SIS Journal of Projective Psychology & Mental Health

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 prepared in accordance with the format of the Journal of Personality Assessment/ SIS Journal of Projective Psychology and Mental Health. The manuscript should be prepared only in MS Word. No other formats are acceptable. An MS Word Template for preparing manuscript can be downloaded from the SIS Website. MANUSCRIPTS SUBMISSION: The typewritten manuscript in MS Word should be submitted only through email to the Editor Emeritus or Editor-in-Chief. The print version of the manuscript is not considered. The manuscript should be emailed on following Email IDs. (1) Dr. Bankey L. Dubey, Ph. D. Editor Emeritus, SIS Journal, Email: bldubey@gmail.com (2) Dr. Naveen Gupta, Ph.D. Editor-in-Chief, SIS Journal, Email: dr_naveengupta@yahoo.com (3) Dr. Rakesh Kumar, Ph.D. Executive Editor, SIS Journal, Email: jain.imhh@gmail.com Note: The Editorial Board of SIS Journal of Projective Psychology and Mental Health have full rights to accept/reject or require a re-submission of submitted manuscripts. Minor additions/ deletions/ changes can also be made in the manuscript at the level of Editors. JOURNAL SUBSCRIPTION: The SIS Journal of Projective Psychology and Mental Health is delivered to the members of the Somatic Inkblot Society as a membership privilege according to the nature of the membership and opted preference for Print Version or Soft Copy. We encourage the individuals and Institutions to become member of the Somatic Inkblot Society on the prescribed Membership Application Form available in this issue of the Journal to receive a copy of the journal. Non-members may purchase any single issue in print version or soft copy on the prevailing rates which are quoted in the latest issue of the journal. Current Rates: Foreign: $45 and Indian Rs. 600/- per issue. (1) All online payments or direct cash deposit for the journal should be made to following bank account: Name of Account: SIS Journal of Projective Psychology and Mental Health Bank Name: State Bank of India Branch Address: Krishna View Plaza, Marble Market, Plot # 20, Sector 20, Dwarka, New Delhi-110075 Account No.32297525238 IFS Code:SBIN0011361 (2) All payments through Multi City Cheque (or Demand Draft payable at State Bank of India Delhi)in favor of “SIS Journal of Projective Psychology and Mental Health”be sent to the following address by Registered/Speed Post: Dr. Naveen Gupta, Ph.D., Director, Hindustan Institute of Management and Computer Studies, Farah, Mathura-281122 U.P. (INDIA) Email: dr_naveengupta@yahoo.com, Cell: 91-9627182913 CHANGE OF ADDRESS: Any changes in address should be submitted to us through email for updating our records and seamless receipt of the Journal and other communications. Email: bldubey@gmail.com Copyright ©1994. SIS Center, India/Anchorage SIS Website: http://www.somaticinkblots.com

Editorial Projective Techniques True “Mirror” of Self Sensorium-oriented self-system peeps into the external reality in search of bodily pleasure and its resonance in mind. In the process itself, it encounters pains at times. Pleasure and pain are inevitably entwined. To have peace, harmony and the deep feelings of serenity in this stimuliconglomerated world, our target should be the experience of bliss and just not pleasure. To attain bliss, our internality of self, needs to be fathomed in calm state of mind. The world of projection radiates the internal elements in the subjective coloration of one’s own schema. Schema-content is once again the product of sensorium-transmitted external objects. The frames and fringes of projection need tender care to understand one’s internal contents and dynamics of personality. Such understanding differentiates between healthy and pathological frames of personalities. Assessment of mental health offers beads of comfort and, in their integration, a productive person for the society. Pathology, detected through projective techniques, opens up the gates of connection to initiate productivity in a person. Today’s world has non-stop sparkling stimulations. Our sensoriums are overloaded with them. Our mind not only has sharp clarity of these stimulations, often they are clouded with doubts and anxieties, and crowded with too many contents to touch the “feel good” zones in life. Helplessness in interpretations is obvious in the absence of clarity. The added streaks are lack of trust and faith in life-contents. The resultant conditions are sufferings in enormity. The situation is calling for a change. Established efforts are there in Psychology domain to use projective techniques to know the unknown frames of the hidden self. SIS seems to be a very potent set in the context. The use of SIS in the Indian context is expected to bring out Indian personality dynamics one day. The paint-brushes of Psychology would be more eloquent then to speak our own stories. In current academics, researches are umpteen in number. This is the indication of quest for knowledge in scientific frames. The backdrop scenario has life-canvas, with sketches of pleasures and pains, happiness and sufferings with boundless lines. The academic efforts are to trace the pathways of improving life-conditions through human knowledge, particularly in terms of realizational contents in experientiality, so that abundance of pains can be reduced in rates. The kaleidoscopic view of life shows bright colors with patches of darkness. These dark areas are either inevitability of life or else crafted by the unacknowledged primitivity of human mind. Psychology as science offers the avenues to accept traumas with grace, to attain and maintain stability in life. It also helps us to fathom the deep layers of hidden mind through projective assessment techniques. These are doors of self-knowledge that need to be kept open to usher in positive approaches to embroider the soothing fringes of personal experiences. We blame others in our frustrations without realizing this may be one’s unrealistic expectations that are getting baffled in the process or else, this is the blamer’s own projection in the form of projective identification on to someone else. True logical perspective developed within oneself is the “mantra” of attaining peace and escaping the clutches of mis-readings leading to pains. Projective techniques are just not to know “others” in totality, but also to peep into one’s own world, develop self-knowledge to adopt right cleansers, to attain a crystal-clear mind. Nilanjana Sanyal, Ph.D. Professor and Former Head, Dept of Psychology, University of Calcutta, 92 A.P.C. Road, Kolkata 700009

Emotional Intelligence, Exner’s Special Indices on Rorschach in Schizophrenia Pushpanjali Vishwakarma, Satyadhar Dwivedi and Rakesh Kumar The present study aimed to explore the associations among emotional intelligence and Rorschach’s special indices in patients with schizophrenia. A sample of 30 male patients with different types of schizophrenia (diagnosed using ICD 10) each within age range of 18-45 years was taken. Subjects were selected by purposive sampling on the basis of inclusion and exclusion criteria from the in-patient department of IMHH. MSREIS-R test and Rorschach inkblot test (Exner system) were administered on the patients to assess different components of emotional intelligence and the special indices respectively. The results revealed that two components of emotional intelligence (a) ability to utilize emotions and (b) to manage emotions in self were significantly reflected on following Exner’s indices (i) Suicide constellation (ii) Depression Index and (iii) Coping Deficits index. Emotional intelligence is a global capacity of regulation, management, control, and use of emotions in decision-making. Emotional intelligence promotes healthy and adaptive functioning. It is also related to understand and control own and recognize others’ emotional states. People with high level of emotional intelligence tend to experience a healthy balance of feelings such as: motivation, awareness, peace of mind, friendship, balance, self-control, autonomy, freedom, contentment and appreciation. In contrast people with lower level of emotional intelligence tend to feel more: loneliness, fear, guilt, frustration, depression, emptiness, bitterness, lethargy and disappointment, anger, dependence and failure (Darwin, 1965).Several researchers studied the importance and the application of emotional intelligence in schizophrenia. A lower level of emotional intelligence has a significant association with schizophrenia on all measures of El and demonstrates poorer neuro-cognition and social functioning (Dawsons et al., 2012). Lack of social cognition may also be a risk factor for psychosis such as poor performance on social cognition tasks was significantly correlated with psychosis in young people who were at ultra-high risk of psychosis (Kim et al., 2011). Other studies indicate that impaired social cognition is significantly associated with schizophrenia. Impairments have been documented in several domains including personal decision making, handling stress, lack of empathy, self-disclosure, selfacceptance, insight, affect recognition (Edwards et al., 2002; Fiszdon& Bell., 2009; Hoekert et al., 2007; Pinkham et al., 2007).However, little is known about other aspects of emotion processing that are critical for adaptive functioning. Rorschach is a known as a projective tool assessing different aspects of personality and the special scores given tend to assess the severity of psychopathology. Exner’s system also includes the different standardized indices to tap coping deficits (CDI), obsessive (OBS) and suicidal tendency (S-CON), hyper-vigilance style (HVI), depression (DEPI) and perceptual thought disorder (PTI) where PTI tends to measure the severity of psychopathology in perceptual and thinking processes. In the response pattern of Rorschach psychodiagnostic test on schizophrenic patients, the productivity of responses can be low or high, organization capacity can be low, whole responses are fewer than normal, there can be less or even absence of movement responses, color responses can be high and can be absent if it is not reactive schizophrenia. Besides these, form quality is poor, popular responses are less, position response may be present, pathognomonic Pushpanjali Vishwakarma, Clinical Psychologist, Satyadhar Dwivedi, Asst. Professor, Rakesh Kumar, Head, Department of Clinical Psychology; Institute of Mental Health & Hospital, Agra-282002 Email: jain.imhh@gmail.com (Corresponding Author) Key word: Rorschach in Schizophrenia, Exner’s indices.

signs are likely to be present, human responses can be low or absent. In the year 1884, 1986, Exner identified a five item index, involving eight variables related to mediation or ideation which was designated as ‘Schizophrenia Index’ (SCZI). The SCZI was revised in 1991 including 12 variables used in six criterions (Exner, 1991) such as : SCZI1= x+%<.61 and S-%<.41 or X+%<.50, SCZI2= X-%>.29, SCZI3= FQ->=FQu or FQ- >FQo+FQ+, SCZI4= Sum Level 2 Special Scores>1 or FAB2>0, SCZI5= Sum6> 6 or WSum6>17, SCZI6= M-> 1 or X-%>. 40). It proved useful for the diagnosis of the possible presence of a psychotic-like condition, especially schizophrenia and also in discriminating psychotic disorders from non-psychotic disorders. However, it was suggested that it might be better considered as a ‘Psychosis Index’ and later the term ‘Perceptual Thinking Index’ (PTI) was used (Exner, 2000). The resulting items that comprise the special indices and the criteria for their application are:- PTI (Perceptual- Thinking Index): XA% < .70 and WDA% < .75 (ii) X-% < .29 (iii) LVL2 > 2 and FAB2 > 0 (iv) R < 17 and WSUM6 > 12 or R > 16 and WSUM6 > 17 (v) M - > 1 or X-% > .40 The PTI replaces the schizophrenia index (SCZI). There is no critical cut-off value. If PTI score of four or five signify considerably patients have more meditational/ideational trouble than score of zero, one or two. S-Constellation (Suicide Potential): (i) FV + VF + V + FD>2 (ii) Color-Shading Blends > 0 (iii) 3r + (2) / R <. 31 or > .44 (iv) MOR > 3 (v) Zd> + 3.5 or Zd< - 3.5 (vi) Es> EA (vii) CF + C > FC (viii) X + % < .70 (ix) S > 3 (x) P < 3 or P > 8 (xi) Pure H < 2 (xii) R< 17 The S-CON was developed in 1970 using the protocols of 59 individual that affected their own death (Exner& Wylie 1977) in which are included 12 heterogeneous variables. When the S-CON score is eight or greater it is likely that the person has suicidal tendency. S- CON cutoff criteria, being less than 8, should not be interpreted to mean that no selfdestructive preoccupation exists. Some interpreters are inclined to worry over protocols that have S-CON values of 7. DEPI (Depression Index): (i) FV+ VF+ V> 0 ) or (FD> 2) (ii) (Col – Shd Blends > 0) OR ( S> 2 ) (iii)(3r + (2) / R > .44 and Fr + rF = 0) OR( 3r + (2) / R <. 33) (vi) (Afr< .46 ) OR ( Blends < 4 ) (v) Sum Shading > FM = + m ) OR ( Sum C’ > 2 ) (vi) (MOR < 2) OR ( 2 x AB + Art + AY > 3 ) (vii) Cop < C2) OR (Bt + 2 x CI + Ge + Ls + 2 x Na / R > .24) The DPI values represent the affective problem rather than specifically equating positive value with diagnostic categories (Exner, 2001) in which are included 7 heterogeneous variables. When the positive DEPI score is five or more, likelihood of the person tends to be diagnosed as a being depressed, or having an affective disorder, such as being emotionally distraught, cognitively depressed and having sense of helplessness. CDI (Coping Deficit Index): (EA < 6) OR ( Adj< 0 ) (ii) (COP < 2 and (AG < 2 ) (iii) (Weighted Sum C < 2.5 ) OR *(Afr< . 46 ) (vi) (Passive > Active + 1) OR (Pure H < 2 ) (v) (Sum T > 1 ) OR (Isolate / .24 ) OR (Food > 0) The positive score of four or five on CDI suggests issues of interpersonal skill, adjustment and social deficits (Weiner &Exner, 1991; Exner&Sanglade, 1992). HVI (Hypervigilance Index): FT + TF + T = 0 (ii) (2) Zf> 12 (iii) (3) Zd> + 3.5 (vi) (4) S > 3 (v) H + (H) + Hd + (Hd) > 6 (vi) (H) + (A) + (Hd) + (Ad) > 3 (vii) H + A:Hd + Ad < 4:1(viii) Cg > 3 When the positive score is five on HVI, it is likely that the person is having paranoid-like features or is irrationally suspicious of others. This was supported by Exner (1986) who identified during a study of 150 paranoid schizophrenics of whom more than 70% were positive for all five variables, and more than 85% were positive for at least four of the five. OBS (Obsessive Style Index): (i) Dd> 3 (ii) Zf> 12 (iii) Zd> + .3 0 (vi) Populars> 7 (v) FQ + > 1 The OBS index is positive if 1 or more is true: Conditions 1 to 5 are all true, 2 or more of 1 to 4 are true AND FQ + > 3, 3 or more of 1 to 5 are true AND X + % > .89, FQ + > 3 AND X + % > .89

The OBS is not found positive among schizophrenic and inpatients depressed cases (Exner, 1990). The perceptual cognitive processes that invoke subjects in formulating and articulating their responses provide clues to their characteristic ways of dealing with life experiences and their psychological state and traits. It also helps to understand how they process information and how they prefer to cope with problem solving situation (Weiner, 1997). However the Rorschach test is the most widely used method for assessing suicide risk in clinical settings and assess broad personality characteristics and their behavior (Blatt, 1990; Exner,1988; Weiner, 1997) by evaluating cognitive processing via examination of the individual has assigned to their perceptual experiences (Exner,1978; Weiner,1997). PTI and CDI have been found positively correlated with the ICD-10 diagnosis of schizophrenia (Kumar &Khess, 2004; Gomilla, 2011; Rosenbaum, 2012; Gooding, et al., 2012).Exner, (1986) conducted study on 150 patients with paranoid schizophrenia; they found that paranoid schizophrenics had more than 70% positive for all five variables on HVI (Hypervigilance index) and more than 85% positive for at least four of the five. Study done by Hilsenroth et al., (1998) using Rorschach Inkblot Test on schizophrenic patients and normal population, indicated that the schizophrenic patients differed significantly on the Rorschach Schizophrenia Index SCZ11 =x+%<.61 and s-%<.41 or x+%<.50 and also Exner (2001) found that positive DPI values noted in 30% of inpatients schizophrenia who have Lambda value less than 1.0, and about 22% of inpatients schizophrenic that have Lambda value of 1.0 or greater. These finding lead to the conclusion that positive DEPI value are associated with affective problem. Rationale for the study: Persons with schizophrenia reflect impairments in social cognition either during the course, following the illness or even in prodromal phase (Dawsons et al., 2012). Social cognition encompasses the concept of emotional intelligence, and furthermore, deficits in emotion perception and processing have been extensively documented in schizophrenia and have also been associated with poor psychosocial functioning (Kee et al., 2009, Ellen et al., 2007). However, little is known about other aspects of emotion processing that are critical for adaptive functioning. These studies have also established the association of impairments in emotional intelligence with the severity of psychopathology in schizophrenia (Kee et al., 2009). Rorschach is a known projective tool assessing the different aspects of personality and the special scores given tend to assess the severity of psychopathology. Exner’s system also includes the different standardized indices to tap coping deficits (CDI), obsessive (OBS) and suicidal tendency (S- CON), hyper-vigilance style (HVI), depression (DEPI) and perceptual thought disorder (PTI) where PTI tends to measure the severity of psychopathology in perceptual and thinking processes.Thus, it can be hypothesized that impaired psychosocial and adaptive functioning, as a reflection of impaired emotional intelligence, should also be present in Rorschach profile and must be reflected in different indices just like psychopathology is assumed to be reflected in the profile. PTI and CDI have been found positively correlated with the ICD-10 diagnosis of schizophrenia (Kumar &Khess, 2003; Gomilla, 2011; Rosenbaum, 2012; Gooding, et al., 2012), but none of the study has correlated directly Exner’s special indices with emotion intelligence so far. Therefore, the present study seeks to go one step ahead exploring the association among Emotional Intelligence, psychopathology and Exner’s special indices. The present study thus aimed to explore the extent to which emotional intelligence and Exner’s special indices were correlated with one another and in what manner.

Method: The study was conducted at Institute of Mental Health & Hospital, Agra. Study Protocol was approved by ethical & scientific committee of the Institute of Mental Health & Hospital, Agra. Sample consisted of 30 male patients between 18 to 45 years of age with diagnosis of schizophrenia as per ICD-10 Diagnostic criteria. Following tools were administered: 1. Multidimensional Self-Report Emotional Intelligence Scale-Revised(MSREIS-R) MSREIS-R test developed by Panday and Anand,(2008) for the purpose of assessing emotional intelligence in five different dimensions- ability to express and appraise emotion, ability to utilized emotion, ability to manage emotion in self, ability to manage emotion in others. This is a Likert scale score arranged on 1-6 point scale like strongly disagree, averagely disagree, somehow disagree, somehow agree, averagely agree, and strongly agree. Minimum score will be 51 and maximum will be 306. Full scale reliability Cronbach’s alpha coefficient is .95. 2. Rorschach inkblot test (Exner system) developed by Herman Rorschach in 1921. Scoring was done using Exner’s Rorschach Comprehensive System according to the following areas: Location (L), Determinants (D), Content (C), Developmental Quality (DQ), Form Quality (FQ), Popular Responses (P), Organizational Activity (Z), Special Scoring and also integrated 6 section (Core section, Ideational section, Affect section, Meditational section, Processing section and Interpersonal section) and 7 special indices (S-Constellation, Perceptual-Thinking Index, Depression Index, coping Deficit Index, Hypervigilance Index, Obsessive Style Index). Inter scorer reliabilities of 0.85 or higher. Early Meta analyses indicated that validity ranged from 0.40 to 0.50. Results: The study was a cross sectional correlation study conducted on patients with schizophrenia diagnosed as per ICD 10- Diagnostic criteria. Table 1: Socio-demographic and Clinical Characteristics of the Sample Demographic Variables (Continuous) Patients with Schizophrenia (n=30) Age (in Years) Mean± S.D. 34.60± 6.85 Age on onset of illness (in years) Mean±S.D. 26.70±6.59 Duration of illness (in years) Mean±S.D. 7.27±5.03 Demographic Variables (Categorical) N % Marital status Married 60.0 % Unmarried 40.0 % Religion Hindu 93.3 % Muslim 6.7 % Education Primary 6.7 % Middle 50 % High school and Intermediate 30% Graduate 13.3 % Occupation Employed 23.3 % Unemployed 76.7 % Socioeconomic Status Lower 33.3 % Upper lower 46.7 % Middle 13.3 % Upper middle 6.7 % Habitat Rural 53.3 % Urban 46.7 %

Table 2: Correlation Coefficients between Scores of MSREIS-R test and Special Indices on Rorschach Factors of MSREIS-R PTI S-CON DEP CDI Ability to express and appraise emotions -.228 -.165 -.153 -.306 Ability to utilize emotions -.145 -.369* -.387* -.219 Ability to manage emotions in self .059 -.245 -.125 -.494** Ability to manage emotions in other -.157 -.222 -.288 -.319 Full scale score -.159 -.310 -.294 -.386* ** p<0.01 , *p<0.05 Table 1 elaborates different sociodemographic variables including marital status, religion, education, occupation, socioeconomic status and habitat. Sample included 18(60%) married and 12(40%) unmarried patients among whom (93.90%) of patients belong to Hindu religion while only 2(6.7%) are Muslims and 16(53.3%) patients are living in rural areas. 2(6.7%) of patients are educated up to Primary level, 15(50%) up to Middle, 9 (30%) up to High school or Intermediate and only 4(13.3%) patients are educated up to Graduation. Most of the sample (N=23, 76.7%) is unemployed. 10(33.3%) patients belong to low socio-economic status, 14 (46.7%) to upper lower, 4(13.3%) to middle, and only 2 (6.7 %) belong to upper middle economics status. Mean and standard deviation of the continuous variable like, age, age of onset, and duration of illness were determined. The mean age of the sample is 34.60 with a standard deviation of 6.85. Minimum age of onset of the sample is 20.11, with maximum age of onset being 33.29. Duration of illness varies from 2.23 to 12.31. Table 2 explores the bivariate correlation between MSREIS-R test scores and special indices on Rorschach test. Ability to express and appraise emotions is not found correlated significantly with any of the special indices on Rorschach. But a significant negative correlation of the ability to utilize emotions was present with both, the suicidalconstellation index (p<0.05, r=-.369) and the depression index(p<0.05, r=-.387). The ability to manage emotions in self is found highly but negatively correlated with the coping deficit index only (p<0.01, r=- .494).Significant negative correlation is also present between the total scores of MSREIS- R test with the coping deficit index (p<0.05, r= -.386). Discussion: The present study was conducted in the Institute of Mental Health and Hospital, Agra with the purpose of exploring the relationship among emotional intelligence, and Exner’s special indices on Rorschach test. It was a cross-sectional correlation study in which subjects were selected by using purposive sampling technique based on inclusion and exclusion criteria. Sample consisted of 30 patients with schizophrenia those who were already diagnosed by consultant psychiatrist using ICD-10 diagnostic criteria (WHO, 1993). Emotional intelligence was measured by using Multidimensional Self-Report Emotional intelligence Scale-Revised. Rorschach Inkblot test (scoring done by Exner’s system) was used to find the scores on special indices like Perceptual thinking index, s-constellation index, coping deficit index, depression index,Obsessive style index, and hypervigilance index. Emotional Intelligence and Rorschach Special Indices: The main objective of the investigation was to find the correlation between emotional intelligence and special indices on Rorschach. The Scores on MSREIS-R demonstrated significant correlations with several of the special indices on Rorschach in patients with schizophrenia. The result showed significant negative correlation of the ability to utilize emotions with both the suicide-constellation index (SCON) and depression index (DEPI). The three components, ability to express and appraise emotions, and the ability to manage emotions

in self and in others, were not found significantly associated with any of the indices whether being DEPI, SCON, PTI or CDI. The patients of schizophrenia have always been labeled for their abnormal emotional reactions. Individual with low level of emotional intelligence tend to suffer from feelings of loneliness, fear, frustration, guilt, emptiness, depression, instability, lethargy, disappointment, anger, dependence and failure (Darwin, 1965). Usually they feel difficulty in expressing their self in society, at the same time; they feel that others do not understand their emotions that further leave them frustrated and sad. However, this is not the case in our finding as DEPI or SCON were not correlated with the ability to express or appraise emotions. Poor insight towards illness in schizophrenia may bring more problems in utilizing their emotions. Most of the suicides have been quoted in postschizophrenic depression or when they are gaining insight (Sharaf et al., 2012). Such problems make schizophrenic patients more vulnerable to depression, leading further to suicide. Kee et al. (2009) highlighted that complexity with emotional intelligence in patients with schizophrenia let them feel extreme level of difficulty to manage and adjust to the society, or follow norms of the society. In this study, significant negative correlation was found between the ability to manage emotions in self (but not in others) with the CDI. Total scores on MSREIS-R were significant but negatively correlated with the CDI. But the CDI showed no correlation with the ability to utilize emotions or with the ability to express and appraise emotions. Low emotional intelligence of patients with schizophrenia is an accumulative result of the underlying disease over time. It is the ability to perceive feelings and thoughts through proper and appropriate words, discriminating between real and unreal emotional expression and utilize emotions for personal growth (Mayer & Salovey, 1997). However problem in the ability of management of emotions in self was the only component found associated with CDI in the present study. Thus, the present findings support the association between emotional intelligence and Exner’s special indices to some extent. The present study has further attempted to explore the possibility of associations between the deficits in emotional intelligence and special indices because the deficit in emotional perception and processing have been extensively documented in schizophrenia and have also been associated with poor psychosocial functioning. Conclusion: The aim of the study was to explore associations in emotional intelligence and Exner’s special indices on Rorschach in patients with schizophrenia. The results revealed that two components of emotional intelligence (a) ability to utilize emotions and (b) to manage emotions in self were significantly reflected on following Exner’s indices:

(i) Suicide constellation, (ii) Depression Index, and (iii) Coping Deficits index. These three indices are linked with underlying affective spectrum of sadness which could be represented as follows: coping deficits lead to depression which in turn leads to suicidal thinking. There is a need to further examine the role of above two components of emotional intelligence in depression not only in persons with schizophrenia but also in other population. Whether the problems in ability to utilize emotions and manage one’s own emotions serve as risk factors for severe emotional problems like depression, need to be established empirically. This may further help in identification of at-risk population and providing psychosocial support for primary prevention. The sample included all subtypes and only male participants limiting generalization.

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Bender-Gestalt Test Usage Worldwide: A Review of 30 Practice-based Studies Chris Piotrowski The Bender-Gestalt Test (B-G) has long been a standard measure in the assessment of perceptual-motor integration and frequently relied upon by psychologists and psycho-educational specialists. Historically, this instrument has ranked amongst the top tests in clinical usage. Moreover, this rather unique test has been adapted for multidimensional purposes, such as a neuropsychological screening indicator and as a projective technique. It is for these latter functions that the B-G has garnered much criticism in the clinical literature. The past 2 decades have witnessed a steady stream of condescending commentary directed largely on the lack of psychometric credibility of individual projective methods. Piotrowski (2015a), in an exhaustive review of surveybased studies, found that the major projective methods continue to be amongst the top tests used in practice; however, the B-G Test was not included in the analysis. In order to address this gap, the intent of the current study is to determine whether the collective movement against ‘drawing’ techniques has had a deleterious impact on the professional use of the B-G in practice worldwide. To that end, the author identified, through an extensive literature review, published survey research that reported on test usage patterns from 1992-2015. The 30 identified studies, from nations around the world, served as the data pool to ascertain the extent of use (or disuse) of the B-G Test by mental health practitioners. Although the majority (70%) of samples was from the USA, other countries (e.g., South Africa, UK, Spain, Belgium, Brazil) were represented. This analysis showed that the B-G was ranked amongst the top 10 tests, in terms of usage, in 15 of the 30 studies. However, it appears that in the USA the test has been used more commonly by school psychologists for psychoeducational purposes, whereas overseas the B-G is relied upon more as a clinical instrument. Moreover, this review indicates that the B-G seems to be used moderately in neuropsychological assessment. Since 2008, survey-based studies suggest a slight decline in reliance on the B-G as an assessment tool; however, this trend may be tentative and awaits further study. Overall, the findings of the current analysis confirm continued use (albeit to a lesser degree than 20 years ago) of the Bender-Gestalt Test among mental health practitioners worldwide, despite the onslaught of perennial criticism regarding projective techniques in the research literature. Thus, the general conclusion is that practitioners tend to a) ignore ‘biased’ critiques regarding specific tests in the literature, b) find the B-G particularly amenable when evaluating children, c) find the B-G useful in generating working-hypotheses, d) rely on the B-G as a brief, rapid-assessment diagnostic tool, and/or e) rely more on an idiographic versus nomothetic approach. The Bender-Gestalt Test (B-G, hereon) has garnered much research attention, and modifications to the original test have appeared over the past decades (Brannigan& Brunner, 2002; Brannigan& Decker, 2006; Piotrowski & Keller, 1992; Reichenberg& Raphael, 1992). Although the extent of clinical use of the B-G has been reported earlier (e.g., Piotrowski, 1995), a review of recent research regarding usage, since the introduction of the Bender-Gestalt II, has not appeared. Thus, the aim of the current study is to address this gap in the literature. Historically, the B-G has ranked amongst the most popular psychological tests in the clinical armamentarium of mental health practitioners. For example, Sundberg (1961), Lubin et al. (1984), and Piotrowski & Keller (1989), in national surveys on test use in mental health facilities in the USA, all reported the B-G to rank 3rd amongst a myriad of testing instruments. In fact, one survey found the B-G to be ranked #1, based on surveys of psychologists (see Piotrowski, 1978). In a review of published surveys in the 1980s, Piotrowski et al. (1993) found that the BG ranked amongst the top 10 tests. It must be noted that the B-G has been warmly embraced by school psychologist for psychoeducational evaluation purposes (Goh et al., 1981). In a study on assessment in adolescent populations, Archer et al. (1991) reported that the B-G ranked 4th a Chris Piotrowski, University of West Florida, USA, Email: cpiotrowski@uwf.edu Key Words: Bender Gestalt Test

a test for inclusion in standard test batteries. Moreover, this popularity was mirrored by academic training programs, where the BG was touted as a prominent test in clinical and internship training (Durand et al., 1988; Piotrowski & Belter, 1999; Wade & Baker, 1977). However, more recent data of graduate education settings indicate that training emphasis with the BG has drastically declined over the past decade; for example, Neukrug et al. (2013) reported that the BG was ranked #31 by training faculty, and Ready and Veague (2014) found little faculty interest in any of the projective techniques. In an analysis of studies regarding professional psychology training, Piotrowski (2015b) found a precipitous decline in educational training emphasis with projective techniques since 2005. This decline, I would argue, to some extent reflects the perennial criticism bestowed on the general class of projective techniques, evident in the clinical literature over the past 2 decades (see Garb et al., 2002; Hunsley& Bailey, 1999; Lilienfeld et al., 2000; Motta et al., 1993; Wood et al., 1996). However, other researchers, in reviewing meta-analytic studies, have reported positive differential diagnostic outcomes regarding several projective tests (e.g., Kahill, 1984; Kubiszyn et al., 2000; Mihura et al., 2015; Piotrowski, 1999). Despite the onslaught of condescending critique regarding ‘drawing’ techniques in assessment (Lally, 2001, 2003; Mahmood, 1988; Motta et al., 1993; Smith & Dumont, 1995; Ziskin, 1995), research interest in the B-G has not waned, as reflected by advancements and modifications to the test itself. In fact, investigatory study on the B-G has been rather robust (see Table 1) and evident in recent active research endeavors worldwide. Moreover, Piotrowski (2015a), in an extensive review of 28 survey-based studies over the past 2 decades, reported on the continued popularity and usage of the major projective techniques. Thus, in order to gain a contemporary perspective on the status of the BG in professional practice settings, particularly when the clinical stature of projective techniques in training settings has severely declined, the current review of the B-G seems warranted. Method: A bibliometric analysis of the extant literature, targeting survey-based studies reporting on test usage of drawing techniques (including the B-G), was conducted via a systematic search of the database PsycINFO (published by the American Psychological Association), as this research repository is considered the leading scholarly file of research in the social and behavioral sciences worldwide. This search identified 30 published studies since 1992 that appear in journals, based on clinician/practitioner samples worldwide. Findings: This section discusses the findings on usage of the Bender-Gestalt Test across assessment domains reported in 30 surveytype studies of either practicing psychologists, mental health practitioners, school psychologists, or mental health settings worldwide since 1992. Table 2 presents a summary of the country of origin, Table1: Major Investigatory Aspects of References on the Bender Gestalt Test Indexed in PsycINFO Publication Type N Journal article Dissertation Text/edited book Methodology (Journal articles) Empirical analysis Quantitative approach Literature review Clinical case study Qualitative study Age Group Children (1-12 yrs. of age) Adolescents (13-17 yrs. of age) Adult (18+ yrs. of age) Aged (65+ yrs. of age)

samples surveyed, and extent of test use. In general, the overall analysis indicates that the B-G is continuing to be used (to some degree) in the majority of countries surveyed over the past 20 years. In fact, in 50% of these studies (n=15), the B-G was ranked amongst the top 10 tests in terms of usage. Due to its amenability and flexibility, the B-G appears to be quite popular in assessment of children, and thus used frequently by school psychologists historically (Goh et al., 1981). However, it appears that the test is used less for intellectual (IQ) or cognitive assessment, social-adaptive evaluations, or in neuropsychological testing. Moreover, there appears be a slight decline in reliance on the B-G in assessment practice since 2008. It is difficult to ascertain whether this recent deemphasis on the B-G is a reflection of scholarly criticism or the impact of the proliferation of ‘newer’ psycho-educational instruments available commercially (and in published studies) to practitioners. Based on scholarly interest, however, it must be noted that research activity on the B-G Test continues to be rather robust worldwide; i.e., in Argentina (Cesar & Ryan, 2013), Brazil (Keppeke et al., 2013; Sisto et al., 2010), Turkey (Ozer, 2011), Japan (Murayama et al., 2007), Germany (Heuer&Hegele, 2015), India (Sulanki& Prakash, 2015), Hong Kong (Chan, 2001), Italy (Mazzeschi& Lis, 2000), Peru (Santos et al., 2014), and Sweden (Bohm et al., 2010). The current analysis supports the view that the B-G continues to be relied upon across diverse psychological practitioner groups, in various clinical settings, for all age groups (children, adolescents, adults), across many countries worldwide, over the past decades. These findings corroborate the continued popularity of and interest in projective assessment and drawing techniques, as evidenced in scholarly books on these select instruments (Dana, 2014; Frick, Barry, &Kamphaus, 2010; Groth- Marnat, 2009; Harwood, Beutler, &Groth- Marnat, 2011). The affirmation on professional and research interest in the B-G Test, based on this extensive analysis of the literature, seems to counter several highlycited studies (e.g., Lilienfeld et al., 2000; Wood et al., 2000) and research compendiums (e.g., Ziskin, 1995) which contend that drawing techniques are moribund in clinical practice, lack psychometric credibility, and should be excised from graduate education and internship training. Conclusion: The current study was designed to provide an objective, data-based approach in determining whether the perennial weight of criticism against projective methods, over the past 2 decades, has impacted usage of the Bender-Gestalt Test in applied settings worldwide. The findings of the analysis indicate that although the B-G may be used selectively for different assessment goals, this multi-dimensional test continues to be a clinical resource in the assessment armamentarium. Perhaps the B-G’s popularity reflects professional clinical interest in ‘drawing’ techniques (e.g., Yama, 1990), or comfort in reliance on nonstandardized assessment tools quite evident in current clinical practice (see Cook et al., 2015). At the same time, the evidence suggests that many practitioners embrace the merits of the B-G as a non-threatening ‘introduction’ tool to formal assessment, as a ‘brief-assessment’ diagnostic tool, and as a generator for ‘working’ hypotheses in clinical assessment (Basu, 2014; Piotrowski, 1985). In this context, the B-G may support the multimethod assessment model espoused by contemporary testing proponents (i.e., Hopwood & Bornstein, 2014). Finally, updated studies on test use patterns and test coverage in graduate-level education in countries not represented in the current analysis would be a welcome addition to the literature (see Cheung, 2004; Boucherat- Hue, 2001; Datu, 2013; Ogawa & Piotrowski, 1992; Poortinga et al., 1982; Schober, 1977).

Table 2: Summary on Professional Use of the Bender-Gestalt Test across 30 Survey-based Studies (1992-2014) Study Country Sample Findings Hutton et al. (1992) USA 389 members of the National Association of School Psychologist (NASP) In the area of Personality assessment, the B-G ranked 6th (used by 17% of sample); In the area Perceptual-motor evaluation, the B- G ranked #1 (used by 60% of sample). Kennedy et al. (1994) USA School psychologists The B-G ranked 2nd; used primarily in assessment of cognitive/perceptual style rather than social-emotional functioning. Stinnett et al. (1994) USA 123 members of the National Association of School Psychologists (NASP) The B-G ranked #1 in the area of perceptual-motor assessment; #16 in behavioral-social-emotional evaluation; but not ranked highly for intellectual-cognitive assessment. Chan & Lee (1995) Hong Kong 50 practicing psychologists in 1993 The B-G ranked 2nd for educational psychologists, but dropped to 13th place for clinical psychologists. Watkins et al. (1995) USA 412 clinical psychologists The B-G was ranked 7th. Wilson &Reschly (1996) USA 251 members, listed in the National Association of School Psychologists (NASP), who were ‘practitioners’; survey data obtained in 1992 Amongst a variety of tests, the B-G ranked 3rd (behind the Wechsler IQ Scales and ‘structured observation’). Lees-Haley et al. (1996) USA 100 forensic neuropsychology experts The B-G ranked 7th; used by 34% of the respondents. Ackermann & Ackermann (1997) USA Practitioners in courtrelated settings The B-G was ranked 13th. Frauenhoffe r et al. (1998) USA Surveyed 487 mental health practitioners (psychologists, counselors, social workers) The B-G ranked #4 for psychologists and # 10 for mental health counselors in terms of usage. Piotrowski et al. (1998) USA 137 practitioners in National Register of Health Service providers in Psychology In terms of ‘importance to practice’, the B-G was ranked 11th by respondents. Muniz et al. (1999) Spain, Portugal, & Latin America Test use by Practicing psychologists B-G ranked 6th in terms of overall use in testing practice. Boccaccini& Brodsky (1999) USA 80 practicing forensic psychologists; use in personal injury cases B-G was not ranked amongst the top 11 tests. Viljoen et al. (1999) South Africa 61 practicing psychologists; attitudes 60% of the sample reported disinterest in assessment; deficits in training in many

toward their clinical training mental health testing instruments were noted, including the need for advanced training on the BG Test. Camara et al. (2000) USA 179 practitioners, mostly psychologists The B-G was ranked highly (5th) by clinical psychologists, but infrequently (25th) by neuropsychologists. Archer & Newsom (2000) USA 346 psychologists, working with adolescents Amongst many reported tests, the B-G ranked 22nd on use in practice. Boothby & Clements (2000) USA Correctional (prison) psychologists The B-G was ranked 4th in terms of usage. Muniz et al. (2001) European (Spain, UK, Holland, Slovenia, Croatia, Belgium) 3,455 professional psychologists use of psychological tests Overall, the B-G was amongst the top 10 tests, and used by about 27% of practicing psychologists in both Croatia and Slovenia; not highly ranked in the UK, the Netherlands, and Belgium. Bow et al. (2002) USA 84 psychologists, assessment practices with parents in child custody disputes Although the B-G was not discussed specifically, projective drawings were considered the most useful diagnostic aid in allegations of child sexual abuse. Lally (2003) USA 64 Diplomate-status forensic psychologists, test use in court-related evaluations Although the B-G was not mentioned specifically, projective drawings were considered ‘unacceptable’ by 95% of sample. Palmiter (2004) USA Surveyed 309 psychologists, psychiatric social workers, & counselors regarding child assessment Although specific tests were not reported, objective rating scales were predominantly used; 20% of sample did not considered research findings on tests very important. Bekhit et al. (2005) England 158 British clinical psychologists 50% of sample use projective drawings, but only ‘informally’ in the assessment process; the B-G was not noted specifically. de Oliveira et al. (2005) Brazil 35 professional psychologists The B-G was ranked 2nd in terms of clinical usage. Hojnoski et al. (2006) USA 170 school psychologists reported use of projective tests About one-third (38%) use projective assessment; the B-G ranked 2nd in usage. Archer et al. (2006) USA 152 forensic psychologists’ use of projective techniques in court-related assessments B-G ranked 3rd in the neuropsychological assessment category. Herzberg & Mattar (2008) Brazil Clinical psychology faculty use of projective tests in practice, University of Sao Paulo Overall, 87% of sample use projective techniques, a decrease from a decade earlier. The B-G ranked 14th in terms of usage. Smith et al. USA 404 members of the Findings indicated that personality

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Measuring Child and Adolescent Psychiatric Treatment Outcomes: The Development and Validation of the Symptom Acuity Rating Scale David J. Sperbeck and M. Andrew Mayo Use of psychiatric treatment outcomes is critical to informing treatment, revising care plans, and determining criterion for placement in levels of acute, sub-acute, or residential care. As such, psychiatric treatment outcomes are widely recommended but seldom implemented due to the lack of consensus about the meaning and therefore measurement of mental illness, especially among children and adolescents. A systematic review of published and unpublished research revealed a lack of a comprehensive and standardized assessment tool for establishing and tracking psychiatric symptom acuity among children and adolescents referred for intensive psychiatric treatment. The current studies sought to identify patient symptom domains responsible for referral to an acute children’s psychiatric hospital. These patient symptom domains were empirically derived by identifying the most prevalent admission precipitants for 3,150 patients admitted to an acute children’s psychiatric hospital in Anchorage, Alaska over a five year period (2005-9). Sixty-three (63) primary symptoms resulting in hospital admission were synthesized by factor analysis into 9 clinical domains (high risk behaviors, affective instability, social dysfunction, family functioning, aggression, self-harm, academic problems, cognitive dysfunction, and outpatient treatment failures). Trained mental health clinicians rated each of the 63 symptoms for 194 patients according to clinical acuity ratings using a 5 point Likert-scale. (Inter-rater reliability and testretest reliability correlations across the nine clinical domains ranged from .0987-1.00. Cronbach’s Alpha measures at posttest ranging between .709-.899 suggested high levels of internal consistency and reliability within the 9 clinical domains). A total of 194 children aged 5-17 years old were subsequently rated for their symptom acuity both at admission and at discharge by the same rater. Pre-post (i.e. admission-discharge) data comparisons suggested differential rates of improvement in psychiatric symptom acuity based upon age and length of stay, with statistically and clinically significant improvements noted in all clinical referral domains rated, with the most significant improvements occurring in the areas of reduced suicide potential, improved family communication, improved behavioral control, and improved mood instability. Implications for clinical practice suggest that the SARS is a reliable instrument for informing: clinical treatment care plans, length of stay, levels of care, clinical supervision issues, and hospital treatment program development. Background: The efficacious use of child and adolescent psychiatric treatment resources has become increasingly urgent in recent years due to the escalating costs of medical care (Barber, Neese, Coyne, Fultz, &Fonagy, 2002). Identifying and implementing reliable and valid measures for evaluating psychiatric treatment outcomes has become especially crucial for informing acute psychiatric hospitalizations, revising care plans, and determining levels of aftercare. Further, the use of psychiatric treatment outcome measures is frequently used to determine client eligibility for services (Hodges, Wong, & Latessa, 1998) and may eventually serve as the basis for providers’ reimbursement rates. In addition, cost-containment strategies employed by managed-care organizations, public and governmental health agencies, and private insurance companies raise consumers’ concerns about the possible decline in the quality of clinical services delivered (Lambert, Salzer & Bickman, 1998). Mental health agencies and providers at all levels of care and acuity need to be able to assess the effectiveness of their clinical services in order to ensure consumer confidence and compliance with ongoing treatment recommendations. Unfortunately, very few psychiatric treatment outcome measures exist that reliably assess the wide range of psychopathy presented in children and adolescents (Hodges and Wong, 1997). David J. Sperbeck, Ph.D. Clinical Professor of Psychiatry & Behavioral Sciences and M. Andrew Mayo, Ph.D.Asst Clinical Professor of Psychiatry & Behavioral Sciences, University of Washington School of Medicine, WA 98195 (Correspondence to the authors at North Star Behavioral Health Hospital, 2530 Debarr Road, Anchorage, Alaska 99508. Email: to David.Sperbeck@UHSINC.com. Or Andy.Mayo@UHSINC.com). Key Words: child and adolescent psychiatric treatment outcomes, Symptom Acuity Rating Scale

Traditionally, instruments such as the Children’s Depression Inventory (Kovacs, 1992) or the Child andAdolescent Functional Assessment Scale (Hodges & Wong, 1997), both widely-accepted and valid instruments that have been used to evaluate the efficacy of psychiatric treatment with children and adolescents, have been noted to be narrowly focused and difficult to administer to a broad range of child and adolescent psychopathology (Barber et al., 2002; Gale, Pfefferbaum, Suhr, & Overall, 1986). Too narrow of a focus in assessing psychiatric treatment outcomes can result in false negative or false positive findings which fail to identify critical secondary and tertiary factors related to the child’s condition due to diagnostic oversimplification. Too broad of a focus in outcome studies can likely result in false negative findings due to the lack of specificity in the identified symptoms targeted for study (Henderson et al., 2010). Attempts have been made to address some of these issues by creating broader but better-informed measures such as the Target Symptom Rating (TSR), which increased the number of informants (e.g. patients, parents, clinicians, etc.) and shortened the period of time during which ratings were based (Barber et. al., 2002). The TSR, which consists of 5 point ratings for 13 targeted symptoms (family conflict, peer relationships, school difficulties, depression, anxiety, psychosomatic problems, suicidality, selfdestructive behaviors, aggression, substance abuse, psychotic symptoms, runaway problems, and impulsivity), has been demonstrated to be sensitive to change in brief and extended treatments as rated by parents, patients, and primary clinicians (Barber et al., 2002). Despite efforts to strengthen existing measures or create more informed and targeted approaches to assessing treatment outcomes, current standardized psychiatric treatment outcome measures for children and adolescents remain narrowly focused and/or fail to adequately capture the clinical problems represented by a large and diagnostically heterogeneous children’s psychiatric hospital population. Problem: Alaska is a geographically and culturally diverse region with minimal availability of acute psychiatric resources for children and adolescents. North Star Behavioral Health Hospital, located in Anchorage, is the only acute psychiatric hospital specifically dedicated to Alaskan children and adolescents. As such, the diagnostic problems presented upon admission to this facility are often complicated by significant cultural, neurodevelopmental, regional, socioeconomic, and ethnic variables. Additionally, these clinical demographics are further complicated by a highly transient military, seasonal, and youthful workforce, all of whom usually serve as the primary caregivers of most child and adolescent patients admitted for treatment. Attempts to assess reliable and clinically relevant psychiatric treatment outcomes following acute psychiatric inpatient hospitalizations (average length of stay = 30 days) had been plagued by the aforementioned narrowly focused outcome measures previously reviewed. As such, a rating scale was developed that comprehensively and empirically defined the diagnostically diverse population served by this hospital. Method: Study 1: Identifying SARS Target Symptoms & Establishing Content Validity: Participants for this study consisted of 3,150 patients admitted to a private inpatient psychiatric facility with 110 acute beds between January 2005 and December 2009. Participants ranged from 4 years to 17 years old with a mean age 13.2 years (SD= 3.0). Forty eight percent of the sample was male. Ethnic composition of the sample consisted of 38% Caucasian, 33% Native Alaskan, 5% Hispanic, 4 % African American, 4% Pacific Islanders, 3% multi-racial, and the remaining 13% composed of other ethnic groups. Symptom Acuity Rating Scale (SARS): 83

Participants’ average length of stay in the acute psychiatric facility was 31.8 days (SD=2.5) and ranged 25-38 days. Seventy eight percent of had no previous psychiatric hospitalizations. The primary diagnosis received by study participants and assigned at admission by the admitting psychiatrist was Affective Disorders (42%), Disruptive Behavior Disorders (22%), Anxiety Disorders (20%), Cognitive Disorder NOS (10%), and Psychotic Disorders (5%). A content analysis of the 3,150 patients’ admission evaluations described above was conducted. The targeted sample included all male and female patients admitted to the acute psychiatric hospital from ages 4-17 years old with a general length of stay of at least 30 days in the acute hospital setting. The three primary presenting symptoms resulting in the clients’ hospital admission were identified and tabulated for participant. A total of 63 primary symptoms were identified. These 63 primary symptoms accounted for more than 98% of the patients admitted to the acute hospital setting. These 63 primary symptoms comprised the basis of the Symptom Acuity Rating Scale (SARS, Appendix A). The process of empirically deriving clinical symptoms through content analysis of 3,150 admission summaries contributes to the content validity of the SARS to the extent that content validity is the degree to which elements of an assessment instrument are relevant to and representative of the targeted construct for a particular assessment purpose (Haynes, Richard, &Kubany, 1995). Study 2: Establishing Convergent/Concurrent Validity & Inter-rater Reliability of the SARS: Trained primary clinicians were asked to rate 194 of their patients (ranging in age from 4- 17 years old) at admission (i.e., pretreatment) and at discharge (i.e., posttreatment) following 30 days of acute inpatient psychiatric treatment on each of the SARS 63 primary symptoms using a 5-point Likert-scale (0-no acute problem, 4-very serious acute/consistent problem). Administration of the 63 SARS item ratings averaged between 15-25 minutes per client, depending upon client characteristics such as the client’s age, verbal skills, cooperativeness, and maturity level. Inter-rater reliability assessment of the SARS was accomplished by having two clinicianraters independently score each client’s response to the instrument.. Pearson product-moment correlation coefficients between paired independent ratings of the same clients provided a measure of consistency with which the clinical phenomena were observed and evaluated. The inter-rater reliability correlation coefficients in this study ranged from .0987- 1.00 (See Table 1). Table 1: Inter-rater Reliability Pearson r SARS Clinical Domain Pearson r High Risk Behavior .991 Affective Instability .997 Social Dysfunction .992 Family Functioning .990 Aggressive Behaviors .987 Self- Harm Behaviors .994 Academic Problems .993 Cognitive Dysfunction .997 Outpatient Treatment Failures 1.000 Additionally, to assess convergent validity, these same 194 clients who completed the SARS were also administered the Columbia Impairment Scale (CIS), the Depression, Anxiety, and Stress Scale (DASS), and the Brief Psychiatric Rating Scale for Children (BPRS-C) at both admission and discharge. A factor analysis of the original 63 targeted symptoms by the SARS instrument yielded 9 clinical domain factors: High Risk Behaviors, Affective Instability, Social Dysfunction, Family Functioning, Aggressive Behaviors, Self-Harm Behaviors, Academic Problems, Cognitive Dysfunction, and Outpatient Treatment Failures. From a convergent validity perspective, these nine empiricallyderived clinical domains were remarkably similar to the theoretically/clinician-derived 13 targeted symptom domains identified on the Target Symptom Rating by Barber et al., 2002). Additionally, Cronbach’s Alpha

measures at posttest ranged between .709- .899, suggesting high levels of internal consistency and reliability within the SARS’ nine clinical domains. Concurrent validity of the SARS was assessed through correlation studies conducted between the SARS’ nine clinical domains and the CIS, DASS, and the BPRS- C. Pearson r correlations between the SARS domains of High Risk Behaviors, Self-Harm Behaviors, Affective Instability and Aggressive Behaviors were moderately (r >.20-.39) and strongly (r > .40 or higher) related to the DASS and BPRS-C at pretreatment and post-treatment respectively. Likewise, the SARS domains of Social Dysfunction and Family Dysfunction were strongly (r>.40 or greater) related to the Columbia Impairment Scale. Study 3: Establishing the Ability of the SARS to Detect Treatment Effects: Trained primary clinicians used the SARS to rate 269 children from 4-17 years old both at admission and at discharge following a 30- day acute hospital stay in order to assess clinical acuity changes as a consequence of treatment during their inpatient treatment. Table 2 summarizes the results of the two way (pre-treatment vs. post-treatment) ANOVA studies for all nine SARS clinical domains (N=269). Table 2: 2-Way ANOVA for SARS Clinical Domains Clinical Domain df Within Main Effect (Improvement from Admit to discharge) Two-Way Interaction Time x Unit F Value p F Value p High Risk Behaviors 132.215 .000* 1.014 .387 Affective Instability 101.557 .000* 0.978 .403 Social Dysfunction 124.021 .000* 4.898 .002* Family Dysfunction 74.899 .000* 1.970 .119 Aggressive Behaviors 143.381 .000* 2.578 .054 Self- Harm Behaviors 143.269 .000* 5.315 001* Academic Problems 44.139 .000* 1.931 .125 Cognitive Dysfunction 13.445 .000* 3.748 .012* Outpt. Treatment Failures 22.502 .000* 1.238 .297 *Denotes a significant effect A review of the main effects reflects that for all nine clinical domains, clients were significantly less impaired after treatment/discharge than at the time of admission as assessed by the SARS. A closer examination of the SARS’ clinical utility was made by analyzing pre- and posttreatment effects as a function of treatment unit location, i.e., Children’s Unit (ages 4-7 years), Preteen Unit (ages 8-12 years), Adolescent Girls Unit (ages 13-17 years), and Adolescent Boys (ages 13-17 years). Post hoc comparisons between treatment units using Cohen’s d revealed that the magnitude of improvement was fairly consistent across all four units on five scales: High Risk Behaviors, Affective Instability, Family Dysfunction, Academic Problems, and Outpatient Treatment Failures. However, the magnitude of improvement differed significantly (p<.05) across units on three scales (Social Dysfunction, Self-Harm Behaviors, and Cognitive Dysfunction) and differed marginally (p< .051) across units on one scale, Aggressive Behaviors. Unanticipated findings observed repeatedly throughout Studies 2 & 3 were reports from primary clinicians that conducting the SARS ratings forced them to closely examine clients in clinical domains that typically would not be the focus of inquiry at admission in every case. That is to say, traditional admission screening efforts would usually focus upon the 2-3 specific areas triggering the clients’ referral for inpatient care. However, when forced to inquire into all nine Symptom Acuity Rating Scale (SARS): 85

clinical domains, primary clinicians often rated areas that were not the initial focus of the client’s acute problem as acute and consistent problem areas which could and at times should be the focus of treatment. In fact, in many cases, the SARS instrument compelled clinicians to address otherwise unintended foci, and thereby guide and drive a more well-informed and comprehensive treatment plan. Discussion: The present study had three main findings. First, a content analysis of the principal factors leading to the psychiatric hospitalization of 3,150 children yielded 63 acute symptoms accounting for more than 98% of the patients observed. A factor analysis of these 63 symptoms demonstrated 9 clinical domains defined as High Risk Behaviors, Affective Instability, Social Dysfunction, Family Functioning, Aggressive Behaviors, Self-Harm Behaviors, Academic Problems, Cognitive Dysfunction, and Outpatient Treatment Failures. Secondly, SARS clinical domains theoretically related to the DASS and the BPRS-C (i.e. High Risk Behaviors, Self-Harm Behaviors, Affective Instability, and Aggressive Behaviors) were moderately to strongly correlated to the DASS and the BPRS-C. Further evidence of the SARS’ concurrent validity was obtained by the strong correlations observed between the SARS Social Dysfunction and Family Dysfunction domains and the CIS. Thirdly, despite concurrent validity between the SARS and extant instruments assessing similar clinical phenomena in this population the data presented demonstrated that the SARS instrument can uniquely serve as a brief, reliable, and valid clinical rating instrument for assessing changes in children and adolescents over a 30-day period of acute psychiatric hospitalization along the nine clinical domains noted above in ways that drive and guide pertinent clinical decision-making for serving this population. Based upon the ANOVA main effects data presented, the empirically-derived symptoms which comprise the nine clinical domains of the SARS appear to be highly sensitive to assessing therapeutic changes in clients following a 30-day psychiatric hospitalization. Interactive effects based upon treatment units, age of patient, nature of symptom cluster, and static vs. dynamic clinical problems require further study. However, it is clear that when trained primary clinicians are asked to assess their clients at admission and later at discharge, the SARS is a useful instrument for providing a valid and reliable assessment of significant changes in symptom acuity necessary for appropriate treatment planning and decisions regarding discharge. Implications: The principal benefits of employing an objective, reliable, and valid outcome measure such as the SARS both at the onset of an acute psychiatric hospitalization and for determining discharge include: 1. the fact that when primary clinicians review and rate their clients at admission along 63 symptom dimensions comprising nine major clinical domains, the primary clinician is more thoroughly informed and therefore able to provide a more accurate and comprehensive intake assessment and treatment plan by incorporating the SARS ratings; 2. SARS data at discharge can provide an objective, reliable, and valid psychiatric treatment outcome measure for both individual clients as well as their post-discharge guardians and aftercare providers; 3. aggregate SARS data can serve as a basis for treatment program development and/or enhancements and can inform clinical supervision activities by identifying areas where post-treatment changes in acute symptoms identified at admission were clinically and statistically negligible; and 4 aggregate SARS data can be used for making prudent resource allocation in healthcare organizations to ensure maximal benefits are provided to the clients they serve.

References: Barber, C.C., Neese, D.T., Coyne, L. Fultz, J. &Fonagy, P. (2002). The target symptom rating: A brief clinical measure of acute psychiatric symptoms in children and adolescents. Journal of Clinical Child Psychology, 31, 181-192. Gale, J., Pfefferbaum, B., Suhr, M.A., & Overall, J.E. (1986). The brief psychiatric rating scale for children: A reliability study. Journal of Clinical Child Psychology, 15 (4), 341-345. Haynes, S.N., Richard, D.C.S., &Kubany, E.S. (1995). Content validity in psychological assessment: A functional approach to concepts and methods. Psychological Assessment, 7 (3), 238-247. Henderson, L., McIlhaney, K., & Wasser, T. (2010).Measuring outcomes of multiple diagnosis groups in residential treatment using the brief psychiatric rating scale for children (BPRS- C).Children and Youth Services Review, 32, 98-102. Hodges, K. & Wong, M.M. (1997).Use of the child and adolescent functional assessment scale to predict service utilization and cost.The Journal of Mental Health Administration, 24 (3), 278-290. Hodges, K., Wong, M.M., &Latessa, M. (1998).Use of the child and adolescent functional assessment scale (CAFAS) as an outcome measure in clinical settings.The Journal of Behavioral Health Services & Research, 25 (3), 325-336. Kovacs, M. (1992).The Children’s Depression Inventory. New York: Multi-Health Systems. Lambert, W, Salzer, MS., Bickman, L (1998) Clinical outcome, consumer satisfaction & ad hoc ratings of improvement in children’s mental health.Journal of Consulting and Clinical Psychology, 66 (2), 270-79 Acknowledgement: The authors wish to acknowledge the contributions made to this study by M. Nelson, LCSW, C. Cavanaugh, M.A, J. Fitterling, Ph.D, J. Petraitis, Ph.D, & C. Lampman, Ph.D. Financial support for Studies II & III was provided by Universal Health Services, Inc. Symptom Acuity Rating Scale (SARS): 87

Cognitive Behaviour Therapy in Social Phobia- A Case Study Soheli Datta and Sanjukta Das Cognitive Behaviour Therapy (CBT) is one of the most practised forms of psychotherapies for the treatment of patients suffering from social phobia. The present case study is an attempt to provide therapeutic intervention programme to a 21 years old, unmarried female client suffering from social phobia. The patient was treated by using Cognitive Behavioural techniques. However, most of the therapy structures are based on western culture where it was difficult to practice in Indian culture; hence a deviation in the format was made to suite the culture. The presenting symptoms, assessment strategies and treatment elements have been covered in details. After 15 sessions of therapeutic intervention, significant improvement was noticed. The sessions include assessments, psycho-education, cognitive restructuring and relaxation training. Social Phobia is a disorder consisting of marked and persistent fear of encountering people, usually in small groups; or doing certain acts in a public place. They often suffer from fear of being humiliated, embarrassed, or judged negatively in social situations. They may fear that they will behave inappropriately or possibly be scrutinized by others. Typical situations that are avoided or endured with distress are initiating or maintaining a conversation; speaking, performing, eating, drinking, or writing in front of people; meeting new people; attending social gatherings; and talking on the phone. Many of them experience psychological symptoms of poor self-confidence, show anxiety on trifles and may be very conscious of some physiological or psychological defect in them, as a result, they may develop secondary depression. Muscle twitches, blushing, dry mouth, heart racing, sweating, and trembling often occur as part of a fear reaction to social situations (Amies, Gelder, & Shaw, 1983). Social Phobia is the third most common mental disorder in adults worldwide, with a lifetime prevalence of at least 5%. There is an equal gender ratio in treatment settings; but in catchment area surveys, there is a female preponderance of 3:2. Affected individuals are more likely to be unmarried and have a low socio-economic status. Social fears and phobias evolved as a byproduct of dominance hierarchies among animals such as primates (DimbergandOhman, 1983). Humans have an evolutionary based predisposition to acquire fears of social stimuli that signal dominance and aggression from other humans. Prevalence in relatives of patients with social phobia is high than in other anxiety disorders or with no mental disorder (Knowles, et al, 1995; Stein, 1998). Behaviorally inhibited infants, who are easily distressed by unfamiliar stimuli, are shy and avoidant are more likely to become fearful during childhood and by adolescence show increased risk of developing social phobia (Hayward et al., 2000). Social phobia is also a result of both direct and vicarious classical conditioning such as experiencing or witnessing that target of anger or criticism (Mineka andZinbarg, 1991, 1995). They experience anticipatory anxiety found are found to have increased blood flow in the right dorso-lateral prefrontal cortex, left inferior temporal cortex and left amygdaloidhippocampal region Cognitive theorists are of the view that individuals with social phobia share typical negative beliefs about themselves in social situations. Clark and Wells (1995) assume that individuals with social phobia activate a series of negative beliefs about themselves as social subjects when they are faced with social situation. These assumptions are to likely cause social phobic to perceive threat Soheli Datta, Asst. Professor, Dept of Applied Psychology, Email: datta.soheli@gmail.com, and Sanjukta Das, Ph.D. Asso. Professor, Dept of Psychology, University of Calcutta,Kolkata-700009. Key words: anxiety, social phobia, cognition, behaviour, psychotherapy, relaxation

in such circumstances. These thoughts elicit anticipatory anxiety and avoidance, leading to short-term anxiety reduction. This way, cognitive responses and applied strategies to control increasing anxiety result in a vicious circle that maintains social anxiety. On entering social situations social phobics appraise the situation as dangerous. They believe that they will act in an inapt and unacceptable fashion and such behaviors will have catastrophic consequences in terms of loss of status, rejection, and humiliation by others. In order to prevent social catastrophe safety behaviors are used (Wells et al., 1995). CBT appears to have high success rates in treatment of social phobia and is aimed at training patients in the basic tenets of cognitive therapy, especially the link between faulty assumptions or irrational thinking about social situations and anxiety experienced in those situations (Albano andDiBartolo, 2007; David, 2003; Leichsenring et al., 2009). Rapee and Heimberg (1997) and Clark and Wells (1995) suggested that individuals with social anxiety disorder perceive social situations as dangerous and that the perception of potential evaluation by others initiates a cognitive routine that furthers the experience of anxiety.

This mental representation, which is likely to be negatively distorted, is compared to an estimate of what the person believes may be expected of him or her. As this discrepancy increases in a negative direction, the perceived probability of negative evaluation is increased and he becomes hyper-vigilant for negative external cues(signs of boredom or disinterest from the audience) and internal cues (unpleasant physiological sensations), and these cues further inform the person’s mental representation. The cycle repeats itself, with anxiety increasing as the person continually anticipates negative outcomes, and the situation comes to an end or the person escapes. Thereafter, the person may engage in post-event processing, repeatedly reviewing and reconstructing the memory of the situation in a negative and ultimately maladaptive fashion and is thus posed to experience equal or greater anxiety at the next occurrence of a similar situation. However, interpretation of the social situation varies across cultures and so does the clinical manifestations of the symptoms. Hence deviating from the prescribed CBT structure practiced in the western culture, some changes has been made in the format across the therapeutic process in the present study. Case Description: The patient, a 21 years old female, Bengali speaking Hindu, belonging to a suburban residence and nuclear family type was brought by her parents with the chief complaints of frequent change of decisions and sensitiveness to criticisms for the last 2 years. As per the patient, she is sensitive to criticisms, trembling of hands and feet and difficulty in initiating conversations for the last 2½ years, with increased sleep, decreased appetite and energy and unchanged sexual energy and interest. There was no history suggestive of first rank symptoms, substance abuse, and persistent elevated or depressed mood, features of physical symptoms with no organic basis or any persistent repetitive thought or act. Treatment history was suggestive of her currently being in medication, with past medical illness of chicken pox 1 year before, with no past psychiatric illness. There was no family history of significant psychiatric illness. Personal history revealed pre term caesarean delivery at birth, birth cry present, delay in the attainment of developmental milestones, childhood disorders of school phobia and temper tantrums and average academic performance. Mental status examination revealed well kempt and tidy appearance, presence of touch with surroundings, proper eye contact, cooperative attitude towards examiner, normal motor behaviour, speech being soft, normal reaction time to stimulus, normal speed, normal productivity, relevant,

coherent and goal directed, with intact orientation, sustained attention. General intelligence was assessed to be average, functional abstraction, satisfactory social, and personal and test judgement. Subjective mood was sad and objective affect being anxious, with no disturbances in thought stream, form and possession with thought content revealing ideas of worthlessness and somatic preoccupation, with no perceptual disturbances. Insight was at grade II (slight awareness of being sick but denying at the same time), leading to the provisional diagnosis of Social Phobia. Implementing Cognitive Behavior Therapy (CBT): The purpose of using CBT includes presence of marked cognitive distortions, presence of significant anxiety of client about current problems, presence of avoidance behaviours and the patient was amenable to the use of verbal challenging and logical thinking required for psychotherapy. Areas to be focussed include reduction in the level of anxiety and distress of the patient by getting rid of the current problems, reduction in avoidance behaviours, modification of dysfunctional appraisals and beliefs, correction of negative self-evaluation and cognitive errors, enabling restore self-worth and maintenance of logical pattern of thinking. The Session details are as follows: Sessions 1- 4: The client was accompanied by her parents. Detailed case history and mental status examination was taken from the parents and the client. Therapeutic alliance was establishedwith the client. Major areas of difficulty were identified from both the parents State-Trait Anxiety Inventory (STAI) was administered to rate the client’s current level of state and trait anxiety. Both State and Trait anxiety was found to be within normal range. Hamilton Anxiety Rating Scale (HAM A) wasalso administered which indicated moderate anxiety. Liebowitz Social Anxiety Scale (LSAS) was administered to assess the degree of social anxiety and degree of avoidance. Findings revealed presence of severe social phobia. Beck Depression Inventory (BDI) was administered to rate the client’s current level of subjective distress, which indicated no subjective distress.The scores onHamilton Depression Rating Scale (HDRS) was also found within normal range. Meta-cognition Questionnaire (MCQ): the questionnaire was administered to assess the client’s positive beliefs about worry, negative beliefs about uncontrollability and danger of worry, cognitive confidence, need for control, cognitive self-consciousness. The client’s positive beliefs about worry and negative beliefs about uncontrollability and danger of worry were found to be above average range. Positive and Negative Affect Scale (PANAS) was administered to assess positive and negative affect in the client. Both positive and negative affect was found to be within normal range. Session 5 and 6: Psycho-education on the Disorder: This provides an opportunity to the client to increase her understanding of her own symptoms and the context in which it occur. Psycho-education given to the client on the following topics: How the client’s symptoms matches the diagnosis, what is it, prevalence rates, causes, What is CBT, Need for CBT, role of social support network, protective factors, Importance of homework, Treatment expectations, etc. Session 7-9 (Case Conceptualisation and Cognitive Restructuring): Case formulation was done using the Cognitive Model of Social Phobia. The formulation explains occurrence of the phobia and how it is maintained. When the client is faced with a triggering situation where she has to speak to a group of friends,

she feels a negative belief that she would shake and would not be able to say in an organized way. Her self-conscious is then endorsed with the idea that she might lose control of herself. She then engages in safety behaviours of avoiding the situation, feels tightness in her body and prefers not moving out of her house. Her anxiety features then centres around breathlessness and palpitations accompanied by being trembled. On a 10 point scale, of Subjective Unit of Distress (SUD), starting from 0 – 10, with 0 being having no subjective distress and 10 having the greatest subjective distress, the client was asked to rate her distress on the scale. The client rated 9 out of 10. The client was involved in Socratic Questioning to elicit negative automatic thoughts but gradually she could recognize them and become aware of, thereby, it gave rise to positive statements as outcome. The narration revealed her negative thought, that examination is nearing and she would not be able to appear for it, this is because, unseen and difficult questions would be coming and she would not be able to attempt any questions. She would get very less marks and might get failed. Moreover, she might have to re-appear for the exam and a year would be at loss. She feels that she would lag behind as compared to others. She has a fear that helplessness would grasp her and she would get into depression. On discussing about how to deal with this negative apprehension, she showed hope of getting counselled, which she believed would minimize her depression. Thereby in future she hoped to live and move freely and would appear for the next examination with good preparations. The client was given homework on situations she is facing now-a-days, and where she could do better. Review of home work was done on the next session; the client could manage to write 2 of the situations she faced the last week. A. Getting irritated and jittery: When one keeps on repeating a single thing, I get irritated. However, I must ask the person to stop after saying once. Moreover, this irritability causes anger in me, which I am unable to show hence I get jittery, hence, If not possible, I would possibly leave the place or else I will listen to it immediately. I will face rather than flight and I would bring control to my emotions. B. Lack of motivation and initiative in any tasks: Because of lack of motivation, there is loss of focus on tasks and there is loss of patience as well leading to irritability. I must be motivated enough and pay full attention to the task and try not to leave it unfinished. Irritability gets increased when the task is not done or is left incomplete, I feel that I won’t be able to do the task, I will always remain worthless and a fear is generated towards the task and I have the feeling that others would think I am irresponsible and in future they might doubt before giving me any task. Hence, I must be independent and responsible and would prove that I have the ability like others. SUD recorded on the session was 8. Various behavioural experiments (role playing and reverse role playing) were practised, like how she should- • Wish the teachers • Asking for help from a senior She was then introduced with the thought record form and was given the homework of filling up the thought record form in the following week. SUD was rated to be 7.5 in the following session. Thought record form revealed some of the activating events that were perceived in the preceding week. • When the activating event is travelling on a crowded bus, she feels she would get breathless and won’t be able to come out of the bus and reach home. She rated her emotion to be 90 on fearfulness and 85 on tensions. The consequence being avoiding moving out of the house or ride in a bus. The alternative thought to this was, like, others are travelling comfortably, without getting

breathless; she would also be able to. On this, she rated her emotion to be 20 on fearfulness and 15 on tension. • When the activating event is taking initiative to talk to others, she feels she won’t be able to organize my speech and would get freeze. She rated her emotion to be 70 on fearfulness. The consequence being avoiding talking and socializing with others, specially mates. The alternative thought to this was, like, she would have built in confidence within herself and approach them. On this, she rated her emotion to be 10 on fearfulness. • When the activating event is while going out of the house for a work, she feels she won’t be able to reach her destination. She rated her emotion to be 80 on fearfulness and 80 on tensions. The consequence being avoiding moving out of the house. The alternative thought to this was, she would have moved out of the house as others do day to day in their lives. On this, she rated her emotion to be 80 on happiness and 10 on fearfulness and tension. The client was then explained various metaphors. Therapy metaphors use a story or illustration to see alternative ways of looking at something. Every culture and religion uses these types of stories, analogies to improve understanding, make a point more memorable, and help us make positive changes. Metaphor was used to help get a different view of her thoughts, feelings and self- evaluation. The metaphors used were passengers on the bus, helicopter view, the tunnel, and the circus act. The client was asked to continue with thought recording in the following week. She was then introduced with activity scheduling and was also asked to fill up the forms for the following sessions. Session 10: SUD was recorded to be 6 on the session. Reassessment was done using A. State-Trait Anxiety Inventory (STAI) B. Beck Depression Inventory (BDI) C. Meta-cognition Questionnaire (MCQ) D. Positive and Negative Affect Scale (PANAS) E. Liebowitz Social Anxiety Scale (LSAS) F. Hamilton Anxiety Rating Scale (HAM-A) G. Hamilton Depression Rating Scale (HAM- D) Session 11-14: SUD was recorded to be 6, 5.5, 5 and 5 respectively in the sessions. Review of Thought Record Form revealed • When the activating event is going for shopping, she feels she would be fooled and cheated by shopkeepers. She rated her emotion to be 50 on fearfulness. The consequence being avoiding shopping or else avoid approaching shopkeepers alone. The alternative thought to this was, like, others are shop freely, she would also shop. Getting cheated a few times would make her learn. On this, she rated her emotion to be 10 on fearfulness. • When the activating event is riding a bicycle, she feels that she would fall down and get injured. She rated her emotion to be 30 on fearfulness. The consequence being avoiding riding it and take other means. The alternative thought to this was, if she doesn’t fall a few times, she would never be able to learn. On this, she rated her emotion to be 10 on fearfulness. • Introduction to Jacobson’s Progressive Muscle Relaxation (JPMR): The relaxation response is proposed to involve decreased arousal of the autonomic nervous system and central nervous system as well as increased parasympathetic activity characterized by lowered musculoskeletal and cardiovascular tone and altered neuroendocrine function.In situations of stress, there is increased activity of the sympathetic nervous system, which leads to the "fight or flight" response. Physiologic changes include increased heart rate, blood pressure, rate of breathing, blood supply to the muscles, and dilation of the pupils.

It has been found that frequent stressful situations may lead to negative effects on health, such as high blood pressure, raised cholesterol levels, gastrointestinal distress, or depression of the immune system. In contrast to the stress response, relaxation is characterized by reduced sympathetic nervous system tone and increased parasympathetic activity. This may include decreased metabolism, blood pressure, oxygen consumption, and heart rate, as well as a feeling of calmness. Homework was assigned to practise the steps involving the hand only on the first week, followed by head, face and neck on the second week, back on the third week and abdomen, buttock, legs and feet on the fourth week. Session 15: SUD was recorded to be 4 on the session. Reassessment was done using A. State-Trait Anxiety Inventory (STAI) B. Beck Depression Inventory (BDI) C. Meta-cognition Questionnaire (MCQ) D. Positive and Negative Affect Scale (PANAS) E. Liebowitz Social Anxiety Scale (LSAS) F. Hamilton Anxiety Rating Scale (HAM-A) G. Hamilton Depression Rating Scale (HAM- D) The following Graphical Representation shows Therapeutic Progress based upon scores obtained on different psychological tools administered before the introduction of Cognitive Behaviour Therapy, after sessions and after session. Discussion: Cognitive Behaviour Therapy is a psychotherapeutic approach based upon a basic idea of how one’s thoughts affect one’s mood and behaviour. The treatment is based on a cognitive formulation, the beliefs and behavioural strategies that characterize a specific disorder (Alford and Beck, 1997). Both cognitive and behavioural strategies are employed for dealing with the client’s maladaptive thoughts, feelings and behaviours. The therapy is aimed at decreasing somatic symptoms through sessions on relaxation, increasing confidence to initiate conversations with others, encouraging and conducting more role plays, reverse role plays and behavioural experiments and assertiveness and social skills training. Findings suggest that there Graphical representation of the Therapeutic Progress Before intervention After 5 sessions of CBT After 9 sessions of CBT

has been a decrease in avoidance to social situations, reduction in negative affect, decrease in anxiousness and decrease in negative belief about worry and increase in the need for controlling worry and cognitive confidence. The results of the study are in line with previous studies that indicate the significance of CBT in the treatment of patients suffering from Social Phobia (Ponniah and Hollon, 2007). Psycho-education provide to be useful in understanding the dynamics and features of the client’s problems as well as to enable the client to proceed in positive direction with the help of emotional support. There was both a decrease in distress and anxiety level. Moreover, Jacobson’s Progressive Muscle Relaxation technique was also useful in decreasing anxiety. This is also at par with the findings of David (2003). However, the initial sessions took place with longer gaps, the only reason to it being the client’s uneasiness and unwillingness to move out of her home, the fear being, getting lost and unable to reach back home or getting breathless in a bus. Throughout the therapeutic process, an intricate interplay between culture and social phobia has been recognized. Culture is the source of various cognitive and behavioural elements. The withdrawn behaviours are found to be accepted by the society leading towards a psychopathologic manifestation of social phobia (Dragunsand Tanaka-Matsumi, 2003). The parents quite easily accepted her fear and never forced her to move out alone and always came along her to every place she went. This reinforced her phobia and maintained it. Moreover, in the therapy process it was found that the client involved less in behavioural techniques like homework assignment. Hence more of the cognitive techniques were used first to involve the client in the therapy process. Moreover, in the present collectivistic culture, harmony within the group is the highest priority, and norms and role expectations have a considerable impact on behaviour. Thus, more rules and guidelines for social behaviour possibly exist that make social slips more obvious than in individualistic cultures. This is a source of embarrassment. Here also in the present case, continuous embarrassment confronted by the client at her college, made her get forced to stay at home, avoiding approach to mates and 7.5 5.5 Session 7 Session 8 Session 9Session 10Session 11Session 12Session 13Session 14Session 15 Graphical Representation of changes in SUDs across Therapeutic Process

seniors. Singelis and Sharkey (1995) have suggested that it is easier to embarrass individuals from South-East Asia because more rules for social behaviours exist there. Asian individuals should, therefore, be more concerned and worried about their social behaviour because social deviations are easier to detect. Conclusion: This present case study provides an example of how CBT works with Social Phobia and how it can be effectively treated and intervened. Key ingredients to treatment success included fidelity with flexibility in implementing CBT treatment; attention to individual and cultural factors; the use of creative strategies for carrying out of the underlying theoretical principles of the treatment. The study highlights the efficacy of CBT in the present socio-cultural context and how deviations from pre-determined therapy structure, based on western culture, was involved to bring about a favorable outcome in the client. References: Albano, A.M., DiBartolo, P. (2007). CBT for Social Phobia in Adolescents, Therapist Guide. New York: Oxford University Press. Alford BA, Beck AT: The Integrative Power of Cognitive Therapy. New York, Guilford, 1997 Amies, P. L., Gelder, M. G., & Shaw, P. M. (1983). Social phobia: A comparative clinical study. British J. of Psychiatry, 142, 174–179. Clark, D. M., & Wells, A. (1995).A cognitive model of social phobia. In: R. Heimberg, M. Liebowitz, D. A. Hope, & F. R. Schneier (Eds.), Social phobia: diagnosis, assessment and treatment (pp. 69–93). New York: Guilford Press. David, V. (2003).Treatment of Social Phobia. Advances on Psychiatric Treatment, 9:258-264 Dimberg,U. &Ohman, A. (1983). The effects of directional facial cues on electrodermal conditioning to facial stimuli.Psychophysiology, 20. 160-167 Draguns, JG.., Tanaka-Matsumi, J., Assessment of psychopathology across and within cultures: issues and findings. Behav Res Ther. 2003 Jul; 41(7):755- Hayward, C., Killen, J. D., Kraemer, H. C., & Taylor, C. B. (2000).Predictors of panic attacks in adolescence. Journal of the American Academy of Child and Adolescent Psychiatry, 39, 207-214. Knowles, J. A., Mannuzza, S., &Fyer, A. J. (1995). Heritability of social anxiety. In M. B. Stein (Ed.), Social phobia: Clinical and research perspectives (pp. 147–161).Washington, DC:American Psychiatric Press. Leichsenring, F., Salzer, S., Beutel, M. E., von Consbruch, K., Herpertz, S., Hill4er, W., Hoyer, J., Husing, J., Irle, E., Joraschky, P., Konnopka, A., Konig, H. H., de Liz, T., Nolting, B., Pohlman, K., Ruhleder, M., Schauenburg, H., Stangier, U., Strauss, B., Subic-Wrana, C., Vormfelde, S. V., Weninger, G., Willutzki, U., Wiltink, J., &Leibing, E., (2009). SOPHO-NET- a research network on psychotherapy for social phobia. PsychotherPsychosom Med Psychol, 59 (3-4): 117- 123. Mineka, S., &Zinbarg, R. (1991).Animal models of psychopathology. In C. E. Walker (Ed.), Clinical psychology: Historical and research foundations (pp. 51–86). New York: Plenum Press Mineka, S., & Cook, M. (1995). Expectancy bias as sole or partial account of selective associations?Behavioral and Brain Sciences, 18, 307-309. Ponniah K, Hollon SD: Empirically supported psychological interventions for social phobia in adults: a qualitative review of randomized controlled trials. Psychol Med 38:3-14, 2007 Rapee RM, Heimberg RG: A cognitive-behavioral model of anxiety in social phobia. Behav Res Ther 35:741- 756, 1997 Stein, M. B. (1998). Neurobiological perspectives on social phobia.From affiliation to zoology.Biological Psychiatry, 44, 1277–1285. Singelis TM, Sharkey W. Culture, self-construal, and embarrassability. J Cross Cult Psychol. 1995;26:622–644 Wells, A., Clark, D. M., Salkovskis, P., Ludgate, J., Hackmann, A., &Gelder, M. (1995). Social phobia: the role of in-situation safety-behaviors in maintaining anxiety and negative beliefs. Behavior Therapy, 26,153e161.

Personality Profile and Coping Strategies of Suicidal Attempted Individuals Jashobanta Mahapatra, Narendra N.Samantaray and Aakankshya Mishra The purpose of the present investigation was to find the personality profile and coping strategies of individuals with attempted suicide.Sixty individuals participated in the study out of which thirty had attempted suicide and thirty were normal subjects. It was a purposivesampling. The tools used in the study were NEO – Five Factor Inventory and Ways of Coping Scale. General Health Questionnaire – 12 was also used to screen out individuals belonging to a non-clinical population. The data were analyzed using Mann – Whitney – U test. The result of the present investigation indicates that individuals with attempted suicide were high on neuroticism, and used coping strategies such as confrontive coping, distancing, and escape-avoidance to deal with difficult situation. Suicide is a fatal act that represents the person’s wish to die. About 800,000 people commit suicide worldwide every year (WHO, 2012) out of which 135, 000 (17%) are residents of India (Government of India, 2012). From 1987 to 2007, the suicide rate has increased from 7.9 to 10.3 per 100000 (Vijaykumar, 2007) with higher suicide rates in southern and eastern states of India (Polgreen, 2010). In 2012, Tamil Nadu (12.5% of all suicides), Maharashtra (11.9%) and West Bengal (11.0%) had the highest proportion of suicides. The male to female suicide ratio has been about 2:1 (Government of India, 2012). A broad view of all of the risk factors associated with suicidal behaviour is important for the clinician to consider during the assessment. However, the most important factors are the personal risk factors, including the mental state, impacting on the individual’s life. Hopelessness is one of the main factors mediating the relationship between depression and suicidal intent (Rudd et al., 1994). Some people experience hopelessness may conclude that death is a better alternative than living a life in which they believe there is no hope for positive future. Other cognitive factors that are associated with suicide are problem solving deficits, cognitive rigidity, dichotomous thinking, perfectionism, personalising, and catastrophizing (Öncü & Sakarya, 2013). Faulty coping strategies have often been linked to suicidal behaviour. Studies conducted with adult populations indicate that the use of emotion-focused and avoidant coping are associated with higher levels of suicidal ideation (Edwards & Holden, 2001; Marusic & Goodwin, 2006; Pienaar et al, 2007). The relation of specific coping behaviours to depression and suicidal ideation has also been examined with adolescents and adults. Specific problemfocused strategies such as active coping (Gonzales et al., 2001), help-seeking (Gould et al., 2004), and planning (Aldridge &Roesch, 2008) have been associated with positive outcomes. Behavioural disengagement, which involves giving up the attempt to deal with a situation, is a risk factor and symptom of depression in adolescents (Kaminsky et al, 2006; Wadsworth & Compas, 2002). Self-blame has been associated with depression in adolescents (Fear et al., 2009; Tilghman- Osborne et al., 2008) and suicidal ideation in adults (Ullman &Najdowski, 2009). Denial has also been shown to relate to depressive symptoms in adults (Burker et al., 2005; Kortte et al, 2003). .

Jashobanta Mahapatra,Ph.D. Asso. Prof.& H. O. D, (Email: jashobanta.orissa@gmail.com) and N.N. Samantaray, Cl. Psyst-cum-Faculty, Dept of Clin.Psy., Mental Health Institute, SCB Medical College & Hospital, Cuttack, Email: narendra.samantaray@gmail.com and Aakankshya Mishra, Clin.Psycst, District HQ Hospital Gajapati, Email: aku.mishra04@gmail.com Key words: Attempted Suicide, Personality of Suicidal individuals

Certain personality traits have also been linked to suicidal behaviour. Four main constellations of personality characteristics are associated with suicidal behaviour: impulsivity, hostility– aggression, introversion, and anxiety-neuroticism. A rich body of data details the association between suicide attempts and impulsivity. Impulsivity has been shown to be a risk factor for suicidal behaviour in a variety of adults (Beautrais et al., 1999; Corruble et al., 1999; Oquendo et al., 2004; Michaelis et al., 2004) and adolescents (Fergusson et al., 2000; Kingsbury et al., 1999) with psychiatric illness, in a forensic psychiatric population (Stalenheim, 2001) and in the general population (Grucza et al., 2003). A significant relationship between neuroticism and suicidal ideation has been regularly demonstrated (Fergusson et al., 2000; Statham et al., 1998; Velting, 1999; Kerby, 2003) and the same holds true for neuroticism and attempted suicide (Beautrais et al., 1999; Colson, 1972; Pallis&Birtchnell, 1976; Isherwood et al., 1982; Ashton et al., 1994; Chance et al., 1994). Neuroticism is a higher order trait that measures a predisposition to experience anger, anxiety, depression, guilt, and other negative emotions or cognitions. Objective: The objective of the study was to compare the personality profile and coping strategies of suicide attempted individuals with that of matched normal subjects. Method: Sample: The sample consisted of 60 individuals out of whom were individuals who had attempted suicide and 30 were matched control. The educational qualification of the subjects varied from 12th to graduates. A purposive sampling technique was followed for the collection of sample. The participants were in the age range of 20 – 45 years, married and from middle socio-economic status. The participants were taken from the Mental Health Institute of S.C.B. Medical College and Hospital, Cuttack, (India). Tools: 1. Personality of the participants was assessed using the NEO-Five Factor Inventory. It is the shorter version of the NEO-Personality Inventory. It has 60 questions that measure the Big Five personality traits: Extraversion, Agreeableness, Conscientiousness, Neuroticism, and Openness to Experience. 2. Ways of Coping Questionnaire was used to assess the coping strategies used by the participant in a given situation. The coping scale consists of items arranged in eight scales, by which people generally cope with difficult problems and situations. The eight scales are: Confrontive coping, Distancing, Self-control, Seeking social support, Accepting responsibilities, Escape-avoidance, Planful problem-solving and Positive appraisal. 3. General Health Questionnaire was used to screen out the matched control group. It is a self-report questionnaire used for the detection of psychiatric distress related to general medical illness. Procedure: The study continued for over a period of six months. The normal group was selected on the basis of the score of each individual on the General Health Questionnaire. The instructions for each part of the questionnaires were adequately explained and care was taken that they understood the instructions. Care was also taken to assure the participants that their participation in the study was voluntary and their response would remain confidential and be used only for research purpose. The participants were asked to go through the questionnaire and give their responses. Responses of the participants were then scored according to the scoring key and tabulated for further statistical analysis.

Table 1: Mann – Whitney – U test Performed on Personality of both the Groups Personality Domains Suicidal Individual Matched Controls Z Value Mann–Whitney – U Mean Ranks Sum of Ranks Mean Ranks Sum of Ranks Neuroticism 45.30 1359.00 15.70 471.00 -6.572* 6.000 Extraversion 18.67 560.00 42.33 1270.00 -5.258* 95.000 Openness 19.13 574.00 41.87 1256.00 -5.057* 109.00 Agreeableness 17.35 520.00 43.65 1309.00 -1.624 55.500 Conscientiousness 24.42 732.00 36.58 1097.00 -2.703* 267.500 *p < .05 Table 2: Mann – Whitney – U test Performed on Coping Strategies of both the Groups Coping Strategies Dimension Suicidal Individual Matched Controls Z Value Mann– Whitney – U Mean Ranks Sum of Ranks Mean Ranks Sum of Ranks Confrontive Coping 42.20 1266.00 18.80 564.00 5.223* 99.000 Distancing 37.33 1120.00 23.67 710.00 -3.054* 245.000 Self-controlling 17.98 539.50 43.02 1290.50 -5.575* 74.500 Social Support Seeking 16.50 495.00 44.50 1335.00 -6.225* 30.000 Accepting Responsibility 28.97 869.00 32.03 961.00 .687 404.000 Escape Avoidance 39.93 1198.00 21.07 632.00 -4.194* 167.000 Planful Problem Solving 17.35 520.50 43.65 1309.50 -5.850* 55.000 Positive Reappraisal 17.70 531.00 43,30 1299.00 -5.697* 66.000 *p < .05 Results: Table 1 presents the comparison of the personality of suicidal individuals and matched controls. The result suggests that there is significant difference between both the groups in the personality domains of neuroticism, extraversion, openness to experience and conscientiousness (Z = - 6.572, p< .05; Z = -5.258, p <.05; Z = -5.057, p < .05; Z = -2.703, p < .05 respectively). The results further suggest that individuals who have attempted suicide were higher on neuroticism than normal controls (M =45.30 for suicidal individuals and 15.70 for matched controls). The suicidal individuals were lower on the domains of extraversion (M = 18.67 for suicidal individuals and 42.33 for matched controls), openness to experience (M = 19.13 for suicidal individuals and 41.87 for matched controls), and conscientiousness (M = 24.42 suicidal individuals and 36.58 for matched controls). However, no significant difference was found between both the groups in the domain of agreeableness (Z = -1.624, p > .05). Table 2 presents the comparison of the coping strategies used by suicidal individuals and matched controls. The result suggests that there was significant difference between both the groups in confrontive coping, distancing, self-controlling, social support seeking, escape avoidance, planful problem

solving and positive reappraisal (Z = 5.223, p< .05; Z = -3.054, p <.05; Z = -5.575, p < .05; Z = -6.225, p < .05 Z = -4.194, p< .05; Z = -5.850, p <.05; Z = -5.697, p < .05 respectively). The table further suggests that suicidal individual were higher than matched controls on confrontive coping (M =42.20 for suicidal individuals and 18.80 for matched controls), distancing (M =37.33 for suicidal individuals and 23.67 for matched controls), and escape avoidance (M = 39.93 for suicidal individuals and 21.07 for matched controls). The suicidal individuals were lower on selfcontrolling (M = 17.98 for suicidal individuals and 43.02 for matched controls), social support seeking (M = 16.50 for suicidal individuals and 44.50 for matched controls), planful problem solving (M = 17.35for suicidal individuals and 43.65 for matched controls), and positive appraisal (M = 17.70 for suicidal individuals and 43.30 for matched controls). Discussion: The findings of the present study show that the individuals who had attempted suicide scored significantly higher on the domain of neuroticism than normal. The individuals who had attempted suicide scored lower on extraversion, conscientiousness, and openness to experience domain than the normal subjects. However, there was no significant difference in the domain of agreeableness between suicidal patient and the normal subjects. The present finding is consistent with the earlier observations by Stankovic et al., (2006) who examined the dimensions and appropriate aspects of personality using the five-factor model of personality of depressive patients with attempted suicide. He found that depressive patients with history of attempted suicide were significantly different in all personality domains except in agreeableness from healthy persons. However, there was no difference in personality domains of depressive patients with and without the history of attempted suicide. In another similar study investigating the personality factors underlying suicidal behaviour in 1659 on military youth, it was found that there was significant positive correlation between neuroticism and suicidal ideation; however, there was significant negative correlation between other personality traits – extraversion, agreeableness and conscientiousness and suicidal ideation (Soltaninejad et al., 2014). The overall findings also suggest that suicidal individuals were higher on confrontive coping, distancing, and escape-avoidance than the normal subjects, may indicate that individuals with attempted suicide use more aggressive efforts to alter the situation and detach themselves from the problems. They were significantly lower on self-control, social support seeking, plan full problem solving and positive reappraisal. However, no significant difference was observed between suicidal individual and matched controls on measure of accepting responsibility. In another study conducted by Kumar and Goerge (2013) to analyze and compare the type and severity of life events, coping strategies, social support, and quality of life of individuals with history of attempted suicide versus matched normal controls, suggested that positive coping was found to be lower among individuals with history of attempted suicide than normal controls. Mathew & Nanno, (2013) studied psychological stressors and patterns of coping in adolescents attempting suicide and compared with normal, found that the normal subjects employed coping mechanism of self-control; seeking social support, accepting responsibility, plan full problem solving, and positive reappraisal to greater extent than individuals with history of attempted suicide. The negative strategies of escape avoidance, distancing and confrontive coping were used more by individuals with attempted suicide than normal.

Conclusion: The present study concludes that the individuals who had attempted suicide scored significantly higher on the domain of neuroticism and lower on extraversion, conscientiousness and openness to experience domain than the normal subjects. The findings also reveal that the individuals who have attempted suicide used less useful coping strategies during problem situation. However, the findings may not be generalised because of small sample size. References: Aldridge, A.A. & Roesch, S.C. (2008). Developing coping typologies of minority adolescents: A latent profile analysis, Journal of Adolescence, 31(4), 499– 517. Ashton, C.H., Marshall, E.F., Hassanyeh, F., Marsh V.R. & Wright-Honari, S. (1994).Biological correlates of deliberate self-harm behaviour: A study of electroencephalographic, biochemical and psychological variables in parasuicide. Acta Psychiatrica Scandinavia 90: 316–323. Beautrais, A.L., Joyce, P.R. & Mulder, R.T. (1999). Personality traits and cognitive styles as risk factors for serious suicide attempts among young people, Suicide and Life Threatening Behaviour 29: 37–47. Burker, E.J., Evon, D.M., Losielle, M.M., Finkel, J.B. & Mill, M.R. (2005). Coping predicts depression and disability in heart transplant candidates, Journal of Psychosomatic Research, 59(4), 215–222. Chance, S.E., Kaslow, N.J. & Baldwin, K. (1994) Anxiety and other predictors of severity of suicidal intent in urban psychiatric inpatients, Hospital and Community Psychiatry, 45: 716–718. Colson, C.E. (1972). Neuroticism, extraversion and repression-sensitization in suicidal college students, British Journal of Social and Clinical Psychology 11: 88–89. Corruble, E., Damy, C. &Guelfi, J.D. (1999). Impulsivity: A relevant dimension in depression regarding suicide attempts, Journal of Affective Disorder 53: 211–215. Edwards, M.J. & Holden, R.R. (2001). Coping, meaning of life, and suicidal manifestations: examining gender differences, Journal of Clinical Psychology, 57(12), 15 17-1534. Fear, J.M., Champion, J.E., Reeslund, K.L., Forehand, R., Colletti, C. & Roberts, L. (2009). Parental depression and interparental conflict: Children and adolescents’ self-blame and coping responses, Journal of Family Psychology, 23(5), 62–766. Fergusson, D.M., Woodward, L.J. & Horwood, L.J. (2000). Risk factors and life processes associated with the onset of suicidal behaviour during adolescence and early adulthood, Psychological Medicine 30: 23–29. Gonzales, N.A., Tein, J.Y., Sandler, I.N., & Friedman, R.J. (2001). On the limits of coping: Interaction between stress and coping for inner-city adolescents, Journal of Adolescent Research, 16(4), 372–395. Gould, M.S., Velting, D., Kleinman, M., Lucas, C., Thomas, J.G., & Chung, M. (2004). Teenagers’ attitudes about coping strategies and help-seeking behavior for suicidality, J. American Academy of Child & Adolescent Psychiatry, 43(9), 1124– 1133. Government of India (2012). Suicides in India, The Registrar General of India. Grucza, R.A., Przybeck, T.R., Spitznagel, E.L. & Cloninger, C.R. (2003). Personality and depressive symptoms: A multi-dimensional analysis, Journal of Affective Disorder 74: 123–130. Isherwood, J., Adam, KS. & Hornblow, A.R. (1982). Life event stress, psychosocial factors, suicide attempt and auto-accident proclivity, Journal of Psychosomatic Research 26:371–383. Kaminsky, L., Robertson, M., & Dewey, D. (2006). Psychological correlates of depression in children with recurrent abdominal pain, Journal of Pediatric Psychology, 31(9), 956 966. Kerby, D.S. (2003). CART analysis with unit weighted regression to predict suicidal ideation from Big Five traits, Personality and Individual Differences 35: 249–261. Kingsbury, S., Hawton, K., Steinhardt, K. & James, A. (1999). Do adolescents who take overdoses have specific psychological characteristics. A comparative

study with psychiatric and community controls, Journal of American Academic, Child & Adolescence Psychiatry 38: 1125–1131. Kortte, K.B., Wegener, S.T. & Chwalisz, K. (2003).Anosognosia and denial: Theirrelationship to coping and depression in acquired brain injury, Rehabilitation Psychology, 48(3), 131– 136. Kumar, P. N. S., & George, B. (2013).Life events, social support, coping strategies, and quality of life in attempted suicide: A case-control study, Indian Journal of Psychiatry, 55(1), 46–51. Marusic, A. & Goodwin, R.D. (2006). Suicidal and deliberate self-harm ideation among patients with physical illness: The role of coping styles, Suicide and Life-Threatening Behaviour, 36(3), 323–328. Mathew, A., &Nanoo, S. (2013). Psychosocial stressors and patterns of coping in adolescent suicide attempters. Indian Journal of Psychological Medicine, 35(1), 39–46. Michaelis, B.H., Goldberg, J.F., Davis, G.P., Singer, T.M. & Garno, J.L. (2004). Dimensions of impulsivity and aggression associated with suicide attempts among bipolar patients: A preliminary study, Suicide and Life Threatening Behaviour 34: 172– 176. Öncü, B. & Sakarya, A. (2013). Role of cognitive factors and distortions in adolescent suicides, Current Approaches in Psychiatry, 5 (2), 232-245. Oquendo, M.A., Galfalvy, H., Russo, S., Ellis, S.P., Grunebaum, M.F., Burke, A. & Mann, J.J. (2004). Prospective study of clinical predictors of suicidal acts after a major depressive episode in patients with major depressive disorder or bipolar disorder, American Journal of Psychiatry 161: 1433–1441. Pallis, D.J. &Birtchnell, J. (1976). Personality and suicidal history in psychiatric patients, Journal of Clinical Psychology 32: 246–253. Pienaar, J., Rothmann S., & Van De Vijver, F.J.R. (2007).Occupational stress, personality traits, coping strategies, and suicide ideation in the South African Police Service, Criminal Justice and Behaviour, 34(2), 246–258. Polgreen, L. (2010). Suicide, Some for Separatist Cause, Jolt India, The New York Times. Rudd, M.D., Rajab, M.H. &Dahm, PF. (1994). Problem solving appraisal in suicide ideators and attempters, American Journal of Psychiatry, 64:136-149. Soltaninejad, A., Fathi-Ashtiani, A., Ahmadi, K., Mirsharafoddini, H. S., Nikmorad, A., & Pilevarzadeh, M. (2014). Personality factors underlying suicidal behaviour amongmilitary youth. Iranian Red Crescent Medical Journal, 16(4), e12686. Stalenheim, EG.(2001). Relationships between attempted suicide, temperamental vulnerability and violent criminality in a Swedish forensic psychiatric population, European Journal of Psychiatry 16: 386– 394. Stankovic, Z., Saula-Marojevic, B. &Potrebic, A. (2006). Personality profile of depressive patients with a history of suicide attempts. Psychiatria Danubina, 18:159–68. Statham, D.J., Heath, A.C., Madden, P.A.F., Bucholz, K.K. &Bierut, L. (1998). Suicidalbehaviour: An epidemiological and genetic study, Psychological Medicine 28:839–855. Tilghman-Osborne, C., Cole, D.A., Felton, J.W. & Ciesla, J.A. (2008). Relation of guilt, shame, behavioral and characterological self-blame to depressive symptoms in adolescents over time, Journal of Social and Clinical Psychology 27(8), 809–842. Ullman, S.E. & Najdowski, C.J. (2009).Correlates of serious suicidal ideation and attempts in female adult sexual assault survivors, Suicide and Life- Threatening Behavior, 39(1), 47–57. Velting, D. (1999). Suicidal ideation and the five factor model of personality, Personality and Individual Differences 27: 943–952. Vijaykumar, L. (2007). Suicide and its prevention: The urgent need in India, IndianJournal of Psychiatry; 49: 81-84. Wadsworth, M.E. & Compas, B.E. (2002).Coping with family conflict and economic strain: The adolescent perspective, Journal of Research on Adolescence, 12(2), 243–274. World Health Organization (2012).Suicide Prevention (SUPRE)

SIS-II Profile of Non-chronic and Chronic Schizophrenia Patients Ranjan Kumar, M. Jahan, M. Dutta and S. K. Deuri There is accumulating evidence that projective techniques can be successfully used in clinical differential diagnosis. The present study was conducted to compare SIS profile of non-chronic schizophrenia patient and chronic schizophrenia patient. Results show that non-chronic schizophrenia and chronic schizophrenia patients differed significantly on Human (H) and Sex indices of SIS-II. The non-chronic schizophrenia patients have psychologically more social isolation tendencies and have higher sexual anxiety in comparison to chronic schizophrenia patients. Schizophrenia is heterogeneous group of disorders characterized in general by fundamental and characteristic disorders of thinking and perception, and by inappropriate or blunted affect, poor emotional control, and ineffective interpersonal relationship, positive symptoms, negative symptoms, and disorganized behaviors. The chronic schizophrenia is operationally defined when the duration of illness is more than two years. Patients may have more deficits symptoms such as social withdrawal, under activity, blunt affect, apathy and lack of initiative. Projective technique is a psychological assessment procedure which helps the respondents in projecting theirunconscious material and feelingson ambiguous stimuli. The somatic Inkblot Series (SIS-II) is a semistructured, projective, diagnostic procedure helps in understanding the psychopathology of the case. It further helps in the management of the case as therapeutic intervention tool (Cassell and Dubey, 2003). The SIS-II indices are used as measures of ego strength, interpersonal relationship, social isolation tendencies, imaginative capacity, functional intelligence, psychologically immaturity, self-image, sexual anxiety and thought process. The review of literature on SIS reveals that SIS- II (Booklet form) has been used in various psychiatric disorders (Cassell and Dubey, 1980,1980a, 1990, 2003, 2004, Dosajh, 1998, Vermaet al., 1994; 1996; Prasad et al., 1997; Rathee et al., 1995; 2002, Singh and Dubey, 1997; Singh et al., 1997; Kumari et al., 2009). It would be of interest to see if the chronicity of illness produces a different picture on inkblots perception. The present study was carried out to comparethe SIS-IIindices of non-chronic and chronic schizophrenia patients and to identify SIS-II indices that differentiate these two groups. Materials and Method: Sample: Thirty non-chronic and chronic schizophrenia patients, using purposive sampling were selected from the LGBRIMH, Tezpur, Assam (India). The patients were diagnosed schizophrenia as per ICD – 10 diagnostic criteria.The patients with duration of illness two years or more were considered as chronic schizophrenia and with less than one year of duration were considered as nonchronic schizophrenia. They were in the age range of 20 to 50 years (with mean age 20.9 ± 7.27 years for non-chronic patients and 34 ± 4.38 years for chronic patients). The Mean duration of illness was 7.93 ± 2.59 months for non-chronic group and 78.4 ± 25.35 months for chronic patients. Majority of the patients were literate, employed and married. Ranjan Kumar, M. Phil., Clinical Psychologist, (ranjan.counsellor@gmail.com) ,Maitrayee Dutta, Ph. D., Asst Prof. and Shailendra K. Deuri, M. D., Professor & Director, LGBRIMH, Tezpur and Masroor Jahan, Ph. D., Addl. Prof., RINPAS, Kanke, Ranchi Key word: Non-chronic Schizophrenia, Chronic Schizophrenia, SIS II Profile

Tools: Socio-demographic and Clinical Data Sheet was used to collect the information about patients. Brief Psychiatric Rating Scale (BPRS) was used to assess severity of symptoms of schizophrenia. Patients with severe level of psychopathology were excluded to ensure proper understanding of instructions. Procedure: SIS-II test was administered individually and the scoring of the responses was done as per given procedure (Cassell and Dubey, 1993). The consent of the patients was obtained. Statistical Analysis: Data was statistically analyzed using Chisquare for group comparison, Pearson’s product moment correlation to find out correlation between variables and SIS indices, and Stepwise discriminant function analysis to identify discriminating variables. Result and Discussion: The mean and S.D. of SIS-II indices in two groups are given in Table1. The findings show non- significant difference between both the groups on Total no of responses (R), Animal responses (A), Anatomical responses (At), Movement responses (M), Most Typical responses (MT),Typical responses (T), Atypical responses (AT), and Rejection of images (Rej). It suggests that performance of both groups was similar on variables related to imaginative capacity, self- image, logical thinking, psychological or psychiatric disturbance and thought process. Similar response pattern have been observed in previous studies on schizophrenia patients (Verma et al., 1994; 1995; Kumari et al., 2009, Kandhari et al., 2010). Table 1: SIS Indices of Non-Chronic Schizophrenia and Chronic Schizophrenia Non-Chronic Schizophrenia Chronic Schizophrenia Mean SD Mean SD R 60.23 2.12 60.73 2.24 H 25.26 5.30 27.33 7.48 A 5.56 5.60 3.23 2.52 At 15.70 4.91 17.13 4.51 Sex .66 .75 4.86 2.87 M 1.40 1.19 2.20 1.37 MT 7.73 2.44 6.56 2.17 T 16.86 3.71 16.40 2.67 AT 34.50 4.19 32.46 5.28 Rej 1.70 2.11 1.16 2.10 Table 2: Comparisons of SIS-II Indices in two Groups of Schizophrenia SIS-II Indices Value of Chi Square Significance Level Total Responses (R) 10.19 ns Human Responses (H) 25.60 .05 Animal Responses (A) 12.54 ns Anatomical responses (At) 12.90 ns Sex Responses 34.40 .001 Movement Responses (M) 6.25 ns Most Typical Responses (MT) 10.49 ns Typical Responses (T) 13.45 ns Atypical Responses (AT) 16.85 ns Rejection of Images 8.34 ns

Chronic schizophrenia patients gave more Human responses (M=27.33 ± 7.48) in comparison to Non-chronic schizophrenia patients (M=25.26 ± 5.30). The difference of Human responses was statistically significant (χ2=25.60, p<.05) suggesting more psychological immaturity in non-chronic schizophrenia patients. Similar findings have been reported in comparison of acute and chronic schizophrenia patients (Vives, 1983; Gomila, 2011). Analysis of sex responses (Sex) suggests that non-chronic schizophrenia patients gave significantly less number of sex responses (M= .66 ± .75) in comparison to chronic schizophrenia patients (M = 4.8 ± 2.87). The significantly difference (χ2=34.40, p< .001) on sex responses may suggests that chronic schizophrenia patients were more expressive about sexual content in comparison to nonchronic schizophrenia patients. More sex responses have been reported to be associated with sexual anxiety and/or dysfunction (Cassell, 1980,1980a). To find out correlation between age at onset of illness and duration of illness with SIS-II indices, Pearson’s product moment correlation was computed (Table 3). No significant correlation was found between age at onset of illness and SIS indices. However, in non-chronic schizophrenia patients with increasing age at onset of illness the total number of responses increased. Duration of illness was significantly negatively correlated with animal response and positively correlated with sex and movement response. It shows that sex and movement responses increased with increasing duration of illness and animal responses decreased with increasing duration of illness. Table 3: Correlation between Socio-demographical Profile versus Age of onset and Duration of Illness SIS-II indices Total Patients Non-Chronic Schizophrenia Chronic Schizophrenia Age of Onset Duration of Illness Age of Onset Duration of Illness Age of Onset Duration of Illness R .11 .11 .36* .02 -.23 .02 H -.14 .13 -.25 .18 .01 -.04 A .00 -.26* -.05 .16 .02 -.19 At -.15 .15 -.23 -.28 .02 .10 SEX -.12 .72* .04 .11 -.10 .27 M .18 .30* .24 .15 .26 .10 MT .21 -.25 .15 -.22 .24 -.08 T -.22 .03 -.31 .11 -.06 .35 AT .12 -.09 .27 .05 -.12 .27 REJ -.08 -.13 -.36 -.01 .33 -.05 Table 4: Stepwise Discriminant Function Analysis of the Non-chronic Schizophrenia and Chronic Schizophrenia Patients on SIS-II Indices GROUP Predicted Group Membership Non-chronic Schizophrenia (N %) Chronic Schizophrenia N (%) Non-chronic Schizophrenia 30 (100) 0(0) Chronic Schizophrenia 9 (30) 21 (70) 85.0% of original grouped cases correctly classified

Stepwise Discriminant Function Analysis (Table 4) was performed to examine classification accuracy of SIS-II variables in discriminating the two group of patients. The results show that 30% of chronic schizophrenia patient showed similar response indices as non-chronic schizophrenia patients. Seventy percent chronic schizophrenia patient showed significantly different response indices as compared to non-chronic schizophrenia patients. Sex (Wilk’s Lamda value .955) and AT (Wilk’s Lamda value.492) responses were most discriminating variables with classification accuracy of 85% with a sensitivity of 100% and specificity of 70%. High discriminant value suggests SIS indices of Sex and AT can discriminate between chronic and non-chronic schizophrenia patients. Conclusion: The findings suggest that non-chronic schizophrenia patients tend to have more social isolation tendencies and higher sexual anxiety in comparison to chronic schizophrenia patients. Duration of illness affects a few of the SIS-II indices. Sex and AT response are most discriminating variables for chronic and non-chronic schizophrenia patients. References: Cassell, W. A. (1980) Body Awareness and Somatic Delusions Involving Sexual Organs. American J.of Psychoanalysis, 40: 125-135. Cassell, W. A. (1980a) Somatic Inkblot Series- II Aurora communication, Inc. Cassell, W.A. and Dubey, B. L. (1990) Interpreting Inner world through Somatic Imagery: Manual or the somatic in Somatic Inkblot Series, SIS Centre, Anchorage, AK 99516 (USA). Cassell, W, A. and Dubey, B. L. (2003) Interpreting Inner World through Somatic Imagery: Manual of Somatic Inkblot Series. Anchorage (USA): SIS Center. Cassell, W, A. and Dubey, B. L. (2004) Somatic Inkblot Series: Historical Background and Earlier Projects, SIS Journal of Projective Psychology & Mental. Health, 11:11-18 Dosajh, N. L. (1998) Use of SIS-II and other Projective Tests in the Treatment of a Case of Schizophrenia. SIS Journal of Projective Psychology & Mental Health, 5: 46-50. Frank L.K. (1939) "Projective methods for the study of personality" The journal of psychology 8, 389-414 Gomila, M. V., (2011) The Rorschach test in the differential diagnosis of schizophrenic inpatients, Annuary of Clinical and Health Psychology, Volume 07 , Pages 79 to 93 Kandhari, S., Sharma, J. and Kumar, R., (2010) Discriminating Power of the Comprehensive Scoring System for SIS-I, SIS J. Proj. Psy.& Ment. Health 17 : 16-22 Kumari. D., Prakash, J., Singh. A. R., and Chaudhury. C. (2009) Personality prfile of Schizophrenia and Bipolar Affective Disorder (Mania on SIS- II, SIS J. Proj.Psy.&Ment. Health, 16: 134-137. Overall, J.E. and Gorhan, D. R. (1963) The BPRS Recent Development in ascertaining and scaling, Psycho-pharmacological Bulletin, 24(1), 93-97. Pershad, D., Verma, S. K. and Bhagat, K. (1997) Body Image Disturbance in Psychiatirc Cases, SIS J. Projective Psychology & Mental Health, 4 91) :60- 68. Rathee, S.P., Pande, V. and Singh, A. (1995) Diagnostic efficacy of Somatic Inkblot Series-II among Psychiatric Patient of Armed Forces.SIS journal of Projective psychology and Mental Health, 2(1), 61- 66. Singh,A.R., Dubey, B.L. and Banarjee K. R. ( 1997) Prognosis utility of Somatic Inkblot Series-II, SIS Journal of Projective Psychology and Mental Health 4( 2), 141-144. Verma, S. K., Pershad, D. and Nehra, R. (1994) Cross- Validation of SIS-II in Psychiatric Population. SIS Journal of Projective Psychology & Mental Health, 1: 15-18. Verma, S. K., Pershad, D., Kaur, R. and Nehra, R. (1995) Diagnostic Significance of SIS-II. SIS Journal of Projective Psychology & Mental Health, 2: 72-76. Vives, M. (1983).Analisis of Rorschach data from acute andchronic Spanish schizophrenics.Estudio no. 291 (inedito) de la Rorschach Workshops.

Cognitive Insight and Executive Function in Schizophrenia Kiran Srivastava and Rakesh Kumar Insight has been widely studied in clinical setting. Nowadays, attention has shifted to cognitive insight or the ability to scrutinize and correct one’ incorrect convictions. Schizophrenia may be conceptualized as a chronic neurocognitive disorder with diverse levels of functioning and symptoms presentation, including deficits in attention, memory, processing speed, and executive functioning. These cognitive deficits may be considered core symptoms of schizophrenia. The present study focused on the association of cognitive insight and executive functioning in schizophrenia. Thirty patients with schizophrenia diagnosed as per ICD-10 criteria were drawn from Institute of Mental Health and Hospital, Agra. Beck Cognitive Insight Scale (BCIS)and Wisconsin Card Sorting Test (WCST) were administered. Mean S.D. and Pearson product moment correlation were computed for BCIS and scored variables on WCST. Detailed results will be presented. Schizophrenia is always characterized as a disorder which disturbs insight or awareness into their illness and symptoms. In spite of substantial research, we are at standstill to provide a full understanding of the factors involved in causing poor awareness. However, in this condition, exist dimensions of awareness into mental illness: of being ill, awareness of having symptoms as well as treatment compliance. Lack of awareness of illness and symptoms is a prevalent characteristic of schizophrenics, where 80% of sufferers fail to acknowledge that they have a mental illness (Amador, 2004). However, low awareness reflects poor treatment compliance (David,1990;Young, Davila, &Scher., 1993; Greenfeld et al 1989) and prognosis (Carpenter, Strauss &Bartko., 1973; Bartko, Herczeg&Zador., 1988; . David et al, 1995) thus elucidating that insight in schizophrenia may lead to medication that can improve adherence to treatment and hence patient outcome. Insight has a several aspects. In psychosis, the clinical dimension of insight implies the ability to label atypical mental events as something unusual on one hand and to recognize having a mental disorder as well as need for treatment on the other hand (David, 1990). Poor insight has damaging effects on symptom relapse and frequency, adherence to treatment and quality of life (Caton et al., 2006). This is why Beck and colleagues (2004) integrated the clinical dimension of insight with cognitive insight, and explained it as the ability to evaluate and modify misperceptions and delusions as well as to integrating modified information. It is considered to reflect the metacognitive cornerstone of insight into illness, namely self-monitoring and regulation of one’s own performance (Beck et al., 2004; Koren et al., 2004; Gilleen et al., 2010).Thus cognitive insight runs parallel with clinical insight, because it deals with patients’ definite capability to process information about their situation. The Beck Cognitive Insight Scale (BCIS) (Beck et al., 2004) was developed to assess two aspects of cognitive insight: (i) self-reflectiveness (SR), or the aptitude for self-reflecting, to inquire about atypical experiences and to consider corrective feedback and (ii) selfcertainty (SC), or the reluctance to transform one’s interpretations and overconfidence in making judgments. These factors represent two contradictory cognitive attitudes that are likely to affect the overall cognitive dimension of awareness of illness (Gilleen et al., 2010). In schizophrenia, a low score on cognitive insight index indicates a poor realism in monitoring one’s own misperceptions and distorted experiences; therefore, it characterizes more impaired subjects (Beck et al., 2004; Pedrelli et al., 2004). Kiran Srivastava, Research Scholar (kiran_srivastava63@yahoo.com) and Rakesh Kumar, Ph.D. Visiting Expert, Mewar University, Gangrar, Chittorgarg (Rajasthan) Key Words: Cognitive Insight in Schizophrenia, Executive Function in Schizophrenia, WCST

Furthermore, in schizophrenia, lower global cognitive insight and SR and higher SC were found related to worsen cognitive performances (Buchy et al., 2009; Lepage et al., 2008; Cooke et al., 2010; Orfei et al., 2010). In the light of these considerations, the clinical relevance of cognitive insight shows potential, because of its prognostic aspect for identifying patients at risk of poor compliance and developing more competent remedial strategies. Executive functions are integrated cognitive processes that determine goal-directed and focused behavior and are super ordinate in the systematic execution of daily life functions, which includes the capability to devise goals; to initiate behavior; to predict the consequences of actions; to plan and organize behavior according to the spatial, temporal, logical sequences; and to monitor and adapt behavior to fit a particular task or context (Cicerone et al., 2000) It has been stated that poor insight in schizophrenia is (1) a direct expression of positive, negative, or disorganized symptoms; (2) a separate, autonomous symptom realm; (3) a defensive coping strategy; or (4) a role of impaired neurocognition, similar to the condition of anosognosia explained in some neurological conditions. However, many studies have laid emphasis on the association betweenimpaired insight and symptoms. The outcome concerning positive and negative symptoms are mixed, with studies suggestive of both positive correlations (Amador et al., 1993; Amador et al. 1994; Kemp and Lambert 1995; Collins et al. 1997) and no obvious associations (Cuesta and Peralta, 1994; Lysaker and Bell, 1994; Peralta and Cuesta, 1994) between these symptoms and poor insight. Other studies have revealed relationship between insight in depression as well as in disorganized symptoms, with poor insight being positively associated with disorganized symptoms (Amador et al., 1994; Lysaker and Bell, 1994; Collins et al., 1997; Kim et al., 1997); and either positively associated (Amador et al. 1993; Collins et al. 1997) or inversely associated (Peralta and Cuesta, 1994; Kemp and Lambert, 1995) with depression. Recent studies have tried to explore the relationships between insight and performance on tests of neurocognition, hypothesizing that poor insight in schizophrenia is largely a function of poor information processing capacities.. These neurocognitive domains were preferred for study because of the prevalence of frontal lobe deficits in schizophrenia and also because of their similarity of insight deficits to the syndrome of anosognosia seen in neurological conditions involving parietal lobe malfunctioning (McGlynn and Schacter, 1989). Young et al. (1993) in a study investigated Scale to Assess Unawareness of Mental Disorder (SUMD) on schizophrenics (Amador et al., 1993) and hypothesized relationship between impaired frontal lobe functioning (card sorting deficits) and both symptom unawareness and misattribution .Two other studies used the SAI to assess insight in schizophrenic patients (Kemp and David, 1996; Collins et al., 1997). In these studies, frontal lobe deficits (trail making and card sorting) correlated extensively with insight deficits, although regression equations suggested that these variables did not add a unique contribution to the forecast of insight above and beyond the effects of positive and depressive symptoms. Research has confirmed that insight is not a dichotomous aspect that a person either completely possesses or completely lacks (Markova & Berrios, 1995).There are several degrees of insight ranging from complete denial, to vague recognition of illness (eg, trouble with “nerves,” being “unwell”), to full appreciation of one's diagnosis (Bayard et al, 2009). Currently, there has been an inclination of research focusing on the assessment of insight, as well as its associations with neuropsychological impairment in schizophrenia. But, studies

conducted revealed inconsistent results (Kaustav & Debasish, 2010). Lack of insight is a general feature of schizophrenia and indeed of psychosis in general (Amador & David, 2004). Impaired insight is of clinical importance, as it has been related to poor treatment compliance as well as poorer global functioning, severity of psychopathology, recurrence, and poorer outcome (Kemp & David, 1997). Although several studies account for unawareness of illness to be associated with dysfunction on several neuropsychological tests, the findings are inconsistent (Morgan & David 2004). A relationship of insight with performance on the Wisconsin Card Sorting Test (WCST) has been reported in abundance (Young et al., 1993; Rossell et al, 2003). A number of studies have failed to replicate such a relationship (e.g. Cuesta et al, 1995).These results propose a link between basic cognitive deficits and poor insight, and may be more relevant to poor insight than cognitive deficits per se. An examination of relationship between these two cognitive aspects would be of immense help in cognitive remediation programs. This study will contribute to the fund of knowledge in better management of cognitive functions and insight. Aim: The aim of the study was to determine the relationship between executive functioning and cognitive insight in schizophrenia. Method: Sample: 30 schizophrenics diagnosed with Schizophrenia (ICD-10) in the age range of 18-45 years, both Male and Female, and were able to comprehend the test requirements, were included in the study. It was based on purposive sampling. Tools: Following tools were used to assess the cognitive insight and executive function of schizophrenic patients. Wisconsin Card Sorting Test (WCST): The Wisconsin Card Sorting Test was developed by Heaton, (1981).The Wisconsin Card Sorting Test was originally developed to assess abstract reasoning ability and the ability to shift cognitive strategies in response to changing environmental contingencies (Berg,1948; Grant and Berg, 1948). WCST can be considered a measure of “executive function,” with the ability required to develop and maintain an appropriate problem-solving strategy across changing stimulus conditions in order to achieve a future goal (Luria,1973; Shallice, 1982). The WCST is considered as highly reliable and a valid tool to assess the executive functioning of the patients. Interscorer reliability coefficients ranged from .895 to 1.000 for the 11 scores of the WCST. Intra-scorer reliability coefficients ranged from .828 to 1.000 (Axelrod et al., 1992). Beck's Cognitive Insight Scale (BCIS): Developed by Beck A.T et al. (2004), is a self-report inventory designed to assess cognitive insight in patients with psychoses consisting of 15 statements rated on a 4- point Likert scale (0 = do not agree at all to 3 = agree completely). Based on factor analyses, Beck and co- workers divided the 15 items into 2 subscales. The first component consisted of 9 items, measuring objectivity, reflectiveness and openness to feedback and is given the label selfreflectiveness. Under the umbrella of decision-making and resistance to feedback, 6 items were united in a second component of the scale, labeled self-certainty. High scores on the subscale self-reflectiveness and low scores on subscale self-certainty are considered as normal. Procedure: Patients diagnosed as having schizophrenia as per ICD-10 and meeting the inclusion criteria were selected for the study. Sociodemographic Information was gathered from the sample on a semi- structured sociodemographic data sheet. Clinical details of the patients were collected and then Beck’s Cognitive Insight Scale was used to assess cognitive insight. After that Wisconsin Card

Sorting Test was applied to assess the executive functioning of the patients. Results: Table 1 showing mean and S.D of schizophrenic patients in terms of their age, education and onset of illness. The mean age was found to be 37.80 yrs., education was 5.88, and for onset of illness was 27.56. Table 1 :Mean and S.D. of salient sample characteristics Mean Std. Deviation Age 37.80 10.48 Education 5.88 3.23 Onset of illness 27.56 7.04 Table 2: Mean and S.D of WCST VARIABLES MEAN S.D Total Error 85.06 13.50 % Error 64.40 14.93 Perseverative Response 11.93 11.39 % Perseverative Response 8.99 8.96 Perseverative Error 63.93 23.01 % Perseverative Error 65.33 87.86 Non-perseverative Error 22.33 24.48 % Non-perseverative Error 17.06 19.36 Conceptual Level Response 7.50 4.02 % Conceptual Level Response 5.80 3.11 No. of Categories Completed .86 1.25 Trials of Complete First Category 71.70 55.56 Failure to Maintain Set .36 1.6 Table 3: Mean and S.D of BCIS Variables MEAN S.D Self-reflectiveness 4.63 2.68 Self- certainty 12.60 4.23 Composite index 8.70 3.64 Table 4: CORRELATION COEFFICIENTS WCST VARIABLES BCIS SCORES Self-reflectiveness Self- certainty Composite % Error .24 .75** .73** Total Error .30 Perseverative Response -.03 .78** .79** % Perseverative Response .03 .77** .78** Perseverative Error .02 .30 .30 % Perseverative Error .10 .03 .03 Conceptual Level Response .02 .57** .58** % Conceptual Level Response .22 .54 ** .57** No. of Categories Completed .09 .74** .75** Trials of Complete First Category .26 .38** .38** Failure to Maintain Set .31 .12 .13

Correlation was computed to explore the effect of BCIS on WCST variables. Table 3 indicates significant correlation between the percent error, perseverative response, percent perseverative response, conceptual level response, percent conceptual level response, number of categories completed and trials to complete first categories. Discussion: The present study was an attempt to determine the relationship of Executive Functions and Cognitive Insight in schizophrenia. For the said purpose, thirty schizophrenic patients were taken for the purpose. Impaired insight is the most defining feature in patients with schizophrenia. Neurocognitive impairments, predominantly is related to prefrontal cortical and parietal functioning, which appear to be a close association to impaired insight. Many studies demonstrate the association of insight in psychopathology, while other studies refute this association (Mintz, Dobson, Romney, 2003). However, insight appears to deliver a predictive value on the course and treatment response in schizophrenics (Pijnenborg et al., 2013). Cognitive insight in recent times has emerged as a significant aspect of research on insight in schizophrenia, because it acts as a moderator as how schizophrenics respond to cognitive behaviour therapy (Granholm et al., 2005, 2006). Significant relationship was found between the two domains of Beck’s cognitive insight, namely, self-certainty and composite index along with WCST scores. The self-certainty dimension reflects decision making regarding mental products: certainty about being right and resistance to correction, over-confidence in decision making (Beck et al., 1994). Similar findings have been reported where, in a study of 31 chronic schizophrenic patients who were administered on 2 variables on the WCST (viz., the number of categories completed and percent perseverative response), they were found to significantly discriminate between subjects of high versus low awareness (Pyne, Bean and Sullivan., 2001). In another study, the researchers administered the WCST and again repeated the test after a year on the patients of schizophrenia with unimpaired insight (Pijnenborg., 2013). Results indicated that patients with impaired insight demonstrated consistently poorer performance than those with unimpaired insight. Subjects with impaired insight made significantly more perseverative errors and achieved fewer categories correct, an overall performance deficits identified with neuropsychological dysfunction in schizophrenia. In the present study, significant difference were found in perseverative errors as well as in number of catagories completed which shows significant level of impairment. Similar findings have been reported by Cuesta and Peralta (1994) who explored the relationship of frontal neurological signs, abnormal involuntary movements, soft neurological signs with insight using neuropsychological battery. No correlation between poor performance and lack of insight was found on any test (Cuesta & Peralta, 1995). This finding is found to be consistent with several findings. For example, in one study by Young et al. (1993), they found a significant association between frontal lobe deficit as measured by the WCST and lack of awareness of illness in chronic schizophrenia (Amador, 1991). It is notable that they had also studied different measures of executive functions other than WCST like trail making tests and verbal fluency test, but only the WCST showed a significant statistical relationship with poor insight. Moreover, Collins et al. (1997) showed significant association between neuropsychological functions (measured by WCST) and impaired insight of mental disorder (Collins et al., 1997). Their results demonstrated that 44% of the variance in the insight of mental disorder could be explained by the neuropsychological functions. However

WCST performance reflects capability of mental flexibility, maintenance and switching of mental sets, along with the ability to use feedback to overcome errors. It would appear that such executive functions are interrelated with the dimension of awareness of illness. Probing further into the present study where self-certainty and executive function reflected poor cognitive insight, is likely to be related with the inability to form and follow a strategy, somewhat with the tendency to perseverate on a neuropsychological test. Insight as a construct theoretically requires a wide range of inputs from various neurocognitive functions predominantly, frontal and parietal (Drak& Lewis., 2003; Boyer, 2012; Goodman et al, 2005). It has been documented that patients with schizophrenia demonstrate deficits in various neurocognitive measures, predominantly prefrontal cortical and parietal measures, even when there is a great heterogeneity in this aspect (Palmer, Dawes and Heato, 2009). It has also been suggested that diminished functioning of the prefrontal cortex, which is responsible for impaired mental flexibility, mental abstract reasoning and self-reflection, could lead to impairment in insight. Neurocognitive measures form a part of many closely linked variables that might be responsible for poor insight in schizophrenia patients (Mingrone, et al, 2013) Various studies report that unawareness of illness in psychosis is in relation with impairment on many neuropsychological domains (Morgan and David, 2004). Ritsner and Blumenkrantz (2007) attributed poor insight to impairment in executive functions. Studies have shown that deficits in attention could be a cause for the inability to define the psychotic condition and the related inability to characterize the psychotic experiences towards mental illness in the patient (Subotnik et al 2005). Of the various domains, executive function and working memory impairment, have been found to have a significant relationship with lack of insight (Simon et al 2009; Donohoe, et al, 2005). Mohamed et al (1999) reported that the poor insight is significantly associated with deficits in some aspects of executive functioning. Those with poor insight were found to have more perseverative errors and executive dysfunction in addition to the presence of neuroanatomical changes in the prefrontal cortical regions (Shad et al., 2004). Impaired insight was related to poor working memory and such an association was reflected even in first episode schizophrenia (Mutsatsa et al., 2006). However, Monteiro et al (2008) observed that insight could be related with neurocognitive dysfunction and they argued that this relationship is mediated by the disorganized factor, especially in the schizophrenics (Monteiro et al, 2008) In a meta-analysis, Aleman et al. (2006) concluded that impairments in neuropsychological aspects, particularly those of set-shifting and error monitoring, resulted in poor insight in schizophrenia. The two variables of WCST, namely, perseverative errors and percent perseverative errors, did not correlate with poor cognitive insight. The Perseverative errors arise through a failure to recognize that a previously successful strategy is currently producing errors – i.e., poor ability to monitor error. This finding is important in the context of a neuropsychological model of poor insight, suggesting that a failure to detect errors may be particularly important in schizophrenics reflecting in the lack of awareness of illness as well as symptoms into their illness (Larøi et al., 2000). If the above findings were correct for the neuropsychological feature of cognitive insight, one would expect poor cognitive insight to be associated with greater perseverative errors which was not the case in the present study, thus casting doubt on Larøi and colleague's suggestion. Thus it can be concluded that poor insight in schizophrenia stems from enduring cognitive

impairments, and studies have reflected that these impairments are similar to those experienced by anosognostic patients (Amador al 1991). Broadly speaking, researches had emphasized that poor insight is significantly related with executive functioning, particularly measured by Wisconsin Card Sorting Test (Young, 1993). There are various theories like those of Startup’s (1996) model explaining the cause of poor insight. Firstly it is due to neuropsychological deficits which are important components of the frontal lobe (executive) dysfunction of schizophrenia. This causes patients to be unable to be aware of all or some of the characteristics of mental illness. At times, poor awareness of illness reflects larger unawareness of illness including the neuro-cognitive problems of attention, memory, judgments and critical thinking. The other theory of poor insight among the schizophrenic patients is considered a major psychological defense, which protects the individual from recognizing that he has any psychiatric illness by avoiding the suffering. Another consideration is that what seems to be a lack of insight is basically an alternative health belief which is shaped by that individual’s belief system acquired by the culture and the society in which he resides. Hence the confusion regarding the impact of executive function on insight still prevails and in India, there is lack of literature addressing this issue. Conclusion: In conclusion the present setting of an Indian psychiatric institute shows majority of patients with poor insight come from the lower socioeconomic status of the society. This leads to poor compliance and higher relapse rates. To break this vicious circle, cognitive insight needs much more attention from its theoretical as well as practical point of view. References: Aleman, A., Agrawal, N., Morgan, K.D. & David, A.S.(2006)

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Felicitti., J.T. Giacino(2000). Evidence based cognitive rehabilitation: Recommendations for Clinical Practice. Archive of physical medicine and rehabilitation, 81, 1596-1615. Collins ,A.A., Remington, G.J., Coulter, K. & Birkett, K. (1997) Insight, neurocognitive function and symptom clusters in chronic schizophrenia. Schizophrenia Research., 27(1), 37–44. Cooke, M.A., Peters, E.R., Fannon, D., Aasen, I., Kuipers, E. & Kumari, V. (2010). Cognitive insight and verbal memory in first episode of psychosis. European Psychiatry, 23, 368–74. Cuesta, M.J & Peralta, V.(1995) Cognitive disorders in the positive, negative and disorganization syndromes of schizophrenia. Psychiatry Research,58, 227–35. Cuesta, M.J. & Peralta V.(1994) Lack of insight in schizophrenia. Schizophrenia Bulletin,20(2), 359– 366. David, A.S. (1990) Insight and psychosis. British Journal of Psychiatry,156, 798–808. David, A., van, Os, J., Jones, P., Harvey, I., Foerster, A. & Fahy, T.(1995) Insight and psychotic illness. Cross-sectional and longitudinal associations. British journal of Psychiatry, 167, 621–8. Donohoe ,G., Corvin, A. & Robertson, I.H. (2005) Are the cognitive deficits associated with impaired insight in schizophrenia specific to executive task performance? Journal of Nervous Mental Disorder, 193, 803–8. Drake, R.J. & Lewis, S.W. (2003) Insight and neurocognition in schizophrenia. Schizophrenia Research,62, 165–73. Gilleen, J., Greenwood, K. & David, A. (2010).Anosognosia in schizophrenia and other neuropsychiatric disorders: similarities and differences. In: Prigatano, G.P. The Study of Anosognosia. Oxford: University Press. Goodman ,C., Knoll, G., Isakov, V.& Silver, H. (2005) Insight into illness in schizophrenia. Comprehensive Psychiatry, 46, 284–90. Granholm, E., Auslander, L., Gottlieb, J., McQuaid, J., & McClure, F.(2006.) Therapeutic factors contributing to change in cognitive-behavioral group therapy for older persons Greenfeld, D., Strauss, J.S., Bowers, M.B. & Mandelkern, M.(1989) Insight and interpretation of illness in recovery from psychosis. Schizophrenia Bulletin, 15, 245–52. Heaton, R.K. (1981) Wisconsin Card Sorting Test Manual. Odessa, FL: Psychological Assessment Resources, KaustavC, & Debashis B (2010) Insight in schizophrenia- A comprehensive update. German Journal Of Psychiatry,13,17-30. Kemp, R.A & Lambert, T.J. (1995) Insight in schizophrenia and its relationship to psychopathology. Schizophrenia Research, 18, 21– 8. Kim, Y., Sakamoto, K., Kamo, T., Sakamura, Y, & Miyaoka, H. (1997) Insight and clinical correlates in schizophrenia. Comprehensive Psychiatry, 38, 117– Koren, D., Seidman, L.J. & Poyurovsky, M.(2004). The neuropsychological basis of insight in first-episode schizophrenia: a pilot metacognitive study. Schizophrenia Research, 70, 195–202. Larøi, F., Fannemel, M. & Rønneberg, U.(2000) Unawareness of illness in chronic schizophrenia and its relationship to structural brain measures and neuropsychological tests. Psychiatry Research, 100(1), 49–58. Lepage, M., Buchy, L., Bodnar, M., Bertrand, M.C., Joober, R. &Malla, A. (2008).Cognitive insight and verbal memory in first episode of psychosis. European Psychiatry, 23, 368-74. Luria, A.R. (1973). The working brain. New York: Basic books. Lysaker, P. & Bell, M. (1994) Insight and cognitive impairment in schizophrenia: performance on repeated administrations of the Wisconsin Card Sorting Test. Journal of Nervous and Mental Disease., 182(11), 656–660. Markova, I.S. & Berrios, G.E. (1995) Insight in clinical psychiatry. A new model. Journal of Nervous and Mental Disease, 183, 743–51 McGlynn, S.M. & Schacter, D.L. (1989) Unawareness of deficits in neuropsychological syndromes. Journal of Clinical and Experimental Neuropsychology,. 1, 143–205. Mingrone, C., Rocca, P., Castagna, F., Montemagni, C., Sigaudo, M., & Scalese, M. (2013). Insight in stable schizophrenia: Relations with psychopathology and cognition. Comprehensive Psychiatry, 54, 484–92. Mintz, A.R., Dobson, K.S., & Romney, D.M. (2003) Insight in schizophrenia: A metaanalysis. Schizophrenia Research,61, 75–88.

Mohamed, S., Fleming, S., Penn, D.L., & Spaulding, W. (1999) Insight in schizophrenia: Its relationship to measures of executive functions. Journal of Nervous Mental Disorder,187, 525–31 Monteiro, L.C., Silva, V.A. & Louza, M.R. (2008) Insight, cognitive dysfunction and symptomatology in schizophrenia. European Archive of Psychiatry Clinical Neuroscience .258:402–5. Morgan, K.D. & David, A.S.. (2004) Neuropsychological studies of insight in patients with psychotic disorders. Insight and Psychosis. Oxford University Press,.177–93. Mutsatsa, S.H., Joyce, E.M., Hutton, S.B & Barnes, T.R. (2006) Relationship between insight, cognitive function, social function and symptomatology in schizophrenia: The West London first episode study. European Archive of Psychiatry Clinical Neuroscience,256, 356–63. Orfei, M.D., Spoletini, I., Banfi, G., Caltagirone, C. &Spalletta, G. (2010). Neuropsychological correlates of cognitive insight in schizophrenia. Psychiatry Research, 178, 51–6. Palmer, B.W., Dawes, S.E. & Heaton, R.K. (2009) What do we know about neuropsychological aspects of schizophrenia? Neuropsychology Review journal,. 19, 365–84. Pedrelli, P., McQuaid, J.R. & Granholm, E. (2004). Measuring cognitive insight in middle-aged and older patients with psychotic disorders. Schizophrenia Research, 71, 297–305. Pijnenborg, G.H., Van, Donkersgoed, R.J., David, A.S., & Aleman, A. (2013) Changes in insight during treatment for psychotic disorders: A metaanalysis. Schizophrenia Research,144,109–17. Pyne, J.M., Bean, D., & Sullivan, G (2001) Characteristics of patients with schizophrenia who do not believe they are mentally ill. Journal of Nervous Mental Disorder,189, 146–53 Ritsner, M.S. & Blumenkrantz, H. (2007) Predicting domain-specific insight of schizophrenia patients from symptomatology, multiple neurocognitive functions, and personality related traits. Psychiatry Research, 149,59–69 Rossell, S.L., Coakes, J., Shapleske, J., Woodruff, P.W.R. & David, .A.S. (2003) Insight: its relationship with cognitive function, brain volume and symptoms in schizophrenia. Psychological Medicine., 33(1), 111–119. Subotnik ,K.L, Nuechterlein, K.H., Irzhevsky, V., Kitchen, C.M., Woo, S.M. &Mintz ,J. (2005) Is unawareness of psychotic disorder a neurocognitive or psychological defensiveness problem? Schizophrenia Research,75, 147–57. Shad, M.U., Muddasani, S., Prasad, K., Sweeney, J.A. & Keshavan, M.S. (2004).Insight and prefrontal cortex in first-episode Schizophrenia. Neuroimage, 22, 1315–20 Shallice, T. (1982).Specific impairment in planning. The Neuropsychology of Cognitive Functions, 199-209. London: the Royal Society. Simon, V., De, Hert. M., Wampers, M., Peuskens, J. & VanWinkel, R. (2009) The relation between neurocognitive dysfunction and impaired insight in patients with schizophrenia. European Psychiatry, 24, 239– 43. Startup, M. (1997) Awareness of own and others’ schizophrenia illness.Schizophrenia.Research,.26, 203-211. Young, D.A., Davila, R. & Scher, H. (1993) Unawareness of illness and neuropsychological performance in chronic schizophrenia. Schizophrenia Research,10:117–24. SIS Abstracts Download The soft copies of the abstracts of published papers of all issues in SIS Journal of Projective Psychology and Mental Health commencing from Volume 1 (Launching year 1994) to the current year can be downloaded free of cost from the website of Somatic Inkblot Society on following URL: SIS Abstracts: http://somaticinkblots.com/abstracts/ Copyright ©1994. SIS Center, India/Anchorage

SIS-II Indices and Suggestibility Ruchi Jain, Sandhyarani Mohanty and Rakesh Kumar SIS is a projective tools which can be employed to tap both intra-psychic and interpersonal aspects of a person. We were interested to study if any of SIS-II indices are linked with suggestibility of the respondents. We sampled 18 adults in the age range of 18-35 years after screening on GHQ-12. We then administered SIS-II (Booklet Form) and Hypnova Suggestibility Questionnaire. The non-parametric correlation coefficients were significant for Total Responses Vs. Physicla Suggestibility and Most Typical Responses Vs. Emotional Suggestibility. These results suggest that suggestibility can have some influence on SIS-II indices. We have drawn an implication for empirically studyingthe potentials of SIS in terms of suggestibility. Suggestibility is an openness to suggestions. In suggestibility a person’s behaviour can get modified in accordance with the given suggestions irrespective of its basis in rationality and logicality. Weitzenhoffer (1974) defined suggestibility more specifically as the "capacity to produce the classical suggestion effect that is, a non-voluntary (or avolitional) response relevant to the content of a communication intended to be a suggestion". Kappas (1987) classified suggestibility into two types – Emotional and Physical Suggestibility. (a) In emotional suggestibility a person responds to the suggestions by inferrring the meaning; that is by reading in between lines. They may more or less fail to respond in accordance with the suggestions that are very specific and concrete. (b) In physicalsuggestibility, the person responds literally to the suggestions. He does not interpret or add one’s meaning to the given suggestions. Emotionally suggestible persons give more emphasis on thinking, whereas the physically suggestible are guided more by their emotions. Physicals are more regulated by their hearts and emotions. They react to the life by what they feel rather than by what they think. The emotions come first then the logic. The suggestibility is linked to both the cognitive processes involved in inferrence and also the emotionality. The inkblots are capitalized on the interpretation/inference potentials of ambiguous stimuli. A person is presented with the unstructured task and he is required to come with associations to inkblots by way of interpreting the patterns of inkblots. While analyzing the interpretations (responses) of the subjects to the inkblots, a clinician discern the personality, cognitive, interpersonal and emotional correlates of the associations. The responses such as Movement, Human, Color, Pathological Scales give clues to the emotional climate of the respondent. In this context, we hypothesized that inkblot response patterns should correlate with the tests of suggestibility. Aim:For empirical evaluation, we opted SIS- II due to its unique system of content analysis for exploring the associations of inkblot responses with the tests of suggestibility. Method: Sample: A sample of 18 psychologically healthy adult persons in the age range of 18- 35 years was drawn through non-probability sampling from Agra, India. Tools: Following tools were individually administered on the subjects. General Health Questionnaire (GHQ)-12: This questionnaire was developed by Goldberg (1972). It consists of 12 items. The questions are based on behavioral and psychological functioning. This test is used to screen out persons with possible mental

Ruchi Jain, M.A., PGDCP, Research Scholar, MewarUniveristy, Chittorgarh. Sandhyarani Mohanty, Ph.D. Research Officer; Rakesh Kumar, Ph.D. HOD, Clinical Psychology, Institute of Mental Health and Hospital, Agra- 282002 (Corresponding Author Email: jain.imhh@gmail.com) Key Words: Suggestibility, hypnotizability, projective techniques, inkblots, SIS

health issues. In this study only those adults falling in category of ‘healthy’ were included. Hyp-Nova suggestibility Scale: This scale is based on the work of John Kappas (1987). It consists of two sets of questionnaire – physical suggestibility and emotional suggestibility. Each set has eighteen yes or no questions. The score of the questionnaire can range anywhere between one and one hundred. Test measures physical and emotional suggestibility of the subjects. Somatic Inkblot Series-II: Somatic Inkblot Series-II consists of 62 images in a booklet. A person is required to associate to the partially ambiguous images. The responses are then analyzed on following 11 variables: Total Responses, Typical Responses, Most Typical Responses, Atypical Responses, Anatomy Responses, Human Responses, Movement Responses, Animal Responses, Sex Responses, Image Rejection and Pathological Responses – Depression, Pathological Anatomy, Hostility and Anger, Paranoia. This test is being employed in a variety of conditions which provide extremely useful information regarding psychodynamics and interpersonal relationship of the person. Procedure: The prospective participants were identified, approached and briefed about the nature of the study. Suggestibility Questionnaire and SIS-II were administered on the participants. Scoring was done for individual subjects with respect to each of the variables in accordance to the standard procedure of scoring. Data Analysis: Mean, S.D. and Spearman Rank Order Correlation Coefficients were computed to analyze the data. Results and Discussion: Table 1: Mean and S.D of SIS-II Indices and Suggestibility Measure Scored Variables Mean Std. Deviation Total Responses 62.11 5.92 Human Responses 24.11 4.82 Animal Responses 9.61 4.67 Anatomy Responses 14.33 6.50 Sex Responses .78 1.06 Movement Responses 7.89 5.20 Most Typical Responses 11.22 3.24 Typical Responses 46.22 5.41 Atypcial Responses 15.16 5.44 Image Rejection 2.33 4.81 Pathological Anatomy .67 .90 Depression 1.17 1.61 Hostility and Aggression .33 .84 Paranoia .11 .32 Physical Suggestibility 54.56 12.06 Emotional Suggestibility 43.78 10.60 Table 2: Correlation Coefficients in SIS-II Indices and Suggestibility Measure Scored Variables Physical Suggestibility Emotional Suggestibility Total Responses -.541* .355 Human Responses -.187 .281

Animal Responses -.418 .228 Anatomy Responses -.268 .454 Sex Responses -.299 .077 Movement Responses -.114 .041 Most Typical Responses -.349 .491* Typical Responses -.223 .411 Atypical Responses .022 -.233 Image Rejection .287 -.151 Pathological Anatomy .091 .023 Depression .123 .015 Hostility and Aggression -.062 .148 Paranoia -.274 .343 *Significant at .05 level The findings of this study suggest that physical suggestibility is inversely related with the quantity of responses on SIS-II. The physically suggestible persons use less of their imagination and creativity in producing associations to the ambiguous tasks presented in SIS. The second finding is that most typical responses are positively associated with emotional suggestiblity. Most typical responses on SIS-II suggest a shared thinking with the group also the potentials of team membership. This shared thinking involves understanding the context and the rules both explicit and implicit which are in effect in a group or social situations. Since, the emotionally suggestible persons are better in making inferences, the finding is in agreement with the conceputal framework of emotional suggestibility. The analysis of the data revealed that only two variables Total Responses and Most Typical Responses are associated with suggestibility of the respondents. Still, it is interesting to note the observed correlations which at the first instance suggest that the responses on inkblots can have at least some associations with the suggestibility of the persons. If it is so, systematic investigations can also be conducted for group comparisons by suggesting different tasks for the groups. For example, group researches can be designed by giving a preorientation to the groups such as Group-I can be oriented that SIS is a tool to assess interpersonal relationships. You will find interesting interpersonal situations depicted in the images of SIS. A Group-II can be oriented that SIS is a powerful tool to asses intra-psychic conflicts, wishes, frustrations etc. The situations depicted in SIS are such which can penetrate into the deeper layers of the mind. More such group orientations can be conceptualized. Such kind of experiments can yield useful information on the potentials of SIS as well as would encourage versatile applications of Somatic Inkblot Series. Conclusion: Some of the SIS-II indices are significantly associated with suggestibility. SIS can be a potentially good tool to explore the effects of suggestibility on the responses of the participants. It opens a new area and avenues for empirical researches on Somatic Inkblot Series. References: Goldberg, D. (1972). The detection of psychiatric illness by questionnaire: A technique for the identification and assessment of non-psychotic psychiatric illness. London, New York: Oxford University Press. Kappas, J.G. (1987) Professional Hypnotism Manual: Introducing Physical and Emotional Suggestibility and Sexuality. Panorama Publishing Company. Weitzenhoffer AM (1974) When is an ‘instruction’ an ‘instruction’? International Journal of Clinical and Experimental Hypnosis. 22: 258–69.

Draw A Person Test: A Case Study T. Jothimani and S. Deepak Kumar Children have variety of problems and are highly vulnerable to physical and verbal abuse, sexual victimization, critical traumatic experiences, and accidents. They are exposed to unhealthy habits like smoking, drug usages, theft, robbery and other illegal activities. They don't express their feelings and concerns freely with anyone. Drawing can be used to assess those hidden expressions of the child. Drawings can be used in school settings with students who are struggling with normal developmental issues (Chen Foley, Y., Mullis, F., 2008). The present case study analyzed a VIII standard school student who had difficulties in studies as well as some behaviour problems by using Draw-a-Person test. Children are observing each and everything from their environment, while they grow. They try to imitate the behaviour of others and consider them as role models. When they are observing right they do right, if not they act accordingly. Their learnt behaviours are either reinforced or punished that determine the occurrence of the behaviour. When they are allowed freely to express the feeling and behaviours observed, by parents and significant others, they develop a positive regard and trust over others and self (Wenar, Kerig, 2000). If they are restricted or not motivated to do so result in negative selfimage, social withdrawal, and they avoid participating in social gatherings. Suppressing their emotions within them self creates problems internally and it is exhibited through their academic performance, hostile behaviours towards others, problems in interpersonal relationships, etc (Sarason and Sarason; 2012). Problems like anxiety exist in all ages of life. In childhood and adolescence, labelling, school phobia, parental punishments, fears of failures, others are some of the commonly found sources of anxiety and other hostile behaviours in their age (Wenar&Kerig, 2000). These are also associated with problems in academic performances, relations with teachers and friends, etc.; Problems of these concerns are not expressed by the children while conducting psychological tests using questionnaires or rating scales. Hence the Projective tests play an important role in finding out such latent content of the client especially in children. Drawing can be used to assess those hidden expressions of the child. Drawings can be used in school settings with students who are struggling with normal developmental issues (Chen Foley and Mullis, 2008). Children’s drawings are indicators of emotions, selfesteem, and social competence, as well as other aspects of their personality (Di Leo, 1973; Malchiodi, 1998), and also a way for children to call attention to topics that are personally important or emotionally significant (Thomas & Silk, 1990). Goodenough (1926) along with other clinicians realized that the Draw-A-Person test (DAP) provided possible indicators of personality dynamics, in addition to intellectual aptitude. With this in mind, the DAP test was adapted for personality description and interpretation by Machover (1952). She hypothesized graphic expressions within drawings reflected specific characteristics (Oster & Gould, 2004). Case study: Mr. J of age 13, male studying VIII standard in a private school was referred for his poor academic performance and inappropriate behaviours. He was administered with a tool to check for Specific Learning Disability. Further he was administered with Draw-a- Person test (DAP), to elicit the root cause for his inappropriate behaviours. T. Jothimani , Ph.D. Asst. Professor (Email:jothi.psy@gmail.com)and S. Deepak Kumar, M.A. Final student, Dept. of Psychology, PSG College of Arts and Science, Coimbatore-14. Key Words: Children, hazards, developmental issue, draw-a person test, expressions.

The human figure drawn by him revealed some problematic features existing within him are discussed in detail in this study. The analysis of his performance in Specific Learning Disability tool revealed that he has difficulty in reading, paying attention, in recall, and concerns in mathematical graded functions. He was highly distracted by his external surroundings. His behaviours and non-verbal expressions were not appropriate to the surrounding. He was restless and highly defended in the initial phases of interview but still rapport was established in short time. However he was shy to express his thoughts and feelings and been restless in the whole session. After collecting necessary details the DAP test was administered. The figure drawn is shown ahead. The Scoring and Interpretations was made as per standard procedure (Van Neikirk, 1978). Initiation to Draw and Possible Interpretation: As soon as he was provided with a paper, pencil and instruction to follow, he started drawing the human figure. He looked uncertain, tense, anxious and insecure. He took more time to complete the drawing indicating his perfectionism and over-precise in his drawing. Formal Characteristics of the Drawing: Position: The drawing was made on the left side of the paper indicating an introversion tendency, being self-conscious, with insecure feelings. Use of Lines: The lines were faint, very light which shows that he is shy, reserve and insecure. Further the lines were fragmentary which revealed his anxiety, feelings of inadequacy and insecurity, hesitant, weak-willed and has a unwillingness to explore things. He did not use any colour in the figure and did not make anything other than a human figure. Size of the Figure: The size of the picture is small, thin and frail in general, indicating the feeling of inadequacy, rejected, need to withdraw and insecure. Appearance, Attitude and Perspective: The human figure made by him, though being small, was with good integration over body parts, head and body in front view and feet were in profile. This shows his dependency, and also the readiness to communicate with others. The feet were drawn in opposite directions showing his experiences in his surroundings (educational situations) are problematic and he is dissatisfied and unhappy about it. The human figure is stiff and passive, portraying him as self-conscious, tense, anxious, reserved, and having problems with interpersonal relationships. Particular Content: Clothing: The clothing was appropriate to gender and normal to his age. However, some features like over emphasis on “Belt Region” showing his puberty problems, with this finding his anxious and insecure feelings about sexual Draw A Person Test:: 119

concerns could be elicited. The greatly emphasized “Buckle Button” in the navel shows his dependency towards his mother. The greater importance in portraying the “Pockets” reveals his infantile character, being dependent on others, and deprivation of love. The “Shoes” were also over emphasized which possibly portraying his insecure feeling, anxious, dependency and problems in education. Parts of Figure (Body Parts): The drawing has all parts of the human body except eye pupils and chin and some parts were given less importance. The body parts were integrated with each other. The Head was drawn very smaller compared to the size of body and whole picture. The “Small Head” in his drawing shows that he is a despondent, introvert, uncertain in social relationships and self-conscious. The “Hair” is also being emphasized and it was observed that it was drawn as last part of the drawing that portrays his tendency to be aggressive, puberty problems, being bodily inadequate and his problems in interpersonal relationships. The “Mouth” was emphasized only with outline and it shows him being depressed, moody, experiences body in terms of food fantasies. The “Chin” area is being omitted that shows his feeling of inadequacy and infantile character. The “Eyes” were drawn without pupils which portrays his troubles meeting and socializing with people (Chen Foley, Y., Mullis, F., (2008), affectively liable, egocentric, and body experience as weak sighted. The “Ears” were drawn in its actual size and it was appropriate to the size of the head. The “Nose” drawn as flat and as outline, showing his rejection, contempt for symbol, maybe a signal feelings of powerlessness, shyness or withdrawal (Chen Foley, Y., Mullis, F., (2008). The “Neck” was long and thin portraying his inadequacy, bodily weakness, and aggression. Specific details were given on belt and it is appropriate for a boy and button by navel showing his overdependence with others especially with mother. The “Arms” were drawn straight down the body exhibits him as being tense, withdrawing, unwilling to explore, passive and affectively liable. The “Hands” were vague, dim showing his lack of confidence in interpersonal relationships. The “Fingers” were sharp pointed indicating that he is openly aggressive. The “Legs and Feet” were overly emphasized and it shows his feeling of insecurity and helplessness. Finally the “Toes” in his drawing reflects his aggressiveness. Other Evident Interpretations: According to Koppitz (1968) scoring manual for 30 Emotional Indicators, some features of human drawing made by this boy like tiny figure, tiny head, big hands, confirms possible emotional concerns. The long and spike lines of hands indicated aggressive and hostile behaviours. The small head shows obsessive-compulsive traits and also intellectual inadequacy. The size difference in the different parts of the body in the drawing showing that he might have mixed feelings regarding being independent and shoulders drawn squared shows that he is overly-defended and hostile towards others (Jolles1971 and Mitchell et.al 1994). The “Light Line” quality of the drawing may indicate low self-esteem and the overall small size of figure may indicate that he is insecure, withdrawn, depressed and having feelings of inadequacy. The “Large Hands” may indicate acting out behaviours. The emphasis on “Belt” and around the “Waist Region” shows possible sexual conflicts and covert tension (Machover,1952). Conclusion: As a whole, the human figure drawn by the boy was appropriate to the age and gender. Some features of the drawing showed that he is anxious, hostile towards others, feeling inadequate, not interested in socializing processes, withdrawn and shy. Some of the features in the figure portrayed his dependency on others and problems in

interpersonal relationships. He seems to be not interested in expressing to anyone. Based on the findings, suitable treatment modalities like SLD remedial teaching, social skills training etc., were recommended to the child. Reference: Chen Foley, Y &, Mullis, F., (2008).Interpreting children's human figure drawings; Basic guidelines for school counselors. GSCA Journal, Vol 1 (1), 28-37. DiLeo, J. H. (1973). Children's drawings as diagnostic aids. New York: Brunner/Mazel. Goodenough, F. L. (1926). Measurement of intelligence by drawings. New York: Harcourt, Brace & World. Jolles, I. (1971). A catalog for qualitative interpretation for H-T-P. Los Angeles: Western Psychological Services. Koppitz, E.M. (1968). Psychological evaluations of children's human figure drawings. Orlando, FL: Grune& Stratton. Machover, K. (1952). Personality projection in the drawing of human figure. Springfield, IL: Chrales C. Thomas. Malchiodi, C.A. (1998). Understanding children's drawings. New York: Guilford Press. Mitchell, J., Trent, R., & McArthur, R (1994). Human Figure Drawing Test (HDFT): An illustrated handbook for clinical interpretation and standardized assessment of cognitive impairment. Los Angeles: Western Psychological Services. Oster, G.D.& Gould, P. (2004). Using Drawings in Assessment and Therapy: A Guide for Mental health Professionals (2nd ed.). New York: Brunner/Routledge. Sarason, I.G & Sarason, B.R. (2012).Abnormal Psychology: The Problem of Maladaptive Behaviour (11th edition). New Delhi: PHI Learning Pvt Ltd. Thomas, G. V., & Silk, A. M. J. (1990).An introduction to the psychology of children’s drawings. NY: NewYork University Press. Van Neikierk P A., (1978). Orthopedagogiese Diagnostiek. University Publishers and Booksellers.Stellenbosch.Wenar C., Kerig P (2000). Developmental Psychopathology: From Infancy through Adolescence (4th ed). Mc Graw Hill Higher Education. 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 Draw A Person Test:: 121

John E. Exner: A Man Who Revived the Rorschach Test Ranjeet Kumar Exner Jr’s contribution in the area of Clinical Psychology especially personality assessment has been remarkable. He has devoted his entire professional life in the development of Rorschach and his comprehensive system. His methods, procedures and interpretation of Rorschach became standard for mental health professionals worldwide. Exner involved collaborative approaches and efforts in countries through ought the world for research related to personality & Rorschach and due to his meticulous efforts his comprehensive system became internationally accepted system. “Imagine for a moment, that you are a young graduate student who has developed an abiding interest in the Rorschach. Would you consider yourself blessed or at least quite fortunate, to spend a summer with the greatest name in Rorschach, well that just happened to young John Exner ... not only did Exner get to know Samuel Beck and Bruno Klopfer in this manner, but he was also fortunate enough to maintain lifelong relationships with both men” (Handler, 1996). Exner has a great impact and contribution in the field of psychological assessment. His name became synonymous with the Rorschach test. Through his extensive research, publication of literatures related to Rorschach, and training of psychologist all over the world, John Exner has evolved a common method of Rorschach Test. Early History: Exner was born in Syracuse, New York. He received his BS & MS degree in psychology from Trinity University and later in 1969 was awarded PhD in clinical psychology from Cornell University. While graduating in 1954 summer, he assisted Beck in a workshop in Chicago. It was an intellectually & emotionally nourishing experience for Exner. In next summer he assisted Klopfer in conducting workshop in California and spent more time with him to discuss about Rorschach system. He served as faculty at DePauw University and Bowling Green University from 1968 to 1969. He joined as a Director of the East Asia/Pacific and North Africa for the office of selection of Peace Corps of the United States. After this Exner joined as a faculty member at Long Island University, where he served as director of clinical training from 1969to 1979 and later elevated to Emeritus Professor in 1984. Exnerwas the past president of the international Rorschach society and curator of the Rorschach archives and museum in Bern Switzerland. He was executive Director of Rorschach workshops in Asheville, NC. More than four decades he focused on the Rorschach and developed a standardized system for its interpretation, widely known as Comprehensive System of Interpretation. It was first published in 1974 has more of numerical objective interpretation of Rorschach. For his outstanding lifetime contribution he received the Bruno Klopfer Distinguished Contributions Award in 1980 from the Society of Personality Assessment. He was the author of 14 books and several research articles on Rorschach. Exner expired at the age 77 on 20th February 2006 after courageous fight with leukaemia. He is survived by his wife Doris and five children. Doris is continuing as the administrator of Rorschach workshops since its inception. To remember Exner’s contribution, the Society of Personality Assessment, gives “Young Researcher Award” every year. Ranjeet Kumar, Ph.D., M.Phil.,AsstProf.Clin. Psych., Gwalior Mental Hospital, Gwalior (India) Email: ran_psy@yahoo.co.in

Overview of Comprehensive System: Dr. Exner developed the comprehensive system as a scientifically valid clinical useful and reliable method of the Rorschach inkblot test. He did this by working with a number of Rorschach experts such as Klopfer, Beck, Rappaport, and Hertz (Handler, 1996). During his graduation, he was impressed by Klopfer and Beck. Later he found that both men were against each other. They refused to speak to one another as stated by Handler in his personal communication with Exner (Handler 1996). His desire to bring them together eventually became the guiding forces behind the development of Exner”s Comprehensive System. Beck suggested to Exner to do a paper describing the difference between two systems. Surprisingly Klopfer also thought it was a good idea. Exner started to work on what he thought would be a 20 to 25 pages, but soon he realized how difficult it was to summarize the differences. Later Exner began to feel that it’s better to write short monograph to compare all existing systems. After this work, Exner decided to bring the documents as a book and it was Beck who helped him to publish it. Exner sent them to each of the five experts for evaluation. But he was very disappointed when he came to know that neither Klopfer nor Beck liked the book because in the conclusion Exner did not explicitly stated whose system was best. Handler stated that “Klopfer told me the big mistake you made is you did not say who the best was; too bad you couldn’t decide which one is best. Even Piotrowski was also unhappy because he believed his Rorschach interpretation system was best”. The book took seven years and several interviews with these folks. Exner was quite unhappy with his two godfathers, they disappointed him very much. After reviewing the research for almost 2 years and attempting to determine which system was most valid he came to the conclusion that each system has its assets and each had limitations.

The Comprehensive System is the result of addressing these differences. Exner has rescued the Rorschach test and brought it back to life. In the preface of his first publication of comprehensive system in 1974, Exner stated that, this system draws from the original five systems, incorporating those features, under careful scrutiny. Exner established Rorschach workshops in 1969 to study the merits and difference between all five existing system at that time. After developing the comprehensive system, Rorschach workshops added to continuing education programme. Its objective shifted to expansion of knowledge concerning its applicability based on empirical research. By this continuous effort, Exner’s Rorschach workshops foundation trained more than thousands of clinical psychologist around the world. The over emphasis on objective /numerical interpretation of projective inkblot responses was criticised by Rorschachians who believed in psychoanalytic interpretation of inkblot responses to tap the unconscious repressed material (Cassell and Dubey, 2003; Dubey et al, 2005). Contributions of John E. Exner: Exner was committed to advancing the science of personality assessment by his empirical research in the development and application of assessment instruments. Exner developed the Comprehensive System and revised several times to include the findings of researches. Prior to Exner's systematizing efforts, the Rorschach test had five different scoring systems (Exner, 1974). Exner selected the important indices from these systems and combined them to form the basis of his comprehensive system. Because of this, lot many indices are common but the procedure of administration, inquiry and the criteria used to score the responses are different to some extent. Exner incorporated several new variables such as adding developmental quality, Form Dimension and Special Scores along with their severity level, which helps in establishing the psychopathology. The most distinguishing achievement in it has been the development of various constellations empirically derived to predict certain clinical phenomenon to John E. Exner: 123

assist in differential diagnosis, namely Schizophrenia index (SCZI) currently modified as Perceptual Thinking Index (PTI), Depression index (DEPI), Suicide potential (S-CON), Obsessive Cognitive Processing (OBS) index and index for assessing Social and emotional coping factors (CDI). Books: Exner has authored/edited several books such as, the Rorschach: Basic Foundations and Principals of Interpretation (1974); The Rorschach: A Comprehensive System- Volume 2: current research and advanced interpretation (1978); Dimensions of Personality (1978); The Rorschach, Assessment of Children and Adolescent (1982); History and Directory: Society for Personality Assessment (1989); The Rorschach Interpretation (1991); The Rorschach, advanced interpretation, (1991); Issues and methods in Rorschach research(1995); A Rorschach Workbook for the comprehensive system (1996); A Primer for Rorschach Interpretation (2002); The Rorschach : A Comprehensive System (2005) etc. Acceptability of the Exner’s system internationally during his life time speaks about the objectivity, reliability, and validity of Exner’s system. He has very efficiently integrated different scoring systems and created interest in keeping the test alive. Bibliography: Cassell, W, A. and Dubey, B. L. (2003) Interpreting Inner World through Somatic Imagery: Manual of SIS. Anchorage: SIS Center. Dubey, B. L. ,Cassell, W.A. and Dubey, Anand(2005) Impact of Number of Responses on the Interpretation of Rorschach Indices, SIS Journal of Projective Psychology & Mental. Health, 12: 27-48. Exner, J.E. (1969). The Rorschach systems. New York: Grune& Stratton. Exner, J.E. ( 1974). The Rorschach : A Comprehensive System; Vol. 1,New York; Wiley Exner, J.E. ( 1978). The Rorschach ; A Comprehensive System; Vol. 2, New York; Wiley. Exner, J.E.(1995). A Rorschach workbook for the Comprehensive System.Aseville, NC; Rorschach workshops. Handler,L. (1996). John Exner and the book that started it all: A review of the Rorschach systems. J Pers. Assessment, 650-658. APPEAL Dear Life Members, We are thankful to you all for the continued support and association with SIS. We are encouraging our esteemed Life Members with 10 years or more membership to upgrade their Membership to the level of Fellow of the Society by submitting Membership Application Form accompanied by payment of Rs. 2500/- only. Bankey L. Dubey, Ph.D., Director SIS Centre, 4406 Forrest Rd, Anchorage, AK 99517, E-mail: bldubey@gmail.com Web: www.somaticinkblots.com

Cognitive Drill Therapy: A Potent Application of the Principles of Psychology for OCD and Phobia Rakesh Kumar and Bankey L. Dubey Cognitive Drill Therapy (CDT) capitalizes on the principles of classical conditioning, operant conditioning, cognitive appraisal and linguistics. Combined together in a customized manner, application of these principles have the potentials of efficient handling of stimulus bound anxiety more specifically phobia and Obsessive- Compulsive Disorder (OCD). In these disorders, exposures to neutral objects tend to trigger fear reactions amounting to panic in some cases. The patients learn to deal with these fears by avoiding as far as possible the exposure to such fear provoking stimuli. For example, a person with claustrophobia exhibit fear reaction in closed places. As and when such patient comes into contact with closed places like lift, MRI Scanner, metro trains, closed bathroom etc. will experience severe anxiety reaction. To prevent the experiences of fear reactions, he/she will avoid these situations by opting staircase even in multistory buildings, Open MRI Scan or scanning under anesthesia; avoid using metros and take bath in open bathrooms. The avoidance in this manner reinforces the patients’ strategy and the patients adopt a life style which minimally involves exposure to closed places. Whatever, is the lifestyle adopted by the patients to avoid closed places or objects of any phobia for that matter imposes limitations on the optimal functioning of the patients. The life is crippled in many cases. Cognitive Drill Therapy conceptualizes stimulus bound anxiety as a two layer structure; (a) Top Layer also called as surface structure/conscious structure. (b) Bottom Layer Structure also called as underlying fear structure consisting of imagined feared consequences/ subconscious structure because the patients remain dimly aware of the bottom layer. The top layer structure consists of objects of fear such as closed places, heights, open places, crowds, animals, insects, pointed objects, examination (as seen in specific phobia); social situations like asking a question in class, talking to superiors, making a presentation on stage, giving a speech, talking with authorities (as seen in social anxiety); being away from home, in a crowded place (as seen in agoraphobia); dirty and contaminated objects; abusive, sexual and aggressive thoughts in religious places, sexual thoughts and images for family members; objects kept in disorganized manner, displaced objects, locking of doors (as seen in OCD). These apparently neutral objects elicit fear and disgust reactions in the patients. These reactions are usually associated with psychophysiological arousal characterized by accelerated/shortness of breath, faster heart beat, tense muscles, sweating, blurred vision, trembling. The patients subjectively feel discomfort, uneasiness and psychic pain at cognitive level. To deal with the arousal or to prevent the arousal, the patients would avoid exposure by taking alternative routes so that feared objects are not encountered, shy away from the social situations, would not leave the house alone; keep on cleaning the apparently clean objects, would repeatedly check the doors, gas, locks; seek forgiveness from the God for abusive and sexual thoughts, would go at length to keep the objects organized and in order. These attempts are successful for a temporary period; and the cycle continues. The Top Layer can be summarized as follows: Exposure to objects of fearPsychophysiological arousal/Subjective experience of pain or discomfortEscape/Avoidance patterns (negative reinforcement) Temporary Relief Rakesh Kumar, Ph.D. HOD Clinical Psychology, Institute of Mental Health and Hospital, Agra; Bankey L. Dubey, Ph.D. President, SIS Email: jain.imhh@gmail.com Website: www.Cognitivedrill.com (Free Manual Download) Key Words: Cognitive Drill Therapy, Exposure Therapy, OCD, Phobia

The bottom layer consists of a series of underlying fears and imagined feared consequences such as fear of suffocation and death in closed places; fear of negative evaluation, ridicule, rejection, loss of selfimage in social anxiety; fear of catching a disease like rabies in dog phobia, fear of failure, going blank, losing face, spoiling career in examination anxiety; fear of inhaling germs and spreading contamination and disease in OCD; fear of God’s punishment, causing curse or misfortune to the family in aggressive/sexual thoughts for God and so on. In Cognitive Drill Therapy, it is believed that the patients remain struck in top layer and rarely deal with the underlying fear structure. For efficient handling of these problems we need to directly address the bottom layer and expose the patients to this underlying fear structure. Once this underlying fear structure is destroyed, the patients will show proportionate improvements in OCD and phobia. The drill therapy utilizes the principles of exposure therapy to attack on the underlying fear structure. The protocol of the therapy is very specific, clear and straightforward. A patient is given proper psychoeducation which consists of sharing the diagnostic label of the problem, communicating the understanding of two layer structure, handling magical thinking that merely by having thoughts in one’s mind actual physical events cannot be caused. An education regarding anxiety curve and mandatory requirement of homework is also given. The patients are specifically educated about the future orientation of anxiety. They are made to realize that anxiety looks into the future. Under conditions of fears, their subvocal speech centers around imagined possibilities of harms in some future time; and our task is to convert this future orientation into past or present orientation. The objects of phobia are implicitly and mistakenly perceived as predictive of harmful future consequences. One of the important goal of Cognitive Drill Therapy is to destroy the perceived predictability of the neutral objects leading to harmful consequences. The neutral objects are neutralized in the process. The patients are also educated regarding the Concept of Universal Probability, which means that harmful consequences can occur to any person any time. All of us are having more or less equal probability of such an outcomes. Having given the psychoeducation, the patients are required to imagine objects of phobia and repeat covertly or verbalize the imagined feared consequences by converting the tense to the present or the past. For example, in claustrophobia, imagine yourself in a closed place and verbalize “I am suffocated”; “I am experiencing suffocation”; “I have died of suffocation”. Initially it leads to quick spike of fear reaction and with continuous repetitions, it leads to resolution of fear within minutes. This procedure is repeated for as many objects of fear as possible both in sessions and in homework. Drill & Daring is the slogan. Perform drill and dare to expose yourself to objects of phobia. The resolution of phobia can occur in a single or a few sessions. OCD takes longer time. The pre-post case studies (Kumar et al. 2012; Dwivedi & Kumar, 2015) documented the efficacy of this therapy. Many more researches are in pipeline. We are looking forward for task based fMRI researches for demonstrations of live changes in the brain during drill therapy and inclusion of projective techniques such as Somatic Inkblot Series-II and Live Images Version for exploring changes in the perception of objects and inner cry through this therapy. References: Kumar.R., Sameer.A., Singh.B. (2012). Preliminary Test of Cognitive Drill as an Intervention. Indian J.Clini. Psych., 39, 67-74. Dwivedi, S. and Kumar, R. (2015) Efficacy of Cognitive Drill Therapy in Agoraphobia with Panic Disorder: A Case Study. SIS Journal of Projective Psychology and Mental Health, 139-146.

SOMATIC INKBLOT SOCIETY Membership Application Form Membership Type: Full Name: Correspondence Address including PIN/ZIP: Email: Cell with Country Code: Date of Birth Education: (Degree, Year, Institution, Major Field of Study) Employment: Current position, employer, dates (Graduate Students indicate area of study and degree toward which you are working). Training and Experience in Personality Assessment Sponsor (Name Address cell and Email) Mention whether you need Print Version of the Journal or Only Soft Copy (Go Paperless and Environment Friendly) Types of Memberships and Fee Details Individual Annual Membership (Foreign) US $50 Individual Life Membership (Foreign) US $300 Fellow Member- After 10 Years Life Membership (Foreign) US $150 Institutional Annual Membership (Foreign) US $100 Individual Annual Membership (Indian) Rs. 1000/- Individual Life Membership (Indian) Rs. 5000/- Fellow Member-After 10 Years Life Membership (Indian) Rs. 2500/ Institutional Annual Membership (Indian) Rs.1500/- Institutional Life Membership (Indian) Rs. 10,000/- Pay Membership Fee through Bank Deposit Bank Name and Address: State Bank of India, Krishna View Plaza, Marble Market, Plot # 20, Sector 20, Dwarka, New Delhi-110075 (India) Name of Account: SIS Journal of Projective Psychology & Mental Health Account No. 32297525238 IFS Code: SBIN0011361 Pay Membership Fee through Cheque payable to SIS Journal of Projective Psychology and Mental Health Submit Membership Application Form through Email Dr. B.L. Dubey, Ph.D. Editor Emeritus, Email:bldubey@gmail.com Copy to Prof. Naveen Gupta,Ph.D., Director. Editor in Chief, Email: dr_naveengupta@yahoo.com Or Submit Print Version of Membership Application Form by Speed Post to Prof. Naveen Gupta, Ph.D. Director, Hindustan Institute of Management and Computer Studies, Farah, Mathura-281122, India Mention Fee Deposit Details: Declaration by Applicant: I certify that the information provided above is accurate and correct. Signature of the Applicant with Date: Affix Your Photograph

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 Editor: Rakesh Kumar, Ph.D. 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. Sandhyarani Mohanty, 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) STATEMENT SHOWING OWNERSHIP AND OTHER PARTICULARS ABOUT SIS JOURNAL OF PROJECTIVE PSYCHOLOGY AND MENTAL HEALTH Place of Publication: Mathura-281122 Periodicity of Publication: Half Yearly Editor: Dr. Naveen Gupta Nationality: Indian Address: Hindustan Institute of Management and Computer Studies, Farah, Mathura-281122 U.P. Owner: Somatic Inkblot Society Printer’s/Publisher’s Name: Mr. Sunny Kushwah I, Dr. Naveen Gupta, hereby declare that the particulars given above are true to the best of my knowledge and belief. Sd/ Dr. Naveen Gupta, Editor-in-Chief SIS Journal of Projective Psychology and Mental Health Published by Dr. Naveen Gupta, on behalf of Somatic Inkblot Society at IMPERIAL COMPUGRAPHICS 2/12, Swadeshi Bima Nagar, Civil Lines, M.G. Road, Agra – 2 Email : imperialprintersagra@yahoo.com Phone No. 0562-4045083

SIS JOURNAL OF PROJECTIVE PSYCHOLOGY AND MENTAL HEALTH: ACHIEVEMENTS Journal in WHO Listing Members of Somatic Inkblot Society will be glad to know that SIS Journal 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

Journal in ProQuest Listing: We are glad to inform you that SIS Journal of Projective Psychology & Mental Health has been listed in academic research database ProQuest Psychology Journals™. ProQuest is a company in Michigan, United States. It is a leading provider of electronic databases for academic libraries. Databases are used in over 20,000 academic libraries around the country and around the world including some of the most prestigious higher education institutions such as Harvard, Yale, Princeton, Oxford etc. ProQuest provides abstracts and indexing for more than 640 titles, with over 540 titles available in full text. Users get access to charts, diagrams, graphs, tables, photos, and other graphical elements essential to psychological research.

Abstracted in “APA” Psyc INFO “ Regd. No. 71632/99, RNI Delhi SIS JOURNAL OF PROJECTIVE PSYCHOLOGY AND MENTAL HEALTH

July 2016

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 Forrest Rd, Anchorage, AK 99517, E-mail: bldubey@gmail.com

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

EXECUTIVE EDITOR:

Rakesh Kumar, Ph.D. Senior Clinical Psychologist 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 NilanjanaSanyal, 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 Anjana Mukhopadhyay, Ph.D. India 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 David J. Sperbeck, Ph.D., U.S.A. Edward M. Petrosky, Ph.D., U.S.A. Harmesh Kumar, Ph.D., USA Jayanti Basu, Ph.D., India Jothimani T.,Ph.D., India K.S.Sengar, Ph.D. India 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 Sudhir Kumar, M.D., India Suprakash Chaudhury, M.D., Ph.D. Yogesh K. Arya, Ph.D., India