for the child’s first social achievement, separation from the mother, the intra-psychic process that Mahler, Pine and Bergman (1975) termed separationindividuation. Damania (1988) states that children in institutions represent one of the most disadvantaged group of children in the country. The long and short term effects of institutionalization have been described by researchers like Venugopal and Kodandaram (1983) in terms of deficits in language, cognitive and social development. Orphan children who have been institutionalized often reach their maturity by creating a vulnerable structure of their personality. If not adequately supported further, they remain vulnerable to face difficulty in organizing and integrating their life. Deprivation of adequate familial care, education, health and social protection during the formative years of life, not only threatens their physical, psychological and social development but also brings them to the risk of not being able to self-empower in order to actively participate in the social life and have a balanced personality development. ‘Highly deprived class of society’ is what institutionalized children are considered to be. They are left helpless, abandoned and neglected by the parent or caregivers and are deprived of one or more necessities of life. Separation from or absence of parents results in deprivation of parental care, love, affection, warmth, security, acceptance and discipline during childhood. This disrupts their normal socio-emotional development and thus it becomes necessary to know whether orphans, most of whom are institutionalized, who are devoid of family life, grow up normally and how well they are able to cope with themselves as well as adjust to the demands of the environment and society, when compared with

their normal counterparts. In the present study, orphan children are defined as those whose parents are not alive and who are institutionalized. Normal children, on the contrary, are considered to be those who stay with both their parents at their residences. The present study is guided by the following objectives: (a) To find out whether there is any significant inter-group difference, i.e., difference between orphans and normal controls with respect to aggression (anger), attachment style and personality as well as their different respective dimensions. (b) To find out whether there is any significant gender difference, i.e., difference between boys and girls with respect to aggression (anger), attachment style and personality as well as their different respective dimensions. (c) To reveal whether there is any significant intra-group difference with respect to the selected variables and their respective dimensions. Method Sample: The sample consisted of 60 orphan children and 60 normal children of both sexes (30 boys and 30 girls in each of the two groups) living with both parents at their residences after matching them with respect to their ages (7-11 yrs.), sex, intelligence (average intellectual functioning and above), socio-economic status (low), education (grade I-V), religion (both Hindu and Muslim), nationality (Indian), location (residing in different reputed orphanages) and duration of stay in any institution (at least 2 years). Children in these two groups were free from any past history of psychiatric disorder, chronic physical illness and organic ailment. Tools used: 1. Specially designed information schedule 2. State-Trait Anger Expression Inventory – 2 TM Child and Adolescent (STAXI-2 TM C/A) by Brunner and Spielberger (2009) - to assess anger as a precursor to aggression; 3. The Security Scale by Kerns et al. (1996) – to assess attachment in middle childhood. 4. The Somatic Inkblot Series (SIS) by Cassell and Dubey (2003) – to elicit intrapsychic associations and interpret the inner world through somatic imagery. All the above mentioned measures were administered only to those children who possessed at least “average” level of intelligence after screening them on the basis of Coloured Progressive Matrices (CPM) by Raven, Court, and Raven (1986).

106 Chakraborty et al. Results: Table 1: Means (M) and Standard Deviations (SD) for the selected variables and their respective dimensions corresponding to orphans and normal children Variables Orphan children (N=60) Normal children (N=60) Mean S.D. Mean S.D. 1. Aggression a. State-Anger Feelings (S-Ang/ F) b. State-Anger Expression (S-Ang/ VP) c. Trait-Anger Temperament (T-Ang/ T) d. Trait-Anger Reaction (T-Ang/ R) e. Anger Expression Out (Ax-O) f. Anger Expression In (Ax-I) g. Anger Control (AC) h. Attachment Style 2. Personality a. Total number of responses (R) b. Human responses (H) c. Animal responses (A) d. Anatomical responses (At) e. Sex responses (Sex) f. Movement responses (M) g. Most typical responses (MT) h. Typical responses (T) i. Atypical responses (AT) j. Rejection (Rej) 1. Pathological Anatomy Scale (PAS) 2. Depression (D) 3. Hostility and Aggression Scale (HAS) i. Paranoia (P) 5.22 5.15 8.45 10.20 9.57 8.80 9.90 50.47 63.05 20.62 11.37 8.10 0.22 10.48 8.03 18.12 36.57 1.10 0.22 0.20 2.23 0.00 0.83 0.82 1.95 1.98 2.35 2.15 2.60 6.53 3.0 4.51 4.36 4.75 1.19 5.59 2.36 4.53 6.27 1.94 0.49 0.55 1.65 0.00 5.02 5.08 7.77 9.85 8.68 9.68 9.72 51.13 58.63 20.80 8.88 4.83 2.23 9.88 7.48 21.42 34.38 0.53 0.22 0.23 1.92 0.08 0.13 0.38 1.95 2.32 2.48 2.03 2.35 5.17 14.18 10.10 5.0 4.59 6.53 7.20 5.54 9.24 15.61 1.14 0.61 0.62 1.98 0.38 Orphan children were found to have significantly higher mean scores in only one dimension of aggression, namely, Anger- Expression Out (AX-O); certain indices of personality, namely, Total number of Response (R), Animal responses (A), and Anatomical Responses (At). Again, normal children were found to have significantly higher mean scores in only one dimension of aggression, namely, Anger-Expression In (AX- I) and certain indices of personality like, Sex responses (Sex), and Typical responses (T) as revealed through further analysis in terms of two-way analysis of variance (ANOVA).

Table 2: Means (M) and Standard Deviations (SD) for the selected variables and their respective dimensions corresponding to male and female children as a whole Variables Males (N=60) Females (N=60) Mean S.D. Mean S.D. 1. Aggression a. State-Anger Feelings (S-Ang/ F) b. State-Anger Expression (S-Ang/ VP) c. Trait-Anger Temperament (T-Ang/ T) d. Trait-Anger Reaction (T-Ang/ R) e. Anger Expression Out (Ax-O) f. Anger Expression In (Ax-I) g. Anger Control (AC) h. Attachment Style 2. Personality a. Total number of responses (R) b. Human responses (H) c. Animal responses (A) d. Anatomical responses (At) e. Sex responses (Sex) f. Movement responses (M) g. Most typical responses (MT) h. Typical responses (T) i. Atypical responses (AT) j. Rejection (Rej) 1. Pathological Anatomy Scale (PAS) 2. Depression (D) 3. Hostility and Aggression Scale (HAS) i. Paranoia (P) 5.00 5.08 7.73 9.52 8.85 9.38 9.78 50.37 63.85 22.42 10.43 7.03 0.22 9.98 6.50 18.97 38.43 0.93 0.32 0.16 2.45 0.05 0.00 0.38 1.81 2.12 2.27 1.67 2.64 5.71 4.25 6.26 4.04 5.06 1.18 5.53 3.05 4.76 7.32 1.61 0.65 0.42 1.96 0.29 5.23 5.15 8.48 10.53 9.40 9.10 9.83 51.23 57.83 19.00 9.82 5.90 2.23 10.38 9.02 20.57 32.52 0.70 0.12 0.27 1.70 0.03 0.83 0.82 2.07 2.09 2.61 2.52 2.31 6.05 13.55 8.78 5.54 4.77 6.53 7.25 4.89 9.35 14.63 1.62 0.42 0.71 1.60 0.26 Significant gender differences were also mapped in terms of results of two-way analysis of variance (ANOVA) . Male children scored significantly higher than female counterparts with respect to certain indices of personality, namely, Total number of responses (R), Human responses (H), Atypical responses (AT), Pathological Anatomy Scale (PAS) and Hostility and Aggression Scale (HAS). Female children, on the contrary, scored significantly higher with respect to certain dimensions of aggression, namely, State-Anger/ Feeling (S- Ang/ F), Trait-Anger/ Temperament (T-Ang/ T), Trait Anger/ Reaction (T-Ang/ R) and certain dimensions of Personality such as Sex responses (Sex), Most Typical responses (MT). Interaction effect as revealed through two-way analysis of variance (ANOVA) has also been found to be significant with respect to total number of responses (R), Sex responses (Sex), Most Typical responses (MT), Typical responses (T), Atypical responses (AT), responses with depressive contents (D) and Hostility and Aggression Scale (HAS) indices of personality.

Table 3: Means (M) and Standard Deviations (SD) for the selected variables and their respective dimensions corresponding to orphan male and female children and normal male and female children Variables Orphan males (N=30) Orphan females (N=30) Normal males (N=30) Normal females (N=30) Mean S.D. Mean S.D. Mean S.D. Mean S.D. 1. Aggression a. State-Anger Feelings (S-Ang/ F) b. State-Anger Expression (S-Ang/ VP) c. Trait-Anger Temperament (T-Ang/ T) d. Trait-Anger Reaction (T-Ang/ R) e. Anger Expression Out (Ax-O) f. Anger Expression In (Ax-I) g. Anger Control (AC) h. Attachment Style 2. Personality a. Total number of responses (R) b. Human responses (H) c. Animal responses (A) d. Anatomical responses (At) e. Sex responses (Sex) f. Movement responses (M) g. Most typical responses (MT) h. Typical responses (T) i. Atypical responses (AT) j. Rejection (Rej) 1. Pathological Anatomy Scale (PAS) 2. Depression (D) 3. Hostility and Aggression Scale (HAS) i. Paranoia (P) 5.00 5.07 7.80 9.63 9.10 9.23 10.17 50.50 62.83 21.23 11.40 8.10 0.37 10.40 7.67 18.63 36.53 1.37 0.27 0.30 2.23 0.00 0.00 0.37 1.58 1.85 2.17 1.87 2.76 6.04 3.26 4.13 3.88 5.30 1.65 4.55 2.50 4.28 7.50 1.92 0.52 0.53 1.76 0.00 5.43 5.23 9.10 10.77 10.03 8.37 9.63 50.43 63.27 20.00 11.33 8.10 0.07 10.57 8.40 17.60 36.60 0.83 0.17 0.10 2.23 0.00 1.14 1.10 2.09 1.98 2.47 2.36 2.44 7.09 2.75 4.85 4.87 4.21 0.37 6.54 2.21 4.79 4.88 1.97 0.46 0.55 1.57 0.00 5.00 5.10 7.67 9.40 8.60 9.53 9.40 50.23 64.87 23.60 9.47 5.97 0.07 9.57 5.33 19.30 40.33 0.50 0.37 0.03 2.67 0.10 0.00 0.40 2.04 2.39 2.37 1.46 2.50 5.46 4.89 7.73 4.02 4.66 0.25 6.42 3.14 5.25 6.74 1.11 0.76 0.18 2.15 0.40 5.03 5.07 7.87 10.30 8.77 9.83 10.03 52.03 52.40 18.00 8.30 3.70 4.40 10.20 9.63 23.53 28.43 0.57 0.07 0.43 1.17 0.07 0.18 0.37 1.89 2.20 2.62 2.49 2.19 4.77 17.46 11.46 5.83 4.31 8.77 8.01 6.56 11.70 19.42 1.19 0.37 0.82 1.46 0.37 108 Chakraborty et al.

Summarily: the results may be understood by the tabular representation as follows: Orphan vs. Normal Children Male vs. Female children Orphan males vs. Orphan Females Normal males vs. Normal females Orphan children Normal children Males Females Orphan males Orphan females Normal Males Normal females Have significantly higher mean scores in: Only one dimension of aggression, namely, Anger- Expression Out (AX-O) Certain indices of personality, namely, Total number of Response (R), Animal responses (A), and Anatomical Responses (At) Have significantly higher mean scores in: Only one dimension of aggression, namely, Anger- Expression In (AX-I) Certain indices of personality like, Sex responses (Sex), and Typical responses (T) Have significantly higher indices of personality, namely, Total number of responses (R), Human responses (H), Atypical responses (AT), Pathological Anatomy Scale (PAS) and Hostility and Aggression Scale (HAS). Have significantly Higher dimensions of aggression, namely, State- Anger/ Feeling (S-Ang/ F), Trait-Anger/ Temperament (T-Ang/ T), Trait Anger/ Reaction (T- Ang/ R) and certain dimensions of personality such as Sex responses (Sex), Most Typical responses (MT) Higher sex respons es (Sex), typical respons es (T),depr ession (D) Higher total number of respons es (R), Most typical respons es (MT), atypical respons e (AT) Higher total number of responses (R), atypical responses (AT), hostility and aggressio n (HAS) Higher sex response s (Sex), most typical response s (MT), Typical response s (T), depressio n (D) Discussion: A. Inter-group analyses: Group-wise significant differences have been revealed with respect to selected dimensions of Anger Expression- out (AX-O) and Anger Expression- In (AX-I) as regards aggression. Orphan children scored significantly higher in AX-O dimension of aggression (Table- I & IV). Thus they tend to be more frustrated because of intense emotional deprivation in their formative years as a result of which they tend to externalize their anger to external objects in the environment. Like adults, children are grieved by the loss of their parents, but unlike adults, children often do not feel the full impact of the loss simply because they may not immediately understand the finality of death. This prevents them from going through the grieving process which is necessary to recover from the loss (Brodzinsky, Gormly & Ambron, 1986). Children therefore are at risk of growing up with unresolved negative emotions which are often expressed with anger and depression later on. Many orphans may become withdrawn and passive or develop sadness, anger, fear, and antisocial behaviour and become violent or depressed (Subbarao & Coury, 2004). In the same tune, these children scored significantly lower in AX-I dimension. This reflects the fact that normal counterparts of orphan children tend to be more sophisticated in anger control by internalizing their anger and portraying a socially desirable façade in the external world in order to maintain stable family status in terms of values and set patterns of behaviour.

110 Chakraborty et al. Orphans scored significantly higher in the Total number of responses (R) compared to their normal counterparts. This reflects their higher extent of productivity and imaginative capacity (Cassell & Dubey, 2003), owing to the projection of their unconscious, thereby revealing greater number of responses. This finding has also been supported by a previous study done by Chaudhury et.al (2006). The SIS images appeared to be a vent out mechanism to their emotional pains, consequently resulting in greater number of responses. Significantly higher number of animal responses (A) by orphan children might be explained by the fact that orphan children appeared to be more comfortable with animals than human beings and are psychologically immature (Cassell & Dubey, 2003; Holtzman et. al, 1961). This may be because of their non-available emotionally warm human figures in the earlier stages of life and spontaneous warmth of animal behavior available to them. This was supported by a study of Kawai & Aoki, (1983) pinpointing that human responses tend to decrease by disturbed interpersonal relationships as in case of orphan children. In particular, it has been found that double orphans (both parents absent) are more likely to experience behavioral and emotional difficulties along with low rates of trusting relationships (Baaroy & Webb, 2008; Kang, M., 2008; Zhao, 2010). Anatomical responses (At) were also significantly much higher among orphan children which is indicative of poor self-image and preoccupation with their internal body organs ( Cassell & Dubey, 2003) as compared to their normal counterparts. It was also found that they were significantly less concerned in giving sex responses (S) as compared to their normal counterparts. This may be due to the co-morbid depressive symptomatology which was found in a study of Chaudhury et. al (2006). Normal children have scored significantly higher on sex responses (S) which is considered to be indicative of pressing latent erotic need and heightened sexual anxiety in such children as a whole (Chaudhury, Murthy, Banerjee, Kumari, Alreja, 2011). Typical responses (T) are indicative of reality testing and healthy perception (Cassell & Dubey, 2003). Significantly higher scores in typical responses (T) on SIS images among normal children is suggestive of their psychosocial maturity that leads to healthy perception and reality testing in accordance to the group norm as compared to orphans. Orphan children are found to have remarkably higher, although not statistically significant, trend in comparison to normal children as far as the Trait anger-temperament (T-Ang/T) and Trait Anger- Reaction (T-Ang/R) dimensions of aggression are concerned. This may be explained by the presence of prevailing emotional deprivation among orphans and the absence of an emotional anchor, in the form of parental figures. This results in such children to have higher extent of irritability and lower frustration-tolerance capacity. Orphan children seem to be socially deprived and they tend to encounter higher emotional distress, hopelessness and frustration than nonorphans (Mbozi,Debit, & Munyati,2006). Consequently, such children tend to have aggressive predisposition to a greater extent in contrast to normal children. Less sophisticated behavior manifesting poor impulse control had been found to be a consistent feature of orphan children. The underlying reason stands to be their emotionally wretched life. As because the comforting emotional cushions were not available to them in the growing years, they lack this sophisticated tune in their

ultimate shape of personality (Kedija, 2006; Family Health International, 2002; Atwine, Cantor-Graae & Bajunirwe, 2005). Movement responses (M) in inkblot tests are considered as indicative of internalization and ability to handle more deliberate and sophisticated experiences in emotionally controlled way (Rorschach, 1942), awareness towards the external world and reflective of some unexpressed conflicts and emotions in the realistic world (Beck,1944), motoric expression of affect (Werner,1948), and implicit potential for dynamic energy (Holtzman et. al, 1961). Movement responses were noticeably higher in case of orphan children than normals which may be due to the fact that orphans might prefer to see humans and animals active and dynamic as a compensatory mechanism for their emotional vulnerability. Most typical (MT) and Atypical (AT) responses were remarkably more for orphan children than their normal counterparts. This may lead to some contradictions as because these two types of responses oppose each other. Higher number of MT responses is suggestive of coherent, logical thinking, ability to keep up to the demands of society and are signs of ego strength, team concept and group conformity (Cassell & Dubey, 2003). On the contrary, higher number of atypical responses indicate marked deviations of responses from the expected responses suggesting poor quality of responses with vague percept, either in structure or verbalization; while at the same time higher number of atypical responses are also indicative of intelligence and creative imagination. This may suggest that orphan children vary in their reactions to their environment in the sense that they respond to the environment in the same way as others do to conform with the group to meet up to environmental demands resulting in higher MT responses; whereas in other occasions they either react poorly having a vague perception of the surrounding environment (Cassell & Dubey, 2003) or they react in creative manner by applying their imaginations intelligently (Verma & Singh, 2014). This may be because of their disturbed life pattern. However, they also have higher most typical responses because of the developmental phase of children as a whole which is shared by all children generally (Mondal and Das, 2014). Orphan children are found to have higher score, though not significant, on Rejection (R) in comparison to normal children showing blockage in their thought process leading to the inability to think properly when their ego feels threatened by the “visual touches” of the projective imagery in the form of SIS images. Logic shows that images of inkblots are linked to negative psychological experiences of some individuals and these activate conflicts which become overwhelming and consequently the images are rejected (Verma & Singh, 2014). Remarkable higher score on Hostility & Aggression Scale (HAS) among orphan children indicates that they tend to be more hostile and aggressive to others reflecting the tendency to cause physical or verbal assault or body injury to external environment whenever their needs are not met. This is probably because of their greater extent of aggressive predisposition as reactions to their inner frustrations, conflicts and coping failures in contrast to their normal counterparts. B. Gender-wise analysis of results: Significant differences have been revealed with respect to selected dimensions of State- Anger/Feelings (S-Ang/F), Trait- Anger/Temperament (T-Ang/T) and Trait Anger-Reaction (T-ang/R) as far as aggression is concerned. Female children scored significantly higher in S-Ang/F, T-Ang/T and

112 Chakraborty et al. also in T-Ang/R dimensions of aggression (Table II & IV). Higher S-Ang/F score among females suggests that females experience higher angry feelings internally than male children as Indian society and culture does not allow female to express their anger overtly. In Eastern culture, gender differentiation seems to be so predominant that females automatically imbibe in their system neglect, affectional deprivation and comparative “unwantedness” that makes them emotionally vulnerable resulting in higher irritability, lower frustration-threshold and frequent experiences of anger (Ahuja, 1999; Seymour, 1999). This also results in having lower extent of externalized aggression to portray a socially desirable image in the public façade. Males scored significantly higher in total number of responses (R) compared to female children. This reflects that male children are more productive and imaginative than females. This may be explained perhaps by the greater extent of exposure. Moreover, it also suggests that male children try to express their internal emotional experiences through these images, as a result of which the total number of responses increase. Significantly higher number of human responses (H) as given by the male children are suggestive of healthy interpersonal relationships with people around them (Cassell& Dubey, 2003). It goes along with the prevailing norm of the society to provide more opportunity to males to interact with people around them than is the case for female counterparts. Females are found to have significantly higher scores on sex responses (Sex) than male children indicating sex urge resistance and sexual conflicts. The probable reason may be existing cultural taboos which do not allow direct expression of sex by females. But while responding to SIS images, unknowingly the unconscious canvas of females depicting normal sense of sexuality came out in responses. The efficacy of SIS images has also been proved in the sequence. Significantly higher number of most typical responses (MT) among female children than male partners indicates the natural tendency of females to adhere to the existing socio-cultural norm. Similar finding was reported by Singh and Rani (2014). In contrast, males have comparatively stronger need for individuation for which they are more likely to act and respond differently than what females do. Consequently this tendency results in significantly greater number of Atypical response (AT) among male children. The Pathological Anatomy Scale (PAS) and Hostility and Aggression Scale (HAS) scores were significantly higher for male children in comparison to their female counterparts. The higher number of PAS responses among males reflect their excessive concern about physical health for which they may have cravings to be taken care of a supportive and dependable care-giver. Significantly higher PAS score among males has also been found by Singh and Rani (2014) than their female partners. Higher HAS responses by male children was also found by Singh and Rani (2014). The tendency of male children to show greater hostility and aggression goes along with the existing social norm which considers males to be always the prominent ones in society in general. Animal responses (A) are noticeably, though not significantly, higher among males which is indicative of the fact that male children are more comfortable with animals than human beings or it might be a sign of their psychological immaturity than their female counterparts. Such psychological immaturity

leads males to seek supportive caregivers who can take care of them. Movement responses (M) and Typical responses (T) are noticeably higher among female children (though not statistically significant) which suggests that females prefer to see people and animals to be engaged in some activity. Singh and Rani (2014), in their study, also found significantly higher number of movement responses in females. Females also have a tendency to follow common rules of the society and to “go along” with their views as reflected by higher score on Typical responses as compared to their male counterparts. Tables I and II show no significant difference among the groups (orphans and normal children) and gender (males and females) with respect to attachment style as reflected by more or less similar scores on the variable. This may be due to inherent and usual tendency of every child to be attached with his or her parents or parental figures. Moreover, intra-group findings also were in tune with the findings already mentioned for which they are not being elaborated in the present section. Over all, it may be said that the unique profile of personality of orphan children has been mapped out against the backdrop of their normal counterparts. Conclusion: · Orphan children have significantly higher reactive aggression, are more impulsive and are emotionally immature. Normal children have better anger-control, have healthy relationships with significant others and tend to be group-complaint to a greater extent than their orphan partners. · Male children, on the whole, have higher productivity; maintain inter-personal relationships to a greater extent and have greater strive owing to greater extent of aggression. Female children, contrarily, have higher extent of anger-feelings, reaction, and temperament, having ruminative style to a higher extent. They also tend to comply with the norms to a greater extent. Hence from the above findings, it can be concluded that the personality profile of orphan children is distinctly different from their normal partners as understood through the “visual touches” of projective imagery and selected personality questionnaires. Their inner cry for emotional warmth and attachment seems to be the key feature of orphan children which paves the journey for shaping their overall personality in terms of affection, cognition and conation. References: Ahuja, R. (1999). Indian social system.Rawat Publications. New Delhi. Atwine, B., Cantor-Graae, E. and Bajunirwe, F. (2005). Psychological distress among AIDS orphans in rural Uganda. Social Science & Medicine, Aug; 61(3):555-64. Baaroy, J., & Webb, D. (2008). Who are the most vulnerable? Disaggregating orphan categories and identifying child outcome status in Tanzania. Vulnerable Children and Youth Studies, 3(2), 92- 101. Beck, S.J. (1944).Rorschach Test Process, Vol.1., New York: Greene & Stratton. Bee, H. (1997).The Developing Child. Addison Wesley Longman, Inc. Bowlby, J. (1979). The making and breaking of affectional bonds. London: Tavistock. Brodzinsky, D. M., A.V. Gormly and S.R. Ambron. (1986). Lifespan Human Development (3rd ed.). New York: CBS College Publishing. Brunner, T. M., and Spielberger, C. D. (2009). State-Trait Anger Expression Inventory-2TM Child and Adolescent. Professional Manual, Psychological Assessment Resources, Inc (PAR), USA. Cassell, W.A., and Dubey, B.L. (2003). Interpreting inner world through somatic imagery: Manual of the Somatic Inkblot Series (2nd revision). Somatic Inkblot Center, Anchorage, Alaska, USA.

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Management of Depression in India Naveen Gupta, Abhilasha Singh and Riju A. Singh By the year 2020, depression is estimated to become the second leading cause of disability. Much has been written about the incidence of depression in western countries but, an area of significance is the developing country like India where depression is engulfing people from all walks of life (WHO, 2005). The present case study deals a young Indian married woman with psychosomatic symptoms with Depressive features who committed suicide. She was administered Somatic Inkblot Series (SIS) - II test. The significant responses on SIS are discussed in the case study. Medically, the term depression means, a condition of mental disturbance characterized by such feelings to a greater degree than seems warranted by the circumstances, typically with lack of energy and difficulty maintaining concentration or interest in life. Depression is a common mental disorder worldwide, with an estimated 350 million people suffering from it. It is the leading cause of disability worldwide, and is a major contributor to the global burden of patients (WHO, 2005). It is different from usual mood fluctuations and short-lived emotional responses to challenges in everyday life. Feeling sad, or depressed, happens to all of us but the sensation passes off after a while. However, people with a depressive disorder (clinical depression) find their mental state interferes with their daily life. Their normal functioning is undermined to such an extent that it affects to them and their care takers. It is estimated that by the year 2020 if current trends continue, the burden of depression will increase to 5.7% of the total burden of diseases and it would be the second leading cause of Disability-Adjusted Life Years (DALYs), second only to ischemic heart disease (WHO, 2005). At its worst, 40% patients may commit suicide. According to WHO (2005), the following symptoms must be present for classification as depression: 1. Depressed mood to a degree that is definitely abnormal for the individual, present for most of the day and almost every day, largely uninfluenced by circumstances, and sustained for at least 2 weeks. 2. Loss of interest or pleasure in activities those are normally pleasurable. 3. Decreased energy or increased fatigability At least two of the above three symptoms must be present, for at least two weeks to qualify as per ICD-10 Criteria for Depressive Episode. In addition, at least two of the following seven symptoms should also be present: 1. Loss of confidence and self-esteem. 2. Unreasonable feelings of self-reproach or excessive and inappropriate guilt. 3. Recurrent thoughts of death or suicide, or any suicidal behavior. 4. Complaints or evidence of diminished ability to think or concentrate, such as indecisiveness or vacillation. 5. Change in psychomotor activity, with agitation or retardation (either subjective or objective). 6. Sleep disturbance of any type. 7. Change in appetite (decrease or increase) with corresponding weight change. ……………………………………………………………………………………………………………………………………………... Naveen Gupta, Ph.D., Professor, Abhilasha Singh, Ph.D. Asst. Professor, and Riju A. Singh, Asst. Professor, Department of Business Management, Hindustan Institute of Management & Computer Studies, Farah, Mathura (Corresponding author Email: dr_naveengupta@yahoo.com). Key Words: Depression, SIS intervention

The National Crime Records Bureau’s (NCRB, 2013) statistics reveal that a total of 1,35,445 people committed suicide in 2012 which amounts to a an average of 15 suicides an hour or 371 suicides daily. The number of suicides in the country during the decade (2003–2013) has recorded an increase of 21.6% (1,34,799 in 2013 from 1,10,851 in 2003). In 2013, Maharashtra had recorded the highest incidents of 16,622 cases of suicide (12.30%) followed by Tamil Nadu (16,601), 12.3%, Andhra Pradesh (14,607) 10.8%, West Bengal (13,055) 9.7%, Karnataka (11,266) 8.4% of the total suicide cases in the country. These 5 states together have accounted for more than 50% of the total suicides reported in the country during 2013. Delhi has reported the highest number of suicides (2,059) among Union Territories, followed by Puducherry (546). The States and UTs which have reported significant percentage increase in suicides in 2013 over 2012, were Arunachal Pradesh (76.2%) followed by Bihar (39.3%). India has been in a transition phase, since the last 15-20 years, with changing values and support system. Excessive expectations to excel, aspirations of a better career and financial prospects, and dissatisfaction with what one has, are the factors that contribute largely to rising financial and emotional insecurities, interpersonal conflicts, stress and depression. Moreover, many Indians are depressed because they always think to get more money and better tomorrow. They often ignore today in shaping tomorrow. Stress levels have gone up right from school days. Around 10 million Indians are suffering from depression and 50% of other illness is psychosomatic in nature. Joint families are broken leading to lots of insecurities (Grover et al, 2010; Venkoba, 1981; Reddy and Chandrashekhar, 1998). As per the NCRB report, social and economic issues like unemployment, professional pressures, lead men to depression and committing of suicide while emotional and personal issues like family conflicts, marital disharmony, domestic violence, and sexual coercion by the partner have driven women to depression and committing of suicide. Elderly often commit suicide due to loneliness, terminal illness, family feud, etc. The ‘Family Problems’ has accounted for 24.0%, and was found the major cause of suicides. The present case study of a married young woman, suffering from psychosomatic disorder with major symptoms of Depression, was administered Inkblots procedure (Somatic Inkblots Series) to detect inner cry and unprocessed unconscious material helping her in therapeutic intervention and management. The significant responses of SIS and interview are discussed in the case study. A Case Study: The case (Mrs. X) is 29 Years, married for one year (love marriage), working as a management professional with a Bank in NCR Delhi was referred for psychological intervention by a physician. Her father is a well-placed, senior officer in State Government. Since last two weeks, she was complaining of varied physical symptoms. Her ill health had started affecting her professional as well as personal life. She was found taking leave frequently from Bank. The family consulted a physician and was surprised to know that she was normal on various medical investigations and had no pathology. The physician advised her to consult a psychiatrist. She consulted a psychiatrist, who diagnosed a case of psychological disorder. She was prescribed psychiatric medicines, which she took reluctantly on her parents’ advice. After a few days, she discontinued the medicines 116 Gupta et al.

because of its side effects such as drowsiness and dullness. Her parents approached a psychologist (one of the authors), who administered Somatic Inkblot Series(SIS) - II test to her. Some of the significant responses are interpreted below: Image A4: On this image she perceived “a butterfly with broken wings”. The butterfly may indicate her own self and the broken wing may indicate her passive mood and restricted freedom and feeling of captivity after marriage. Majority of parents do not approve love marriage of their children and often cut off the relationship. In such situation the female is left alone because she is not accepted by her husband’s family and also lost her parent’s home. If the couples are not sound economically, such situation may lead to frustration, guilt feeling and suicidal. Image A5: she viewed on this image “a small man with turban” may indicate incapable husband who is not able to support and care his wife. The small man may also connote incapable in sexual relations though boasting with lots of superiority as shown by turban. In Indian culture the status of husband is much higher than the female whereas in this case wife is an earning woman, equally competent and sharing equal responsibility in the family. Any discrimination between the couples may further lead to frustration. Image A13: On this image she responded as ‘hand in fire’ may indicate lot of difficulties and agony which she finds difficult to manage. Such response may be highly significant as suicidal indicators and she must get hospitalized for critical management of suicidal behavior with pharmacological treatment along with psychotherapy. She was administered sessions of counseling. She used to cry initially and after three sessions she started showing improvement with reasoning for future management. Noticeable improvement started after 5 sessions of therapeutic intervention. Her family was happy and reported positive changes in her approach and behavior. She then went to visit her hometown for two weeks, to celebrate Holi festival (Festival of colors in India). She discontinued further sessions and follow up. After 6 weeks of termination of the therapy session, she committed suicide. Such suicides are increasingly alarmingly in India. Although there are known, effective treatments for depression, fewer than 10% get such treatments. Barriers to effective care in India include ignorance, lack of resources, social stigma and lack of trained health care providers. Another barrier to effective care is non availability of psychological assessment and therapeutic intervention. Also, many patients visit to Witch Doctors and Faith Healers for psychiatric problems and at the end when their condition gets worst, are brought to hospital for psychiatric treatment (Raju, et.al.1979, Ponnudurai, et. al., 1981). Due to ignorance of knowledge about mental health problems, the family is unable to identify the early symptoms of depression. Very few people know that mental health is directly related to hormonal imbalance or chemical changes leading to psychiatric problems. All this misconception ensures that people are not able to distinguish between sadness, normal anxiety and clinical depression that require treatment. While people rush to a doctor for a normal cold and flu, they avoid seeing a psychiatrist. The General medical practitioner may not be a right choice for psychological patients. However, we do not have enough psychiatrists to cater psychological problems in India (Raju, 1980).

Recommendations and Future Direction: While Indian psychiatrists have rejected a World Health Organization (WHO) study portraying India as the depression capital of the world, they say it has indirectly drawn attention to an acute shortage of trained personnel and facilities to deal with mental illness. While the WHO figures for major depression in India may be exaggerated, we will have to accept that there is a growing incidence of depression in our country and that the average age of a depressed Indian is 31 years which will drop fast in the near future unless timely measures are taken. Depression should be in the priority attention of the Government of India, Corporate sector, and Individuals. The aim should be to provide adequate trained personnel and facilities to deal with depression. With proper care, psychosocial assistance and medication, millions of people with depression, can lead normal lives. The corporate have a moral responsibility to practice healthy work culture and environment as employees spend major period of the day at work place. Management has to recognize its responsibility for minimizing stress, thereby reducing stress and mental health problem among employees. Promotion of healthy organizational culture that values individual workers, participative management style, redesigning the jobs leading to Job enrichment, opportunities for career development, recognition of employees for good performance, preventing excessive working hours, ensuring healthy working conditions, can improve mental health and productivity. Policies and actions focusing on improving social network and educational programs, designed to educate the public with regard to the risks inherent to change of jobs, residence, pattern of living as well as how to protect against odd situations must be given due importance. Also, there is a need for further study of factors like cost and course of treatment, its occurrence and attitude towards such patients in India will determine the need of future action. Studies should also evaluate the cost-effective models of treating Depression, best suited in the primary health care settings of India. References: Grover, S., Dutt, A. and Avasthi, A.(2010) An overview of Indian research in depression. Indian J Psychiatry, 10; 52, 178-88 National crime records bureau, India (2013) http://ncrb.gov.in Ponnudurai, R, Somasundaram, O., Balakrishnan , S. and Srinivasan, N. (1981) Depression-a study of 80 cases. Indian Journal of Psychiatry, 23: 256-58. Raju, S.S. (1979) Frequency of depressive disorders in psychiatric clinics in India: A comparative analysis. Indian Journal of Psychiatry, 21: 176-9. Raju, S.S., Kumaraswamy, N. and Mani, A.J. (1980) Socio-demographic factors of depressive disorders in India: A comparative appraisal. Indian Journal of Psychiatry, 22: 356-60. Reddy, M.V. and Chandrashekhar, C.R. (1998) Prevalence of mental and behavioral disorders in India: a meta- analysis. Indian Journal of Psychiatry, 40: 149-57. Venkoba Rao A. (1981) Mental health and ageing in India. Indian Journal of Psychiatry, 23: 1. WHO (2005) ICD-10. 2nd edition, Geneva; thewildernessroad.wordpress.com http://archive.indianexpress.com/news/study-says-indiamost-depressed-country/82 118 Gupta et al

The Relationship between Body Esteem, Attachment Anxiety and Attachment Avoidance among Young Adults M. Mili and A.S. Raakhee The body image is closely related to what we feel about our body. The present study was conducted to find out the relationship between body esteem, attachment anxiety and attachment avoidance in young adults. A sample of 60 subjects (30 males and 30 females) between 22 to 30 years of age was selected using purposive sampling. The subjects were given ECR-R (Fraley, et.al. 2000) to obtain attachment anxiety and attachment avoidance scores and BES (Franzoi and, Herzog, 1986) to obtain the body esteem score. The results indicated that body esteem has an inverse relationship with attachment anxiety and attachment avoidance and did not show significant gender differences among the scores. Self-esteem is a judgement placed on the emotional, intellectual, and behavioural aspects of the self-concept. This judgment (positive, negative or neutral), is very subtle and is constantly present (Frey and Carlock, 1989). The Self Esteem is based on one's own perception of value and potential that developed over time. The level of our selfesteem determines how we operate in life - how we interact with others- spouse, children, friends, and strangers. It determines our own goals and what we strive for, our achievements, and our own satisfaction and happiness in life. Body esteem is closely linked to our self-esteem and is sometimes referred to as “body image”. Body image is related to how we feel about our own body and how we care for it. It is also the mental image we have of our bodies, and how we feel we appear to others. It also reflects how we feel placed in society and how we compare with others. Having a positive body image means that most of the time, we see ourselves accurate, we feel comfortable and good about the way we look. It is normal to struggle with our body image, no matter who we are. Severe negative body image can lead to serious eating and exercise disorders. Positive body image is a clear, true perception of our shape we see the various parts of our body as we really are. We feel proud and accepting of our unique body and refuse to spend an unreasonable amount of time worrying about food, weight, and calories. We feel comfortable and confident in our own body boundaries. Negative body image is a distorted perception of our shape - we perceive parts of our body unlike we really are. We are convinced that only other persons are attractive and that our body size or shape is a sign of personal failure. They feel ashamed, self-conscious, and anxious about their bodies. People with negative body image more likely to suffer from feelings of depression, isolation, low self-esteem, and obsessive with weight loss and are likely to develop an eating disorder (Cassell, 1965, 1980, Fisher and Cleveland, 1958, Nicolini, 2002). Also, unrealistic body image disturbances are seen in body dysmorphic disorder, eating disorders and severe depression (DSM IV-TR). Most of the research to date on body image shows that women are much more critical of their appearance than men – much less likely to admire what they see in the mirror. ………………………………………………………………………………………………………………… M. Mili, Research Scholar in Psychology, Kerala University Library, University of Kerala, Email:milimdas@gmail.com and A.S. Raakhee, Ph.D.,Asst Prof. in Psychology, Sreenarayana College, Chempazanthy, Trivandrum email: raakheeajithas@gmail.com Keywords: body esteem, attachment anxiety, attachment avoidance, young adults

Body dissatisfaction was more common and felt more strongly in women, yet men were also clearly affected by body dissatisfaction (Brennan et al, 2010). Girls and young women might be dissatisfied with their appearance as they compete for socially valued goals, such as romance and jobs, but less dissatisfied in adulthood when there is less social pressure for attractiveness (Feingold and Mazzella, 1998). Feingold and Mazzella argued that gender differences in body image have sociocultural roots. In contrast, men are reported to be generally satisfied with their body weight and body shape (Drewnowski and Yee, 1987). However, due to western cultural influences, men are becoming more concerned with body image (Grogan and Richard, 2002). Both genders experienced body dissatisfaction, though in different shape dimensions. The appearance-related feedback appears to operate in similar ways to affect men's and women's overall body satisfaction (Vartanian, et. al., 2001). The positive relationship has been reported between body image and interpersonal functioning among adults. For both sexes, positive body image was linked to less secure general attachment, especially more preoccupied general attachment and more anxious romantic attachment (Cash, et.al, 2004). In people with high attachment anxiety, they have the constant fear of losing their partners, fear of abandonment, fear of getting cheated and not being good enough for their partners. In people with high attachment avoidance, people generally avoid intimacy and romantic relationships because they view themselves as undeserving of the love and support of others (Bartholomew, 1990). For both men and women, the secure attachment style was associated with greater relationship interdependence, commitment, trust, and satisfaction than being the anxious or avoidant attachment styles. The anxious and avoidant styles were associated with less frequent positive emotions and more frequent negative emotions in the relationship, whereas the reverse was true of the secure style. Avoidant men experience significantly less post-dissolution emotional distress than other people (Simpson, 1990). Individuals whose self-worth is more contingent on appearancerelated standards, experience more negative consequences than those who do not perceive what the opposite sex finds attractive, but whose self-worth is less contingent on appearance (Bergstrom et al, 2004). Generally, people who have low levels of satisfaction in relationships and those who have number of failed relationships are basically anxious and explain that they don’t/ did not match up with their partners in appearance. This is a descriptive study to investigate whether body esteem plays an important role in relationships. Objectives of the study: The study is conducted to find out the relationship between body esteem and attachment related anxiety and avoidance. Method: The study was descriptive in nature with ex post facto research design. Sample: The sample consisted of 30 men and 30 women in the age range of 20 - 30 years, selected from various colleges in Bangalore and Kerala, using purposive sampling technique. Consent of the subjects to participate in the research was taken and confidentiality was assured. They were given two questionnaires - one to measure attachment anxiety and attachment avoidance of the person and the other to measure the 120 Mili & Raakhee

body esteem of the person. Only voluntary participation was entertained. Instruments: Body Esteem Scale (Franzoi and Shields, 1984): The Body esteem scale is a 35 item test. This questionnaire asks participants to rate body parts and functions on a 5 point scale (1= strong negative feelings to 5= strong positive feelings). According to Franzoi (1994) when BES was administered to university students, it proved to be a reliable and valid measure of body esteem and showed high test retest reliability for both male and female population. Experiences in Close Relationships (ECR- R) (Fraley, Waller and Brennen, 2000): The ECR-R is a 36 item test. This test gives you an attachment anxiety score as well as an attachment avoidance score. Both the scores range from 1 to 7. Longitudinal analyses suggest that the ECR-R provided highly stable indicators of latent attachment during a 3-week period (85% shared variance). Hierarchical linear modeling analyses further validated the ECR-R, suggesting that it explained between 30% to 40% of the between-person variation in social interaction diary ratings of attachmentrelated emotions experienced during interactions with a romantic partner and only 5% to 15% of that in interactions with family and friends. Statistical Analysis: The data thus collected was analyzed using Statistical Package for Social sciences (Version 21). Correlational analysis, one sample t-test and one way ANOVA were computed to find the relationships. Results and Discussion: The sample consisted of 30 males and 30 females, thus both sexes constituting 50% of the sample. Roughly 36% of the subjects were 21 years of age since most of them were college going young adults. 35% were 22 yrs of age and 18.33%, 6.67% and 3.33% were 23yrs, 27yrs and 30 years respectively (Table 1). Table 1: Frequency and Percentage of Demographic details in the selected sample Variables Frequency Percentage Age 21yrs 22yrs 36.67 23yrs 18.33 27yrs 6.67 30yrs 3.33 Gender Male Female Correlational Analysis revealed that body esteem has an inverse relationship between attachment avoidance (-.671) and attachment anxiety (-.766). This showed that people with low body esteem tend to have high attachment avoidance and attachment anxiety or vice versa. People with low body esteem are not happy with themselves and feel that they are not good enough for their partners. This further reflects their poor interpersonal functioning. They either have irrational anxiety of losing their partner or constantly avoid intimacy because of a fear of abandonment in the future. Likewise, people with body esteem shows confidence in themselves by feeling a sense of security in interpersonal relationships. The results showed a positive correlation between attachment anxiety and attachment avoidance. This indicated that as the attachment anxiety increases in an individual, the tendency to avoid intimacy or interpersonal relationships also increases. So an individual who has low attachment anxiety has little concern in entering interpersonal relationships (Bartholomew, 1990). The anxious and avoidant styles were associated with less frequent positive emotions and more frequent negative emotions in the relationship (Simpson, 1990) (Table 2).

Table 2: Comparison of attachment anxiety and attachment avoidance One-Sample Test Test Value = 0 t df Sig. (2- tailed) Mean Difference Upper Attachment anxiety 23.24 .000 2.08 1.90 2.26 Attachment Avoidance 19.21 .000 2.11 1.89 2.34 The attachment anxiety had a mean of 2.09 and 2.11 for attachment avoidance. The “t” Test did not show significant difference between the two means of the scores and analysis. This confirms the assumed strong relationship between attachment anxiety and attachment avoidance (Bartholomew, 1990) (Table 3). Table 3: Relationship between body esteem, attachment anxiety and attachment avoidance Correlations Attachment anxiety Attachment avoidance Body esteem Attachment anxiety .397 -.766 Attachment avoidance -.671 Body esteem The One way analysis was carried out to find gender differences in Body esteem. The findings did not show significant differences in body esteem between males and females in the selected sample. This indicated that both males and females maintained healthy body esteem. McKinley, (1998) has also complimented the feminist views in body esteem, 1998) (Table 4). Table 4: One way ANOVA analysis of gender differences in body esteem Source Type III Sum of squares df Mean Square F Sig. Corrected Model 5.400a 5.400 .030 .863 Intercept 756228.267 756228.267 4204.356 .000 Sex 5.400 5.400 .030 .863 Error 10432.333 179.868 Total 766666.000 Corrected total 10437.733 Conclusion: Body esteem like self- esteem has an impact on one's interpersonal functioning. The findings of this study showed that the body esteem has an inverse relationship between attachment anxiety and attachment avoidance. The attachment anxiety and attachment avoidance are found to have a direct relationship and the analysis proved no significant differences in both variables. No differences in genders (between male and female) were found in the present study. The findings further showed the importance of having positive and healthy body esteem in successful interpersonal functioning. Limitations: The limited sample size is the major drawback of this study. A larger sample size might give better insights into the gender differences in Body esteem. The study should have included important variables like marital status, parenting styles, education, age differences etc in understanding the factors affecting the body esteem. 122 Mili & Raakhee

References: Bartholomew.K (1990). Avoidance of Intimacy: An Attachment Perspective. J. Social and Personal Relationships, 7: 147-148. Bergstrom RL, Neighbors C, Lewis MA. (2004) Do men find “bony” women attractive? Consequences of misperceiving opposite sex perceptions of attractive body image. Body Image: An International Journal of Research. 1:183-191. Brennan, M.A., Lalonde, C.E. and Bain, J.L. (2010). Body Image Perceptions: Do Gender differences exist? Psi Chi Journal of Undergraduate Research. 15(3): 130-138. Cash, T.F., Theriault, J., Annis, N.M. (2004). Body image in an interpersonal context: Adult attachment, fear of intimacy, and social anxiety. Journal of Social and Clinical Psychology, 23: 89-103. Cassell, W. A. (1965) Body Perception and Symptom Localization. Psychosomatic Medicine, 27: 171- 176. Cassell, W. A. (1980) Body Symbolism and the Somatic Inkblot Series. Anchorage, Alaska. Aurora Publishing. Drewnowski.A. and Yee.D.K. (1987) Men and body image: are males satisfied with their body weight, Psychosomatic Medicine, 49: 626-634. Feingold, A.and Mazzella, R. (1998) Gender Differences in Body Image, Psychological Science, 9: 190-195. Fisher, S. and Cleveland, S.E. (1958) Body Image and Personality. Princeton: Van Nostrand. Fraley, R. C., Waller, N. G., and Brennan, K. A. (2000). An item response theory analysis of self-report measures of adult attachment. Journal of Personality and Social Psychology, 78: 350-365. Franzoi, S.L. (1994). Further evidence of the reliability and validity of the body esteem scale. J. of Clinical Psychology, 50: 237-239. Franzoi,S.L.and Herzog,M.E. (1986). The Body Esteem Scale: A Convergent and Discriminant Validity Study. Journal of Personality Assessment, 50: 24-31. Franzoi, S.L. & Shields, S.A. (1984). The Body-Esteem Scale: Multidimensional structure and sex differences in a college population. Journal of Personality Assessment, 48: 173-178. Frey, D. and Carlock, C.J. (1989). Enhancing Self Esteem. Accelerated Development. Second Edition. 5-8. Grogen, S. and Richards.H (2002). Body Image: Focus Groups with Boys and Men. Men and Masculinities, 4: 219-232. McKinley, N. M. (1998). Gender differences in body esteem: The mediating effect of objectified body consciousness and actual/ideal weight discrepancy. Sex Roles: A Journal of Research, 39: 113-123. Nicolini, P. (2002) Diagnostic Value of SIS-I and EDI-2 Tests in the Obese Patients- Presentation of a Clinical Case. SIS Journal of Projective Psychology & Mental Health, 9: 133-152. Simpson, Jeffry A. (1990). Influence of attachment styles on romantic relationships. Journal of.Personality and Social Psychology, 59: 971-980. Vartanian, L. R., Giant, C. L. and Passino, R. M. (2001) Ally McBeal vs Arnold Schwarzenegger: comparing mass media, interpersonal feedback and gender as predictors of satisfaction with body thinness and masculinity. Social Behaviour and Personality: an International Journal, 29: 711-723 PAPERLESS POLICY OF SIS The Members of SIS are invited to Contribute to the Paperless Policy of Somatic Inkblot Society by opting for Soft Copies of SIS Journal of Projective Psychology and Mental Health instead of Print Version. The soft copies of every issue will be delivered directly on members Email. This will not only save our trees and be environment friendly but also would be time efficient. Write to me directly for opting out print version of SIS Journal on my Email ID: bldubey@gmail.com Bankey L. Dubey

Somatic Inkblot Series–II Profiles of Iranian Couples: An Exploratory Study M. Kruthi, Mrs. Mahboubeh Cariappaa and L. S. S. Manickam Somatic Ink blot Series (SIS) has been used with different clinical groups in India and found to be very effective tool in diagnostic evaluation and therapeutic intervention. It has also been used on various normal populations. However, the review of literature is scanty so far as the Iranian population is concerned. The present study is a modest attempt to compare the profiles of Iranian couples with existing Indian norms. Ten Iranian couples, studying in Mysore and living together, having no history of marital discord were administered SIS-II Booklet Form individually by one of the authors. The mean scores on the eleven scoring categories of SIS were compared. The mean age of the male was 42 years and female was 35.5 years. The mean scores on the eleven indices were as follows: Total number of responses (M:64; F:66.1), Human responses (M:19.4; F:23), Animal responses(M:8; F:10.8), Anatomical responses (M:17.7; F:16.3), Sex responses(M:3.9; F:3.8), Movement responses(M:3.2; F:5.7), Most typical responses (M:13.5; F:14), Typical responses (M:22.5; F:22.4), Atypical responses (M:7.9; F:7.8),Rejection of images (M,0.5; F,0.5), PAS (M,0.1; F,0.2), Depression (M,0.6; F:0.8), HAS (M:0.5; F:0.9) and Paranoia (M:0.5; F:0.6).The scores were almost similar to the scores reported by earlier studies. Since the results are based on a small sample, a larger sample may be assessed before the findings are generalized as an Iranian profile. After initial clinical experimentation for 20 years, the Somatic Inkblot Series (SIS) was developed in 1980 in order to provide an opportunity to release the ‘inner cry’ and to facilitate the abreaction of the ‘unprocessed material from the unconscious’ (Cassell, 1980). The SIS has got three variants and is available in the form of cards (SIS-I, 20 images), the booklet (SIS-II, 62 images) and video images (SIS-II DVD/Video). The SIS has proven its clinical effectiveness both as a diagnostic as well as a therapeutic procedure (Cassell and Dubey, 1996, 2010; Manickam et al, 2013). The SIS-I Card and SIS-II Booklet forms are more popular in India whereas Video/DVD of SIS-I, SIS-II and Living Images are more popular in western countries. The test is found to have high reliability and validity. Various types of reliability such as Test-Retest reliability, Split-Half reliability and Parallel Form reliability were found to be very high. The test has high content validity. Both the series A & B of SIS-II have high correlation and can be used independently for quick assessment (Cassell and Dubey,2003). However, administration of the full test helps in complete assessment of personality and therapeutic intervention. The test is able to discriminate normal subjects from clinical groups (Anxiety Neurotics, Depressives, Schizophrenics, Alcoholics, Drug Dependents and many more). The Rorschach test and the SIS were compared on nine common indices such as R, H, A, M, FM, Anatomical, Sex, Rejection, and Most Typical/ Popular and found compatible. The SIS appraises the same construct as the Rorschach test. However, due to the use of self-administration and video technology, it reaches beyond the Rorschach test (Cassell and Dubey, 1998, Dubey and Cassell, 2014). From psychotherapeutic perspective, SIS has been used effectively with different clinical population (Manickam and Suhani, 2003; Manickam et al, 2004; 2013; Cassell, 2006). As a therapeutic intervention procedure, the SIS serves as a “lens” and “window” and it offers opening to the unconscious in a non-threatening way (Sanyal, 2013). ……………………………………………………………………………………………………… M. Kruthi, Research Scholar,Email:kruthi.reddy25@gmail.com , Mrs. Mahboubeh Cariappaa, Formerly Psychology Intern and L. S. S. Manickam, Ph.D., DMSP, Professor in Clinical Psychology, JSS University ,Mysore (India). Key words: Somatic Inkblot Series –II, Projective Techniques, Iranian Couples, Marital Discord

The responses help the therapist in peeping through the inner self of the suffering individuals and bringing out the painful material on surface for processing. Such verbalization is a powerful therapeutic procedure recommended by many projective therapists (Freud, 1953, Lerner, 1991). The SIS has been used to study gender differences (Singh, et al. 1999), Marital discord (Manickam and Suhani, 2014), PTSD (Cassell, 2006, Cassell, et. al.1999, 2000, Cassell and Dubey, 2014) and somatised grief (Cassell and Dubey, 1996). From the clinical perspective, the SIS emphasizes qualitative interpretations of the responses (Cassell and Dubey, 2003). Several studies have been conducted on normal population in order to develop norms (Cassell and Dubey, 2003, Dubey and Cassell, 1993, Dubey and Cassell, 2014, Dubey, et al, 1995, Kandhari, et.al, 2011, Singh, 2007, Srivastava, 2002). Studies using SIS on different nationalities are also reported (Cassell and Dubey, 2003, Khromov, et al 1999a, 1999b, Manickam et al, 2013, Nicolini, 2000, 2002). However, there is no study that had used SIS on the Iranian population. The present study aimed to develop the SIS-II profile of Iranian couples, studying and living in Mysore and who did not report having any marital discord. Method: Sample: Ten Iranian couple who were studying and living in Mysore (India) and who did not report having any marital discord formed the sample of the study. The age of men ranged from 26- 57yrs (mean 42 Years) and that of women ranged from 21-52 years (mean age 35.5 years) (Table1). They were living in Mysore for last 3 years (on an average) and enrolled in Mysore University for Diploma courses, Under Graduate, Graduate and Doctoral programs. Five participants were pursuing diploma, 4 were pursuing under graduate studies, 10 were pursuing Master’s Degree, and one was enrolled for doctoral program. Table 1: Age and Education of Couples Subjects Age Education A MA AX M.Sc B BA BX MBA C Diploma CX Diploma D BA DX MBA E BA EX Ph.D F Diploma FX MA G MA GX M.Sc H Diploma HX MBA I BA IX M.Sc J Diploma JX M.Sc Tools: The Somatic Inkblots Series-II (SIS-II): The SIS-II was developed in 1980 (Cassell, 1980) and consisted of 62 inkblot images, in Series A and B, each with 31 images printed in eight page booklets. There is also a sample image in the beginning. The stimulus images are printed on the first seven pages. The last page is printed with instructions for selfadministration, and a place for brief health history and personal data. Procedure: Each of the subjects was administered SIS-II test individually by an intern (MG1) who was conversant in Persian language. The first author (MK) who was blind to the details of the participants and who was well trained in scoring SIS-II scored all the protocols. Series–II Profiles of Iranian Couples: 125

Results and Discussion: The mean scores on the eleven scoring categories of SIS were compared and presented in Table 2. There is concordance in responses in all the scoring categories of SIS- II except on the Movement response (M). However, compared to women, the number of movement responses given by men was less. The findings was in contrast to a report by Kandhari et al, (2011) where it was observed that males and females differed significantly on Total number of Responses(TR) and common blot area (CBA). This may be due to cultural variation. Table 2: SIS Responses of Male and Females (Couples) on Various Indices SIS Score Ag e R H A At Se x M M T T AT Rej PA S D HA S P S R- SI SR - NS I NS R- SI Subjec ts 1A 1AX 2B 2BX 3C 3CX 4D 4DX 5E 5EX 6F 6FX 7G 7GX 8H 8HX 9I 9IX 10J 10JX Mean women 35. 66. 10. 16. 3.8 5. .4 7. .50 .20 .8 .90 .6 2. 1.9 Mean men 19. 8.0 17. 3.9 3. .5 .5 7. .5 .10 .6 .50 .5 2. 1.6 6.8 Z Score - 1.3 - 1.5 - .81 - .56 - .11 - 2. 3* - .7 - .1 - .3 .00 - .57 - 1. -1.3 - .0 - .7 - .33 - .68 * Sig at 0.05 level 126 Kruthi et al

Table 3: Comparison of scoring categories with the previous studies

SIS Indices Present study N=20 (21+Adults) Dubey, et.al. 1998, MF, 22+Adults, (n=300) Dubey et. al. 2014 (25-60) Executives (n=892)MF Singh, et.al. 2009 , MF, (14-17yrs) Edu 9-11, (n=700) Chaudhury et. al, 2010, Normal Adults, MF (n=100) R 65.05 70.25 68. 00 59.40 64.3 H 21.2 14.20 (20) 18. 20 14.97(25.00) 23.8 A 9.4 8.45 (12) 8.60 7.89(13.00) 7.2 At 11.40 16 12.80 13.00(22.00) 9.5 Sex 3.85 4. 20 (6) 3.15 1.90(3.00) 6.0 M 4.45 8.35 6.30 2.89 7.3 MT 13.75 14.55 14.80 12.96 11.5 T 22.45 NR 32.00 21.86 25.4 AT 7.85 NR 9.00 4.26 13.8 Rej 0.50 0.75 (1.00) 0.60(0.85) 2.62(4.30) 0.4 PAS 0.15 0.6 0.5 0.52(0.8) 0.3 D 0.70 0.4 0.6 1.20(2.00) 0.1 HAS 0.70 0.5 0.4 2.03(4.00) 0.4 P 0.55 0.02 0.3 1.16 (2.00) 0.1 (Percentage of responses shown in parenthesis) Manickam et al, (2013) observed that there could be responses that can be considered as ‘typical’ for those from the Middle East region and response like ‘looking like a shepherd’s coat’ on image B11 could be a typical one. One who administered the test hailed from the Middle East region and she also felt that the percept of ‘shepherds coat’ is a common one in that geographical area and ‘any one from our region would say the same’. In the present sample 25% of the participants gave responses like ‘may be a shepherd’s coat’ and ‘shirt’ on image B11. Probably administering SIS to a larger number of participants would help to find out whether there are culture specific percepts emerging for different geographical areas. In addition to the eleven scoring categories, the additional scoring categories of Sex Responses on Sex Images(SR-SI), Sex Responses on Non Sex Images (SR-NSI) and Non Sex Responses on Sex Images (NSR-SI) were also compared (Pandey et al, 2003; Manickam et al, 2013). And it was observed that the responses are similar to the pattern observed in the previous study (Pandey et al, 2003). But it was different from the study of Manickam, et al (2013), who studied the couple with marital discord. Therefore, it would mean that SIS could be administered to couples with marital discord to establish marital discord and to explore the areas of marital conflicts. In comparison to other studies, Total Number of Responses(R) and Human responses (H) are almost equal to that of Chaudhury et al. (2010) and there was not much variation with the other studies. Most Typical responses (MT) were also similar to that of the previous studies, indicating that irrespective of cultural differences, people tend to perceive the images in a typical way. However, the Anatomical responses (At) of the present study was much higher than the earlier studies Series–II Profiles of Iranian Couples: 127

(Dubey et.al 1998, 2014, Singh et.al, 2009 and Chaudhury et.al, 2010). The higher Anatomical responses may indicate A high number of anatomical responses may indicate somatic preoccupation and associated somatic symptoms. This may also indicate insecurity and tension in Iranian couples who have fled from their country. A high number of animal responses may indicate their aggressive attitude and immature thinking. The Low number of Movement response (M) may further indicate low ego strength and withdrawal tendency which might be quite normal in immigrants. Compared to the studies of Dubey et al. (1998), and Chaudhury et al (2010) the Sex responses (Sex) were low, but similar to that of Dubey et al (2014). However it was much higher than Singh (2009), due to the fact that the sample constituted of adolescents. On the other hand, Typical (T) and Atypical responses (AT) were found to be more than that of adolescents (Singh et.al. 2009). Human responses (H) were lesser than other studies which may indicate disturbed interpersonal relationship, staying away in different country from their entire family and feeling of loneliness. In view of the small sample one has to be cautious in generalizing the findings. However, the scores on pathological scales are normal. In the present study no standardized tool was used to assess the marital conflict or the quality of marital life. Probably screening those using tools similar to Marital Quality Scale (Shah, 1995) could help us to compare between those with high and low level of marital satisfaction. The small sample size of the present study also limits the generalizability of the findings. It may be worth exploring whether there will be any difference in the profile of the protocol of the participants living in Iran and those who temporarily migrate to other countries. The findings of the present study also imply that SIS-II is a culture free test and can be used with different cross cultural population and those hailing from different nationalities. References: Cassell, M. A., Cassell, W. A., Dubey, B. L., Dwivedi, P., Molchanov, E., O’Roark, A. M., & Routh, L.C., (1999). A video projective technique for PTSD in women. SIS Journal of Projective Psychology & Mental Health, 6, 3-28. Cassell, W. A. (1980). Somatic Inkblot Series-I. Anchorage, Alaska: SIS Centre. Cassell, W. A. (2006). SIS cognitive psychotherapy for spouse induced PTSD. SIS Journal of Projective Psychology & Mental Health, 13, 25-36. Cassell, W. A. and Dubey, B. L. (1996). The Use of the Rorschach and SIS in releasing somatised grief. SIS Journal of Projective Psychology & Mental Health, 3: 3 -32. Cassell, W. A., & Dubey, B. L. (1998). Application of Somatic Inkblot Series in personality assessment, diagnosis, screening and therapy. SIS Journal of Projective Psychology & Mental Health, 5, 3-32. Cassell, W. A., & Dubey, B. L. (2003). Interpreting inner world through somatic imagery: Manual of the Somatic Inkblot Series (2nd revision). Somatic Inkblot Center, Anchorage, Alaska, USA. Cassell, W. A., & Dubey, B. L. (2010). Questionable validity of projective technique and SIS intervention. SIS Journal of Projective Psychology & Mental Health, 17, 4-15. Cassell, W. A., & Dubey, B. L. (2014). SIS incites long term PTSD combat memories and survivor guilt. SIS Journal of Projective Psychology & Mental Health, 21, 68-80. Cassell, W. A., Dubey, A., & Dubey, B. L. (2000). SIS projective responses in PTSD and dissociative disorder. SIS Journal of Projective Psychology & Mental Health, 7, 93-108. Chaudhury, S., Prakash, J., Walia, T. S., Seby, K., Sukumaran, S., & Kumari, D. (2010). Psychological distress in alcohol dependence syndrome. SIS Journal of Projective Psychology & Mental Health, 17, 38-44. Dubey, B. L., & Cassell, W. A. (1993). Some experiences with Somatic Inkblot Series. British J. of Projective Psychology, 38(1), 19-41. Dubey, B. L., Cassell, W. A., Pershad, D. & Dwivedi, P. (1995). Diagnostic utility of Somatic Inkblot Series. SIS Journal of Projective Psychology & Mental Health, 2, 77-84. Dubey, B. L., Dwivedi, P., Cassell, W. A., & Dubey, A. (1998). Diagnostic compatibility of SIS and the Rorschach with emphasis on hearing the inner 128 Kruthi et al

Series–II Profiles of Iranian Couples: 129 cry of their individuals. Mid-Winter Meeting of Society for Personality Assessment, Boston, Feb 18-22. Dubey,B.L., & Cassell, W. A. (2014). Hand Book of Inkblot Technique: Rorschach, Holtzman and Somatic Inkblots Series, SIS Center, Anchorage, Alaska. Freud, S. (1953). Fragment of an Analysis of a Case of Hysteria. Standard Edition of the Complete Psychological Works of Sigmund Freud, Vol. 7, pp. 7, Hogarth Press London, 1953. Kandhari, S., Sharma, J., Kumar, R., & Kumar, D. (2011). Gender differences in SIS-I profile of normal population. SIS Journal of Projective Psychology & Mental Health, 18 (1), 14-21. Khromov, A. B., Cassell, W. A., & Dubey, B. L. (1999a) A comparative study of personality problems of Russian and American female adolescents. SIS Journal of Projective Psychology & Mental Health, 6, 29-33. Khromov, A. B., Cassell, W. A., & Dubey, B. L. (1999b). Some personality correlates of selected SIS variables: Russian experiments. SIS Journal of Projective Psychology & Mental Health, 6, 35-40. Lerner, P. (1991). Psychoanalytic theory and the Rorschach. The Analytic press, Hillsdale New Jersey. Manickam, L. S. S., & Suhani, B. T. (2003). Psychotherapeutic usefulness of SIS-II in a male client with somatoform disorder: Case illustration. SIS Journal of Projective Psychology and Mental Health, 10 (2), 209-218. Manickam, L. S. S., Suhani B. T. & Jasseer, J. (2004). Psychotherapy of a Male Patient with Dissociative Convulsive Disorder: SIS Breaks the Resistance. SIS Journal of Projective Psychology and Mental Health, 11, 36-44. Manickam, L. S. S., & Suhani, B. T. (2014). Marital Conflict: An exploration of relationship issues in couples through SIS-II. SIS Journal of Projective Psychology and Mental Health, 21, 37-41. Manickam, L. S. S., Ghanbary, M., & Kruthi, M. (2013). Therapeutic effectiveness of SIS-II in an Afghanistan person with Psychogenic cough. SIS Journal of Projective Psychology and Mental Health, 20, 91-97. Nicolini, P. (2000). The corporeal perception in subjects with psychosomatic disorders evaluated with the SIS-I Test. SIS Journal of Projective Psychology & Mental Health, 7, 127-132. Nicolini, P. (2002). Diagnostic value of SIS-I and EDI-2 tests in the obese patients- Presentation of a clinical case. SIS Journal of Projective Psychology & Mental Health, 9, 133-152. Pandey, R., Mishra, M., & Dwivedi, C. B. (2003). Diagnostic significance of sex responses on SIS- II on sex and non-sex images. SIS Journal of Projective Psychology and Mental Health, 10, 205-208. Shah, A. (1995), Clinical validity of Marital Quality Scale. NIMHANS Journal, 13, 23-31. Sanyal, N. (2013) Somatic Inkblot Series-II: The Therapeutic Window of Emotionally-Withdrawn Children, SIS Journal of Projective Psychology & Mental Health, 20:2, 81-90. Singh, M. P., Singh, A., & Dubey, B. L. (1999). Effect of age and sex on SIS-II responses. SIS Journal of Projective Psychology & Mental Health, 6(2), 51- 76. Singh, U., Verma, N., & Singh, N. (2009). SIS-II indicators of creativity. SIS Journal of Projective Psychology & Mental Health, 16, 128-133. Singh, U. (2007). Gender differences in factor structure of SIS-II responses. SIS Journal of Projective Psychology & Mental Health, 14(2), 110-116. Srivastava, A. K. (2002). Somatic Inkblot Series-I: A Meta Analysis. SIS Journal of Projective Psychology & Mental Health, 9, 33-37. SIS Doctoral Research Award Somatic Inkblot Society announces an award to the Research Scholars who have employed any version of Somatic Inkblot Series as a tool in their doctoral dissertation. The award carries a Citation and a cash award of Rs. 5000/- to the research scholars. Submit a soft copy of your doctoral dissertation to claim your award on Email ID: bldubey@gmail.com. The Award will be delivered in the next International Conference of SIS. Bankey L. Dubey Director, Somatic Inkblot Centre

Areas of Research in Somatic Inkblot Series Rakesh Kumar Somatic Inkblot Series (SIS) was conceptualized in 1959 by Dr. Wilfred A. Cassell and has attracted clinicians internationally. The SIS is based on the theory of body symbolism, somatic imagery theory and inner cry for help. Somatic Imagery Theory proposes that “everyone has a unique and highly personalized system of attitudes, both conscious and unconscious, that is projected onto the body concept as a special entity…” (Cassell and Dubey, 2003 pp. 14-15). The present paper is specially prepared for clinicians and researchers to view the areas of research in future on Somatic inkblots procedure.

SIS procedure is a set of semi-structured projective inkblots tools in which somatic images have been embedded within the framework of ambiguous stimuli with an explicit aim to stimulate projection of unconscious urges and conflicts. It is clubbed in the family of inkblot techniques, but stands out from other inkblot procedures like Rorschach Inkblot Test and Holtzman Inkblot Test due to its utilization of the theories of somatic representations. It emphasizes more on content analysis with fewer quantitative indices to peep into the deeper layers of consciousness. The analysis and interpretation is more analytical and dynamic which helps a clinician to listen to the inner cry of the clients. It is both examiner and client friendly. SIS helps in diagnosis and treatment of the persons with psychological, emotional, interpersonal, psycho-somatic and health related problems. Instead of simple diagnostic labeling, it gives deeper insight into the intra-psychic forces of an individual. SIS consists of five procedures (1) SIS-I is card form and consists of 20 stimulus cards (2) SIS-II is in a booklet form and consists of 62 images in two sets - A & B. It can be selfadministered. (3) SIS-II Video/DVD consists of 62 images of SIS-II which are presented to the client on a screen. (4) SIS-I Video consists of 20 stimulus images of SIS-I which are presented on a screen and (5) SIS Living Images is an innovative concept which depicts ambiguous images related to female body parts, specially designed to help sexually/physically traumatized females and projected on a screen. Except the SIS-I card form, all four procedures have been used as self/group administered test. To stimulate the application and researches on somatic inkblot series, the Somatic Inkblot Society was established in 1991 in Anchorage, Alaska and got registered in 1993. The main objectives of the society are as follows: 1. To promote teaching, research and practice of SIS test. 2. To extend the use of the SIS to the field of mental health, personality assessment and related areas. 3. To organize symposia, seminars, conferences and exhibitions in order to acquaint people of the facts and scientific principles of mental health. 4. To cooperate and collaborate with national and international agencies in the area of projective psychology. 5. To prepare and publish papers, periodicals, pamphlets etc., in the furtherance of the aims and objectives of the society. ………………………………………………………………………………………………………………… Rakesh Kumar, Ph.D., MM &SP, FSIS, FIACP. Head, Department of Clinical Psychology, Institute of Mental Health and Hospital, Agra-282002, Email: jain.imhh@gmail.com Key Words: Somatic Inkblot Series, Areas of Research on SIS.

In order to attain the 5th objective of the society, an official journal with the nomenclature “SIS Journal of Projective Psychology and Mental Health” was registered in 1993. The first issue of the journal was published in July 1994. SIS Journal publishes researches and topics that are primarily related to the field of projective psychology and especially the researches employing inkblots procedure (Rorschach/Holtzman and SIS). It has a distinct status of timely publication since its inception. 42 issues have been published in past 22 years. It has been listed by World Health Organization (Global Forum for Health Research) among 25 indexed journals that have published the highest number of articles on mental health from LMICs in Latin America, Africa and Asia (Medline and PsycINFO). It has also been listed in academic research database ProQuest Psychology Journals™. In this paper, I reviewed all issues of SIS Journal to summarize the themes of the researches that have been published so far and added my insight into the potential areas of researches that can be undertaken by researchers to enrich the application of SIS. While reviewing the published paper on SIS in the Journal, I included all case reports and empirical studies which used any version of SIS. In the process, I identified 147 instances of SIS usage in the published work. January 2003, Vol. 10 Issue No. 1 is akin to the manual of SIS, which is extremely useful resource for the SIS users. I did not include the case studies published in the journal. Also, each issue of the journal contains vision, scope and application of SIS in its Editorial section which did not constitute the data for this review. A few doctoral thesis and research projects at post-graduation level employing SIS have also been included. Four Ph.D. level theses employing SIS test have been awarded by Universities in India. One research project was carried out at diploma level in clinical psychology which used SIS as one of the primary tools. The documented work could be summarized as follows: Ph.D. Thesis: 1. Deepak Kumar (2002) Diagnostic Indicators on SIS-I and Roschach among manic and depressive patients. Dr. Bhimrao Ambedkar University, Agra 2. Ruchi Jain (2004) Diagnostic indicators on SIS-I and Rorschach among children with Attention Deficit Hyperactivity Disorder. Ch. Charan Singh University, Meerut. 3. Sunita Kandhari (2008) Development of A Comprehensive Scoring System for SIS-I. Ch. Charan Singh University, Meerut 4. Jashobanta Mohapatra (2009) A Comparative Study of Schizophrenia and Affective Disorders on SIS-I and Rorschach. Sambalpur University, Orissa 5. Bhawana Singh (2012) Diagnostic Efficacy of SIS Indices in Relation to Rorschach among Paranoid and Non-paranoid Schizophrenics, Ch. Charan Singh University, Meerut Diploma Level Research Projects: Pragya Sharma (1999) A study of SIS-I indices among chronic schizophrenic patients. St. John’s College, Agra. The above thesis and project are based on the quantitative approach to SIS-I. Conditions of psychological morbidity are compared either with general population or with other morbid conditions. The covered morbidities are – attention deficit hyperactivity, schizophrenia and bipolar affective disorders. One of the doctoral dissertations by Sunita Kandhari (2008) expanded the scope of quantitative

(2008) expanded the scope of quantitative approach by considering many other scoring variables which included blot areas, chromatic colors, shading etc. The SIS made major departure from other inkblots by simplifying the scored variables and giving more emphasis on content based analysis. Only following 11 variables are considered quantitatively in all versions of SIS. 1. Total Number of Responses 2. Typical Responses 3. Human Responses 4. Atypical Responses 5. Animal Responses 6. Rejection of Images 7. Anatomical Responses 8. Sex Responses 9. Movement Responses 10. Most Typical Responses 11. Pathological Responses: a. Pathological Anatomy (PAS) b. Depression (D) c. Hostility and Aggression (HAS) d. Paranoia (P) The above scoring variables turned to be highly reliable and valid and generated lots of normative data on general as well as clinical population, which have been covered extensively in Vol. 10 Issue No. 1 of 2003. The review of published papers on SIS revealed that following clinical and other conditions have been covered through quantitative approach: Table1: Quantitative Studies Using Somatic Inkblot Series-I Sl. Authors Year SIS Study Population/ Theme Rathee et al 1994 SIS-I Coronary Cases Gaetani et al 1995 SIS-I Corporal Perception in HIV Positive and Negative Heroin- Addicts Rathee & Singh 1996 SIS-I Gender differences Mitra & Mukhopadhyay 1996 SIS-I Social anxiety in drug addicts Banerjee et al 1998 SIS-I Heroin addicts and normal Banerjee et al 1998 SIS-I Drug addicts Khromov et al. 1999 SIS-I Russian female adolescents Sarkar et al. 1999 SIS-I Generalized anxiety disorder Mitra & Mukhopadhyay 2000 SIS-I Drug addicts and normal Nicolini 2000 SIS-I Headache Kumar et al. 2001 SIS-I Hospitalized Male Chronic Schizophrenics Khromov 2001 SIS-I Achondroplasia and traumatically shortened extremities Nicolini 2002 SIS-I Obesity Kumar et al. 2003 SIS-I Manic patients Khromov et al. 2004 SIS-I Students attitude towards vital problems Kumar et al. 2004 SIS-I Schizophrenic and manic patients Kumar et al. 2005 SIS-I Manic and depressive patients Kumar 2005 SIS-I Schizophrenia, mania and normal Jain et al. 2005 SIS-I Attention Deficit and Hyperactivity Disorder Dubey & Dubey 2005 SIS-I Psychological intervention on police personnel Kumar et al. 2006 SIS-I Gender differences in manic patients Kumar et al. 2006 SIS-I Schizophrenia 132 Rakesh Kumar

Kumar et al. 2007 SIS-I Inter-correlations in scoring indices in Normal adults Kumar & Singh 2007 SIS-I Normal children and adolescents Kumar et al. 2008 SIS-I Role of gender in scored productivity Kumar et al. 2009 SIS-I Correlation with Rorschach in normal persons Cassell & Dubey 2009 SIS-I Premenstrual dysphoric syndrome Kumar 2009 SIS-I Factor structure Mahapatra et al 2009 SIS-I Ego-strength in schizophrenia Kandhari et al 2010 SIS-I Mania, depression, schizophrenia Kandhari et al 2010 SIS-I Normal persons Kandhari et al 2011 SIS-I Gender differences in normal persons Saldanah et al 2011 SIS-I Persons with psychosexual dysfunction and normal Mahapatra et al 2011 SIS-I Ego strength in depression Singh et al 2011 SIS-I Persons with non-paranoid schizophrenia and normal Kandhari et al 2012 SIS-I Schizophrenia, mania, depression, normal Table 1 reveals that SIS-I was used only in 37 publications in 42 issues published so far. The rate of publication is .86 per issue which is less than 1%. Srivastava (2002) meta-analyzed the available data of 14 studies on SIS-I and summarized the results of following groups – (a) Normal (b) Coronary heart disease (c) Generalized anxiety disorder (d) Schizophrenics. This version of SIS is mostly used on persons with major psychiatric disorders and a few somatic conditions apart from general populations. Table 2: Quantitative Studies Using Somatic Inkblot Series-II and Other Versions Sl. Authors Year SIS Study Population/ Theme Dharamvir et al. 1994 SIS-II Body imagery in vertigo patients Rathee et al 1995 SIS-II Psychiatric Patents of Armed Forces Verma et al 1995 SIS-II Psychotics and Neurotics Dubey et al 1995 SIS-II & Video psychiatric patients Brady 1995 SIS-Video Medial setting Pershad & Verma 1995 SIS-II Schizophrenia and Depression Dwivedi et al 1995 SIS-II Neurotics and Schizophrenics Verma et al 1996 SIS-II Personality variables Bailey & Murstein 1996 SIS-II Paranoia in college population Pandey et al. 1996 SIS-II Liked and disliked images in neurotics, schizophrenics and normal Singh & Banerjee 1996 SIS-II OCD and Normal Singh & Dubey 1997 SIS-II Drug and alcohol dependent cases Gayatri Devi & Kaliapan 1997 SIS-II Tension Headache Mishra & Dwivedi 1997 SIS-II Normal, Neurotic and Schizophrenics Nehra et al. 1997 SIS-II Speech defects Sharma et. al. 1997 SIS-II Alpecia areata Singh & Dwivedi 1998 SIS-II Managers & students Kaur & Verma 1998 SIS-II Psychiatric patients Rathee et al. 1998 SIS-II Psychopathological cases of armed forces

Singh et al. 1999 SIS-II Adolescents and adults Singh et al. 1999 SIS-II Age and gender differences Pandey et al 1999 SIS-II Stability of responses in general population Singh et al. 2000 SIS-II Murderers Singh et al. 2001 SIS-II Murderers Pandey et al. 2001 SIS-II Age related changes Chaudhury et al 2001 SIS-II Alopecia areata Rathee et al. 2002 SIS-II Psychotic and neurotic cases of armed forces Pandey et al. 2003 SIS-II Significance of sex responses in neurotics and schizophrenics Dubey et al. 2004 SIS-II Psycho-sexual disorder Ramjee Lal 2004 SIS-II Persons with physical disability Singh 2007 SIS-II Facture structure in High school students Singh & Singh 2008 SIS-II Role of school environment on percepts Ranjan et al. 2008 SIS-II Alcohol dependents Alreja et al 2009 SIS-II Children with mental retardation and normal Cassell & Dubey 2009 SIS-II Pregnant women Singh et al 2009 SIS-II Creativity of students Kumari et al 2009 SIS-II Schizophrenia and Bipolar affective disorder Alreja et al 2009 SIS-II Medical practitioners Mishra et al 2010 SIS-II Persons with epilepsy and normal Dubey & Dubey 2012 SIS-II Executives Tiwari et al 2012 SIS-II Depressives and normal Singh & Rani 2014 SIS-II Suicide ideation in adolescents Singh & Rani 2014 SIS-II Gender specific suicide ideation Verma & Singh 2014 SIS-II Role of age and education on the percepts Bhogta et al. 2014 SIS-II Thalassemia Kruthi et.al 2015 SIS-II Profiles of Iranian Couples Table 2 reveals that SIS-II has been used in publications following quantitative approach. The rate of publication based on SIS-II is about one paper per issue (42 issues and 45 publications). It has been used in a variety of conditions that include psychotics, affective disorder, drug dependents, psychosomatic disorders, medical conditions, managers, epilepsy, creativity, murderers, speech defects and headache etc. Kumar (2000) published a meta-analysis of the findings of 19 studies using SIS-II appeared by the time. The results for following conditions were pooled and summarized: (a) Normal (b) Neurotics (c) Psychotics (d) Substance dependents and (e) Murderers. The data of meta-analysis suggested significant group differences in several variables of comparison groups. SIS is a versatile tool which has been employed in a variety of case studies. The case studies yielded deeper understanding of mind and the potentials of SIS in tapping unprocessed unconscious material needs processing. The case studies are mostly based on content analysis and psychoanalytic interpretation of SIS responses helping in therapeutic management of the patients. The 134 Rakesh Kumar

case studies using qualitative approach and psychoanalysis are enumerated below: 1. Transsexuals (Sahay & Srivastava, 1994; Dasgupta et al., 2012) 2. Body imagery in a female with multiple traumatic experiences (Ramchandra & Chaturvedi, 1995) 3. Family conflicts in females (Dubey et al., 1995) 4. Somatised Grief (Cassell & Dubey, 1996,Sengupta et.al,2012) 5. Repeated Miscarriages (Cassell & Dubey, 1996) 6. Therapeutic Dream Stimulation (Cassell & Dubey, 1997,Cassell et al,2015) 7. Somatized Pain (Singh & Dwivedi, 1997; Sengupta et al., 2012) 8. Sexually Traumatized Female (Dwivedi et al., 1998) 9. Depression (Tewari & Dwivedi, 1999; Vimal, 2004; Radhe Shyam et al., 2009; Kumar & Mishra, 2010,Gupta et.al,2015) 10. PTSD and Dissociative Disorder (Cassell et al., 2000; Manickam et al. 2004; Brock et al., 2015) 11. Male with somatoform disorder (Manickam & Suhani, 2003) 12. Panic attack in a child (Savage, 2003) 13. Hypochondriasis (Vimal & Mishra, 2003) 14. Paranoid ideation (Radheyshaym, 2007) 15. Tension headache (Cassell et al., 2013) 16. Psychogenic Cough (Manickam et al. 2013) 17. Marital Conflict (Manickam & Suhani, 2014) 18. Body Dysmorphic Disorder (Sachacher & Jahan, 2014) SIS is helpful in understanding inner cry, team building, interpersonal behavior, intra-psychic conflicts, ego strength, emotional problems, productivity and other psychological attributes. There are ample scope for researchers to consider SIS-I and SIS-II in many other conditions using both quantitative and qualitative approach. Some of the conditions where SIS can be applied in future research are highlighted below: 1. Psychiatric Conditions: Apart from major psychiatric disorders, SIS can be used in other psychiatric conditions like personality disorders, anxiety disorders, phobias, OCD, adjustment disorders, stress reactions, dissociative disorders, somatoform disorders, hypochondriacs, somatization disorder, eating disorders, sleep disorders, sexual dysfunction, psychophysiological disorders, conduct disorders, enuresis, encopresis, Stammering and so on. 2. Medical Conditions: Many medical conditions evoke anxiety, fears, insecurity, low self-esteem and other emotional problems. SIS can be a good tool to understand emotional consequences of serious medical conditions like cardiac problems, skin disorders, infertility, HIV, cancer etc. 3. Personnel Selection: SIS has been used extensively in selection interviews as a potential tool to match the personality traits with the required job specifications. The variables like scored productivity, group conformity, image rejection, presence of pathological items can suggest potential problems in a person. SIS has proved to be a helping tool during personnel selection. However, none was rejected on the basis of psychological test. Selection was finalized on the basis of overall performance in the interview. 4. Organizational Health: The persons working in an organization may face variety of problems which include their own individual problems, family problems and the problems related to the organization such as mismatch in the goals and achievements, demands placed by the organization, interpersonal disputes and attitude of seniors. The organizations have their own problems affecting the lives of the people working over there. SIS can be used to

understand psychological, emotional and interpersonal problems of the employees. 5. Premarital Counseling: SIS can help in understanding the personality issues, emotional needs, interpersonal problems, attitude towards opposite gender, sexual conflicts, paranoid ideation and fear of marital adjustment. It may be considered to explore the compatibility of the individuals prior to marriage. 6. Evaluation of changes in the course of psychotherapy: SIS has proved to be a quite sensitive tool in tapping changes in the individual’s psyche over time. The pre and post assessment of the individuals undergoing psychotherapy reflects positive changes in the person. The application of SIS in counseling and psychotherapy could be considered on priority. 7. Integration of SIS and Psychophysiological Measurements: Sophisticated psychophysiological devices have been developed which can transmit the data to computers for storage and analysis. The digital devices can be intuitively integrated with SIS. The SIS images in video format can be displayed to the clients without having them to verbalize anything. During the course of presentation of SIS images, the psychophysiological measurements may be gathered at the same time. Any abnormal psychophysiological response to the specific images can be identified. If there is any exaggerated emotional response to a specific image or set of images, this may provide a clue to the clinician for the significance of those images and the area elicited by those images. Further psychodiagnostic and therapeutic work can be done using such identified images. It can be hypothesized that the exaggerated responses are indicative of underlying conflicts and unprocessed unconscious material needs processing. 8. Applications under hypnotic trance: SIS and hypnosis can be used to understand conflicts and inner cry of an individual. A clinician can take note of images rejected by the client and major departure in the percepts during normal course of administration of SIS. Having gathered this data, a person can be put to hypnotic trance, and while in trance, these enlisted images can be presented to the subject one by one with an instruction on the pattern of ‘free association’. “Look at this image and tell me everything that comes to your mind”. This can grant an access to highly emotionally charged data which can be used for effective psychotherapy to resolve the underlying problems. 9. SIS Video: The video versions of SIS are very popular in United States but less used in India. It is because of lack of supportive tele-system in clinic setup in India. The researchers can exploit these unexplored versions in a variety of psychiatric and other conditions. 10. Application of SIS in Groups: SIS is a unique tool which can be administered in groups too. The Video/DVD versions of SIS images are presented on the screen to a group of 20 to 30 persons. The group members can record their responses and additional details. The Video procedure is a self as well as group administered test with instructions to take the test. 11. Computerized Version: The computerized version is also on advanced stage under “Game Changer” and available on Internet. Researchers are invited to help in devising software for presentation, recording responses and 136 Rakesh Kumar

analyzing the data through programmed instructions. 12. Online Applications: SIS can be integrated for online administration, scoring and interpretation of the data. The SIS Center is helping people living in remote area, far away from medical centers through Video/internet administration and tele-therapy. 13. Personality Correlates of SIS: A number of assessment approaches to personality have been evolved for which sophisticated tools are developed; e.g. 16 PF, MBTI, Neo Five, MCMI, TCI. Researches can be undertaken to correlate SIS indices with the dimensions of personality assessed by these tools. This will help in enhancing the understanding of the personality through SIS indices. 14. Symptom Value of SIS Variables: SIS procedures can generate huge data with regard to the emotional, interpersonal, psychological functioning of an individual. Efforts could be made to catalogue the symptom or interpretation value of SIS variables. A single variable can denote different things in an individual. A variable is unlikely to have an infinite interpretation. The researchers can prepare a catalogue of possible meaning and psychological correlates of each scored variable. For example, MT (Most typical responses) may indicate team building capacities, group conformity, shared thinking, fear of departure from cultural norms, rebellious behavior, opposition tendencies, and field independence and so on. This exercise will be extremely helpful in integrating the SIS in routine work up with the clients of various backgrounds. Conclusion: SIS is a series of five tests having immense potentials for stimulating researches on human behavior in a wide variety of context. The researchers can use their creativity for expanding the application and uses of this procedure. The term “somatic” should not be construed as indicative of its restricted applications in the conditions involving ‘soma’. The researches done so far indicated its width of applications in varied conditions. This spirit of expansion and versatile application of SIS can be promoted for optimum use of the tools. References: Banerjee, S., Mukhopadhyaya, A and Singh, U. (1998) An In depth Study of Somatization in Heroin Addicts through SIS-I & Rorschach Inkblot Test. SIS Journal of Projective Psychology & Mental Health, 5:33-39 Brock, D. Cassell, W. A. Tyrone, C. Maureen, C. Dubey, B. L. Halia, J. Leigh R. & Laurel, S. (2015) SIS Symbols of PTSD & the Need for Empathy in Therapy. SIS Journal of Projective Psychology and Mental Health.22:3-8. Cassell, W A. & Dubey B.L. (1996) Efficacy of Booklet and Monochromatic Version of SIS In a Case of Repeated Miscarriages. SIS Journal of Projective Psychology and Mental Health.3:118-128 Cassell, W A. & Dubey B.L. (1996) The Use of the Rorschach and Somatic Inkblot Series in Relasing Somatic Grief. SIS Journal of Projective Psychology and Mental Health.3:3-18 Cassell, W A. & Dubey B.L. (1997) Therapeutic Dream Stimulation With the Somatic Inkblot Series – Video. SIS Journal of Projective Psychology and Mental Health.4:3-14 Cassell, W A. Pandey,P , Tiwari,A Mishra, N.& Dubey B. L (2013) SIS Guided Therapy for an Adolescent Girl's Tension Headaches. SIS Journal of Projective Psychology and Mental Health. 20:49- 54. Cassell, WA & Dubey,BL (2003) Interpreting inner world through somatic imagery: Manual of the somatic inkblot series. pp. 14-15. Anchorage:Somatic Inkblot Centre.

Cassell,W A Dubey, A & Dubey, BL (2000) SIS Projective Responses in PTSD and Dissociative Disorder. SIS Journal of Projective Psychology and Mental Health. 7:93-108 Dasgupta,T., Dasgupta,R. and Dwivedi,P. (2012) Somatic Inkblots imagery in Transsexual: A Case study. SIS Journal of Projective Psychology and Mental Health.19:61-65 Dubey, B.L. Cassell, W.A. Dwivedi, P & Mishra,M (1995) Inner Cry Through Somatic Inkblot Series. SIS Journal of Projective Psychology and Mental Health. 2:111-118 Dwivedi, P. Mishra, N. & Mishra, M (1998) Somatic Inkblot Series on a Sexually Traumatized Female. SIS Journal of Projective Psychology and Mental Health.5:150-153 Kumar, R (2000) Meta Analysis of the Findings on SIS-II. A Meta Analysis. SIS Journal of Projective Psychology and Mental Health. 7:143-147 Kumar, R and Mishra, D (2010) SIS Imagery in Depression with Somatization - Therapeutic Intervention: A Case Study SIS Journal of Projective Psychology and Mental Health 17:69-72 Manickam L.S.S. & Suhani B.T. (2014) Marital Conflict: An Exploration of Relationship issues in Couples through SIS-II. SIS Journal of Projective Psychology and Mental Health. 21:37-41 Manickam, L.S.S. &

Suhani, B.T. (2003) Psychotherapeutic Usefulness of SIS-II in a Male Client with Somatoform Disorder: Case Illustration SIS Journal of Projective Psychology and Mental Health.10: 209-218 Manickam, L.S.S. Ghanbary, M & Kruthi M.(2013) Therapeutic Effectiveness of SIS- II in a Case of Psychogenic Cough Study SIS Journal of Projective Psychology and Mental Health 20:91-97 Manickam., L.S.S. Suhany B. T. & Jasseer J. (2004) Psychotherapy of a Male Patient with Dissociative Convulsive Disorder: SIS-II Breaks the Resistance. SIS Journal of Projective Psychology and Mental Health.11: 36-44 Radhe Shyam (2007) SIS in Paranoid Ideation: A Case Study SIS Journal of Projective Psychology and Mental Health.14: 145-149 Radhe Shyam, Cassell W A. & Dubey, BL (2009) SIS Detection of Invisible Imagery in Bipolar Depression. SIS Journal of Projective Psychology and Mental Health. 16:24-31. Ramachandra S. & Chaturvedi S.K. (1995) Body Imagery in SIS Test. A Case study. SIS Journal of Projective Psychology and Mental Health. 2:41-47. Rathee, S. P., Goel, D. S., Chawla, M. L. and Saldanha, D. (1994) A Study of Somatic Inkblot Series-I in Coronary Cases, SIS Journal of Projective Psychology & Mental Health, 1: 51-64. Rathee, S. P., Pandey, V. and Singh, A. (1995) Diagnostic Efficacy of Somatic Inkblot Series-II amongst Psychiatric Patents of Armed Forces: A Preliminary Study. SIS Journal of Projective Psychology & Mental Health, 2: 1, 61-66. Sachacher, B & Jahan, M.(2014) SIS-II Profile of patient with Body Dysmorphic Disorder: A Case report. SIS Journal of Projective Psychology and Mental Health. 21:59-61 Sahay,M & Srivastava, PK (1994) Somatic Inkblot Series -I in Male Transexuals. SIS Journal of Projective Psychology and Mental Health. 1:70-74. Savage, G. (2003) The Diagnostic Value of the SIS in Treating a Child with Panic Attacks During the Post-Divorce Period: A Clinical Case Study. SIS Journal of Projective Psychology and Mental Health.10: 219-224 Sengupta, A. Mishra, N and Dwivedi, P (2012) SIS in a Case of Somatised Pain. SIS Journal of Projective Psychology and Mental Health. 19:126-130 Singh, MP & Dwivedi, P (1997) Somatised Pain : A Case Study with The Help of SIS-II SIS Journal of Projective Psychology and Mental Health.4:164- Srivastava, AK (2002) Somatic Inkblot Series-I: A Meta Analysis. SIS Journal of Projective Psychology and Mental Health. 9:33-37. Tewari M. K. & Dwivedi, P. (1999) SIS-Video in a Case of Depression. SIS Journal of Projective Psychology and Mental Health. 6:47-49 Vimal, P & Mishra, S. (2003) SIS in a Case of Hypochondriasis SIS Journal of Projective Psychology and Mental Health.10: 225-226. Vimal, V. (2004) SIS in a Case of Depressive Neurosis.. SIS Journal of Projective Psychology and Mental Health.11: 45-46 138 Rakesh Kumar

Efficacy of Cognitive Drill Therapy in Agoraphobia with Panic Disorder: A Case Study Satyadhar Dwivedi and Rakesh Kumar This case demonstrates the role of cognitive drill therapy in the treatment of panic disorder with agoraphobia. A 52-year-old female patient presented with eight years H/O panic disorder with agoraphobia. The Body Sensations Questionnaire, Agoraphobic Cognitions Questionnaire, Mobility Inventory, Generalized Anxiety Disorder scale and Beck Depression Inventory were administered at baseline and follow ups.. Cognitive drill therapy was administered in 10 sessions. She continued pharmacological treatment as usual. The periodic assessments including follow ups indicated substantial change and clinically significant improvement in her condition which is being maintained even at six months follow up and thereafter. Initially called agoraphobia with panic attacks (American Psychiatric Association, 1980), and later renamed panic disorder with or without agoraphobia (American Psychiatric Association, 1987, 1994, 2004), is one of the most cited anxiety disorders due to its high rate of lifetime prevalence (about 5.1% of adults; Bienvenu, 2006). Panic disorder is characterized by its resistance to spontaneous remission, its co-morbidity with other disorders (e.g., depression, alcohol or substance disorders), and the decrease in quality of life. Additionally, panic disorder can have serious social and economic consequences, since a large number of individuals with panic disorder suffer difficulty in maintaining their social relationship and most of them have to leave their work (Klerman et al., 1991; Mitte, 2005; Tsao, et.al, 2005). In order to be diagnosed with panic disorder a patient must have suffered recurrent and unexpected panic attacks over a minimum period of a month, followed by persistent concern about having additional attacks. Panic attacks are commonly accompanied by uncontrollable fear, worry about the implications of the attacks (e.g., losing control, having a heart attack), or a significant change in behavior relating to these symptoms. Furthermore, the attacks are not due to the direct effects of substance abuse or to a medical condition, and they cannot be explained by the presence of another mental illness. On the other hand, panic attacks often come together with agoraphobia, that is, an uncontrollable fear of having a panic attack in a setting from which it may be difficult to escape or receive help. About one in three people with panic disorder develops agoraphobia, but agoraphobia without a history of panic attacks is rare, with a lifetime prevalence of about 0.17% (Bienvenu, 2006). Cognitive Drill Therapy: This therapeutic technique was originally developed by Kumar, et. al.(2012). Cognitive drill therapy is very effective to deal with stimulus bond anxiety. The therapist tries to change patient’s future orientation to past or present orientation at cognitive level. For example, “a patient has fear of travel in train and gets panic attack”. In this situation the therapist would ask the patient to repeat statements like “I am travelling in train; I have got the panic attack”. She is required to repeat such statements continuously until significant reduction in anxiety level, which usually takes 2-5 minutes. The therapist identifies the situations and events which elicit the anxiety response and prescribe drill in similar manner. ………………………………………………………………………………………………………………… Sri Satyadhar Dwivedi, M.Phil (Cl. Psy.) Asst. Professor, Dr. Rakesh Kumar, Head, Department of Clinical Psychology, Institute of Mental Health and Hospital, Agra -282002 (India) Email: jain.imhh@gmail.com Keywords: Panic disorder, agoraphobia, cognitive drill therapy, Psychotherapy

This therapy uses the principles of cognitive exposure, Pavlovian conditioning and a change in linguistic pattern. The application of cognitive drill has yielded promising results in patients with OCD (Kumar et al, 2012). The therapy is useful in patients who have stimulus bound anxiety, specifically when exposure of the anxiety related cues in imagination elicits an anxiety response. The therapy has yielded promising results in conditions like examination anxiety, specific phobia, social phobia, obsessions, compulsions and health related anxiety. The case study has illustrated the effectiveness of Cognitive Drill Therapy in a case of chronic panic disorder with agoraphobia. Case Summary: SK a 52 years old female was diagnosed a case of Agoraphobia with Panic Disorder as per ICD- 10. She was experiencing panic attacks 2-3 times in a week characterized by fainting spells, difficulty in breathing, palpitations, sweating, tachycardia, choking sensations and felt as if she would die since last 8 years. This led to multiple emergency hospitalizations and cardiac investigations, but all the investigations were normal. During panic attack she used to scold her family members and could not attend routine work. She avoided going to public places, travelling in trains, and stopped driving scooter because of fear of getting panic attacks. However, she kept visiting selected places with her husband with confidants. During such visits, she would keep tracking the location of hospitals so that she can get hospitalized immediately in the event of panic symptoms. She resigned her teaching job in a reputed public school and remained mostly at her home. She needed presence of someone while using bathrooms. She also had secondary depression characterized by sad mood, lost of interest in pleasurable activities, weeping spells, hopelessness and helplessness. During the course of illness she lost interest in her hobbies like gardening, going for outing and entertaining children. She did not follow psychiatric treatment regularly and never sought psychotherapy for her psychiatric problems. When she approached for psychological treatment, she was recommended to consult a psychiatrist prior to administration of psychotherapy. She returned back for psychotherapy after about three months with little improvement in her psychiatric condition. Assessment: She was administered the following tools initially with multiple repeat assessments. 1. Body Sensations Questionnaire (Chambless, Caputo, Bright & Gallagher, 1984) 2. Agoraphobic Cognitions Questionnaire (Chambless et al., 1984) 3. Mobility Inventory (Chambless, Caputo, Jasin, Gracely and Williams, 1985) 4. Generalized Anxiety Disorder Scale (Spitzer, Kroenke, Williams, Lowe, 2006) 5. Beck Depression Inventory (Beck at al., 1969). Body Sensation Questionnaire (BSQ) measures various sensations in the body like palpitation, sweating, breathing difficulties etc seen during panic disorder. She had elevated levels of body sensations. Agoraphobic Cognition Questionnaire (ACQ) revealed that she had following prominent cognitions – I am going to throw up, I must have a brain tumour, I will have a heart attack, etc. Mobility Inventory (MI) suggested extreme restrictions in her mobility outside home. She scored very 140 Dwivedi & Kumar

high on Generalized Anxiety Disorder Scale (GADS). Beck Depression Inventory (BDI) score was suggestive of marked depression. Case Formulation: We formulated the primary problems of the patient according to the concepts and relevant theories of cognitive drill therapy which is summarized below: 1. Her anxiety was conceptualized as respondent behavior elicited by a range of external cues like open places, crowded places, travel by train and internal cues like increased respiration, sensations in cardiac region, words, images and thoughts related to panic attack. 2. She avoided anxiety provoking situations which resulted in negative reinforcement and maintained her avoidance of external situations which could potentially activate panic attack. Besides, avoidance at overt level, she also had avoidance at cognitive level. She avoided considering encounters with potentially anxiety provoking situations even at covert level. 3. The external and internal cues elicited anxiety response (classical conditioning) and avoidance of such anxiety provoking situations at cognitive and behavioral level resulted in anxiety reduction which served to maintain the anxiety response (Operant Conditioning). 4. During anxiety, a person holds a future perspective at cognitive level which gets reflected in the language of the patients which consists of frequent use of future tense. For instance, I may have heart attack, I am going to die, I will not survive, what will happen if I get a heart attack, palpitations means I am going to have a heart attack. 5. It is hypothesized that this future perspective may have its specific neurobiological correlates. When a person turns towards this future orientation, the related neurobiological processes get activated which maintain the anxiety response. 6. The depressive condition was hypothesized to be secondary to phobic and anxiety symptoms. Application of Cognitive Drill Therapy: Following components of Cognitive Drill Therapy (CDT) were implemented. Psycho-education: Psycho-education regarding illness is the core foundation of the application of CDT. She was explained that she is having Agoraphobia with Panic Disorder and Secondary Depression. The symptoms of these conditions were enumerated and explained. These conditions are recognized as psychiatric disorders of which she was not aware of. The case formulation was also explained to her in her own language. The process of treatment was also explained to her. It was told to her that she is trying to manage her anxiety and phobic symptoms by avoiding them. The avoidance results in temporary relief which acts as reinforcement instead of improvement. Instead of avoidance, she required to expose herself to anxiety provoking situations. This exposure would initially boost the anxiety response and in the process would get reduced. She was also explained the concept of cognitive exposure. It was told that during the initial phase of treatment it is not necessary to expose her to actual anxiety provoking events and situations. This can be done at cognitive/imaginative level. The concept of excessive use of future perspective during anxiety activation was also explained. She was told that she would be trained to expose

herself to anxiety provoking situations at cognitive level and integrated the tweak of future perspective into past or present perspective. Appropriate examples were used to clarify the concepts and applications of CDT. She was asked to continue her psychiatric treatment. Identification of Anxiety Cues: With the help of the patient a number of internal and external anxiety cues were identified. The list was updated as and when additional cues became apparent in the course of the treatment. Some of the cues are listed such as: thoughts related to death by cancer; deaths of family members, travelling in train/metro; visiting multi-storey buildings; elevators; market place; thoughts of heart attack; thoughts of being alone in the home; crowded places etc. Cognitive Drill: In cognitive drill, specific thoughts and images were identified, converted into past/present tense and she was required to verbally repeat the converted statements in bulk until anxiety reduction which usually takes about 2-5 minutes. The cognitive drill was applied initially for mild anxiety cues, then to moderate and finally severe anxiety provoking cues. For example, I have died of heart attack; family members have died; I got stuck in metro and no help is available and so on. Behavioural Tests: Upon significant reduction in anxiety during cognitive drill, she was told to expose herself to the real life anxiety provoking situations to which drill has been applied to test whether the real life situations still elicit anxiety response. If it did so, then she was recommended to repeat the cognitive drill for such cues. Usually, the application of drill reduces/eliminates anxiety response to many real life situations. Home-Work: She was asked to consider our sessions as training sessions. Learn the procedure of cognitive drill therapy and apply the same concepts when you are out of therapy sessions. Specifically, she was told to recognize anxiety cues and practice cognitive drill. Sessions Details: Ten sessions were conducted each lasted from one to two hours. In the sessions, she was required to perform drill on the identified anxiety cues. Her husband was also allowed to remain present during the sessions. The active therapy sessions were conducted in three blocks. Four daily sessions were conducted in second week of July 2014. Again two sessions were conducted in the last week of July 2014. After a gap of about four months, three more sessions were conducted in November 2014. Periodic follow ups were done on telephone and she was asked to submit the filled up scales. Results: Total four formal assessments were done on the listed scales. (1) Baseline on 7th July 2014 (2) Second assessment on 23rd July 2014 (3) Third assessment on 21st August 2014 (4) Last Assessment on 25th December 2014. The results are depicted in following figures. 142 Dwivedi & Kumar

Figure-1 displays the scores on Agoraphobic Cognition Questionnaire on baseline and follow ups. The questionnaire has 15 items which are rated on five point scale where 1 means thought never occurred and 5 means thought always occurs. The maximum possible score is 75 and minimum score is 15. On baseline she scored 58 which got reduced to 20 on last follow up indicating a highly significant improvement in her agoraphobic cognitions. Figure-2 displays scores on body sensations questionnaire on baseline and follow up. It consists of 18 items rated on five point scale where 1 means not at all, and 5 means extremely frightened by the sensations. Maximum possible score is 90 and minimum score is 18. On baseline she scored 60 and on last follow up her score was 22 indicating a significant improvement in her reactions to body sensations. Figure-3 displays scores on Beck Depression Inventory. It consists of 21 items which are rated on four point scale ranging from zero to three. On baseline she scored 46 and on last follow up she scored 11 indicated highly significant improvements in her depression. Figure-4 displays scores on GAD Scale on baseline and follow ups. It consists of 7 items rated on four point scale ranging from zero to three. 0 means not at all sure and 3 means nearly every day. Maximum possible score is 21 and minimum possible score is zero. On baseline she scored 21 which got reduced to 02 on last follow up. Figure-1: Agoraphobic Cognition Questionnaire Figure-3: Beck Depression Inventory-II Figure-4: GAD Scale Figure-2: Body Sensation Questionnaire

Figure-5 displays scores on Mobility Inventory - When Accompanied on baseline and follow up. It consists of 28 items rated on five point scale where 1 indicates never avoid, and 5 indicates always avoid the situation. Maximum possible score is 140 and minimum score is 28. On baseline she scored 90 and on last follow up her score was 31 indicating a significant improvement in her mobility in different situation. Figure-6 displays scores on Mobility Inventory - When Alone on baseline and follow up. It consists of 28 items rated on five point scale where 1 indicates never avoid, and 5 indicates always avoid the situation. Maximum possible score is 140 and minimum score is 28. On baseline she scored 122 and on last follow up her score was 44 indicating a significant improvement in her mobility in different situation. Discussion: The application of Cognitive Drill Therapy produced substantial and clinically significant changes in her anxiety, agoraphobic cognition, body sensations, depression and mobility which were maintained on follow ups. She also showed meaningful improvement in her social relations, affect, self-efficacy, engagement in household work, going away from home even without accompanying person, shopping etc although these aspects were not measured formally. Cognitive drill uses principles of exposure therapy (Vincelli, 1999; Vincelli, et. al. 2000). The repeated exposure at cognitive and verbal level causes extinction and habituation of acquired anxiety response (Watson & Rayner, 1920; Lovibond, 2004 p. 495). The words and images of anxiety cues elicited anxiety in her; and when exposed repeatedly to those words and images at cognitive and verbal level, it had expected effects of extinction and habituation. The exposure to anxiety cues also results in enhancement of self-efficacy (Bandura et al, 1975). The cognitive drill being based on exposure also enhances self-efficacy and other faulty cognitions which are also observed in this patient. One of the hypotheses invoked in Cognitive Drill Therapy relates to the neurobiological correlates of linguistic aspects particularly verbs. That, each tense, present, past and future have their own distinct neurobiological correlates (Ullman, 2008; Pinker & Ullman, 2002; Bickerton 1990; Lightfoot, 1991; Chomsky, 2005). The anxious state has a predominantly future perspective. The conversion of this perspective into past or present at cognitive level somehow modifies Figure-5: Mobility Inventory - When Accompanied Figure-6: Mobility Inventory - When Alone 144 Dwivedi & Kumar

Cognitive Drill Therapy: the future perspective and calms down anxiety response to conditioned stimuli. The testing of this hypothesis would require highly sophisticated and advanced researches involving live scanning of brain during verbs usage. May be future studies at some point of time may take up and consider the hypothesis. Empirically, in clinical settings, it is a common observation that a relief in anxiety through any modality shifts the future perspective of the patient into the present one. It is observed that when there is an extinction of anxiety response to the anxiety cues at verbal and imagination level, there is an automatic generalization to the real world cues in most of the instances. This patient when exposed to anxiety cues at cognitive and verbal level, showed minimal or no anxiety to the real world situations. If still a cue produces anxiety after drill, then drill was repeated and this reduced the anxiety. This cross modality generalization is extremely useful for the purposes of therapy, economic in terms of pain experienced during live exposure vis-à-vis cognitive and verbal exposure, quite faster in resolution of anxiety. In exposure treatment, many patients drop out because of the pain and suffering experienced during live exposure sessions (Michele et al, 2008). The cognitive and verbal exposure is not that much overwhelming and may have a value in decreasing attrition rates in psychotherapy. The studies need to be conducted to compare the rates of drop outs in live exposure therapies and cognitive exposure therapies. Relapse prevention is one of the primary concerns in the treatment of psychiatric disorders (WHO, 2004). Cognitive drill seems to have an inbuilt component of relapse prevention. Because during the course of treatment, a patient learns to identify anxiety cues, formulate drill statements and perform cognitive drill on the fly. Through the intensive treatment it becomes an integral part of coping with the anxiety provoking situations. She also reported that as and when she finds herself in any anxiety provoking situations, she detects her sensations and anxious cognitions and immediately performs the drill. The patient is required to learn only a few concepts and skills which enable him/her to effectively deal with the anxiety provoking situations. Conclusion: The case study demonstrates how time efficient and intensive cognitive drill therapy can be applied in such patients. A clinically significant improvement could be achieved in the relatively short time of two weeks and the gains/improvements of therapy were maintained at 6-month follow-up. The Cognitive Drill Therapy seems to have produced clinically significant results in indexed patient of agoraphobia with panic disorder. To establish a functional relationship between this modality of treatment and outcomes in patients of anxiety disorder, large scale, randomized controlled trials would be required. Controlled studies comparing cognitive drill therapy and cognitive behaviour therapy in panic disorder with agoraphobia could help to understand the specific procedural and process-based aspects that help making this kind of treatment so effective. References: American Psychiatric Association. (1980). Diagnostic and Statistical Manual of Mental Disorders (3rd ed.). Washington, DC: Author. American Psychiatric Association. (1987). Diagnostic and Statistical Manual of Mental Disorders (3rd Ed., Rev.). Washington, DC: Author. American Psychiatric Association. (1994). Diagnostic and Statistical Manual of Mental Disorders (4th Ed.). Washington, DC.

Beck, A., Steer, R., & Brown G. (1996). BDI-II: The Beck Depression Inventory. The Psychological Corporation Second edition. Bickerton, D. (1990). Language and Species. Chicago, IL: University of Chicago Press. Chambless, D. L., Caputo, G. C., Bright, P. and Gallagher, R. (1984). Assessment of fear of fear in agoraphobics. The Body Sensations Questionnaire and the Agoraphobic Cognitions Questionnaire. Journal of Consulting and Clinical Psychology, 52, 1090–1097. Chambless, D. L., Caputo, G. C., Jasin, S. E., Gracely, E. J. and Williams, C. (1985). The Mobility Inventory for agoraphobia. Behaviour Research and Therapy, 23, 35–44. Chomsky,N. (2005). Three factors in language design. Linguistic Inquiry. Clinical Protocol. 36, 1–22. Deacon, B. and Abramowitz, J. (2006). A pilot study of two-day cognitive-behavioural therapy for panic disorder. Behaviour Research and Therapy, 44, 807–817. Ehlers, A., Margraf, J., Chambless, D. L. (1993). Fragebogen zu ko¨rperbezogenen Angsten,Kognitionen und Vermeidung (AKV) mit den Skalen BSQ, ACQ und MI. Weinheim: Beltz. Foa, E. B., Jameson, J. S., Turner, R. M. and Payne, L. L. (1980). Massed vs. spaced exposure sessions in the treatment of agoraphobia. Behaviour Research and Therapy, 18, 333–338. Kumar.R., Sameer.A., Singh.B. (2012). Preliminary Test of Cognitive Drill as an Intervention. Indian J.Clini. Psych., 39, 67-74. Lightfoot, D. (1991). Subjacency and sex. Language and Communication 11, 67– 69. Lovibond, P.F. (2004)Cognitive processes in extinction. Learning and Memory. 11:495–500. Mathews, A.M., Gelder, M. G. and Johnston, D.W. (1981). Agoraphobia: nature and treatment. New York: Guilford Press. Michele, A., Schottenbauer, C.R., Glass, D. B., Arnkoff, V.T. and Sheila, H. Gra.(2008) Nonresponse and Dropout Rates in Outcome Studies on PTSD: Review and Methodological Considerations. Psychiatry 71(2) 134-168. Pinker, S., Ullman, M. T.( 2002).aThe past-tense debate: The past and future of the past tense. Trends in Cognitive Sciences 6, 456–463. Ullman, M. T. (2008). Variability and redundancy in the neurocognition of language. Paper presented at the DGfS workshop on Foundations of Language Comparison: Human Universals as Constraints on Language Diversity, Bamberg, Germany. Universitat Bamberg, 27–29 Vincelli, F. (1999). From imagination to virtual reality.The future of Clinical Psychology. CyberPsychology & Behavior 2(3):241– 248. Vincelli, F., Molinari, E., Wiederhold, B.K. , Riva, G.(2000) Cyberpsychology & Behavior ,3, Watson, J.B., Rayner, R.(1920)Conditioned emotional reactions. Journal of Experimental Psychology. 3:1–34. World Health Organization.(2004). Prevention of Mental Disorders. Effective interventions and policy options. Summary report. Jeneva, SIS JOURNAL OF PROJECTIVE PSYCHOLOGY AND MENTAL HEALTH (An Official Publication of Somatic Inkblot Society) Published Regularly Twice a Year in January and July First Volume Published in 1994 All Volumes of the SIS Journal are also available in PDF Format Individuals/Institutions can become Member of Somatic Inkblot Society by Submitting Membership Application Form Given in the Journal and Receive Print Version/Soft Copy of the Journal Published After the Date of Membership Free of Cost Bankey L. Dubey, Ph.D., DPM, DM&SP, Editor Emeritus, SIS Journal of Projective Psychology and Mental Health, E-mail : bldubey@gmail.com 146 Dwivedi & Kumar

Book Review Mental Health Survival Guide for Individuals and Families of Indian Origin Greesh C.Sharma, Ph.D, DMSP. Clinical Psychologist Published- http:// www.Amazon.com From the cover pages to the contents in 12 chapters and 157 pages, Mental Health Survival Guide for Individuals and Families of Indian Origin seizes the reader’s attention whether one is a mental-health consumer, provider or teacher or a person engaged in helping the Indian Diaspora at large or undergoing personal crisis. The Guide reassures the consumer to be bold and rise above denials and stigma. It provokes the reader to be proactive, and guides him/her to get proper, timely help. It sensitizes reader to be empathic towards the feelings of others and perceptive as to the challenges that loved ones experience. This is a must-read to understand the significance of mental-health issues, whether relate to stress at work, feeling emotionally overwhelmed, experiencing marital distress, undergoing intergenerational conflicts, struggling with addictions, or living with paralyzing emotional illness, such as schizophrenia, bipolar disorder, post-traumatic stress disorder, depression, panic, or intermittent explosive disorder. This book provides ample case studies to make it easier to understand how emotional problems can manifest in disguise and sabotage the good life, success at work, and potentially happy relationships. The Guide is insightful guide whether one lives in India, work or studies abroad, has settled in countries with different cultures, or is undergoing transition. The book elucidates Indian core values, highlights vulnerabilities, and confronts Indians’ habitual denials as to accepting mental health-challenges. It suggests that in the Indian Diaspora, there is no place to hide from the universal fact of mental illness being an equal opportunity victimizer. Success, affluence or accomplishments do not guarantee immunity. Information, openness to learn about available resources, and seeking confidential help can prevent unnecessary crises, losses, damages, and irreparable negative outcomes. The book speaks to those who are motivated to seek psychotherapy for personal growth, are interested in improving the quality of their relationships, and those who are feeling alienated, ambivalent, insecure, inadequate, overwhelmed, ineffective, indecisive, or emotionally paralyzed. This Guide is an excellent tool for those aiming to go abroad for the first time, raising a family in foreign cultures or contemplating inter-racial marriage. Dr. Sharma’s Guide goes beyond traditional practice of offering diagnostic clues, names of mental illnesses, types of medications, and differences between interdisciplinary specialties and proposes types of available counseling/therapies, and self-help techniques as well. B.L.Dubey, Ph.D. Director, SIS Center, 4406 Forrest Road, Anchorage, AK 99517 (USA) Email: bldubey@gmail.com

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Members of Somatic Inkblot Society will be glad to know that SIS Jr. of Projective Psychology and Mental Health has been listed by World Health Organization (Global Forum for Health Research) among 25 indexed journals that have published the highest number of articles on mental health from LMICs in Latin America, Africa and Asia (Medline and PsycINFO). Extract from table-6 of “Research Capacity for Mental Health in Low - and Middle - Income Countries: Results of a Mapping Project “(www.globalforumhealth.org) is given below:

Rank Journal Country Language Revista de Psicoanalisis Argentina Spanish Revista de Neurologia Spain Spanish Revista Brasileria de Psiquiatria Brazil Eng.,Spani.,Portuguese, Arquivos de Neuro-psiquiatria Brazil Portuguese Acta Psiquiatrica y psicologica de Amercia Laina Argentina Spanish Journal of the Medical Association of Thailand Thailand English, Thai 7 British Journal of Psychiatry UK English Acta Psychiatrica Scandinavica Denmark English Salud Mentale Mexico Spanish Vertex Argentina Spanish Journal of Personality and Clinical Studies India English Social Psychiatry and Psychiatric Epidemiology Germany English Revista Medica de Chile Chile Spanish South African Journal of Psychology South Africa Afrikaans, English Psychological Reports USA English South African Medical Journal South Africa Afrikaans, English The Australian & New Zealand Jr. of Psychiatry Australia English International Journal of Social Psychiatry U. K. English Psychiatry Research Ireland English Social Science & Medicine U. K. English Revista De Saude Publica Brazil Portuguese International Journal of Geriatric Psychiatry U. K. English SIS Journal of Projective Psychology and Mental Health India English Journal Brasilerio de Psiquiatria Brazil Portuguese Psychiatry and Clinical Neurosciences Australia English

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SIS JOURNAL OF PROJECTIVEPSYCHOLOGY & MENTAL HEALTH

Volume 22 Number 2 July 2015 EDITORS EMERITUS : Wilfred A. Cassell, MD, FAPA, Director, SIS Center, 4501E,104th Avenue, Anchorage, AK.99516 (USA). E-Mail: siscassell2@yahoo.com

Bankey L. Dubey, Ph.D., Director SIS Centre,4406 Forest Rd, Anchorage, AK 99517, E-mail: bldubey@gmail.com

EDITOR-IN-CHIEF : Naveen Gupta, Ph.D., Director, Hindustan Institute of Management and Computer Studies, Farah, Mathura-281122, Email: dr_naveengupta@yahoo.com Cell: 91-9627182913

EXECUTIVE EDITOR:

Rakesh Kumar, Ph.D. HOD, Clinical Psychology Institute of Mental Health and Hospital, Agra-282002 U.P. Email: jain.imhh@gmail.com

EDITORS : Anand Dubey, MBA, 4406 Forrest Road, Anchorage, AK 99517 Email: anand.dubey@gmail.com

L. Sam S. Manickam, Ph.D., Professor Clinical Psychology. Department of Psychiatry, JSS University, Mysore-570004, Email: lssmanickam@gmail.com

Nilanjana Sanyal, Ph.D., Prof. Department. of Psychology, University of Calcutta, 92 A. P. C Road, Kolkata-700009 Email: sanyal_nilanjana2004@rediffmai.com, EDITORIAL CONSULTANTS :

Abhilasha Singh, Ph.D. India Ailo Uhinki, Ps.D., Finland Ajay Tiwari, Ph.D., India Amool R.Singh, Ph.D.India Anatoly B. Khromov. Ph.D., Russia Antonio Cervigni, M.A., Italy Arvind K. Keshary, Ph.D. India Barry A. Ritzier, Ph.D., U.S.A. Brig. D. Saldanha, M.D. India Carina Coulacoglou, Ph.D., Greece Edward M. Petrosky, Ph.D., U.S.A. H. Kumar, Ph.D., USA Jayanti Basu, Ph.D., India Lisa Milne, Ph.D., Australia M.P.Singh, Ph.D. India Manisha Dasgupta, Ph.D. India Nalini Mishra, Ph.D., India Padma Dwivedi, M.A., USA Paola Nicolini, M.A., Italy R.N.Singh, Ph.D. India R.P. Gupta, M.A., India Radhe Shyam, Ph.D.India Rakesh Pandey, Ph.D. India Ranjeet Kumar, Ph.D., India Robert B. Williams, Ph.D., Canada Sandhyarani Mohanty, Ph.D. India Stefano Reschini, M.A, Italy Suprakash Chaudhury, M.D., Ph.D. Umed Singh, Ph.D. India Yasho V. Verma, Ph.D., India Yogesh K. Arya, Ph.D., India