SIS Journal of Projective Psychology & Mental Health

ISSN 0971-6610 SIS Journal of Projective Psychology & Mental Health

Volume: 25 Number: 01 January 2018 Editorial: 25 Years in Promoting Projective Assessment: A Silver Jubilee Tribute Chris Piotrowski 1-4 Somatic Inkblot Series and the Journal of Projective Psychology & Mental Health: Inception to Silver Jubilee Bankey L. Dubey, Rakesh Kumar and Anand Dubey 5-34 Two Contemporary Rorschach Systems: Views of Two Experienced Rorschachers on the CS and R-PAS Anthony D. Bram and Jed Yalof 35-43 The Rorschach in Research on Neurocognitive Dysfunction: An Historical Overview, 1936-2016 Chris Piotrowski 44-53 Projective Personality Assessment: Evidence for a Decline in Training Emphasis James M. Stedman, Joshua Essery and Cindy A. McGeary 54-59 Sentence Completion Methods: A Summary Review of 70 Survey-based Studies of Training and Professional Settings Chris Piotrowski 60-75 Efficacy of Cognitive Drill Therapy in Treatment of Multiple Phobias: A Case Study Sandhya Verma, Bhavana Arya, Neetu Kandhari and Rakesh Kumar 76-79 SIS Indices in Parents of Children with ADHD and Intervention Steps Mahesh Kumar Singh and Anjana Mukhopadhyay 80-85 Cognitive Drill Therapy in Illness Anxiety Disorder: A Case Study Noor Shabina, Tarana Jain, Preeti Singh and Rakesh Kumar 86-91 Implicitly Measured Self Definition and Social Definition Relate to Self-Reported Interpersonal Problems Circumplex Scales Katherine M. Weber, Jeffrey Vance, Alana Harrison and Sharon Rae Jenkins 92-101 Official Publication of the Somatic Inkblot Society www.somaticinkblots.com Silver Jubilee Volume Celebrating 25 Years of SIS Journal of Projective Psychology & Mental Health

The Somatic Inkblot Society’s 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 APA. 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 print version of the manuscript is not considered. The typewritten manuscript in MS Word should be submitted only through email to any one 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 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 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: State Bank of India, EPFO, G-83, Vardhman Plus City, Sector-23, Dwarka, New Delhi-110075. Account No. 32297525238 Type of Account: Saving Bank 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 communicated for updating our records and seamless receipt of the Journal to Prof. B.L.Dubey Email: bldubey@gmail.com Copyright ©1994.Somatic Inkblot Society, India/Anchorage SIS Website: http://www.somaticinkblots.com

Editorial 25 Years in Promoting Projective Assessment: A Silver Jubilee Tribute Historically, projective techniques have left an impressive, yet contentious, footprint worldwide (Groth-Marnat, 2009; Handler & Thomas, 2014; Musewicz et al., 2009; Piotrowski, 2015; Piotrowski, Keller, & Ogawa, 1993; Teglasi, 2010; Wood et al., 2011). Interestingly, survey data from recent „test use‟ studies point to a rather bleak view regarding the status of projective techniques. Ready and Veague (2014) reported that no projective tests ranked among the top 10 tests being taught in clinical psychology programs. Wright et al. (2016), in a national sample of professional psychologists, found that the Rorschach was the only projective method used frequently (ranked in top 13 tests) among a myriad of psychological assessment domains. But do these reports provide an accurate portrait regarding the extent of clinical emphasis devoted to projective techniques in both training and practice? Undoubtedly, there is a perennial need to empirically address the clinical breadth and status of specific projective methods and their place in contemporary assessment practices. As 2018 denotes the 25th year of continuous publication of the SIS Journal of Projective Psychology & Mental Health, this editorial attempts to elucidate the issue regarding the extent of current usage and emphasis on projective techniques in the mental health field. To that end, I provide data-based evidence in support of the sustainability of projective testing in contemporary professional psychology, based on data reported in very recent studies, from 2013- 2017, on a) training in psychological testing, and b) assessment practices by professionals. Moreover, to provide a complete composite on the use of projective methods, surveybased findings in the periodicals literature as well as data reported in recent dissertation research are presented. First, an objective appraisal regarding research interest in projective techniques seems in order. An online search of the database PsycINFO (conducted September 28, 2017), on the term „projective techniques‟, yielded 1,857 articles, 43 dissertations, and 73 book chapters since the year 2000. Based on this search, Table 1 presents the top journals, in rank order, where major research findings on projective techniques have been published. Surely this illustration does not reflect a moribund state of affairs regarding projective assessment. Table 1. Major Publication Outlets Journal of Personality Assessment SIS Journal of Projective Psychology & Mental Health Psychologie Clinique et Projective Qualitative Market Research Rorschachiana Perceptual & Motor Skills Attachment & Human Development Bulletin de Psychologie Pertinent to the debate regarding projective tests, an interesting Delphi poll study on “discredited” tests, found that Human-Figure- Drawings, H-T-P, TAT, Rorschach, and Sentence completion methods were not considered „probably discredited‟ (Norcross et al., 2006). Although some lesser-known projective instruments have fallen out-of-favor, a recent study reported that the Somatic Inkblot Series has attracted robust research attention worldwide (Piotrowski, 2017a; see Dubey et al. in this issue, for a review). Thus, while projective techniques have lost some of their luster over the decades, based on recent survey-based findings, there is still avid interest on projective approaches in mental health assessment by devoted clinicians. Table 2 presents 10 survey-based studies, reported over the past 5 years, on the topic of assessment practices in both professional training and practice settings. Given the

proliferation of broad-band personality tests and brief, symptom-focused scales that have been introduced in the professional literature over the past 2 decades, it is rather commendable that several projective techniques continue to rank among the top 50 most popular psychological tests. Moreover, while projective methods have indeed been de-emphasized in graduate clinical training (Piotrowski, 2015b), several projective tests continue to be embraced by clinical faculty at internship sites (see Bates, 2016; Ready et al., 2016; Stedman et al., 2017). In fact, internship directors encourage pre-internship instruction, obtained during doctoral clinical training; in projective assessment methods (see Faith, 2016). The key factor, in terms of sustainability of projective techniques, will be centered on the status of personality assessment in the professional curriculum (Evans & Finn, 2017; Piotrowski, 2017b). Thus, based on the findings of these recent reports, Projective methods indeed have a worthwhile place in the clinical armamentarium- Undoubtedly, not as lofty a place as in the decades past, but still cherished by a select minority of proponents who appreciate the challenge in trying to understand the complexities of how individuals perceive and deal with both internal and external reality. So as SIS celebrates its 25th Jubilee, projective assessment is represented well in this commemorative issue on topics such as the Somatic Inkblot Series, the Rorschach, the TAT, Sentence Completion methods, and assessment training. Indeed, verbal expressive techniques (Panek et al., 2013) and idiographic assessment (Beltz et al., 2016) continue to attract both research and clinical attention. It is apparent that the projective assessment enterprise is not moribund—well exemplified by Teglasi (2013, p. 113), “Insofar as variation in projective test responses are caused by constructs‟ capturing phenomena that matter in the lives of individuals, projective techniques are legitimate tools for science and practice.” Table 2. Recent (2013-2017) Survey-Based Studies on Testing Emphasis with Projective Techniques Study Country Sample Major Findings Neukrug et al. (2013) USA Based on survey data from 210 counselor educators across the U.S., this study examined graduate-level coverage of assessment instruments by instructors TAT ranked #12; H-T-P #13; Rorschach #16; Kinetic Family Drawings #30; Sentence completion #36; Children‟s Apperception Test #40; Human Figure Drawings #48. Peterson et al. (2014) USA 926 counselors (clinical mental health, school, occupational) rated tests of all types regarding usage Amongst a copious set of testing instruments, House-Tree-Person ranked 17th; Human-Figure-Drawings 21st; DAP 35th; TAT 40th; Kinetic Family Drawings 47th; Sentence completion 52nd; Rorschach 57th. Ready & Veague (2014) USA Compared training in psychological assessment across 3 training models (Clinical-Science, Scientist- Practitioner, Practitioner- Scholar) in APA-Accredited programs No projective tests ranked in the top 10; only practitioner-scholar programs offer limited coverage on projective techniques. Wechsler et al. (2014) Iberian/L atin- Test development & usage in Portugal, Spain, Argentina, Projective tests very popular in Venezuela; Rorschach somewhat

American countries Venezuela, and Brazil popular in Brazil and Argentina; Spain and Portugal indicated low usage of projective tests. Sentence completion methods are not used by practitioners in any of these countries. Ready et al. (2016) USA & Canada 236 internship directors‟ views on pre-doctoral academic training in testing and assessment 36% of directors endorsed the Rorschach; 25% favored Sentence completion tests; 19% approved projective drawings; PT is somewhat more emphasized in child clinics. Wright et al. (2016) USA Views of 279 professional APA psychologists on assessment/testing practices In the projective testing category, only the Rorschach ranked in „Top 10‟. Kohns (2016) USA Experiences of 148 advanced clinical students from both APA & non-APA professional psychology programs regarding assessment training Academic exposure to projective assessment was rather high (30 coursework hours); but mostly focused on Rorschach CS & R-PAS. Bates (2016) USA 182 APPIC internship directors‟ views on extent of emphasis in specific assessment/testing training Sites emphasizing PT usage by interns (TAT-45%; Sentence completion-44%; Rorschach-40%; Drawings-32%); although there has been a noted decrease in emphasis on most PT in recent years, directors prefer incoming interns to have academic exposure to projective assessment. Mihura et al. (2017)

USA Assessment/testing training reported by 83 APA clinical psychology programs 63% of programs „covered‟ the TAT & Rorschach; Sentence completion (47%); Figure drawings (36%); Roberts Apperception Test (27%); PT was more emphasized in practitioner-focused clinical programs. Stedman et al. (2017)

USA 335 APPIC psychology internship sites Across child, adult, and „mixed‟ program types, the Rorschach was used by interns (in 26-35% of sites); Thematic tests (in 19-41%); Sentence Completion (in 18-41%); Drawing tests (in 9-36%). References: Bates, S. (2016). Internship directors‟ perspectives on psychological assessment training: Current status and emerging trends. Unpublished doctoral dissertation, Pepperdine University. Beltz, A.M., Wright, A., Sprague, B.N., & Molenaar, P. (2016). Bridging the nomothetic and idiographic approaches to the analysis of clinical data. Assessment, 23(4), 447-458. Evans, F.B., & Finn, S.E. (2017). Training and consultation in psychological assessment with professional psychologists: Suggestions for enhancing the profession and individual practices. Journal of Personality Assessment, 99(2), 175-185. Faith, A. (2016).Internship directors‟ perspectives on emerging trends in psychological assessment training and practice. Unpublished doctoral dissertation, Pepperdine University. Groth-Marnat, G. (2009). Handbook of Psychological Assessment (5 thed.). Hoboken, NJ: Wiley. Handler, L., & Thomas, A.D. (Eds.) (2014). Drawings in assessment and psychotherapy: Research and applications: New York: Routledge. Kohns, B.C. (2016). Doctoral training in psychological assessment and competency in assessment ethics. Unpublished doctoral dissertation, Alliant International University, San Diego.

McCloskey, L.C. (2014). Construct and incremental validity of the Rotter Incomplete Sentences Blank in adult psychiatric outpatients. Psychological Reports: Measures & Statistics, 114(2), 363-375. Mihura, J.L., Roy, M., & Graceffo, R.A. (2017).Psychological assessment training in clinical psychology doctoral programs. Journal of Personality Assessment, 99(2), 153-164. Musewicz, J., Marczyk, G., Knauss, L., & York, D. (2009).Current assessment practice, personality measurement, and Rorschach usage by psychologists. Journal of Personality Assessment, 91(5), 453-461. Neukrug, E., Peterson, C.H., Bonner, M., & Lomas, G.I. (2013).A national survey of assessment instruments taught by counselor educators. Counselor Education & Supervision, 52, 207-219. Norcross, J.C., Koocher, G.P., & Garofalo, A. (2006).Discredited psychological treatments & tests: A Delphi poll. Professional Psychology: Research and Practice, 37(5), 515-522. Panek, P.E., Jenkins, S.R., Hayslip, B., & Moske, A.K. (2013). Verbal expressive personality testing with older adults: 25+ years later. Journal of Personality Assessment, 95(4), 366-376. Peterson, C.H., Lomas, G.I., Neukrug, E.S., & Bonner, M.W. (2014).Assessment use by counselors in the United States. Journal of Counseling & Development, 92, 90-98. Piotrowski, C. (2017a). Rorschach research through the lens of bibliometric analysis: Mapping investigatory domain. Journal of Proj. Psychol. & Mental Health, 24(1), 34-38. Piotrowski, C. (2017b). The linchpin on the future of projective techniques. Journal of Proj. Psych.& Mental Health, 24(2), 71-73. Piotrowski.C. (2015a). Projective techniques usage worldwide: A review of apsplied settings 1995-2015. Journal of the Indian Academy of Applied Psychology, 41(3), 9-19. Piotrowski, C. (2015b). Clinical instruction on projective techniques in the USA: A review of academic training settings 1995-2014. Journal of Proj.Psycho.& Mental Health, 22(2), 83-92. Piotrowski, C., Keller, J.W., & Ogawa, T. (1993). Projective techniques: An international perspective. Psychological Reports, 72, 179-182. Ready, R.E., & Veague, H.B. (2014). Training in psychological assessment: Current practices of clinical psychology programs. Professional Psychology: Research and Practice, 45(4), 278- 282. Ready, R.E., Santorelli, G.D., Lundquist, T.S., & Romano, F.M. (2016).Psychology internship directors‟ perceptions of pre-internship training preparation in assessment. North American Journal of Psychology, 18(2), 317-334. Stedman, J.M., McGeary, C.A., &Essery, J. (2017).Current patterns of training in personality assessment during internship. Journal of Clinical Psychology, 73, in press. Teglasi, H. (2013). The scientific status of projective techniques as performance measures of personality. In D.H. Saklofske, C.R. Reynolds, & V.L. Schwean (Eds.), Oxford handbook of child psychological assessment (pp. 113-128). New York: Oxford University Press. Teglasi, H. (2010). Essentials of TAT and other storytelling assessments (2 nded.). New York: Wiley. Wechsler, S.M., Oakland, T., Leon, C., et al. (2014). Test development and use in five Iberian Latin American countries. International Journal of Psychology, 49(4), 233-239. Wood, J.M., Nezworski, M.T., Lilienfeld, S.O., & Garb, H.N. (2011). What‟s wrong with the Rorschach: Science confronts the controversial inkblot test. New York: Wiley. Wright, C.V., et al. (2017). Assessment practices of professional psychologists: Results of a national survey. Professional Psychology: Research and Practice, 48(2), 73-78. Chris Piotrowski, PhD Senior Editor University of West Florida USA Email: cpiotrowski@uwf.edu

Somatic Inkblot Series (SIS) emerged as an extension to the existing inkblot techniques, including the Rorschach Inkblot Test. This unique assessment method relies heavily on content analysis to understand the inner cry of a person and penetrates into deeper layers of unconscious in order to elicit underlying conflicts and intra-psychic processes which contribute to emotional and interpersonal issues in one‟s life. The Series has also made conceptual and procedural advancements by introducing the concept of inkblots into three major forms: (i) Card Form (ii) Booklet Form and (iii) Screen/Video Form. An interview assessment of an examinee focused on image rejection, distorted perceptions of easy to perceive inkblot forms allow an easy access to perturbing areas into the psyche. To make Somatic Inkblot Series available worldwide and promote the projective assessment, Somatic Inkblot Society was formed in 1989 and a peer-reviewed bi-annual publication of Journal of Projective Psychology and Mental Health was launched in 1994 which has a track record of timely publications since its inception. The journal has stimulated researches and applications in Somatic Inkblot Series and related projective techniques, and proved to be a major bibliometric resource to academicians, researchers and practitioners of inkblot techniques. In the course of applications, it became apparent that Somatic Inkblot Series is a reliable tool to map personality attributes that are conducive to management and organizational contexts. The present paper is an attempt to summarize and elucidate various aspects of Somatic Inkblot Series and provide an overview of related inkblot techniques. Future directions for the field of assessment are noted. Somatic Inkblot Society (SIS) was established in India in the year 1989 and got registered in 1992. SIS is publishing “Journal of Projective Psychology & Mental Health” a biannual scientific Journal in January and July since 1994. The Journal is devoted to the advancement of research in the areas of projective psychology, personality assessment, psychotherapy and mental health. It 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 present paper is prepared to highlight: (1) the Development of inkblot tests, (2) Progress of “Journal of Projective Psychology & Mental Health”, and (3) Research Contribution, International Conferences and Workshop organized by the Society. The development of Inkblot tests: The history of the inkblot procedure is traceable only through Rorschach's own writings, and through the writings of Emil Oberholzer, Walter Morgenthaler, and George Roemer. Zubin et al. (1965) indicated that the concept of formless stimuli, used in inkblot techniques to stimulate the imagination, could be traced back to Leonardo Da Vinci and Botticelli in the fifteenth century. The concept of projection is generally credited to Freud who used this term as early as 1896

(Freud, 1950). He defined it as a defensive process in which impulses, wishes and ideas of aggressive and sexual in nature became externalized. During projective testing, the subject matter serves as a lens of projection and the recorded material of elicited behavior is the screen with the picture projected on it (Rapaport, et al., 1968). Before the publication of Rorschach “Psychodiagnostik‟ in 1921, many scientists (Bartlett, 1916; Kirkpatrick, 1900; Parsons, 1917;Pyle, 1913; Whipple, 1910) had used their own versions of inkblots in earlier exploration of the mind. Rorschach Inkblot Test: The real beginning of a concept based technique started with Hermann Rorschach when he began to experiment with inkblots as early as in 1911. While he was fully aware of the earlier experiments with inkblots, he was more stimulated by Konard Gehring. As a teacher, Gehring had discovered that certain children gave very similar responses to a variety of inkblots, even though the figures were quite different in their form and/or color. Apparently initially Rorschach had no intention of constructing a psychodiagnostic test (Roemer, 1967). His first purpose was to investigate “reflex hallucinations”. These likely were visual form of hallucination. If this speculation is true he needs to be given credit to studying how Swiss psychotic disturbances may be projected on to inkblots. In any case, it was not until much later when he started collecting material in a systematic manner for diagnostic purposes (Roemer, 1967) Roemer also indicated that Rorschach discovered the diagnostic possibilities of the inkblot technique somewhat accidentally, while working at Herisau in Switzerland. Emil Oberholzer a close associate of Herman Rorschach made the test alive after the untimely death of Rorschach. Oberholzer supported Rorschach's work and taught Levy in Switzerland. Levy came to New York with the test. Beck studied under Levy, and then did a dissertation on it, collected norms for children. Hertz in Cleveland did the same, and made different norms. Beck, Klopfer, Piotrowski and Hertz all attributed great significance to Levy‟s enthusiasm for the Rorschach. He organized the first Rorschach‟s seminar in Chicago in 1925. Bruno Klopfer was a German psychologist, who stayed in Zurich during the year 1934 and then moved to Columbia (USA) to escape Nazism. He was influenced by Jung and by psychoanalysis and his general approach has been described as "phenomenological" and "qualitative". Samuel Beck, on the contrary, had a more behaviorist training and put more emphasis on quantitative and "objective" data. Beck had also been trained in Rorschach methodology under Oberholzer in Switzerland. Both, Klopfer and Beck did not agree to each other particularly on the scoring of Location, Movement and Colors and the difference brought two prominent Rorschach systems. The Beck´s Rorschach was summarized in Rorschach´s Test (1937) and Klopfer´s system in The Rorschach Technique (Klopfer & Kelley, 1942). Walter Klopfer continued at Columbia and Beck went to Harvard and they led discussion groups on the Rorschach test. Beck was more faithful to Rorschach's ideas, while Klopfer added more stuff to the scoring system. They started a paper debating the test, its merits and scoring, which turned to be the “Journal of Personality Assessment” in 1936. However, they started showing disagreement on various issues and Hertz tried to bring them together with no results. Klopfer taught Piotrowski in New York, and in 1939 he was separated from others with his own scoring system. Beck and Levy moved to Chicago Michael Reese, and continued for rest of their life. Rapaport made a new scoring system at the Menninger Foundation in Kansas with the help of Gill and Schaefer in 1940. They were interested in using a battery of tests rather a single test. This is how the five distinct Rorschach Scoring systems emerged but none was consistent with the original fifteen scores of Rorschach.

Campos (2011) opined that we must not forget that the ultimate goal of the testing is to get close to the “psychological truth” of the person who is being assessed, harmonizing and mastering theories and methods. The psychologist should not be merely a test user, but a kind of expert who decides what is needed and should be done in a particular case. Psychological assessment should allow a true interpretation of the data; it is not only a science, but also an art. The task of interpreting data in a meaningful, accurately and inclusive way, and the "transformation" of the results and their interpretation on something that might be useful to address the issues that triggered the assessment and the client needs, is still an art. In my opinion, no psychological assessment is possible without the use of at least one projective technique. Issues with Rorschach Test: Although the Rorschach test represented a major step forward in inkblot projective technique, as might be expected, eventually its limitations were gradually exposed. Bartol (1983) commented that "Nobody agrees how to score Rorschach responses objectively. There is nothing to show what any particular response means to the person who gives it. And, there is nothing to show what it means if a number of people give the same response. The inkblots are scientifically useless." Anastasi (1982) had also made an adverse remark in his book “Psychological Testing: 5thed” and commented that “Even when objective scoring systems have been developed, the final steps in the evaluation and integration of the raw data usually depend on the skill and clinical experience of the examiner. There are many more renowned psychologists who have criticized Rorschach test but most of them are user of questionnaires - so called objective test and have hardly used Rorschach as an assessment tool. However, the over emphasis on indices based interpretation by many Rorschachians, has been criticized for wrong conclusions. Most of interpretation of Rorschach is based on the total number of responses given by the subject and the ratios. Fiske & Baughman (1953) reported that practitioners feel that the variation in the total number of responses is too much to be able to interpret the ratio scores adequately. Also, the meaning of the indices changes depending upon the length of the protocol, because the relationship between Rorschach scores and the total number of responses is complex and curvilinear (Dubey, 1982). Many workers compute percentage ratio in an effort to control the length of the protocol. Holtzman (1956) pointed out that such procedures were very unsatisfactory, not only because of the non-linear relationships between R and other Rorschach's scores, but also because of the crude, unstable and metric qualities of most Rorschach variables. Dubey (1982), in a study on 300 subjects, found that most of the Rorschach indices are dependent upon the number of responses. When the groups of Normal, Neurotics, and Schizophrenics were divided, on the basis of number of responses, into high productivity and low productivity, many indices, which were found to be significant earlier, lost their significance. It further strengthened the findings of Fiske and Baughman, and supported the intention of Holtzman. Holtzman et al. (1956) pointed out that much of the controversy over the Rorschach arises from the failure to distinguish between the Rorschach as a projective technique in the hands of a skilled clinician, and the Rorschach as a psychometric device, that yields scores having relevance for personality assessment. The analysis of responses to inkblots has ranged all the way from one extreme to the other of the projective psychometric continuum. Wayne Holtzman developed “Holtzman Inkblot Technique” in 1956 to overcome the limitations of the Rorschach test.

Holtzman Inkblot Test (HIT): The main limitation of the Rorschach, as experientially determined, was the problem of variation in the length of the protocol (Dubey et al. 1978; 1979; 1989;Fiske & Baughman, 1953; Holtzman, 1956). Consequently, the usual effect of R linear regression methods for removing the confounding effect of R will generally fail (Dubey, 1982; Fiske & Baughman, 1953). Holtzman was convinced right from the beginning that the new inkblot technique would have several distinct advantages over the standard Rorschach. First the number of response per individual could be held to a relatively constant value. Second, because each response would be to independent stimulus, the resulting protocol would be much more amenable to psychometric treatment. Third a fresh start in the production of stimulus materials could result in a richer variety of stimuli capable of eliciting far more information than the original 10 Rorschach plates. Forth, two parallel forms of the inkblots to use in the test-retest studies of personality change could be constructed easily from item analysis data in the experimental phase for development. And fifth, adequate estimates of reliability based on internal consistency and parallel test– retest correlations could be obtained independently for each major variable (Holtzman, 1988). Subsequently, the HIT was translated into other languages and used as research tool and for clinical assessment in many countries. Suitable versions for group administration using projected images of inkblots were also developed and published (Holtzman & Swartz, 1963; Holtzman et al. 1963). Somatic Inkblot Series (SIS): In developing the Somatic Inkblot Series (SIS), Wilfred A. Cassell had the benefit of insights traceable from the contributions of Hermann Rorschach and Wayne Holtzman. The SIS has the quality of Unstructured Inkblots like Rorschach and the larger numbers of images like Holtzman. There are unstructured, semi structured and structured images numbering from 20 in Card Form (SIS-I), 62 in Booklet Form (SIS-II). The Projective techniques are especially helpful in evaluating those having limited language and verbal skills such as children, foreign born or new immigrants, native peoples, the learning disabled or the mentally sub normal. There is enough structure in many of the SIS inkblots to provide a sense of security and a measure of self-confidence. Those with limited language and verbal skills usually rely more on visualization and adapt better to projective technique than verbal interviews or testing that requires reading or language skills. Such images use the language of dreams, visual imagery, and symbolic thought, the most basic forms of thinking and expression. It is also the language of repression and brings whatever is buried in the mind closure to consciousness, accessible for processing. Expression stimulated by ambiguous or partially ambiguous visual input can be used in therapy to test insight and to help measure treatment progress. Wilfred A. Cassell initially recognized in 1959 the need for developing a measure of “Body Image”, as psychiatric resident conducting a collaborative study on hirsutism, with a psychoanalyst Marc Hollender (Hollender & Cassell, 1972). Subsequently Hollender, who was Chairman of the Department of Psychiatry at the Upstate Medical Center in Syracuse, New York, brought Seymour Fisher a colleague of Wayne Holtzman to join the research group. This enabled Cassell the opportunity to train in projective assessment under the guidance of Fisher. He had constructed two inkblot content scales derived from studying patients suffering from Rheumatoid arthritis: the Barrier and Penetration. The former was based upon a summation of responses depicting the periphery of objects. It was created to assess the degree of definiteness experienced by an

individual regarding self- perception of body boundaries. In regard to the latter, this was conceptualized as a mixed measure denoting both the notion of Body Boundary “indefiniteness” (e. g. references to opening such as windows broken containers etc.) and “Interior body awareness”(e.g. responses representing projections of internal organs). Background work had been presented in a book entitled Body Image and Personality (Fisher & Cleveland, 1958). After learning Rorschach content analysis theory, Cassell explored the test validity of Fisher and Cleveland‟s Penetration index as an operational measure of internal body awareness. He investigated, what in the post- World War II period, were classified in a now invalid diagnostic category as “Psychosomatic” conditions. However, no relationship was found between the channeling of stress induced physiologic activity to internal organs, such as heart and stomach, and scores on this index. This failure led him to next independently reappraise the content constructs underlying the Penetration score. This revealed that regarding somatic orientation within the body gestalt, that this index was spatially mixed and summed separate conceptual categories (e.g. “apples” versus “oranges”). The second scoring category of Fisher and Cleveland included responses theorized to symbolize “indefinite exterior body boundaries”, erroneously added with those concretely depicting internal organs. As a follow-up to this analysis, Cassell constructed a new index based solely upon interior anatomy content. This was called the “Projective index of Body Interior Awareness” (Cassell, 1964)‟ Originally during his residency, Cassell was strongly influenced by such speculative, overly optimistic thinking of his professors. He hoped that designing inkblots with various degrees of resemblance to the human heart might provide an operational measure of “heart awareness”. After field testing the newly designed somatic inkblot series, studies were initiated to assess subjects with medical histories of stress induced somatic symptoms (Cassell, 1965). Ultimately several versions of the SIS were created. These provided a potentially powerful projective electronic system promising to provide new research and clinical diagnostic/therapeutic applications (Cassell, 1977; 1979; 1980) and internet application. The SIS was initially developed as a research technique to facilitate the study of stress induced psychophysiological in 1959.Itis a structured, projective, diagnostic procedure and an adjunct to psychotherapy. It is structured by a sequential presentation of intentionally designed and field-tested inkblotlike images. These stimuli demonstrate typical and atypical response potentials. This technique is based on spontaneous, individually generated responses to semiambiguous figures, which elicit intrapsychic associations specific to the person presented with them. The SIS is a diagnostic procedure as a consequence of the interaction of structure and stimuli. These stimuli evoke symbolism and meanings unique to the responding individual such as present in somatic delusions and affect charged dreams. The test stimuli can be differentiated from typical and atypical peer norms, and can be analyzed according to internationally recognized diagnostic criteria. The procedure is an adjunct to therapy because responses can be further explored to create a more effective treatment plan, and can be re-addressed in later discussions, providing opportunities to elicit deeply defended material. During the administration of the SIS procedure, clients, patients and students may abreact emotional conflict raised to consciousness by the images, which can be a therapeutic experience in itself. The viewer writes responses on an answer sheet. Most of what is included in the ambiguous structure relates to specific life

situations and post-traumatic dream content that has been found to have clinical significance. Viewing the SIS has both diagnostic and therapeutic applications that are far reaching. The SIS procedures have been used internationally on different normal and clinical population. Various researchers have reported high reliability and validity of the test (Cassell, 1969; 1971; 1972; 1977; 1980, 1988; Cassell & Dubey, 2003; 2009b; Dubey & Cassell 1991; Dubey et. al. 1995; 1993;Goel et. al. 1990; Kaur &Verma, 1998; Kumar, 2000; 2009; 2010; Kumaret al.200; 2005; 2008; Nicolini, 2002; Pandey, et.al.1999;Pershad & Dubey, 1994; Rathee et al.1998; Singh & Banerjee, 1996; Verma & Kaur, 1999). There are three subtests in Somatic Inkblot Series: Somatic Inkblot Series-I: (20 Cards and Electronic Version of 20 Cards) The Somatic Inkblot Series- I consists of 20 inkblot images printed on white cards, each measuring 16.5 X 20.5 cms. The images are printed in black, red, and gray (screened black). Eight of them are black and red (serial numbers 1, 2, 3, 4, 5, 6, 7, and 8); three are exclusively red (serial numbers 10, 11, and 12); and nine are achromatic (serial numbers 9, 13, 14, 15, 16, 17, 18, 19, and 20). Images provide enough obvious anatomical structure to evoke spontaneous verbalization, but not enough to limit the responses solely to the naming of body parts or colors. In this way, obvious anatomical structure provides a feeling of security, which makes deeper and more symbolic repressed material more accessible to the person taking the procedure. The SIS provides clinicians and researchers with a new diagnostic aid for body percept assessment. It can be used to assess the depth and significance of somatic symptoms, conversion reactions, somatic delusions and sexual dysfunction. Analysis of mutilated or distorted anatomy responses can assess the possibility or level of castration anxiety (Cassell, 1980). Responses depicting themes of body assault may further clarify the extent of aggressive impulses (Cassell, 1977). As a diagnostic tool, the series can help to evaluate undetected affective disorders such as “masked depression” where depressive feelings are denied during the interview and in non-projective psychological tests. The flow of cognition might reveal early defects of schizophrenic disorder. “Death anxiety” in those facing major surgery or those with a terminal illness may be signaled by excessive anatomical responses (Cassell, 1979). The Somatic Inkblot Series can be used to help design a treatment program which might include body awareness exercises, such as physical therapy. It also may be used in other therapies, such as sensory feedback training, behavioral therapy, and desensitization for psycho-physiological symptoms associated with pathological anatomy responses (Cassell, 1977). This technique has been described in the book, “Body Symbolism” (Cassell, 1980), which has been translated into Italian and Russian. The electronic version of the test is designed for supervised self-administration. It can also be used as group administered test. (II) Somatic Inkblot Series-II Booklet Form (62 Images and Electronic Version/DVD of 62 Images): In 1980, after initial success with SIS-I, the development of SIS-II (booklet form) was initiated. It consists of Series A and Series B, each with 31 images (total of 62 images). There is also a sample image in the beginning to make the subject comfortable. The stimulus images are printed in rectangles measuring about 5x6 cm. All the images are contained in an eight page booklet. The first seven pages consist of the stimulus images and the last page is printed with instructions for selfadministration, and a place for a brief health history and personal data. Unlike SIS-I, it

consists of images printed with blue ink on grey paper. The printed instructions on the back of the book as follows: “Most people find this test fun and relaxing. First relax, take a few deep breaths, and prepare to enjoy. Please turn this Booklet over and read the sample response. Notice that you may write on the picture or the space below it. Label each in terms of what they resemble or look like to you. Please include everything that you see, even if it reminds you of something, remote, vague, dreamlike, highly personal or even potentially embarrassing. Please include every that you see with as much detail as possible. Also include any outstanding emotional reactions that you might experience in responding to these pictures. Please begin on the first page, study the sample, and continue until completed. Enjoy!” The SIS-II can be used in a variety of ways, but was designed for self-administration after supervised instruction. Some clinicians use the booklet with the patient or to unobtrusively observe the self- administration to observe reaction times and significant verbal and nonverbal responses for each inkblot (delays, overreaction and content shock). Others prefer to allow the patient to take the booklet home and write in responses whenever they have the time to relax and review the figures (intermittent administration), or if they prefer, at one time (continuous administration). Some have found it useful to have the patient complete the test booklet before going to bed, to stimulate the unconscious to process repressed materials in dream during sleep. Usually, clinically significant, blocked material, will over-ride typical normative responses directly (manifest), or it will appear in symbolized imagery, similar to dream work (latent). Because there is no time limit, “test anxiety” is reduced, and the individual is free to react in his own time, often exhibiting significant verbal and non-verbal clues to each of the inkblots. Since there is no text to read, the Somatic Inkblot Series does not require a high reading level, therefore, it is applicable to all age groups and a wide variety of cultures. In SIS-II, the subject is asked to rate the threeinkblot images that he “most liked” and the three images that he “least liked.” This inquiry invites positive or negative affectual discharge. The subject‟s emotional investment provides valuable diagnostic clues to his/her psychological function. The SIS-II can successfully identify various groups of clinical subjects, and can be used to screen out abnormal subjects from normal subjects. (III) The 30 image Web Version was launched after the success of SIS-II Booklet /Electronic version in 2017. It is a selfadministered test which has also been used as group administered test during personality assessment in business organizations. It is also available in computerized version which has rendered internet application (www.somaticinkblots.com). The Instruction and Administration are similar to SIS-II. The viewer writes responses on an answer sheet. Viewing the SIS has both diagnostic and therapeutic applications that are far reaching. The SIS is highly innovative and, in a sense, a "time machine." It takes the viewer away from present reality. If there is unresolved painful material in the past memory storage, through the magic of electronic television, the projected responses will tend to be shaped by this material. What emerges in projective awareness is deep seated material, even though the viewer may have long forgotten the buried traumatic imagery and associated affect. It facilitates the expression of feelings and earlier forgotten life events underlying many forms of mental illness and conversion pain. When the viewer rates those images, which are the most threatening, the examiner gets a quick psychological overview of the subject‟s state of mind. The technique enables the

professional to more readily empathize. The hypnotic like administration of the SIS is designed to maximize the pulling power of inkblot projection. By writing responses, rather than verbalizing them, just like in hypnotic writing, the subject may more readily access and release painful material. In addition to the cathartic, therapeutic response, the person may gain some insight and sense of mastery of the traumatic material by the act of drawing and labeling the images. Also, when the procedure is assigned repetitively over time, the experiencing of the healing flowers, in association with the threatening, anxiety-laden images may serve to desensitize the viewer. Applications of this procedure have proven to be far-reaching and international. The use of graphic images, rather than words, allows the computer version to cross both cultural and language boundaries. The number of uses in medical diagnosis, psychological assessment and psychotherapy is rapidly growing. It is anticipated that in the 21st century, all students of the healing arts and psychology, during their training will have the opportunity to be introduced to this technique. Currently, a complete data bank is being developed where individuals from various SIS Centers around the world may submit data and access information via modem or facsimile communication. This could truly be a comprehensive artificial intelligence system to be employed for good in a world beset by evil. Reliability and Validity of Somatic Inkblot Test: Cassell & Dubey (2010) pointed out that some psychologists question the validity of projective test as they do with Questionnaires. They forget that the projective tests cannot be verified on the same parameters as questionnaires. We put our perception and feelings in to the mind of subject by asking them to choose their answers as “Yes” or “No”, “True” or “False” “Agree” or “Disagree” etc. The true validity of a test should be decided “if it measures for what it was made”. An Inkblot test is a powerful instrument. It brings unprocessed symbolic material through projection which cannot be measured /assessed through so called objective questionnaires. The projective tests, such as the SIS, cannot be tested for validity, like objective tests. The SIS is a method of observation and appraisal. With regards to a test that measures some aspects of personality, it is legitimate to ask, "Is it valid?" However, in regard to a method of observation, the appropriate questions are: "Is it useful?", "Is it productive?", and “Does it conform to some construct?" The SIS is an objective procedure for observation; therefore validity in psychometric terms cannot be determined. The question then arises; can we still call it a valid procedure? The clinical interview and the diagnostic procedures are based on the information elicited from the patient/client and his observations. Has anyone doubted the validity of such clinical interviews and diagnostic procedures? If not, the validity of the projective test, the SIS in particular, must be recognized since its utility would appear to be established at a clinical case history level. It is therefore, necessary to demonstrate empirically the content and construct validity of the SIS. The other types of validity generally given in textbooks cannot be determined (Cassell & Dubey, 2009b)”. The content validity of the test can be demonstrated if the patient/client suffering from focal somatic symptoms project altered patterns of anatomical responses. In a number of studies, it has been found that relationships exist between an individual's physical disturbances and his/her projected anatomical responses (Cassell, 1969; 1971; 1972‟ 1977; 1980;1990; Dubey & Cassell 1993). In a study on heart patient in India, results suggested that the somatic preoccupation was not verbalized any more than compared with a healthy control. It was interpreted that the body disturbances were consciously denied (Goel et al. 1990).

To have construct validity on the basis of existing literature on inkblot technique, it can be assumed that Most Typical responses and Atypical responses have to be different in broad psychiatric diagnostic categories compared to healthy controls. This hypothesis was tested on Neurotics, Schizophrenics, and healthy Normal subjects. The Atypical responses were found to be significantly higher in Psychotics than Neurotics and Normal. Likewise, Most Typical responses were significantly higher in normal subjects compared to psychiatric patients (Cassell, 1988; Cassell & Dubey. 2003, Dubey & Cassell. 1993). Several researchers have found SIS test as highly reliable and valid instrument (Kaur &Verma,1998;Nicolini, 2002; Pershad & Dubey, 1994; Singh & Banerjee, 1996; Verma & Kaur, 1999). Pershad& Dubey (1994) established the reliability and validity of the SIS Test. The correlation for the content categories over a period of four weeks, on repeat testing was found to be in the range of .69 to .88. The split-half reliability was established by splitting the test into two equal halves. These equal halves are the natural divisions of the test that consists of two series, A and B. Except MT and Human Responses, correlation for R, Animal, Anatomical, Sex, Movement and Rejection of images was found to be in the range of .66 to .89. Inter-scorer reliability for the indices was scored separately by a trained and experienced clinical psychologist, having experience with the SIS, and by a fresh psychologist who was provided with a set of definitions for the variables. It was discovered that there was no difference between their two independent scorings. It can be argued that it was not a scoring, but merely a counting of the responses under different categories (Total number of Responses: Human responses, Animal responses, Anatomical responses, Sex responses, Movement responses, Most Typical responses and Rejection of images). Rathee et al. (1998) administered Somatic Inkblot Series-II on 200 psycho-pathological cases of Armed Forces and found that out of 10 common indices of SIS and Rorschach, five variables in schizophrenia, four in affective psychosis, seven in unspecified psychosis, five in Anxiety, four in Depression and seven in Hysteria, showed high and positive correlations. The findings indicate the high diagnostic validity of SIS-II indices against those of Rorschach's among six psycho-pathological groups of armed forces. The Meta- Analysis of the findings of the studies on SIS-II was carried out to provide combined mean and S.D. of various groups to see if SIS-II indices could differentiate the groups statistically. All the studies appeared in Journal of Projective Psychology and Mental Health 1994-2000 were considered for the purpose. The studies were combined into five groups based on specified criteria: Normal, Neurotics, Psychotics, Substance Dependents and Murderers. Critical Ratio were computed on combined mean and standard deviation for inter group comparisons. Results indicate that SIS-II indices do differentiate the comparison groups (Kumar, 2000).Srivastava (2002) also confirmed the findings of Kumar‟s study SIS-I indices significantly differentiate the various comparison groups such as Normal, Coronary Heart Disease, Generalized Anxiety Disorder and Schizophrenia. Cassell & Dubey (2009) presented two previously unpublished early statistical studies on SIS content validity. The first was completed in 1978 with the SIS-I. It used a content analysis scoring system to quantify projective responses in a group of 13 women suffering from Premenstrual Dysphoric Syndrome (PMDD). As compared to a control group of 37 women these subjects projected significantly more responses depicting reproductive and sexual symbols. Based upon chi squared analysis, statistically significant differences were found for such sex related anatomical responses, but not for unrelated body parts such as heart and lungs. The

second study was completed in 1988 with the SIS-II Booklet Version. The data were analyzed for 37 of the 62 SIS stimuli. In the comparison pregnant women were compared with 27 non-pregnant controls. A Chi-square analysis revealed that pregnant women projected more response related to reproduction and/or pregnancy. Sanyal et al. (2011) highlighted the clinical probing of a case, aged 8 years, first born, and belonging to a middle socio-economic strata, living with maternal grandparents, and having adjustment problems. She was administered with the CAT, Fairy Tale Test, and Somatic Inkblot Series -II. The three different projective tests were administered for cross-verification of the findings. Results revealed striking congruence of the signs of the searches in relation to the clinical delving of the interview and the projective probing of the case, reflecting the clinical efficacy of projective tests in general.Cervigni (2013) administered SIS-I (Card form) to two cases for diagnostic formulation and therapeutic intervention in Italy. The test was found valid in assessing personality and diagnostic evaluation and the test must be included in every clinic as a therapeutic procedure. It helped in therapeutic planning and trapping unprocessed unconscious material. Dewangan & Roy (2015) studied Social Desirability Biasness in Rorschach Inkblot and found that many psychologists rely more on projective psychological assessment to identify any personality pathology or clinical symptoms with the believe that projective tools are protected from social desirability biasness. Basu (2014) critically relocates the debate concerning the validity and utility of projective tests within multiple interpretative and process oriented approaches. Some scholars opine that there could be alternate ways of looking at projective tests, for example using it as a technique to elicit cognitive and emotional states or as behavior samples. Supporting, modifying or denigrating the use of projective tests may reflect different underlying attitudes toward ambiguity and multiple interpretation of a situation. Thus it represents either of two different traditions of psychology: one, aspiring to attain a structured and organized view of human behavior facilitating prediction, and the other, an acceptance and appreciation of idiographic and divergent responses that may not necessarily be predictive, but informative about the multiple possibilities of human thought process. This latter approach would be more concerned with the process of experiencing rather than with obtaining a relatively final and fixed answer to the dilemmas of existential conditions. The possibility of such approach was always present in the history of projective tests, but has been subdued under the hegemonic pressure of diagnostic utility. It was argued that a process oriented view of responses to ambiguous situations, along with a sensitivity to human diversity and multiple interpretations rather than emphasizing commonality, may open up a fresh relocation of projective technique within psychology. Training of projective technique may incorporate this consideration for future researchers. Khromov & Dubey (2016) measured the correlation of Rorschach, SIS-I and SIS-II inkblot tests to find out the mutual empirical validity with MMPI test. The three tests were administered to 98 subjects. The results were ciphered on identical forms containing 54 categories which were correlated with MMPI test. The structure of correlation in each pair matrix of three inkblot tests was calculated and has been compared. Сronbach has commented that projective techniques give wider strip of information and lower reliability in comparison with objective psychometric tests whereas Cassell (1980) emphasized that increased structure of projective stimulus have raised level of reliability of projective tests. The findings of present research revealed, that psychometric properties of inkblots tests increased after increasing the stimulus from Rorschach to SIS-I 20 images

and from SIS-I to SIS-II (62 images). However, it was not able to increase the ability to differentiate subjects‟ specific mental disorders. Correlation between ambiguity and projection of properties of the person has nonlinear character, and the moderate level of ambiguity gives an optimum variant at displaying. Theoretical Postulates of Inkblot Tests: Hermann Rorschach did not postulate a specific theory with regard to his inkblot technique either for personality evaluation in general or clinical diagnosis (Exner, 1969). However, Zygmut A. Piotrowski (1957) has postulated a theory of Rorschach test known as Percept analysis. In spite of its limitations in terms of theoretical postulations, the Rorschach method offers a procedure through which the individual is induced to reveal his „private world‟ by telling what he „sees‟ in the 10 cards upon which he may project his meanings, significance and feelings. Frank (1939) as many others also believe (Beck, 1937; Klopfer, 1939) that the Rorschach method is essentially a procedure for revealing the personality of the individual. Currently there are six such systems, none of which completely different from the others, or from the Rorschach‟s original conceptions. The differences that exist in the present day Rorschach Systems seem to have been precipitated by two factors. First, none of the authors of the six systems, Beck, Klopfer, Hertz, Piotrowski, Rapaport with his colleague Schafer and Exner, had any direct contact with Hermann Rorschach. The second and much more fundamental reason appears to be the general training and background to which each were exposed. Although there are major differences, there are major agreements too. For example, all those who developed scoring system tended to endorse some form of psychoanalytical theory and accepted many of Rorschach‟s original interpretative hypotheses (Exner, 1969). All of these persons developed different systems for Rorschach‟s scoring and interpretations. The systems, however, have been heavily drawn from the basic procedure suggested by Hermann Rorschach based on his empirical findings. Among these systems Beck, Klopfer and Exner‟s systems are used most frequently depending upon the training the user has received? Wilfred A. Cassell has postulated three theories of SIS: Somatic Imagery Theory, Theory of Body Symbolism and Theory of Inner Cry. These have fulfilled the theoretical gap of Rorschach test. The theories proposed (Cassell & Dubey, 2003) have been illustrated below: Somatic Imagery Theory: Somatic imagery theory proposes that everyone has a unique and highly personalized system of attitudes, both conscious and unconscious, that is projected onto the body concept as a special entity. These interact with external environmental feedback sources and internal sensations. Relatively discrete mental representations exist for particular somatic regions, which constantly compete for full registration in consciousness. Somatic awareness transiently increases in states of hunger, physical exertion, emotional arousal and sexual excitement. Subsequently, the mental representations in the body fade into the background of consciousness. Alterations in body perception also occur in physical illness. In the diseased body, pathologic physiologic processes give rise to percepts from the diseased area, which directly or indirectly, enter into awareness. The patient's sensitivity to these depends partially on the pre-existing body concept. Sensations that arise from regions of high priority in the body gestalt are more likely to register than those from more perceptually silent areas. If the sensations are subjectively considered aberrant, the individual must then cognitively evaluate their potential abnormal significance. At this stage, the medical patient

experiencing somatic symptoms then makes a kind of lay "diagnosis." Intense pain or gross changes in body function are readily distinguished from normal body processes. However, other alterations such as early stages of disease formation pose problems for subjective interpretation. The cognitive appraisal of the altered body state is influenced by factors such as age, sex, socioeconomic status and past medical and family history of disease experience. There may be a strong motive, conscious or unconscious, to adopt a sick role to obtain disability compensation. There may also be a stress-induced wish to regress to an infantile, dependent position, and be taken care of by parental figures such as a spouse, grown children, physicians, nurses or nursing home staff. Interaction between these multiple mind-body (“psychosomatic”) determinants will influence whether or not an individual decides to consult a physician to report subjective experiences. Such "symptoms" reported in the early stages of an initial visit represent verbal communication, containing localized reference to specific organ images within the body gestalt. Their cognitive content reflects altered anatomical awareness associated with the patient's belief that the given region has impaired function. Once professional consultation is obtained, the physician formulates a series of diagnostic hypotheses based on "presenting symptoms", on the nature of the underlying disease processes. Then a former structured medical interview is conducted, with questions designed to uncover the pathological significance of somatic symptom clues. In most instances, an insightful physician will be in a relatively strong position to establish a working diagnosis upon completion of the history. In this situation, there is no strong need for additional aids in diagnostic interviewing, such as anatomical like projective test techniques. There are, however, some cases when the diagnosis is not clear. Patients may present symptoms, which do not fit into recognizable disease patterns, or there may be major obstacles in communication with the individual. Some patients minimize or deny physical illnesses while others exaggerate them. Clinical experience, upon which the SIS procedure builds, indicates that persons suffering from stress induced physical disturbances or (“hypochondriac“) conversion reactions, malingering etc will report perceive abnormal anatomical structure on SIS blots. There may be sensitization with anatomy (increase in number of anatomical responses) or repression with avoidance of somatic content. This clinical use of content analysis follows the interpretation principles described by Schafer (Schafer, 1954; 1960). When the responder projects the response "sick stomach," it may indicate a concern about individuals own health or that of the loved one. Alternatively in a more physiologic fashion, it may signify a deeper level of body awareness involving the stomach. This is consistent with Hermann Rorschach's believe that certain anatomical responses may be a projection of kinesthetic sensations in the musculature. By assessing an individual's responses, and associations to them, much can be learned about the person's innermost thoughts and feelings. What is seen or imagined in semiambiguous inkblots reveals his deeper layer of self-perception. It is hoped that these evolving technique may be applied by investigators of inner psychic space leading to the creation of new body-mind-spiritual theory. At its present stage, the various forms of the SIS have been found helpful as an aide to enable professional to empathize more sensitively with the suffering individual's "inner cry." Previously, their suffering was more likely hidden because of defensive mental mechanisms. Many existing techniques employed today are highly time consuming,

not particularly cost-effective. Perhaps most important of all, they do not readily provide a transparent window into the inner world. Theory of Body Symbolism: Interest in the symbolic significance of the human body can be traced back to the very dawn of civilization (Wentinck, 1972). Indeed, ancient wall paintings and stone carvings evidence preoccupation with this subject. These distinguish Homo sapiens from less symbolically able species. Throughout history, pictorial representations of the body have been a central theme of artistic expression of humanity's search for identity. Philosophically, such representations are an attempt to integrate mental and physical phenomenon rather than to isolate or reduce them, as in Cartesian mind-body dualism. When someone projects onto an inkblot the response "sick stomach", it may indicate a concern or focus on that organ in one-self or another person. It also might indicate some association or deeper symbolization involving the stomach. An organic or functional disorder in that organ system is consistent with Rorschach's view that certain anatomy responses may be a projection of kinesthetic sensation in the musculature (Rorschach, 1951). Freud, and later Alexander and French, described how gastrointestinal dysfunction or distress can be a manifestation of underlying psychological conflict which is below conscious awareness. Projective techniques geared specifically to body imagery and organ function assesses both organic and functional disorders, real or imagined. Roy Schafer, a psychoanalyst, advocated a content analysis approach (Schafer 1954, 1960). More recently, content analysis has been reviewed in Aronow & Reznikoff's book "Rorschach Content Interpretation" (1973). Qualitative content analysis assesses the individual's imaginable mode of information processing. It taps the same inner perceptual field as dream imagery. This occurs on a continuum from pictorial recall to pictorial metaphor. Pictorial recall is visualized objective reality, rational and realistic. Pictorial metaphor is a complex concept which is highly individualized, consisting of subjective associations of past experiences, interpretation of present realities and future expectations along with their meaning. While "normal" perception matches reality, it is never 100% congruent with objective fact. An example is the relative unreliability of some eyewitness accounts. Memory and dreams are contaminated by personal cognitive and affective percepts. These dynamics often elude both structured interview and a battery of standardized psychological tests. They are more readily understood through extensive symbolic analysis. The Inner Cry for Help: Clinicians worldwide have heard the cry for help in a variety of ways. These range from abused children who escape stress through Dissociative Disorders to victims of catastrophe or war, who suffer from posttraumatic stress disorders. Other manifestations include ongoing frustrations in their life situations and in affective disorders or abnormal behavior. Some cry for help through their bodies, with Somatoform disorders. All these are diagnosable by DSM or ICD criteria through use of definition and symptom checklists. Underlying conflicts can also be manifested in subtle, more complex, and less dramatic ways. Physical symptoms, such as functional disorders, hypersensitivity of an organ system, or pain all in themselves may represent a form of a cry for help. There are daily examples of this somato-psychic interaction in such expressions as "it's a real pain in the neck" (or elsewhere), "my heart was pounding" (broken, bleeding, or heavy), "what a headache", "he's a hothead", etc. For physicians, therapists and researchers, the body, its organ systems and its perceived

functions are "doorways to the mind." By observing and assessing how people perceive or misperceive body and organ function, much can be learned about their innermost thoughts and feelings. What they see in ambiguous and semi-ambiguous inkblots shows how they see themselves, the quality of their life and lifestyle, their adjustment to conflict, their coping skills and their view of the reality of life. The Somatic Inkblot Series can help therapists more sensitively "hear" a suffering individual's cry for help, the "inner cry" that is not only hidden from others, but often hidden from one's own conscious awareness as well. This is the "magic"; the unique and distinguishing feature of projective testing. While the SIS uses somatic inkblots that involve body and organ imagery, they have identified a variety of personal problems and mental disorders also. As stated above, everyday conversations are replete with examples of the mind-body connection, such as "broken heart" for depression or grief; "stuck in my craw", "eating at my gut", "pain in the neck," or "what a headache" are used for anger or frustration; "butterflies in my stomach" or "scared shitless" are used for fear or panic, to name just a few. Since projective tests are not based on verbal communication, they more effectively penetrate a person's "outer shell" of defenses and surface behaviors. Unlike personality and intelligence tests, projective tests do not require reading questions or manuals, so they more directly access mental processes. They use the language of dreams, visual imagery and symbolic thought, the most basic forms of thinking and expression. Projective tests speak the language of repression and bring whatever is buried in the mind closer to consciousness, so it is accessible for processing. By developing a practiced eye and ear for this imagery, therapists can more directly share the perceptual world of their patients with less interference, and fewer variables than in structured interviews or so-called "paper and pencil tests." If, as the saying goes, "a picture is worth a thousand words," inkblots are picture recognition tests, and therefore are potentially more powerful than verbal interviews and tests. Therapists willing to more directly know and experience the patient's psychic pain will be rewarded with clearer understanding of the psycho-dynamics involved, and therefore be able to provide more effective therapy. SIS Imagery and Dreams: During psychophysiological arousal, this feedback process can give rise to real and symbolic somatic imagery during dreaming. A dreamer with a full bladder sending sensations to the brain will often experience scenes related to the need to urinate. Similarly, tensions in the reproductive structures can stimulate sexual imagery and related physical responses. If these feedback mechanisms were activated under laboratory controlled experimental conditions in associations with projective testing, it might be expected that similar somatic responses would be projected. Against this conceptual background, apart from cognitive “familiarity”, affect linkage influences the intensity that heart percepts compete for registration in body gestalt awareness. Affect linked processes can then either heighten awareness or through neural inhibition, block organ specific imagery from registering in full consciousness. Evidence of this emotion based phenomenon is observed clinically in the mental disorders by “thought blocking”, “amnesic episodes, “conversion reactions” etc. Two clinical approaches that examine this theoretical consideration were completed. One involved the creation of a reduced state of viewing arousal, by inducing hypnotic relaxation; the other involved the use of sedating medication (Intervenous barbiturates). These approaches led to observations, that reducing anxiety/threat can free up the release of previously inhibited

somatic imagery. Such clinical insights played an important role when SIS-II Video version was designed. Influence of Culture on Inkblot perception: Dana (2000) compared Exner‟s normative data of North Americans with European and South American subjects and found marked differences on some important variables. For example, texture response is typically zero in European subjects (a European would express it only when it reaches the level of a craving for closeness) and there are fewer "good form" responses in comparison to the North American norms. Form is most often the only determinant perceived by European subjects, while Color is less frequent than in American subjects. The European subjects see more of Color-Form responses than Form-Color responses in comparison to North American subjects. The differences in Form quality are attributable to purely cultural aspects: different cultures will exhibit different "common" objects (e.g. French subjects often see a chameleon on card VIII, which is normally considered as an "unusual" response, as opposed to Cats and Dogs by Scandinavians. Christmas Elves on card II and Musical Instrument on card VI is a popular response for Japanese subjects (Weiner, 2003). Form quality, popular content responses and locations are the only coded variables in the Exner systems that are based on frequency of occurrence, and thus immediately subject to cultural influences; therefore, culturaldependent interpretation of test data may not necessarily need to extend beyond these components (Weiner,2003). Similarly total numbers of responses are comparatively low among Indian subjects than North America. Army personnel give significantly low number of Responses in comparison of other Indian norms (Dubey, 1982). Similarly, we have noticed different responses on Somatic Inkblot Images by North American subjects and Indian subjects. Dancing lady and Apple are popular response on image A7 in North Americans whereas two Snakes along with Dancing lady and Apple are commonly perception by subjects in India. Alaskan subjects rarely project a Snakes response in in Alaska. With regard to projection of sexual responses for A 25, A27, and B18 North American subjects gave a higher number of responses than those living in India. It might be inferred that less were seen by Indians because of cultural impact and religious practices. Eve with an Apple is the common response on image A7 in North Americans. Similarly it is often perceived by Indians educated in Christian/English Schools in contrast with other Indian subjects. Similar findings have also been reported in various case studies published in several issues of SIS Journal of Projective Psych. & Mental Health. Weiner (2003) has also advised when possible, to administer projective testing in the subject's native language. Test responses should also not be translated into another language prior to analysis except possibly by a clinician mastering both languages. It is hoped that Anthropologist will follow up on these observations. Interpretation of SIS: What Constitutes a Projective Test? The quantitative inkblot response indices for the Rorschach Holtzman tests and SIS have considerable historical research and clinical merit derived from a foundation of normative data. While assigning numerical summation scores to subjective inner world phenomenon may make such an approach appear “Objective” scientifically, the application of mathematics in this context does not have the same ring of reality as counting physical objects. In recent years, skeptical critics have raised fundamental questions regarding their applicability in 21st century clinical settings.

Historically, the categories “Human”, “Animal” and “Movement”

utilize principles of projection, more than those assessing such constructs as “form” and “color”, which are more analogous to measurements made use of in neuropsychological tests. The later indices are based more upon the optics of perception of objects in the outer world, as opposed to the subjective inner world of emotion colored imagery. Consequently for psychometricians to label such tests as strictly “Projective” tends to be somewhat of a misnomer. Content analysis is a more of a treatment oriented approach, than diagnostic one. Yet it must be acknowledged that the cost of controlled statistically based therapeutic outcome studies has so far prohibited their completion. However, there are many individual cases with the SIS highly suggestive of clinically significant positive results. My revised conceptual model proposes that content derived from the phenomenon of “inkblot” projection involves imaginative viewing of visual input, which are sufficiently ambiguous to stimulate the release from memory storage of otherwise unavailable deep seated imagery. What ordinarily is released with content analysis is more akin to fantasy, dreams. PTSD flashbacks etc., and ultimately the suffering individual„s “inner cry”. However, it must be acknowledged that content analysis does not readily lend itself to quantification scoring and has been criticized for not being “Objective”. A subject‟s projective profile tends to be highly unique and idiosyncratic. Often, the deep seated information surfaces and is projected in a disguised symbolic language, initially interpretable only by a trained professional. Consequently, much of the clinical SIS work has relied on an individual case history reports, as illustrated in many cases published in SIS Journal of Projective Psychology & Mental Health from 1994-2018). In clinical settings, the responses can reflect emotionally charged misperceptions of other “Humans“, the individual‟s faulty sense of self as a “Human”, distortions in perception of the individual‟s own body, as well of those of others, etc. On a temporal scale, the projected imagery tends to be highly fluid; fluctuating rapidly in the level of projective awareness during the period an inkblot series is viewed. As previously outlined, the visualized imagery may surface at any point in a spectrum, ranging from either a photographic like representation of past real life events, or their distorted misperceptions. Moreover the images may be projected as symbolic defensive representations. However, in the more severe mental disorders having an organic neurological basis, the mental material that is projected, may primarily reflect underlying neuropathology and symbolism only secondarily. Prior to the resultant imagery being recognized by the neurophysiologic processes giving rise to awareness and recognition, the inkblot information from the visual input is reshaped by psychological defense mechanisms. These control the competitive balance between “sensitization” and “repression”. The psyche forces attracting an image to the door of conscious awareness and ultimate recognition are opposed by opposing ones activating neural inhibitory processes. Whether or not the image passes through the door and is then projected onto ambiguous inkblot stimuli depends upon the interplay between such competitions. When threatening affect causes inhibition to override sensitization, then secondarily activated brain circuitry search the same brain regions, as those which give rise to anxiety arousing dreams. Afterwards, if the affect released is potentially too threatening, what is brought to the responder‟s projective mind are disguised affect neutralized symbols. While these may

have less disturbing affect linkage then the original stressful memories, the unfelt affect may be converted to a variety of secondary physical and mental symptoms. Content Analysis: Historically, Herman Rorschach‟s assessment of content was relatively limited not only due to his early death, but also to the limited understanding of the mental mechanisms underlying mental disorders in his lifetime. He assigned content to one of six categories: Animal content, Human content, Animal detail, Human detail, Inanimate object and Landscape. Several subsequent workers such as Beck et al. (1961) and Klopfer et al. 1954 expanded upon the number of content categories. Holtzman et al. (1961) included five categories: Human, Animal, Anatomy, Sex, and Abstract. The high degree of somatic structure in the SIS taps into an important psychophysiological dimension. Previously, a book written by Schafer (1960), describing the relevance of anatomical content analysis in psychoanalytic treatment was noted. He outlined the importance of “Body Image” concepts as follows: “The blots themselves are equivalent to bodies. Their treatment as stimuli, that is, their use of colors, shadings and forms and their scores reflecting this usage, can be seen to additionally relate awareness of the expression of the subjective experience of bodies”. For a comprehensive overview of the field as it appeared in 1976, the reader is referred to a book written by Aronow & Reznikoff in their 1976 book, Rorschach Content Interpretation. Content analysis is given more emphasis in interpretation of Somatic Inkblot responses. It frequently helps to bring out the unprocessed unconscious material on surface. What is seen through the response profile, along with the affect linkage, may have direct or symbolic significance either in the present or in the viewer's past. It is quite analogous to assessing such material as the in-depth study of dreams. While the professional's own theoretical frame of reference will strongly influence the interpretative process, it is the authors, viewpoint that in most clinical therapeutic situations, content analysis for any given individual is a richer approach. Several Clinical cases are illustrated applying Content Analysis for understanding the power of inkblot instrument and outcome of therapeutic intervention in the book “Interpreting Inner World through Somatic Imagery (Cassell & Dubey, 2003). However, for the help of researchers, (Quantitative Analysis) emphasis on the analysis of various indices, such as number of responses(R), number of human, Animal, Anatomical, Sex, Popular/MT, Movement, and various indices in Determinants and Content categories has been given in the Manual of Test. Normative data and clinical indicators have been established on larger population. These indices are established for evaluating a series of mental constructs in various normal and clinical groups. The prognosis is estimated to be more guarded if the number of Rejection, along with the Pathological responses becomes elevated. In short it can be concluded that the INKBLOT Test, particularly the Somatic Inkblots has taken care of earlier lacuna and has developed newer version of the procedure to have pace with the development of technology. This is the only inkblot test which has been administered as successful GROUP TEST in Industry during preliminary screening and selection in Indian industry. It is also becoming popular internet tool during Teletherapy. Research papers published in the Journal: From its first publication in July 1994, two issues are published in January and July each year and reached to its members in time. Credit goes to Editor In Chief, Editors, Editorial Consultants and publication Manager for their efforts in getting the Journal ready

before time. About articles were published using projective tests, case report and therapeutic interventions in 25 years. The Journal has reached to renounced Institute and Libraries in different countries with international membership. The paper published using projective tests are given separately in Bibliography section at the end. Doctoral Dissertations Using Somatic Inkblot Series: Somatic Inkblot Series has even stirred the interest of research scholars to pursue their doctoral dissertations using any of the versions of the series. Following dissertations have been awarded the degree of doctor of philosophy in psychology. 1. Mridula Mishra, Compatibility of SIS-II and the Rorschach Indices in Normal, Neurotics and Schizophrenics, awarded in 1996, from Banaras Hindu University, Varanasi, under the guidance of Prof. C.B.Dwivedi. 2. Gopa Mitra,“Some Psychological Factors in Drug Addicts and Normals: A Comparative Study”, awarded in 1997, from Banaras Hindu University, Varanasi, under the guidance of Prof. Anjana Mukhopadhyay. 3. M.P.Singh, “Effect of age and sex on the projective responses of SIS-II” awarded in 1999 Punjabi University Patiala. 4. S.P.Rathee, “Diagnostic value of Somatic Inkblot Series -II for Psycho-pathological cases in Armed forces" awarded in 1999 by Punjabi University, Patiala. 5. Deepak Kumar “Diagnostic Indicators on SIS-I and Rorschach among manic and depressive patients”, awarded in 2002 from Dr. Bhimrao Ambedkar University, Agra, under the guidance of Dr. Rakesh Kumar. 6. Ruchi Jain “Diagnostic indicators on SIS-I & Rorschach among children with Attention Deficit Hyperactivity Disorder” awarded in 2004 from Ch. Charan Singh University, Meerut under the guidance of Dr. Beer Singh and Dr. Rakesh Kumar. 7. Sunita Kandhari, “Development of a Comprehensive Scoring System for SIS-I” awarded in 2008 from Ch. Charan Singh University, Meerut under the guidance of Dr. Jyotsna Sharma and Dr. Rakesh Kumar. 8. Jashobanta Mahapatra, “A Comparative study of Schizophrenia and Affective Disorders on SIS-I and Rorschach”. A warded in 2009 by Sambalpur University, Orissa under the guidance of Prof. PK Mishra and Dr. Rakesh Kumar. 9. Bhawana Singh “Diagnostic Efficacy of SIS Indices in Relation to Rorschach among Paranoid and Non-paranoid Schizophrenics”, Awarded in 2012 by Ch. Charan Singh University, Meerut under the guidance of Dr. Rajni Kashyap and Dr. Ajai Srivastava 10. Mahesh Kumar Singh, “Cognitive and Affective Aspects of Attention Deficit Hyperactivity Disorder (ADHD) Children and Intervention through Parental Education”, Awarded in 2014, from Banaras Hindu University, Varanasi, under the guidance of Prof. Anjana Mukhopadhyay. 11. Kamlesh Rani: Projective and Psychometric Personality Correlates of Suicide Ideation" awarded in 2015, from Kurukshetra University, Kurukshetra under the guidance of Prof. Umed Singh. 12. Rachana Kumari, “Effect of Psychological Intervention PTSD Symptoms, Impulse Control and Emotion Regulation in Trauma Affected Individuals” submitted in June 2017 in Banaras Hindu University, Varanasi, under the guidance of Prof. Anjana Mukhopadhyay. International Conferences and Workshop organized by the Somatic Inkblot Society: The Society has organized following International Conferences on Somatic Inkblot Series: 1. First SIS International Conference, held at Punjab University, Chandigarh, April 7-8, 1990. 2. Second SIS International Conference, held at G.B.Pant Hospital, New Delhi, Nov 14, 1992. 3. Third SIS International Conference, held at Panjab University, Chandigarh, on Feb. 22-25, 1996

4. Fourth SIS International Conference, held at Panjab University, Chandigarh on Nov, 24-27, 2000. 5. Fifth SIS International Conference, held at Kochin, November 26-28, 2004 6. Sixth SIS International Conference, held at Ranchi Inst. of Neuro-Psychiatry & Allied Sciences, Ranchi Feb 9-11, 2008 7. Seventh SIS International Conference, SIS Center, Anchorage, AK - 99507 (USA) October 5-7, 2012 Workshops on Somatic Inkblot Series: Apart from regular workshops which are being conducted on somatic inkblot series, following workshops on the application of Somatic Inkblot Series were conducted in International Conferences. 1. Personality Profile of Indian Executives. XXIV International Congress of Psychology. Sydney. (August 1988). 2. SIS as an aid to Diagnosis and Therapy, 1st SIS International Conference, Panjab University, April 1990,Chandigarh) 3. SIS - An Indian Experiment. 49th International Council of Psychologist, San Francisco, August, 11-15, 1991 4. Clinical Utility of SIS, 50th Conference of International Council of Psychologist, Amsterdam, July 19-23,1992 5. Diagnostic utility of SIS-Video.25th International Congress of Psychology, Brussels, July 24-28,1992. 6. Application of Somatic Inkblot Series. 25th International Congress of Psych., Brussels, July 1992 7. Reliability and validity of SIS-Video, 25th International Congress of Psychology, Brussels, July24-28,1992 8. Inner cry through SIS, 51st Conference of International Council of Psychologist, Montreal, Aug 15-19,1993 9. Somatic Inkblot Series in adolescents. 23rd International Congress of Appl. Psych., Madrid, July 1994. 10. Assessment of traumatic life experience reaction, Workshop n 23rd International Congress of Applied Psychology, Madrid, Spain July 18,1994. 11. Application of SIS, 14th International Congress of Rorschach and Projective Method, Boston, USA, July, 8-12,1996 12. Clinical significance of SIS, 26th International Congress of Psychology, Montreal, Canada, August 16-21,1996 13. Diagnostic Compatibility of SIS and the Rorschach, Mid-Winter Meeting of Society for Personality Assessment, Boston, Feb 18-22, 1998. 14. Compatibility of SIS and Rorschach.24th Congress of International Association of Applied Psychology, San Francisco, August 9- 14,1998 15. Compatibility of Rorschach and SIS. SPA Midwinter Conference, New Orleans, USA March 24-28,1999 16. HRD Intervention in a Public Sector Organization, SPA Mid-Winter Conference, Philadelphia, USA, March 2001 17. Personality Profile of a Public Sector Organization. APA Div 13, Consulting Psychology, in the Session “International Perspectives on Organizational Consulting" August 25, 2002, Chicago. 18. Personality Profile of Executives and Management Students in India. APA Div 13, Consulting Psychology, in Metro Toronto Convention center, August 10, 2003, Toronto, Canada. 19. Role of SIS in Psychosexual Disorder in India, workshop in SIS International Conference, Kochin, Nov.26-28, 2004 20. Efficacy of SIS as Therapeutic procedure, Workshop in 6th SIS International Conference, held at Ranchi Inst. of Neuro-Psychiatry & Allied Sciences, Ranchi Feb 9-11, 2008 21. Dream and SIS imagery, Workshop in 7th SIS International Conference, SIS Center, Anchorage (USA) Oct 5-7, 2012 22. Workshop on the “Application of Somatic Inkblot Test” was conducted in Ahmedabad, Bangalore, Calcutta, Chandigarh, Cochin, Delhi, Gurgaon, Hyderabad, Jaipur, Jodhpur, Lucknow, Madras, Mumbai, Mysore, Udaipur, Varanasi, Visakhapatnam etc.

23. Workshops on the application of Somatic Inkblot Test were conducted in following Universities: 1. South Carolina University, SC 2. Rose bridge Medical Institute Concord, CA 3. Connecticut College, CT 4. University of Alaska, Anchorage, AK 5. Alaska Pacific University, Anchorage, AK 6. Fordham University, NY 7. Long Island University, NY 8. National University, Singapore 9. Tasmania Medical Institute Hobart, Australia 10. Vrije University Amsterdam Future Directions: Somatic inkblot series has been becoming increasingly popular as an assessment tool in clinical as well as non-clinical settings and stimulated ample interest of the researchers. There are many versatile areas in which still more advancements could be contemplated. One such area is real time brain imaging by exposing the participants to SIS images and identify which areas get stimulated during exposure to SIS images. To begin with this huge task can be reduced to using rejected images as the basis of investigation. Persons affected by specific emotional issues can be administered SIS and their rejected and least liked images can be identified. Further, these images could be exposed during real time brain imaging which can give additional insight into the dynamics and corresponding neural correlates. Long term follow up studies could also be undertaken to see changes in projection on SIS at baseline, termination of psychotherapies, and subsequent follow ups. This will further establish the value of SIS in tapping pattern of intrapsychic changes over time. Trance and SIS could be seamlessly integrated. An exploration of intrapsychic determinants of image rejection and least liked images could be explored under hypnotic trance which could potentially recover the suppressed painful emotional experiences leading to pin pointed catharsis and developing insight which could accelerate the therapeutic process. SIS could also be used along with psychophysiological measurement. The participants could be exposed to SIS images on screen and simultaneous psycho-physiological monitoring could be done. Such an administration could be done non-verbally to identify emotionally charged imagery. Upon identification of imageries that elicit abnormal level of psychopathology, could be used to stir and access the emotional correlates of those images. Conclusion: Inkblot techniques and handling of the data gathered through inkblots are still evolving. Inkblots are unique tools that provide an opportunity to the examiner to analyze the data both qualitatively and quantitatively. SIS is a potent tool in the family of inkblots that has distinct advantages which could be put to use in assessment, application and research settings. It is a relatively new tool and Journal of Projective Psychology and Mental Health has emerged as a primary database for the knowledge and applications of Somatic Inkblot Series. Bibliography: Anastasi, A. (1982). Psychological testing (5th ed.). New York: Macmillan Aronow, E. & Reznikoff, M. (1976).Rorschach Content Interpretation. Grune and Stratton, NY. Bartlett, F.C. (1916).An experimental study of some problems of perceiving and imaging, British Journal of Psychology, 8,222-267. Bartol, K. M. (1983). Turnover among DP Personnel: A causal Analysis. Communications of the ACM, 26, 807-811. Beck, S. J. (1937). Introduction to the Rorschach Method: A Manual of Personality Study. American Ortho Psyc. Assoc. Monograpgh. Cassell, W. A. (1965). Body Perception and Symptom Localization. Psychosomatic Medicine, 27, 171- 176.

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Schaefer, R. (1954). Psychoanalytic Interpretation in Rorschach Testing. Grune& Stratton, Inc., New York. Schaefer, R. (1960). Bodies in Schizophrenic Rorschach Responses. J. of Projective Tech. & Personality Assessment, 24, 267-281. Weiner, I.B. (2003). Principles of Rorschach Interpretation, Mahwah, N.J.: Lawrence Erlbaum. Wentinck, C. (1972).The Human Figure. Livingston, Wynnewood, Pennsylvania. Whipple, G.M. (1910). Manual of Mental & Physical tests, Warwick & York Baltimore Chapter XI, Test Inkblots pp 430-435 Zilboorg, G. (1962). Psychoanalysis and Religion., New York: Farrar, Straus & Cudahy. Zubin, J., Eron, L. D. & Schumer, F. (1965).An Experimental Approach to Projective Techniques. John Wiley & Sons, NY. Research Papers using Projective tests & psychotherapy published in Journal of Projective Psychology and Mental Health 1994-2017 Alreja, S., Mishra, D.K., Sengar, K.S., Singh, A.R. &Chaudhury, S. (2009). SIS-II Profile of Medical Practitioners, 16, 178-179. Alreja, S., Mishra, D.K., Varghese, M.M., Sengar, K.S., & Singh, A. R. (2009). SIS-II Profile of Mentally Retarded Children,16,51-54 Bailey, C J. &Murstein, B. I. (1996). Paranoia Assessment with the SIS-II: In a College Sample. 3, 109-122. Bala, K., Mishra, D.K. & Jahan, M. (2010). SIS-II Profile of Patient with Antisocial Personality: A case report, 17, 178-179 Banerjee, S., Mukhopadhyaya, A & Singh, U. (1998). An In depth Study of Somatization in Heroin Addicts thru SIS-I & Rorschach Inkblot Test. 5,33-39. Basu, J. & De, S. (1997). Utility of Projective Tests in the Psychological Assessment of Transsexual Patients: A Case Study Approach, 4, 41-55. Basu, J. & Nandy, R.(2004). Substance Dependence, General Mental Health and Somatization Responses : A Study of Ganja Smokers, Tobacco Smokers and Non- Smokers, 11, 5-84. Basu, J. (2014). Psychologists‟ Ambivalence toward Ambiguity: Relocating the Projective Test Debate for Multiple Interpretative Hypotheses, 21(1), 25- 36. Bellamy, E. N. (1995). Hospitalized Suicidal Patients and The Somatic Video Procedure: A descriptive Study. 2, 85-91. Bhogta, S.K., Roy, S. Jahan, M., Sengar, K.S. & Singh, A.R. (2014).SIS-II Profile of Patients with Thalassemia, 21(2), 119-12. Brady, D. (1995). A study of Somatic Inkblot Series : Application in Medical Setting, 2, 129-134. Bram A. D. & Yalof J. (2018).Two Contemporary Rorschach Systems: Views of Two Experienced Rorschachers on the CS and R-PAS, 25, 35-43 Brock, D., Cassell, W.A., Tyrone, C., Maureen, C., Dubey, B.L., Halia, J., Leigh, R. & Laurel, S. (2015). SIS Symbols of PTSD & the Need for Empathy in Therapy, 22(1), 3-8. Campos, R.C. (2011). It might be what I am: Looking at the use of Rorschach in psychological assessment, 18(1), 28-38. Cassell, M. A., Cassell, W. A. Dubey, B. L., Dwivedi, P., Molchanov, E, O‟Roark, A.M. & Routh, L.C. (1999) . A Video Projective Technique for PTSD in Women, 6,3-28. Cassell, W, A. & Dubey, B. L. (2003).Interpreting Inner World through Somatic Imagery: Manual of SIS. Anchorage (USA). Cassell, W, A. & Dubey, B. L. (2004). Somatic Inkblot Series: Historical Background and Earlier Projects, 11, 11-18 Cassell, W, A. & Dubey, B. L. (2004a). A Nervous System based Model for SIS Inkblot Projection and Consultation, 11, 95-104. Cassell, W. A. & Dubey, B. L. (2006).Tracing the Roots of Violence by associating Dream and SIS Images: A Vicarious Visit to an Adolescent‟s Birthday Party, 13(2), 85-106. Cassell, W. A. & Dubey, B. L. (2007). Restructuring Rorschach Pathological Body Symbolism in the Somatoform Disorders with Truth Serum Behavior Therapy, 14, 20-29. Cassell, W. A. & Dubey, B. L. (1996).The Use of the Rorschach and SIS in Releasing Somatised Grief, 3, 3 -32. Cassell, W. A. & Dubey, B. L. (1996a). Efficacy of the Booklet and Monochromatic Version of the SIS in a Case of Repeated Miscarriages, 3, 131-145. Cassell, W. A. & Dubey, B. L. (1997). Therapeutic Dream Stimulation with SIS- Video, 4, 3-23. Cassell, W. A. & Dubey, B. L. (2000). Inkblot Responses as an Aid to Therapy, 7,3-10. Cassell, W. A. & Dubey, B. L. (2002).Application of Somatic Inkblot Series-I: New Scoring System, 9, 5-22. Cassell, W. A. & Dubey, B. L.(1998). Application of Somatic Inkblot Series in Personality

assessment, Screening, Diagnosis and Therapy, 5,3-32. Cassell, W. A. & Dubey, B. L.(1998a). Mental Disorders Triggered by Exposure to Violent Imagery in the Media and in Electronic Games, 5,87-104. Cassell, W. A. & Fields, D. (1995). Somatic Inkblot Series - Video: Case Report and Discussion, 2, 3 -18. Cassell,W.A. (1994). Somatic Inkblot Series: Continuing Rorschach‟s Conceptualization. 1: 3-14. Cassell, W. A. (1995). Editorial. 2, 93- 95. Cassell, W. A. (1996). Future Direction of Projective Technique, 3, 91-94. Cassell, W. A. (1997).Editorial, 4, 87-88. Cassell, W. A. (1998). Somatic Inkblot Series: A therapeutic tool for 21st Century, 4, 1-2. Cassell, W. A. (1998).The Somatic Inkblot Series and Eye Movement Desensitization and Reprocessing (EMDR). 4, 69-70. Cassell, W. A. (2001). SIS Explorations of Human Consciousness, 8, 3-14. Cassell, W. A. (2002).Editorial: Intellectual Struggle in Advancing SIS Knowledge, 9, 1. Cassell, W. A. (2004).Editorial: SIS Lessons, 11 (1), 73-4 Cassell, W. A. (2005).Presidential Address: SIS Stimulation of Beacon Imagery, 12, 3-8 Cassell, W. A. (2005a). Editorial: Evidence Based Medicine and the SIS, 12, 2, 85 Cassell, W. A. (2005b). Assessing Suicidal/Homicidal Impulses with the SIS, 12 (2), 99-106. Cassell, W. A. (2006).SIS Cognitive Psychotherapy for Spouse Induced PTSD, 13, 25-36. Cassell, W. A. (2007). Editorial: Historical Periods in SIS Theory and Practice, 14, 1-2. Cassell, W. A. (2007a). Body Consciousness in Exhibitionism, 14, 3-13. Cassell, W. A. (2007b). Desensitization Therapy for Body Image Anxiety, 14, 14-19.

Cassell, W. A. (2008). Editorial: Basing SIS Theory in Psychophysiologic Reality,15, 1-2. Cassell, W. A. (2008a). Viewing Holocaust Nightmares through the Lens of SIS Imagery: A Psychobiographical Study, 15, 1, 3-24. Cassell, W. A. Dubey, B. L. & Roth, G. J. (1997). Medical, Psychological and Spiritual Application of the SIS Inkblots, 4, 89-112. Cassell, W. A., Dubey, A. & Dubey, B. L. (2000). SIS Projective Responses in PTSD and Dissociative Disorder, 7,93-108. Cassell, W. A., Dubey, B. L., Molchanov, E. & Routh, L.C. (1999). Stimulating Beacon images for meditation and projective psychotherapy, 6,7-30. Cassell, W. A., Illardi, F.J., Collins, A., Mishra, M. & Dubey, B.L. (2001).Optimizing Spiritual Healing by Assessing Dream and SIS Imagery, 8, 75-94. Cassell, W. A., Schaeck, A.M. &Mohn, D. (2002). Symbolism in Violent Hallucinations, 9, 81-92. Cassell, W.A. & Dubey, B.L. (2008).The Mutilated Breast Syndrome - SIS Augmentation of Psychotherapy in Postpartum Onset OCD, 15,103-112. Cassell, W.A. & Dubey, B.L. (2009). SIS and Sand Tray Psychotherapy of Suicidal Adolescents, 14(2), 87-97 Cassell, W.A. & Dubey, B.L. (2009b). Content Validity of SIS-I and SIS-II Booklet Version, 16, 58-59. Cassell, W.A. & Dubey, B.L. (2010). Questionable Validity of Projective Technique and SIS Intervention, 17, 4-15. Cassell, W.A. & Dubey, B.L. (2010a). Infectious Suicidal Imagery in Combat PTSD, 17, 27-37. Cassell, W.A. & Dubey, B.L. (2010b). SIS II-Video and Treatment of Alcoholism, 17, 104-119. Cassell, W.A. & Dubey, B.L. (2011). Childhood PTSD Roots of Borderline Personality Disorder- Emotionally Unstable Personality Disorder (ICU- 10), 18, 3-9. Cassell, W.A. & Dubey, B.L. (2012a). Spiritual Warfare and SIS Spiritual Symbols, 19(2), 80-90. Cassell, W.A. & Dubey, B.L. (2014). Dream and SIS Symbolism in Bereavement, 21(1) 3-10. Cassell, W.A. & Dubey, B.L. (2016).A SIS-II Projective Case Study of Becker‟s Concept “Denial of Death”, 23(1), 2-11. Cassell, W.A. & Dubey, B.L. (2017). Efficacy of a Case of Post-Traumatic Stress Disorder, 24(2), 74-82. Cassell, W.A. & Dubey, B.L.(2012). SIS Screening for Dangerous Impulses- A Blog Based Training Exercise for Students, 19, 5-17. Cassell, W.A. (2009). Editorial: SIS Portraits of the Inner Mental World Painted by Blog Pooling of Interpretations, 16, 1-2. Cassell, W.A. (2010). Editorial: The SIS Journal as a Cyberspace Scientific Meeting Hall for Sharing Scientific Based Truths, 17,1-3. Cassell, W.A. (2010b). Editorial: Genetic Determinants of SIS Projection, 17, 101-103. Cassell, W.A. (2011). Editorial: Changing Personal and Professional SIS Perspectives, 18, 1-3. Cassell, W.A. (2011a). Editorial: Dissolving Death Anxiety with Yoga Empowered, 18, 123-128. Cassell, W.A. (2012). Editorial: “Wizard of OZ” Empathy Deficient Sociopaths - A Challenge for SIS Unmasking, 19 (1), 1-4.

Cassell, W.A. (2012a). Editorial: Memory Interaction with SIS Perception” Versus “Projection”, 19 (2), 77-79.

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Anthony D. Bram, PhD, ABAP, Private Practice, Lexington, MA, Cambridge Health Alliance/Harvard Medical School, Boston Psychoanalytic Institute and Jed Yalof, PsyD, ABPP, ABAP, ABSNP¹, Immaculata University Austen Riggs Center Psychoanalytic Center of Philadelphia, Private Practice, Haverford, PA (Correspondence concerning this article to: Anthony D. Bram, PhD, Massachusetts Avenue, LL#11, Lexington, MA 02420 Email: Anthony_Bram@hms.harvard.edu ) Note: Jed Yalof received support for this project from the Immaculata University College of Graduate Studies, Graduate Enhancement Model. Keywords: CS and R-PAS, Two Contemporary Rorschach Systems: Views of Two Experienced Rorschachers on the CS and R-PAS Anthony D. Bram and Jed Yalof There are two prominent evidence-based systems of the Rorschach currently in practice: the Comprehensive System (CS; Exner, 2003), which dominated the field for nearly four decades, and the more recently published Rorschach Performance Assessment System (R-PAS; Meyer, Viglione, Mihura, Erard, & Erdberg, 2011). The existence of two systems has raised questions and dilemmas for assessment clinicians and educators. In this article, as experienced psychoanalytic assessors and supervisors, we offer commentary regarding our view on the differences between the CS and R-PAS, their strengths and limitations, the tradeoffs inherent in choosing one system over the other, and suggestions for advancing the Rorschach forward in a way that is meaningful for practitioners and students involved in clinical personality assessment. These are challenging times for depthoriented personality assessment and its practitioners, exacerbating concerns for the future of the field. Graduate psychology programs continue to marginalize and eliminate training in traditional performancebased (projective) assessment (Piotrowski, 2015), notably the Rorschach. Despite the fact that multimethod assessment in clinical practice—involving the systematic integration of self-report, collateral-report, and performance-based data—is widely accepted and valued (Bram & Peebles, 2014; Hopwood & Bornstein, 2014; Weiner & Greene, 2008), the mainstream of clinical psychology, which shapes training and thus the future practice of psychology (see Piotrowski, 2017), has shown a trend toward marginalizing the research evidence-base of performance-based personality assessment.

Indeed, a consortium of psychology researchers (Kotov et al. 2017) recently proposed a new quantitative, evidence-based, diagnostic scheme for mental health, and the authors included numerous examples of assessment methodologies; not surprisingly, there was no mention at all of any performance-based personality measures. Recent findings of Wright et al.’s (2017) survey has raised similar concerns that despite lip service to multimethod assessment, graduate programs restrict training in self-report and performance-based personality measures (see also Waugh, 2016). At a time when depth assessment is embattled within the wider sphere of clinical psychology, many practitioners in our subdiscipline are also experiencing tension, uncertainty, and confusion associated with dilemmas around which Rorschach method to use. There are now two prominent Rorschach systems of administration, scoring, and interpretation from which to choose, the Comprehensive System (CS; Exner, 2003), which had dominated the field for close to four decades, and the more recently published Rorschach Performance Assessment System (R-PAS; Meyer, Viglione, Mihura, Erard, & Erdberg, 2011), which derived much of its direction from the CS, while introducing new ideas with respect to test procedure, coding, and interpretation. Anectodally, we and other clinicians, training directors, and supervisors (personal communications) have struggled with the question of which method to teach; at times, becoming locked into a binary, which

we view as necessary in delineating differences, but potentially divisive in foreclosing discussion, given that the one of these two Rorschach may be more or less patient-focused, depending on the referral goals. In this article, after a very brief summary of the historical context for the emergence of R- PAS, we describe our efforts as clinicians– more specifically as experienced psychoanalysts and assessors (Bram & Yalof, 2015)—to consider the merits and weaknesses of each system, tradeoffs in selecting one over the other, clinical opportunities for integration, and conditions under which each system may be more or less beneficial. Based on our personal views, we will also describe implications for further developing RPAS (we cannot do the same for the CS because that system has been frozen by Exner’s heirs). Brief Historical Context: The second author (Yalof, 2017) published an essay in the online R-PAS Community Forum and discussed some of the differences between R-PAS and the CS that can affect clinician decision-making about which test to use. Yalof addressed (a) R-PAS’s controlling for number of responses, (b) R-PAS’s inclusion of new variables and elimination of other CS variables based on meta-analytic findings (Mihura, Meyer, Dumitrascu, &Bombel 2013), (c) R-PAS’s norms being derived from CS norms, despite different administration procedures, and (d) the challenge of psychologically transitioning to R- PAS when feeling loyal to CS. The R-PAS team (Mihura, Meyer, & Viglione, 2017) responded to Yalof’s commentary by noting their loyalty to CS, but also sharing how the historical development of R-PAS emerged from the rigor of questions raised by Exner in a 1997 Alumni Newsletter, when describing the mission of the Rorschach Research Council, and the reason to move forward with R-PAS following Exner’s death in 2006 and his heirs’ wishes to leave the CS unchanged. The Council was involved with various developments with CS procedures and variables which, after Exner passed, were incorporated into R-PAS, thus bridging R-PAS to CS both in continuity of ideas and mission. Moreover, the Rorschach meta-analytic study that led to decisions about variables and coding, began when Mihura joined the Council, thereby further highlighting the loyalty to CS and its research, driven initially by immersion in CS and championed further by R-PAS. These two essays lead us to a discussion of some key differences between CS and R-PAS. Summary of Key Differences between CS and R-PAS: R-PAS deviates from the CS in a number of ways (see Diener, 2013). Here, we briefly highlight some of the most meaningful changes from CS to R-PAS. Most notably, in the interest of enhancing the validity of Rorschach summary variables to aid interpretation, the format of Rorschach administration has been altered in R-PAS to increase the likelihood of eliciting an optimal number (18-27) of responses. With respect to coding, R-PAS offers a revision of the CS Form Quality (FQ) tables; eliminates coding form dominance of achromatic color, shading, and reflection responses; eliminates 11 content categories; adds thematic codes for aggressive content, implicit dependency, and object representations. To aid interpretation of Rorschach variables, R-PAS converts raw scores or ratios to a standard score with mean of 100 and standard deviation of 15, akin to the Wechsler (e.g., 2008) intelligence tests. Meyer et al. (2011) described their statistical modeling procedures for generating norms from an international reference sample that was collected using CS administration procedures. Commentary: Our commentary on differences between the CS and R-PAS will address considerations

related to administration, coding, summary scores and indices, and interpretation. Administration: The differences in administrations between the CS and R-PAS involve tradeoffs of advantages and sacrifices. At the most basic levels of pragmatics and time and cost efficiency, clinician and patient friendliness, and interpretability of summary scores, there is much to like about the R-Optimized (R-Opt) administration of R-PAS. R-PAS’s initial instructions to the patient are to ―give two, maybe three responses to each card.‖ In turn, clinicians are instructed to ―prompt for two responses‖ and ―pull after four‖ for each card. These changes offer a welcome relief to those of us who, when using the CS, are filled with dread when it is looking like the patient will not give the requisite responses or, alternatively, offer an inordinate number of responses, making scoring that much more difficult. Both sources of dread involve concerns about the potential added time to and thus cost (whether passed on to the patient or other payers or not) of testing. Many assessors, experienced with the CS, might relate to our experience along these lines: ―I thought I left enough time for the Rorschach….Oh no, I have a therapy patient coming in 45 minutes…. Will we be done with Inquiry by then?‖ But perhaps even more dreaded is the awkward and often shaming confrontation of the patient who in on track to offer fewer than 14 response and for whom it may be necessary to re-administer the entire set of 10 cards from scratch, informing the patient that their performance was not good enough (Yalof & Rosenstein. 2014). Occasionally, with a narcissistically fragile patient, this CS requirement can disrupt the diagnostic alliance, even to the point of threatening completion of the evaluation or openness to subsequent test feedback (e.g., Bram, 2010). What is lost, though, in moving from the CS to R-PAS administration, is, in our opinion, the attenuation of the Rorschach’s role in the test battery of sampling psychological functioning and behavior under conditions of minimal external structure. Level of external structure—in assessment, treatment, and life—involves clarity of instructions, expectations, and rules; familiarity and predictability; and the availability of others to provide monitoring, enforcement of rules, and feedback. Historically, the Rorschach has been the epitome of the unstructured assessment method. This was carried forward in the CS, where there are no explicit guidelines for how many responses to give to each card: Patients are on their own to figure this out, and how they respond is often meaningful data—how constricted vs. activated and flooded do they become and, if so, when (e.g., beginning or end? chromatic or achromatic cards? around particular content?)? And with such constriction or activation, what happens to other aspects of ego functioning (e.g., reality testing, reasoning, affect regulation, relatedness), as assessed by careful configurational and sequence analyses (Bram & Peebles, 2014; Schafer, 1954; Weiner, 1998). From a psychometric standpoint, there are an optimal number of responses (18-27) to guide empirically-based interpretation of scores, and R-PAS instructions are designed to elicit this. But from a broader clinical perspective, particularly when referral questions are related to how much structure a patient needs in treatment or other aspects of life, the R-Opt procedure of R-PAS can undercut the Rorschach’s ability to more fully assess psychological functioning when less external structure is available. In this sense, the CS Rorschach task differs from the R-PAS task. As R-PAS administration adds meaningful degrees of structure to the Rorschach task, we believe that CS administration (and thus scoring and interpretation) is more conducive to answering such questions. Additionally, even though above we spoke to some relief in R-PAS’s shift away from the potentially criticizing and shaming inherent in the CS procedure for R<14 protocols of telling the patient ―There is a problem…You didn’t give enough responses‖ and requiring full readministration, this shift is not without a sacrifice. Yalof and Rosenstein (2014) described a creative approach in which this CS procedure provided an incidental opportunity to assess a patient’s superego functioning and self-esteem regulation. How does a patient manage in the face of an authority figure telling them they did not do what was expected or was not good enough (even if what was expected was not made explicit)? Does the patient become selfcritical and self-attacking? Self-protective and attacking of the examiner? Apologetic and wishing to please? How do the content and structure of responses and patient-examiner interactions vary between the initial and readministration, and what clues do this offer about the experience of superego pressures and/or the regulation of shame? The CS administration potentially affords us this opportunity to answer such treatment-relevant questions, while R-PAS administration forecloses on it1. Coding and Recording of Codes: As psychoanalysts, we were pleased with R- PAS’s addition of the clinically and theoretically meaningful and empiricallysupported scores assessing implicit dependency, internalized object relations, aggressive preoccupation, and ego impairment, respectively Oral Dependent Language (ODL), Mutuality of Autonomy Health and Pathology (MAH and MAP), Aggressive Content (AGC), and the Ego Impairment Index (EII-3). Although these measures have not been added to the CS consistent with the Exner family’s wishes, reportedly Exner himself was considering doing so (Mihura, Meyer, & Viglione, 2017). So it is possible that assessors continuing to use the CS can score these adjunctively and access the R-PAS coding rules and norms for interpretation. We find the results of the Mihura et al. (2013) meta-analyses so compelling that we support wholeheartedly their recommendation that assessors using the CS focus interpretation only those variables receiving at least modest empirical support. In our opinion, the greatest single clinical loss if one moves completely from the CS to R- PAS involves the latter’s jettisoning of form dominance coding for shading (Y, T, V), achromatic color (C’), and reflection (r) determinants. In R-PAS, for example, rather than determine whether a response with texture (T) should be coded FT, TF, or pure T (as has been the case in CS), any response having texture would be coded as plain T. Our understanding is that the authors of R- PAS eliminated this procedure because of (1) real concerns about inter-rater reliability involved in coding form dominance (e.g., differentiating among FT, TF, and pure T) and (2) the fact that the each of the different the gradations of form dominance for each determinant (e.g., again FT vs. TF vs. T) are low count variables that are difficult to study empirically, so it makes more sense to aggregate all T (or Y, V, C’, or r) responses. Although we appreciate this rationale, our concern is that clinically essential aspects of such responses are not captured when these scores are collapsed. Notably, in a classic article, Kleiger (1997) described how, just as in the case of responses with color as determinant, the degree of form dominance informs us about level of ego involvement or cognition that mediates the experience of different affects represented by shading and achromatic determinants. Thus, not all shading or achromatic responses are equivalent, but the failure to code form dominance risks obliterating this fine-tuned, meaningful differentiation. Bram and Peebles (2014) provide a series of contrasting ―moth‖ responses to Card I that vividly illustrates how coding the degree of form dominance along with shading and achromatic determinants captures essential aspects of the psychological process underpinning a response (see pp. 168-170). We also acknowledge our ego-psychological bent (Rapaport, Gill, & Schafer, 1968) in which form implies a certain degree of cognitive control over the emotional aspects of the response process, and hope that additional research will support the utility of re-adding distinctions according to form dominance.

We worry that future Rorschachers, who might only be familiar with R-PAS, are liable to not even be aware of such distinctions that are crucial to systematic configurational and sequence analysis of response structure (constellation of form quality, degree of form dominance, cognitive scores) and content (Bram & Peebles, 2014; Schafer, 1954; Weiner, 1998). In our approach to Rorschach assessment, we value and strive to integrate both nomothetic interpretation of the scores (e.g., comparing to norms, what the sum of T responses might be linked to empirically) and this kind of disciplined idiographic analysis. For one of us (JY), referral questions requiring a more nuanced assessment of affect regulation might tip the scale toward a CS administration and scoring (but also coding AGC and ODL from R-PAS). For the other (ADB), use of R-PAS routinely involves supplemental coding all shading and achromatic determinants for form dominance, employing Viglione’s (2010) stepwise guidelines for making this coding distinction reliably. Compared to concerns about the exclusion of form dominance, our other concerns about changes from CS to R-PAS are admittedly quibbles that may well not be of concern to many of our contemporaries, let alone future assessors. One is that the R-PAS sequence for recording codes within a response (i.e., horizontally across on the Code Sequence form) makes sense from a scoring standpoint, especially for students learning Rorschach coding, but it alters the familiar syntax of expressing the structure and content of a response. The familiar shorthand left-to-right sequence (especially the following: Location, Determinants, Form Quality, Content, Special Scores) of scoring a response is so ingrained as part of the process of configurational/sequence analyses, which plays such a central role in our interpretive approach. Our (older) brains are used to scanning code sequences in a way that sets off a complex, implicit, and explicit cognitive chain of inference-making, so we find it somewhat jarring and decelerating of our interpretive process to work with the R-PAS sequence. Most notably, in R-PAS the placing of Form Quality ahead of Determinants has been difficult to adjust to, but we also recognize that it comes much easier after practice and with the use of coding rubrics that require thinking through the process in a way that corresponds to R-PAS. One of us (ADB) routinely transposes R-PAS codes for each response back into CS-like syntax, creating a column on a customized Code Sequence page in way to facilitate configurational/ sequence analyses. Thus, W SR AnSy 2 – FM in the R-PAS sequence gets reconfigured back to W SR Sy FM- A 2. Note that it is in this added column that this clinician (ADB) also includes the aforementioned coding of form dominance for shading, achromatic color, and reflection determinants. Computing Summary Scores and Indices: Both of the authors have great affinity for the CS Structural Summary, which we have studied and interpreted for many years. One of us (ADB) attributes his appreciation for and depth of knowledge about the Rorschach to an early training experience in which he was encouraged to routinely generate the Structural Summary by hand, a daunting proposition at the time. Prior to this, the process of coding, entering scores in a computer program, and generating and reading the structural and narrative printout felt tedious, mechanical and confusing amid a sea of hieroglyphics and jargon. But tallying and computing each score by hand contributed to an immersion in the data and appreciation of where the scores came from and what they meant. For example, knowing the distinction between how XA% and WDA% are computed made it possible to make meaningful, experience-near, ―conditionsunder-which‖ inferences (i.e. a low XA% alongside normative WDA% would illuminate reality testing vulnerable under conditions in which the patient focuses on less relevant aspects of a situation [Dd’s]). In the case of nearly every CS score, hand calculation led to greater understanding and mastery.

With R-PAS, however many of the scores and ratios involve algorithms too complicated to compute by hand and then convert to standard scores to plot (not to mention making adjustments for complexity), so it just is not practical to do this. Diener (2013) also notes that the R-PAS Manual does not contain all of the data points necessary to convert to standard scores, even if clinicians wanted to do this by hand. Advantages of having little choice but to rely on R-PAS’s computer scoring include eliminating sources of human error in computations and the programs’ automated translation into standard scores. To mitigate the lost training opportunity, we encourage supervisees new to the R-PAS to hand-score select variables on the R-PAS Counts and Calculations page, notably those related to Location, Form Quality, Cognitive Scores, Human Movement, Chromatic Color ratios, R8910% (akin to the Afr in CS), and Critical Contents. Although it may be overlooked within the voluminous R- PAS Manual, the authors encourage ―new learners…to understand how each variable on the Profile Pages was obtained. The summary and composite scores cannot be interpreted meaningfully without knowing the elements that contribute to the final score‖(Meyer et al. 2011, p. 323). Interpretation: We believe that with R-PAS, conversion to standard scores and their visual presentation on whisker plots makes interpretation of scores relative to norms accessible to more clinicians. In contrast, we believe that most clinicians using the CS—who do rely on computer calculation of the Structural Summary and on the associated narrative interpretive report—have less of a routine opportunity to consider and learn the meaning and interpretation of each specific score and ratio. Our opinion is that this may lead, if only for time-saving, to an over-reliance on the jargon-laden narrative printouts, canned passages of which are apt to be paraphrased, if not outright pasted into, test reports. Understanding the psychological rationale behind test variables allows for much more flexibility with interpretations and comprehensible inferences. We hope and expect that R-PAS’s use of standard scores and whisker plots, as well as the test manual’s (Meyer et al., 2011) clear, experience-near language describing the interpretive meaning of variables, will facilitate deeper interpretive understanding of Rorschach scores to a degree, and for more trainees and clinicians, that will outweigh the aforementioned loss of the relative ease of hand-scoring we experience with the CS. Another major strength of R-PAS for interpretation, compared to the CS, is its building in methodology to consider and adjust scores based on the overall Complexity of a protocol (i.e., taking into account such variables as number of responses, use of determinants other than pure Form, blends, and synthesized responses). Previous factor analytic studies of Rorschach variables had revealed Complexity as the factor accounting for the most variance (Meyer et al. 2011). Being able to adjust for Complexity helps us put raw scores and ratios into greater interpretive perspective. For example, in a highly complex protocol, a lower raw score on SumH might take on even more meaning (in terms of lack of interest in people) versus in a low-complexity protocol in which the same low raw score might be less surprising and more indicative of cognitive or motivational/selfprotective factors affecting engagement in the Rorschach task. In the first instance, we know that the patient was sufficiently engaged in and capable of the task, so we are more confident that the conventional interpretive meaning of the low SumH can be accepted with (this results in a Complexity Adjustment that further lowers the standard score); in the second, we are not as clear whether the low SumH is more an artifact of cognitive limitations or self-protective constriction on the task (and the Complexity Adjusted standard score would be moved up closer to the mean). Without taking into account such Complexity Adjustments as is built into R-PAS, assessors are more vulnerable to be misled in their interpretation of a given score.

Concluding Comments: We have tried to convey our sense of the strengths and weaknesses of the CS and R- PAS, highlighting that choosing one system over another inherently involves the tradeoff of unique and clinically meaningful attributes of one for the other. We believe that, on the whole, R-PAS is better situated for moving Rorschach assessment into the future and training new assessors, if for no reason other than changes to the system, which would be a normal part of research, are not permissible in the CS. Yet, arguably and paradoxically, though, we assert that at this time the CS has never been on firmer ground, particularly if assessors focus on the variables with most empirical support (Mihura et al. 2013); make of use of the most recent international norms (Meyer, Erdberg, & Shaffer, 2007); and access Viglione’s (2010) guide to complement Exner’s text and workbook (2003; Exner et al., 2001) to enhance coding reliability. Research and clinical application related to the CS remains vibrant (e.g., Ilonen, Salokangas, & Turku Study Group, 2016; Tibon-Czopp& Weiner, 2016). Decisions about which Rorschach approach to use will ultimately fall to the clinician’s judgment. For example, when considering referrals involving questions about how a patient will respond to and make use of a treatment with less external structure (as defined above), such as under what conditions a patient might make use of psychoanalysis (Peebles-Kleiger, Horwitz, Kleiger, &Waugamann, 2006), or how someone is likely to function independently in college with loss of familiar parental and classroom routine and accountability, or whether a patient might require a residential versus outpatient treatment setting. In such instances, we are inclined to opt for the CS because its conditions of administration more closely sample a patient’s psychological functioning when one is more on one’s own to figure out how to respond adaptively to a complex and less certain situation. Future modifications in the Rorschach, however, rest solely on the shoulders of R- PAS and we conclude by offering some ideas, many involving integrating form dominance coding as it is practiced in the CS into R-PAS. 1. We encourage research into what extent the inter-rater reliability of form dominance for shading, achromatic color, and reflections can be bolstered through the use of Viglione’s (2010) guidelines. 2. Assuming that form dominance can be shown to be coded reliably, we wonder about the possibility of reviving and empirically studying a variable along the lines of what Rapaport et al. (1968) referred to as ―the new F% [italics original],‖ the percentage of responses ―in which F is either the sole or principle determinant‖ (p. 339)2 . This would be an omnibus Form Dominance percentage (FDom%) that makes sense conceptually as a putative measure of ego involvement. But such a variable would be potentially meaningful only if form dominance were able to be scored on not only color but also achromatic color, shading, and reflection responses (see #1 above). 3. Also contingent on improved inter-rater reliability of form dominance for achromatic color and shading responses (#1 above, but not necessarily having to wait for research to come in on #2), R-PAS might formalize the option and guidelines (similar to Viglione, 2010) for coding form dominance for Y, T, V, C, and r. Even if this distinction were not reflected on the Counts and Calculations or Summary Scores and Profiles pages of the R- PAS printout, including form dominance in the R-PAS Code Sequence would provide valuable interpretive information at the response, configuration, and sequence level (Bram & Peebles, 2014; Schafer, 1954; Weiner, 1998). 4. To facilitate more fine-tuned ―conditions under which‖ analyses and inferences, we propose the possibility that the R-PAS computerized scoring program be revised so assessors can request more specific breakdowns of the data, which we currently compute by hand (e.g., see Bram & Peebles, 2014, Table 5.1, p. 163). So, for instance, if we were interested in understanding to what extent a patient’s reality

testing and reasoning are impacted by more emotional stirring, we could request separate summary scores of Form Quality ratios and Cognitive Scores, broken down by chromatic versus achromatic cards. There are many such creative and meaningful ways to analyze conditional variability in a person’s functioning, whether it is by location, human versus nonhuman content, the presence or absence of aggressive or other critical contents. 5. Although it is accepted that one of the greatest strengths of R-PAS and the CS is its empirical assessment of thought disorder using the Cognitive (Special) Scores (Mihura et al., 2013), we agree with Kleiger (2017) that there is room for further refinement. Notably, this would involve studying whether it is meaningful to code severity levels for all Cognitive Scores (not only DR, DV, INC, and FAB but also PEC and CONTAM), as in practice we note responses vary quite a bit in their level of disturbance, which is not reflected in either the scoring itself or in the WSumCog. In addition, our experience as teachers, supervisors, and colleagues tells us that the Deviant Response (DR) remains a particularly problematic one in terms of coding reliability in actual practice. This is despite our belief that the R-PAS manual (Meyer et al. 2011) has added useful coding clarifications beyond those offered by the CS. We also retain conceptual concerns (articulated by Kleiger& Peebles-Kleiger, 1993) that DR is a mixed category reflecting many types of thinking problems that, when aggregated, are difficult to make sense interpretively. We believe that even if the current DR scoring remains, R-PAS researchers might study the over-embellished type of DR’s that in the Rapaport system would be considered confabulations, which have more specific and meaningful clinical implications (Bram & Peebles, 2014; Kleiger, 2017). Whether or not other assessment practitioners and researchers agree with our commentary, we assert that developing facility with one or both of these empirically-based systems is a necessary but not sufficient requirement for using the Rorschach clinically. Assessors still must also be grounded in sound principles of inference-making and data integration, understand the patient-examiner relationship, be familiar with various theories of personality, and appreciate how to make meaningful links between test data and treatment. Endnote: 1In the unlikely event that an R-PAS administration yields too few responses (defined as 15 or fewer) in the Response Phase, the examiner is to go through the cards a second time and encourage additional responses, which are then added to the original responses (i.e., so there is not a complete re-administration as is done in the CS). 2We consider most M responses, in which form is implicit, to be form dominant. In addition, for blend responses, form dominance would be tallied only if all determinants within the blend are form dominant (see Bram & Peebles, 2014, p. 157, Footnote 7). Note that there has only been one empirical study that examined Rapaport et al.’s ―new F%‖ variable: In a very small (N=10) sample, Gardner (1951) did not find the predicted association of this variable with measures of impulsivity. The authors thank Dr. Joni Mihura for calling our attention to this research. References: Bram, A. D. (2010). The relevance of the Rorschach and patient-examiner relationship in treatment planning and outcome assessment. Journal of Personality Assessment, 92(2), 91-115. Bram, A.D., & Peebles, M.J. (2014). Psychological testing that matters: Creating a road map for effective treatment. Washington, DC: American Psychological Association. Bram, A.D., & Yalof, J. (2015).Quantifying complexity: Personality assessment and its relationship with psychoanalysis. Psychoanalytic Inquiry, 35: sup1, 74-97. Diener, M. J. (2013, Winter). Focus on clinical practice - Review of 'An Introduction to the Rorschach Performance Assessment System (R-PAS)'. Independent Practitioner, 12-14. Exner, J. E. (2003). The Rorschach: A Comprehensive System Vol. 1: Basic foundations and principles of interpretation (4th ed.). New York, NY: Wiley. Exner, J. E., Colligan, S. C., Hillman, L. B., Metts, A. S., Ritzler, B. A., Rogers, K. T., Sciara, A.D., & Viglione, D. J. (2001). A Rorschach workbook for the comprehensive system (5th ed.). Asheville, NC: Rorschach Workshops.

Gardner, R.W. (1951). Impulsivity as indicated by Rorschach test factors. Journal of Consulting Psychology, 15(6), 464-468. Hopwood, C.J., & Bornstein, R. F. (Eds.).(2014).Multimethod clinical assessment. New York, NY: Guilford Press IIonen, T, Salokangas, R.K.R., & Turku Study Group (2017). The Rorschach Coping Deficit Index as an indicator of neurocognitive dysfunction. Rorschachiana, 37(1), 28-40. Kleiger, J. H. (1997). Rorschach shading responses: from a printer's error to an integrated psychoanalytic paradigm. Journal of Personality Assessment, 69, 342-364. Kleiger, J. H. (2017). Rorschach assessment of psychotic phenomena. New York, NY: Routledge. Kleiger, J., & Peebles-Kleiger, M. J. (1993).Toward a conceptual understanding of the Deviant Response in the Comprehensive Rorschach System. Journal of Personality Assessment, 60, 74-90. Kotov, R., Krueger, R. F., Watson, D., Achenbach, T. M., Althoff, R. R., Bagby, R.M.,…Zimmerman, M. (2017). The Hierarchical Taxonomy of Psychopathology (HiTOP): A dimensional alternative to traditional nosologies. Journal of Abnormal Psychology, 126(4), 454-477. Meyer, G. J., Erdberg, P., & Shaffer, T. W. (2007).Toward international normative reference data for the Comprehensive System. Journal of Personality Assessment, 89(S1), S201- S216. Meyer, G. J., Viglione, D. J., Mihura, J. L., Erard, R. E., &Erdberg, P. (2011). Rorschach Performance Assessment System: Administration, coding, interpretation, and technical manual. Toledo, OH: Rorschach Performance Assessment System, L.L.C. Mihura, J. L., Meyer, G. J., & Viglione, D. J. (2017, March 9). R-PAS Response to Yalof's Essay ―CS or R- PAS: The Travails of a Rorschach Ambitendent‖. R-PAS Newsletter, 22. Mihura, J.L., Meyer, G.J., Dumitrascu, N., & Bombel, G. (2013).The validity of individual Rorschach variables: Systematic reviews and meta-analyses of the Comprehensive System. Psychological Bulletin, 139(3), 548-605. Peebles-Kleiger, M. J., Horwitz, L., Kleiger, J. H., & Waugaman, R. M. (2006). Psychological testing and analyzability: Breathing new life into an old issue. Psychoanalytic Psychology, 23, 504-526. Piotrowski, C. (2015). Clinical instruction on projective techniques in the USA: A review of academic training settings 1995-2014. Journal of Projective Psychology & Mental Health, 22, 83-92. Piotrowski, C. (2017). The linchpin on the future of projective techniques: The precarious status of personality assessment in the (overcrowded) professional psychology curriculum. Journal of Projective Psychology and Mental Health, 24, 71- 73. Rapaport, D., Gill, M., & Schafer, R. (1968). Diagnostic psychological testing (rev. ed.). New York, NY: International Universities Press. Schafer, R. (1954). Psychoanalytic interpretation of Rorschach testing. New York, NY: Grune & Stratton. Tibon-Czopp, S., & Weiner, I. B. (2016). Rorschach assessment of adolescents: Theory, research, and practice. NY: Springer. Viglione, D.J. (2010). Rorschach coding solutions: A reference guide for the Comprehensive System (2nd ed.). San Diego, CA: Author. Waugh, M.H. (2016). Clinical pearls in psychological assessment: Part III: Paradigms in contemporary personality assessment. SPA Exchange, 28(1), 13-16. Wechsler, D. (2008). Wechsler Adult Intelligence Scale- Fourth Edition (WAIS-IV). San Antonio, TX: The Psychological Corporation. Weiner, I. B. (1998).Principles of Rorschach interpretation. Mahwah, NJ: Lawrence Erlbaum. Weiner, I.B., & Greene, R. (Eds.).(2008). Handbook of personality assessment. Hoboken, NJ: Wiley & Sons. Wright, C.V., Beattie, S.G., Galper, D.I., Church, A.S., Bufka, L.F., Brabender, V.M., & Smith, B.L. (2017). Assessment practices of professional psychologists: Results of a national survey. Professional Psychology: Research and Practice, 48(2), 73-78. Yalof, J. (2017, March 9). CS or R-PAS: The travails of a Rorschach ambitendent. Rorschach Performance Assessment System (R-PAS), R-PAS Newsletter, 22. Yalof, J., & Rosenstein, D. (2014). Psychoanalytic interpretation of superego functioning following CS re-administration procedures: Case illustration. Journal of Personality Assessment, 96(2), 192-203.

The status of the Rorschach and its role in neurophysiological assessment has had a rather erratic and not so cherished historical journey. Seminal research in this area largely focused on the Rorschach „sign‟ approach in the study of organic brain disorders, while later research investigated mediating factors such as IQ and affective states. At times, research efforts in this area lay dormant or encountered tepid scholarly reviews. Interestingly, there has been a flurry of recent enthusiasm and research activity on the potential of Rorschach analysis in the study of neurocognitive dysfunction. The current investigation provides a historical review of key research findings in this area, based on 58 studies identified via a bibliometric analysis of the extant mental health literature. The presentation traces the key milestones and findings reported in scholarly research over the past 80 years. The author offers tentative conclusions, based on this provocative body of literature. Psychologists have had a long-standing clinical and research interest regarding the usefulness of the Rorschach in the study of diseases of the central nervous system, neuropsychological deficits, perceptual processes, conceptual complexity, and neurocognitive functioning (Malone et al., 2013; Martin & Estevez, 2005; Meyer, 2016; Muzio, 2016; Piotrowski, 2015; Senkarik, 1989). Historically, however, the role of projective techniques with regard to ecological validity in both research and clinical applications has been questioned (e.g., Jonckheere, 1970; Lilienfeld et al., 2000). Although research attention in this assessment area has waned periodically over the years, there seems to have been a renewed interest, as exemplified by the recent special issue on Neuroscience and the Rorschach appearing in the journal Rorschachiana in 2016. This nexus has been systematically viewed from a) the neurophysiological bases of Rorschach responses (e.g., Porcelli & Kleiger, 2016) and b) the utility of the Rorschach in neuropsychological assessment. Seminal discussions on the potential applications of the Rorschach to organic brain diseases were noted by Hermann Rorschach‟s colleague Dr. Oberholzer during the initial introduction of the inkblots (see Kisker 1944, p. 43 for a discussion). Baker (1956), in a review of over 50 published studies, from 1936-1952 on the Rorschach, concluded that the presence of organic brain involvement was mostly evident in the qualitative aspects of the Rorschach protocol rather than in quantitative signs. Years later, the prominent neuropsychologist Muriel Lezak (1994) touted the potential of the Rorschach in the assessment of perceptual abilities in brain-injured patients such as accuracy in perception, integration of multiple stimuli segments, and response time. Although, over the years, neuropsychological tests have been part of the assessment armamentarium of practicing psychologists (Frauenhoffer et al., 1998; Harwood et al., 2011; Wright et al., 2016), projective tests have been largely neglected in neuropsychological practice (see Piotrowski, 2017; Rabin, 2005; 2016; Smith et al., 2010). The aim of the current study is to gain a perspective, historically, on the status of the Rorschach in research on neurocognitive dysfunction and the potential of this unique assessment method in neuropsychology practice. This review presents scholarly research findings reported in 58 studies on these issues published from 1936-2016.

Method: A bibliometric review entails obtaining a comprehensive search of the literature in order to identify the body of archival research on a select investigatory topic (Piotrowski, 2013, 2017). Since the focus of current study was on the use of the Rorschach in neuropsychological research, the author performed on online keyword search of the database PsycINFO with terms such as Neuropsychological, Organic, Brain impairment, Head Injury. This repository of extant literature is the most comprehensive scholarly file in the field of psychology and behavioral sciences (Perdue & Piotrowski, 1991), including the sub-field of assessment. Second, a cross-reference procedure identified pertinent adjutant literature listed as cited references in key research articles. This systematic retrieval process identified 58 scholarly studies (mostly articles) which served as the data-pool for this historical review (1936-2016) of archival research on the Rorschach-Neuropsychology nexus. Table 1 presents the brief summary review of 58 key research studies. Conclusions: • Nearly 50% of the studies examined the discriminatory diagnostic power of proposed Rorschach „signs‟ in differentiating „organic‟ brain patients from other psychiatric groups or normal populations; the majority of research findings prior to 1970 found tepid support for the Rorschach sign approach in the study of brain injured patients. • Studies reporting success in the utility of the „sign‟ approach have been critiqued for not examining moderator variables that could influence outcome, i.e., several researchers suggested that IQ was a significant confounding variable in these studies. • The sign approach frequently identified a significant number of „false positives‟, providing evidence for a lack of discriminatory power. • Studies post-1970s claimed scant support for increasing incremental validity of neuropsychological testing data by inclusion of the Rorschach in multimethod assessment. • More recent studies have found that Rorschach analysis enhances detection of psychological disturbance, but not neuropsychological impairment or dysfunction. • Since 2000, several studies have noted the benefits of Rorschach analysis in investigations examining cognitive deficits and dysfunction with comorbid emotional liabilities and disturbed affect. • A major criticism has been the lack of an integrated theoretical framework on incorporating the Rorschach in neuropsychological evaluations. • Recent research on the Rorschach has prompted discussion on the synthesis of complex perceptual representations. • Historically, much of the extant research seems to be lacking in research direction; however, in recent years, there has been a resurgence of investigatory interest regarding neurophysiological substrates associated with Rorschach analysis. Table 1: Historical Summary Overview of 58 Research Studies Study Method Findings Z. Piotrowski (1936) Seminal research; Rorschach records of 18 cases of organic cerebral involvement 6.2 „organic‟ Rorschach signs were found in this group compared to 1.5 in other patient groups; This study prompted a series of subsequent research efforts to corroborate these Piotrowski „signs‟ confirming organic brain involvement. Z. Piotrowski (1937) 33 records of 18 patients with organic brain disturbance 10 Rorschach „signs‟ differentiated the organic group from the non-cerebral group; differences were found to be quantitative as opposed to qualitative; presence of 5 or more signs was indicative of brain damage. Z. Piotrowski (1940) 56 patients producing 5 or more organic „signs‟ Results showed that the number of signs was a function of personality change and increasing age;

Findings were tentative. Harrower-Erickson (1940) Studied personality changes in brain tumor patients; Rorschach Main finding was „constriction‟ of personality; authors condone the use of the Rorschach in evaluation of patients with brain tumors. Ross (1941) A replication of the Piotrowski (1940) study Findings showed that the Piotrowski „signs‟ lacked discriminatory power; i.e., identified false positives. Although 55% of the brain-damaged patients had 5 or more signs, so too did 20% of psychotics and 14% of neurotics. Kisker (1944) 20 psychotic patients who underwent prefrontal lobotomy Qualitatively, Rorschach signs pre-post-surgery were not significantly different; evidence for Piotrowski‟s signs were attributed to psychotic processes. Klebanoff (1945) Presents a review of the extant literature, pre-1945, on studies of psychological disturbances associated with brain disorders This review concluded that the Rorschach was not an ideal assessment technique in the evaluation of organic brain disorders. Aita et al. (1947) Tested for Piotrowski‟s organic signs Findings showed that most Rorschach „signs‟ did not differentiate moderate brain injury groups. Hughes (1948) 50 of 218 subjects with brain damage; tested for „signs‟ based on prior studies 82% of the organic patients were classified by these new signs; however, based on Piotrowski‟s signs, only 20% of the organic group was correctly identified. Diers & Brown (1951) Tested Hughes‟ organic signs in MS patients; Rorschach Found that low IQ MS patients exhibited a high number of organic signs, but the authors questioned the validity of the Hughes‟ sign criteria. Dorken & Kral (1952) Examined Rorschach „signs‟ not produced by organic patients 7 signs were identified; using this method, 93% of the organic patients were identified (as opposed to only 50% using Piotrowski‟s signs). Yates (1954) Reviewed the available literature to determine the validity of psychological tests in assessment of brain damage This review found tepid support on the efficacy of the Rorschach on the reliability of organic „signs‟ in organic brain damage; most studies ignored predictive variables such as age and IQ. Hertz & Loehrke (1954) 50 veterans who suffered head trauma; Rorschach records While 5 or more Piotrowski signs could be indicative of post-traumatic encephalopathy, absence of these signs is not contra-indicative of organic pathology; the study found scant support for the Hughes‟ signs in this brain injured sample. Reitan (1955) 65 patients with verified brain damage; validation of Rorschach ratios Formally scored Rorschach variables, with the exception of the Human Movement response, differentiated the brain damaged group from normal; Speed of organizing ratio also differentiated these groups. Hertz & Loehrke (1955) 50 veterans who suffered head injury Based on Rorschach „configurations‟, which reflect qualitative features of the Rorschach, differentiated brain damaged patients; deficits in IQ, memory, and analytical ability were noted; emotional constriction and fatigability were observed. Birch & Diller (1959) Discussed the central importance of „Perceptual‟ indicators of brain damage; Rorschach These authors claim that while the Rorschach does not appear to be sensitive to overall brain damage per se, specific Rorschach „signs‟ do confirm „organicity‟, i.e., an impairment in organization of perceptions. Eckhardt (1961) 700 psychiatric patients from Results showed that although Piotrowski‟s organic

mental hospitals in North Carolina signs were evident in Rorschach protocols of brain disorders patients, these signs were also present in other psychiatric disorders; thus, 5 or more „signs‟ seem to be indicative of intellectual impairment, whether organic or functional. Birch & Belmont (1961) Patients with brain damage to right cerebral hemisphere These patients produced fewer responses than controls with a lessened ability to re-organize the Whole blot into parts; there was no evidence of impaired ability to alter perception on suggestion from examiner. Belmont & Birch (1962) 18 subjects with left cerebral hemiplegia; productivity (# of Rorschach responses) Low Rorschach productivity was associated with clear and specific perceptions; greater response output was related to reduced quality and analytic ability. Neiger et al. (1962) Compared 20 epileptics, 40 schizophrenic, and 80 normal subjects on Piotrowski‟s organic signs Findings identified many „false positives‟ using the Piotrowski criteria, which should be used with caution in predicting brain damage; however, authors concluded that these „signs‟ provide an estimate of the regressive process in chronic psychotic disorders. Haynes & Sells (1963) Reviews prior studies on the use of psychological tests in the assessment of organic brain damage Authors conclude that most studies did not use a multi-method approach (i.e., diagnostic signs, test scatter, qualitative data); authors propose a sequential multivariate measurement approach. Evans & Marmorston (1963) Compared cerebral thrombosis patients (n=108) to heart patients (n=96) across several projective tests All tests, in aggregate, differentiated these 2 patient groups; the Rorschach performed the best; however, other tests were less successful. Evans & Marmorston (1964) Investigated Rorschach „signs‟ in brain-damaged subjects Brain-damaged patients had higher scores on 46 „signs‟ associated with deficits in cerebral functioning; however, the transient cerebral symptom group could not be differentiated from the cerebral thrombosis group; Findings show that the „sign‟ approach has its limitations. Kohen-Raz & Assael (1966) 19 juvenile delinquents suspected of organic brain disorder; Rorschach & EEG Results indicated 4 patients showed maturational developmental lag; 7 Rorschach organic signs were noted. Nedelcu & Zellingher (1971) 30 male patients discharges after suffering cranial trauma; Rorschach On the Rorschach, fewer Form than Color responses were noted; about 50% of the group showed 5+ Piotrowski‟s organic signs; Findings suggest the importance of clinical attention to neuropsychological sequelae post-acute head trauma. Vagrecha & Mazumdar (1974) 20 epileptic patients & functional intellectual impairment; Rorschach Results indicated that although these patients exhibited serious IQ deficits, Piotrowski‟s signs were not evident; Findings confirm the position that IQ and „organic‟ signs on the Rorschach are not related. Vitorovic et al. (1975) 124 psychotic females; studies relationship between EEG & Rorschach Findings showed a high degree of conformity with signs of organic syndrome elicited by Rorschach test; abnormal EEGs were associated with organic psychosis. Wagner et al. (1980) Studied efficacy of 3 projective techniques on differentiating brain damage Several Rorschach signs (i.e., Populars, F+%, m) were predictive of brain damage, but the authors caution that this relationship may be a function of IQ.

Ellis & Zahn (1985) 35 adult patients with severe closed head injury; stepwise discriminant function analyses The CHI group differed from controls on #R, mean X+% and F+%, lower affective ratio (Afr), less color responses, and relation of W to D responses; Rorschach variables (DQV, FC, FQ Dif, T, D) correctly classified these patients the best; low Populars, poor reality testing, and predominance of poor perceptions indicated distortion of the apperceptive process; cognitive deficits included illogical perceptions, poor verbal expression. Shukla et al. (1987) Studied Rorschach „signs‟ with Bender-Gestalt as the criterion; 35 female brain lesion patients vs. 35 schizophrenics vs. controls Results indicated that 3 of Piotrowski‟s signs (low Responses; high Form) identified the organic group. Gold (1987) Critical review of emergent literature on the Rorschach response process Author concludes that Rorschach research neglects study on the linguistic representation of perceptual processes; suggests that adjutant research in neuropsychology and information processing could facilitate the link between perception and verbalization (i.e., language). Frank (1991) Examined the use of the Rorschach in the assessment of cerebral dysfunction These patients manifest a unique cognitive style, i.e., responses tend to be concrete, perseverative, and stereotypical. Acklin & Wu-Holt (1995) Offered a conceptual framework, based on neuropsychology and cognitive science, in understanding the functional operations during the Rorschach response process Authors frame their argument based on clinical research supporting the Rorschach in tapping visual attention, object recognition, associative memory, verbalization, and executive functions. Zillmer & Perry (1996) Provided a conceptual basis on the nexus between neuropsychological abilities and mental health factors Based on factor analytic procedures, the authors proposed that personality and neuropsychological factors are not orthogonal constructs. Exner et al. (1996) 60 adult closed head injury (CHI) patients, within 1.5 months post-injury Rorschach data indicated no evidence of perceptual distortions or thinking disturbance; however, several mental health liabilities were found (simplistic mode of functioning (high L); deficits in decision-making; affective-interpersonal disengagement). Perry et al. (1996) Patients with dementia of the Alzheimer‟s type Based on a „process‟ neuropsychological approach, the findings showed significant differences on linguistic errors and perseveration; Authors conclude that the Rorschach can be used as a tool in neuropsychological problem-solving evaluation. Chaudhury et al. (1998) 60 male inpatients with epilepsy; evaluation of Piotrowski‟s signs These Rorschach „signs‟ identified 65% of these patients, but also, 10% of control subjects. Cattelani et al. (1998) 22 patients with traumatic brain injury (TBI); several neuropsychological measures and Rorschach Findings showed that the Rorschach was sensitive to changes in cognitive style and personality, but more efficacious in severe head trauma patients; authors contend that the Rorschach does not provide incremental clinical data beyond that obtained by

standardized neuropsychology assessment evaluations. Muzio & Luperto (1999) 10 hospitalized elderly women with dementia; Rorschach Compared to control group, significant differences were reported on capacity of mentalization (EA<3), reality testing (X-%>.29), illogical reasoning, and impairment of thinking processes for the dementia patients. Chaudhury et al. (1999) 75 adult patients with head injury; evaluation of organic signs Based on Piotrowski‟s criteria, the authors identified 49 of the 75 patients; Piotrowski‟s signs had a specificity of 92.7%. O‟Leary (2000) A literature review on neuropsychological aspects of borderline personality disorder (BPD) Studies using the Rorschach indicated deficits in visual memory and visual perception; Findings have implications for how BPD patients process emotionalladen material. Sinacori (2000) A dissertation study on 67 neuropsychological evaluations of brain-injured subjects; Rorschach On the Rorschach, 60% of the sample showed positive Coping Deficit indices, an indicator of emotional disturbance; 25% had positive depression indices. de Felipe-Oroquieta (2003) 37 temporal lobe patients; emotional control ability; Rorschach & Stroop Color- Word Test Findings indicated a relationship between ability to inhibit automatic affective impulses and emotions. Muzio (2004) Literature review; historical issues Enthusiasm on the efficacy of the Rorschach in the study of neurological populations was tempered in the 1960s; however, with advances with the Exner CS, there has been a resurgence of research interest in neuropsychology due largely to the amenability of the Rorschach in the assessment of cognitive functioning and affect. Smith et al. (2007) 27 children; Rorschach & Rey- Osterreith Complex Figure Test (ROCF) In this study on the utility of the Rorschach response process in neuropsychological assessment, the findings showed a link between accuracy of ROCF renditions and measures of developmental quality and perceptual accuracy on the Rorschach. Asari et al. (2008) Studied neural substrates that underlie „unique‟ responses on the Rorschach Findings showed that unique responses were associated significantly with activation of the right temporal pole, known to be related to both social and emotive processing, storage of perceptual-emotional linkages, and semantic memory. Castelli et al. (2008) 14 Parkinson‟s disease patients undergoing bilateral deep brain stimulation; pre-post evaluation Rorschach indices indicated no major modifications of personality structure. Asari et al. (2010a) Investigated the link between amygdala volume and production of unique Rorschach responses Results indicated that emotion-related neural circuits in the limbic system seem to be associated to unique perception and FQ-responses on the Rorschach. Asari et al. (2010b) Studied the modulatory effect of the amygdala during the Rorschach response process Findings indicated a link between the Rorschach unique response ratio and WSumC; Results confirmed the interference of emotion on perception when taking the Rorschach. Ozura & Stukovnik (2011) Case study with multiple Although the authors contend that the Rorschach has

sclerosis patients potential in patients in neurology as a problem-solving instrument, this study concluded that the test lacks a theoretical basis framed on brain-behavior relationships needed in neuropsychological assessment. Hiraishi et al. (2012) Used neuroimaging (nearinfrared spectroscopy) to study prefrontal cortex of adolescents; several projective tests Neuro-assessment of the Brodmann Area 10 showed that the Rorschach was right-hemisphere dominant; authors contend that these findings reflect emotion and sociality. Ilonen et al. (2012) 8 sclerosing leukoencephalopathy (PLOSL) patients; Rorschach analysis On the Rorschach, these patients showed low Productivity, few Blends, problems in organization, and disturbed concept formation; In line with neuroradiological data, Rorschach protocols were concordant with signs of frontal type of dementia. Muzio (2016) Editorial comment on „Special issue‟ Author confers the nexus of Rorschach performance in neuropsychological assessment; psychologists need to be aware of neuro-cognitive correlates of Rorschach variables and indices. Meyer (2016) Children; Rorschach-PAS Rorschach scores most linked to neuropsychological perceptual synthesis skills were those related to perceptual accuracy and complex perceptual representations; noteworthy, these scores were more strongly associated with verbal abilities than with perceptual organizational skills. Ilonen & Salokangas (2016) 267 adolescent psychiatric inpatients; 117 adults with psychotic disorders; Rorschach Coping Deficit Index (CDI) This study identified a link between coping deficit and cognitive capacity; impaired comprehension predicted elevated CDI in adolescents, perseveration tendency in adult patients; thus, the CDI seems to tap neurocognitive dysfunction and deterioration. Ishibashi et al. (2016) 40 normal adults; Rorschach & neuroimaging (fMRI); impact of color stimuli For Cards with chromatic color, significant increase in brain hemodynamics was observed in left visual area V4 and left orbitofrontal cortex; Findings support the neuro-cognitive features of the Rorschach response process. Porcelli & Kleiger (2016) Commentary on brain mechanisms and cognitive functioning involving the Rorschach „human movement‟ M response Based on meta-analytic evidence and neuroscience research, the authors claim that M a) activates the mirror neuron system, b) is associated with higherlevel cognitive ability, and c) provides an avenue in understanding of neuropsychological mechanisms underlying Rorschach response processes. Cristofanelli et al. (2016) Reviews potential nexus regarding neuro-imaging (fMRI) techniques and personality assessment; Rorschach Authors propose framework to explore resting-state neural functional connectivity related to perceptual styles and personality traits on Rorschach variables. References: Acklin, M.W., & Wu-Holt, P. (1996). Contributions of cognitive science to the Rorschach technique: Cognitive and neuropsychological correlates of the response process. Journal of Personality Assessment, 67(1), 169-178. Aita, J.A., Reitan, R.M., & Ruth, J.M. (1947).Rorschach‟s test as a diagnostic aid in brain injury. American Journal of Psychiatry, 103, 770-779. Asari, T., Konishi, S., Jimura, K., Chikazoe, J., Nakamura, N., & Miyashita, Y. (2010a).Amygdalar

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projective personality assessment. The authors summarize the historical use of projective testing (particularly the Rorschach) and emerging research examining the use of projectives in both graduate and internship training programs. The current state of the research suggests a decrease in emphasis in training with projective techniques across both graduate and internship training programs. This paper further discusses the University of Texas Health San Antonio clinical psychology internship program as one that continues to value and train interns in projective assessment. The authors end this paper with a brief discussion of the reasons for the decline in projective assessment across graduate schools and internship sites. Projective personality assessment, in its heyday, centered on a cluster of instruments: the Rorschach Inkblot Test, the Thematic Apperception Test, various figure drawing tests, and various versions of the Sentence Completion Test, and post WWII clinical psychology graduate training programs devoted considerable training time to teaching personality assessment with these instruments (see Weiner & Greene. 2008). With the advent of formal internship programs, training with these “projective” instruments extended until completion of the doctoral program. The projective instruments were intertwined with psychoanalytic theory and were thought of as revealing the underlying dynamics, such as conflicts, drives, motives and such. However, the dominant test, the Rorschach, was also seen as having other functions, such as measuring a person‟s reality testing (Beck, 1944) and offering ratios to organize other more psychometric-like features (Klopfer& Davidson. 1962). While the TAT, drawings, and sentence completion instruments remained tied to their projective roots, the Rorschach underwent a major transformation „with the advent of the Exner scoring system (1969) which deemphasized psychoanalytic interpretation and shifted toward a cognitive analysis emphasizing information processing, mediation, and ideation. These data are then organized into a structural summary and interpreted in relation to research findings related to personality characteristics. Exner‟s scoring method was designed to correct criticisms of several scoring methods in use at the time and rather quickly became the method most emphasized in the majority of graduate and internship programs. This tradition in Rorschach assessment has now been supplemented with the Rorschach Performance Assessment System (Meyer et al. 2011). Bram and Yalof (2018) offer a depth analysis of the pros and cons for CS versus R-PAS. This brief (and hopefully mostly accurate) history sets the scene for discussion and review regarding current patterns of projective assessment training at both the graduate school and internship levels. Graduate-level Assessment Training: Piotrowski (2015) has provided a very comprehensive review of the status of graduate school training with the traditional projective techniques. This review highlighted 12 surveys, conducted between 1995 and 2014 on instruction with projective instruments. This analysis identified a

precipitous decline in training emphasis with projective assessment. An earlier study by Hilsenroth and Handler (1995), involving 166 graduate students, found that 50% completed two courses with the Rorschach and 32% administered 5 to 9 protocols. A later study by Belter and Piotrowski (2001) surveyed 82 APA-approved clinical doctoral programs and found that 60% required projective training, primarily with the Rorschach and TAT. Nevertheless, 50 % these training directors confirmed a decrease in instruction with projective instruments in the previous five years. Childs and Ende (2002) found similar results in a survey of 84 APA- approved clinical program and reported that 87% of respondents offered a least one course in projective testing, with training emphasizing the Rorschach and TAT. Of special note is a recent study by Ready and Veague (2014) which investigated training in assessment across three training models (Clinical-Science, Scientist- Practitioner, and Practitioner-Scholar). They found that projective tests were rated significantly below “evidence-based” tests, that only Scholar-Practitioner programs tended to offer projective instruction, and that younger faculty was not interested in teaching projective techniques. This study is perhaps the most comprehensive attempt to gather needed information about current projective personality assessment teaching trends but was hampered by low response rates (32%). Nevertheless, it is the most comprehensive study to date and clearly demonstrated a decline in teaching traditional projective instruments. Another rich source of data regarding current assessment training during graduate school is the APPIC Application for Psychology Internship (AAPI). Every year all applicants for internships fill in extensive data regarding their assessment training experience during graduate school, including course work, practica, and write-up/interpretation requirements. To date, two studies have mined this data (Stedman, Hatch, & Schoenfeld, 2001b; Stedman, Hatch, & Schoenfeld, 2002). The earlier study used AAPI forms collected from multiple internship sites for a total of 238 clinical and 96 counseling students, most of whom were from different programs. The dependent variable was “number of test reports written” without reference to particular test. Results indicated that clinical students claimed a median of 18 reports and counseling students reported a median of 11. The second study of the same sample is of more direct relevance because it broke down “number of test reports written” by test. Findings were the following for clinical students and are reported as medians: Rorschach 4.3, TAT 1.5, sentences 2.0, and drawings 1.0. For counseling students, results were Rorschach 2.0, TAT 2.0, sentences 2.0, and drawings 1.3. In summary, Piotrowski‟s review and the studies cited above offer some quantitative analysis of the status of graduate school instruction with the traditional projective techniques. Those studies and others (Piotrowski & Zalewski. 1993; Watkins et al. 1991) appear to show that graduate school teaching of the traditional projective tests declined in the 1990s, declined further during the later 2000s, and declined perhaps precipitously by 2014. However, it should be noted that none of these investigations captured the data needed to make a definitive statement due primarily to the difficulty related to obtaining sufficient samples. Our suggestion is that systematic data collection from APPI forms would be the best way to capture the samples needed to ascertain current testing instruction patterns during graduate school. This would require multisite participation of graduate schools or an arrangement with APPIC to tap into samples of APPI forms or both. Internship Training in Assessment: There are many more studies of clinical instruction during internship training than during graduate school training. These investigations include all aspects relevant to clinical and counseling psychology, including

testing, and tend to have better sampling of the population, hence, increased confidence regarding generalization. A review by Stedman (1997) noted that three studies in the 1980s (Durand, Blanchard, & Mindell, 1988; Piotrowski, 1984; Petzel& Berndt, 1980) documented that internship directors valued training with projective instruments but found less support for projective training by the “academic community”. Strong support for training with the Rorschach and TAT was demonstrated in a study by Stedman, Hatch, and Schoenfeld (2000).

They asked internship directors to indicate the number of integrated test write-ups, including the Rorschach and TAT, they wanted from applicants. Results varied across internship settings but ranged from 1.0 (Counseling Centers) to 20.0 (Private Psychiatric Hospitals) for the Rorschach. Programs wanted fewer TAT reports but again ranged from 1.0 (Consortia) to 21.0 (Private Psychiatric Hospitals). An additional study by Stedman, Hatch and Schoenfeld (2001a) asked internship directors to rate the importance of pre-internship preparation in test-based assessment and psychotherapy. Although directors rated perpetration on objective testing instruments higher (range across types of sites 5.0 to 3.7 on a 5 point scale), still they rated training in projective assessment at significant levels (4.4 to 2.8, with most sites rating above 3.0). Hence, internships continued to value training with projective instruments. Other studies of internship sites, such as Piotrowski & Belter (1999) and Clemence& Handler (2001), found similar results. There appears to be a gap in direct studies of internship training with projective techniques or methods between the early 2000s and very recently. In fact, Piotrowski asked the first author (Stedman) for an opinion about the status of projective training during internship in 2015, and I speculated that internship training with projectives had indeed declined. Piotrowski‟s question called for an empirical answer and one is now available. Stedman, McGeary, & Essery (in press) surveyed the 733 APPIC internship programs and obtained a 46% response rate (355 programs). These investigators asked internship directors to indicate the following: a) whether they expected personality assessment training during graduate school, b) whether they expected training with specific tests (MMPI, PAI, MCMI, Rorschach, Picture Story, Sentence Completion, Drawings) and their ratings of the importance of that training, and c) their own patterns of training with these instruments (the most important question for our purposes). Results were reported for three categories of internship programs: Adults Only, Child Only, and Mixed Child and Adult. Findings confirmed the speculation that internship programs have severely cut training with the traditional projective instruments. Training with the Rorschach occurs in only 26% of Adult Only, 32% of Child Only, and 33% (Adult rotations) and 35% (Child rotations) of Mixed programs. Training with story techniques (TAT, Roberts, etc.) is as follows: Adult Only 19%, Child Only 39%, Mixed – Child 41%, Adult 29%. Training with Sentence Completion instruments and drawings are even lower, although, as seen above, child programs tend higher. These findings show definitively that rates of training with projective methods have declined to the graduate school levels. In this most recent study, we also tried to ascertain reasons for not providing instruction with these instruments. The response rate for these questions was rather low; however, those responding cited a lack of trained staff, “too labor intensive”, and questionable validity of these types of tests as reasons for not conducting training. UTHSCSA: An Internship Program Continuing to Teach Projective Assessment: One example of an internship program continuing to train and teach projective measures is The University of Texas Health Science Center at San Antonio (UTHSCSA) which offers an APA accredited pre-doctoral internship program through the Department of Psychiatry. The internship operates from a

generalist training model whereby a number of sites in the area offer rotations for interns who also obtain training and learning opportunities at UTHSCA. Whereas the overall internship is generalist in model, UTHSCSA offers three different tracks in order to provide interns more in depth training in a desired area of specialization. The three tracts for the internship are 1) Forensic, 2) Cognitive Behavioral, and 3) Psychodynamic. UTHSCA Forensic and Psychodynamic interns receive exposure to projective measures to differing degrees. Cognitive Behavioral interns do not receive training or seminars on projective tests. For the Forensic Track, interns have the opportunity to administer as well as score projective tests and write interpretive reports under supervision. Forensic Track residents work solely with an adult population. The psychodynamic residents are provided seminars on projective tests, case conferences where projective materials are discussed as well as opportunities to administer, score and provide written interpretation of projective tests under supervision. Psychodynamic residents work with mixed child and adult populations. The most heavily utilized projective test across tracks and populations is the Rorschach. Supervisors have a diversity of training backgrounds with the Rorschach (i.e., Beck, Klopfer, Exner, etc.) but the primary two systems utilized are Exner and R-PAS. Other projective tests used are story telling tests (i.e. TAT and Roberts Apperception Test), sentence completion tests and projective drawings (i.e. House-Tree-Person, Family Kinetic and School Kinetic, etc.). These tests tend to be interpreted qualitatively utilizing a combination of developmental and personality theories to inform interpretation. Interns for the psychodynamic track are taught to administer the Rorschach in a standardized manner utilizing both the Exner and R-PAS systems. Interns are also provided training in the Rapaport method, particularly with younger children or for those who may have a difficult time with the query phase of the Exner or R-PAS approaches, usually due to memory or frustration tolerance. Instruction is provided on the limitations and criticisms of the Rorschach in seminars and interns are taught to administer the test only after deciding if the Rorschach is an appropriate measure for the referral questions being considered. Interns are instructed to be aware of context, age, cultural backgrounds, gender and linguistic abilities when utilizing the Rorschach and these variables are commonly discussed during supervision, seminars and case consultations. Rorschach interpretation methods taught utilize protocol scores as anchors for interpretation. Interpretive methods emphasize the Authoritative, Empirical and Conceptual approaches outlined in chapter 2 of Weiner‟s (2003) text, while what is referred to as the “Ouija Board” approach to interpretation is cautioned. Interns are taught a process of formulating their interpretations utilizing what Weiner (2003) outlines as structural, thematic, and behavioral characteristics as well as sequence analysis. Lastly, psychodynamic interns are employed to utilize developmental and personality theories to contextualize and interpret findings obtained from the earlier described process. This approach provides direction in providing relevant feedback and treatment recommendations to patients, parents and referral sources. Projective Training Circa 1963: For those who have not been in the clinical trenches 50+ years, it might be of some interest to know what the “hayday” of projective assessment was really like. That task falls to the first author, Stedman. So, I enrolled in the ”projectives” offering in the fall 1963, taught by Dr. John Napoli. His motto was, “Napoli‟s the name; Rorschach‟s the game.” So, we did the usual short review of the TAT and proceeded to the Rorschach. The personality assessment portion of a typical report for Professor Napoli and later during my internship went thusly:

1. A paragraph devoted to the patient‟s “reality contact” as determined by scoring the protocol according to the Beck norms. 2. Further consideration of Klopfer ratios and percentages, e.g., the ratio of Movement responses to Sum C, the famous Erlebenstype, indicating response to external or internal stimuli; percent of F- responses with F being Form scorings. 3. A lengthy paragraph or two regarding the patient‟s psychodynamic issues as determined first by the Rorschach and backed up by the TAT, Sentence Completion, and perhaps drawings. The Rorschach was seen as getting at the deepest level of psychodynamic conflict, followed by the TAT. The Sentence Completion and drawings were viewed, at least in my programs, as more superficial measures. 4. Rorschach analysis could occur in what was called “sequence analysis”, conducted on a card by card basis and, at times, a response by response basis. Certain cards had established “pull”. For example, Card IV was the Father Card and Card VII was the Mother Card. This point was brought home to me during my internship when, T, who we thought might be having much conflict with mom, took one look at Card VII, broke it across his knee, and handed it to me. Analysis could also be conducted by reference to the book by Phillips and Smith (1953) who had valuable psychodynamic interpretations for individual types of responses. We were told not to use this text but with a wink. 5. After a lengthy session of puzzlement over all these sources of data, you wrote it all up as a comprehensive picture of the patient. Conclusions: There is now little doubt that training with traditional projective tests has declined at all levels and with all instruments as noted by Piotrowski (2015, 2017) in his reviews. Piotrowski‟s conclusions also noted that researchers and the academic community in general began “hardened opposition” to the projective test cluster in the late 1990s. In fact, as early as 2000, an APA Division 12 Task force recommended that projective techniques not be taught in clinical programs (Lilienfeld et al. 2000) and several authors recommended a” moratorium” for teaching projective instruments (e.g., Wood et al. 2000). Piotrowski speculates that this opposition, the effects of managed care, and other factors (we suspect that the move away from dynamic personality theory and toward behavioral and cognitive-behavioral approaches in clinical training is a strong factor) have contributed to this noteworthy decline. Nevertheless, at the internship level, some adult programs and more child program continue to use and teach at least the Rorschach and picture story techniques. Findings, based on hard data, are much less definitive regarding current training at the graduate school level. However, this training has not disappeared. Those seeking exposure to projective assessment can still find programs teaching and using projective assessment techniques. References: Beck, S. (1944).Rorschach‟s test. New York: Grune and Stratton. Belter, R. W., & Piotrowski, C. (2001).Current status of doctoral-level training in psychological testing. Journal of Clinical Psychology, 57, 717-726. Bram, A.D., & Yalof, J. (2018). Two contemporary Rorschach systems: Views of two experienced Rorschachers on the CS and R-PAS. Journal of Projective Psychology & Mental Health, 25, this issue. Childs, R. A., & Ende, L. D. (2002) Assessment training in clinical doctoral programs: What should we teach? What do we teach? Journal of Personality Assessment,78, 130-144. Clemence, A. J., & Handler, L. (2001). Psychological assessment on internship: A survey of Training directors and their expectations for students. Journal of Personality Assessment, 76, 18-47. Durand, M. V., Blanchard, E. B., & Mindell, J. A. (1988). Training in projective testing: Survey of clinical training directors and internship directors.

Professional Psychology: Research and Practice, 19, 236-238. Exner, J. E. (1969). The Rorschach Systems. New York: Grune and Stratton. Hilsenroth, M. J., & Handler, L. (1995).A survey of graduate students‟ experiences, interests, and attitudes about learning the Rorschach. Journal of Personality Assessment, 64, 243-257. Klopfer, B., & Davidson, H. H. (1962). The Rorschach technique: An introductory manual. New York: Harcourt, Brace and World. Lilenfeld, S. O., Wood, J. M., & Garb, H. N. (2000).The scientific status of projective techniques. Psychological Science in the Public Interest, 1, 27-66. Meyer, G. J., Vigilone, D. J., Mihura, J. L., Erard, R. E., & Erdberg, P. (2011). Rorschach performance assessment system: Administration, coding, interpretation, and technical manual. Toledo, OH: Rorschach Performance Assessment System. Petzel, T.P., & Berndt, D.J. (1980). APA internship selection criteria: Relative importance of academic and clinical preparation. Professional Psychology, 11, 792-796. Phillips,L., & Smith, J.G. (1953). Rorschach interpretation: Advanced technique. New York: Grune and Stratton. Piotrowski, C. (1984). The status of projective techniques: “Wishing won‟t make it go away.” Journal of Clinical Psychology, 40, 1495-1502. Piotrowski, C. (2015). Clinical instruction on projective techniques in the USA: A review of academic training settings 1995 – 2014. Journal of Projective Psychology and Mental Health, 22(2), 83-92. Piotrowski, C. (2017). The linchpin on the future of projective techniques: The precarious statusof personality assessment in the (overcrowded) professional psychology curriculum. Journal of Projective Psychology and Mental Health, 24, 71- 73. Piotrowski, C., & Belter, R. W. (1999). Internship training in psychological assessment: Has managed care had an impact? Assessment, 6, 381-389. Piotrowski, C., & Zalewski, C. (1993).Training in psychodiagnostic testing in APA-approved PsyD and PhD clinical psychology programs. Journal of Personality Assessment,61(2), 394-405. Ready R. E., & Veague, H. B. (2014). Training in psychological assessment: Current practices in clinical psychology programs. Professional Psychology: Research and Practice, 45, 278-282. Stedman J. M., Hatch, J. P., & Schoenfeld (2002).Preinternship preparation of clinical and counseling students in psychological testing, psychotherapy, and supervision: Their readiness for medical school and non-medical school internships. Journal of Clinical Psychological in Medical Schools, 9, 267-271. Stedman, J. M. (1997). What we know about predoctoral internship training: A review. Professional Psychology: Research & Practice, 28, 475-485. Stedman, J. M., Hatch, J. P., & Schoenfeld, L. S. (2000).Preinternship preparation in psychological testing and psychotherapy: What internship directors say they want. Professional Psychology: Research and Practice, 31, 321-326. Stedman, J. M., Hatch, J. P., & Schoenfeld, L. S. (2001b).The current status of psychological assessment training in graduate and professional schools. Journal of Personality Assessment, 77, 398-407. Stedman, J. M., McGeary, C. A., & Essery, J. (In Press). Current patterns of training in personality assessment during internship. Journal of Clinical Psychology. Watkins, C. E. (1991). What have surveys taught us about the teaching and practice of psychological assessment? Journal of Personality Assessment, 56, 380-383. Weiner, I.B. (2003). Principles of Rorschach Interpretation. Mahwah, NJ: Lawrence Erlbaum Associates, Inc. Weiner, I.B., & Greene, R. (Eds.).(2008). Handbook of personality assessment. Hoboken, NJ: Wiley & Sons. Wood, J. M., Lilienfeld, S. O., Garb, H. N., & Nezworski, Mt T. (2000). Limitations of the Rorschach as a diagnostic tool: A reply to Garfield (2000), Lerner (2000), and Weiner (2000). Journal of Clinical Psychology, 56, 441-448.

In a recent editorial, Piotrowski (2017) contends that the fate of projective techniques will be linked to the precarious status of personality assessment in clinical training settings. Moreover, since 1990, projective techniques, as a class, have been the target of extensive criticism in the scholarly literature (e.g., Lilienfeld et al. 2000). This prompts the question: Have Sentence completion methods and tests(SCTs) lost their luster as a major component of the assessment process? Since scholarly reviews of the extant literature on SCTs have rarely appeared in the recent literature (see Holaday et al., 2000; Sherry et al., 2004), an examination on the status of SCTs would be informative. Thus, the intent of the current study is to determine whether recent shifts in testing practices and research attention in the field of assessment have had a deleterious impact on the popularity of SCTs in graduate training programs and professional usage worldwide. To that end, the author identified, through an extensive literature review, published survey research with regard to SCTs that reported on assessment training and test usage patterns from 1989-2015. The 70 identified survey-based or records-based studies served as the data pool in the current review (Training=16; Practice=54). This analysis indicated that, from a historical perspective, sentence completion methods have been popular assessment tools, evident in that 35 of the70 studies (50%) reported that SCTs have been relied upon to at least a „moderate‟ degree. However, reliance on SCTs has been more prominent in academic assessment training (69% of studies) than in practice settings (44% of studies). Quite apparent in this review, was the obvious diminution of SCT usage since 2003 in both professional clinical academic programs and in applied settings. One noteworthy exception is that several very recent (since 2014) surveys of internship settings confirm continued emphasis on SCTs. Regardless, supplemental data point to the reality that coursework and training emphasis with SCTs have been rather cursory and unstructured. In addition, these vast survey-based findings suggest that SCTs are embraced more by child clinicians and school psychologists than in mental health assessment of adults. However, based on the evidence in this exhaustive review, it appears that current usage of SCTs is waning. Thus, the future status of SCTsin the assessment enterprise appears rather limited, but certainly not moribund. Over the past 75 years, Sentence Completion methods and tests (hereon, SCTs), largely within the context of projective methods, have been popular assessment tools in practice (Fisher, 1967; Frank, 1948; Keddy & Piotrowski, 1992; Klopfer & Taulbee, 1976; McGrath & Carroll, 2012; Murstein, 1965; Piotrowski, 1985, 2015a; Piotrowski & Keller, 1992; Rabin, 1986; Reynolds & Kamphaus, 2003; Sherry et al., 2004; Wade & Baker, 1977). Moreover, scholarly research on various SCTs has been rather robust over the years (see Lah, 2001, 1989). In an analysis on the prevalence of projective techniques in published research reported in key journals from 1947-1965, Crenshaw et al. (1968) found the SCT to be ranked 4th in terms of investigatory interest over this time period. A recent bibliometric search (terms in Title: “sentence completion” or “incomplete sentences”, conducted in May 2017) in the database PsycINFO identified 242 article references, dissertations, and book/chapters with a focus on SCTs. Indeed, a cursory examination of recent scholarship shows the research attention to traditional SCTs and newly developed SCTs remains active (e.g., Chan et al., 2012; Huang, 2016; McCloskey, 2014; Weis et al., 2008). Findings from research studies have not only found support for the construct validity of SCTs but also highlight the empirical relevance of sentence completion data in clinical research (see Rusu et al., 2012; Torstrick et al., 2015). Proponents of projective assessment contend that SCTs provide rich idiographic material that reflects

personality characteristics and provide indirect clues to underlying attitudes, affects, stressors, and coping mechanisms (Basu, 2014;Rapaport et al., 1968; Sherry et al., 2004; Weiner & Greene, 2008). Moreover, sentence completion approaches seem very conducive to the assessment process when evaluating children and as a prodigious precursory tool in screening for psychological disturbance or maladjustment (e.g., Kugler et al., 2013). One major drawback in the advancement (and professional acceptance)of this assessment technique has been the multitude of varied formats, sentence stems, and content spectrum of SCTs available to both clinicians and researchers (see Rogers et al., 2003). Another hindrance has been the labeling of SCTs as a strictly projective technique and the lack of formal scoring and interpretive systems. Based on these concerns, projective techniques, in general, have generated much scholarly criticism by clinicians and academicians over the years (Garb et al., 2002; Lilienfeld et al., 2000; Smith & Dumont, 1995), even during the zenith of their popularity (see Butcher, 2006;Harwood et al., 2011; Swensen, 1968; Vukovich, 1983). Critics, like Ziskin (1995, pp. 824-825), aptly stated “The most devastating criticism is that the examiner may engage in as much projection and subjectivity in the interpretation of responses as did the examinee in generating the responses - Not only are the test stimuli ambiguous, but so too is the meaning of the responses given by the examinee.” Thus, based on the apparent acceptability of SCTs in practice venues and, conversely, disparagement of projective assessment in the scholarly literature, the aim of the current study is to review the extant literature on assessment usage of SCTs in both academic training and applied settings. Historical Context: Graduate-level Training Settings: Early surveys, such as McCully (1965), reported rather positive attitudes of internship directors regarding projective techniques, with 76% of respondents considering SCTs as somewhat or very important. In a survey of academic clinical psychologists in APAapproved clinical training programs, Thelen et al. (1968) found that 80% of respondents considered SCTs important to master, with 41% confirming that coverage of SCTs should be required coursework. About this time, Shemberg and Keeley (1970) detected a slight decrease in training in projective techniques in PhD clinical training programs. However, very positive attitudes, toward diagnostic testing, were reported by internship directors several years later (Garfield & Kurtz, 1973); in fact, 64% of internship centers emphasized SCTs. Moreover, clinical psychologists recommended that clinical students learn about SCTs (Wade & Baker, 1977). During the 1980s, where attitudes of academic faculty and internship directors toward projective tests were somewhat tempered, SCTs were still endorsed as important for practice by 62% and of academic clinical psychologists, with 34% stating that SCTs should be required coursework (Pruitt et al., 1985). In a survey of APA clinical psychology programs, Piotrowski and Keller (1984) found that a majority (53%) of directors recommended training in SCTs. Moreover, SCTs continued to be somewhat popular during internship training(see Durand et al., 1988), including extensive clinical experiences with SCTs by advanced clinical interns in child specialty programs (Elbert & Holden, 1987). Supporting this view, Knight and Godfrey (1984) reported that hospital psychologists (45%) in New Zealand recommended that clinical students gain competency in the Rotter ISB. Mental Health Practice Settings: Early on, national surveys on clinical test usage in outpatient and hospital settings found that SCTs ranked 4th and used in almost 50% of mental health agencies (Sundberg, 1961). However, SCTs did not rank highly in a survey of practicing

psychologists (Hinkle et al., 1968). In a nationwide survey of clinical agencies, Lubin et al. (1971) reported that SCTs ranked 8th.Gendreau (1975), in a study on psychological test usage in corrections in Canada, reported that the Rotter ISB was ranked 13th. Other surveys of mental health practitioners in the 1970s found SCTs ranked amongst the „Top 10‟ tests in terms of usage (see Brown & McGuire, 1976; Piotrowski & Keller, 1978). Emphasis in practice with Sentence Completion approaches continued into the 1980s (Harrison et al., 1988; Haynes & Peltier, 1983; Lubin, Larsen, & Matarazzo, 1984; Sweeney, Clarkin, & Fitzgibbon, 1987; Watkins et al., 1988).In fact, one survey found that 47% of practitioners recommended professional competency with SCTs (Piotrowski, 1985). In the area of child assessment, one study of practicing school psychologists reported that 87% of respondents used SCTs in the assessment of personality (Goh et al., 1988), although SCTs have not been found to be popular in the assessment of specific childhood disorders like ADHD (see Rosenberg & Beck, 1986).Interestingly, although child psychologists rely on projective techniques, few (17%) have been reported to use SCTs in clinical work (Tuma& Pratt, 1982). Surprisingly, clinicians such as behavior therapists, with an anathema to projective techniques, have been reported to occasionally rely on SCTs (Piotrowski & Keller, 1984).Noteworthy, the popularity of SCTs has not been evident in practice settings overseas; e.g., based on test usage data from Australian practicing psychologists, Sharpley and Pain (1988) found that SCTs were not highly recommended for inclusion in graduate-level training. Thus, prior to 1990, most surveys indicated reliance on SCTs by mental health practitioners. Investigatory Design: In order to appreciate historical trends on the scope of emphasis and usage of Sentence Completion Tests (SCTs) in graduate-level training and practice/professional settings, the author utilized bibliometric analyses of the extant literature to identify survey-based studies. To that end, a systematic search of the database PsycINFO (published by the American Psychological Association) was conducted, as this research repository is considered the leading scholarly file of research in the social and behavioral sciences worldwide. Table summarizes survey findings of both academic and applied settings on training emphasis and usage of SCTs since 1989. This timeline reflects the inception of the burgeoning critique of projective techniques in the scholarly literature. Thus, this review includes the 70 published studies that were identified in journal publications, based on academic/training and clinician/practitioner samples worldwide. Findings: First, response-rates of the reviewed studies varied widely; thus, the conclusions of the current analysis findings must be tempered by the unknown views of a sizeable percentage of non-responders from the samples under study. Thus, with a cautionary stance, the current analysis showed that, overall, based on data from both academic and practice settings over the past 3 decades, SCTs have been emphasized or used to at least a „moderate‟ degree in 35 of the 70 (50%) studies in this review. This popularity was apparent in doctoral training or internship settings, where SCTs received „moderate to high‟ coverage in 11 of the 16 studies (69%) compared to only 24 of the 54 studies (44%) of practice settings. In fact, 30 of the 54surveys (56%) of applied settings indicated infrequent use of SCTs, although 22% found rather high usage levels in practice. Regarding usage over time, this review revealed that emphasis on the SCTs, overall, has diminished somewhat since the year 2000, both in training and practice. The only exception noted was continued popularity and reliance on SCTs by school psychologists (Hojnoski et al., 2006), child psychologists

(Cashel,2002), and in vocational rehabilitation evaluations (Donoso et al., 2010).However, although substantial levels of training emphasis with SCTs in APA academic programs were reported by Childs and Eyde (2002) and Belter and Piotrowski (2001), coursework exposure to SCTs has been virtually nonexistent in graduate-level training in recent years (see Peterson et al., 2014; Ready &Veague, 2014). Interestingly, SCTs still enjoy moderate levels of emphasis in internship settings (Bates, 2016; Ready et al., 2016).Future studies should shed some light on how this diminution in instructional attention during graduate-level trainingwill impact the status of SCTs over the next decade. Several other trends in practice or applied settings were noted: a)SCTs have been rarely used and are largely neglected by neuropsychologists in assessment of personality (Rabin, 2005; Smith, 2010);b) historically, SCTs have had a central role in the evaluation practices of school psychologists (e.g., Hojnoski et al., 2006; Hughes et al., 2010; Hutton et al., 1992; Kennedy et al., 1994), but the focus on SCTs in academic school psychology programs has diminished over the past decade; and c) there is a dearth of data on the status of SCTs in graduate-level educational or training programs in countries outside the USA; hence, future research needs to examine pedagogic issues and identify trends regarding assessment training, over time, at universities in nations worldwide (see Piotrowski, 2015b for review). Conclusion: • In terms of graduate-level training, prior to 2003, SCTs were well integrated into the assessment curriculum in clinical psychology programs and internship settings. However, in recent years, SCTs have witnessed a sharp diminution in emphasis in professional clinical programs, but (surprisingly) continue to be somewhat valued in internship settings. Moreover, based on supplemental data, it appears that much of the didactic instruction on SCTs has been rather cursory and unstructured. In this regard, scholarly commentary, in recent years, has been devoted on concerns regarding achieving competency in testing during assessment training in professional psychology programs (see Flanagan & Esquivel, 2006; Lan& Chang, 2016; Krishnamurthy et al., 2004). Hence, interested students may need to pursue educational opportunities on SCTs via nontraditional venues such as workshops and individualized instruction in order to gain proficiency and mastery with sentence completion assessments. • In terms of usage in practice, from an historical perspective prior to 2000, SCTs were quite popular in clinical, child, and school psychology settings. However, SCTs have been largely eschewed by neuropsychologists and forensic psychologists. Overall, based on recent surveys, the popularity of SCTs in practice settings has seriously waned in the past 10 years, with the exception of continued use by school psychologists and in specific areas of legal evaluations. This disuse of SCTs by the majority of mental health professionals is perhaps due to managed care constraints (Maruish, 2002; Piotrowski & Belter, 1999; Riaz, 2006), attention on empirically-based assessment (Lilienfeld et al., 2015), and the diminution in training emphasis with projective techniques in professional programs, quite evident in recent years (see Piotrowski, 2015c; Ready et al., 2014). Quite surprisingly, Delphi poll findings point to the general acceptance of SCTs in terms of clinical credibility(see Norcross et al., 2006). • Regarding SCTs usage overseas, the data are rather spotty, with strong emphasis in some countries like Japan but largely neglected in European and South American nations. Moreover, more research on the status of SCTs in graduate-level education and training in nations outside the USA are needed, particularly due to recent research interest in SCTs in select countries (e.g., Bhattacharya et al., 2015). • Based on the emerging literature, it is evident that SCTs are been applied in business research, such as in marketing and consumer psychology (e.g., Vidal et al., 2013).

• These findings, in aggregate, confirm that a minority of mental health practitioners have relied on SCTs and sentence completion methods over the past century, and have done so based largely on several key attributes of these techniques discussed in the assessment literature; notably, that SCTs can contribute to idiographic assessment and serve as an exploratory assessment tool in the mental health evaluation, particularly children and youth (Basu, 2014; Chandler, 2003). In addition, SCTs assist the clinician in understanding and addressing stressors, social-emotional needs, and interpersonal challenges. However, due to the perennial introduction of „new‟ psychological scales and measures, reimbursement limitations, and the proliferation of „brief‟ and abbreviated testing instruments, the status of SCTs in academic training programs has clearly suffered in recent years. Hence, with obvious diminution in training emphasis, enthusiasm for SCTs in practice settings will surely be curtailed. Thus, based on the current systematic review, the future status of SCTs in the assessment enterprise appears rather limited, but not quite moribund. Table-1: Emphasis or Use of Sentence Completion Tests in Training/Practice Settings across 70Studies (1989-2016) Study Country Sample Findings Piotrowski & Keller (1989) USA Test usage in 413mental health facilities 356 of the 413 settings used SCTs, ranked th in overall usage. Tsoi & Sundberg (1989) Hong Kong Division of Clinical Psychology of the Hong Kong Psychological Society SCTs were not ranked amongst the top 10 tests. Bubenzer et al. (1990) USA 743 members of the American Association for Counseling & Development, primarily practitioners SCTs were not ranked highly. *Watkins et al. (1990) USA Data based on 56 directors of counseling psychology training programs 27% of these programs emphasized SCTs in coursework/training. Archer et al. (1991) USA 165 respondents who were either APA Division 12 members, Society for Personality Assessment members, and/or practitioners with a research interest in adolescent assessment The SCTs ranked amongst the top tests for inclusion in a „Standard‟ test battery, endorsed by 46% of respondents. Butler et al. (1991) USA 280 members of the International Neuropsychological Society 36% of respondents in neuropsychology use SCTs for „personality‟ assessment. Ogawa & Piotrowski (1992) Japan Japanese Clinical psychologists SCTs ranked 2 nd in terms of usage in Japan. Hutton et al. (1992) USA 389 school psychologists (members of NASP); update on the Goh et al. (1981) study For the area of personality assessment, SCTs were used by 20% of sample (ranked 5 th). *Piotrowski & Zalewski (1993) USA A 1991 replication of the Piotrowski & Keller (1984) study; 80 Directors of both PhD and PsyD APA clinical psychology programs 35% of the programs suggested competency in SCTs; this reflected a slight decline in emphasis on SCTs compared with findings (53%) of the 1984 survey. Kennedy et al. (1994) USA Practicing school psychologists Overall, projective tests used frequently; SCTs ranked 4th. Stinnett et al. (1994) USA Data analysis based on 123 members of the National Association In social-emotional assessment, 60% use SCTs (ranked #1 in this area).

of School Psychologists (NASP) in 1993 Chan & Lee (1995) Hong Kong 50 practicing psychologists in 1993 Projective tests were quite popular; SCTs ranked 8th. Watkins et al. (1995) USA 412 APA members who were clinical psychologists SCTs used by 84% of practicing psychologists & ranked 4 th overall; 52% of psychologists felt that clinical students should gain competency in SCTs. Borum & Grisso (1995) USA 102 forensic psychologists/psychiatrists For psychologists, SCTs were relied upon by only 6% of respondents; for psychiatrists, 3%. *Wilson & Reschly (1996) USA Data, obtained in 1992, on assessment practices from 251 members of the National Association of School Psychologists (NASP); and faculty in school psychology programs For the practitioner sample, SCTs were not amongst the top 10 instruments; for faculty, SCTs were not covered in coursework nor in supervised training. Lees-Haley et al. (1996) USA Forensic evaluation reports by100 forensic neuropsychology experts SCTs (ranked 10 th) and were used by 28% of respondents in forensic cases. Mardell- Czudnowski (1996) USA Special needs professionals (n=1059) testing practices with children SCTs were rarely used. *Culross& Nelson (1997) USA Surveyed 63 instructors listed in NASP-approved graduate programs in school psychology on tests emphasized in personality assessment coursework SCTs were taught in 62% of personality assessment courses. Patchett- Anderson (1997) New Zealand Test usage by clinical psychologists SCTs were amongst many psychological tests that practitioners recommended clinical students to learn. Ackerman & Ackerman (1997) USA Practitioners in court-related custody evaluations involving children and parents SCTs ranked amongst the top tests (#8); In a re-analysis of the findings, Hagen &Castagna (2001) found that SCTs were used in 19% of assessment reports of parents and in 22% of evaluations of children. Frauenhoffer et al. (1998) USA Surveyed 487 mental health practitioners (psychologists, counselors, social workers) 45% of psychologists rely onSCTs (ranked th); social workers (5 th); professional counselors (6 th). Piotrowski et al. (1998) USA 137 practitioners in National Register of Health Service providers in Psychology Although several projective tests (Rorschach, TAT, HFDs) were considered important to assessment practice, SCTs were not noted. Muniz et al. (1999) Spain, Portugal, & Latin America Test use by practicing psychologists Overall, projective methods were quite popular, but SCTs were used infrequently. Boccaccini & Brodsky (1999) USA Diagnostic test usage in personal injury cases by 80 practicing forensic psychologists SCTs were not frequently used in the assessment of „emotional injury‟. *Piotrowski & USA Extent of graduate-level assessment 32% of these internship sites provided

Belter (1999) curriculum was reported by training directors from 84 APA-approved internship settings training on SCTs; however, SCTs were notconsidered „essential‟ for practice. Holaday et al. (2000) USA 60 members of the Society for Personality Assessment on SCTs assessment usage The Rotter ISB was the predominant SCT used with adults (47%), adolescents (32%), and children (18%); few assessors relied on formal scoring protocols. Camara et al. (2000) USA 179 practitioners, mostly clinical psychologists regarding test usage Neuropsychologists shunned SCTs; but clinical psychologists valued SCTs(ranked th). Archer & Newsom (2000) USA 346 psychologists, working with adolescents SCTs (ranked 3rd) were used by 65% of respondents. *Stedman et al. (2000) USA 324 internship directors across a variety of mental health settings Directors did not mention SCTs to be included in „integrated‟ assessment. Boothby & Clements (2000) USA Correctional (prison) psychologists SCTs were not amongst the top 20 assessment instruments. *Clemence & Handler (2001) USA Surveyed 382 internship settings on use and training of psychological tests Internship directors supported graduatelevel preparation in projective assessment;45% recommended competency and inclusion inSCTs in a „Testing battery‟. Muniz et al. (2001) European (Spain, UK, Holland, Slovenia, Croatia, Belgium) 3,455 professional psychologists use of psychological tests In these 6 countries, projective tests were not used frequently; SCTs were not relied upon in assessment. Luiselli et al. (2001) USA Assessment for autism reported by100 practitioners in national service centers for developmental disabilities in 30 states Although about 25% of service centers use projective tests in the treatment of autism, SCTs were not noted. Quinnell & Bow (2001) USA Testing practices in child custody evaluations by 198 practicing psychologists 30% of the sample use SCTs in assessment of children; 26% in testing adults. *Belter & Piotrowski (2001) USA Survey data on 82 directors of APAapproved doctoral clinical/professional psychology training programs on assessment curriculum Nearly 60% of the programs required a specific course on projective testing; SCTs were emphasized in 23 of the 82 programs (28%). *Childs & Eyde (2002) USA Course syllabi data, from 84 APA clinical psychology programs, determined coverage of assessment techniques 29% of programs indicated that SCTs are covered in the assessment curriculum (12 th ranked test). Cashel (2002) USA 162 child & adolescent practitioners in outpatient, hospital and school settings SCTs were ranked 3 rd amongst 30 tests in the assessment of youth; 75% of respondents use SCTs to some degree. *Stedman et al. (2002) USA Based on survey data from 334 psychology interns, determined extent of pre-internship assessment Results showed that clinical students met or exceeded most expectations of internship training directors by producing a

report writing experiences median of 18 integrated testing reports; however, reports including SCTs were few (M=2). Bow et al. (2002) USA 84 psychologists reported on assessment practices regarding sexual abuse in child custody cases SCTs were used in 13% of assessments of accusing parents and alleged perpetrators. Dugdale & Dunn (2002) New Zealand Practicing psychologists and counselors SCTs were not ranked highly. Demaray et al. (2003) USA Surveyed over 316 school psychologists on assessment practices in ADHD Although 30% supported projective assessment, only 11% relied on SCTs in ADHD evaluations. Lally (2003) USA 64 Diplomate-status forensic psychologists, test use in courtrelated evaluations SCTs were considered „unacceptable‟ from 69%-76% of sample across several forensic domains. Ryba et al. (2003) USA Psychologists‟ test usage in juvenile competency to stand trial evaluations Projective tests were infrequently employed; only 10% reported using SCTs. Shapiro & Heick (2004) USA Determined assessment practices of 648 school psychologists (NASP members) SCTs used infrequently across recent cases involving psychological assessment issues. Echemendia & Harris (2004) USA Test use practices of 911 neuropsychologists No projective techniques were amongst top tests used. Elhai et al. (2005) International sample Test use in PTSD evaluations by 227 members of the International Society for Traumatic Stress Studies SCTs not relied upon. Rabin et al. (2005) USA/Canad a Assessment practices of 747 clinical neuropsychologists Only the Rorschach was amongst the top 40 tests in neuropsychological assessment; SCTs not noted. Hojnoski et al. (2006) USA 170 school psychologists reported use of projective tests SCTs were the most popular projective technique, used by 61% of respondents, mostly for diagnostic purposes &hypothesis development. Archer et al. (2006) USA 152 forensic psychologists‟ use of projective techniques in court-related assessments 15% of respondents (n=22) use SCTs at least „occasionally‟ in forensic evaluations of adults with regard to personality assessment. Koonce (2007) USA 246 NASP members were surveyed on selection of tests in ADHD assessment For direction for selection of ADHD test battery, 30% of respondents relied on SCTs (ranked 9th). Madaus et al. (2009) USA Assessment practices reported by 164 „special education‟ directors in school districts in 5 northeastern states Apparently, projective techniques are not used in the assessment of socialemotional behavior in „special education‟ milieu. Ogawa et al. (2010) Japan 2010 assessment practices of 237 Japanese psychologists in practice; replication study of 2004 survey SCTs used by 50% of respondents; a slight decline in popularity compared to 2004 survey (65% used SCTs); however, only 15% felt that students should pursue instruction on SCTs. Smith et al. (2010) USA 404 members of the International Neuropsychological Society or SCTs were not relied upon in neuropsychological testing nor for

National Academy of Neuropsychology surveyed on personality assessment practices personality assessment. Donoso et al. (2010) USA 150 professionals who conduct vocational rehabilitation evaluations SCTs ranked 9 thand used by 40% of practitioners. Raez (2011) Peru University psychologists in Lima, and members of the Peru Society of Rorschach & Projective Methods 92% of the sample use projective techniques; but SCTs were used infrequently. Ackerman & Pritzl (2011) USA 213 forensic psychologists surveyed on tests used with parents in child custody evaluations 41% of the sample use SCTs in assessment of parents. Evers et al. (2012) 17 European countries Study conducted in 2009; sample included 12,606 professional psychologists regarding testing practices; data analysis based on 400 respondents Projective tests were not ranked highly across all countries; SCTs were rarely used. *Neukrug et al. (2013) USA Based on survey data from 210 counselor educators across the U.S., this study examined graduate-level coverage of assessment instruments by instructors 70% of instructors reported teaching emphasis with the Rotter ISB (ranked th);the Forer SCT noted my 27%. Peterson et al. (2014) USA 926 counselors (clinical mental health, school, occupational) rated tests of all types regarding usage Amongst a copious set of testing instruments, SCTs were used infrequently; the Rotter ISB (ranked #54) and the Forer SCT (#94). Neal & Grisso (2014) International sample: USA (45%), Canada (7%), Europe (3%), Australia- New Zealand (4%) 434 forensic examiners of professional organizations Across a variety of forensic/legal domains, a myriad of testing instruments was used; however, the only projective test noted was the Rorschach. *Ready & Veague (2014) USA Compared training in psychological assessment across 3 training models (Clinical-Science, Scientist- Practitioner, Practitioner-Scholar) in APA-Accredited programs No projective tests ranked in the top 10; only practitioner-scholar programs offer limited coverage on projective techniques; SCTs not mentioned. Wechsler et al. (2014) Iberian/Latin -American countries Test development & usage in Portugal, Spain, Argentina, Venezuela, and Brazil Projective tests very popular in Venezuela; Rorschach somewhat popular in Brazil and Argentina; Spain and Portugal indicated low usage of projective tests.SCTs are not amongst the top tests used by practitioners in any of these countries. Rotomskis et al. (2016) Lithuania Assessment practices of 113 psychologists who work in mental health care institutions SCTs were not frequently used. Rabin et al. USA and 512 neuropsychologists (INS/NAN In the area of personality/mood

(2016) Canada members) on test usage assessment, SCTs were rarely used (by 2.6%) and ranked 15 th in that domain. *Ready et al. (2016) USA& Canada 236internship directors‟ views on predoctoral academic training in testing and assessment SCTs were endorsed by about 25% of these directors; somewhat more emphasized in child clinics (by 40%). Wright et al. (2016) USA Views of 279 professional APA psychologists on assessment/testing practices SCTs not ranked among top tests; in the projective test category, only the Rorschach ranked in „Top 10‟. *Mihura et al. (2016) USA Assessment/testing training reported by 83 APA clinical psychology programs SCTs were „covered‟, overall, in 47% of programs; more emphasized in practitioner-focused training. *Kohns (2016) USA Experiences of 148 advanced clinical students from both APA & non-APA professional psychology programs regarding assessment training Although exposure to projective assessment was rather high (30 coursework hours), specific data on SCTs were not reported. *Bates (2016) USA 182 APPIC internship directors‟ views on assessment/testing training practices Compared to other tests, SCTs ranked 14 th (endorsed by 23% of directors); SCTs are relied upon in assessment by 44% of interns; although emphasis in projective testing decreased substantially in recent years, directors prefer incoming interns to have academic exposure to projective assessment. Egeland et al. (2017) Scandinavia 702 Nordic neuropsychologists‟ use of personality/psychological tests (outside of neuropsychological measures) No projective tests were mentioned. Note. Studies (n=16) marked with asterisk(*) focused on graduate/internship training. References: Ackerman, M.J., & Ackerman, M.C. (1997). Custody evaluation practices: A survey of experienced professionals. Professional Psychology: Research and Practice, 28, 137-145. Ackerman, M.J., & Pritzl, T.B. (2011). Child custody evaluation practices: A 20-year follow-up. Family Court Review, 49(3), 618-628. Archer, R.P., & Newsom, C.R. (2000). Psychological test usage with adolescent clients: Survey update. Assessment, 7(3), 227-235. Archer, R.P., Buffington-Vollum, J.K., Stredny, R.V., & Handel, R.W. (2006). A survey of psychological test use patterns among forensic psychologists. Journal of Personality Assessment, 87, 84-94. Archer, R.P., Maruish, M., Imhof, E.A., & Piotrowski, C. (1991). Psychological test usage with adolescent clients: 1990 survey findings. Professional Psychology: Research and Practice, 22, 247-252. Basu, J. (2014). Psychologists‟ ambivalence toward ambiguity: Relocating the projective test debate for multiple interpretative hypotheses. SIS Journal of Projective Psychology & Mental Health, 21, 25-36. Belter, R.W., & Piotrowski, C. (2001).Current status of doctoral-level training in psychological testing. Journal of Clinical Psychology, 57, 717-726. Bhattacharya, S., Hirisave, U., & Suman, L.N. (2015).Development of the NUMHANS Sentence Completion Test for children and adolescents. Indian Journal of Mental Health, 2(1), 74-79. Boccaccini, M.T., & Brodsky, S.L. (1999).Diagnostic test usage by forensic psychologists in emotional injury cases. Professional Psychology: Research and Practice, 30, 253-259. Boothby, J.L., & Clements, C.B. (2000).A national survey of correctional psychologists. Criminal Justice and Behavior, 27, 716-732.

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threat perception triggered by objects of irrational fears. This paper reports a case study on the application of CDT in a seven years old child, having two irrational fears (a) darkness, and (b) height. Cognitive drill was implemented based upon this child’s unique danger ideations. Clinical outcome was successful in that the brief CDT intervention rapidly resolved his fears. Additional studies on CDT intervention are suggested. Specific phobias are among the most common psychological problems (Kessler et al., 2005) prevalent in the society. People with specific phobias, or strong irrational fear reactions, struggle hard to avoid common places, situations, or objects even though they know there is no objective threat or danger. The fear may not make any sense, but individuals feel powerless to stop it. As per DSM-5 (APA, 2013), in specific phobia, there is a marked fear or anxiety about a specific object or situation (e.g., flying, heights, animals, receiving an injection, seeing blood).The phobic object or situation almost always provokes immediate fear or anxiety.The phobic object or situation is actively avoided or endured with intense fear or anxiety. The fear or anxiety is out of proportion to the actual danger posed by the specific object or situation and to the sociocultural context. Psychosocial interventions, especially exposure-based treatments have robust empirical support as effective treatment for specific phobias. Many studies have reported significant improvements in conditions of specific phobias after receiving 2-3 sessions of exposure-based treatments (Choy et al., 2007; Wolitzky-Taylor et al., 2008; Zlomke& Davis 2008). Cognitions play an important role in the maintenance of specific phobias (Thorpe &Salkovskis 1995). As a result, cognitive therapy (CT), either alone or in combination with exposure, has been considered as a potential treatment option. Cognitive therapy is based upon challenging one’s distorted beliefs, expectations, or predictions pertaining to the feared object or situation in order to reduce anxiety and avoidance behavior. Cognitive behavior therapy has proved effective in the treatment of phobia in both individual and group settings (Silverman et al., 2008). Cognitive behavioral therapy (CBT), a short term, skills-focused therapy combines cognitive and behavioral therapies to enable people to diffuse unhelpful emotional responses by helping people appraise such responses differently and, thus, change their behavior. In addition to the existing modes of treatment of specific phobias; a novel form of verbal exposure known as Cognitive Drill Therapy (CDT) has been developed by Kumar et al. (2012) and Jain (2016). CDT is based on the principles of conditioning and cognitive appraisal for addressing the problems of OCD and phobias. CDT modifies emotions and behaviors through the principles of habituation and promoting experiential realization of the falsity of feared outcomes. The dysfunctional cognition is primarily addressed which produces emotional and behavioral changes. The case-based data generated so far suggest that CDT could be beneficial in reducing irrational fears in conditions of phobia and OCD (Arya et al.,2017;Dwivedi & Kumar, 2015;Kumar et al., 2012). CDT conceptualizes irrational fears having following four components called as OBSD:

1. Objects of Fear (O): any object or situation that triggers a fear reaction such as lift, crowded places, open places, heights, pointed objects, public speaking. 2. Body-Mind Reaction (B): Reactions elicited by an exposure to objects of fear, such as palpitations, nausea, dry mouth, shakiness, sweating. 3. Safety measures (S): Avoidance behaviors or the measures taken by an affected person to ensure safety; such as avoiding use of objects of fears like lift, going at crowded places. 4. Danger Ideation (D): Thoughts of threat perception triggered by actual or anticipated exposure to objects of fear; also called as imagined feared consequences; such as fearing suffocation or fainting in the lift. An affected individual perceives the object as threatening and the onset of the fear reaction pushes the individual towards safety behaviors. This makes it difficult for the individual to examine the validity of the primary determinants of phobia consisting of Danger Ideation. According to CDT perspective, the primary problem is the acquired connection between objects and the danger ideation. A disconnection of danger ideation from objects of phobia and OCD would resolve the problem effectively. After treatment, the objects of phobia and OCD would continue to exist but these conditions will cease to trigger danger ideation; as a result there will be no BMR and the need for safety behavior will not arise. In CDT, particular attention is paid to the nature of danger ideation. All danger ideations, point to a future time reference. Drill statements are formulated by changing the time reference of danger ideation from future to past or present. The affected individuals are asked to imagine objects of fear and verbalize drill statement applicable to their problems. The verbalizations in this manner trigger BMR which is constantly monitored. The continued drill produces a typical anxiety curve in which BMR makes an inverted U. CDT combines empirically supported principles of classical conditioning, operantconditioning, cognitive appraisal, and linguistics. In this paper, we report a case study in which multiple phobias were treated by using Cognitive Drill Therapy. Case summary: A 7 years old boy suffered from fear of darkness and height. 1. His OBSD analysis for fear of darkness: a. Objects of fear- Wearing round neck t- shirts, pouring water on head or applying shampoo as in both the situations he would require to close his eyes and that would obstruct his visibility. Also scared of going in a dark room or becomes startled by power failure. b. Body Mind reaction- Palpitation, crying and breathlessness. c. Safety measures- Refusal for wearing round neck t-shirts, avoid going to dark room, use of shampoo only once an week. d. Danger ideation- thoughts of danger perception are as follows: I. might get hurt in the darkness. II. might see spirits in the darkness. 2. His OBSD analysis for fear of height: a. Objects of fear- Climbing peg tables even up to 1.5 ft high. Racks, raised platforms, swimming pool platforms, terraces, trees. b. Body Mind reaction- Palpitation, dry mouth, shaking of legs and dizziness. c. Safety measures- Refusal to climb places of height. d. Danger ideation- thoughts of danger perception are as follows: I. might fall down. II. might get hurt. Cognitive Drill Therapy was applied. On Day- 1, after having intensive interactive and rapport building session with the client, the diagnoses of height phobia and phobia of darkness were determined. His danger thoughts comprised of getting injured. During the session the boy was

assisted in verbalizing his fears in his own words and converted them into past tense. Drill was then prescribed. On Day 2, his BMR rating was checked by asking him to rate his fear on the scale of 1-10 and he said that he has no fear now. He was then asked to put on a round neck t-shirt, which he would otherwise put on with lot of tantrums or simply refuse to put on but this time he was able to put on his t-shirt easily and could also walk in a dark room. In this session, his fear of heights was also addressed and after a brief session of CDT inside the room, he was asked to climb a structure which was only a few feet high. Post CDT he was able to climb at the top of that structure and also jumped down from it without any fear which otherwise was a scary and impossible task for him. Day 2 ended by giving the homework assignment of practicing the drill statements at home. On Day 3, starting the session by practicing the drill statements for even higher places like jump stand of swimming pool. Post CDT session he was encouraged to climb the jump stand. Initially, he went to only a 3 meter high jump board but then he ended up by climbing a 10 meter high jump board. At the end of the session, a homework assignment to practice drill statements for height and darkness wereprescribed. At the end of the workshop his father reported marked improvement. The client was able to bathe comfortably even when water was poured on his head and shampoo was used. After the session he has not displayed any of the previous behaviors during similar circumstances, and reported having no fear of darkness or heights. Discussion: Cognitive drill therapy directly acts upon the thoughts of threat perception triggered by objects of phobia. In this case also, danger thoughts of injury and spirit were drilled by changing the timeframe from future to the past. The continued repetitions of drill statements in this manner initially lead to escalation in sympathetic arousal which gradually began to decline. In the process of fear activation in response to the drill and its resolution enables an affected person for ‘experiential realization’ that nothing happens in reality which was being anticipated by having an exposure to the objects of phobia. The expectancy of threatening outcomes becomes violated which is considered as a core mechanism in exposure treatment (Craske et al., 2008). Secondly, CDT relies on the theory of within and between sessions habituation, a core mechanism of change proposed by Foa and McNally, (1996) in their theory of emotional processing. CDT effectively produces within session changes regarding reactivity to objects of phobia which are efficiently maintained between sessions. Furthermore, homework assignments play a significant role in consolidation of habituation and generalization. Conclusion: CDT produced significant reduction in the symptoms of phobia of height and darkness in this child, suggesting that large scale studies could be conducted to further validate the therapeutic modalities of Cognitive Drill Therapy. References: APA (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Publishing. Arya,B., Verma,S., & Kumar, R. (2017).Efficacy of Cognitive Drill Therapy in Treatment of Specific Phobia. SIS Journal of Projective Psychology and Mental Health, 24, 48-51. Choy,Y., Fyer,A. J., &Lipsitz, J.D. (2007).Treatment of specific phobia in adults. Clinical Psychology Review, 27, 266–286. Craske, M.,G., Kitcanski, K., Zelokowsky, M., Mystkowski, J., Chowdhury, N.& Baker, A. (2008). Optimizing inhibitory learning during exposure therapy. Behavior Research and Therapy, 46, 5–27. Dwivedi, S. & Kumar, R. (2015). Efficacy of Cognitive Drill Therapy in Agoraphobia with Panic Disorder: A Case Study. SIS Journal of Projective Psychology and Mental Health, 22, 139-146.

Foa, E.B., & McNally, R J. (1996).Mechanisms of change in exposure therapy. In M. Rapee (Ed.), Current controversies in the anxiety disorders (pp. 329- 343). New York: The Guilford Press. Jain, R. (2016) Cognitive Drill Therapy. ISBN-13: 978- 1539554219 Kessler, R.C., Berglund, P., Demler, O., Jin, R., & Walters, E.E. (2005). Lifetime prevalence and age-of-onset distributions of DSM-IV disorders in the national comorbidity survey replication. Archives of General Psychiatry, 62, 593–602. Kumar, R. Sameer, A., & Singh, B. (2012).Preliminary Test of Cognitive Drill as an Intervention. Indian Journal of Clinical Psychology. 39, 67-74 Kumar, R., & Dubey, B. L. (2016). Cognitive Drill Therapy: A Potent Application of the Principles of Psychology for OCD and Phobia. SIS Journal of Projective Psychology and Mental Health, 23(2), 125-126. Salkovskis, P. M. (1991). The importance of behaviour in the maintenance of anxiety and panic: A cognitive account. Behavioural Psychotherapy, 19, 6–19. Silverman, W.K., Pina, A.A., & Viswesvaran, C. (2008).Journal of Clinical Child & Adolescent Psychology, 37, 105-130). Wolitzky-Taylor, K. B., Horowitz, J. D., Powers, M. B., &Telch, M. J. (2008). Psychological approaches in the treatment of specific phobias: A metaanalysis. Clinical Psychology Review, 28, 1021– 1037. Zlomke, K., & Davis III, T. E. (2008). One-session treatment of specific phobias: A detailed description and review of treatment efficacy. Behavior Therapy, 39, 207–223. PRICE LIST OF SOMATIC INKBLOT SERIES SIS ID SIS Version Indian Users Foreign Users SIS-I: Card Form INR: 12000 US $200 SIS-II: Booklet Form INR: 12000 US $200 SIS-II: Video INR: 18000 US $300 SIS-I Video INR: 18000 US $300 SIS Living Images INR: 18000 US $300 All Versions INR: 60000 US $1000 Place Your Orders through Email to: Dr. Bankey L. Dubey, Ph.D., Director SIS Centre, 4406 Forrest Rd,Anchorage, AK 99517, Email: bldubey@gmail.com

The literature indicates that psychopathology of parents of ADHD is a crucial component of failure in the management of ADHD-affected children. The present study aimed to explore parental psychopathological indices in parents of children with ADHD to find out the reason of failure in management which promote psychopathology reciprocally, and frame some systematic intervention steps in parental education. Twenty diagnosed children with ADHD symptoms (5-12years) were studied from clinical centres, Lucknow (India). Children were rated by their parents on the basis of ADHD symptoms. The SIS-I was administered to these parents and result indicated high animal and anatomical response indicating lack of socialization, frustration and preoccupation to inner body parts thereby projecting somatic anxiety. Higher percentage of typical responses and human response denotes a balance between the personality and family pathology of parents of ADHD children. Parenting is the process of actively providing a safe, nurturing environment for the children. It requires flexibility to meet the unique needs of each child. Parenting a child with ADHD often brings special challenges. Children with ADHD may not respond well to typical parenting practices. Also, because ADHD tends to run in families, parents may as well have some problems with organization and maintaining consistency among themselves and thus need active coaching to learn these skills. Training can teach parents to respond appropriately to a child's most trying behaviors with calm disciplining techniques. Parents are the best judge to evaluate the improvement in behavior pattern of different kinds of problem behaviors. They should be given thorough training to train their own children. Basu & Deb (1996) observed that parental training significantly improved the behaviour of children with ADHD. Parents reported improvement in study habits and prosocial behaviour as well as in academic performance of their children during follow up sessions. Parents of ADHD children have reported higher levels of psychopathology and personality disorders than parents of normal control group children (Chazan et al. 2011). Chronis et al. (2006) reported a high percentage of mood disorders and anxiety disorder in parents and siblings of children with ADHD compared to the normal controls. Generally, it has been found that parents who have various forms of psychopathology (includingschizophrenia, depression, antisocial personality, personality disorder, and alcohol abuse or dependence) tend to have children who are at heightened risk for a wide range of developmental difficulties. The focus of most research in this area has been on mothers, but there is good evidence that disordered fathers also make significant contributions to child and adolescent psychopathology, especially to problems such as depression, conduct disorder, delinquency, and ADHD (Phares, et al. 2002). Although some of these effects undoubtedly have a genetic component, many researchers believe that genetic influences cannot account for all of the adverse effects that parental psychopathology has on children (Goodman & Gotlib, 2002; Sher et al. 2005). Researches revealed that mothers of children with ADHD experience higher levels of depressive symptomatology than do mothers of comparative non-ADHD children (Nigg & Hinshaw, 1998). Cunningham et al. (1988)

observed parental depression has been predicting family discord and behavior problems in children with ADHD. McDermut et al. (1997) suggested that if parents are depressed, and affected with distorted perceptions and cognitions and difficulties in communication, they may have problems with objective evaluations of child behavior, which would appear to increase the likelihood of conflictual and negative parent–child interactions. Because parents are often the primary informants about children’s emotional and behavioral disturbance, the possibility of depression-related distortions in perceptions of child behavior is important clinically as well as conceptually. Margari et al. (2013) investigated the possible etiopathogenetic role of ADHD symptoms and psychopathological disorders on parents of 50 children affected by ADHD and of 45 healthy children matched with respect to age and gender. Results revealed that parents of ADHD children have higher levels of ADHD symptoms, depressive disorders and depressive personality disorders than parents of healthy children. Mothers displayed greater presence of depression, while fathers showed problems concerning alcohol use. Johnston & Mash (2001) observed the presence of ADHD in children to be associated in varying degrees with disturbances in family and marital functioning, disrupted parent–child relationships, reduced parenting self-efficacy and increased levels of parenting stress and parental psychopathology, particularly when ADHD is comorbid with conduct problems. Children with ADHD often ignore parental requests, fight with siblings and peers and elicit negative reactions from authority figures. This is because parents of children with ADHD tend to be more controlling, disapproving and rejecting of their children, they give more verbal direction, repeated commands, verbal reprimands and correction than parents of children without ADHD; they are also less rewarding and responsive than parents of children without ADHD (Johnston &Mash, 2001; Kim & Yoo, 2012; Mano & Uno, 2007). Bornovalova et al. (2010) found parental mental illness to affect directly and indirectly on the development of the child affected by ADHD. Humphreys et al. (2012) also found parents of children with ADHD are at risk of experiencing more mental disorders than parents of children with typical development. High levels of parental ADHD symptoms might also intensify the negative parenting of children with ADHD and the arguing patterns of parent–child interactions (Ellis & Nigg, 2009). Kashdan et al. (2004) observed parental anxiety to be individually related to negative parenting practices with ADHD children. Vidair et al. (2011) found maternal depression to be closely associated with ADHD while the use of aggressive behavior and ADHD symptoms are present more in fathers than mothers. In particular, the mothers displayed greater presence of depression, while fathers showed problems concerning alcohol use. Steinhausen et al. (2013) conducted a study on four groups of parents (a) parents with a life long history of persistent ADHD (b) parents with current ADHD (c) parents with remitted ADHD and (d) parents with ADHD not present. They found that parents with lifelong persistent ADHD were most abnormal on all dimensions of ADHD psychopathology. Yousefia et al. (2011) compared parenting stress among mothers with ADHD children and normal children. Results revealed significant difference between parenting stress level and parenting styles in mothers of ADHD children and mothers of normal children. The above review indicates that psychopathology of parents of ADHD is a crucial component of failure in the management of ADHD-affected children. Thus intervention strategies are required to be administered not only on affected children but also on the parents who are their caregivers. Intervention again is required to be tailormade. This prompted the researcher to

explore individual differences in parenting practices (positive and negative) as well as the psychopathology of the affected group along with the temperamental measures of the children to frame appropriate intervention strategies for the clinical group. Objectives: To find out psychopathological indices in parents of children with ADHD. Sample: The sample consisted 20 parents of diagnosed ADHD children. The children registered in clinical centres viz Chetna, Aliganj and Parvarish, Niralanagar, Lucknow (India) were assessed with ADHD screening tool. The children who fulfilled the ADHD criteria of 35 for inattention and 50 for hyperactivity score were focused for the investigation. The parents accompanying the children served for the parent sample of study (N=20). Tools: The following standardized tools have been selected to achieve the above mentioned objectives. 1. ADHD Screening Tool (ADHD Information Library, 2009) – It consists of 37 items which cover symptomatic enquiry of 4 different areas namely, inattention, hyperactivity- impulsivity, rigid thinking, and academic performance. Every statement is to be rated by the caregivers on a five-point scale from ‘not at all’ (1) to ‘severe’ (5). 2. Somatic Inkblot Series (SIS - I) (Cassell, 1980): It was administered individually to each parent to hear the pain and inner cry, projected through somatic images (Cassel & Dubey, 2003). Procedure: Intervention Steps: Case Introduction:

The administrator prepared the personal data of the case with demographic details. Knowledge about ADHD: The administrator interacted with the parents to determine their depth of understanding about attention deficit hyperactivity disorder – issues related to how it develops, causative factors, techniques of managing and the consequences of the same were discussed with the parents, if not intervened earlier. Session 1: Rapport Establishment: The administrator got the consent form signed from the parents for intervention program. Parents were assured that it will be used only for research purpose and will be kept strictly confidential. They were asked to attend eight sessions in this program, each session being once a week with 45-60 minutes duration. Session 2: Learn to pay positive attention to your child: The administrator in this session differentiated the type of positive and negative attention patterns and promoted to pay only positive attention with verbal expressions (eg., super, great job, wow, beautiful, nice going, fantastic, I like it, excellent etc.) and nonverbal sign of approval (eg., hug, pat on the shoulder, smiling, a wink, a light kiss on cheek, rubbing hair, giving a thumbs up sign etc.). Enquiry was made to explore their patterns of attention and the parents were suggested to show their immediate approval. Session 3: Use your powerful attention to gain compliance: Parents were suggested to give specific instruction, provide immediate feedback as how well he is doing. Once it was finished, they were suggested to move on to the next step pointing out the small things that the child might take up next. Session 4: Give more effective commands: Parents were trained to rephrase the command. • Be sure actually what you want. • Don’t present the command as a question or favor. • Don’t give too many commands at a time. • Make sure that child is paying attention to you. • Reduce all distractions before giving the commands. • Ask the child to repeat the command. • Prepare the chore cards. • Set time limits. Session 5: Teach your child not to interrupt your activities: This step trained the parents to keep the child busy with some activity, such as coloring, playing with a toy, watching TV,

or cutting out pictures that the child felt interesting. Then parents were taught to take time out to observe the child, and praise him for staying away and not interrupting. Session 6: Set up a home-token system: In this session, Parents were trained to pair point system or edible things with compliance which can be encashed later for any form of good behavior or not interrupting work immediately after the completion of good work with a smile. Session 7: Learn to punish misbehavior constructively: It happens if the task is lengthy, boring, repetitive or tedious works/instruction to the ADHD child distracts attention. The task is to be designed in small pieces and presented in an interesting manner. Parents were warned not to fine excessively or too frequently. Session 8: Learn to manage your child in public places: • Set up the rules before entering the place. • Set up an incentive for the child for compliance. • Set up your punishment for non-compliance. • Assign any interesting and different activity. Termination and Follow up: Results: Table 1: Descriptive index showing four dimensions of ADHD in the children Groups Inattentivity Hyperactivity- Impulsivity Rigid Thinking Academic Performance Mean SD M SD M SD M SD Group I (N= 20) Diagnosed ADHD Group 38.60 6.73 52.20 7.14 29.00 5.43 26.95 3.10 Table 1 shows that diagnosed ADHD children are very high on inattentivity and hyperactivity –impulsivity dimension. They are poor on academic performance and have high rigid thinking. Table 2- Response percentages of Means and SDs of SIS indices and Mean ratings of pathological contents of Parents of ADHD diagnosed group SIS Indices Group I (N=20) % Mean SD Total Number of Response 49.05 20.29 Human Responses 5.35 7.72 Animal Responses 10.85 16.00 Anatomical Responses 9.35 15.45 Sex Responses 1.20 6.14 Movement Responses 3.40 5.50 Most Typical Response 4.10 5.99 Typical Responses 9.48 Atypical Responses 2.95 5.36 Rejection Response 8.11 Pathological Contents: Mean Ratings SD Pathological Anatomy (PAS) 4.51 Depression (D) 0.25 1.22 Hostility & Aggression (HAS) Paranoia (P) 0.90 2.15 Table 2 depicts percentage of means of SIS indices and mean ratings of pathological contents of SIS administered on parents of ADHD. High animal and anatomical response (10.85 and 9.35 respectively) indicates the

presence of psychopathological prominence as well as high anatomical response which is partially affected with pathological anatomy. A percentage mean of typical responses (M=6.0) along with presence of low ratings (M=0.90) of paranoid ideation indicates that the family pathology of the affected caregivers is not totally absent. Failure in proper training of ADHD children indicates the requirement of specific parental education to the parents of such children. Discussion: The literature supports strongly the genetic component for the occurrence of ADHD symptoms in children. Wang et al. (2012) reported that there may be a parent of origin effect for ADHD candidate genes. Although some of these effects undoubtedly have a genetic component, many researchers believe that genetic influences cannot account for all of the adverse effects that parental psychopathology has on children (Goodman &Gotlib, 2002; Sher, et al. 2005). Buschgens et al. (2010) found severity of ADHD symptoms and the presence of comorbidity to be linked to increase in family conflict, reduced family cohesion and an authoritarian and punitive parenting style. They also investigated that relationship between parental psychopathology and ADHD symptoms in children is complex and appears to influence each other, hence triggering a cycle of cause-and-effect that characterizes the entire family system. McDermut et al. (1997) suggested that if a parent is depressed, having distorted perceptions and cognitions and with difficulties in communication, he/she may have problems with objective evaluations of child behaviour, which would appear to increase the likelihood of conflictual and negative parent–child interactions. Because parents are often the primary informants about children’s emotional and behavioral disturbance, the possibility of depression-related distortions in perceptions of child behavior is important clinically as well as conceptually. Chronis et al. (2006) investigated the role of parent psychopathology and observed parent–child interactions on the development of conduct problems in children with ADHD over early childhood. They concluded that both maternal depression and parenting during early childhood (i.e. observed praise and positive affect) were unique predictors of the developmental course of conduct problems. Summary and Conclusion: Either absence or very limited pathological contents (except more than average in two cases) indicate no adverse effect on the personality of caregivers of ADHD group. However, low human responses and high animal responses indicate lack of socialization, regressive tendency, impulsive behavior and frustration among the parents. High anatomical responses reflect bodily preoccupation and anxiety, which might be the effect of constant care of the children. An intervention step by assessing the potential of success of such parents can be provided to the group. References: ADHD Information Library (2009). A Pretty Good ADHD Screening Tool Retrieved March 18, 2009 from http://newideas.net./pdf/adhd-test-screening.pdf. Basu, S., & Deb, A. (1996). Parent training in children with ADHD: An integrated approach for greater effectiveness. Indian Journal of Clinical Psychology, 23, 184-191. Bornovalova, M. A., Hicks, B. M., Iacono, W. G., &McGue, M. (2010).Familial transmission and heritability of childhood disruptive disorders. The American Journal of Psychiatry, 167, 1066–1074. Buschgens, C. J., van Aken, M. A., Swinkels, S. H., Ormel, J., Verhulst, F. C., & Buitelaar, J. K. (2010). Externalizing behaviors in preadolescents: Familial risk to externalizing behaviors and perceived parenting styles. European Child and Adolescent Psychiatry, 19, 567–575. Cassell, W, A. & Dubey, B. L. (2003).Interpreting Inner World through Somatic Imagery: Manual of Somatic Inkblot Series. Anchorage (USA): SIS Center. Cassell, W.A. (1980). Body Symbolism and the Somatic Inkblot Series. Alaska: Aurora Publication.

Chazan, R., Borowski, C., Pianca, T., Ludwig, H., Rohde, L. A., & Polanczyk, G. (2011). Do phenotypic characteristics, parental psychopathology, family functioning, and environmental stressors have a role in the response to methylphenidate in children with attention deficit/hyperactivity disorder? A naturalistic study from a developing country. Journal of Clinical Psychopharmacology, 31, 309–317. Chronis, A. M., Gamble, S. A., Roberts, J. E., & Pelham, W. E., Jr. (2006). Cognitive behavioral depression treatment for mothers of children with attention-deficit hyperactivity disorder. Behavior Therapy, 37, 143–158. Chronis, A. M., Jones, H. A., & Raggi, V. L. (2006).Evidence-based psychosocial treatments for children and adolescents with attentiondeficit/hyperactivity disorder. Clinical Psychology Review, 26, 486–502. Cunningham, C. E., Benness, B. B., & Siegel, L. S. (1988). Family functioning, time allocation, and parental depression in the families of normal and ADDH children. Journal of Clinical Child Psychology, 17, 169–177. Ellis, B., &Nigg, J. (2009). Parenting practices and attention-deficit/hyperactivity disorder: New findings suggest partial specificity of effects. Journal of American Academy of Child Adolescent Psychiatry, 48, 146–154. Goodman, S.H., & Gotlib, I.H. (2002). Children of depressed parents: Mechanisms of risk and implications for treatment Washington, D.C.: American Psychological Association. Humphreys, K. L., Mehta, N., & Lee, S. S. (2012). Association of parental ADHD and depression with externalizing and internalizing dimensions of child psychopathology. Journal of Attention Disorders, 16, 267–275. Johnston, C., & Mash, E. J. (2001). Families of children with attention deficit hyperactivity disorder: Review and recommendations for future research. Clinical Child and Family Psychology Review, 4, 183–207. Kashdan, T. B., Jacob, R. G., Pellhem, W. E., Lang, A. R., Hoza, B., &Blumenthal, J. D. (2004). Depression and anxiety in parents of children with ADHD and varying levels of oppositional defiant behaviors: Modeling relationships with family functioning. Journal of American Academy of Child Adolescent Psychiatry, 33, 169– 181. Kim, D. H., &Yoo, I. Y. (2012). Relationship between attention deficit hyperactive disorder symptoms and perceived parenting practices of school-age children. Journal of Clinical Nursing http://dx.doi.org/10.1111/j.1365- 2702.2012.04343.x in press. Mano, S., & Uno, H. (2007).Relationship between characteristic behaviors of children with ADHD and mothers’ parenting styles.No to Hattatsu. Brain and Development, 39, 19–24. Margari, F., Craig, F., Petruzzelli, M.G., Lamanna, A., Matera, E., & Margari, L. (2013).Parents psychopathology of children with attention deficit hyperactivity disorder. Research in Developmental Disabilities, 34, 1036–1043. McDermut, J. F., Haaga, D. A. F., &Bilek, L. A. (1997).Cognitive bias and irrational beliefs in major depression and dysphoria. Cognitive Therapy and Research, 21, 459–476. Nigg, J. T., & Hinshaw, S. P. (1998). Parent personality traits & psychopathology associated with antisocial behaviors in childhood attention-deficit hyperactivity disorder. Journal of Child Psychology, Psychiatry and Allied Disciplines, 39, 145–159. Pershad, D. & Dubey, B. L. (1994).Relaibility and validity of SIS in India. SIS Journal of Projective Psychology and Mental Health, 1, 33-38. Phares, V., Duhig, A.M., & Watkins, M.M. (2002). Family context: Fathers and other supports. In S. H. Goodman & I. H. Gotlib (Eds.), Children of depressed parents: Alternative pathways to risk for psychopathology (pp. 203-225). Washington, D.C.: American Psychological Association. Sher, K. J., Grekin, E. R., & Williams, N. A. (2005). The development of alcohol use disorders. Annual Review of Clinical Psychology, 1, 493-523. Steinhausen, H.C., Julia Göllner, J., Daniel Brandeis, D., Müller, U. C., Valko, L., & Drechsler, R. (2013).Psychopathology and Personality in Parents of Children with ADHD. Journal of Attention Disorders, 17, 38–46. Verma, S. K., Pershad, D., Kaur, R., & Nehra, R. (1995).Diagnostic significance of SIS II. SIS Journal of Projective Psychology and Mental Health, 2, 72-76. Vidair, H. B., Reyes, J. A., Shen, S., Parrilla-Escobar, M. A., Heleniak, C. M., & Hollin, I. L. (2011). Screening parents during child evaluations: Exploring parent and child psychopathology in the same clinic. Journal of the American Academy of Child and Adolescent Psychiatry, 50, 441–450. Wang, K. S., Liu, X., Zhang, Q., Aragam, N., & Pan, Y. (2012).Parent-of-origin effects of FAS and PDLIM1 in attention-deficit hyperactivity disorder. Journal of Psychiatry and Neuroscience, 37, 46– 52. Yousefia, S., Far, A. S., & Abdolahian, E. (2011). Parenting stress and parenting styles in mothers of ADHD with mothers of normal children. Procedia - Social and Behavioral Sciences, 30, 1666 –1671.

was treated with Cognitive Drill Therapy. Following outcome measures were used to map the status of illness anxiety on baseline, termination and follow up. (i) Sheehan Patient Rated Anxiety Scale (ii) Health Anxiety Questionnaire and (iii) Overall anxiety severity and impairment scale. The results revealed a significant reduction on all three outcome measures which were maintained on follow up. A person with Illness Anxiety Disorder (IAD) presents with excessive concern about having or developing a serious and undiagnosed general medical disease. According to DSM-5 (American Psychiatric Association, 2013) in IAD, there is a preoccupation with having or acquiring a serious illness. There is an absence of somatic symptoms and if present they are of mild intensity. The individual has high levels of anxiety about health and performs excessive health-related behaviors of repeated checking of body for signs of illness and may exhibit maladaptive avoidance of hospitals. The excessive concern about illness persists despite negative findings on appropriate physical examination and laboratory investigations. Cognitive behavioral theorists (Salkovskis & Warwick, 1986; Thibodeauet al., 2013) implicated core cognitive and behavioral features in illness anxiety disorders. The individuals with IAD hold a disease conviction and perceive apparently harmless bodily sensations as indicative of serious disease. They may hold dysfunctional beliefs such as that medical practitioner might have missed something vital in their assessment; there might be errors in laboratory findings and medical investigations. They remain preoccupied with diseases and adopt safety behaviors such as repeated checking of their body for presence of abnormal sensations and changes, doing some of the assessments by their own such as repeated checking with blood pressure instruments, repeated investigations of blood samples, electro-cardiogram, using different laboratories for investigations to rule out the probabilities of errors in specific laboratory, avoiding cues such as specialty hospitals, discussions, pictures and discussions related to the specific disease conviction, seeking repeated reassurance from medical professionals, self-prescribed investigations, browsing internet and youtube for signs, symptoms and treatment of specific disease. These investigations and reassurance may provide fleeting relief to the individual and the disease conviction and the anxiety continue to exist. These safety behaviors and the resultant transient relief strengthen and maintains the dysfunctional beliefs and associated distress and imposes limitations in functional capacities of affected individuals (Haenen et al., 2000; Warwick & Salkovskis, 1990). Cognitive Drill Therapy (CDT) is a form of exposure treatment that heavily relies on verbal exposure of imagined feared consequences which are found in the conditions of irrational fears such as phobia and OCD (Jain, 2016; Kumar, 2017a; Kumar, 2017b; Kumar, Sameer & Singh 2012). Cognitive Drill Therapy has been found useful in Obsessive-Compulsive Disorder (Bhutani & Singh, 2017; Kumar et al. 2012), a female with panic disorder and agoraphobia (Dwivedi, & Kumar, 2015), specific phobia (Arya, Verma & Kumar, 2017), multiple-phobia (Verma et al. 2018). It is being studied in conditions of specific phobia, social anxiety, agoraphobia and Obsessive-Compulsive Disorder including illness anxiety disorder.

Objective: In the case being reported here, the role of Cognitive Drill Therapy was explored in illness anxiety disorder. Case Summary: Mr. AP, a 37 year old, married, Hindu male was suffering from illness anxiety since last one and half years. The symptom of anxiety started after a small growth on his neck for which biopsy was done with negative results, to rule out Cancer. Physiotherapy and other pharmacological intervention helped him to recover from the side-effects of biopsy. Postsurgical procedure, he increasingly became aware of the possibility of developing cancer and began to check his body for possibilities of developing this disease. He also identified hardening of small muscle tissue for about one year for which he used to get scared for the repetitive medical procedure as it was too painful and reminded him the possibility of developing the actual disease. He reported that before surgery he was fine and his body image was OK. After surgery he got shocked to experience the quantum of surgery and the whole procedure. He was perturbed postsurgery even in hospital and wished if there were someone would could listen to his emotional distress and suffering. He had developed sadness and anxiety and no psychological support was available to him. He met the DSM-5 diagnostic criteria for illness anxiety disorder, care-avoidant type. He remained fearful and was preoccupied with the possibility of developing cancer. He would avoid any cues associated with cancer such as posts on social media, persons having this disease, specialty hospitals for cancer and the like. This gradually affected his quality of life, relationship with others and occupational involvement. Apart from illness anxiety for cancer, he had severe anxiety for fear of heart attack too which was triggered by sensations, heaviness, pain in cardiac region and abdomen distress. He would avoid topics of heart attack and any reminder cue which could produce these sensations. Design: A single case pre-post and follow up method was used. Only one illness anxiety for cancer was targeted primarily to demonstrate whether CDT helps in combating illness anxiety and secondly to see if the therapeutic gains spills over onto other non-targeted symptoms. This arrangement of intervention was expected to help in determining specificity and generalizability of acquired gains if any. Outcome Measures: His anxiety level were assessed on following outcome measures (1) Sheehan Patient Rated Anxiety Scale (Sheehan, 1983) (2) Health Anxiety Questionnaire (Lucock & Morley, 1996) (3) Overall Anxiety Severity and Impairment Scale (Campbell-Sills et al. 2009). OBSD Analysis: OBSD analysis as per the protocol of Cognitive Drill Therapy (Jain, 2016) was conducted. It consists of Objects of fear (O), Body-Mind Reactions elicited by an exposure to objects of fear (B), Safety Behaviors (S) consists of avoidance behaviors and Danger Ideation (D) refers to the threatening appraisal of the feared cues. The objects of his illness anxiety for cancer consisted of following cues – attention to the scars of surgery, attention to hardened tissue in neck, accidental touching of hardened tissue, pictures and posts on whatsapp and youtube related to cancer, news in print and electronic media on cancer, discussions on the topics related to cancer, exposure to any person having cancer, specialty hospitals for cancer, mere listening to the word cancer, memory retrieval of surgical procedure and so on. Exposure to these objects of anxiety elicited sympathetic arousal and fearfulness in him. For safety behaviors he would avoid exposure to the objects of anxiety as far as possible; and accidental exposure will trigger anxiety in him that may continue for several hours and

triggers preoccupations of developing this disease. The danger probability consisted of fear of developing actual disease, fear of suffering due to disease and surgical procedures. Psychoeducation: The Cognitive Drill Treatment was initiated for his illness anxiety for cancer. He had been educated on OBSD components as identified above. The importance of feared cognition in the form of danger probability was emphasized as the primary maintaining factor for anxiety. Also, during the course of treatment, his ideas for medical investigations for hardened tissue in the neck were explored. He was not at all ready and refuted that there is no non-invasive procedure to detect the same. Again he would pass through the same painful surgery experience. He continued CDT treatment as is without contemplating any further investigations. We were firm in our recommendations for the medical investigations for the unexplained hardening. He was thoroughly educated on OBSD components and made him aware that external cues such as hospitals, social media posts, and topics of cancer direct his attention to body sensations, scars and hardened tissues which in turn trigger feared cognition that he might develop cancer. This threat perception further elicits sympathetic arousal and anxiety symptoms for which he sought safety behaviors in the form of avoidance of external feared cues. Psychoeducation also consisted of communicating a natural probability of developing any fatal disease in general population irrespective of illness anxiety for any specific disease. Any person in the population can develop a disease due to pathophysiological process whether he/she is scared or not. Getting scared does not alter the probability of developing the disease. A person with illness anxiety and a person without illness anxiety could develop a specific disease. So, our task was to normalize the fear associated with specific disease anxiety for cancer. Also, it was explained that we would be using verbal exposure systematically which will initially elicit fear reaction and with continued exposure there would be reductions in the magnitude of anxiety. This typically follows an anxiety curve in which the anxiety would escalate rapidly with each exposure and decline gradually. By using exposure in this manner, both external and internal feared cues would cease to elicit anxiety response. He would be required to bear some amount of anxiety activation during the process. A timeframe of about sessions was communicated with the caveat that if required more sessions could also be conducted. Also, it was told to him that we would be teaching him in our sessions how to implement exposure and he would be required to practice the exposure in his real life as home work. Cognitive Drill Statements: Based upon his OBSD analysis, following sample cognitive drill statements were formulated for his ‘imagined feared consequences’. The core concepts of drill dilution, emotionally charged key words and conversion of time reference in ‘imagined feared consequences’ were used for formulation of cognitive drill statements. 1. Extra-growth in the body 2. I have developed Extra-growth. 3. I am repeating, I had extra-growth 4. Cancer 5. I have developed cancer Cognitive Drill Protocol: Since he was having severe distress and avoidance of cancer related cues, maximum drill dilution was used to implement cognitive drill for him. Initially, the therapist modeled all the statements and he was just required to listen to the cognitive drill statements drilled by the therapist. Mere listening to the cognitive drill statements elicited severe bodymind reactions (BMR) in him which were managed by appropriate pauses for a few seconds. Moment to moment, BMR ratings were obtained. Upon escalation of BMR at

high or very high level, pauses were implemented. In due course of treatment, he began to listen to the therapist’s statements with little BMR. He realized that this method could result in reduction of distress and anxiety associated with feared cues of cancer. Gradually, he began to own and repeat the drill statements. Initially, the drill statements were mechanically repeated by him. When habituation occurred, he was asked to imagine the feared cues as vividly as possible and continue the drill. He continued the drill and at times there were surges in streams of experiences and mental images triggered by cognitive drill. He was required to allow the flow of imaginations and memories without any judgment. He had to be re-assured that the process is normal and it does happen during cognitive drill. The feared memories and emotions associated with feared cues got activated and flowed like a stream in the consciousness. Pauses were also implemented when plateau were observed in the anxiety response. During pauses either silence were maintained or he was asked to allow his mind to wonder at its own pace. Homework: Drill-Daring and Distraction were recommended as homework. He was encouraged to design his own exposure to the feared cues in his environment like hospitals, news, social media posts etc with the support of sub-vocal drill on the spot. Also, he was encouraged to continue his work whatever he wanted to do and any pending work which he had made contingent upon recovery from this illness anxiety. He complied with homework assignments and continued to expose himself as prescribed. No. of Sessions and Follow up: Nine sessions of Cognitive Drill were conducted. Each session lasted for about 60 minutes. He had significant reduction in his illness anxiety for cancer and follow up session was scheduled at three months. Results: To assess within session habituation, frequent BMR ratings were obtained from him for the drill statements. Sample BMR ratings over time within sessions are displayed in following figures. The scores on three outcome measures at baseline, termination and follow up are displayed in following figures Time BMR Rating (SUD) Figure-1: Drill Statment: Growth in the Body Tim e BMR Rating (SUD) Figure-2: Drill Statement: Cancer Baseline assessment Post assessment Follow Up S c o r e s S c o r e s Figure-3: Sheehan Patient Rated Anxiety Scale

Discussion: The results suggested that on three outcome measures (1) Sheehan Patient Rated Anxiety Scale(2) Health Anxiety Questionnaire(3) Overall Anxiety Severity and Impairment Scale, his scores decreased significantly which further were either maintained or even further reduced on follow up sessions suggestive of the effectiveness of Cognitive Drill Therapy in illness anxiety disorder. The results are in agreement with other case studies of stimulus bound anxiety treated with CDT (Arya et al. 2017; Bhutani & Singh, 2017; Dwivedi & Kumar, 2015; Kumar et al. 2012; Verma et al. 2017). There are specific and identified components in Cognitive Drill Therapy which can be implicated to attribute the therapeutic gains. (i) OBSD analysis helps in exact conceptualization of underlying structure in stimulus bound anxiety. During the condition of anxiety, a patient usually attributes his problems to feared cues and engages in safety behaviors. A psychoeducation through OBSD analysis leads to cognitive restructuring which facilitate re-attribution of the problem to feared cognition which conforms to the theoretical framework of cognitive theories. There is a shift from dealing with feared cues to the feared cognition. (ii) Feared cues and stimuli act as conditioned stimuli in the perspective of classical conditioning paradigm and through the process of generalization a number of stimuli become associated with fear reaction based on the principle of similarity. The feared cues elicit psycho-physiological response and the fear emotion. Repetitions through cognitive drill leads to ‘experiential realization’ that feared cues are not associated with feared outcomes which results in extinction of fear response associated with conditioned stimuli. (iii) Words representing the fearful emotional state are considered as higher order conditioned stimuli. Repeated verbal exposure of conditioned words also results in dissociation of acquired connections between words and psycho-physiological/ fear emotional response. (iv)Cognitive Drill Therapy provides a unique opportunity for controlled and systematic presentation of feared cues through Drill Dilution. For example, ‘I have developed’; ‘Cancer’ can be presented in fragments, with slow pace, can be intercepted by pauses, can be modeled by a therapist and so on. The fear activation can be efficiently managed depending upon the emotional reactivity of the patient so that the task becomes less overwhelming and manageable on the part of the patient. (v) Drill, Daring and Distraction capture the essence of generalization to real life settings which also facilitate maintenance of acquired therapeutic gains. (vi) A change in time reference in cognitive drill statements is also hypothesized to hasten the process of Baseline assessment Post assessment Follow up S c o r e s Figure-4: Health Anxiety Questionnaire Baseline assessment Post assessment Follow up S c o r e s Figure-5: Overall Anxiety Severity and Impairment Scale (OASIS)

extinction and experiential realization of the falsity in the predictability of feared consequences. (vii) An inbuilt component of response prevention. When verbal exposure is implemented, a patient may display avoidance behaviors by avoiding eye contact, turning face to other side, tilting backward, and the like but quickly regains tolerance for listening and speaking the drill statements addressing feared cues and feared cognition. Elimination of safety behaviors eliminate negative reinforcement which are conceptualized as maintaining factor in the perspective of operant conditioning. There are other concepts too which would need be investigated through future researches to properly understand the mechanisms of action involved in verbal exposure. Comparative researches are needed to establish the relative efficacy of verbal exposure compared to other treatments such as Cognitive-Behavior Therapy. References: American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (5th Ed.). Washington, DC: Author Bhutani, B & Singh, S. (2017) Application of Cognitive Drill Therapy to ERP in Obsessive Compulsive Disorder: A Case Study. Paper Presented in ICCBI 2017, AIIMS, New Delhi. Campbell-Sills, L., Norman, S. B., Craske, M. G., Sullivan, G., Lang, A. J., Chavira, D. A., Stein, M. B. (2009). Validation of a Brief Measure of Anxiety-Related Severity and Impairment: The Overall Anxiety Severity and Impairment Scale (OASIS). Journal of Affective Disorders, 112(1-3), 92–10 Dwivedi, S., & Kumar, R. (2015). Efficacy of Cognitive Drill Therapy in Agoraphobia with Panic Disorder: A Case Study. SIS J.Proj.Psy.& Mental Health, 22(2), 150-157 Haenen, M.A., de Jong, P. J., Schmidt, A. J., Stevens, S., &Visser, L. (2000). Hypochondriacs' estimation of negative outcomes: Domain-specificity and responsiveness to reassuring and alarming information. Behaviour Research and Therapy, 38(8), 819–833. Jain, R. (2016) Cognitive Drill Therapy. ISBN-13:978- 1539554219 Kumar R (2017b) Verbal Exposure for Irrational Fears: New Directions in Research and Applications. Clinical and Experimental Psychology 3: 157. doi: 10.4172/2471-2701.1000157 Kumar, R. (2017a) HN Murthy Oration: Experiences in Verbal Exposure for Stimulus Bound Anxiety. Indian J. of Clinical Psychology, 44 (1), 14-20 Kumar, R. Sameer, A., & Singh, B. (2012).Preliminary Test of Cognitive Drill as an Intervention. Indian Journal of Clinical Psychology, 39, 67-74. Lucock MP, Morley S.(1996) The Health anxiety questionnaire. British J.of Health Psych,1,137–50 S. Verma., A., Bhavna.,& Kumar, R.(2017) . Efficacy of Cognitive Drill Therapy in Treatment of Specific Phobia: A Case Study. SIS J. of Projective Psychology and Mental Health, 24(1), 48-51. Salkovskis, P.M., & Warwick, H. M. (1986). Morbid preoccupations, health anxiety and reassurance: A cognitive–behavioural approach to hypochondriasis. Behaviour Research and Therapy, 24(5), 597–602. Sheehan, D. V.(1983).The anxiety disease. Scribners, NY Thibodeau, M.A., Asmundson, G. J. G., & Taylor, S. (2013). Health anxiety. In G. Simos,& S. Hofmann (Eds.), CBT of anxiety disorders: A practitioner book (pp. 135–160). New York: Wiley Verma, S., Arya, B., Kandhar, N. & Kumar, R. (2018): Efficacy of Cognitive Drill Therapy in Treatment of Multiple Phobias: A Case Study. SIS J.Proj.Psy. & Mental Health, 25, 76-79 Warwick,H.M.,& Salkovskis,P.M. (1990).Hypochondriasis. Behaviour Research and Therapy, 28(2), 105– 117. 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

Social definition and self definition are implicit personality styles in which individuals either adopt or may not conform to societal norms when defining their identity, respectively. The content validity of the scoring categories for this thematic apperceptive technique (TAT) scoring system suggests that self-defining people‘s worldview are causally organized and reason-driven, whereas the socially defined worldview includes random events, ineffectual actors, and mental-state preoccupations. One‘s implicit style may predict life directions, shape one‘s ability to cope, and be related to the types of interpersonal problems one encounters. The Inventory of Interpersonal Problems Circumplex Scales (IIP-C) were designed to describe the types of interpersonal problems one tends to encounter, organized around two orthogonal axes: Dominant-Nonassertive and Self-Sacrificing-Cold, with eight subscales arranged in octants. The bidirectional self-defining versus socially defined scale score was correlated positively with self-reported Domineering problems and negatively with Socially-Inhibited problems. These findings suggest that at the maladaptive extremes of the self-defining versus socially defined continuum, characteristic interpersonal concerns are excessive dominance and interpersonal avoidance, respectively. The way one goes about defining oneself and making decisions has the potential to shape the life course one chooses, as well as one‘s experiences along that path. Some people define themselves and their choices based on their own internal values, attitudes, or ideals, whereas others look to the worldview of a social or cultural group. The former, referred to as ‗self-defining‘ individuals, are distinct from the latter, who consciously or unconsciously adopt the values or prescribed behavior of their social group (i.e., those described as ‗socially defined‘). When pressed to conform to stereotypes assigned to their cultural group, socially defined persons are more likely to adopt features of these external definitions; self-defining persons more often adhere to their own preferences as guides for their life decisions. These contrasting styles, originally measured by Stewart and Winter (1974), are based on John Paul Sartre‘s (1948) writing on identity development in Jewish individuals within the context of anti-Semitic societal norms. Stewart and Winter also credited Simone de Beauvoir‘s (1949) ideas on women‘s identity development, given the limited ‗acceptable‘ roles that society afforded European-heritage women at the time. Each philosopher noted that those placed under social constraints could either choose to form identities within the bounds afforded to them by society, or they could resist these constraints on identity. To study the spontaneous organization of identity under real-life conditions, a less constraining measurement method was needed, so Stewart and Winter (1974) chose a thematic apperceptive technique (TAT), used pictures to elicit stories from their participants, and derived the Self Definition and Social Definition Scoring System empirically. The present study extends this literature into the clinical realm by exploring whether self-defining and socially defined individuals report different patterns of interpersonal problems. The sections that follow describe first, the previous research on the self-definition-social definition dimension, then the circumplex model of interpersonal problems, and finally the rationale for the present study.

Self/Social definition and interpersonal problems: 93 Self- Definition and Social Definition: Much of the research on the self-definingsocially defined dimension has been related to women‘s career paths because in the United States in the 1970s, many middle-class American women were seeking higher education and paid employment during a time when gender-role norms dictated they should be full-time stay-at-home wives and mothers. These women‘s career choices and aspirations provided insight into how readily they were willing to conform to these societal expectations. Those who chose stereotypically ‗male‘ careers (e.g., careers in the physical or social sciences) were actively choosing their own path despite societal prescriptions for ‗appropriate‘ female careers. This initial and subsequent research suggested that women who are self-defining are distinct from those who are socially defined in many respects, including preference for autonomy, instrumental problem solving orientation, understanding of social situations (both cognitive and emotional), and underlying fears (Jenkins, 1996; Stewart & Winter, 1974). Studies of men have similarly identified self-defining men as resistant to gender-role constraints, while socially defined men prefer traditional masculine role behavior (reviewed in Stewart, 1992a). Several studies have shown theory-consistent differences between self-defining and socially defined people‘s career aspirations and behavior, coping styles, and internal experiences as well as interpersonal concerns. In terms of career aspirations and individual autonomy, self-defining individuals tend to prefer autonomous working conditions, and their career aspirations are more likely to differ from what society expects from their gender. For example, in the 1960s and 1970s, self-defining American women were more likely to aspire to (and actually pursue) careers in traditionally male-dominated careers than were women who were socially defined (Stewart & Winter, 1974). Jenkins (1982) found that self-defining women in their senior year of college in 1967 tended to have career aspirations that mirrored their own desires for achievement, rather than reflecting others‘ support for their choices or suitability with traditional gender roles. Socially defined women, however, were more likely to follow career paths that were supported by important people in their lives and were in line with feminine role norms (Jenkins, 1982). Thus, self-defining women are more willing to break from societal norms to pursue their own career interests than are socially defined women. Self-defining men are also more willing than their socially defined peers to engage in behavior that varies from societal gender expectations. In a longitudinal study, selfdefining men were more likely to value intrinsic satisfaction in their jobs such as liking the work, whereas socially defined men valued extrinsic aspects such as income, convenient hours, job security, and leisure time (Tse et al., 2012). Self-defining men were more likely to have wives with non-traditional careers (Winter, Stewart, & McClelland, 1977). Both men and women who were selfdefining reported feeling less conflict between their family and career roles than did those who were socially defined (Jenkins, 1996; Winter, Stewart, & McClelland, 1977), perhaps because self-defining adults of both genders are more psychologically minded than their socially defined counterparts (Wright, et al. 2012). Although these styles seem related to career preferences, they might not predict career success, which depends also on the demand characteristics of the work situation. Rehfuss and Borges (2006) explained that in medicine, both selfdirected and other-directed occupational choices can lead to success, although by different routes. The research has also revealed differences in coping style amongst those with different definitional styles (Stewart, 1978). In Stewart‘s study, women who were self-defining tended to see themselves as capable of finding solutions to their problems and able to take effective action towards resolution. Women who were socially-defined tended not to take

instrumental action to solve problems, perhaps because they were more likely to see themselves as part of the problem, whereas self-defining women saw problems as external to themselves but solutions as within themselves. Both Stewart (1980) and Jenkins (1996) found that self -definition was significantly correlated with successful negotiation of conflicting family and work life demands. Thus, self-defining individuals appear better equipped to use their understanding of how problems arise to problem-solve effectively, whereas socially defined people may not organize their understanding of problems sufficiently to formulate and act on appropriate solutions. This orientation concerning instrumental action might have implications for interpersonal kinds of problems. Definitional style appears to influence how one navigates interpersonal situations in relation to one‘s cognitive and emotional experiences (Jenkins, 1996; Stewart & Winter, 1974). Chester (1981) reported that selfdefining women were more likely to describe themselves in ways that contrasted with the traditional other-directed femininity seen in socially defined women‘s self-descriptions. According to Jenkins (1996), self-defining women tend to engage with others in a way that buffers them from the impact of social pressure. For example, they may start groups or organizations, or take leadership roles in order to shape their social environment rather than be governed by it. However, Stewart & Winter (1974) noted that self-defining women when listing their secret fears more often mentioned social problems, social isolation, and that others might discover their (feared) dependency and inferiority. Although there may be benefits of crafting one‘s identity on the basis of one‘s own morals, values, and ideals, if one‘s values are distinct enough from the values and expectations of the social group, they may well lead to isolation. In contrast, by conforming to the roles society expects of them, socially defined people may be less likely to face social rejection. However, socially-defined women reported fears of, among other things, others‘ actions toward or opinions of themselves, including being rejected by romantic partners. These women also reported keeping secret their tabooed feelings such as hostility (Stewart & Winter, 1974). The distinct fears and secrets of those with different definitional styles might impact the interpersonal problems each group experiences. For example, perhaps harboring secret feelings of dependency would result in different interpersonal concerns than those caused by secret hostile feelings. Thus, understanding the relationship between definitional style and interpersonal concerns may benefit our conceptualization of how personality impacts one‘s interpersonal problems. In summary, self-defining people are more likely to describe themselves in ways that are not congruent with external role expectations, and they are likely to pursue careers that they desire, regardless of whether those careers are seen as traditionally appropriate for their gender. Socially-defined people, by contrast, seem primed to adopt societal norms for their gender role, and their career aspirations and self-descriptions reflect this adoption. These differential responses to social norms, along with their fears and secrets, suggest that these individuals might report different kinds of interpersonal problems. A Circumplex Model of Interpersonal Problems: In 1957, Timothy Leary introduced his theory of personality and how it relates to interpersonal functioning. He proposed that personality styles exist along a continuum from more to less functional, and these personality styles could be summed up in a circumplex model with two axes: Domineering versus Nonassertive and Cold versus Self- Sacrificing. Leary also argues that one‘s personality operates within a broader social context and that one‘s character and one‘s social situation cannot be disentangled. Thus, the psychological problems an individual has can be understood in terms of their

Self/Social definition and interpersonal problems: 95 interpersonal behavior. For example, depression may be conceptualized as the result of social isolation or withdrawal and the belief that rejection by others is inevitable. The modern day circumflex is based on Leary‘s two axes (Alden, Wiggins, & Pincus, 1990). Individuals scoring near the extreme on Domineering may tend to be too interpersonally forceful or aggressive, whereas those who are strongly Nonassertive are likely too passive or accommodating of others. Likewise, those at the extreme Cold end of functioning likely have difficulty establishing emotional closeness with others, whereas those who are Self-Sacrificing tend to try to please people even at the expense of their own emotional needs. The original Inventory of Interpersonal Problems (IIP) was a self-report inventory that was designed to measure changes in interpersonal function (or dysfunction) over the course of therapy (Horowitz, et al. 1998). The circumplex version (IIP-C; Alden, Wiggins, & Pincus, 1990) built upon Leary‘s foundation by selecting 64 items organized into eight scales, four of which are on the two above-mentioned axes (Domineering, Nonassertive, Cold, and Self-Sacrificing). The other four are as follows: The Vindictive scale measures characteristics that are both Cold and Domineering; those who are high on Vindictiveness tend to be aggressive, distrusting, and unempathetic towards others. Those high on the Socially-Inhibited scale tend to be socially anxious, as Socially- Inhibited combines Cold and Nonassertive descriptors. Individuals who score high on the Intrusive scale may be seen as ‗aggressively‘ warm (combining Domineering and Self- Sacrificing). Lastly, the Exploitable scale shares both Self-Sacrificing and Nonassertive characteristics. These individuals may be too trusting of others. The IIP-C provides insight regarding an individuals‘ unique profile of the interpersonal problems they experience in terms of eight scales organized on the axes of Domineering versus Nonassertive and Cold versus Self- Sacrificing. These two axes enumerate problems related to assertiveness over others and connectivity to others, respectively. Given Leary‘s (1957) conceptual association between individual character and social context, interpersonal problems and definitional style may be intertwined. The Present Study: The purpose of the current study was to determine whether there is a relationship between one‘s definitional style and selfreported interpersonal problems. We hypothesized that the self-definition versus social definition dimension would correlate positively with the IIP-C Dominance scale and negatively with the Non-Assertive scale. Logically, perceiving one‘s behavior as a problem is a two-step process. First, one must do the behavior, at least sometimes; and only then can one see it as a problem. We reasoned that self-defining individuals‘ tendency toward instrumental problem-solving and taking leadership roles in social groups might provoke concern about overdoing it and/or elicit feedback to that effect from others, with social isolation as a feared consequence. The socially defined appear more reticent, afraid of their own hidden hostile feelings and of others‘ rejection, so perhaps they not only attempt less dominant or assertive behavior (therefore less often view it as a problem) but also may perceive their reticence and withdrawal itself as their more typical problem. We further reasoned based on their fears (Stewart & Winter, 1974) that self-defining people seem to be aware of social norms despite their freedom from behavioral conformity. Thus, concerning possible gender differences, self-defining women might more often see their inclination toward assertion as problematic domineering than would selfdefining men because dominant behavior is supported by the masculine gender role definition but censured by the feminine role definition. Although this argument could be mirrored for men regarding ‗unmanly‘ nonassertive behavior, since non assertion

draws less attention to itself as a role violation than domineering does, we had less confidence in this possibility. Method: Participants: Participants in the current study were 87 McNair Scholar undergraduate students. McNair Scholars are either first-generation college students or members of underrepresented groups who are funded by the U.S. Department of Education and participate in faculty research as preparation for graduate school. The sample were recruited from six southwestern U.S. colleges and universities. There were 23 men and 64 women in this student, with a mean age of 25 and a median age of 22. Forty-two percent were Hispanic, 21% were Non-Hispanic White, 18% were African American, and 12% identified as ―Other.‖ Measures: Self definition and social definition (Stewart, 1992b). Self-definition is an implicit personal style in which individuals' internally referenced identity shapes their actions more strongly than do societal norms and situational pressures. Social definition is a style in which individuals adopt cultural definitions of identity and behavior consistent with their social group memberships, and are more influenced by social norms and pressures (Jenkins, 1996; reviewed in Stewart, 1992a). The content validity of the self-definition-social definition scoring system for thematic apperceptive techniques (Stewart, 1992b) suggests that self-defining people‘s worldview is causally organized and reason-driven, whereas the socially defined worldview includes random events, ineffectual actors, and mental-state preoccupations. This presence-absence content analysis scoring system includes two self definition categories: Causality (C; scored for the presence of causal statements) and Reason-Action Sequence (RA; scored when reasons given for action are followed by action or a plan of action). C and RA are each scored as +1 if present in a story. The three social definition categories, each scored -1, are Mental State Ending (MSE; scored for stories ending in feelings or mental states, rather than action or instrumental thought), Uncaused Action (UA; scored for actions without apparent cause or explanation), and Ineffective Action (IA; scored for action that is ineffective, a failure to act, or portrayal of action as futile). Scores are summed within each narrative and then across stories to create the self versus social definition continuum (see Stewart, 1992b). Four undergraduate scorers were trained in a group using the methods described by Jenkins (2008). Two teams of two scorers each scored the stories then reconciled their differences. One team scored cards 1, 2, 5, 6, and 9. This team‘s interrater reliability on total per-story scores, as measure by Pearson‘s r, ranged from .68 to .98. The other team scored cards 3, 4, 7, and 8, with interrater reliabilities ranging from .79 to .99. Internal consistency, as measured by Cronbach‘s alpha, was .43. Since TAT stories are independent behavior samples rather than convergent items (Jenkins, 2017a) and scores represent an index, not a scale (see Streiner, 2003), high alpha is neither expected nor required. Also, since story length might be a confounding source of method variance, scores were correlated with story length (number of words in stories). That association, r(82) = .14, p = .211, was not significant. Thus, no correction for length was used. Inventory of Interpersonal Problems- Circumplex Scales(IIP-C; Alden, Wiggins, & Pincus, 1990).The IIP-64 was derived from the 127-item structured self-report Inventory of Interpersonal Problems (Horowitz et al., 1988). Seventy-eight of these items begin with the phrase ―It is hard for me to...‖; the remaining 49 begin with ―These are things I do too much.‖ Items are scored from 0 (not at all) to 4 (extremely). The IIP-C is comprised of 64 of the original 127 items (Alden, Wiggins, & Pincus, 1990) that were selected for their fit with eight circumplex scales comprised of eight items each: Domineering, Vindictive, Cold, Socially-Inhibited, Nonassertive,

Self/Social definition and interpersonal problems: 97 Exploitable, Self-Sacrificing, and Intrusive. Each scale score is re-centered on zero by subtracting the individual's mean score to yield positive scores for more severe problems and to minimize the influence of method variance and the general complaint factor. The scales were constructed based on the factor-analyzed responses of undergraduate students to the original 127 items. The measure was then cross-validated in another sample of 974 undergraduates (Alden, Wiggins, & Pincus, 1990). The IIP-C scales converged with the Revised Interpersonal Adjective Scales (IAS-R; Wiggins, Trapnell, & Phillips, 1988), and several IIP-C scales were significantly related to psychotherapy outcome after seven sessions of psychotherapy (Alden, Wiggins, & Pincus, 1990; Ruiz, et al. 2004). Procedures: Each of nine thematic picture stimuli was presented for 30 seconds and the participants were given five minutes to write out a story by hand in a group setting. The cards used were: 1. A young boy is contemplating a violin which rests on a table in front of him (Card 1; p. 18, Murray, 1943). 2. Country scene: in the foreground is a young women with books in her hand; in the background a man is working in the fields and an older woman is looking on (Card 2; p. 18, Murray, 1943). 3. On the floor against a couch is the huddled form of a boy with his head bowed on his right arm. Beside him on the floor is a revolver (Card 3BM; p. 19, Murray, 1943). 4. Two women are wearing lab coats. One is working in with test tubes while another looks on (p. 387, McClelland, 1975). 5. A young man is lying on a couch with his eyes closed. Leaning over him is the gaunt form of an elderly man, his hand stretched out above the face of the reclining figure (Card 12M; p. 20, Murray, 1943). 6. A woman is clutching the shoulders of a man whose face and body are averted as if he were trying to pull away from her (Card 4; p. 19, Murray, 1943). 7. A black businessmen and a white business man in an office scene (p. 218, Fleming, 1984). 8. A man on a trapeze grasping the hands of a woman under a circus tent (p. 388, McClelland, 1975). 9. A young woman‘s head against a man‘s shoulder (Card 10; p. 19, Murray, 1943). This thematic methodology was used since the TAT has been found to be a rather popular assessment instrument in both training and practice (Piotrowski, 2017), and because process-based personality styles are not consistently captured by self-report scales (Jenkins, 2017a). Participants then completed a series of selfreport scales including the IIP-C and an interview that gathered data not reported here. The stories were transcribed into Word files and organized by picture to reduce scoring biases (Jenkins, 2008). Results: Descriptive Statistics: Univariate descriptive statistics are presented in Table 1. Self-definition scores were unrelated to age, gender, and ethnicity. Table 1.Descriptive Statistics by Gender Measure Total Sample Men Women M SD N M SD N M SD N Self definitionsocial definition -.26 .56 -.35 .56 -.23 .56 Domineering -.28 .47 -.18 .57 -.32 .42 Vindictive -.28 .45 -.17 .47 -.31 .44 Cold -.04 .57 -.19 .65 -.13 .52

Socially-Inhibited .14 .60 -.17 .54 .13 .62 Nonassertive .22 .63 -.07 .66 .28 .61 Exploitable .10 .53 -.03 .55 .15 .51 Self-Sacrificing .24 .53 .10 .45 .29 .55 Intrusive -.10 .57 -.16 .49 -.09 .59 Tests of Hypotheses: Since self-definition-social definition is scored on a continuum, positive correlations represent associations with the self-defining end and negative correlations indicate an association with social definition. As predicted, bivariate correlations revealed significant relationships between selfdefinition and the Domineering (r = .24, p = .03) scale of the IIP-C. Contrary to our hypotheses, self definition was not significantly related to the Non assertive scale (r = -.06). However, social definition was significantly related to the Socially-Inhibited scale (r = -.30, p = .006), which captures aspects of both the Nonassertive and Cold scales. There were no significant relationships between self definition and the remaining IIP- C scales, as shown in Table 2. Table 2.Correlations of IIP Scores with Self Definition-Social Definition Scores by Gender Measure Total Sample (N = 84) Men (n = 23) Women (n = 61) r p r p r p Domineering .24 .031 .13 .542 .32 .012 Vindictive a .11 .366 .37 .079 .03 .844 Cold -.08 .477 .15 .498 -.15 .256 Socially-Inhibited -.30 .006 -.34 .112 -.28 .027 Nonassertive -.06 .598 -.18 .401 -.03 .810 Exploitable -.06 .583 -.12 .597 -.06 .627 Self-Sacrificing b .11 .315 -.16 .461 .17 .181 Intrusive .13 .247 .16 .481 .12 .379 aGender difference Fisher z = -1.38, p = .083. bGender difference Fisher z = -1.28, p = .100.

Gender differences in associations are presented in Table 2. (Note that with the small number of men statistical significance is not reached even with moderate effect size correlations). Fisher‘s z was used to test the significance of the largest differences and none was statistically significant. Nonetheless, it is important to note that for women selfdefinition was positively related to Domineering, r = .32, p = .012, whereas for men it was related to Vindictiveness, r = .37, p = .079. The negative relationship to Socially-

Self/Social definition and interpersonal problems: 99 Inhibited remained similar between men, r = - .34, p = .112, and women, r = -.28, p = .027. Other notable differences include associations with Cold (Men r = .15, Women r = -.15) and Self-Sacrificing (Men r = -.16, Women r = .17) which were small but in opposite directions. Discussion: The aim of the current study sought to explore associations between one‘s definitional style and the characteristic interpersonal problems he or she may experience. Based on the conceptualization that those with a selfdefining style acted independently of social norms, took instrumental, agentic approaches to solving problems, and initiated social interactions (e.g., taking leadership roles in organizations), we hypothesized that definitional style would likely correlate with the IIP-C axes related to agency (Domineering- Nonassertive). Specifically, we expected selfdefinition to be correlated positively with selfreported Domineering problems on the IIP-C and social definition would be associated with Nonassertive problems. Our results supported the first hypothesis but not the second. However, self-definition did correlate negatively with the Socially-Inhibited scale of the IIP-C; that is, those on the socially defined end of the continuum rated themselves higher in inhibited, socially withdrawing problems. Although this scale does not precisely align with the IIP-C axis related to agency, those who score high on Socially-Inhibited tend to have problems related to both a lack of assertiveness and an inclination to withdraw from social situations. These findings indicate that excessive interpersonal dominance may be the domain that concerns those who are self-defining. This finding contrasts with Stewart and Winter‘s (1974) report that self-defining women secretly fear being thought ‗dependent‘ or ‗inferior‘. Perhaps those who are self-defining sometimes overcompensate for their dependency concerns—or fear that they do--with an overly domineering interpersonal style that might be disruptive to their relationships. Alternatively, noting that for men this finding was not significant and had a small effect size, to the extent that others in their social context expect women to conform to feminine role norms, self-defining women may be reporting their perceptions of interpersonal frictions related to their out-ofgender-role behavior. Both women and men who are socially defined reported being most concerned about problems related to interpersonal shyness and anxiety. Since women who are socially defined tend to harbor fears of being hurt by others (Stewart & Winter, 1974), and the same might be true of such men even if they adhere to the traditional masculine role, their reported concerns about interpersonal problems on the IIP-C are consistent with these fears. Additionally, because those with this definitional style tend to take action only if they are supported by societal norms and bolstered by important people in their lives, it is possible that the IIP-C reflects their acknowledgement of the limitations of being socially defined. For interpretation of these findings, measurement method matters: the IIP-C is a self-report measure, which reports selfattributed beliefs about interpersonal problems rather than observed behaviors. Although Stewart (1992a) reported evidence that self-defining women valued autonomy and achievement, there was no indication they behaved in a domineering manner or were so regarded by others, or that socially defined persons were behaviorally inhibited. Thus, their concerns may not match their actual interpersonal behaviors. Future research might benefit from gathering collateral reports. There are some limitations to this study. The participants were all high-achieving university students and may not represent all university students or the general population. Furthermore, the majority self-identified as ethnic minority. Individuals who are firstgeneration college students or who are underrepresented may report concerns in a university environment that are different from

or more pronounced than those individuals who grew up in families familiar with university culture or those who feel demographically represented in their field of study (Jenkins, et al. 2013). Additionally, it is unclear whether a mediating variable, such as intelligence, explains the relationship between definitional style and interpersonal concerns. Since social cognition is an aspect of intelligence (Rapaport, Gill, & Schafer, 1968), and the scoring system for definitional style assigns points for narratives with clear cause and effect relationships and active problem solving, it is possible that greater intelligence leads to narratives containing increased creative problem solving and clearer explanations for the reasons why characters act (as opposed to simply stating feelings or describing a lack of action). Despite these limitations, the cross-method findings of this study are notable as they share no method variance (McClelland, et al. 1989). That is, TAT narratives sample social cognitive behavior and measure implicit behavioral trends (McClelland, 1980), in contrast to the IIP-C, which measures conscious self-attributed concerns on the part of the participant. Thus, the findings of this study are not attributable to method error variance. The unusually large and varied number of picture situations sampled in this multimethod study, which goes beyond the content limitations of the Murray (1943) Thematic Apperception Test to include images of people at work, balances the generalizability of scientific precision with the individuality of stories (Jenkins, 2014, 2017b). Knowing a client‘s definitional style may provide clues about the likelihood that they will be concerned about being viewed as domineering, vindictive, or socially inhibited. These concerns can then be evaluated in the light of their probable habits, how they likely define problems, and how they cope with them, as well as their possible vulnerability to or capacity to resist social norm pressures. This clinical information can then be used to tailor interventions that will complement, rather than conflict with, an individual‘s definitional style. Acknowledgements: Wethank Ashley Allison (team leader), Zara Baker, Joshua Payberah, Amanda Vela, and Mikayla Wynter for scoring self definition and social definition. References: Alden, L. E., Wiggins, J. S., & Pincus, A. L. (1990). Construction of circumplex scales for the Inventory of Interpersonal Problems. Journal of Personality Assessment, 55(3-4), 521-536. Chester, N. L. (1981). Coping with the stresses of new parenthood: A longitudinal study. Unpublished doctoral dissertation, Boston University. De Beauvoir, S. (1972). The Second Sex. 1949. Trans. HM Parshley. Harmondsworth: Penguin. Fleming, J. (1984). Blacks in college: A comparative study of students‘ success in black and in white institutions. San Francisco: Jossey-Bass Publishers. Horowitz, L. M., Rosenberg, S. E., Baer, B. A., Ureño, G., & Villaseñor, V. S. (1988). Inventory of Interpersonal Problems: Psychometric properties and clinical applications. Journal of Consulting and Clinical Psychology, 56(6), 885-892. Jenkins, S. R. (1982). Person-situation interaction and women‘s achievement - related motives. Unpublished doctoral dissertation, Boston University. Jenkins, S. R. (1996). Self definition in thought action, and life path choices. Personality and Social Psychology Bulletin, 22(1), 99-111. Jenkins, S. R. (2008). Teaching how to learn reliable scoring. In S. R. Jenkins (Ed.), Handbook of clinical scoring systems for thematic apperceptive techniques (pp. 39–66). Mahwah, NJ: Erlbaum. Jenkins, S. R. (2014). Thematic apperceptive techniques inform a science of individuality. Rorschachiana, 35, 92-102. doi: 10.1027/1192-5604/a000065 Jenkins, S. R. (2017a). The narrative arc of TATs: Introduction to the JPA special section on thematic apperceptive techniques. Journal of Personality Assessment, 99, 225-237. doi: 10.1080/00223891.2016.1244066

Self/Social definition and interpersonal problems: 101 Jenkins, S. R. (2017b). Not your same old story: New rules for thematic apperceptive techniques (TATs). Journal of Personality Assessment, 99, 238-253. doi: 10.1080/00223891.2016.1248972 Jenkins, S. R., Belanger, A., Londoño, M., Boals, A., & Durón, K. M. (2013). First generation undergraduates‘ social support, depression, and life satisfaction. Journal of College Counseling, 16, 129-142. Leary, T. (1957).Interpersonal diagnosis of personality: A functional theory and methodology for personality evaluation. New York: Ronald Press. McClelland, D. C. (1980). Motive dispositions: The merits of operant and respondent measures. In L. Wheeler (Ed.), Review of personality and social psychology (Vol. 1, pp.10-41). Beverly Hills, CA: Sage Publications. McClelland, D. C. (1975). Power: The inner experience. New York: Irvington Publishers. McClelland, D. C., Koestner, R., & Weinberger, J. (1989). How do self-attributed and implicit motives differ? Psychological Review, 96(4), 690. Murray, H. A. (1943). Thematic Apperception Test manual. Cambridge: Harvard University Press, 1943. Piotrowski, C. (2017). Thematic apperception techniques (TAT, CAT) in assessment: A summary review of survey-based studies of training and professional settings. Journal of Projective Psychology & Mental Health, 24(1), 3-17. Rapaport, D., Schafer, R., Gill, M. M., & Holt, R. R. (1968). Diagnostic psychological testing. New York: International Universities Press. Rehfuss, M. C., & Borges, N. J. (2006).Using narratives to explore other-directed occupational choice and academic success. Journal of Vocational Behavior, 68(1), 64-72. doi:10.1016/j.jvb.2004.11.001 Ruiz, M. A., Pincus, A. L., Borkovec, T. D., Echemendia, R. J., Castonguay, L. G., & Ragusea, S. A. (2004). Validity of the Inventory of Interpersonal Problems for predicting treatment outcome: An investigation with the Pennsylvania Practice Research Network. Journal of Personality Assessment, 83(3), 213-222. Sartre, J. P. (1948). Anti-semite and Jew. New York: Schocken Books. Stewart, A. J. (1978). A longitudinal study of coping styles in self-defining and socially defined women. Journal of Consulting and Clinical Psychology, 46(5), 1079. Stewart, A. J. (1980). Personality and situation in the prediction of women‘s life patterns. Psychology of Women Quarterly, 5(2), 195-206. Stewart, A. J. (1992a). Self definition and social definition: Personal styles reflected in narrative style. Motivation and personality: Handbook of thematic content analysis (pp. 481-488). Cambridge: Cambridge University Press. Stewart, A. J., &Winter, D. G. (1974). Self‐definition and social definition in women. Journal of Personality, 42(2), 238-259. Stewart, A.J. (1992b). Revised scoring manual for self definition and social definition. In C. P. Smith (Ed.), Motivation and personality: Handbook of thematic content analyses (pp. 489-499). New York: Cambridge University Press. Streiner, D. L. (2003). Being inconsistent about consistency: When coefficient alpha does and doesn‘t matter. Journal of Personality Assessment, 80, 217–222. Tse, P., Love, A., Leoo, K., Allison, A., & Jenkins, S. R. (August, 2012). Social class and career values of self-defining and socially-defined men. Presented at the meeting of the American Psychological Association, Orlando, FL. Wiggins, J. S., Trapnell, P., & Phillips, N. (1988).Psychometric and geometric characteristics of the Revised Interpersonal Adjective Scales (IAS-R).Multivariate Behavioral Research, 23(4), 517-530. Winter, D. G., Stewart, A. J., & McClelland, D. C. (1977). Husband's motives and wife's career level. Journal of Personality and Social Psychology, 35(3), 159. Wright, B. C., Jenkins, S. R., Harrienger, J., Davis, B., & Allison, A. (May, 2012). Psychological mindedness varies by personality style in women and men. Presented at the meeting of the Association for Psychological Science, Chicago, IL.

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SIS JOURNAL OF PROJECTIVE PSYCHOLOGY AND MENTAL HEALTH: ACHIEVEMENTS Journal in WHO’s 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 AmerciaLaina Argentina Spanish Journal of the Medical Association of Thailand Thailand English, Thai British Journal of Psychiatry UK English Acta Psychiatrica Scandinavica Denmark English SaludMentale 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 SaudePublica Brazil Portuguese International Journal of Geriatric Psychiatry U. K. English SIS Journal of Projective Psychology and Mental Health India English Journal Brasilerio de Psiquiatria Brazil Portuguese Psychiatry and Clinical Neurosciences Australia English

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Abstracted in “APA” Psyc INFO Regd. No. 71632/99, RNI Delhi UGC Journal No.: 48979 Somatic Inkblot Society’s JOURNAL OF PROJECTIVE PSYCHOLOGY AND MENTAL HEALTH January 2018

EDITORS EMERITUS : Wilfred A. Cassell, MD, FAPA, E-Mail: siswilfredacassell@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 Inst. of Mgt.& Computer Studies, Farah, Mathura-281122(India) Email: dr_naveengupta@yahoo.com

EXECUTIVE EDITOR: Rakesh Kumar, Ph.D. Head Dept of Clinical Psychology, Institute of Mental Health & Hospital, Agra-282002 (India). Email: jain.imhh@gmail.com

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

Christopher Piotrowski, Ph.D. Research Consultant, University of West Florida, 504 Concordia Blvd. Pensacola, FL 32505 (USA) Email: cpiotrowski@uwf.edu

L. Sam S. Manickam, Ph.D., Email: lssmanickam@gmail.com

Nilanjana Sanyal, Ph.D., Former Prof. University of Calcutta, Email: sanyal_nilanjana2004@rediffmai.com

PUBLICATION MANAGER: Brijesh.K.Gupta, MBA EDITORIAL CONSULTANTS : Abhilasha Singh, Ph.D. Ailo Uhinki, Ps.D. Amita Puri, Ph.D. Amool R. Singh, Ph.D. Anand P. Singh, Ph.D. Anatoly B. Khromov, Ph.D. Anjana Mukhopadhyay, Ph.D. Antonio Cervigni, Ph.D. Arvind K. Keshary, Ph.D. Barry A. Ritzler, Ph.D. Brig. D. Saldanha, M.D. Carina Coulacoglou, Ph.D. David J. Sperbeck, Ph.D. Dharmendra Jain, D.M. Greesh C. Sharma, Ph.D. H. Kumar, Ph.D. J.V. Weissenberg, M.Sc. Jashobanta Mahapatra,Ph.D. Jayanti Basu, Ph.D. M.P.Singh, Ph.D. Manisha Dasgupta, Ph.D. Nalini Mishra, Ph.D. Padma Dwivedi, M.A. Padmakali Banerjee, Ph.D. Paola Nicolini, M.A. Prasant K. Roy. M.Phil. R.P.Gupta, Ph.D. Radhe Shyam, Ph.D. Rakesh Pandey, Ph.D Ranjeet Kumar, Ph.D. Robert B. Williams, Ph.D. S.Chaudhury, M.D., Ph.D. Sandhya Verma, Ph.D. Sandhyarani Mohanty, Ph.D. Sanjukta Das, Ph.D. Shashi Sethi, Ph.D. Sudhir Kumar, M.D. Yogesh K. Arya, Ph.D.