SIS Journal of Projective Psychology & Mental Health

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

Volume: 25 Number: 02 July 2018 Editorial: Marital & Family Therapy: Which Are the Prominent Assessment Instruments in Research Studies in the Field? Chris Piotrowski 103-105 Inaugural Address: Future Direction of Somatic Inkblot Test as a Projective Psychotherapeutic Technique. Bankey L. Dubey 106-108 Anatomical Rorschach Responses and Death Symbolism Wilfred A. Cassell and Bankey L. Dubey 109-119 Assessment Measures in Research on Eating Disorders: Most Prominent Evaluation Methods Spanning the Scholarly Literature Chris Piotrowski 120-127 Psychological Identification with Parents: Implications for Late Adolescent Psychological Adjustment Phebe Cramer 128-137 Comparison of Male and Female Psychopaths on Select CS Rorschach Variables Jason M. Smith, Carl B. Gacono and Ted B. Cunliffe

138-155 Risk Assessment in the Forensic Evaluation of Child Sexual Offenders: A Diagnostic Framework based on 5 Case Reports John E. Bingham and Chris Piotrowski 156-165 Psychological Testing and Psychoanalysis: Fixable Gap or Great Divide? Anthony D. Bram, Jed Yalof and Kiley A. Gottschalk 166-172 Impact of Childhood Sexual Abuse on Female Sexuality Shweta Sharma 173-177 Intervention through Somatic Inkblot Series and CBT in a case of Gender Identity Disorder Satyadhar Dwivedi and Richa Verma 178-181 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: SBI, Property No.4, Block-A, Sector-23, Dwarka, New Delhi-110075, Account No. 32297525238 IFS Code: SBIN0032182 Type of Account: Saving Bank (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 Marital & Family Therapy: Which Are the Prominent Assessment Instruments in Research Studies in the Field? Over the past 30 years, there has been increasing clinical interest regarding the issue of assessment and use of specific mental health measures in the field of marital and family therapy (MFT) (Carlson et al., 2013; Fredman & Sherman, 1987; Nurse 1999). Yet, diagnostic testing in the MFT field has been critiqued as a “neglected competency” among practitioners (Bagarozzi, 1989). In fact, in a survey of MFT therapists in Israel, Lavee and Avisar (2006) reported that only 28% of their sample used „standardized‟ instruments for assessment in couple therapy, and even the most popular measures were used rather sparsely; i.e., ENRICH, 14%; MMPI-2, 9%; Marital Satisfaction Inventory, 9%; Family Adaptability and Cohesion Evaluation Scale (FACES), 7%; Dyadic Adjustment Scale, 7%. These findings were similar to an earlier survey study on assessment practices of MFT practitioners (Boughner et al., 1994). Due to the complexity in elucidating the underlying dynamics of marital and family processes, many professionals are rather skeptical that comprehensive evaluation via assessment instruments can significantly contribute to therapeutic outcome. One major reason for such pessimistic views toward mental health testing is that graduate training in assessment methods has been largely disparaged and neglected in MFT programs (Bray, 1995), and, in recent years, in the majority of clinical/professional training programs in the United States (Piotrowski, 2015; Stedman et al., 2018). Despite this rather gloomy portrayal of assessment practice, mental health clinicians frequently encounter the necessity to conduct a formal assessment to address salient issues within a couple, marital, or family framework. Hence, most practitioners will probably need to consult the research literature in order to identify the most prominent assessment measures and tests that target dysfunctions that are prevalent in MFT. Some 20 years ago, Piotrowski (1999), via a keyword search of the database PsycINFO, identified the most researched MFT-related instruments in the literature from 1974-1997; (in rank order), the Family Environment Scale, the Dyadic Adjustment Scale, FACES, FIRO-B, Conflict Tactics Scales, McMaster Family Assessment Device, Marital Adjustment Test, Marital Satisfaction Scale, and the Marital Satisfaction Inventory. In a more recent systematic analysis, where the focus was on psychometric credibility and clinical utility, Hamilton and Carr (2016) touted high marks for the McMaster Family Assessment Device, FACES, Beavers Systems Model Self-Report Family Inventory, the Family Assessment Measure III, and the Systemic Clinical Outcome Routine Evaluation (SCORE); and failing grades for the Family Environment Scale and the Family Relations Scale. Due to the lack of consensus regarding assessment approaches in the MFT field, I thought it would be informative to examine the mental health literature to determine which MFT-related tests/measures have received the most research coverage and attention in scholarly journals during the time frame 2000-2018. In effect, this exercise is a partial-replication of my earlier 1974-1997 bibliometric analysis (Piotrowski, 1999). Both an “All Fields” search and a Keyword search: imputing Term--Family therapy and (assessment OR testing)-- was conducted in the PsycINFO database, restricted to years 2000-2018 inclusive. Online search results in PsycINFO provide a side-bar display on type of reference (i.e., journal, book, dissertation) — for the „All Fields‟ search 2,453 journal entries were identified; for the „Keyword‟ search 170 journal entries were listed. For both these searches, another side-bar lists the names of tests/measures most noted in these search results. Table 1 presents the test

ranking and the number of articles specific to each measure within the results produced by the above searches. The „All Fields‟ search represents a more comprehensive metric (i.e., over-inclusive) in that the test/measure is mentioned somewhere in each article, whereas the Keyword search is much more restrictive based on major study focus.

Table 1.Top Testing Instruments Noted in PsycINFO (search term: Family Therapy & (Assessment OR Testing) PsycINFO (All Fields) PsycINFO (Keyword) Test/Measure # of Articles Test/Measure # of Articles Child Behavior Checklist (CBCL) Dyadic Adjustment Scale Beck Depression Inventory Family Assessment Device Global Assessment of Functioning Scale Global Assessment of Relational Functioning Scale Dyadic Adjustment Scale Self-Report Family Inventory SCL-90 Family Environment Scale Brief Symptom Inventory Marital Satisfaction Inventory Eyberg Child Behavior Inventory McMaster Family Assessment Device Children‟s Global Assessment Scale Adult Attachment Interview Family Assessment Device Child Behavior Checklist Although this analysis is limited due to variations in search strategies and procedures used, this exercise illustrates some of the major tests and measures tied to scholarly exposure and discussion in the MFT literature. In fact, several of these instruments of general psychopathology (i.e., Beck Depression Inventory, CBCL, SCL-90) have continued to be popular assessment instruments as reported in „test usage‟ surveys of professional practice over recent decades (Frauenhoffer et al., 1998; Piotrowski, 2017; Wright et al., 2017). Specific to the MFT field, only several measures have maintained their popularity with researchers over the past 20 years, i.e., the Dyadic Adjustment Scale, the McMaster Family Assessment Device, the Marital Satisfaction Inventory, the Family Adaptability and Cohesion Evaluation Scale (FACES), and Family Environment Scale. Moreover (and noteworthy), the Global Assessment of Functioning Scale appears to be a key measurement device in MFT-related research. In addition, over the past decade, clinicians have touted support for „brief‟ versions of some of these MFT instruments (see Balderrama-Durbin, 2015). Finally, I thought it would be of interest to observe the extent of research focus on these popular MFT-specific instruments in the „general‟ mental health literature, 2000-2018. Table 2 presents, in rank order, the results of the online PsycINFO search, where each measure was noted in the Abstract of articles. Thus, when mental health practitioners are presented with the challenge of conducting a comprehensive assessment on MFT-related clinical matters, the measures noted in these analyses should provide a handy reference guide in identifying key assessment instruments to assist treatment outcome. Table 2. Rank order, the results of the online PsycINFO search in the Abstract of articles Measure/Test Times Noted in Abstract of journal articles (2000-2018) Dyadic Adjustment Scale Family Environment Scale McMaster Family Assessment Device Family Adaptability & Cohesion Evaluation Scale Marital Satisfaction Inventory

References: Bagarozzi, D.A. (1989). Family diagnostic testing: A neglected area of expertise for the family psychologist. American Journal of Family Therapy, 17, 257-272. Balderrama-Durbin, C., Snyder, D.K., & Balsis, S. (2015). Tailoring assessment of relationship distress using the Marital Satisfaction Inventory-Brief Form. Couple and Family Psychology: Research and Practice, 4(3), 127-135. Boughner, S.H., Hayes, S.F., Bubenzer, D.L., & West, J.D. (1994). Use of standardized assessment instruments by marital and family therapists: A survey. Journal of Marital and Family Therapy, 20, 69-75. Bray, J.H. (1995). Family assessment: Current issues in evaluation of families. Family Relations, 44, 469- 477. Carlson, C. I., Krumholz, L.S., & Snyder, D.K. (2013). Assessment in marriage and family counseling. In K.F. Geisinger et al. (Eds.), APA Handbook of testing and assessment in psychology, Vol. 2: Testing and assessment in clinical and counseling psychology (pp. 569-586). Washington, DC: APA. Frauenhoffer, D., Ross, M.J., Gfeller, J., Searight, H.R., & Piotrowski, C. (1998). Psychological test usage among licensed mental health practitioners: A multidisciplinary survey. Journal of Psychological Practice, 4(1), 28-33. Fredman, N., & Sherman, R. (1987). Handbook of measurements for marriage and family therapy. New York, NY: Brunner/Mazel. Hamilton, E., & Carr, A. (2016). Systematic review of selfreport family assessment measures. Family Process, 55(1), 16-30. Lavee, Y., & Avisar, Y. (2006). Use of standardized assessment instruments in couple therapy: The role of attitudes and professional factors. Journal of Marital and Family Therapy, 32(2), 233-244. Nurse, A.R. (1999). Family assessment: Effective uses of personality tests with couples and families. New York, NY: Wiley. Piotrowski, C. (2017). The status of the Beck Inventories (BDI, BAI) in psychology training and practice: A major shift in clinical acceptance. Journal of Applied Biobehavioral Research, e12112. Piotrowski, C. (2015). On the decline of projective techniques in professional psychology training. North American Journal of Psychology, 17(2), 259-265. Piotrowski, C. (1999). Use of tests and measures in marital and family research. Psychological Reports, 84, 1251-1252. Stedman, J.M., Essery, J., McGeary, C.A. (2018). Projective personality assessment: Evidence for a decline in training emphasis. Journal of Projective Psychology & Mental Health, 25(1), 54-59. Wright, C.V., et al. (2017). Assessment practices of professional psychologists: Results of a national survey. Professional Psychology: Research and Practice, 42(2), 73-78. ---------------------------------- Chris Piotrowski, Ph.D., Senior Editor, University of West Florida, Email:cpiotrowski@uwf.ed

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/

Inaugural Address Future Direction of Somatic Inkblot Test as a Projective Psychotherapeutic Technique Bankey L. Dubey, President Somatic Inkblot Society 8th International Conference of SIS, Panjab University, Chandigarh (India) on April 27-29, 2018 Respected Chief Guest, dignitaries on the dais, distinguished delegates, friends, students, ladies and gentlemen! On behalf of the members of the Somatic Inkblot Society, and on my own behalf, I express deep sense of gratitude to the organizing team of this Conference. It is customary that the President of the Association delivers an address on such an occasion. Accordingly, I have the privilege of addressing this august body. The theme of the conference is Personality Assessment and Psychotherapeutic Intervention through Projective Inkblots Procedure in Clinical and Organizational settings. This conference is indeed a special occasion as it is being held at the completion of 25 productive and engaging years of the Somatic Inkblots Society and its flagship Journal “SIS Journal of Projective Psychology & Mental Health”. The SIS Society and the SIS Journal had their seminal beginnings at the University Business School, of this university in 1993, and the Silver Jubilee Conference is also celebrated here. The concept of projection, as used in the administration of projective tests

in contemporary settings, is generally credited to Freud who had referred to this clinical term as early as 1896 (Freud, 1950). He defined „projection‟ as a defensive process in which impulses, wishes, and ideas of an aggressive and sexual nature are internalized since their conscious recognition would be too painful to acknowledge to the ego. The subject matter used in this procedure serves as a lens of projection, and the recorded material of elicited behavior is the screen with the picture projected on it (Rapaport, Gill, & Schafer, 1968). Since projective tests are not, for the most part, based on verbal communication, these clinical evaluation methods tend to more effectively penetrate a person‟s „Outer Shell‟ of defenses and surface (conscious???) behavior. Unlike personality questionnaires, projective tests do not require reading questions or manuals, so these techniques more directly assess mental processes. Indeed, projective methods use the language of dreams, visual imagery, and symbolic thought, the most basic forms of thinking and expression. In addition, Projective tests speak the language of repression and bring whatever is buried in the mind closer to consciousness, so revealed subject matter is accessible for mental processing and dealing with reality (Cassell, 1990). Projective techniques received their impetus as a revolution against self-report, paper and pencil tests of the first half of the twentieth century, which were notoriously susceptible to „social desirability‟ effects, or the tendency of test-takers to present themselves in the most favorable light (Piotrowski, 2015). Moreover, Projective techniques were envisioned by their creators as “depth” instruments, which could penetrate the individuals‟ defenses, and would thereby provide a royal road to the unconscious (Murstein, 1995). Two main criticisms stressed by clinical opponents were: first, that these techniques did not correlate highly with overt behavior, and second, that projective methods did not correlate highly with other paper and pencil tests, and were, therefore, produced invalid clinical material. These critics failed to grasp

that these methods were exactly those techniques, not tests in the psychometric sense. As evaluation techniques, projective were highly dependent on the skill of the examiner. Just as a Stradivarius violin in the hands of a chimpanzee would not result in rhythmical music, an unskilled, or insufficiently trained examiner should not be expected to utilize projective techniques to their full potential (Murstein, 1995). Professor Murstein was quite correct in his contention to support the power of projective technique over so called objective techniques. The Somatic Inkblot test was administered during selection interviews to determine various personality traits, the nature of interpersonal relationship, Ego/Self image, healthy body imagery, erotic imagery, hostility/aggression, insecurity and team building concepts across various Indian industries. The SIS….procedure was found to be a successful screening test. In addition, The Somatic Inkblot Series was also used as a therapeutic intervention technique for executives having stress due to work/family pressures. The outcome of the therapy was very encouraging and participants became symptom free. Over the centuries, intellectually courageous and pioneering people in India contributed much to our early understanding of the universe. For example, in ancient times the mathematical concept of zero (shunya) was first recognized by Indian thinker. Indian psychologists were the first to recognize the centrality of the concept of self in the personality and developed technique of yogic meditation, the basis of many healing programs. Yogic meditation helps in controlling the mind body functions. A logical extension of this is the interest of many Indian mental health professionals in Somatic Inkblot Series, which attempts to establish the psychopathology of problems of living and effective psychotherapeutic intervention. The relaxing effect of floral presentation during SIS administration is helpful while treating clients through hypnotic relaxation therapy. The electronic version of Somatic Inkblots is a newer addition on internet available for assessment and therapy. Testing Responses are analyzed at the SIS Center, Anchorage, Alaska which will then reach back to individual clients with possible solutions. The SIS Centers, located at different parts of the globe, are engaged in promoting mental health through this SIS procedure. SIS professionals in future will be able to employ many fascinating and highly promising new electronic methods of presentation of the 62 or 30 SIS images. By employing advances in Mobile technology, it is possible to project an somatic image onto a television screen in a remote areas hundreds of miles from the clinic, and access the viewer‟s response pattern for the purpose of assessment and treatment. The somatic images can also be presented on a computer screen and having the individual interact with the presentation. This process would be conducted both locally and via Internet transmission of images, which can be completed by typing the responses into the computer or actually touching the screen to create a new type of data response profile. The Somatic Inkblot Center Anchorage is connected electronically with other centers globally, and thus can share clinical assessment data with interested clinicians and researchers. Dubey Business Services - an associate of Somatic Imagery Series Center, managed under the supervision of Anand Dubey, Former Director ETS, State of Alaska. Considerable excitement has been generated by this procedure/technology in the scientific community around the world. We are also very privileged to have a long time friend and colleague Dr. Rakesh Kumar Jain, Head, Clinical Psychology Division, Institute of Mental Health and Hospital, Agra for placing all Journals from Vol 1 to 25 (1994 to 2018) on Internet along with other documents and relevant papers on internet (www.somaticinkblots.com). At this occasion, I also appreciate the contribution of present Editor-in-Chief Prof. Naveen Gupta, Director Hindustan Institute of Management &

Computer Studies, Farah Mathura and Senior Editor and Research Consultant Prof. Chris Piotrowski, University of West Florida (USA) and my friends Past Editors Prof. Amool Ranjan Singh, RINPAS, Ranchi and Prof. Rakesh Pandey, Banaras Hindu University for their contribution in realizing the attainment of the SIS Journal of Projective Psychology & Mental Health among the top recognized Journals on projective psychology. Lastly, it is my hope that this conference will provide us food for thought and cognitive stimulation regarding the assessment process. Clinicians employing the Somatic Imagery procedure will help other clinical psychologists to learn this latest technique and deviate from the stereotyped numerically based interpretation of inkblots tests which label assessors more a Lab Technician than a Clinical Psychologist. Challenging the cult like use of existing psychological instruments and reductionist scoring systems may promote the erroneous view of SIS clinicians as a heretic and suffer some degree of professional stigma. The psychological tests- particularly the projective procedures are administered to obtain data-based information not available from the client, case history and the significant family members. The projected responses provide windows to venture into the innerdeep recesses of the person and hear (and appreciate) the inner cry of the client. I sincerely hope that the beneficial effects of SIS would be available to the patients residing anywhere on the planet earth. A therapist while sitting in his clinic in another part of the world can still provide therapeutic aid to clients through the venue of modern technology. The ultimate vision is to provide competent mental health care through the creative use and ease-of-availability of the Somatic imagery procedure. References: Cassell, W.A. (1990). Somatic Inkblot Series Manual, SIS Centre, Anchorage, Alaska (USA).Fiske, D.W. and Baughman, E.E. (1953). Relationship between Rorschach Scoring Categories and the total number of responses, The journal of Abnormal and Social Psychology, 48,25-32. Cassell, W.A. & Dubey, B.L. (2003). Interpreting Inner World through Somatic Imagery. SIS Centre, Anchorage, Alaska USA). Freud,S. (1950); Further Remarks on the Defense Neuro- Psychoses (1896). Collected Papers, Vol. I, Hograth Press London, pp. 155-182. Holtzman, W.H. (1956), Inkblot Perception and Personality, University of Texas Press, Texas. Lerner, P. (1991) Psychoanalytic Theory and the Rorschach‟, The Analytic Press, Hillsdale N.J.USA. Murstein, B. I. (1995). The Relationship of Stimulus, Projection and Pathology in Projective Techniques and the “Levels Effect”. SIS J. Projective Psychology and Mental Health, 2,41- 52. Rapaport, D., Gill, M.M. and Schafer, R. (1968). Diagnostic Psychological Testing, International Universities Press Inc., New York. Piotrowski, C. (2015). Projective techniques usage worldwide: A review of applied settings 1995- 2015. Journal of the Indian Academy of Applied Psychology, 41(3), 9-19. SIS CERTIFICATION Be a certified trainer and practioner of Somatic Inkblot Series. The Participants will be certified by International Somatic Inkblot Society. The certificate program is open to Psychiatrists, Clinical Psychologists, Psychologists, Psychiatric Social Workers, and HR Professionals. Prof. Bankey L. Dubey, Ph.D., Director SIS Centre, 4406 Forrest Rd, Anchorage, AK 99517, E-mail: bldubey@gmail.com

Three case histories involving individuals suffering from existential death anxiety were administered the Rorschach Inkblot Test to illustrate the responses indicating symbolic death content and death anxiety. The over emphasis on somatic content (many „Anatomical‟ responses) on Inkblot tests, might reflected the presence of unconscious anxiety and anticipated decay of one‟s physical body, may be the plausible symbolic interpretation and indicator of death anxiety. This is not possible if the responses are interpreted using quantitative analysis. In addition,the somatic content demonstrates the healing power of spiritual symbols. The paper will motivate young clinicians and clinical psychologists to use content interpretation to understand the power of projection and take advantage of spiritual symbolism during therapy. Subjects related to death and dying have been an area of clinical concern in the literature (Weisman, 1972). As a result, more psychologically sensitive approaches for assisting the dying patient are now evolving. However, questions may be raised concerning the applicability of those accumulating insights to psychological and psychiatric practice. Are fears of death seen in other than terminal patients, and if so, how many they be evaluated by psychological testing? In attempting to find an answer to this question, attention might be initially given to the psychoanalytic literature. Freud (1953) originally introduces the concept of “thanatos” or death instinct considered to play a significant role in certain types of mental functioning. However, he did not fully develop this concept in his later work. Becker (1973) has suggested that this failure to enlarge upon this theme was due to the fact that he suffered from a type of “Thanatos phobia” himself. The latter, according to Becker, manifested itself psychophysiologically in certain of Freud‟s fainting spells which were precipitated when he was confronted on the subject of dying by Jung. Perhaps because many, like Freud, find the subject anxiety provoking, with the exception of the existential therapists, it has tended to remain in the background of thinking relative to everyday clinical practices. This is not surprising since according to Kubler-Ross (1969) that “in our unconscious death is never possible in regard to ourselves”. What is written about the subject appears infrequently but when it does, it is claimed that death anxiety plays a significant role in many of the common metal disorders; for example, Zilboorg (1943) reported that “There always lurks the basic fear of death, a fear which manifests itself many ways. One is free of the fear of death…. the anxiety neuroses, the various phobic states, even a considerable number of depressive suicidal states and schizophrenias amply demonstrate the ever present feat of death which becomes woven into major conflicts of the given psychopathological conditions. We may take for granted that the fear of death is always present in our metal functioning”. Along the same line, Wahl (1959) indicated that in children and adolescent many neurotic symptoms are primarily related to the fear of deaths. He reported that “The child‟s concept of death is not a single thing, but rather a composite mutually contradictory of paradoxes… death itself is not a state but a complex symbol, the significance of which will vary from one person to another and from one culture to another”. It is suggested that, the resistance in exploring the psychopathological significance of death anxiety is not just related to the clinician's own discomfort with the subject. It

also pertains to the fact that in ordinary mental functioning, this type of existent anxiety is strongly repressed.

In one psychopathological theory of personality structure which encompasses this subject, Perls (1969) conceived of a neurotic structure as a thin edifice built upon four layers. At the deepest layer man‟s fear of death exist. Only when we get to this fourth layer says Peels, we get to the “authentic self?” Based on the depth nature of such material, objective studies in this area are very difficult. The vast majority of patients, even when faced with medically document terminal illness, disclaim fear of deaths on a verbal level (Feifel et al, 1973: Levine & Zigler 1975). Professor Ernest Becker, won the Pulitzer book prize for publishing "THE DENIAL of DEATH" has expressed that most people cope with their personal fears of dying by employing the mental mechanism of Denial (Cassell, 2017; Cassell & Dubey, 2016). Cassell, et al, (2013) using the Somatic Inkblot Series SIS-II dealt with the seemingly impossible perception of one‟s own dead body. It involved a Vietnam solder suffering from Combat PTSD, who in a transient psychotic state hallucinated seeing his own dead body in a mass grave along with those of deceased loved ones. The unique case enables the reader to graphically understand the clinical concomitants of severe Death Anxiety. In addition, it also demonstrates the healing power of spiritual symbols, yoga powered spiritual imagery (Cassell, 2011). As a follow-up introspective illustration, Cassell (2014) reported a vivid “Death Dream” that strongly suggested viewing an “Afterlife” mystical continent-symbolic of death anxiety. Certain workers have also attempted to resolve this problem by employing psychological techniques to evaluate death anxiety at the subconscious as well as the conscious level. An example of an approach in this regard is the use of the word association test, which measures the subject‟s reaction times to words associated with death (e.g. "coffin", "funeral", etc.). By means of this procedure, it has been shown that dying heart and cancer patients take significantly loner to respond to death related as compared to neutral words. As a result of such work it has been concluded that terminal patients, as compared to non-terminal patients are more afraid of death on an unconscious level, although most deny such fears when interviewed about their conscious concerns. Other investigators have tried to examine the same level of unconscious material by measuring a subject's autonomic nervous system responses to related words (Alexander, 1957; Greenberg & Alexander 1962; Golding, 1966). The relative depth nature of such studies dramatically emphasizes the practical problem facing the clinician who might wish, to follow this line of inquiry in diagnostic interviewing. If dying patients who are informed of the gravity to their somatic condition, tend to deny fears of dying, consider how much more difficult it is to identify and assess the significance of death anxiety in non-terminal patients. This is especially true where the threat of dying is ordinarily much more intangible having primarily existential considerations. It would therefore appear that there is a need for further evaluations techniques in this area, especially those which have the capacity to tap the unconscious level of functioning. As a possible contribution to clinical investigation in this field, the present report proposes to introduce a new conceptualization of death anxiety which lends itself to projective assessment? The conceptual background is derived from a series of studies by one of the author on body perception (Cassell, 1964, 1965, 1969, 1972, 1977). It is based upon the view that fears of dying, even though originating in what at time may be essentially philosophical considerations, are ultimately experience by the ego as anxiety about the state of the body. If the latter are not properly resolved, it is postulated that there can result heightened body cathexis which manifests itself objectively by a tendency for the

individual to project pathologic anatomical responses when viewing ambiguous stimuli, such as inkblots. It is suggested that the last provided a clinical measure of the individual‟s death anxiety at an unconscious level. Against this conceptual background, perhaps it might be useful to briefly review certain case histories which illustrate the phenomenology under discussion. Hence, several cases are presented below. Case 1: The first patient- a 47 year old married woman - was originally referred for psychiatric evaluation and treatment of severe pelvic pain. While the pain was experienced in all pelvic structure, it did tend to be more severe in the area of the right ischial tuberosity. Subjectively she described it as being in the rectal area, right hip and lower back. She described it as being a “very searing, not jabbing pain” that “worked up” in intensity. The patient‟s medical history indicated that she had originally developed ulcerative colitis at 41 years of age and four years later developed cancer of the bowel. Surgery had removed the lower bowel including, most of the rectum. Following this she had a permanent colostomy. Her pain symptoms had developed shortly after surgery in the absence of any recurrence of her primary disease. What was remarkable about her clinical history was her apparent lack of concern in regard to the potential life - threatening aspects of the cancer. This is perhaps best illustrated by considering a portion of a tape recorded interview. Patient: “I had ulcerative colitis for quite a few years and then it was… it would be four years ago...I believe it's four years four.. .at Christmas time all of a sudden after that I started to bleed from the rectum and I didn't tell any or say anything about it until the middle of February... and then they made me to go to see Dr. Z. and he set up a barium right away to look at things and when I was waiting for the results I flew to Vancouver and had a holiday with my sister...I was trying to forget about this for a while but when I got hack he told me that I was just like ostrich sticking my head in the sand And not knowing what was the matter with me. Doctor: What was the eventual diagnosis? Patient: It was cancer. Doctor: I see. Patient: And he (the surgeon) had a very good idea at the time that this is what was...he just didn't say...he wanted to be definitely sure. Doctor: How did you feel when he told you that you had cancer? Patient: You know I can't remember his telling me this…. not until everything was over. I know my husband knew., .and whether they had me drugged and told me I don't remember but I really don't know remember telling him until everything was over with...it and it didn't bother me because he said that he got it all out...they told me I would be a new girl and everything would be fine...you know they gave me a temporary colostomy. Doctor: You say it didn't bother you that you had cancer. Could your clarify that? Patient: Well some people would worry and think well you know, I've had this...maybe I've still got it and you know...but it didn't bother me. Doctor: Has it bothered you since? Do you ever think about it? Patient: Oh...once in a great while I may be think about it but not really. In reviewing this interview, it might be noted that she used the mechanism of denial and repression in responding to her life - threatening disease. This led her to initially delay in seeking medical treatment. In conceptualizing of her psychosomatic symptom, it may be noted that there was only pain in conscious awareness, not anxiety about her body status. It is hypothesized that, the somatic discomfort represented the conscious equivalent of her unconscious

psyche distress. In considering this formulation attention might be next given to examining her unconscious body attitudes as revealed in her anatomical responses projected with Rorschach testing. Initially, the test was administered in the traditional way with the following results in regard to content. Card I: “Bug…Bat…Beetle” Card II: “X-ray of pelvis… Kidney… Card III: “Two people… funny looking drops of blood” Card IV: “Feet…monster lying there” Card V: “Bat” Card VI: “A fur rug” Card VII: “Animals upside down sitting on their heads…pelvis shape” Card VIII: “Two animals crawling up… rats” Card IX: Caped “Deer with horns” Card X: “A bunch of bugs attacking the pelvic area” A content analysis of the anatomical responses indicates that three of these reflected the presence of pelvic imagery in her projective consciousness. A further interpretation is that seeing "feet" in Card IV represented a downward displacement of pelvic anxiety. Having observed these responses, the Rorschach procedure was modified prior to the detailed inquiry. This was done by placing all 10 cards on a couch in front the patient and asking her to put, them in order from those which were "most upsetting" to "least upsetting". This was done because previous experience by the author with rating the level of emotional arousal evoked by the cards has suggested that this modification of the standard Rorschach technique has particular value in body percent research. When they are assembled as a visual unit, essentially it treats the ten inkblots more as an overall gestalt. When the cards are arranged in terms of their degree of effectual arousal, comparable anxiety levels between adjacent cards in the hierarchy serve as the common link in the affectual chain. It has been found that this rating procedure maximizes the projective "pull' of the inkblots since it facilitates the affectual interaction between the various images that are evoked in consciousness. Moreover, even though it confuses the concept of Rorschach norms, it operationally makes for logical coherence in the associational chain to begin the detailed inquiry with anatomical imagery that is associated with the highest level of anxiety. In the present instance when this was done, the patient under discussion arranged the series in the following order: X, VIII, IV, V, III, VII, IX, I, II, and VI. It might be noted that Card X was extremely anxiety - provoking to her. When asked rate the anatomical imagery that this inkblot evoked on a scale from zero, to one hundred, with the latter operationally defined as being the "most upsetting thing she ever experienced in her life", she assigned a value of 99 to the card. Thus, the anatomical content pertaining to the pelvis was highly threatening to her. Starting with this inkblot, the results of the detailed inquiry now follow: Patient: Well I just see all kinds of...they look like weird bugs of some sort, all attacking...and it almost looks like in the pelvic region and it goes up into the lungs Doctor: "The pelvic region is where?" Patient: "Down here pointing to the central red configuration”… this is part of the pelvic region to me...this looks like it." Doctor: "That's the area in red primary is it? Patient: "Yes...and I always think they are just attacking …I just...it really bothers me...that picture really does." Card VIII: Patient: "These look like rats or something like that (pointing to the red objects on the sides of the inkblot configuration)”.

Doctor: "You are referring to the objects on either side?" Patient: "Yes" Doctor: "And what are those rats doing?" Patient: "Well they are attacking too... it looks like they are going in and either eat you up or something." Doctor: "What part of the body are they attacking?" Patient: "Well this is again the pelvic region (pointing to the lower area of the inkblot configuration). A little higher up...to me this is more down here in the pelvic...they are going up a little bit higher." Doctor: "So the lower area is the pelvic region and they are going up into what part the body?" Patient: "A little bit higher up into your stomach, up into your lungs kind of." Card IV: Patient: "Well this just looks like a monster of some type…it would he an immense bugs or something. Doctor: "And what is the bug doing?" Patient: "Well it just looks like it's going...well I don't know...it just feels it is going to do something bad...like it's going to attack again." Doctor: "What is it going to attack?" Patient: "Well again...all of these pictures remind me of the poly' Area...I fee is where they are attacking when I look at these picture." Card V: Patient: "That to me looks like a great big bat…. and I don‟t know if it‟s because of radio and the T.V. always think of vampire Doctor: "Vampire bats?" Patient: "And sucking blood out of people which I don't really know if they do or not that‟s what bothers me about that." Doctor: "Where would you be concerned about their sucking blood from?" Patient: "Well again...you know because of this down here it looks again like it going down to the pelvic region...the bottom end of the bat…you know if you look at in another way it still looks like it‟s part of it again." Card III: Patient: "They look like some strange people of some sort that are banging on a thing that looks like the pelvis and there is blood dripping down on either side which bother me very much." Doctor: "Where would the blood be coming from and what type of people would they be? Patient: "Well they just...they...they look like something from outer space not, like something real...like see something unreal and it looks like they're...whatever they're its making this person lose blood somehow and it's dripping down." Doctor: "And what part of the body is bleeding would you say?" Patient: "It looks like it's coming from a little bit higher than the pelvic region”. Doctor: "Like where would you say?" Patient: "Well I say up in the lungs." Card VII: Patient: "Well this is a little bit different...in a way it looks like two animals are upside down with their heads like this and then again when you look at it this way… it looks like a well… I don‟t known an awful looking person or something… something not real… that again is looking not quite down cause they‟re looking like they‟re just going to attach it like that”. Card IX: Patient: "There again I see two very strange creature up there...it almost looks like claws down here (lower green area) and again attacking down to the lower region."

Doctor: "In the lower red area?" Patient: "yes and these (pointing to the upper green areas) are attacking around the lungs...and these (lower green area) whatever they are...they're awful looking creature they each have a big claw on them." Doctor: "And where is the claw attacking?" Patient: "Well that is attacking down into the pelvic region." Card I: Patient: "That just looks like sort of a butterfly and a moth combined...kind of all ragged and rings on it and you can see the feelers un here...it doesn‟t bother me at all that much...I don't like it...as I say it is similar to that vampire bat but it is a different type of thing...it is more on the bug line." Doctor: "Is this attacking anything?" Patient: "Well again all of these pictures are shaped to me like the pelvic area and this is why it bothers me that they would be attacking there." Card II: Patient: "Here again they're made to look like some kind of animals un here again of some sort prancing around...and it looks like there is pain down here in the' pelvic area with the red patch hanging in there." Doctor: "The lower red is the pelvic area?" Patient: "Yes...whether they're causing it I don't know...but they are up there doing something and it just...you can just see it coming here (pointing to the red colors within the black areas)." Card VI: Patient: "Oh this one doesn't bother me too much...it makes me feel like it‟s a big rug. In reviewing the overall responses on the ten inkblots, it is evident that in the detailed enquiry, when the cards were presented in an anxiety hierarchy, the anatomical responses more clearly depicted psychopathological body fantasies. The most anxiety laden material was evoked with Card X. In this instance, the patient conjured up in consciousness a fantasy involving the pelvic area as being attacked by various “bugs”. It is suggested that this projective material represented unconscious death anxiety related to the fear that her body was being invaded by cancer tissue. A further suggestion is that the reference to the “lungs” being attacked relate to unconscious anxieties about the secondary spread of her pelvic cancer to the chest. Her response to Card II warrants additional comments. It represented the only time her conversion symptom of pain was directly projected in the Rorschach. This implied a direct causal relationship in her unconscious fantasy life between the “attacking creatures” symbolizing cancer and her pelvic pain. Thus, this modification of the Rorschach effectively uncovered the psychopathological processes underlying her conversion reaction. It might be noted that these data and this formulation are consistent with Szasz‟s original proposal (Szasz, 1960) that psychosomatic pain arises from the activation of unconscious fantasies involving threat of body assault. At this time certain other relevant clinical data will be briefly mentioned. One concerned that fact that after testing, initially an interpretative psychotherapeutic approach was attempted employing the Rorschach as an aide. Thus, it was pointed out to the patient in a subsequent interview that many of her responses symbolized unconscious fears that her body was being attacked by cancer tissue. Perhaps predictably enough, considering the intensity which was focused upon the pathologic imagery, she initially chose to reject this interpretation by saying “Well these are just pictures I am looking at like I‟d buy in a store… they don‟t have to do with my pelvic etc.” In this manner she was able to defend against the unconscious cancer fear with only a slight detectable increase in her overt anxiety level.

Two additional clinical observations related to the hypothesis that she has unconscious death anxiety. One pertained to the fact that she reported having occasion‟s anxiety laden dreams in which she imagined herself dying of terminal cancer. The other was that during the course of interviewing under the hypnotic influence of intravenous sodium amytal, she transiently acknowledged having fears that the operation had not removed all the cancer. Case History 2: The next patient to be described a 57- year old businessman - was initially seen in psychiatric consultation on a surgical ward. The history indicated that he had become hostile, suspicious and uncooperative three days after having corrective surgery to improve the blood supply to his heart. When examined he was diagnosed as suffering from a reactive paranoid psychosis. He had the delusion that toxic fumes were coming through the window poisoning him. There was no neurological psychological evidence of cerebral organicity. His past psychiatric history was negative. In spite of his psychosis, he was well oriented and liable to participate in psychological testing. Initially he was given the Rorschach and the Holtzman Inkblot Test. Of the 10 Rorschach inkblots, six (Cards I, II, III, VII, VIII, and X) were stated to represent the "heart" and four (Cards IV, V, VI and IX) the "lungs". Similarly, of the 45 Holtzman inkblots, 38 were stated to represent the "heart" and two the "lungs": No non-anatomical responses were projected with either test. In appraising the psychopathological significance of this dramatic emphasis on anatomical imagery, an attempt was made to relate it to possible anxiety that this particular man might have in regard to his health status. This seemed to be a highly plausible approach since he had previously suffered from severe atherosclerotic heart disease and had just undergone life threatening cardiac surgery. However, remarkably enough, in the interview situation when questioned about such body anxieties he employed the psychological defense mechanisms of denial and displacement. Thus he denied that he had any fears whatsoever in regard to his health of fear of dying, rather, be -quickly changed the subject emphasizing the fact that he was subjected to unusually demanding pressures at work. In other words, he readily chose to discuss anxieties about, his social role but not his health status. Consequently, it was formulated that there appeared to be a splitting in mental functioning whereby in conscious awareness anxiety was repressed concerning his body concept except for that symbolically implied in the threat of the "toxic fumes" encapsulated in his paranoid delusions, The latter represented a delusional equivalent of his death anxiety. In considering what psychopathological role such unconscious anxiety could have in his reactive psychosis, attention might be briefly directed to studies where it, has been shown possible to experimentally induce psychotic states in normal subjects by flooding an individual's sensorium with sensory input of a visual or auditory nature (Lipowski,1975). In an analogous manner to these, it is suggested that the flooding of this man's unconscious with death anxiety which he refused to accent in conscious awareness ultimately contribute to his developing a temporary psychotic state. As a follow-up, it might be noted that with appropriate treatment he soon lost his paranoid delusions and developed improved reality testing. However, remarkably enough at no time did he admit that the cardiac illness and subsequent surgery made him afraid of dying? Case History 3: Rather than being exposed to life threatening illness and surgery, the next patient, to be described suffered from what might he considered primarily an existential type of death anxiety related to the psychological threat associated with aging. She was a 64 year old widow who developed an acute reactive psychotic state just prior to a move away from her rural homestead where she had lived for years. It appeared as though the

move to her signified an important milestone in her when she anticipated leaving the family home to end out her years alone in a new environment She was confronted with the need to adopt a new role plus ultimately face advanced aging decay and eventually her demise. Interestingly enough, from the existential viewpoint, her psychotic breakdown was initially triggered when she was attending church. According to her daughter, after the religious service she refused to leave the building. She spoke out loudly about imaginary fears of fires and potential accidents happening to her family. In the psychiatric ward, when questioned about her psychotic behavior, she elaborated about her fears in a delusional manner, reporting that certain of her children were dying as a result of tragic accidents. At all times she denied any fears of her own eventual death. It. appeared that when personal anxiety of this nature approached registration in conscious awareness the mental mechanism of projection was activated. Thus, she projected onto her loved ones fears that they – not herself- were drying. Psychological testing with the Rorschach revealed that her unconscious was literally being flooded with anatomical images in that every response had anatomical connotations. The content of these images is shown below: Card I: - Spine, lungs Card II: - Liver, lungs Card III: - Kidney, lungs Card IV: - Spine Card V: - Liver, lungs Card VI: - Spine, back, neck Card VII: - Stomach, kidneys Card VIII: - Kidneys, spine Card IX: - liver, back, stomach, spine Card X: - Intestines, lungs After the psychotic phase of her mental disorder cleared, she remained quite anxious, but this time focused her concerns on her own health status. In this connection she complained of sharp pains in the low back and epigastrium. Eventually, with neuroleptic medication and repeated reassurance that there was nothing physically wrong her somatic symptoms disappeared. However, six weeks later when tested as an out-patient she virtually gave the same type of anatomical responses. This time she was not overtly psychotic, nor did she have appreciable psychosomatic symptoms. To exclude the possibility that memory of the previous testing with the Rorschach might have influenced her second response pattern, she was asked to view the 45 inkblots in the Holtzman series. Out of these she was able to give twenty-two responses, eighteen of which were anatomical. At this stage of her disorder, it was not associated with somatic symptoms, cerebral organicity or any of the other factors which in the literature are considered to account for heightened anatomical awareness. It was therefore hypothesized that this emphasis on somatic content reflected the presence of unconscious anxiety relative to the anticipated decay of her own body associated with her having to adopt her new role as an elderly person away from her homestead. Discussion: Prior to the advent of modern psychiatry, it was the philosopher Kierkegaard who observed that while man was given spiritual awareness, he was at the same time was given the consciousness of his own death and decay resulting in the concept of "dread" or what, in this context is referred to as death anxiety. Far him this pervaded all mental functioning and posed a final common pathway for understanding much of man's behavior. It was suggested earlier that this existential path was avoided by men because many mental health professional themselves are made uncomfortable by this line of inquiry plus the inherent difficulties of therapeutic

intervention in this area because death anxiety is ordinarily so strongly repressed. It appears that there is a need for more penetrating evaluation techniques in this area. In the face of modern evidence regarding the strength of repressive mechanisms acting in this regard (Becker, 1973; Feifel et al., 1973; Weisman, 1972), in many clinical situations where it may be inferred that existential concerns might be present, it would be highly naive to accent the individual‟s simple denial that there is no fear of death. One should examine deeper levels of consciousness especially in patients undergoing life threatening medical or surgical experiences or who are facing psychological peril associated with aging. It might be noted that this view is in sharp disagreement with those who argue that the subject of death has been overworked (Cohen, 1976; Schnaper, 1975; Vaisrub, 1971). In certain instances, it may be helpful to employ a projective technique such as the Rorschach in appraising death anxiety. It is also possible that this type of existential anxiety might be inadvertently discovered in the course of routine use of the Rorschach. Of course, it is necessary to recognize that it requires careful analysis in interpreting the significance of projected anatomical responses. In this regard, the following classification system is proposed. It is suggested that projected somatic material may he viewed conceptually on a continuum from those responses having primarily sensory feedback implications at one extreme to those having predominantly symbolic connotations at the other. In regard to the former, consistent with Rorschach's origin view (Rorschach, 1951) that certain types of movement responses represented a direct projection of the subject's own proprioceptive sensations. If is hypothesized that many anatomical responses represent a sensory awareness of internal bodily feelings. These may relate to current mind body relationships or his memory engrams of past psychophysiological arousal. An example would be a person who as part of his emotional arousal senses of increased rate and projects “heart” responses in viewing inkblots. Consistent with this model are investigations linking anatomy responses with body perceptual changes underlying medical symptoms formation (Cassel, 1964, 1965, 1969) and psychosomatic illness (Wagner & Williams, 1975). The symbolic significance of anatomical responses may he analyzed at several levels. First, a judgment has to be made as to whether or not the rejected material relates to the individual's own body or to those of other people having psychological significance. The latter which will he conceptualized as whether oriented anatomy responses might be illustrated by sympathetic illness imagery (e.g. A woman projecting heart, responses after her husband has suffered from a cardiac illness), sexual fantasy material and aggressive responses related to the impulse to destroy other people (Cassell,1977). The former might be classified as "self-oriented" anatomical responses. An example of these would be mutilated anatomy referring either primarily to the genitalia or symbolically displaced to other body areas relating to that the psychoanalytic literature refers to as castration anxiety. Another would he the death related anatomical responses under present discussion. In evaluating the latter, it must be emphasized that unlike existing scales (Boyar, 1964; Collett, 1969; Dulok, 1972; Lester et al., 1967; Templer, 1970;) which largely tap conscious attitudes related to dying, the presently outlined approach is based upon fundamental projective principles. It therefore, has particular promise as a clinical aide because it appraises an individual's death anxiety at an unconscious level. It must be emphasized that this approach is designed to detect death fears in people who at the deeper levels of consciousness are anxious about dying but who are reluctant to consciously face this issue. This was true for those individuals whose case histories were outlined in this report. All denied any

conscious fears of dying. By contrast, if patients are willing to accept into conscious awareness concerns of the nature and openly discuss them, they are much less likely to project anatomical reasons. In other words when the individual is effectively dealing with the underlying existential crisis, there is less unconscious cathexis of the body as a symbol of death. Conclusion: Just as the skull and cross bones have long symbolized man‟s dread of death, it is hypothesized that certain Rorschach anatomical responses denote such anxieties. Three case histories involving individuals suffering from unconsciousness existential death anxiety were reviewed to illustrate this newly described Rorschach phenomenon. A classification system was outlined to assist in evaluating such responses for their symbolic death content References: Alexander, I.E. (1957). Is Death a Matter of Indifference? Journal of Psychology, 43, 277-283. Becker, E. (1973). The Denial of death. The Free Press, MacMillan Publishing Company, New York Biem, O., Freeman, H., Levine, S. & Scotch, N. (1970).The Dying Patient. New York: Russell Sage Foundation. Boyar J.I. (1964). The construction and partial validation of a scale for the measurement and fear of death. Dissent.Abst, 25, 2041, Cassell, W.A. (1964). A Projective Index of Body-Interior Awareness. Psychosomatic Medicine, 26,172. Cassell, W.A.(1965). Body Perception and symptom Localization. Psychosom. Medicine, 27, 171-176 Cassell, W. A. (1969).: Responses to Inkblot Configurations Resembling the Heart. Journal of Projective Technique & Personality Assessment, 33, 123-126. Cassell, W.A. (1972). Individual Differences in Somatic Perception. Advance Psychosomatic Medicine, 5,8. Cassell, W.A. (1977). Cassell's Somatic Inkblots. 8thMental Measurements Handbook. Ed. Oscar K. Buros, TheGryphan Press. Highland Park, New Jersey. Cassell W.A. (1977). Aggressive Imagery and Clinical Symptoms in Schizophrenia, British Journal of Projective Technique. 22(1), 21-34. Cassell, W.A. (2011). Editorial: Dissolving Death Anxiety with Yoga Empowered SIS. SIS Journal of Projective Psychology & Mental Health, 18, 123- 128. Cassell, W.A. (2014). Editorial: A Spiritual “Afterlife” Death Dream. SIS Journal of Projective Psychology & Mental Health, 21, 1-2. Cassell, W.A. (2017). Editorial: SIS Journal of Projective Psychology & Mental Health, 24, 1-2. Cassell, W.A. & Dubey, B.L. (2016). A SIS-II Projective Case Study of Becker‟s Concept “Denial of Death”. SIS Journal of Projective Psychology & Mental Health, 23, 2-11. Cassell, W.A., Dubey, B.L., Charles, T. & Dwivedi, P. (2013). Perceiving One‟s Own Dead Body and Death Anxiety Dissolving SIS Spiritual Symbols, SIS Journal of Projective Psychology & Mental Health, 20, 3-17. Cohen, R.(1976). Is dying being worked to Death? American Journal of Psychology. 133, 575-577. Collett, L. and Lester, U. (1969). The Fear of Death and the Fear of Dying. Journal of Psychology, 72. Dulok,J.A. (1972). Measurement of the fear of death: an examination of some existing scales. Journal of General Psychology , 28,515-50, Feifel, H., Freilich, J. & Herman, L. (1973). Death Fear in Dying Heart and Cancer Patient. Journal of Psychosomatic Research. 17,161-166, Freud, S. (1953). Standard Edition oil the Complete Psychological works of Sigmund Freud. Hogarth Press, London, Golding, S.I. (1966). Anxiety and Two Cognitive Forms of Resistance for the Idea of Death. Psychological Reports, 8,359-364, Greenberg, I.M & Alexander, I.E. (1962). Some Correlates of Thoughts and Feelings Concerning Death. Hillside Hospital Journal, 2,120-126, Holtzman, W.H., Thorpe, J.S., Swartz, J.P. & Hermann, E.W (1971). Inkblot Perception and Personality, University of Texas Press, Austin Texas , Kierkegaard, S.(1957). The Concept of Dread,18th Princeton University Press edition, translated by Walter Lawire,

Kubler-Ross, E. (1969). On Death and Dying. The Macmillan Publishing Company, New York, Lester, D. (1967). Fear of Death of Suicidal Persons. Psychol. Rep., 20, 1077-1078, Levine, J. & Zigler, E.(1975). Denial and Self Imago in Stroke, Lung Cancer and Heart Disease Patients. Journal of Consulting Psychology, 43,75-77, Lipowski, Z.J. (1975). Sensory and information inputs overload: Behavioral effect comprehend. Psych, 16,199-221. Rorschach, H. (1951). Psycho diagnostics, A Diagnostic Test Based Doom Perception: translated by Lemi and Kronenbergn, Greene & Stratton. New York. Perls, F.(1969). Gestalt Therapy Verbatum. Real People Press, Lafayette California, Schnaper, N. (1975). An editorial: Death and Dying: Has the Tonic Been Worked to Death? Journal of Nerv. Ent Dis, 160(3),157-158. Szasz, T.A.(1969). Pain and Pleasure: A Study of Bodily feelings. Tavistock Pulick, London. Templer, D.I.(1970). The Construction and Validation of a Death Anxiety scale. Journal of Consulting Psychology. 82,165-177. Vaisrub, S. (1971). Dyingis worked to Death (editorial). Journal of American Medicine. A: 50C. 229. Wagner, E.E. and Williams, L. (1975). Comparison of Rorschach anatomy responses from psychosis outpatients and a matched group of Psychiatric Controls Percept. Motor, 40A83486, Weisman, A.D. (1972). On dying and denying: A psychiatric study of terminality. Behavioral publications Inc. Wahl, C.W.(1959). The Fear of death and meaning of death. Edited by Herman Feifel, Mcgraw Book Coy, New York. Zilboorg, G. (1943). Fear of death. Psychonalytic Quarterly, 12,465-575. PRICE LIST OF SOMATIC INKBLOT SERIES SIS ID SIS Version Indian Users Foreign Users SIS-I: Card Form INR: 13000 US $200 SIS-II: Booklet Form INR: 13000 US $200 SIS-II: Video INR: 20000 US $300 SIS-I Video INR: 20000 US $300 SIS Living Images INR: 20000 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, E-mail: bldubey@gmail.com

Eating Disorders (ED) have attracted extensive clinical and research attention, manifested by the exponential growth of articles and book chapters on ED conditions indexed in the scholarly literature. Yet most mental health practitioners only occasionally treat ED patients and tend to be less informed about specific tests and measures used in the assessment process involving this unique clinical group. Thus, the aim of the current article is to provide a referral guide for the general practitioner on the most relied upon measures, scales, inventories, and tests in the study of ED populations. To that end, a triangulated, bibliometric procedure compiled a listing of more than 100 instruments reported in ED research. Based on this pool of measures, a keyword search (All Fields) on each instrument was conducted in the database PsycINFO in order to determine the number of ‘Hits’ generated by the online search. Since primary research studies were of interest, only the search results for journal articles were tabulated. This first analysis produced a ranking of the most frequently used assessment instruments (n=84) in ED-related research. As this search option depicts comprehensive (overly inclusive) parameters for test inclusion, it was decided to subject the pool of 84 instruments to an online search in the database ProQuest, with the restriction to ‘Abstract only’ inclusion. Based on both analyses, the most prominent and visible measures specific to ED, evident in the research literature were: the Eating Disorder Inventory, Eating Attitudes Test, Three- Factor Eating Questionnaire, Eating Disorder Examination (EDE-Q), Body Shape Questionnaire, Multidimensional Body-Self Relations Questionnaire, Binge Eating Scale, and the Restraint Scale. Several measures of general health status or mental health (e.g., Beck Depression Inventory, SF-36, General Health Questionnaire, Hospital Anxiety & Depression Scale, Barratt Impulsiveness Scale, Brief Symptom Inventory, MMPI) were also frequently included in research studies of ED populations. This listing provides a handy referral guide to the major assessment instruments encountered in ED research. On a cautionary note, these findings illustrate that while there are copious evaluation tools available when treating ED patients, research findings in the field are subject to a lack cohesion and generalizability due to the vast breadth of assessment instruments that serve as the basis for data collection and analysis in ED studies. The topic of eating disorders, over the past 30 years, has witnessed substantial (and ever increasing)clinical, empirical, and theoretical interest in the mental health field (Anderson et al., 2018; Fairburn, 2008; Hudson et al., 2007; Imperatori et al., 2017; Keel &Klump, 2003; Szmukler et al., 1998;Stice et al., 2004; Thompson, 2001), particularly advances in the efficacy of the clinical treatment and management of these challenging, refractory clinical conditions (Gilbert & Commerford, 2000; Johnson et al., 1996; Linardon et al., 2017; Mizes, 1998; Wonderlich et al., 2008).In fact, a recent search of the mental literature (PsycINFO database) indicated the following voluminous scholarship on the issue of assessment/testing regarding eating disorders: 5,684 per-reviewed articles; 68 books; 316 dissertations. Within this burgeoning body of research, the issue of the evaluation and assessment of eating disorders has attracted and generated extensive clinical attention (Allison & Baskin, 2009; Barnes et al., 2012; Berg et al., 2012; Clausen et al., 2011; Grilo et al., 2001; Martin et al., 2000; Mond et al., 2008; Stewart et al., 2017; Walsh et al., 2016). Thus, mental health clinicians increasingly rely on psychometrically-sound methods/approaches for both screening and comprehensive evaluation of patients experiencing a myriad of dysfunctions across the eating disorders spectrum (Sandberg & Erford, 2013; Tury et al., 2010). Yet, a cursory review of the literature points to a vast array of evaluation approaches that frame this clinical area. Moreover, these research streams and investigatory domains, which are rather

expansive, reflect a wide net of coverage involving the study of child and adolescent samples (Micali & House, 2011; Munkholm et al., 2017; Overas et al., 2008) as well as gender differences (e.g., Murray et al., 2017; Woodside et al., 2001), and quality of life issues (Jenkins et al., 2011). Due to the ‘medical’ orientation in viewing ED conditions, much of the clinical and research focus regarding assessment of ED resides outside the purview/scope of psychosocial assessment per se, including the study of personality factors (see Farstad et al., 2016). In fact, there is sparse research on the application of projective techniques in the study of eating disorders (e.g., Daini, 2009). Thus, mental health practitioners are largely unaware on the scope of the myriad of assessment approaches available in the clinical literature when presented with patients suffering from the vast domain of eatingrelated dysfunctions. Hence, the aim of the current study is to a) conduct a bibliometric search of the extant literature on the instruments that have attracted the most attention in research studies related to eating disorders, b) identify key survey-based studies that report the most prevalent, i.e. popular, assessment methods used by clinicians in practice, and c) present a listing of the most prominent instruments discussed in the research literature that should serve as a handy referral guide in the selection of assessment measures, inventories, questionnaires, and scales in the treatment of eating disorders and related conditions. Method: The first task was to compile a listing of potential measures and assessment instruments used by or discussed by ED scholars and clinicians. Both lists and rankings of popular ED measures, scales, questionnaires, and inventories were noted in several published reports on assessment practices of ED professionals (Anderson & Paulosky, 2004; Towne et al., 2017) and reviews of the literature (e.g., Marek et al., 2016; Micali& House, 2011). Second, extensive coverage of tests and measures discussed in books or book chapters on the topic of ED provided additional prospective instruments for inclusion. 3rd, comprehensive online searches of the mental health literature on the subject category of ED also identified prominent instruments noted in side-bar menus regarding ‘measurement/ testing’. Hence, these procedures generated a potential pool of over 100 instruments reported in ED research. The next task was to conduct online searches in the database PsycINFO on each assessment measure. If the measure contained the word ‘Eating’ then the official title of the instrument was used as the input term; otherwise, using Boolean logic parameters, the name of the instrument was combined with the keyword ‘Eating’. In order to identify only primary research, this analysis focused solely on the scholarly journals literature. In PsycINFO, the best parameter for comprehensive coverage of topical searches is to use the ‘All Fields’ search option. This process produces the total number of ‘hits’ for the specific test noted or discussed in the periodical journals indexed by PsycINFO. This procedure was followed for each of the 100+ instruments noted above. This procedure then produced a ranking (based on search ‘Hits’) across all assessment instruments. In order to determine a more targeted focus on individual instruments, a search of the cited in the ‘Abstracts only’ option was needed. Since the database ProQuest provides such a search option, I decided to re-run the listing of the 84tests in ProQuest that had at least 10 ‘Hits’ in the PsycINFO search output. Table 1 shows the ranking of these instruments in PsycINFO, as well as the ‘Abstract’ search output for each measure in ProQuest. Perhaps the ProQuest listing reflects a more reliable estimate on whether a test was a main focus of the research study, whereas the PsycINFO listing depicts an ‘overinclusive’

coverage or mention of the assessment measure. Findings: This rather comprehensive list of prominent assessment instruments under the designation Eating Disorders require a caveat –both professional and research attention to the myriad of conditions under the umbrella of ‘Eating Disorders’ casts a wide shadow – i.e., scholarship in this area spans a diversity of investigatory topics or conditions such as medical (e.g., gastrointestinal, malabsorption, nutrition), psychobiosocial (e.g., anorexia, bulimia, dieting, appetite, body image, appetite), social (cultural factors, nutritional fads, advertising/marketing) and intervention (fasting, appetite, weight management, psychological/behavioral therapy). Accordingly, general evaluation procedures and assessment methods across these areas are quite prolific and emerging research on ‘new’ instruments or measures appears unabated in the scholarly literature. Further, a major reason for the use of a broad spectrum of measures in ED research has been the study of co-morbidity factors, quite prevalent in this clinical population (Anderson et al., 2018). Despite this vast expanse of research, the current analysis illustrates that some measures receive extensive coverage, investigatory attention, and discussion in the extant literature, whereas other measures attract but scant research interest. Based on the rankings in both the PsycINFO and ProQuest database presented in Table 1, it seems that several instruments, specific to ED assessment, have received the most exposure and recognition in the extant literature, i.e., the Eating Disorder Inventory, the Eating Attitudes Test, the Three-Factor Eating Questionnaire, the Eating Disorder Examination (EDE-Q), the Body-Shape Questionnaire, Multidimensional Body-Self Relations Questionnaire, the Binge Eating Scale, and the Restraint Scale. Interestingly, the Child Feeding Questionnaire was quite popular in studies indexed in ProQuest. Likewise, many broadband ‘health status’ measures (e.g., SF-36, General Health Questionnaire) and mental health tests (i.e., MMPI, Brief Symptom Inventory) are frequently applied in comprehensive evaluations of ED populations. Such adjutant applications have been reported in the assessment practices of health psychologists (Piotrowski & Lubin, 1990). At the same time, symptomspecific measures of psychopathology, such as the Beck Inventories, are used in the assessment of mental health factors in medical or healthrelated conditions (Piotrowski, 2017). Thus, traditional psychological tests (see Frauenhoffer et al., 1998; Piotrowski & Keller, 1992), particularly self-report inventories, are a common tool used in the assessment process reported in the methods section of ED research studies. Undoubtedly, instruments recently introduced in the periodicals literature have had limited time to make a mark on the field, and thus, comparison with well-established tests and assessment procedures/formats are difficult to ascertain. However, the current listing, illustrated here, provides a tentative view on the ranking of the most popular assessment instruments garnering visibility in the scholarly (periodicals) literature. Hence, this review a) provides a guiding framework to inform both researchers and clinicians on selection and potential use of assessment approaches regarding the vast expanse of eating disorders, and b) serves as a basis for inspiring continued bibliometric study (see Borner, 2015, pp. 56-59) in order to shed light on ‘mapping’ the extant scholarly literature on the scope and breadth of assessment methods in the clinical area of eating disorders. Conclusion: In addition to the listing in Table 1, several observations during this review and analysis seem noteworthy:

a) Assessment instruments (measures, scales, tests) on the topic of ED reflect a vast scope and cross-disciplinary umbrella, including psychiatry, psychology, behavior analysis, social work, nursing, nutritional sciences, physiology & exercise, complimentary medicine, professional counseling, gastroenterology, public health, and allied health fields; thus, there has been and continues to be a profusion of ED instruments in the field. This creates a double-edged sword, where emerging ED research proliferates at a rapid and exponential pace while, at the same time, advances in knowledge are stymied due to lack of investigatory cohesion and focus of emerging scholarship. Hence, research findings tend to lack generalization and are based on a potpourri of investigatory methods and frameworks. There seems to be few scientific guidelines to standardize research efforts across ED investigations and thus, integrated, coordinated findings, based on a multidisciplinary perspective, are rather infrequently presented or discussed in scholarly reports. b) Due to the lack of systematically integrated assessment protocols across ED studies, both theoretical and clinical applications of research findings have been stymied with regard to advances in identifying and explicating optimal therapeutic interventions in the treatment of eating disorders. c) The perennial debate regarding the efficacy of semi-structured interview formats versus selfreport measures or scales (e.g., Black & Wilson, 1996) in ED research continues unabated. d) There appears to be escalating research attention devoted to the issue of body image over the past decade (e.g., Gilbert & Commerford, 2000; Jiang & Vartanian, 2017). e) Research scholars continue to expand the breadth of available ED instruments by adapting established clinical measures to ED populations. A recent example involves the applicability of the Multidimensional Assessment of Interoceptive Awareness (MAIA) for clinical use (Brown et al., 2017). Table 1 Ranking of the Most Mentioned Assessment Measures on ED in PsycINFO Compared to ProQuest Measures/Scales/Tests PsycINFO ProQuest Database (measure ‘mentioned’ in article) (measure noted in Abstract) Eating Disorder Inventory 2,744 1,296 Eating Attitudes Test 1,940 1,247 Beck Depression Inventory 1,820 Three-Factor Eating Questionnaire Rosenberg Self-Esteem Scale Body Shape Questionnaire Restraint Scale Binge Eating Scale Multidimensional Body-Self Relations Questionnaire Objectified Body Consciousness Scale Dutch Eating Behaviour (DEBQ) Barratt Impulsiveness Scale Hospital Anxiety & Depression Scale Eating Disorder Examination-Questionnaire (EDE-Q) Self-Efficacy Scale Body Esteem Scale Beck Anxiety Inventory Children’s Depression Inventory

Bulimia Test (BULIT-R) Eating Disorder Diagnostic Scale Brief Symptom Inventory Patient Health Questionnaire MMPI/MMPI-2/MMPI-2-RC Emotional Eating Scale Yale Food Addiction Scale General Health Questionnaire Sociocultural Attitudes toward Appearance Questionnaire Questionnaire on Eating and Weight Patterns SF-36 Health Survey Rorschach NEO-Personality Inventory Scoff Questionnaire Children’s Eating Attitudes Test Profile of Mood States (POMS) Physical Appearance Comparison Scale Bulimic Investigation Test-Edinburgh (BITE) Night Eating Questionnaire Body Attitude Test Food Craving Questionnaire Eating Disorders Quality of Life Eating Disorders Questionnaire Body Attitudes Questionnaire Pos. & Neg Perfectionism Scale Body Change Inventory Food Craving Inventory Exercise Addiction Inventory Questionnaire for Eating Disorder Diagnoses Children’s Eating Behavior Questionnaire (CEBQ) Body Image-Acceptance and Action Questionnaire Personality Assessment Inventory Child Feeding Questionnaire Short Evaluation of Eating Disorders (SEED) Compulsive Exercise Test Binge Scale Questionnaire on Eating and Weight Patterns (QEWP) Behaviors Questionnaire Anorectic Cognitions Questionnaire Clinical Perfectionism Questionnaire Millon Clinical Multiaxial Inventory (MCMI) CES-Depression Development & Well-being Assessment (DAWBA) Impact of Weight on Quality of Life-Lite (IWQoL-Lite Q.) Eating Disorder Belief Questionnaire Anorexia Nervosa Inventory Eating Disorders Symptom Impact Scale Anorectic Behavior Observation Scale (ABOS) Self-Liking & Competence Scale

Beck Hopelessness Scale PHQ-9 Multidimensional Health Locus of Control YBC-EDS Setting Conditions for Anorexia Nervosa Scale Food Thought Suppression Inventory Dichotomous Thinking in Eating Disorders Scale Eating Pathology Symptoms Inventory Stirling Eating Disorder Scales Disordered Eating Questionnaire SIAB-EX Sickness Impact Profile WHOQoL Children’s Manifest Anxiety Scale Exercise Orientation Questionnaire Male Body Checking Questionnaire Body Investment Scale Note. Instruments with less than 10 ‘Hits’ in PsycINFO are not listed. References: Allison, D.B., & Baskin, M.L. (Eds.). (2009). Handbook of assessment methods for eating behaviors and weight-related problems: Measures, theory, and research (2nd ed.). Los Angeles, CA: Sage. Anderson, D.A., & Paulosky, C.A. (2004). A survey of the use of assessment instruments by eating disorder professionals in clinical practice. Eating and Weight Disorders, 9(3), 238-241. Anderson, L.K., Murray, S.B., & Kaye, W.H. (Eds.). (2018). Clinical handbook of complex and atypical eating disorders. New York, NY: Oxford University Press. Barnes, J., Prescott, T., &Muncer, S. (2012). Confirmatory factor analysis for the Eating Disorder Examination Questionnaire: Evidence supporting a three-factor model. Eating Behaviors, 13, 379-381. Berg, K.C., Peterson, C.B., Frazier, P., & Crow, S.J. (2012). Psychometric evaluation of the Eating Disorder Examination-Questionnaire: A systematic review of the literature. International Journal of Eating Disorders, 45(3), 428-438. Berg, K.C., Stiles-Shields, E.C., & Swanson, S.A., et al. (2012). Diagnostic concordance of the interview and questionnaire versions of the Eating Disorder Examination. International Journal of Eating Disorders, 45(7), 850-855. Black, C.M., & Wilson, G.T. (1996). Assessment of eating disorders: Interview versus questionnaire. International Journal of Eating Disorders, 20, 43- 50. Borner, K. (Ed.). (2015). Atlas of knowledge. Cambridge, MA: MIT Press. Brown, T.A., Berner, L.A., Jones, M.D., et al. (2017). Psychometric evaluation and norms for the Multidimensional Assessment of Interoceptive Awareness (MAIA) in a clinical eating disorders sample. European Eating Disorders Review, 25(5), 411-416. Burton, A.L., Abbott, M.J., Modini, M., &Touyz, S. (2016). Psychometric evaluation of self-report measures of binge-eating symptoms and related psychopathology: A systematic review of the literature. International Journal of Eating Disorders, 49, 123-140. Clausen, L., Rosenvinge, J.H., Friborg, O., & Rokkedal, K. (2011). Validating the Eating Disorder Inventory-3 (EDE-3): A comparison between 561 female eating disorders patients and 878 females from the general population. Journal of Psychopathology & Behavioral Assessment, 33, 101-110. Daini, S. (2009). Projective methods in the study of eating disorders: An update. Journal of Projective Psychology & Mental Health, 16(2), 117-123.

Darcy, A.M., & Lin, J. (2012). Are we asking the right questions? A review of assessments of males with eating disorders. Eating Disorders, 20(5), 416-426. De Young, K.P., & Anderson, D.A. (2017). An interactive, graphical tool for retrospectively assessing symptom frequency and severity: An illustration with eating disorder behaviors, body weight, and stress. Assessment, 24(7), 835-852. Fairburn, C.G. (2008). Cognitive behavior therapy and eating disorders. New York: Guilford. Farstad, S.M., McGeown, L.M., & von Ranson, K.M. (2016). Eating disorders and personality, 2004-2016: A systematic review. Clinical Psychology Review, 46, 91-105. Frauenhoffer, D., Ross, M.J.,…Piotrowski, C. (1998). Psychological test usage among licensed mental health practitioners: A multidisciplinary survey. Journal of Psychological Practice, 4(1), 28-33. Gilbert, S.D., &Commerford, M.C. (2000). The unofficial guide to managing eating disorders. Foster City, CA: IDG Books Worldwide. Goldner, E.M., Srikameswaran, S., Schroeder, M.L., Livesley, W.J., & Birmingham, C.L. (1999). Dimensional assessment of personality pathology in patients with eating disorders. Psychiatry Research, 85, 151-159. Grilo, C.M., Masheb, R.M., & Wilson, G.A. (2001). A comparison of different methods for assessing the features of eating disorders in patients with binge eating disorder. Journal of Consulting & Clinical Psychology, 69, 317-322. Hudson, J.I., Hiripi, E., Pope, H.G., & Keesler, R.C. (2007). The prevalence and correlates of eating disorders in the National Comorbidity Survey Replication. Biological Psychiatry, 61(3), 348-358. Imperatori, C., Innamorati, M., Lester, D., et al. (2017). The association between food addiction and early maladaptive schemas in overweight and obese women: A preliminary investigation. Nutrients, 9, e1259. Jenkins, P.E., Hoste, R., Meyer, C., & Blissett, J.M. (2011). Eating disorders and quality of life: A review of the literature. Clinical Psychology Review, 31, 113-121. Jiang, M., & Vartanian, L.R. (2017). A review of existing measures of attentional biases in body image and eating disorders research. Australian Journal of Psychology, doi: 10.111/ajpy.12161. Johnson, W.G., Tsoh, J.Y., & Varnado, P.J. (1996). Eating disorders: Efficacy of pharmacological and psychological interventions. Clinical Psychology Review, 16(6), 457-478. Keel, P.K., &Klump, P.L. (2003). Are eating disorders culture bound syndromes? Implications for conceptualizing their etiology. Psychological Bulletin, 129, 747-769. Linardon, J., Fairburn, C.G., Fitzsimmons-Craft, E., Wilfley, D.E., & Brennan, L. (2017). The empirical status of the third-wave behavior therapies for the treatment of eating disorders: A systematic review. Clinical Psychology Review, 58, 125-140. Marek, R.J., Heinberg, L.J., Lavery, M., Rish, J.M., & Ashton, K. (2016). A review of psychological assessment instruments for use in bariatric surgery evaluations. Psychological Assessment, 28(9), 1142-1157. Marek, R.J., Tarescavage, A.M., Ben-Porath, Y.S., Ashton, K., Rish, J.M., & Heinberg, L.J. (2015). Using pre-surgical psychological testing to predict 1-year appointment adherence and weight loss in bariatric surgery patients: Predictive validity and methodological considerations. Surgery for Obesity and Related Diseases, 11(5), 1171-1181. Martin, C.K., Williamson, D.A., & Thaw, J.M. (2000). Criterion validity of the multiaxial assessment of eating disorders symptoms. International Journal of Eating Disorders, 28, 303-310. Micali, N., & House, J. (2011). Assessment measures for child and adolescent eating disorders: A review. Child and Adolescent Mental Health, 16(2), 122- 127. Mizes, J.S. (1998). Neglected topics in eating disorders: Guidelines for clinicians and researchers. Clinical Psychology Review, 18(4), 387-390. Mond, J.M., Myers, T.C., Crosby, R.D., et al. (2008). Screening for eating disorders in primary care: EDE-Q versus SCOFF. Behavior Research & Therapy, 46, 612-622. Munkholm, A., Bjorner, J.B., Petersen, J., et al. (2017). Validation of the Eating Pattern Inventory for Children in a general population sample of 11-to 12-year-old children. Assessment, 24(6), 810- 819.

Murray, S.B., Nagata, J.M., Griffiths, S., et al. (2017). The enigma of male eating disorders: A critical review and synthesis. Clinical Psychology Review, 57, 1- 11. Overas, M., Winje, E., &Lask, B. (2008). Eating disorders in children and adolescents. In S. Wonderlich, J.E. Mitchell, M. deZwaan, & H. Steiger (Eds.), Annual review of eating disorders: Part 2 (pp. 110-124). Oxford: Radcliffe Publishing. Parker, K., & Brennan, L. (2015). Measurement of disordered eating in bariatric surgery candidates: A systematic review of the literature. Obesity Research & Clinical Practice, 9, 12-25. Parker, K., Mitchell, S., O’Brien, P., & Brennan, L. (2015). Psychometric evaluation of disordered eating measures in bariatric surgery patients. Eating Behaviors, 19, 39-48. Piotrowski, C. (2017). The status of the Beck Inventories (BDI, BAI) in psychology training and practice: A major shift in clinical acceptance. Journal of Applied Biobehavioral Research, e12112. Piotrowski, C., & Keller, J.W. (1992). Psychological testing in applied settings: A literature review from 1982-1992. Journal of Training & Practice in Professional Psychology, 6(2), 74-82. Piotrowski, C., & Lubin, B. (1990). Assessment practices of health psychologists: Survey of APA Division 38 clinicians. Professional Psychology: Research and Practice, 21(2), 99-106. Sandberg, K., & Erford, B.T. (2013). Choosing assessment instruments for bulimia practice and outcome research. Journal of Counseling & Development, 91, 359-366. Stewart, K.E., Lanoye, A., Milliken, L., & Milsom, V. (2017). Assessment of eating behavior in primary care. In M.E. Maruish (Ed.), Handbook of psychological assessment in primary care settings (2nd ed., pp. 499-528). New York, NY: Routledge. Stice, E., Fisher, M., & Lowe, M.R. (2004). Are dietary restraint scales valid measures of acute dietary restriction? Unobtrusive observational data suggest not. Psychological Assessment, 16(1), 51-59. Szmukler, G., Dare, C., & Treasure, J. (1996). Handbook of eating disorders: Theory, treatment and research. New York: Wiley. Thompson, J.K. (2001). Body image, eating disorders, and obesity: An integrative guide for assessment and treatment. Washington, DC: APA. Towne, T.L., De Young, K.P., & Anderson, D.A. (2017). Trends in professionals’ use of eating disorder assessment instruments. Professional Psychology: Research and Practice, 48(4), 243- 250. Tury, F., Gulec, H., & Kohls, E. (2010). Assessment methods for eating disorders and body image disorders. Journal of Psychosomatic Research, 69, 601-611. Walsh, B.T., Attia, E., Glasofer, D.R., & Sysko, R. (Eds.). (2016). Handbook of assessment and treatment of eating disorders. Arlington, VA: American Psychiatric Association Publishing. Woodside, D.B., Garfinkel, P.E., Lin, E., et al. (2001). Comparisons of men with full or partial eating disorders, men without eating disorders, and women with eating disorders in the community. American Journal of Psychiatry, 15, 570-574 . APPEAL Dear Life Members,

We are thankful to you all for the continued support and association with SIS. We are encouraging our esteemed Life Members with 10 years or more membership to upgrade their Membership to the level of Fellow of the Society by submitting Membership Application Form accompanied by payment of Rs. 2500/- only. Bankey L. Dubey

Late adolescence is a time during which change often occurs in the relationship between adolescent and parent. In particular, the identification of the adolescent with the parent – the taking on of values, opinions, and mores of the parents -- may change, and these modifications may have important consequences for psychological development. To study this, the parent identification of 160 late adolescents (age 17-20 years) was determined by comparing the adolescents‟ description of their parent‟s characteristics with those that described their own ideal self. Similarity in these two descriptions was taken as a measure of parental identification. For males, only strong identification with father was found to be related to more potent use of the defense mechanism of identification and lesser degrees of anxiety. In addition, for both males and females, weak identification with the opposite-sex parent was related to stronger anxiety. Late adolescence is a time during which change often occurs in the relationship between adolescent and parent.

As described by Koepke and Denissen (2012), at this time the process of separation from the parents begins to occur. This separation allows for the development of a separate self, which is necessary for successfully progressing to mature adulthood. In the process of separation, there may be a questioning of the parents‟ values and standards, which come to conflict with the self-view that represents what the adolescent wants to be – what may be termed the adolescent‟s “ideal self” (Koepke & Denissen, 2012). In this case, the identification of the adolescent with the parent may decrease. Moreover, adolescents may attempt to differentiate themselves from the parents by “distinguishing themselves in behaviors or values” (Perez-Brena et al., 2014, p. 2029). This psychological separation, although part of normal development, may incur some unfavorable consequences for the late adolescent. This paper focuses on the personality characteristics of narcissism, anxiety, and the use of defense mechanisms. Through identification, the adolescent internalizes various qualities of the parents, including their modes of coping with the environment, which in turn supports the adolescents‟ sense of well-being. As the adolescent begins to separate from the parents there is often a decrease in conscious identification with the parents‟ values, behaviors and interests. One of the costs of this disengagement is a felt loss of the parents‟ positive regard, with accompanying insecurity, confusion and anxiety (Frank, Pirsch & Wright, 1990). Thus, as separation occurs and parent identification decreases, there may be changes in personality. For example, a decrease in identification with the parent may result in a change in narcissism. According to theory (Blos,1979), when the adolescent‟s positive regard for the parents is diminished, the narcissistic admiration previously invested by the adolescent in the parent is now directed to the self. Thus, we should expect to find that as parental identification decreases, adolescent narcissism increases. A decrease in identification with the parent may also impact psychological adjustment, at least temporarily. The ability to psychologically separate from parents while at the same time maintaining a connection with them has been discussed as an important factor in supporting psychological adjustment (e.g., Kruse & Walper,2008), and strong attachment to parents has been found to be

related to better psychological adjustment (Laible, Carlo, & Raffaelli, 2000). Thus, separation from parents may have a negative impact on psychological adjustment. Previous Research: The relation between identification with parents and personal adjustment has been studied in different ways, with results not always in agreement, possibly due to different study methods or foci. For example, low identification with parents, when assessed as parent separation, has been found to be positively related to personal problems (Boles, 1999; Lapsley et al.,1989), and to be negatively related to personal problems (Lopez et al., 1986; Majorano et al., 2015). Consistent with the latter findings, assessment of parent-adolescent closeness, including the degree to which the adolescent wants to be like the parent, has been found to be positively related to positive mental health and negatively related to delinquency (Hair, Moore, Garrett, et al., 2008). Furthermore, adolescents who reported greater detachment from parents also reported greater anxiety, lower self-worth and greater insecurity (Delaney, 1998; Frank, Pirsch, & Wright, 1990). Also, adolescents who were in the process of trying to establish an individual identity have been found to be more anxious that those not involved in this process (Kroger, 1985). In the present study, the major hypothesis is that low identification with parents will be positively related to anxiety. Previous research has also shown that adolescents identify more with same-sex than with opposite-sex parents (e.g., Berenson et al., 2005; Boles, 1999). There is also evidence that attachment to mother is more important than attachment to father for predicting adjustment (e.g., Lapsley, 1989). Further, both theory and research suggest that attachment to parents is more important for the psychological well-being of females than males (e.g., Schultheiss & Blustein, 1994). Assessment of Identification: The term identification is used in a number of different ways in the mental health literature (e.g., Amato et al., 2016; van Zalk & Denissen, 2015). The concept of identification is probably most familiar in psychology as referring to the process in which one individual takes on the behaviors, values and/or goals of another. As used in the present study, the term „parent identification‟ refers to the adolescent‟s wanting to be like the parent, as exemplified in the adolescent‟s description of his/her “ideal self” as being like the parent. Operationally, this may be found in “the congruence between an individual‟s description of his ideal self and his description of his parent” (Block & Turula, 1963, p. 946). This measure of parent identification does not ask the adolescent to rate their closeness or similarity with the parent. Rather, the adolescent is first asked to rate a large number of adjectives to describe his/her ideal self, and subsequently, after several intervening tasks, to use these same adjectives to describe a parent. The similarity or difference between the two sets of ratings is used to determine the degree of identification with the parent; the less the similarity, the less the identification with the parent. A second use of the concept of identification refers to a mechanism of defense, i.e., a mental mechanism that functions to reduce anxiety and protect self-esteem in the developing individual. Although less familiar, the idea that one‟s anxiety may be allayed, or self-esteem increased, through identifying with another, has contributed to our understanding of behavior for some time. For example, the concept of “identification with the aggressor” has been used to explain why a person who has been the victim of aggression may begin to act like the aggressor, i.e., to take on the characteristics of the aggressor. Research studies show an increase in the use of identification as a defense during late adolescence. During early childhood, denial is the predominant defense (e.g., Piotrowski &

Dunham, 1983); during later childhood and adolescence, the defense of projection becomes predominant (e.g., Cramer, 1987, 1991a; Cramer & Gaul, 1988; Porcerelli, Thomas, Hibbard, et al., 1998). The use of the defense of identification increases slowly from early childhood to adolescence, with a marked increase occurring in late adolescence. Hypotheses: Based on the preceding theory and research, the following hypotheses are proposed: a) Close parental identification will be related to stronger use of defense Identification. b) Less identification with parents will be associated with higher anxiety. c) Less identification with parents will be associated with higher narcissism. Method: Participants: The participants were volunteer first and second year college students (N = 160: 69 males, 91 females) from an Introductory Psychology class at a small, liberal arts college, with a median age = 19 years, range 17 – 20 years. This convenience sample was tested in small groups, ranging from 3 to 9 individuals, in a private laboratory room with the examiner present, and were given class credit for their participation. Informed consent was obtained from all individual participants included in the study. Measures: Parent Identification. The California Adjective Q-sort (Adj-Q; Block, 2008). The Adj-Q was used to assess Parent Identification. The Adj-Q consists of 70 adjectives describing personality, values, morals, attitudes and intellectual functioning. Each participant was instructed to use these adjectives to describe their “Ideal Self” – the way they would ideally like to be – and subsequently to describe either their samesex parent (n = 86) or their opposite sex parent (n = 74). First, the 70 adjectives were sorted into a forced seven step distribution, ranking the items from most to least like the Ideal Self. Each AdjQ item was then assigned a value of 1 (least like self) to 7 (most like self), based on the placement in the Q-sort. After an intervening task (described below), this same Q-sorting procedure was used to describe either the participant‟s mother or father. Identification with parent was defined as the congruence between a participant‟s ideal-self description and the participant‟s perception of the parent. The sum of the absolute difference in item scores between the Ideal Self Q-sort and the Parent Q-sort provided the measure of Parent Identification. This approach provides an assessment of the degree to which the participant perceives his/her ideal self to be dissimilar to his/her perception of his/her parent. This method for measuring Parent Identification has been used by Adams-Webber and Neff (1996), Block and Turula (1963), Chang and Block (1960), and Cramer (2001). This method has also been used to assess the similarity between self and heterosexual partner (Klohnen & Mendelsohn, 1998). The measure assesses psychological identification, not the actual similarity between two persons. In the present research, the smaller the difference score in the two Q-sorts, the stronger the degree of identification with the parent. Measuring Defense Mechanisms:

The Defense Mechanism Manual (Cramer, 1991a) was employed to assess the use of defense mechanisms in TAT stories. Participants were given standard TAT instructions (Murray, 1943), and wrote stories to three TAT pictures (Cards 1, 14 and 17BM). Without knowledge of the participant‟s gender or other information, each of the 516 stories was scored by an experienced coder for the presence of three defense mechanisms -- Denial, Projection, and Identification -- according to the Defense Mechanism Manual. In the present study, a second coder

independently scored a random selection of 30 stories. For each defense, there are seven categories representing different aspects of the defense; each category is scored as many times as it occurs in each story. The scores for each defense were then summed over the three stories, yielding a total score for Denial, for Projection, and for Identification. The categories for each defense are as follows: Denial: (1) Omission of major characters or objects; (2) Misperception; (3) Reversal; (4) Statements of negation; (5) Denial of reality; (6) Overly maximizing the positive or minimizing the negative; (7) Unexpected goodness, optimism,

positiveness, or gentleness. Projection: (1) Attribution of hostile feelings or intentions, or other normatively unusual feelings or intentions, to a character; (2) Additions of ominous people, animals, objects, or qualities; (3) Magical or autistic thinking; (4) Concern for protection from external threat; (5) Apprehensiveness of death, injury or assault; (6) Themes of pursuit, entrapment and escape; (7) Bizarre story or theme. Identification: (1) Emulation of skills; (2) Emulation of characteristics, qualities, or attitudes; (3) Regulation of motives or behavior; (4) Self-esteem through affiliation; (5) Work; delay of gratification; (6) Role differentiation; and (7) Moralism. A more complete description of these categories, with detailed rules for scoring, is presented in Cramer (1991a, 2006). This measure of defense mechanisms has been demonstrated in previous studies to have good inter-rater reliability, with children, adolescents, adults, and psychiatric patients (e.g., Cramer, 1991a, 1991b, 1995, 1998, 1999; Cramer & Block, 1998; Cramer & Gaul, 1988; Hibbard, Farmer, Wells et al., 1994; Porcerelli, Thomas, Hibbard, et al. 1998). The effective reliability (Rosenthal & Rosnow, 1991) in the present study was .95 for Denial, .88 for Projection, and .86 for Identification, indicating acceptable inter-rater reliability. The validity of the coding approach has been demonstrated both through observational studies of children and adults, in which defense mechanism scores differentiated between age groups or were related to personality variables in ways predicted by theory (Cramer, 1991a; 1995, 1997, 1998, 1999, 2000; Cramer, Blatt, & Ford, 1988; Hibbard at al., 1994; Hibbard & Porcerelli, 1998; Porcerelli et al., 1998). Validity has also been demonstrated through investigations in which an experimental manipulation produced theoretically predicted changes in defense mechanism use (Cramer, 1991b, 1998; Cramer & Gaul, 1988). In the present study, the defense of Identification, as it relates to identification with parents was the main issue of interest. The construct validity of the measure of defense Identification has been demonstrated in experimental studies by showing that the administration of a threat to identity increases defense Identification scores (Cramer, 1991b, 1998). Construct validity has also been demonstrated by developmental studies showing that defense Identification scores increase significantly in adolescence, in conjunction with identity development (Cramer, 1991a; Porcerelli et al., 1998). The California Adult Q-sort (CAQ; Block, 2008). The CAQ consists of 100 widely ranging statements describing personality, cognitive and social functioning. Using the CAQ, each participant was asked to describe themselves. The use of the CAQ as a self-report measure has been found to show significant agreement with observer-based Q-sorts (e.g., Kolar et al, 1996). The 100 statements were sorted into a forced nine-step distribution (5, 8, 12, 16, 18, 16, 12, 8, 5), according to the perceived salience of each item for the individual. Items rated as “very uncharacteristic of me” are given a score of 1; items rated as “very characteristic

or me” are given a score of 9, with intermediate items scored 2 through 8. One of the advantages of the CAQ is that scales representing different dimensions of personality may be developed from the same Q-items. In previous research, measures of Narcissism (Wink, 1992), and Anxiety (Kremen, 1996) have been developed from the CAQ items. In the present paper, CAQ items are used to assess these two personality variables (described below). Narcissism: The measure of Narcissism was based on the CAQ prototype developed by Wink (1992). Nine experienced judges sorted the 100 CAQ items to describe a prototypical narcissist. The inter-rater reliability of the nine judges was,  = .91. Validity evidence for this prototype was provided by Wink (1992), demonstrating that it correlated with both observer and self-report narcissism measures. Based on a subsequent factor analysis of the CAQ items, Wink (1992) created a Narcissism scale consisting of the 23 CAQ items from the prototype that are indicative of narcissism, minus the CAQ items that are contraindicative of narcissism. The scale has been used successfully in previous research (Cramer, 2011a, 2011b; Wink,1992). This scale was used to determine each participant‟s Narcissism score. The score for each of the 33 items was based on its placement in the participant‟s Q-sort, and could range from 1 to 9. Anxiety: Anxiety was assessed using a CAQ-based scale developed by Kremen (1996). Based on factor analysis of items from a self-report anxiety scale, Kremen (1996) created a “Susceptibility to anxiety” scale with good reliability: Cronbach‟s alpha > .72. Subsequently, Kremen (1996) determined the correlation between this factor scale (Susceptibility to Anxiety) and each of the 100 CAQ items. Those items that were significantly correlated with the Susceptibility to Anxiety scale were used to create a criterion-keyed scale for Anxiety (21 CAQ items: 12 positive, 9 negative). This scale was used in the present study. Procedure: All participants first completed the AdjQ-sort for their Ideal Self. This was followed by the CAQ, used to describe the Real Self. Next, participants wrote stories to three TAT cards. Finally, participants were asked to complete the AdjQ to describe either the Same-Sex Parent (n = 86) or the Opposite-Sex parent (n = 74). Results: Descriptive statistics: Parent Identification: The mean scores for parent identification are presented in Table 1. A smaller score represents greater identification with the parent (less difference). A larger score (greater difference) represents lower identification with the parent. Males were more strongly identified with Father (M = 87.25) than with mother (M = 102.65), t(68 ) = 1.98, p<.03. Females were not more strongly identified with Mother (M = 99.04) than with Father (M = 98.46), t(90) = .08. Males and females did not differ in the strength of their identification with Same-sex or with Oppositesex parent, ts (84,72) = 1.52 and .56. Narcissism: The mean scores for Narcissism are given in Table 1. T-tests indicated no significant difference between males and females, t(158) = .90, p = .37. Anxiety: The mean scores for Anxiety are given in Table 1. T-tests indicated no significant difference between males and females, t(158) = .75, p = .46. Defense Mechanisms: The mean scores for defense mechanism use are provided in Table 2. Males and females

did not differ in their use of the three defenses. However, Projection & Identification were used more than Denial, by both males, ts(69) = 5.64 and 8.25, ps< .001, and females, ts(90) = 6.39 and 10.93, ps< .001. In addition, females used Identification more than Projection, t(90) = 3.43, p < .002 (see Table 2). Table 1. Parent Identification, Narcissism and Anxiety: Males, Females: Means, SDs Patient Identification Males (n=69) Females (n=91) t p d Same sex Parents (N) 1.52 .13 .34 Mean 87.25 99.04 S.D. 34.06 35.31 Opposite sex Parents (N) .56 .58 .13 Mean 102.65 98.46 S.D. 29.85 34.32 Narcissism Mean 57.90 55.99 .90 .37 .14 S.D. 12.64 13.89 Anxiety Mean 11.45 12.66 .75 .46 .12 S.D. 9.04 10.96 . Table 2. Defense Mechanisms: Males, Females: Means, SDs Males (n=69) Females (n=91) t p d Denial Mean 1.05 1.02 .85 .02 SD 1.07 1.25 Projection Mean 2.81 2.48 .87 .38 .14 SD 2.50 2.23 Identification Mean 2.96 3.41 1.60 .11 .26 SD 1.67 1.83 Inter-correlations: Same-sex Parent Identification: For each participant, Same-sex Parent Identification was correlated with Defenses, Narcissism, and Anxiety (see Table 3). For males, Same-sex Parent Identification was negatively correlated with Defense Identification (r = -.43, p< .01), indicating that males who more closely identified with Father (less difference) had higher scores on Defense Identification. Also, males who were less identified with Father had higher Anxiety scores (r = .36, p< .04). For females, Samesex Parent Identification was not correlated with Anxiety, Narcissism or Defense (see Table 3). Table 3. Inter-correlations: Same-sex Parent Identification by Narcissism, Anxiety, Defense Mechanisms (1) (2) (3) (4) (5) (6) (1) Same-Sex Parent Identification b .17 .36* -.06 .22 -.43** (2) Narcissism .18 .57*** -.11 .20 -.18 (3) Anxiety .16 .52*** -.03 .19 -.11 (4) Denial -.11 .03 .06 .14 .08 (5) Projection -.17 .18 .18 .32** -.17 (6) Identification -.02 .03 -.03 .13 .12 * p< 05; ** p< .01; *** p< .001 a - top half = males; bottom half = females b - A positive correlation between Same-sex Parent Identification and Narcissism indicates that lower Identification is related to higher Narcissism. A negative correlation between Same-sex Parent Identification and Defense Identification indicates that stronger parent identification is related to a higher score on Defense Identification.

Inter-correlations: Opposite-sex Parent Identification: Males and females were also compared for the correlation of Opposite-sex Parent Identification with Defenses, Narcissism, and Anxiety (see Table 4). For males, Oppositesex Parent Identification was positively correlated with Anxiety (r = .41, p< .01), indicating that lower Identification with Mother was related to higher Anxiety (see Table 4). For females, Opposite-sex Parent Identification was positively correlated with Anxiety (r = .54, p < .001), indicating that lower Identification with Father (greater difference) was related to higher Anxiety (see Table 4). Table 4. Inter-correlations: Opposite-sex Parent Identification by Narcissism, Anxiety, Defense Mechanisms (1) (2) (3) (4) (5) (6) Opposite-sex Parent Identification .30 .41** .12 .14 -.06 (2) Narcissism .22 .57*** -.11 .20 -.18 (3) Anxiety .54*** .60*** -.03 .19 -.11 (4) Denial -.08 .03 .06 .14 .08 (5) Projection .11 .18 .18 .32** -.17 (6) Identification -.09 .06 -.03 .13 .12 p< 05; ** p< .01; *** p< .001 a - top half = males; bottom half = females b - A positive correlation of Opposite-sex Parent Identification with Anxiety indicates that lower Identification is related to higher Anxiety. Discussion: There are a myriad of developmental changes that occur during adolescence. Among the developmental tasks of this period of life, psychological separation, or decreased identification with parents, plays a central role (Blos,1979; Kruse & Walper, 2008). In the long run, this process is likely to have a positive outcome, facilitating autonomy and individuated identity. But over the short term, the findings of the present study demonstrate that there are some costs associated with this separation. Similar to previous studies (e.g., Boles, 1999), the males in the present study were more closely identified with father than with mother. However, lower identification with both father and mother was related to higher levels of anxiety.

Presumably, weaker parent identification contributes to a loss of security and leaves the male adolescent more vulnerable to the challenges of life away from home, and thus increased anxiety. In addition, for females, lower identification with father was related to greater anxiety. Again, it seems likely that identification with the father provides a kind of security for the late adolescent, which is decreased when identification is reduced, and hence, higher anxiety levels are experienced. However, the hypothesis that lower parent identification would be associated with narcissism was not supported, for either males or females. Most striking was the finding that, for males, those who were closely identified with father made greater use of the defense of identification. This makes sense theoretically, in that males are more likely to identify with the father, including the internalization of his characteristics, and the defense of identification is based on the internalization of the parent‟s characteristics. Importantly, these males did not show greater use of the other two defenses, indicating that it was not defensiveness in general that was related to father identification. It is important to note that previous studies of psychological connection to, or separation from parents have depended on self-report measures (e.g., Amato & King, 2016; Boles,

1999; Kruse & Walper, 2008), allowing for the possibility of self-presentation bias. In the present study, this problem was avoided by using self- and other-ratings that do not directly inquire about relations with parents, and a measure of defense mechanisms that is performance-based. Although self-report questionnaire measures of personality are often convenient to use, these methods may not be appropriate for studying certain characteristics. Individuals may not be able to report on dispositions that operate outside of consciousness. Such is the case with the study of defense mechanisms, which by definition are unconscious. To assess these personality characteristics, the use of a non-self-report, performance-based measure is likely to produce information derived from affective experience (implicit or unconscious motives), whereas self-report, self-attributed motives are influenced by social incentives and are subject to self-presentation bias (McClelland, Koestner, & Weinberger, 1989). For this reason, the use of performance-based measures may be clinically more useful. Limitations: The present study is based on college students from a small liberal arts college; the results may not be characteristic of other groups of late adolescents. Thus, generalization of the findings is tentative. Further research with different groups of participants would help to clarify this issue. Also, as the present results are based on correlational data, it is not possible to attribute causal direction to the findings. It is possible that higher anxiety reduces parent identification. However, it seems more likely that lower parent identification contributes to the higher scores on anxiety. Conclusion: The present study demonstrates that psychological separation from parents occurs with some developmental costs. Males who show low identification with father and mother are characterized by greater anxiety, as are females who are weakly identified with the father. Understanding that these personality changes in late adolescence are often the accompaniments of the normal process of psychological separation from parents may help both parents and counselors navigate their relationship with late adolescents. References: Amato, P.R., King, V., & Thorsen, M.L. (2016). Parentchild relationships in stepfather families and adolescent adjustment: A latent case analysis. Journal of Marriage and Family, 78, 482-497. Adams-Webber, J.,& Neff, G. (1996). Developmental trends and gender differences in construing the self and parents. Journal of Constructivist Psychology 9, 225-232. Berenson, K.R., Crawford, T.N., & Cohen, P. (2005). Implications of identification with parents and parents‟ acceptance for adolescent and young adult self-esteem. Self and Identity, 4,289-301. Block, J. (2008). The Q-sort in character appraisal. Washington DC: American Psychological Association. Block, J., & Turula, E. (1963). Identification, ego control, and adjustment. Child Development, 34, 945-953. Blos, P. (1979). The adolescent passage. Madison: International Universities Press. Boles, S.A. (1999). A model of parental representations, second individuation and psychological adjustment in late adolescence. Journal of Clinical Psychology, 55, 497-512. Chang, J., & Block, J. (1960). A study of identification in male homosexuals. Journal of Consulting Psychology, 24, 307-310. Cramer, P. (1987). The development of defense mechanisms. Journal of Personality, 55, 597 6l4. Cramer, P. (1991a). The development of defense mechanisms: Theory, research and assessment. New York: Springer-Verlag. Cramer, P. (1991b). Anger and the use of defense mechanisms in college students. Journal of Personality, 59, 39-55. Cramer, P. (1995).Identity, narcissism and defense mechanisms in late adolescence. Journal of Research in Personality, 29, 341-361.

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Journal of Personality Assessment, 58, 51-66. Footnotes: 1Appreciation is expressed to Romney Latko for this coding. USE SIS JOURNAL TO SUPPORT US Insert Your Messages and Wishes In Half-Page: Rs. 5000/- In Full Page: Rs. 10000/- Get in Touch with either of us: Dr. Bankey L. Dubey Director, Somatic Inkblot Society Email: bldubey@gmail.com Dr. Naveen Gupta Editor-in-Chief Email: dr_naveengupta@yahoo.com Cell: 91-9627182913

Psychopathy is considered an essential construct in forensic work (Gacono, 2016). Most methodologically sound studies have involved males rather than females (Smith et al., 2014). Gender differences have been found to be, and continue to be considered important in the assessment and management of forensic populations (Cunliffe et al., 2016). Male psychopaths present as pathologically narcissistic whereas female psychopaths manifest a malignant form of hysteria. Both are pathologically self-focused; however, the grandiosity in males is contrasted by women‘s negative self-view. In the current study, male and female psychopaths (males = N = 44; PCL-R M = 33.13; females = N = 46; PCL-R M = 32.93) were compared using select Comprehensive System Rorschach variables. Female psychopaths produced more painful rumination (SumV), helplessness (SumY), and poor selfregard (EGOI ≥ .44 & Fr + rF = 0) than the males. Males were more detached (SumT) than females. Implications for future research, recommendations for these populations, and suggestions for using the PCL-R to assess female offenders are discussed. Despite a 646% increase in the number of incarcerated women over the past 30 years, State and Federal inmates remain predominately male (91%; Guerino, Harrison, & Sabol, 2011; Kaeble & Glaze, 2016). When compared to men, women offenders committing violent offenses are two times more likely to have committed their offense against an acquaintance (Bell Holleran & Vandiver, 2016; Greenfeld & Snell, 1999; Harrison, Murphy, Ho, Bowers, & Flaherty, 2015). This behavioral marker suggests a gender difference related to the psychodynamic/interpersonal world of the female offender as suggested by Gilligan (1982). Female aggression is frequently tied to the fracture of human connection (abandonment) and it signifies the failure of a relationship (Gilligan, 1982), and involves poor emotional control (affective violence) with concerns about disapproval and loss of group membership (Cunliffe et al., 2016). Similarly, gender differences are reflected in the differing patterns of aggression and violence displayed by men and women psychopaths (Gacono & Meloy, 1994). Females tend to have more reactive aggression [emotional dyscontrol] while males have more proactive aggression ([planned and purposeful] Hecht, Berg, Lilienfeld, & Latzman, 2015). Among male forensic subjects (both patients and inmates), psychopaths are responsible for a disproportionate number of serious behavioral problems (Hare, 2003; Hare & McPherson, 1984), are more difficult to manage (Gacono, 2016; Gacono, Meloy, Sheppard, Speth, & Roske, 1995; Gacono, Meloy, Speth, & Roske, 1997; Ogloff, Wong, & Greenwood, 1990; Rice, 1997; Rice, Harris, & Cormier, 1992) and commit a greater number of offenses compared to non-psychopathic offenders (Hare, 2003). Females offenders with elevated PCL-R scores stayed in treatment for lesser periods of time, had more violent and disruptive behavior, avoided urinary analyses, and spent fewer days in the community prior to the commission of a new offense (Richards, Casey, & Lucente, 2003). Impulsivity in psychopathic women has also been linked to violent recidivism (Weizmann- Henelius, Virkkunen, Gammelgård, Eronen, & Putkonen, 2015). Reflected in their violence against strangers, male psychopaths exhibit a detachment from and a contempt for others (Hare, 2016; Hare & McPherson, 1984). Integration of crosssectional studies of aggression suggests that

male violence is frequently driven by their narcissism (Gacono & Meloy, 1994; Hecht et al., 2015). Heightened interpersonal dependency, poor understanding of others, and a limited capacity for introspection all increase the female psychopath‘s risk of offending against her family, friends, and acquaintances (Cunliffe & Gacono, 2005, 2008; Kreis & Cooke, 2011, 2012). While male psychopaths have been studied extensively over the past 60 years, less is known about female psychopathy (Beryl, Chou, & Völlm, 2014; Cunliffe & Gacono, 2008; Cunliffe et al., 2016; Gacono, 2016; Smith, Gacono, Cunliffe, Kivisto, & Taylor, 2014; Verona & Vitale, 2006). As the number of incarcerated females continues to grow, it will become increasingly important to recognize the applied implications of gender differences. Psychopathy and Gender: While gender differences in attachment (Gilligan, 1982), socialization (Block, 1983; Feingold, 1990, 1991, 1992, 1994), gender role (Chodorow, 1975), conduct problems and aggression (Frick & White, 2008; Jang, Livesley, & Vernon, 1997; Pollack & Gilligan, 1982), self-concept (Bem, 1981; Lazare & Klerman, 1968), and personality disorders (Alnaes & Torgersen, 1988; American Psychiatric Association [APA], 2013; Grilo, Becker, Fehon, & Walker, 1996; Jang et al., 1997), have been found, the assessment of male and female psychopathy has generally been considered identical (e.g. the Psychopathy Checklist-Revised (PCL-R). The PCL-R uses the same criteria for both men and women (Hare, 2003). This practice continues despite gender differences such as the cold or detached, remorseless, and callous outward presentation seen in male psychopaths (Gacono, 2016; Gacono & Meloy, 1994), contrasted with the increased interpersonal interest, connection, and group affiliation found in women psychopaths (Cunliffe, Gacono, Meloy, & Taylor, 2013; Kries & Cooke, 2011, 2012). Certain PCL-R items may need slight modifications to account for gender differences (Bolt, Hare, Vitale, & Newman, 2004; Cunliffe et al., 2013, 2016; Hare & Neumann, 2006; Smith, 2013; Smith et al., 2014; Taylor, 2015). The current conceptualization of male psychopathy is an amalgam of a selfcentered, grandiose, and narcissistic personality along with an antisocial/criminal lifestyle (Gacono & Meloy, 1994; Klipfel, Garofalo, & Kosson, 2017; Klipfel & Kosson, 2017). The female psychopath, in contrast, shows less arrogance and selfaggrandizement, more interest in others, and in some situations, less violence (more limited opportunity than males due to reduced physical dominance) (Cunliffe et al., 2016; Smith et al., 2014). Both genders do; however, exhibit similar degrees of instrumental and manipulative behavior, lying, callousness, antisocial behavior, and criminal activity (Bolt et al., 2004; Cunliffe et al., 2016; Forouzan & Cooke, 2005). While male and female psychopaths display similar behaviors and share a comparable personality organization (borderline or psychotic, first noted by Gacono and Meloy (1994), both Rorschach research and other findings suggest that the syndrome is not equivalent across gender (Blinkhorn, Lyons, & Almond, 2015; Cunliffe, 2002; Cunliffe & Gacono, 2005, 2008; Gacono & Meloy, 1994; Smith et al., 2014; Verona & Vitale, 2006; see Figures 1 & 2). Kernberg (1975) utilized levels of personality organization as a way of discriminating among neurotic, borderline and psychotic patients (also see Acklin, 1997). It was a supplement to descriptive approaches to diagnosis and it would aide in differential diagnosis (Kernberg, 1984). Further, the three levels of personality constitute a personality structure while psychiatric diagnoses (i.e., paranoid, narcissistic) would constitute a personality style (Acklin, 1997). Three levels were identified (neurotic, borderline, and psychotic), such that neurotic would be higher functioning, borderline would be intermediate, and psychotic would be the lower functioning. These organizations are broad and could encompass many different personality

disorders. The neurotic level was contrasted from the borderline and psychotic levels due to an integrated identity and use of higher level defenses such as repression (anxietyrelated thoughts and memories are kept in the unconscious). The borderline and psychotic levels are contrasted based on reality testing (difficulty objectively differentiating from the internal and external world). Specifically, the borderline‘s reality testing improves and the psychotic‘s reality testing deteriorates (Acklin, 1997). Extensive Rorschach findings (Gacono, 1988; Meloy, Acklin, Gacono, Murray, & Peterson, 1997) have indicated male and female psychopaths are classified in the borderline or psychotic range. The male psychopathy model (Figure 1), involves four domains: interpersonal, cognitive, affective, and self-perception (adapted from Gacono & Meloy, 1994). The male psychopath is thought to be an aggressive variant of narcissistic disorder organized at a borderline level (Gacono & Meloy, 1994; Kernberg, 1984, 1992). Borderline personality organization is characterized by reality testing deficits (difficulty objectively differentiating from the internal and external world) and a reliance on primitive defenses such as splitting (intense emotions toward one object and contrasting emotions toward another object), devaluation (derogatory statements about others to fend of one‘s own need fulfillment), omnipotence (inflating self-worth to deal with thoughts of powerlessness), and projective identification (describing only good objects to protect against bad objects). Further, within the borderline level, poor impulse control and poor anxiety tolerance is usually observed (Acklin, 1997). Within the interpersonal domain, the male psychopath‘s immature object relations (emotional attachments that people form with objects compared to their interest in themselves) and use of primitive defenses manifest within their detached, sadomasochistic predatory aggression. Within the cognitive domain, the male psychopath has perceptual accuracy difficulties (not accurately perceiving reality) and fantasy based thinking (focused on emotion and imagery without moral or logical constraints). Affectively, the male psychopaths have poor emotional control (poor emotional regulation equivalent to a 5-year old), shallow affect, and a defensive avoidance of emotionally toned situations due to poor problems regulating the emotions. Finally, they exhibit pathological self-focus (only concerned with self) with grandiosity (self-perception). In Figure 2 (Smith et al., 2014), the female psychopathy model describes a hysterical style organized at the borderline level of personality organization (reality testing deficits and reliance on primitive defenses). Though hysteria currently has a negative connation as it can be considered misguided, stereotypic and non-existent, what is suggested here is related to a set of clinical symptoms in the psychodynamic sense. As described by Chodoff and Lyons (1958) a person that is ―vain and egocentric … display[s] labile and excitable but shallow affectivity, [is] dramatic, attention seeking and [their] histrionic behavior may go to the extremes of lying … are conscious of sex, sexually proactive yet rigid, and … are dependently demanding in interpersonal situations‖ (p. 736). Conceptually, it would be a combination of Borderline Personality Disorder (BPD) and Histrionic Personality Disorder (HPD). The female psychopath differs from males. Most are not detached, and display dysphoric affect (painful negative emotions). As these are selffocused, this process brings pain and uncomfortable feelings (damaged sense of self) unlike the self-aggrandizement found in males (Figures 1 & 2).

Smith, Gacono, Cunliffe, Kivisto, & Taylor (2014) We have found the Rorschach Inkblot Test to be extremely revealing, beyond the PCL-R, for eliciting the personality style of the female psychopath. She perceives herself as ‗damaged‘ (MOR = morbid response, M = 2.39, MOR > 2 = 39%), with her self-focus characterized by poor self-regard and chronic self-criticism (Egocentricity Index [EGOI] < .33 = 43%; EGOI > .33 and Reflections [Fr + rF] = 0; Vista responses [SumV], M = 2.04; Cunliffe & Gacono, 2005, 2008; Cunliffe et al., 2013).

The numbers of female psychopathic ASPDs who produce elevated Egocentricity Ratios without a Reflection on the Rorschach is noteworthy. Although increased Egocentricity Ratios on the Rorschach suggest an inordinate self-focus, high ratios without Reflections indicate a sense of displeasure during self-examination (poor self-regard; Gacono & Meloy, 1994; Weiner, 2003). Although male psychopaths tend to look at themselves with a sense of exaltation, selfadmiration and grandiosity (high Reflections, high Egocentricity Ratio), female psychopaths appear to experience distress while engaging in the same process (Cunliffe & Gacono, 2008). Individuals with a pattern of no Reflections, high Egocentricity Ratios, and Vistas (painful rumination), possess a situation-specific type of self-criticism not related to a true sense of remorse or guilt (Cunliffe & Gacono, 2008; Weiner, 2003). This pattern suggests chronic self-criticism and shame. Rather than experiencing remorse or guilt, the self-critical, unhappy, and dissatisfied presentation of the female psychopath may be viewed as an insidious negative self-image arising from longstanding frustration over unmet needs for attention and contact with others (shame rather than guilt). Rather than the cold, remorseless, and callous outward presentation seen in males, the female psychopath presents an outward appearance of increased interpersonal interest, connection, and group affiliation. Her behavior would be expected to be characterized by an increased need for contact with others (Rorschach elevated texture responses [SumT] = dependency) rather than the lack of attachment (no Rorschach texture responses [SumT]) found in male psychopathy (Cunliffe & Gacono, 2008; Cunliffe et al., 2016; Gacono & Meloy, 1994; Hare, 2003; Smith et al., 2014). These interpersonal/psychodynamic differences are exhibited in PCL-R Items 1, 2, and 5 (Cunliffe et al., 2013; 2016). All are on the same facet (1; Interpersonal) and they have been found to cluster together in research and clinical experiences (Gacono, 2005; Gacono & Hutton, 1994; Hare, 2003). For Item 1, as defined by Hare (2003) this item involves a ―verbally facile individual who exudes an insincere and superficial sort of charm...always ready with a clever and quick comeback…seems too slick and smooth to be entirely believable.‖ (p. 35). Male glibness presents in a boastful and swaggering fashion. Rather than glibness, the female manifestation is often characterized by a coy, coquettish, and seductive interpersonal style. Rather than the more physically and interpersonally dominant behavior of the male psychopath, the female would be more likely to present as a ―damsel in distress‖ to charm the interviewer. Combined with fewer indicators of dominance (i.e., lack of narcissism), the female psychopath is less prone to physical control and intimidation and more likely to manipulate others through dramatic, demure, and seductive displays (Item 5). Additionally, this greater need for contact is also reflected in the higher incidence of relational and affective violence. Therefore, the seduction on her part would be more likely to manifest in an attempt to elicit sympathy rather than the charming, slick and smooth attempts by the male psychopath to impress and cajole the evaluator. The description of Grandiose Sense of Self (Item 2) states the male has ―a grossly inflated view of his abilities and self-worth…may impress as a braggart...appears self-assured, opinionated, and cocky during the interview…perhaps giving the impression he is performing or giving a press conference.‖ (Hare, 2003, p. 36). In males, this item on Factor 1 has a strong relationship to the diagnosis of Narcissistic Personality Disorder (NPD; APA, 2013; Klipfel & Kosson, 2017; Klipfel et al., 2017) and describes an individual who is arrogant, self-centered, and overvalues his self-worth. However, base rates for NPD in women have been found to be significantly lower than in male samples (Stinson et al., 2008) while the prevalence for Borderline and Histrionic Personality Disorders (APA, 2013) have been found to be

significantly higher in women than in men. This lack of an individualistic orientation may also be understood as a reflection of Gilligan‘s (1982) suggestion that autonomy (separation from the group) would be more likely to be viewed by women as dangerous and contrary to a desire to maximize group affiliation. Thus, NPD is the more likely diagnosis with male samples while BPD and HPD are more likely to be found in females. Additionally, as reflected in the lower observed levels of agency found in female offender samples (Hicks, Vaidyanathan, & Patrick, 2010), a female offender would not be expected to present as ―self-assured, opinionated, and cocky‖ (Hare, 2003, p. 36) but instead would be more likely to engage the examiner in a more passive, subdued way. For example, contrary to bragging or engaging, active displays designed to impress the examiner or take control of the interview (males), a subtle glance or seductive body posture might be employed to lure the object of their attention. Item 5 is described as ―the use of deceit and deception to cheat, bilk, defraud, or manipulate others…use of schemes and scams motivated by a desire for personal gain…carried off in a cool, self-assured, and brazen manner.‖ (Hare, 2003, p. 37). Item 5 has been identified by a number of investigators (Bolt et al., 2004; Hicks et al., 2010) as a poor descriptor of psychopathy in females. Lower levels of agency and a greater likelihood of an active-dependent orientation (Millon & Davis, 1996) would contribute to a more accurate appreciation of how this particular item might manifest in women. Hare‘s (2003) depiction of the prototypic presentation on the item connotes an individual who is actively attempting to dominate another person by manipulative means as evidenced by their ―brazen manner‖ and the use of ―schemes and scams.‖ The female presentation is likely to occur in a much greater subtle form. Hypotheses: Based on previous research that has suggested that male and female psychopaths differ on how they perceive themselves, select Comprehensive System Rorschach variables (self-perception cluster/controls; EGOI, Fr + rF, Pairs, PER, MOR, SumV, SumT, and SumY) were examined. Specifically, these variables measure the following on the Rorschach: Egocentricity (EGOI), self-focus (Fr + rF = Reflections), Pairs (seeing two of something on the Rorschach related to egocentricity), PER (personalized responses; self-aggrandizement and/or defensiveness), MOR (morbid responses; damaged sense of self), Sum V (Vista responses; painful rumination), SumT (texture responses; affectional relatedness), and SumY (shading responses; helplessness). The following hypotheses were rendered: No differences would be seen between males and females on the EGOI. Males would have significantly more Fr + rF and PER while females would produce more Pairs, MOR, SumV, SumT, and SumY. Further, different variable values were also compared (i.e., SumT = 0, SumT = 1, SumT > 1). Method: Participants: Archival data were used which was collected at various federal and state prisons in the United States (California, Wyoming, and Kentucky) by the authors. The security levels of the inmates ranged from camp to maximum. The sample consisted of 44 males and 46 females. Males were comprised of 68% Caucasian, 18% African American, 11% Hispanic and 2% Native American. The ethnicities of the females were 63% Caucasian, 24% African American, 11% Hispanic, and 2% Asian. See Tables 1 & 2 for ages, IQ, total PCL-R score, and types of crime.

Table 1. Demographics for Male and Female Psychopaths Male Psychopaths (N = 44) Female Psychopaths (N =46) t-test p es M SD Range M SD Range Age 31.32 6.48 18-43 35.20 11.31 20-70 1.90 0.051 ns IQ 101.30 9.58 81-137 100.37 13.41 81-155 0.38 0.705 ns PCL-R Total Score 33.14 2.32 30-38 32.93 2.61 30-39 0.39 0.697 ns Responses 20.52 7.62 14-52 20.96 8.32 14-50 0.26 0.80 ns Lambda 0.92 0.62 0.13-2.50 0.75 0.50 0.06-2.13 1.42 0.16 ns Note. M = mean; SD = standard deviation; Freq = frequency; es = effect size; ns = not significant; Lambda = task engagement . Table 2. Frequencies for Rorschach Response Styles and Types of Crimes Male Psychopaths (N = 44) Female Psychopaths (N = 46) % % Response Style Ambitent Extratensive Introversive Type of Crime Violent 15.9 39.1 Drug 18.2 17.4 Sex 15.9 10.9 Theft 15.2 Fraud 10.9 Unknown/Other 50* 6.5 Note. There were no significant differences between males and females on response style or type of crime (p > .05). * Unknown/Other crime type category was not analyzed in the comparisons. Ambitent = inconsistent problem-solving style; Extratensive = a trial and error problem solving style; Introversive = a problem-solving style characterized by thinking things through carefully. Only those participants scoring 30 or higher on the PCL-R were included in the study. A PCL-R score ≥ 30 is recommended when performing categorical psychopathy research (Gacono 2016; Gacono & Gacono 2006; Hare 2003) as it ensures that there are ‗‗real psychopaths‘‘ in the study and increases the generalizability of the findings. Recently, researchers have questioned the use of a cut score of 30 (e.g., Balsis, Busch, Wilfong, Newman, & Edens, 2017), others have stressed the importance for the use of this cut score as it presents a more homogenous presentation of psychopathy (Gacono, 2016; Hare, 2016; Ruscio, 2007). Further, using statistical methods to show lower scores on the PCL-R (e.g., 24) as capturing a high level of psychopathy (Balsis et al., 2017) does not translate clinically (Gacono, 2016). Measures: The Shipley Institute of Living Scale (SILS; Shipley & Zachary, 1986) or the Shipley-2 (Shipley, Gruber, Martin, & Klein, 2009), Psychopathy Checklist-Revised (PCL-R), and Rorschach Inkblot Test (Exner, 2003; Rorschach, 1921/1942) were administered in accordance with procedures outlined in the test manuals. The SILS/Shipley-2 were used to screen out participants whose IQ score was lower than 80. The Psychopathy Checklist-Revised (Hare, 1991, 2003) was used to measure psychopathy. This measure contains 20

items and is administered via a semistructured interview (Gacono, 2005). Prior to the interview, an in-depth file review is needed in which medical, legal, psychiatric, and pertinent institutional files are reviewed. Following the clinical interview, the personality characteristics and antisocial behaviors are evaluated on a three-point ordinal scale with a total score range of 0 to 40. Gacono‘s (2005) Clinical and Forensic Interview Schedule (CFIS) was used to organize record and interview information. The inter-rater reliability estimates (Spearman Rho) were .98 for total PCL-R score (20 total comparisons). The Rorschach Inkblot Test has been proven to be useful for elucidating the inner world of individuals and is not used to ‗diagnose‘ psychopathy (see Gacono, 1998; Piotrowski, 2017). Rather, it was used to further elucidate the personality functioning of the psychopath (Gacono & Meloy, 1994). While the total PCL- R scores of the groups may be similar, the Rorschach data were used to ferret out personality differences (Gacono 1998; Gacono, Kivisto, Smith, & Cunliffe, 2016). The following variables from the Exner Comprehensive System (2003) were examined: Egocentricity Index (EGOI), PER (defensiveness, self-aggrandizement), Reflections (Fr + rF; self-focus), Pairs [(2)], MOR (damaged sense of self), SumT (affectional relatedness), SumV (painful rumination), and SumY (helplessness). Recent meta-analytic researchers have reported the EGOI and other CS Rorschach variables are problematic in general and with psychopathy in particular (Mihura, Meyer, Dumitrascu, & Bombel, 2013; Wood et al., 2010). However, critical examination of these meta-analyses has identified methodological flaws in the studies limiting the validity of these meta-analyses (Cunliffe et al., 2012; Smith, 2017; Smith et al., in press). All the Rorschach protocols were administered and scored per the Exner Comprehensive System Guidelines (Exner, 2003; Piotrowski, 1996) by doctoral level (Ph.D. or Psy.D.) clinicians. Furthermore, these had been scored reliably in regards to the Exner Comprehensive System. Kappa coefficients ranged from .75 to 1.00 (all in the excellent range [Meyer, 1999]). Moreover, 20 protocols were scored by two raters and inter-rater reliability was calculated from these protocols. Procedure: The archival records were examined. Previously, the participants were unpaid volunteers. They randomly received a flyer requesting their participation in their respective study. Exclusion criteria for selection were IQ < 80, previous diagnosis of a major mental illness (as these participants may confound the psychopathy presentation), and/or a lack of fluency in the English language. For this study, only participants that had a PCL-R total score ≥ 30 were used. PCL-R interviews and ratings, SILS/Shipley-2 and the Rorschach were completed by doctoral level clinicians (Ph.D. or Psy.D.) with extensive training in the scoring, administration, and interpretation of the measures. Data Analysis: The Statistical Package for Social Sciences (SPSS) version 22, was used for all calculations. For select variables, the data were analyzed for means, standard deviations, minimums, and maximums. Parametric statistics (t-tests) were used to compare the males and females on variables of age, IQ, EGOI, R, PCL-R total score, and Lambda (task engagement). Due to the nature of the Rorschach variables selected (SumV, Fr + rF, MOR, Pairs, PER, SumY, and SumT), these variables were examined with nonparametric statistics (Chi-square and Mann- Whitney U statistics; Viglione, 1995). Results: No significant differences between gender in regards to PCL-R total score, age, IQ, types of crime (other/unknown crime type was not compared), Responses (amount produced), and Lambda (measure of test engagement) were found (see Table 1 & 2). The female psychopaths produced a Rorschach response

style that was predominantly ambitent (inconsistent problem-solving style) whereas the male psychopaths produced a style that was predominantly extratensive (a trial and error problem solving style); however, there were no significant differences on any response style (see Table 2). There were no significant differences when comparing gender and the following Rorschach variables (see Table 3): Fr + rF (self-focus), PER (self-aggrandizement/ defensiveness), pairs [(2); related to eogcentricity], SumY (helplessness), SumV (painful rumination), and MOR (damaged sense of self). The male and female psychopaths significantly differed on Sum T (affectional relatedness), such that female psychopaths produced more SumT than the male psychopath. Table 3. Statistics for Select Comprehensive System Rorschach Variables Variable Male Psychopaths (N = 44) Female Psychopaths (N = 46) Statistic p es (r) M SD Freq (%) M SD Freq (%) Fr + rF 0.86 1.07 22 (50%) 0.61 1.02 15 (33%) 851.50* 0.14 ns Fr + rF > 0 22 (50%) 15 (33%) 2.81** 0.09 ns Fr + rF > 1 9 (20%) 8 (17%) 0.14** 0.71 ns SumV 0.64 1.08 19 (43%) 1.35 2.28 18 (39%) 965.00* 0.67 ns SumV > 1 3 (7%) 12 (26%) 6.01** 0.01 0.26 SumV > 2 2 (5%) 10 (22%) 5.75** 0.02 0.25 EGOI 0.40 0.17 44 (100%) 0.40 0.16 46 (100%) 0.20*** 0.84 ns EGOI ≥ .44 & Fr + rF ≥ 1 16 (36%) 12 (26%) 1.11** 0.29 ns EGOI ≥ .44 & Fr + rF = 0 3 (7%) 10 (22%) 4.05** 0.04 0.21 PER 2.77 2.53 36 (82%) 2.41 2.60 32 (70%) 897.50* 0.35 ns PER = 0 8 (18%) 14 (30%) 1.82** 0.18 ns PER = 1 10 (23%) 8 (17%) 0.40** 0.53 ns PER ≥ 2 20 (45%) 16 (35%) 0.24** 0.62 ns SumY 1.18 1.53 23 (52%) 1.48 1.22 34 (74%) 807.00* 0.09 ns SumY = 0 21 (48%) 13 (28%) 3.63** 0.06 ns SumY = 1 11 (25%) 9 (20%) 0.38** 0.54 ns SumY ≥ 2 12 (27%) 24 (52%) 5.81** 0.02 0.25 SumT 0.11 0.49 3 (7%) 0.89 1.46 21 (46%) 617.50* <0.001 0.34 SumT = 0 41 (93%) 25 (54%) 17.34** <0.001 0.44 SumT = 1 2 (5%) 13 (28%) 9.11** 0.003 0.32 SumT > 1 1 (2%) 8 (17%) 5.71** 0.02 0.25 Pairs (2) 5.64 4.12 44 (100%) 6.80 4.79 46 (100%) 883.50* 0.30 ns Pairs > 10 3 (7%) 12 (26%) 6.01** 0.01 0.26 MOR 1.82 1.92 30 (68%) 2.26 2.36 34 (74%) 914.50* 0.42 ns MOR = 0 14 (32%) 13 (28%) 0.14** 0.71 ns MOR = 1 9 (20%) 11 (24%) 0.16** 0.69 ns MOR ≥ 2 21 (48%) 23 (50%) 0.05** 0.83 ns Note. * Mann-Whitney U test; ** test; *** t-test; M = mean; SD = standard deviation; Freq = frequency; es = effect size; ns = not significant; EGOI = egocentricity index. Fr + rF = Reflections [self-focus]; SumV = Vista responses [painful ruminations]; PER = personalized responses [self-aggrandizement/defensiveness]; SumY = shading responses [helplessness]; SumT = texture resposnes [affectional relatedness]; (2) = Pairs [related to egocentricity]; MOR = morbid responses [damaged sense of self].

Further, with these Rorschach variables and the nature of the test, the male and female psychopaths were compared on values of specific variables (see Table 3). These analyses were hypothesized prior to data analysis. These comparisons used were based on specific Rorschach interpretations (Cunliffe & Gacono, 2008; Exner, 2003; Gacono & Meloy, 1994; Weiner, 2003). No significant differences were found on the majority of the comparisons (see Table 3). Significant differences were found for SumV > 1, SumV > 2, EGOI ≥ .44 & Fr + rF = 0, SumY ≥ 2, SumT = 0, SumT = 1, SumT > 1, and Pairs > 10 (see Table 3). Specifically, the female psychopaths produced a significant amount more SumV responses (painful rumination) than the male psychopaths. Further, more females had more SumY ≥ 2 (helplessness) responses and Pairs > 10 (related to egocentricity) than the males. The females produced more protocols with EGOI ≥ .44 & Fr + rF = 0 (poor self-regard) than the males. The male psychopaths produced significantly less SumT (affectional relatedness) than the female psychopaths. A content analysis (where specific Rorschach responses are reviewed to determine the quality of the response) was done on the SumT (texture) responses for the female psychopaths. It was found that 73% of the female psychopaths‘ texture responses were spoiled (did not give a normal healthy response to the Rorschach card). This indicated that when the female psychopath produced a SumT response, they had difficulty either with how they perceived the situation, viewed themselves as damaged, or responded in an idiosyncratic manner. Discussion: This is the first known study to compare male and female psychopaths with the Rorschach. With regard to participants, there were 40+ participants in each group with PCL-R scores ≥ 30. This ―cut score‖ (Hare, 2003, p. 30) for psychopathy groups cannot be stressed enough. It ensures ‗real psychopaths‘ (categorically determined) are included in the study and increases generalizability (Gacono & Gacono, 2006). While various cut-off scores are useful clinically to determine levels of risk, offering management recommendations and so forth, only the ≥ 30 cut-off is recommended for designating psychopathy as a category and forming psychopathy research groups (Gacono, 2016; Hare, 2003, 2016; Neumann, Vitacco, & Mokros, 2016). When examining the findings, some of the hypotheses were not supported. Males did not produce more reflections (Fr + rF; self-focus) or more PER (self-aggrandizement and/or defensiveness) than the females. Further, the females did not produce more morbid (MOR; damaged sense of self) responses than the males. The MOR response has been correlated with the AgPast response (tendency to view oneself as a victim; Gacono & Meloy, 1994; Gacono, Gacono, Meloy, & Baity, 2008; Smith et al., 2014). Therefore, both groups may take the victim stance, a common thinking error in a correctional population (Walters, 1990; Walters & Di Fazio, 2016; Yochelson & Samenow, 1977). The differences in SumY (females producing more than the males) may be related to the females expressing more helplessness than the males. Further, less SumY for males may be related to shallow affect noted and a defensive use of their grandiosity in warding off threats to self-esteem and avoiding affect/any painful feelings. There was support for other hypotheses. First, the male and female psychopaths had the same value on Egocentricity Index (EGOI; M = 0.40). The normative value for the EGOI is between 0.30 - 0.40 which suggests an adequate self-view. This was expected as a criterion of psychopathy is increased egocentricity. A more useful comparison between the groups was examining the EGOI and the Reflections in tandem. An increased EGOI (≥ .44; suggests pathological self-focus) with or without Reflections is more telling than

the two independent of each other. An increased EGOI with reflections in psychopaths suggest pathological narcissism (presence of a grandiose self-structure), whereas a high EGOI without reflections indicates a self-focus; however, there is a sense of displeasure with it (Cunliffe & Gacono, 2005, 2008; Weiner, 2003). In this study, more females had more EGOI without reflections compared to the males. When factoring in SumV (painful rumination) between the groups, the differences in expressing grandiosity is expanded. SumV can be described as a failed reflection (Gacono & Meloy, 1994). The females produced more than the males. In antisocial personality disorder in general and psychopathy in particular, the SumV can be seen as a situation-specific self-criticism rather than true guilt/remorse (Gacono, Meloy, & Heaven, 1990; Weiner, 2003). Therefore, it appears that the females rather than the males are more prone to self-criticism. The processes that regulate their self-worth are not effective in warding off painful affect and stabilizing their personality as is the grandiosity in the male psychopaths. Interpersonal difficulties were seen with the significant differences for SumT. Overwhelmingly, the male psychopaths did not produce any SumT signaling a lack of desire for closeness or attachment, while the females produced more SumT in comparison to the males. In a sense this T in the women acts as an intrapsychic (occurring within the mind) irritant (much like the T in the sexual homicide perpetrators; Gacono, Meloy, & Bridges, 2000). Without the T, there would be less drive toward relationships where all the other personality deficits are activated and play themselves out. The male psychopath does not have this troubling pull toward interpersonal relationships. These results help lend more support to both the underlying personality structures and the manifest personality style of the male and female psychopaths. Both are organized at the borderline personality level (Gacono & Meloy, 1994; Kernberg, 1992; Smith et al., 2014). Again, this finding suggests both have lapses in reality testing (difficulty objectively differentiating from internal and external world) and use primitive defenses such as splitting (intense emotions toward one object and contrasting emotions toward another object), devaluation (derogatory statements about others to fend of one‘s own need fulfillment), omnipotence (inflating self-worth to deal with thoughts of powerlessness), and projective identification (describing only good objects to protect against bad objects). However, the styles among them are different (see Figures 1 & 2). Male psychopathy has been viewed as an aggressive variant of NPD organized at a borderline level of personality functioning, the female psychopath presents with a malignant form of hysteria (BPD & HPD; Cunliffe & Gacono, 2008; Gacono & Meloy, 1994; Smith et al., 2014). Malignant hysteria has been described as a hysterical personality (―vain and egocentric, who display labile and excitable but shallow affectivity, whose dramatic, attention seeking and histrionic behavior may go to the extremes of lying, who are conscious of sex, sexually proactive yet rigid, and who are dependently demanding in interpersonal situations‘‘; Chodoff & Lyons, 1958, p. 736), ego-syntonic aggression, and antisocial tendencies. As can be seen with these findings, both displayed egocentricity (EGOI); however, the narcissism (high EGOI and Reflections) was not observed with the females. Rather, the females presented with a pathological selffocus and self-criticism (EGOI without Reflections & SumV). Thus, these women appear to not take pleasure in their self-focus. Interpersonally, the finding with SumT (more for females than males) appear to signify that the males are more detached while the females prefer interpersonal contact. However, other researchers have suggested (Cunliffe & Gacono, 2008; Forouzan & Cooke, 2005; Kreis & Cooke, 2011, 2012) this attachment in female psychopaths is a mechanism to gather attention and admiration rather than forming healthy relationships. Further, the spoiled SumT responses of the

females suggest this attachment is not mature. As reflected in the presence of the texture variable, researchers have found that female aggression is related to interpersonal relationships (Gacono & Meloy, 1994; Gilligan, 1982; Greenfeld & Snell, 1999). Further, both genders have a pathological self-focus (EGOI); however, the lack of reflections and increased SumV for the females suggest a damaged sense of self rather than the grandiose sense of self normally expressed by the male psychopaths. PCL-R & Gender Differences: ―The PCL-R has become the international standard for the clinical assessment of psychopathy, for both basic research and applications to the criminal justice system‖ (Hare, 2016, p. 44). Researchers (Gacono, 2016; Hare, 2016) have found it presents a better model and assesses the construct better than other models and measures (i.e., Triarchic model; Patrick, Fowles, & Krueger, 2009; Psychopathy Personality Inventory- Revised [PPI-R; Lilienfeld & Widows, 2005]). However, the measure was created with males and then it was accepted that the same items would be valid with females. Researchers have suggested certain items may not capture female psychopaths and it may be a better measure of psychopathy in males than females (Bolt et al., 2004; Forouzan & Cooke, 2005; Cunliffe et al., 2013, 2016; Smith, 2013; Smith et al., 2014; Taylor, 2015). As highlighted by current and previous findings, PCL-R Items 1, 2, and 5 may need a slight modification. Although male psychopaths frequently present with bravado designed to impress the examiner or take control of the interview (dominance, contempt for others), females are more likely to use coyness, subtle glances or seductive body movements to lure the object of their attention. A possible interpretation for females would be less focused on the arrogant, grandiose, and haughty behavior described for males (PCL-R; Hare, 2003). A failure to consider how this item might be expressed differently in a female would likely result in a lower score on these items. Therefore, clinicians should assess behavioral and interpersonal indicators for a preoccupation with how the female is perceived by others, a tendency toward self-dramatization, and impressionistic (lacking in detail) speech. Despite these suggestions, a complete revision is not needed, but something similar to expressing slight gender differences within the item descriptions. A female psychopath would not be expected to present as ―self-assured, aloof, opinionated, and cocky‖ (Hare, 2003, p. 36) but instead would be more likely to engage the examiner in a more active and seductive way. This is similar to the active dependent style of the histrionic personality described by Millon and Davis (1996). With this personality, the main characteristics described were an active dependence (active-other) and the use of seduction to achieve the attention they desire. This individual would be described as actively manipulating the environment by employing a variety of interpersonal maneuvers and giving nurturance to others in the service of receiving praise or attention from others. However, the nurturance was not interpreted to be for the benefit of others but rather is viewed as a way to solicit and ensure they receive attention in return. However, the clinician should not be surprised by a defensive, hostile reaction when her image (manifested in fabricated stories and direct lying) is confronted (see the case of Karen; Gacono & Meloy 1994). Recommendations: The presentation of psychopathy appears to differ in subtle ways between the males and females. Therefore, clinicians working with these populations need to be aware of the differences. Assuming that males and females present the same could result in lowering their PCL-R scores. In clinical work with criminal and forensic populations, a comprehensive understanding of psychopathy is imperative. Although in research investigations the study of primary

psychopathy (prototype) is important to highlight key differences between psychopathic and non-psychopathic individuals, the construct is more effectively used in a clinical context when viewed as a continuum (low to high) to improve assessment, management and treatment decisions. The following caveats are offered for the assessment of male and female psychopaths: 1. Male psychopaths may present with a narcissistic bravado (EGOI, Reflections) intended to charm the clinician via an insincere, glib and superficial charm designed to present themselves in a positive light. However, one presentation by the females may be to present in a coy, coquettish and seductive fashion in order to garner sympathy or present themselves as a helpless victim in need of protection (SumT). Clinicians are advised to pay particular attention to countertransferential thoughts and feelings (the clinician‘s feelings about the patient) with female offenders (also see Kosson, Gacono, Klipfel, & Bodholt, 2016). 2. Due to their heightened needs for attention and approval from others (SumT), female psychopaths could be expected to actively seek out therapeutic services and may present themselves as improving in therapy. However, the clinician is encouraged to adopt a ‗just the facts‘ approach and carefully check all of her claims against available records and clinical observations. 3. While male psychopaths may impress others as an arrogant braggart with an overblown sense of self-importance (increased EGOI & Reflections > 0), the female presentation may be characterized by poor self-regard and chronic self-criticism (increased EGOI, Reflections = 0, SumV > 0). It is suggested that the presence of these Rorschach variables not be viewed as evidence against the presence of psychopathy. 4. Contrary to males, females are more likely to express caring and concern for others (SumT). However, despite her statements, objective evidence of connection to others would be expected to be lacking (contact with family members, attempts at restitution, and observed altruistic behavior). Limitations and Future Directions: An exploration of facet and factor PCL-R scores could not be conducted as the male psychopathic group only had total PCL-R scores available. This is a limitation of the study and these differences between the two groups could not be explored. Though there were more than 40 participants in each group, more participants would give the results more potency. Therefore, the findings should be treated as preliminary. Future research should focus expanding the results with more participants and hope that it will lead to more scientific investigation. Such studies could focus on other Exner Rorschach clusters (Affective, Interpersonal, and Cognitive). Other scoring systems such as the Rorschach Oral Dependency Scale and the Gacono and Meloy (1994) Rorschach Extended Aggression Scores may provide more robust details on the differences between these populations. Conclusions: Psychopathy is an important construct that clinicians need to be aware of when working within criminal justice settings. Therefore, it is imperative to understand the differences in presentations when working with male and female psychopaths. These Rorschach comparisons begin to showcase the differences in an empirical fashion. Further, the Rorschach remains a valuable tool in helping empirically validate the inner lives of psychopaths. The Rorschach is a performance-based or processed-based task. This method allows the clinician to receive direct data and may provide different data than self-report assessment. Though it does not assess psychopathy (Gacono & Meloy, 2009; Cunliffe et al., 2012), when Rorschach findings are combined with the PCL-R, this approach provides a deeper understanding of male and female psychopaths.

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John E. Bingham, Ed.D. Cordova Counseling Center, Pensacola, Florida USA; Email: john_bingham@cordovacounseling.com (Corresponding author); Chris Piotrowski, Ph.D., Research consultant, University of West Florida, Email: cpiotrowski@uwf.edu Risk Assessment in the Forensic Evaluation of Child Sexual Offenders: A Diagnostic Framework based on 5 Case Reports John E. Bingham and Chris Piotrowski In professional mental health, requests from the legal community for determination of ‗risk assessment‘ in the adjudication of child sexual offenders are a popular and cardinal feature in forensic practice. In the contemporary milieu, a central concentration of both clinical and research interest is the efficacy and validity of expert predictions of recidivism based on data from specific risk assessment instruments, within the purview of the overall mental health evaluation. With the advent of the Internet and availability of modern communication technology, legal cases involving child pornography, sexting, pedophilia, child-contact offenses, and ‗sex stings‘ are escalating at an unprecedented rate. This paper reflects the forensic work of 2 forensic professionals with copious experience in the research and evaluation of child sexual offenders. In order to illustrate the nature and process of conducting legal requests for determination of recidivism/re-offense potential in child sexual offender cases, the authors elucidate the overall evaluation process and outcome by presenting 5 recent cases where the focus was on risk assessment. In addition, the authors caution that while expert evaluations can contribute to accurate predictions of sexual dangerousness, findings from research investigations have not yet confirmed the efficacy of risk assessment instruments in determining when child sex offenders are no longer a public threat following incarceration and/or treatment. Undoubtedly, the contemporary forensic examiner needs to be cognizant of these limitations and strive to be strictly objective, candid, and mindful of current research findings when expert testimony is at issue. The assessment, treatment, and legal adjudication of sex offender populations is a prominent clinical area in mental health practice (Hanson & Morton-Bourgon, 2005; Seto & Eke, 2017; Wright, 2009). Moreover, clinical interest with reference to sex offenders has expanded at an exponential pace over the past years, reflecting a robust concentration on the study of pedophilia (Seto, 2008), within the domain of child sexual abuse. Hence, the research literature on this specific offender group has grown exponentially, best illustrated by the results of an online search of the mental health literature—A keyword search (term: Pedophilia) of the PsycINFO database produced the following output of references: peer-reviewed articles (n= 1,122); book chapters (n=139); dissertations (n=170). Yet the study of pedophilia is beset with a myriad of challenges such as consensus regarding diagnostic accuracy (Coid et al., 2009; Mokros et al., 2017), online versus offline aberrations (Quayle & Jones, 2011; Ribisl & Quayle, 2012;), delineation of sexual ‗interest‘ versus the acting-out or direct contact with children, co-morbidity factors, sexual maturity preferences, heterogeneity confounds, propensity for child pornography (Seto & Eke, 2017), and the breadth and scope of test/assessment methods available in the literature (as there is no ‗Gold Standard‘ evaluation protocol). Undoubtedly, a central concern in pedophilia, from both a clinical and forensic perspective, is the issue of recidivism, risk assessment, and/or progression to direct child contact (Hanson & Morton-Bourgon, 2009; Schmidt et al., 2013; Seto & Eke, 2017). In addressing these noted challenges, the role of conducting a comprehensive evaluation of child sexual offenders is a central and critical feature of assessment, and more specifically, risk assessment. Over the past 30 years, the first author (J.B.) has been predominantly involved in the evaluation and treatment child sex offenders and has shared incisive clinical insights as a forensic mental health practitioner through a series of articles (see Bingham & Piotrowski, 1989, 1996; Bingham

et al., 1995; Turner et al., 2000), whereas the second author (C.P.) has served as a research consultant to expert witnesses since 1982. Thus, the aim of the current study is to provide a framework for conducting a forensic evaluation of convicted child sexual offenders when the central legal issue involves propensity for pedophilic interest, probability of recidivism, re-offense, and/or direct child contact. To that end, this paper illustrates the most salient features and issues pertinent to a forensic evaluation within the framework of a ‗risk assessment‘ involving this type of sex offender by presenting a concise summary of 5 recent case reports (where the authors were involved). Before proceeding, 1 caveat is in order: Both the mental health and forensic assessment process involve a myriad of tests, scales, measures and broad-band instruments (not including projective techniques, see Piotrowski, 2015) used in addressing legal questions in the Evaluation-Diagnostic tool-kit. While many of these assessment tools are traditional, popular mental health tests such as the MMPI (and related revisions), the Millon Inventories, and individual IQ tests (see Frauenhoffer et al., 1998; Piotrowski & Keller, 1992), others are sex offender-specific scales which include both well-seasoned measures/tests (Hempel et al., 2013; van den Berg et al., 2018) and emerging instruments (e.g., CPORT; see Seto & Eke, 2015) reported in the forensic assessment literature (Archer & Wheeler, 2013; Piotrowski, 2007). Forensic Case Reports Case #1 -- Possession of Child Pornography: Case History: A 64-year old Caucasian male was referred for a risk assessment evaluation as a result of having been charged and convicted of possession of child pornography. This man‘s personal history indicates that he is married and continues residing with his one and only wife. Three children were born to this union. He completed high school and attended college for a brief period of time. His first significant employment was the military followed by similar positions with the United States Government where he was employed at the time of his arrest. Due to the sensitive nature of his work, he has undergone several psychological and psychiatric evaluations so that he could maintain a Top-Secret clearance. Other than his current conviction, no prior legal history was identified. Childhood and teenage years were described as ―normal and routine‖ and he mentioned having an excellent relationship with his parents who are now deceased. He denied ever having been abused in any manner and states that there was no domestic violence occurring in his parent‘s home, nor has there been any violence between him and his wife. Risk Assessment: Mr. A has been viewing adult pornography for several years. More recently he began viewing child pornography which he ―came across‖ on a peer-to-peer website. As described by this man, the child pornography he viewed was primarily focused on the 13 to 16- year age group, primarily females, over a period of 1.5 years. Forensic investigative review confirmed the presence of child pornography, mostly in the stated age ban, although there were photos of children as young as seven. Even though an exact ratio could not be determined, there was clear evidence to suggest that the pictures and videos consisted primarily of adult pornography when compared to the amount of child pornography that was recovered which would be consistent of his statement that described viewing adult pornography for several years. His psycho-sexual history was confirmed by sexual history polygraph examination which was found to be negative for any contact offense and consistent with Mr. A‘s statements. He advised that he had begun viewing child pornography out of sexual curiosity and reliving sexual fantasies of his first sexual encounter when he was approximately 14 years of age.

Mental Health Evaluation: The major aim of the forensic evaluation was to determine level of risk for re-offense, i.e., recidivism. One method of obtaining objective data when conducting a risk assessment is by the utilization of psychological tests. Although most of these instruments are not designed specifically to identify a ―pedophile,‖ they can be used to identify ‗personality‘ profiles revealing specific risk factors. Several studies have determined that a severe psychiatric disturbance has been associated with a high risk of sexual recidivism. As determined by the Minnesota Multiphasic Personality Inventory – 2 Restructured Form (MMPI-2RF), the Millon Clinical Multiaxial Inventory – III (MCMI-III), mental status examination, and structured clinical interview, Mr. A did not present with any mental health history, abnormality, disability, or other behavioral characteristics often considered as a risk factor. Thus, there appeared to be an absence of a major mental disorder. Forensic Evaluation: Antisocial personality/ orientation is one of the most robust risk factors for criminal re-offense probability and has been found to correlate significantly with sexual recidivism. While there are several avenues of approach when attempting to identify antisocial orientation, in this specific case the following was utilized. As described in the DSM-V, antisocial personality disorder is a pervasive pattern of disregard for and violation of the rights of others. The MMPI- 2RF and MCMI-III were used to demonstrate a lack of personality features consistent with a disorder of this nature. In addition, character references also describe a consistent behavioral pattern of this offender helping others over the course of several years. Furthermore, his work history was consistent and there were no prior legal offenses. Individuals experiencing a substance use disorder often present with an increase in behavioral disinhibition. When considering this potential risk factor, the Substance Abuse Subtle Screening Inventory – 4 (SASSI-4) was utilized. The findings noted an absence of a substance use disorder which was consistent with this offender‘s self-report. To further evaluate the likelihood of reoffense, two structured tools based on professional judgment protocols were utilized, i.e., Sexual Violence Risk -20 (SVR-20) and the Child Pornography Offender Risk Tool (CPORT). Both instruments have been empirically derived and are well grounded based on psychometric credibility in the scientific literature (Smid et al., 2014; Rettenberger et al., 2010). Although the CPORT continues to undergo validation studies, the utility of this instrument appears quite promising. Based on the test results of these 2 instruments, this offender presented with a Summary Risk Rating of ‗Low‘ in terms of a propensity estimate for re-offense. Disposition: Based on the findings of the total assessment, the defense council submitted the report to the prosecuting attorney requesting modification of the initial charges. However, since a consensus was not met, this man‘s case was ―pled straight up‖ to the court. At his final hearing, Mr. A was sentenced as a sexual offender; however, adjudication was withheld. He was ordered into sexual offender treatment and placed on 10 years sexual offender probation with the stipulation that on successful completion of the 5-year probation he could request termination of sentence. Case #2 -- Female Pedophilic Offender: Case History: Although somewhat atypical, there are occurrences in which the offender is a female. In the case of Ms. B, a 26-year old female, was arrested for attempted sexual battery of a 14-year old male. She was referred for a risk assessment by her defense attorney whose defense strategy was to use the findings of the overall evaluation as factors in mitigation. Ms. B was single, never married, and had never given birth to any children. Although reared in an economically deprived familial environment, Ms. B came from an intact family of working parents with four older

siblings. As a young child she described how several of her siblings and cousins were frequently left in the care of an elder. She recalls having been sexually abused as early as six years of age, a behavior that continued until her mid-teens. Academic progress was often derailed due to severe bullying, especially during the 6th through 8th grades, resulting in Ms. B having to repeat the 7th grade. Although she graduated from high school, school records indicated that she had a learning disability. This woman did not report any significant medical or mental health treatment history. She did report the use of marijuana which began around the 6th grade, but denied the use of all other substances, including alcohol. At the time of her arrest she was employed with a private security company, having worked there for approximately six years. Prior to this she worked at local convenience stores. Documents reviewed found no prior legal involvement. Excluding sexual abuse, this woman had sexual engagements with approximately 14 males, mostly in her age ban with one or two being 10 years her senior. By agreement, Ms. B met the victim at his home; however, prior to sexual engagement, the young man‘s mother came into his room and the episode was discontinued. Risk Assessment: The assessment process consisted of a mental status examination, structured clinical interview, and administration of the MMPI- 2RF, MCMI-III, STAXI-2, SASSI-4, WAIS-IV, SVR-20, and a sexual history polygraph examination. The Static 99R was not administered during this evaluation as this instrument is not recommended for females. Mental Health Evaluation: The mental status examination and structured clinical interview revealed an absence of a major thought disorder, i.e., psychosis. Although both the MMPI-2RF and MCMI-III ruled-out a diagnosis of Antisocial Personality Disorder, as determined by the low RC4 on the MMPI-2RF and the low Antisocial Scale on the MCMI-III. However, the PTSD Scale on the MCMI-III was elevated, which could be anticipated as a result of her reported sexual abuse as a child. The results of the SASSI-4 suggested that Ms. B presented with a low probability of a substance use disorder, whereas the STAXI-2 demonstrated a lack of anger management issues as well as decreased assertiveness. In order to gauge her intellectual maturity, the WAIS-IV was administered, resulting in a Full- Scale IQ in the Borderline-Low Average range. Forensic Evaluation: The sexual history polygraph examination confirmed this woman‘s self-report of no sexual engagements with minors after she reached the age of majority. The presence of antisocial propensities is perhaps one of the highest risk factors present in general criminality and sexual offenses. Conversely, the absence of this disorder serves as a protective factor as in the case of Ms. B, which was confirmed by several sources, e.g., test results, personal history, character references, and no previous legal history. Behavioral disinhibition due to a substance use disorder and the presence of a major mental disorder (psychosis), both dynamic risk factors, was found to be noncontributory as determined by the SASSI- 4 and mental status examination. The SVR- 20 identified only one of the 20 empirically derived risk factors, i.e., child sexual abuse. Given that only one risk factor was identified, this woman‘s Summary Risk Rating for sexual re-offense was determined to be ‗Low‘. Disposition: As determined by the overall evaluation, Ms. B met the criteria for low risk of sexual re-offense. Due to these findings, her offenses were reduced to simple battery during plea negotiations. At sentencing the court accepted these factors in mitigation, requiring specialized treatment for a mental disorder, i.e., PTSD, which was unrelated to substance abuse or addiction. Ms. B was sentenced to two years state probation and ordered into mental health treatment to resolve PTSD issues, e.g., exposure to acts of sexual abuse resulting in prompting fear and feelings of helplessness in interpersonal relationships.

Case #3 -- Pre-Case Consultation: Forensic evaluations have a unique structure and focus when compared to mental health evaluations prior to initiation of treatment. When conducting a forensic evaluation, the examiner is attempting to present data-based probability estimates on mental health or forensic factors that often suggest a clarifying opinion that may or may not be favorable for the client in legal situations. On the other hand, mental health treatment is typically focused on assisting the client in resolving issues (Mussack & Carich, 2014). A major issue to consider prior to accepting a client for a forensic evaluation is determining if the assessment process will provide favorable assistance for the client, being mindful that the referring attorney has this as a primary concern and outcome. One way of addressing this issue is to conduct a brief consult with the client prior to case ‗acceptance‘ as presented in the following case. Case History: Mr. C, a 32-year old male, was referred for a forensic evaluation whose pending charges involve travelling to meet a minor, 13-year old male, for allegedly sexual purposes and using a two-way electronic communication device to solicit inappropriate sexual behavior. The referring attorney requested that a psychosexual evaluation be conducted and that the findings address factors in mitigation and risk of sexual reoffense. When conducting a consult, very specific and personal information has to be obtained in a relatively brief period of time. Importantly, the client must be apprised of the reason for the consult as most individuals have the expectation that their case has been accepted as evidenced by their attorney‘s referral. Initial Client Consultation: Due to the limited scope of the consult, the client is informed of the importance of providing factual information, explaining that there is a high probability that during the course of the evaluation most personal ‗secrets‘ will be discovered or identified. During this process, the examiner found it helpful to describe each of the psychological tests that would be administered, as well as explaining that the person‘s sexual history will be verified by a sexual history polygraph examination. Although not specifically designed for the purpose of conducting a consult, the SVR-20 has proven to have considerable utility. The SVR-20 is a structured professional judgment (SPJ) guideline composed of 20 empirically derived risk factors. In Mr. C‘s case, several risk factors were identified by the information obtained during the consult which included sexual deviation (two prior sexual offenses when 17 years of age), an absence of treatment history, a history supportive of a substance use disorder, two failed marriages, several places of employment of brief duration, prior misdemeanor offenses (e.g., retail theft), and possession of marijuana with one violation of probation. When Mr. C was questioned about his behavior at the time of the alleged offense in question, his explanation focused more on the victim‘s behavior as opposed to his input. Describing himself as bisexual, he reported a greater number of male than female sexual engagements initially in his age ban, but as he matured, his sexual contacts were much younger. Disposition: As a result of the consult, Mr. C‘s attorney was contacted (with official permission) and informed that due to his client‘s sexual history and the identified risk factors, a risk assessment would likely prove of little assistance in this case. By addressing a forensic referral in this manner, the examiner is able to abate any potential expectations the attorney may have as opposed to inter-professional tensions that may arise after a comprehensive forensic evaluation has been completed. In addition, this cautionary practice prevents the client from having to incur examination costs and undergo numerous hours of assessment and testing, as well as having to experience the potential embarrassing and emotionally painful process of the evaluation.

Case #4 -- Request for Supervised Visitation with Offender’s Children: As a rule, risk assessment evaluations are comprised of several components, which include case history, mental health and forensic evaluation, and disposition. However, as will be seen in Case #4, other salient components are a significant aspect of the overall evaluation. Case History: Mr. D was referred by his attorney for a risk assessment evaluation which would be presented to the court when requesting supervised visitation with his 10- year old son and 7- year old daughter. In 2011, this man had been convicted and sentenced as a sexual offender for travelling to meet and solicit sex with a 14-year old female (with parental consent) and attempted lewd and lascivious behavior. The actual event was a ‗sting‘ operation and Mr. D was sentenced to county jail followed by house arrest, with 15 years probation. He had no prior convictions. Mr. D‘s history revealed having been reared in a dysfunctional familial environment. As a result of his father having been in the military, the family changed geographic locations frequently. He described his father as an ―alcoholic and stoner‖ and mentioned that his parents ―fought all the time.‖ At age 5, Mr. D was sexually abused by his brother and friend three years his senior. The sexual and physical abuse continued until Mr. D was 15. This man joined the military at the age of 23. Mr. D‘s first marriage ended in divorce due to his infidelity. There were no children born to that union. He married a second time to the mother of their two children but divorced four years later. Since his conviction he has remained in a steady relationship. Even though Mr. D described himself as a poor student, he graduated from high school, obtained an AA Degree, and earned certification in a technical field. After receiving his Honorable discharge from the military, he obtained employment in his chosen field where he has remained ever since. Mr. D denied any significant medical conditions but began psychological treatment in 2003 primarily for hypersexual behavior. He remained in treatment on an on-and-off basis until he was admitted and successfully completed a sexual offender treatment program in 2012. Mr. D confirmed that he used marijuana on an occasional basis until 2004. In addition, he experimented with cocaine on one occasion and consumes alcohol weekly but denies abuse or dependency. Mr. D confirms a bisexual orientation with greater interest in females (100+ contacts) than males (30+ contacts). He reported one prior sexual engagement with a 14-year old female when he was approximately 20, but denies any other involvement with minors or having ever viewed child pornography. Risk Assessment: Mental Health Evaluation: There were no findings to indicate a major mental disorder as determined by the mental status examination and structured clinical interview. The SASSI-4 confirmed an absence of substance use disorder, consistent with his reported history, and the STAXI-2 did not reveal any anger management issues. The MMPI-2RF noted symptoms of PTSD (elevated emotional/internalizing dysfunctional, EID Scale), as did the PTSD Scale on the MCMI- III. Findings of this nature were anticipated given the extensive sexual and physical abuse Mr. D experienced as a child. Importantly, there were no findings of any antisocial features. Forensic Evaluation: Typically, the sentencing court (as in this case) will request that a risk assessment be conducted before approving supervised visitation for a sexual offender. As determined by the SVR-20, only two risk factors were identified, i.e., victim of sexual abuse and relationship problems, resulting in a Summary Risk Rating for sexual violence as being Low. Mr. D scored a ‗1‘ on the Static 99R, placing him in the Low risk category relative to other adult male sexual

offenders. In addition, he passed the sexual history polygraph examination. Because of the nature of this assessment, an outline of specific questions was presented to individuals providing character references, e.g., ―Please comment on Mr. D‘s parenting skills, discuss observations of Mr. D with his children prior to conviction, and describe any significant observations of Mr. D when he is around children.‖ Specific to these issues, all character references returned with favorable responses. Another component with evaluations of this nature requires that the non-offending parent (in this case the mother) must be informed of the results of the risk assessment as well as have input into the development of the safety plan for supervised visitation. This examiner has found two non-authored tools that have provided considerable utility when used to meet statutory guidelines and can be completed during the interview with the nonoffending parent. The first instrument provides consent for children to have supervised contact with Mr. D This instrument ensures that the mother has been given full disclosure of the risk assessment, Mr. D‘s current legal status, and that she had been involved in the development of the safety plan. The Family Safety Plan attempts to establish clear boundaries for visitation and/or reunification. Maximizing the safety of the children during supervised visitation is the primary goal and establishes clear rules and responsibilities for each of the family members. Before being submitted to the court for final approval, all parties must review and approve the plan. In this specific case, approval had to be obtained from the treating therapist, probation officer, and the children‘s mother and father (sexual offender). There were specific guidelines identified pertaining to the supervised visitation between the father and his two children. Examples include the father will not be alone with any child at any time, the specific time periods, locations allowed for visitation, the individuals approved to supervise contact between the father and his children, physical hygiene assistance (which includes toileting, bathing, and dressing) will never be done by the father, the father will never enter the bathroom while a child is in the bathroom or allow a child to enter the bathroom while he is in the bathroom, the father will not have any secrets with his children, and no tickling or wrestling between the father and his children. Most important, no pornography of any type or media will be in the home. Disposition: At the time of the request for the risk assessment, Mr. D had been in the community post-conviction over six years and had maintained consistent employment. As estimated by Harris et al. (2003), sexual offender recidivism risk declines by about half if individuals remain offense free for approximately five years. As determined by the risk assessment in this case, Mr. D was found to be Low risk of re-offense, had favorable character references, had successfully completed sex offender treatment, had not encountered any new violations during the past six or more years, and with the approval of the children‘s mother, the petition for supervised visitation was granted. Case #5 -- Video Voyeurism: Case History: Mr. E, a 37-year old male, has always resided with his now elderly parents. His brother holds a doctorate in nuclear physics while his sister is a vice-president of a large research institute involving A.I. This man‘s childhood and teenage years were without family discord or traumatic events. Both of his siblings were well above average in academia and social interactions, while Mr. E describes himself as having been a homebody with self-imposed restricted social activities. With encouragement and arrangement by family members, Mr. E maintained a steady relationship with his girlfriend/fiancée for a little over two years. However, the relationship failed due to her infidelity and becoming pregnant. Having failed a grade during elementary school, this man was placed in

special education classes where he remained until graduating from high school. During elementary and middle school Mr. E was severely bullied, both verbally and physically. He graduated from high school and then completed a vocational training tract. With assistance from a family member, Mr. E obtained a position as a stock clerk which he held until he was arrested. Mr. E has never received any type of mental health treatment or evaluation and he denies ever having experienced any significant medical problems other than gross obesity. This man also denied ever having experienced the use of any type of substances other than a very limited and occasional consumption of alcohol. He denied ever having been inebriated. Mr. E denies any prior legal involvement until his current arrest and conviction for video voyeurism. Mr. E‘s primary sexual orientation (based on very limited history) appears to be heterosexual with age mates. Actually, his only reported sexual experience occurred with his fiancée. He began ―peeking‖ and taking pictures and videos of family members during his teenage years which later progressed to his current offense. As described in the criminal Offense Report, Mr. E. utilized two methods to achieve up-skirting. The first method involved taping a cell phone to his shoe which he placed underneath a woman‘s dress. The second method involved kneeling beside the victim, pretending to be looking for an item on the lowest shelf at which time he would slide a video cam recorder under the woman‘s dress. It was the second method that led to his arrest and an additional charge of simple battery which occurred when he touched the victim‘s ankle when positioning the recording device underneath her dress. The victim responded aggressively, confronting Mr. E, demanding (loudly) possession of the camera and requesting security personnel. Mental Health Evaluation: As determined by the MCMI-III, elevations on the Avoidant and Dependent Scales indicated that a moderate level of pathology characterized the overall personality orientation of this offender. Specifically, defective psychic structures suggested an absence of adequate internal cohesion and less than satisfactory level of coping strategies which influenced his poor foundation for socially acceptable interpersonal contacts. These findings were confirmed by the MMPI-2RF as evidenced by elevation on the I.P.P. (Interpersonal Passivity) and S.A.V. (Social Avoidant) Scales. These findings, along with the information and date obtained from the mental status examination (i.e., restricted affect and depressed mood with an overlay of anxiety), raised concern regarding social inhibition. However, Mr. E‘s desire to engage in social relationships tended to rule out introversion. Additional confirmation regarding his passivity came from the STAXI-2 which noted that on limited occasions, when this man did experience anger, he quickly suppresses these emotions. Moreover, Mr. E‘s protocol suggested problems in interpersonal relationships and potential risk for medical issues. Due to the presence of deficits in socialemotional reciprocity, additional testing was indicated which included the WAIS-IV, Wide Range Achievement Test – Revision 4 (WRAT4), and the Adult Autistic Spectrum Quotient. The WAIS-IV determined that Mr. E was functioning in the borderline-average range with deficits in Verbal Comprehension, Working Memory, and Processing Speed while the WRAT4 found him to be several grade levels below expectancy with one significant anomaly, i.e., Word Reading 3rd grade level and Sentence Comprehension 12th grade level. His score on the AASQ was 28. Typically, a score of 32 or greater suggests the possibility of Asperger‘s syndrome.

Nevertheless, significant impairment in social interactions and social communication has resulted in social deficits and occupational functioning.

Forensic Evaluation: Polygraph examination (which he passed) and sexual history were consistent. The SVR-20 noted one risk factor, i.e., poor relationships. His Static 99-R Score of ‗2‘, i.e., unrelated victim and stranger victim, placed him in the Low Moderate risk category relative to other male sexual offenders. Based on the information and data obtained during this evaluation, there was indication that Mr. E required specialized treatment for a mental disorder that is unrelated to substance abuse or addiction. Moreover, this offender was found to be amenable to treatment. Disposition: At time of sentencing, Mr. E‘s maximum potential exposure to prison was between five and 10 years. However, based on his lack of prior legal involvement and consideration of the mitigating factors, Mr. E was sentenced to two years in prison to be followed by four years in sexual offender probation. Conclusions: Scholarly work on the topic of child sexual offenders is advancing at a rapid, exponential pace. In professional mental health, requests from the legal community for determination of ‗risk assessment‘ are a popular and cardinal feature of assessment and treatment in forensic practice in the adjudication of child sexual offenders, particularly in pedophilia cases. Within this purview, a central concentration of both clinical and research interest is the issue of professional evaluation of risk assessment potential, and more importantly, the efficacy and validity of recidivism based on specific risk assessment instruments. With the advent of the Internet and ubiquity of modern communication technology, legal cases involving child pornography, sexting, pedophilia, childcontact offenses, and ‗sex stings‘ are escalating at an unprecedented rate (Seto, 2013). This paper reflects the forensic work samples of 2 professionals with copious experience in the research and evaluation of child sexual offenders. In order to illustrate the nature and process of conducting legal requests for determination of recidivism/reoffense potential in child sexual offender cases, the authors elucidate the overall evaluation process by presenting 5 recent cases where the focus was specifically on risk assessment. At the same time, the authors caution that while expert evaluations can contribute to accurate predictions of sexual dangerousness, findings from research investigations have not yet confirmed the efficacy of risk assessment instruments in determining when child sex offenders are no longer a public threat following incarceration and/or treatment (see Hanson, 2003). In this context, there has been recent scholarly attention devoted to the issue of the decisionmaking process of forensic mental health professionals and the influence of ‗cognitive bias‘ regarding diagnostic opinions offered in forensic evaluation reports (Zapf et al., 2017). Undoubtedly, the contemporary forensic examiner needs to be aware of these limitations and strive to be objective and mindful of emergent research findings when expert testimony is at issue. References: Archer, R.P., & Wheeler, E. (Eds.). (2013). Forensic uses of clinical assessment instruments (2nd ed.). New York, NY: Routledge. Bingham, J.E., & Piotrowski, C. (1996). Online sexual addiction: A contemporary enigma. Psychological Reports, 79, 257-258. Bingham, J.E., & Piotrowski, C. (1989). House arrest: A viable alternative for sex offenders? Psychological Reports, 65(2), 559-562. Bingham, J.E., Turner, B.W., & Piotrowski, C. (1995). Treatment of sexual offenders in an outpatient community-based program. Psychological Reports, 76(3), 1195-1200. Coid, J.W., Yang, M., Ullrich, S., Zhang, T., Sizmur, S., & Farrington, D. (2009). Most items in structured risk assessment instruments do not predict violence. Journal of Forensic Psychiatry & Psychology, 22(1), 3-21. Frauenhoffer, D., Ross, M.J., Gfeller, J., Searight, H.R., & Piotrowski, C. (1998). Psychological test usage among licensed mental health practitioners: A multidisciplinary survey. Journal of Psychological Practice, 4(1), 28-33.

Hanson, R.K. (2003). Who is dangerous and when are they safe? Risk assessment with sexual offenders. In B.J. Winick & J.Q. La Fond (Eds.), Law and public policy; Protecting society from sexually dangerous offenders: Law, justice, and therapy (pp. 63-74). Washington, DC: APA. Hanson, R.K., & Morton-Bourgon, K.E. (2009). The accuracy of recidivism risk assessments for sexual offenders: A meta-analysis of prediction studies. Psychological Assessment, 21, 1-21. Hanson, R.K., & Morton-Bourgon, K.E. (2005). The characteristics of persistent sexual offenders: A meta-analysis of recidivism studies. Journal of Consulting & Clinical Psychology, 73, 1154-1163. Harris, A., Phenix, A., Hanson, R.K., & Thornton, D. (2003). Static-99 coding rules: revised 2003. Ottawa: Department of the Solicitor General of Canada. Hempel, I., Buck, N., Cima, M., & van Marle, H. (2013). Review of risk assessment instruments for juvenile sex offenders: What is next? International Journal of Offender Therapy and Comparative Criminology, 57(2), 208-228. Mokros, A., Habermeyer, E., & Kuchenhoff, H. (2017). The uncertainty of psychological and psychiatric diagnoses. Psychological Assessment, in press. Mussack, S.E., & Carich, M.S. (2014). Psychosexual evaluation. In M.S. Carich & S.E. Mussack (Eds.), Handbook of sexual abuser assessment and treatment (pp. 13-43). Brandon, VT: Safer Society Press. Piotrowski, C. (2015). Projective techniques usage worldwide: A review of applied settings 1995-2015. Journal of the Indian Academy of Applied Psychology, 41(3), 9-19. Piotrowski, C. (2007). Forensic psychological testing as a function of affiliation and professional setting. Organization Development Journal, 25(1), 94-98. Piotrowski, C., & Keller, J.W. (1992). Psychological testing in applied settings: A literature review from 1982-1992. Journal of Training & Practice in Professional Psychology, 6(2), 74-82. Quayle, E., & Jones, T. (2011). Sexualized images of children on the Internet. Sexual abuse, 23, 7-21. Rettenberger, M., Matthes, A., Boer, D.P., & Eher, R. (2010). Prospective actuarial risk assessment: A comparison of five risk assessment instruments in different sexual offender subtypes. International Journal of Offender Therapy and Comparative Criminology, 54(2), 169-186. Ribisl, K., & Quayle, E. (Eds.). (2012). Internet child pornography. Devon, England: Willan. Schmidt, A.F., Mokros, A., & Banse, R. (2013). Is pedophilic sexual preference continuous? A taxometric analysis based on direct and indirect measures. Psychological Assessment, 25, 1146-53. Seto, M.C. (2013). Internet sex offenders. Washington, DC: APA. Seto, M.C. (2008). Pedophilia and sexual offending against children: Theory, assessment, and intervention. Washington, DC: APA. Seto, M.C., & Eke, A.W. (2017). Correlates of admitted sexual interest in children among individuals convicted of child pornography offenses. Law and Human Behavior, 41(3), 305-313. Seto, M.C., & Eke, A.W. (2015). Predicting recidivism among adult male child pornography offenders: Development of the Child Pornography Offender Risk Tool (CPORT). Law and Human Behavior, 39(4), 416-429. Smid, W.J., Kamphuis, J.H., Wever, E.C., & van Beek, D. (2014). A comparison of the predictive properties of nine offender risk assessment instruments. Psychological Assessment, 26(3), 691-703. Turner, B.W., Bingham, J.E., & Andrasik, F. (2000). Short-term community-based treatment for sex offenders: Enhancing effectiveness. Sexual Addiction & Compulsivity, 7(3), 211-223. Van den Berg, J.W., Smid, W., Schepers, K., Wever, E., et al. (2018). The predictive properties of dynamic sex offender risk assessment instruments: A metaanalysis. Psychological Assessment, 30, in press. Vincent, G.M., Maney, S.M., & Hart, S.D. (2009). The use of actuarial risk assessment instruments in sex offenders. In F.M. Saleb, A.J. Grudzinskas, J.M. Bradford, & D.J. Brodsky (Eds.), Sex offenders: Identification, risk assessment, and legal issues (pp. 70-88). NY: Oxford University Press. Wright, R.G. (2009). Internet sex rings. In R.G. Wright (Ed.), Sex offender laws: Failed policies, new directions (pp. 117-158). New York, NY: Springer. Zapf, P.A., Kukucka, J., Kassin, S.M., & Dror, I.E. (2017). Cognitive bias in forensic mental health assessment: Evaluator beliefs about its nature and scope. Psychology, Public Policy, and Law, in press.

provide an analog of sorts to the psychoanalytic situation can support treatment planning, including decisions about whether to convert a psychotherapy patient to psychoanalysis and the training of psychoanalytic candidates. Two possible resistances that might work against the integration of psychoanalytic assessment with psychoanalysis are: (1) the strongly held views that psychoanalytically-informed assessment may have little to offer the experienced analyst, and (2) the notion that assessment is a perceived intrusion in the analytic process. The current paper discusses these salient clinical issues. Alternative perspectives are discussed to counter potential resistances to psychoanalytically-based assessment. In addition, suggestions for increasing awareness of these issues within the analytic community are noted. Finally, a model for formally studying what psychoanalysts know and how they utilize assessment is suggested. Ostensibly, the fields of psychological assessment and psychoanalysis share much history and conceptual DNA (e.g., Lerner, 1998; Rapaport, Gill, & Schafer, 1968; Schafer, 1954) and thus ought to be a fertile ground for clinical collaboration (i.e., analysts’ referring regularly for psychological testing and assessors’ providing timely, meaningful, and useful feedback and reports). Although research documentation is lacking, based on the authors’ experience as seasoned psychoanalysts and personality assessors, it is quite certain that this kind of clinical collaboration is rare in current therapeutic settings. One need only review case studies in such psychoanalytic journals as The Journal of the American Psychoanalytic Association, Psychoanalytic Inquiry, Psychoanalytic Psychology, The International Journal of Psychoanalysis, and Contemporary Psychoanalysis to appreciate the lack of integration of a psychoanalytically-informed assessment with a psychoanalytic case study. It may be that authors with psychoanalytic orientations who publish case studies are not invested in psychoanalytic methods of assessment; however, even the Journal of Personality Assessment, which explicitly supports the integration of case study and psychological assessment and which has published psychoanalytic psychotherapy clinical material conjoined with assessment (e.g., Bram, 2010, 2017, 2018), has yet to publish a study in which psychoanalysis and personality assessment are synthesized. This leads us to believe that there is something about psychoanalysis itself (i.e., at 3-5 times per week, preferably use of the couch) that provokes a distancing from psychological assessment. One such idea is that psychoanalysts and assessors are camped into “either-or” positions (i.e., doing either psychoanalysis or assessment, but not practicing both and, in some cases, not valuing both), despite seemingly constructive reasons to collaborate. For example, a recent article (Bram & Yalof, 2015) described the benefits of integrating psychoanalytic assessment with psychoanalytic treatment, including a review of Appelbaum’s (1977) report indicating that analysts who opted to ignore personality assessment data, even when the data were available to them in report-format, had poorer therapeutic

outcomes than analysts who used assessment findings. Both the history of psychoanalysis and personality assessment, and the potential benefits of their continued partnership, would therefore appear to invite more integration of these two disciplines, especially given the complexity of “widening scope” (Stone, 1954) patients now seen with increasing frequency in analysis. Yet, other psychological personality tests (Wright et al., 2017), including self-report methods are more popular among practitioners than “performance-based” (Meyer & Kurtz, 2006) measures (e.g., Rorschach: Exner, 2003; Meyer, Mihura, Viglione, Erard, & Erdberg, 2011; Thematic Apperception Test: TAT, Murray, 1943). These tests use lessstructured stimuli modeled on a psychoanalytic treatment paradigm in order to study underlying personality structure, defense mechanisms, object relations, selfrepresentation, alliance, and transferencecounter transference paradigms; that is, the core of psychoanalytic work. And, although we know little or nothing that is quantifiable about the assessment utilization practices among psychoanalysts, we do know is that the types of tests that might be of value to analysts are on the decline in academic graduate programs (see Piotrowski, 2015) and are taught less often, based on survey responses, in clinical-science and scientistpractitioner than in practitioner-focused programs (Mihura, Roy, & Graceffo, 2017). These findings do not appear to bode well for any future integration of psychoanalytic personality assessment, organized around such core measures as the Rorschach and TAT (c.f., Schafer, 1958, 1967), and psychoanalysis (e.g., such as studying early, mid-phase, termination, alliance, and outcome), save for those students and proponents whose motivation leads to further post-graduate training in both psychoanalysis and psychological testing. Shedler’s (2010) review of empirical evidence underscored the long-term benefits of psychoanalytic psychotherapy, but did not address psychoanalysis per se. But before we delve into our understanding of reasons for this disappointing state of affairs and potential remedies for bridging psychoanalysis with psychoanalytic personality assessment, we will briefly review the shared history and DNA of the personality assessment and psychoanalysis. Notably the two fields share a commitment to understanding people in-depth and conceptualizing treatment in individualized, meaningful ways. Moreover, assessment and psychoanalysis share the premise that there is more to understand about a person than self-report and that the Rorschach test provides a valid base for this type of assessment (Mihura & Meyer, 2018), with sophisticated psychoanalytic inferences applicable even on the more structured Wechsler (2008) intelligence tests (e.g., Bram, 2017) and thematic measures (e.g., Allison, Blatt, and Zimet, 1968). This premise-- namely, that assessment would address both conscious (explicit and declarative) and unconscious (implicit or procedural) processes-- was consistent with the theoretical consensus of the psychoanalytic community at that time. This perspective had begun to be incorporated into practices of personality assessment as far back as the 1940’s, when David Rappaport (of the Menninger Foundation and subsequently the Austen Riggs Center) established a battery of cognitive (i.e., intellectual), neuropsychological (i.e. sorting and memory tests), and projective personality tests (performance-based) to assess ego functioning under varied conditions in a manner that could provide direction for psychological treatment (Rapaport, Gill, & Schafer, 1968; Schafer, 2006; see also Yalof, 2006). Subsequently, Roy Schafer elaborated this tradition and went on to write about and mentor others (see Blatt, 2006) in the practice of applying psychoanalytic ego psychology to diagnostic clinical testing (Schafer, 1954) and psychoanalysis (Schafer, 1967).

Many

psychoanalytic clinicians and writers have continued to use and refine these approaches through the present (e.g., Allison, Blatt, & Zimet, 1968; Bram & Peebles, 2014; Kleiger, 1999; Lerner, 1998; Peebles-Kleiger, 2002; Rosenstein & Yalof, 2014; Tuber, 2012). Clearly, personality assessment and psychoanalysis share conceptual foundations valuing depth in understanding people and the process and goals of treatment. However, psychoanalysts and analytic clinicians do not refer for clinical psychological testing as often as one would expect. This comes as a surprise, considering how important treatment efficacy and quantifiable outcomes have become to the field of mental health. The authors contend that the evolution and refinement of these methods, and ways of thinking, remain clinically relevant and useful, and share our understanding of reasons that the current interface between personality assessment and psychoanalysis falls far short of its potential. In what follows, we identify two major areas of impediment to meaningful movement toward this potential: (1) Too few analysts understand what psychological testing/assessment can offer, and may therefore resist making referrals regarding testing, and (2) Challenges in the training of assessors with the necessary skills and sophistication to offer value-added to the clinical understanding of highly trained analysts. Resistances and Impediments to Analysts’ Referrals for Psychological Assessment: Psychoanalysis, in endeavoring to understand an individual’s unique qualities, can be complemented by personality assessment, as the latter, in taking a nomothetic approach, can aid in delineating the contours of an individual’s unique characteristics by means of relating it to empirically-derived norms. The multi-method approach described by Hopwood and Bornstein (2014) exemplifies a “surface to depth” assessment model that corresponds to the way in which many analyst’s work. This approach is expertly illustrated, for example, by Allison, Blatt, & Zimet (1968) in their comprehensive case review and integration of Wechsler, TAT, and Rorschach data. Moreover, research by Applebaum (1977) indicated that experienced analysts who did not utilize available testing data had less success at predicting treatment outcomes than those who did take into account test data augmented by interview data. Based on the authors’ experience, analytic candidates are challenged to find sustainable cases for 3-4x/week analysis, that cases emerging from low-fee clinic consultations can pose particular dilemmas around conversion to analysis, and that early alliance building can be aided by a thoughtful assessment of conditions under which the patient might prematurely regress. Therefore, with psychological assessment offering both a both a concurrent and predictive adjunct to analysis, why might analyst’s shy away from utilizing assessment consultatively when assessment can assist with decisions related to analyzability, obstacles to conversion, risk assessment, and impasse? Psychoanalytic candidates, for example, who are in supervision with the goal of transitioning a therapy case to analysis, might benefit from a consultative assessment. There are costs associated with the assessment that might serve as a realityobstacle of sorts that militates against requesting an assessment consultation, but we feel that there may be more to it than meets the eye. We note several such considerations: First, we want to note the possible fantasy of “What can you tell me that I don’t already know or can’t figure out myself?” Schafer (1954) described the tester’s omniscience, secondary to looking beneath defenses to ascertain the depths of pathology that only projective testing can unearth. However, we speculate that a similar construct may be operable in many analysts; that is, the belief in the power of their ability to formulate a case based on their clinical acumen. We refer back to what Appelbaum (1977) found when clinical insight alone was relied upon to come up with how an analysis will unfold. For most analysts,

there is probably a limited knowledge base associated with what a psychoanalyticallyinformed personality assessment can offer and when it might prove clinically useful. This knowledge gap is fixable through an instructive presentation, accompanied by a reading that highlights how and when assessment can assist the analytic process. Whether this parlays into referrals is an interesting issue to investigate. Second, testing might be perceived as an unwelcome intrusion on the analytic process. That is, the assessment can unearth material that the client is defended against and, moreover, the assessor is seen as the analyst’s henchman, hired to do the dirty work and rob the patient of his mind. This dynamic duo can play out in a good-cop/bad cop fantasy, with the assessor on the short end of things, but also with the patient questioning the analyst’s skill set, which might not be transference, but might be what Langs (1982) has called non-transference or accurate perception (not to be confused with distortion). What about medication management, adjunctive couples therapy with someone else, AA meetings, or even group therapy ongoing with analysis? What about children or adolescents who meet regularly with a school guidance counselor? Each contact can be brought back to the analysis, and the analyst might listen to the latent transference themes with respect to how the patient represents these other professionals to the analyst. However, the analyst has actively or passively agreed to work with the patient under these conditions, and they might be facilitative to the patient’s progress, even if they do not follow the slower and “defense conscious” pacing of the analyst. But each also disrupts what many consider to be the natural unfolding of the treatment. At what point does transference cease to be transference when there are other inputs operating within the treatment, each accessing elements of the patient’s mind, differently? Ultimately, is psychological testing all that different? Limited Training and Availability of Qualified Psychoanalytic Assessors: Perhaps the most significant obstacle on the assessment side to reinvigorating clinical collaboration with psychoanalysts involves the realities of recent and ongoing training priorities and patterns for psychologists. The past three decades have seen fewer and fewer graduate programs offering training in (1) depth-oriented personality assessment and (2) psychoanalytic theory and practice, let alone both (Piotrowski, 2017). The number of graduate programs, internships, and postdoctoral fellowships that offer rigorous training in both domains is miniscule. Although there are many motivated students, trainees, and early career psychologists, who are interested in the interface of assessment and analysis, it is difficult for them to find formal training opportunities with optimal levels of immersion in depth-oriented assessment and analytic thinking. The reason we emphasize immersion is that we are not sure there is any more challenging cognitive task as a clinical psychology trainee or practitioner than disciplined inferencemaking and crafting and writing a wellorganized, focused, and synthesized psychoanalytically-informed test report. The learning curve is incredibly steep, and it just plain takes considerable time, practice, supervisory feedback, rewriting, and repeated testing opportunities to develop a robust, competency-based skill set. Beyond mastering basics of administration and scoring (no longer a given, coming out of a doctoral program, even one that teaches clinical assessment), there is so much to learn about the dynamic meaning of formal test scores, inference-making, hypothesis testing, and how to understand and utilize the patientexaminer relationship. These points about training are entwined with and lead to a second impediment on the assessment side to more clinical collaboration with analysts: The quality of assessment feedback and reports is highly variable, and quite frankly but unfortunately, many

formulations and reports are not up to snuff, especially to be of use to highly-trained and skilled analysts who are already able to understand their patients with complexity. By virtue of the rigor of their training and their appreciation of depth and complexity, analysts are apt to be among the most demanding and discerning consumers of testing. Findings and reports that do not adequately address referral questions, do not integrate findings in a sophisticated way, and do not entail meaningful treatment implications are unlikely to provide value-added for the referring analyst and his or her patient. Such an experience will not engender further referrals and collaboration. What is likely to make for a more valuable product for analysts? Multimethod evaluations that make use of selfreport, performance-based, and collateralreport data, and integrate seemingly incongruous findings, and result in reports that are patient- and treatment-centered (rather than assessment-centered). By the latter, we mean reports that focused on referral questions, are empathic and evocative (Appelbaum, 1970), and include a clear formulation of what is going on underneath and driving symptoms; deficit, conflict, character, and/or trauma (Peebles, 2012) and implications for therapeutic alliance, optimal treatment focus, likely transference and counter transference paradigms, and potential sources of resistance (Bram & Peebles, 2014). When these criteria are met, our experience is that this not only does this assist the analyst and his or her patient and increases the likelihood of future collaboration with the analyst, but leads to spreading the word among colleagues in the analytic community. So, to return to the earlier point, without more immersive training and mentorship that can take students/early career psychologists through that difficult learning curve, there will remain a small minority of assessors who can fulfill this potential. Conclusion: We conclude with some ideas for doing so, involving outreach to the analytic world and fostering training and mentoring opportunities. First, analysts who also assess would do well by being a presence in the local analytic communities, even if it does not directly involve our psychological testing interests. Immersion in local analytic culture and has led to referrals and resulted in gratifying collaborations. Second, we suggest that these analysts search for more opportunities for immersion at the national level through workshops, trainings, distance learning, certification programs, presentation, and collaborative writing. We stress however, that the content of outreach to analytic communities must include what assessment provides above and beyond a clinical interview? How assessment informs the therapist regarding salient issues that a patient may not be able to self-report; the value of integrating the idiographic with the nomothetic. Illustrating the types of questions that the assessment process can answer, such as: What conditions will facilitate and impede an alliance with a patient with a history of failed treatments? Whether and how to proceed when considering conversion of therapy to analysis? How to restart a previously terminated treatment with a difficult patient? How to understand a protracted transference-counter transference impasse? Presenting testing case material and demonstrating how it informed an analyticallyoriented treatment would be as likely as anything to prove compelling to an analyst less familiar with assessment. Based on the authors’ experience with our (e.g., Yalof, Bram, & Gallagher, 2017) annual American Psychoanalytic Association Discussion group, including the referring analyst as a copresenter can enhance demonstration of the value of the assessment. Third, we encourage creating new opportunities for immersion in psychoanalytically-oriented testing. But this poses significant challenges, the most significant being the funding and time commitment in building programs within an existing graduate program or analytic institute. Fourth, further study might survey psychoanalysts in relation to (a) psychological assessment utilization (i.e., refer for and/or

test), (b) reasons for requesting testing; (c) orientation (e.g., conflict/ego psychological, relational, Kohutian), (d) degree (medical, psychology, counseling, social work), (e) specialty (child, adolescent, adult), and (f) training levels (e.g., candidate in training, graduate of an accredited psychoanalytic institute, certified, training and supervising analyst). References: Allison, J., Blatt, S.J., & Zimet (1968). The interpretation of psychological tests. New York, NY: Harper & Row. Appelbaum, S.A. (1970). The art and persuasion in the psychological test report. Journal of Consulting and Clinical Psychology, 35(3), 349-355. Appelbaum, S.A. (1977). Anatomy of change. New York: Plenum Press. Blatt, S.J. (2006). A personal odyssey. Journal of Personality Assessment, 87(1), 1-14. 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. (2017). Reviving and refining psychodynamic interpretation of the Weschler intelligence tests: The Verbal Comprehension subtests. Journal of Personality Assessment, 99(3), 324-333. http:// dx.doi.org/10.1080/00223891.2016.1236342 Bram, A.D. (2018). Understanding a therapeutic impasse: Using R-PAS in a multimethod assessment of alliance dynamics and underlying developmental disruption. In J. L. Mihura & G. J. Meyer (Eds.), Using the Rorschach Performance Assessment System (R-PAS; pp. 119-137). New York, NY: Guilford Press. 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: suppl., 74-97. doi:10.1080/07351690.2015. 987595 published online: 06 Jan 2015 Exner, J.E. (2003). The Rorschach: A Comprehensive System Vol. 1: Basic foundations and principles of interpretation (4th ed.). New York, NY: Wiley. Hopwood, C.J., & Bornstein, R.F. (Eds.). (2014). Multimethod clinical assessment. New York, NY: Guilford Press. Kleiger, J.H. (1999). Disordered thinking and the Rorschach: Theory, research, and differential diagnosis. Hillsdale, NJ: The Analytic Press. Langs, R. (1982). Psychotherapy: A basic text. Northvale, NJ. Aronson. Lerner, P. (1998). Psychoanalytic perspectives on the Rorschach. Hillsdale, NJ: The Analytic Press. Meyer, G.J., & Kurtz, J.E. (2006). Advancing personality assessment terminology: Time to retire “objective” and “projective” as personality test descriptor. Journal of Personality Assessment, 87(3), 223-225. 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., Roy, M., & Graceffo, R.A. (2017). Psychological assessment training in clincial psychology doctoral programs. Journal of Personality Assessment, 99, 153-164. http:// dx.doi.org/10.1080/00223891.2016.1201978 Mihura, J.L., & Meyer, G.J. (2018). (Eds.). Using the Rorschach Performance Assessment System (R- PAS). New York, NY: Guilford. Murray, H. (1943). Thematic Apperception Test manual. Cambridge, MA: Harvard University Press. Peebles-Kleiger, M. (2002). Elaboration of some sequence analysis strategies: Examples and guidelines for level of confidence. Journal of Personality Assessment, 79(1), 19-39. Peebles, M.J. (2012). Beginnings: The art and science of planning psychotherapy (2nd ed.).New York: Routledge. Piotrowski, C. (2015). On the decline of projective techniques in professional psychology training. North American Journal of Psychology, 17(2), 259-266. Piotrowski, C. (2017). Editorial: The linchpin on the future of projective techniques: The precarious status of personality assessment in the (overcrowded) professional psychology curriculum. Journal of Projective Psychology & Mental Health, 24(2), 71-73.

Rapaport, D., Gill, M., & Schafer, R. (1968). Diagnostic psychological testing (rev. ed.). New York: International Universities Press. Schafer, R. (1954). Psychoanalytic interpretation in Rorschach testing. New York, NY: Grune & Stratton. Schafer, R. (1958). How was this story told? Journal of Projective Techniques,22, 181-210. Schafer, R. (1967). Projective testing and psychoanalysis. New York: International Universities Press. Schafer, R. (2006). My life in testing. Journal of Personality Assessment, 86(3), 235-241. Shedler, J. (2010). The efficacy of psychodynamic psychotherapy. American Psychologist, 65, 98-109. doi: 10.1037/a0018378 Stone, L. (1954). The widening scope of indications for psychoanalysis. Journal of the American Psychoanalytic Association, 2, 567-594. Tuber, S.B. (2012). Understanding personality through projective testing. Lanham, MD: Jason Aronson. Wechsler, D. (2008). Wechsler Adult Intelligence Scale- Fourth Edition (WAIS-IV). San Antonio, TX: Psychological Corporation. 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 & Practice, 48(2), 73-78. http://dx.doi.org/10.1037/ pro0000086 Yalof, J. (2006). Case illustration of a boy with nonverbal learning disorder and Asperger’s features. Neuropsychological and personality assessment. Journal of Personality Assessment, 87, 15-34. 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. doi:10.1080/00223891.2013. 836528 Yalof, J., Bram, A.D., & Gallagher, K. (2017, January). Assessment and the analytic identity. In J. Yalof, & A. D. Bram (Chairs). Discussion Group at the National Meeting of the American Psychoanalytic Association, New York, NY. Note: An earlier version of this paper by the first two authors was presented at the Annual Convention of the Society for Personality Assessment, Washington, DC, March 2018. Correspondence should be sent to Anthony D. Bram: Anthony_Bram@hms. Harvard.edu Paperless Policy of SIS The Members of SIS are invited to Contribute to the Paperless Policy of Somatic Inkblot Society by opting for Soft Copies of SIS Journal of Projective Psychology and Mental Health instead of Print Version. The soft copies of every issue will be delivered directly on members Email. This will not only save our trees and be environment friendly but also would be time efficient. Write to me directly for opting out print version of SIS Journal on my Email ID: bldubey@gmail.com Bankey L. Dubey

aspects of the sexual abuse. This can be reflected in both psychological and physiological responses. Difficulties can range from psychological abhorrence or fear of any intimacy associated with the sexual activity to physiological symptomatology such as veganism and orgasmic disorders. These sexual difficulties can have a severe impact on the woman‟s ability to sustain long-term or interpersonal relationships. There is some evidence for greater difficulties in interpersonal and particularly intimate relationships among female adults who were sexually abused in childhood. There will be four different psychological case studies reviewed to analyze longterm impact of childhood sexual abuse which is different in terms of age, educational and social-economic background. Child sexual abuse is inappropriate sexual behavior with a child. It includes fondling a child's genitals, making the child fondle the adult's genitals, intercourse, incest, rape, sodomy, exhibitionism and sexual exploitation. To be considered „child abuse‟, these acts have to be committed by a person responsible for the care of a child (for example a baby-sitter, a family member, or a daycare provider).In 2010, a government commissioned survey (The survey, sponsored by WCD ministry and carried out by the NGO Prayas in association with Unicef and Save the Children) has found that more than 53% of children in India are subjected to sexual abuse, but most do not report the assaults to anyone. This may be due to the attitude of a large numbers of families in India. In most of the cases of childhood sexual abuse, victims are from female population in India. Literature supports the fact that childhood sexual abuse impacts negatively on many women‟s experiences of sexual contact. Victims of childhood sexual abuse often have associations, flashbacks and memories related to the specific aspects of the sexual abuse.

Difficulties can range from psychological abhorrence or fear of any intimacy associated with sexual activity to physiological symptoms such as veganism and orgasmic disorders. The experience of having been sexually abused is associated with a wide range of psychological symptoms and difficulties (Kendall-Tackett et al, 2002; Briere & Elliott, 2003; Putnam, 2003) and these problems can persist over years (Tebbutt et al, 1997). These include increased instability in relationships, more sexual partners, an increased risk of sexual problems and greater negativity towards partners (Isley et al, 2008; Roberts et al, 2004). These sexual difficulties can have a severe impact on the woman‟s ability to sustain long-term interpersonal relationships. The present study assumed that child abuse in India, as in other developing societies, is a phenomenon which is widespread and cuts across ethnic, social and economic boundaries. My therapeutic intervention with working women during last 3.5 years, referred by Psychiatrists and Gynecologists, who have been sexually abused during childhood, supports the findings of earlier mentioned studies. Most of these sexually abused women during childhood were found to be reserved, defensive and less willing to share their internal pain and survive in dysfunctional and negligent family environments (Blatt, 1975). Methodology: Tools used: Four cases with history of sexual abuse were administered Rorschach (Exner

Method) to understand the inner cries and pains of the clients. Statistical Analysis: Values of Rorschach were shown in Percentile. Results & Case Descriptions: Case 1: Index Patient A, was sexually abused by her cousin 5 years older than her, in her parental house during summer vacations in the absence of her parents. She was 9 yrs old at that time and enjoyed because those were pleasurable activities for her. After this she went back to her hostel. She was so beautiful during her adolescence, got many proposals of marriage, but she had subconscious fear of closeness which kept her away to get involved in any kind of relationship with males. She started masturbation to get feeling of sexual pleasure. She realized at her 20s that it was childhood sexual abuse by her cousin and developed guilt feelings and refused marriage proposals. After a few years she again started looking for new relationship after her conflict got resolved with continuous efforts of her mother. However, she was not able to trust any person for sexual relationship or compatibility. Sexual numbness is the term which she used to explain her avoidance for marriage and relationships. She is now 58 years old, well-educated lady from an upper strata but unmarried, living alone. On Rorschach test she perceived responses, with higher number of blood (Bl), clothing [Cg], sex [Sx], Human experience [Hx], Anatomy [An] and active Movement. D and Dd were the most viewed Locations. Deviant Verbalization [Level 1], Perseveration and Special content characteristic [AB, AG, COP, MOR] presented as a special score. Mostly responses were Personalized along with Poor Human Representation. Case 2: Index Patient B, a 12th grade college student, from middle strata was sexually abused for a continuous period of 6 years by her own elder brother in the form of a game in which she had to follow all his instructions to win. After 6 years her brother went to hostel for further studies and problems started with her behavior when she became more active sexually. She always tried to be in physical touch with her male classmates and asked for special attention through inappropriate physical gestures. School management reported her behavior to her parents. She told everything to her mother but mother suppressed her complaints under social prestige. Thereafter the girl started online friendship with random people for sexual conversation. She started to pay less attention to her studies. She tried to be friend with boys only. According to her, “My mind is obsessed with sexual thoughts only. I am used to imagine myself in being involved with someone and sometimes it‟s become too hard to control myself in the presence of my male friends. I don‟t want to go anywhere, and want to lock myself in the room.” Her brother is completely away from the scene because her mother told both of them to be separated and didn‟t share anything to their father. On Rorschach protocol, she perceived a total of 15 responses and rejected cards II, III and IX (all chromatic Cards), suggesting emotional conflict. She also viewed more of Human detail [Hd], clothing [Cg], Human experience [Hx], Anatomy [An] with Form Color and active Movement determinant. Mostly used locations were D and Dd. Perseveration and Special content characteristic [AG, COP] presented as a special score. Mostly responses were Personalized along with the presence of Poor Human Representation. Case 3: Index Patient C, an MBA graduate girl from upper-middle class army background family, got married at her mid-20s by her choice. Her family was against the marriage; they broke up all relationship with her. She was abused

by several male servants at the age 4 to 7 years, which resulted in faulty form of sexual satisfaction. After her marriage, she never experienced sexual satisfaction from her husband although both loved each other. Gradually she started making physical distance from her husband and involved in a new relationship with a guy who was younger than her. After sometime, she got fed up with this relationship and again developed a new relationship with a married man. As of now she is satisfied with this new relationship and wants to continue with him apart from the fact that they both have kids as well as family. On Rorschach protocol, she perceived 36 responses, with preponderance of sex [Sx] blood [Bl], clothing [Cg], Human experience [Hx], Anatomy [An], Form Color, active Movement and Pairs determinants. Mostly used locations were D and Dd. Special content characteristic [AG, COP] presented as a special score. Mostly responses were Personalized along with Poor Human Representation. Case 4: Index Patient D, A 23 yrs old girl, from a middle class family, who just completed her graduation, reported sexual abuse by her biological father since her childhood [about 4- 5 yrs of age].Initially she was not able to understand about such behavior and got disgusted towards her father and developed hatred. She reported it to her mother who asked her father about it. He replied that it is his way to show affection towards her, she is taking it in the wrong way. Her mother explained her in the same way as her father did to her mother. After her complaint, her father became more aggressive and started physical abuse as well. Nobody in the family was ready to believe her and thought it a cooked story to gain special attention as she is a girl child. At the age of 20, she left her home for further study and broke up her relationship with her parents. After a few days she got a phone call from her younger sister that her father is abusing her sexually. She decided to get a job to get settled with her sister. She joined a company but whenever a male colleague passed by her side or tried to start conversation with her, she became uncomfortable and tried to maintain a distance. She developed a gradual fear of sexual abuse. She was not able to concentrate on her duties and finally she left her job. She is currently not able to use any kind of public transport, to attend any social gathering, and is not comfortable with male doctors. Currently she is staying with her maternal uncle who is very kind and understanding but whenever her aunt goes out of home, she locks herself in the room due to her fear of being sexually abused. In her own words, during therapy sessions she said… “I can‟t go outside, they‟ll rape me, all males are same, and they just want to touch me, always try to have physical relations with me. I want to die, do not want to face all this. Please suggest me some easiest way to commit suicide.” She attempted suicide twice after leaving the job, as per her maternal aunt‟s information. On Rorschach test she viewed 19 responses and rejected two cards- IV and VI. Rejection of both cards IV and VI confirms conflicting relationship with father and conflict with the male genitalia. The rejection of cards is very strong indicator of perpetuator‟s behavior which she had undergone for years together and was unable to process the pain inflicted to her. She had higher blood [Bl], Human details [Hd], clothing[Cg], sex [Sx], Human experience [Hx], Anatomy[An] with Color Form and active Movement determinant. Mostly used locations were D, Dd. Dds. Deviant Verbalization [Level 1], and Special content characteristic [AG, COP, MOR] were presented as special scores. Mostly responses were Personalized with the presence of Poor Human Representation with Special Color Phenomena [Color Projection].

Table 1. Rorschach’s findings Rorschach‟s Finding Case 1 Case 2 Case 3 Case 4 Percentage of Human Responses 78 % 30 % 85% 42% Percentage of Response on Cards VIII, IX, X 47% 26% 55% 42% Rejection of Card IV Father Fig No No No Yes Rejection of Card VII Female Sex/Mother Figure No No No No Rejection of Card VI Male Sex Figure No No No Yes Percentage of Anatomical Response 27% 44% 20% 47 % Number of Rejection of Cards Discussion: The index cases clearly indicate severe impact of sexual abuse on woman‟s ability to sustain long-term interpersonal relationships. All the cases were from different socioeconomic backgrounds but affected from the same cause being “childhood sexual abuse”. In cases 1 & 4, both victims were not able to maintain an intimate relationship because of the impact of their past painful sexual relationship. They had developed feelings of insecurity towards males. These women were either unable to trust men or were overly trusting in closeness of their relationship with men. Mullen et al (1994) concluded their study by reporting that the women who continued to be affected by childhood sexual abuse developed a fear and distrust towards men and reported sexual problems as the most frequent long term sequel of the abuse. Instability in relationships and more sexual partners was seen in case 3 as supported by Isely et al (2008) and Roberts et al (2004). It was due to her sexual dissatisfaction and confusion about her own sexuality, which is supported by Mullen et al (1994), who reported that the victims of child sexual abuse expressed dissatisfaction with their sex life and were more likely to experience difficulties with their own sexuality compared to a control group of women who had not been sexually abused. Experiencing intrusive or disturbing sexual thoughts were seen in case 2. Mullen et al (1994) also found that child sexual abuse impacted on a number of important developments of the child. “It puts at risk the emerging sexual identity. It puts at risk the acquisition of a sense that the world is a reasonably safe and essentially benign environment. It puts at risk trust in others, particularly those on whom they are critically dependent. It puts at risk children‟s emerging sense of themselves as active agents with some control over their world; and finally, it puts at risk their developing self-esteem.” As far as the Rorschach‟s findings are concerned, the above cases clearly indicate evidence-based findings in relation to past research findings. High movement responses are a warning sign to indicate marked presence of conflict or internal tension. Such people probably see themselves as surrounded by treating persons and are unable to reconcile themselves with their environment [Exner 1993]. Frieswyk & Colson (1980) reported that borderline personality disorder patients frequently gave aggressive responses on the Rorschach test, and these cases seem to have significant features of borderline personality disorder. High Hd associated with preoccupation with the self restricts the degree of contact with others [Klopfer & Davidson, 1962], as we have seen in cases 1 & 4. Presence of Special Scores suggests some kind of cognitive distortion in these cases [Exner, 1991, 1993].

Conclusion: The commitment of sexual abuse is a mental sickness of the perpetuator which is the result of a distorted kind of mind-set. This mind-set consists of false beliefs about sex, and a kind of learned behavior from the abusive family or sexual abuse during childhood/ early adolescent. It is important to remember that sexual activity, as a part of sexual assault or abuse, is not a healthy behavior. It is possible to shift a sexual abuse mind-set to healthy sexual attitudes after re-educative and hypnotic psychotherapy. Projective tests help in peeping through the inner depth of suffering individuals and the responses helps to formulate therapeutic intervention. References: Blatt, S. J. (1975). The validity of projective techniques and their research and clinical contributions. Journal of Personality Assessment, 39(4), 327- 343. Briere, J. & Elliott, D.M. (2003). Prevalence and psychological sequelae of self-reported childhood physical and sexual abuse in a general population sample of men and women. Child Abuse & Neglect, 27(10), 1205-1222. Exner, J.E. (1991). The Rorschach: A comprehensive system Vol. 2: Interpretation (2nd ed.). New York: Wiley. Exner, J.E. (1993). The Rorschach: A comprehensive system Vol. I: Basic foundations (3rd ed.). New York: Wiley. Frieswyk S. & Colson D.(1980).

Prognostic considerations in the hospital treatment of borderline states: the perspective of object relations theory and the Rorschach. New York: International Universities Press; p. 229– 255.https://www.childlineindia.org.in/pdf/MWCD -Child-Abuse-Report.pdf (retrieved:August,2016) Isely, P. J., Isely, P., Freiburger, J. & McMackin, R. (2008). In their own voices: A qualitative study of men abused as children by Catholic clergy. Journal of Child Sexual Abuse, 17(3-4), 201-215. Kendall-Tackett, K. A. (2002). The health effects of childhood abuse: Four pathways by which abuse can influence health. Child Abuse & Neglect, 26(6-7), 715-729. Klopfer, B., & Davidson, H.H. (1962).The Rorschach Technique : An introductory manual. New York : Harcourt,Brace & World. Mullen, P.E., Martin, Anderson, J.L., Romans, J.C. & Herbison, G.P. (1994).The Effects of Child Sexual Abuse on Social, Interpersonal and Sexual Function in Adult Life. British Journal of Psychiatry, 165, 35-47. Putnam, F. (2003). Ten-year research update review: Child sexual abuse. Journal of the American Academy of Child and Adolescent Psychiatry, 42(3), 269-278. Roberts, R., O'Connor, T., Dunn, J., Golding, J. & ALSPAC Study Team (2004). The effects of child sexual abuse in later family life; mental health, parenting and adjustment of offspring. Child Abuse & Neglect, 28(5), 525-545. Tebbutt, J., Swanston, H., Oates, R. K. & Otoole, B. I. (1997). Five years after child sexual abuse: Persisting dysfunction and problems of prediction. Journal of the American Academy of Child and Adolescent Psychiatry, 36(3), 330-339. SIS Doctoral Research Award Somatic Inkblot Society announces an award to the Research Scholars who have employed any version of Somatic Inkblot Series as a tool in their doctoral dissertation. The award carries a Citation and a cash award of Rs. 5000/- to the research scholars. Submit a soft copy of your doctoral dissertation to claim your award on Email ID: bldubey@gmail.com. The Award will be delivered in the next International Conference of SIS. Bankey L. Dubey Director, Somatic Inkblot Centre

This case demonstrates the use of cognitive behavioural therapy in the treatment of Gender Identity Disorder. An 18-year-old male presented with complaint of feeling of discomfort with his sex organ for several years. He had taken treatment for it with no relief. The Somatic Inkblot Series was administered to understand the underlying psychopathology and conflict of his gender dystopia. The Cognitive Behaviour Therapy was administered in 12 sessions along with pharmacological treatment. The periodic assessments including follow ups indicated substantial change and improvement in his condition which is being maintained even after six months of follow up. The case is presented to highlight the effectiveness of CBT. Body image is a complex multifaceted construct including physical characteristics, psychological traits, and societal norms (Cash, 2004). Body image can be studied through the assessment of body-related satisfaction, feelings, ideals, and quality of life. In people with gender dysphoria (GD), body dissatisfaction-resulting from the discrepancy between ―assigned‖ sex at birth and experienced gender—often leads to seeking medical care. Earlier research has shown that body dissatisfaction of people with GD at admission is high and often reaches beyond the characteristics of sex (Grift at al., 2016; Becker at al., 2016). Because not all body parts are affected by treatment, it is uncertain whether medical transition can completely dissolve body dissatisfaction. The diagnosis of Gender Identity Disorder (GID) is dependent on two components. The first, in adults, a strong and persistent cross-gender identification; and in children, various behaviours like the insistence that they are the opposite sex, a preference for crossdressing, and a preference for playmates of the opposite sex. The second component involves persistent discomfort with his or her sex or a sense of inappropriateness in the gender role of that sex (Karasic & Drescher, 2006). Transgender people may be sexually oriented in attractions, behaviours, and identities toward men, women, other transgender people, or any combination (Grant et al., 2011; Iantaffi & Bockting, 2011; Nuttbrock et al., 2011). The present case study aimed to re-educate the client towards resolving his identity issue. The SIS-II was administered to find out the underlying psychological trauma, if any, leading to such behaviour and the therapeutic intervention with the help of Cognitive Behaviour Therapy. Brief Clinical Description: Index patient is 18 year old male, un-married, studying in B.Sc. First year, Hindu, Hindi speaking, hails from urban area of Agra and belongs to lower-middle socio economic background. He was apparently doing well until he ran away from home without informing anyone. Three months later, with the help of Police, he was located in Delhi while moving with a group of Transgender in Delhi, dressed up like a girl. His parents got shocked after seeing their son dressed up like a female. They took him back home and enquired about everything. The patient told them that he feels good while living with transgender and it provides his Identity and as he always felt being trapped in a male body. When asked if getting a chance, ever, would he change his gender ?, he replied ‗Yes‘. While living with trans-genders, he took injections to develop breasts and complete all rituals to become a transgender. He started going out with other

group members and earned money by dancing in marriages and trains. The patient adopted feminine mode of carrying himself and clapped like transgender. He further said that it always fascinated him to interact with transgender individuals right from his school days. During three months when he was away from home, his parents got to know from one of his friends that the patient used to meet the transgender group of local area daily and spent one to two hours interacting with them after his tuition classes. Patient‘s parents reported that he always liked to spend his time more with girls rather than boys in school days. Dancing, cooking and grooming himself like girls were always his hobbies. When he was brought to home from Delhi, he tried to run away several times, but was caught by his uncle and brought to Institute of Mental Health and Hospital, Agra for treatment. Cognitive Behaviour Therapy in Gender Identity Disorder: Psychological treatments deal with responses of the individual to stressors related to the social experience of Gender Dysphoria. Talking with the psychotherapist helps process through one‘s feelings of fear, anxiety, sadness, shame. Cognitive Therapy has been shown to be an effective treatment for psychological stressors. Twelve sessions of CBT were administered with the objective to convince him to be as "Male". The first four sessions were taken on alternative days, the next four sessions were administered twice a week and last four sessions were administered once a week. Session One: Started with psycho-education about his nature of problem - prevalence, incidence, psychological and pharmacological treatment facilities available in India for GID. During the session he was sensitized about side effect of such treatment and was asked to rethink about his decision. Session Two: This session was started with taking feedback of last session and about his final decision about sex transformation. He was 100% sure to go for hormonal and surgical process for transformation of sex. In this session he was asked to think about different role of sex in society and whether he is a good fit in such roles and social norms. Session Three: This session started with discussion about female sex and how much he is comfortable to be a female in society. He came to know that after sex transformation, he may lose productivity as a male and may not be able to be a father or mother in future. Session Four: He was not willing to come in this session as he was conformed to his individual decision but he was brought by an attendant of the respective ward for session. During this session he was sad and did not want to stay in inpatient setting of the Hospital. Sessions Five to Eight: He was motivated for not undergoing sex transformation; instead stay at home and follow the norms of the family and society. He was further discussed issues from where he developed this interest. He narrated the history about his interest, playing with girls during his early child hood and preference of female play/game rather games played by boys and was more happy to wear the cloths of girls. Sessions Nine to Twelve: His family was called and counselled about how they can help the client. They were also advised to develop new interest in life and not to lock him at home. Somatic Inkblot Series-II: The Somatic Inkblot Series (SIS) is a structured, projective, diagnostic procedure and is an adjunct to psychotherapy. It is based on spontaneous, individually generated responses to semi-ambiguous figures, which elicit intra-psychic associations specific to the person presented with them. The Somatic images evoke symbolism and meanings unique to the responding individual. These 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 may abreact emotional conflict raised to consciousness by the images, which can be a therapeutic experience in itself (Cassell & Dubey, 2003). The SIS 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 which brings whatever is buried in the mind closure to consciousness, accessible for processing. Expression stimulated by ambiguous imagery can be used in therapy to test insight and to help measure treatment progress (Dubey, et al,2014). A few significant responses relevant to this case are analysed below: A1 He perceived this image as " looking like lungs, ugly looking." This indicates low body imagery and a kind of low self. A5 "Cartoon and looks good" may indicate his desire to keep smiling and happy. The common response on this image is "happy man" A7 He viewed it as "Funny picture of a girl" though the dancing lady is the most common response on this image. Avoiding to perceive dancing lady may indicate his conflicting behavior and role particularly in female domain which he is not sure to accept forever. A9 He has perceived it as "half pictures" He has again avoided perceiving two persons particularly a male and female, may further bring the gender conflict already brought on earlier image A7. A10 Preponderance of " X-Ray of Stomach" on A10, "ultrasound of Stomach on A14, A15, B10, B11, X- Ray of Lungs and intestine on A17, and A19 suggested his preoccupied bodily anxiety probably due to thinking of changing the sex and adopting new roles in life. Many such responses may further suggest somatization tendency (Klopfer, 1954). A27 In spite of perceiving Breast on this image he has seen "Ladies sandal" which may indicate severe conflict with mother particularly during oral state of development when mother could not take proper care of the child during early life. This was also confirmed during personal interview with mother. A31 "Two faces looks happy" is a good response though he could not perceive whether they are male and female. This again indicates gender conflict. B4 "Two good looking faces of women" on this image where people perceive two males may indicate his liking for females and the fantasy/attitude he has to change to a Female in future. B17 "Heart, sad feeling" may indicate his pensive mood and uncertainty B28 "One woman;" ―avoiding child with mother‖ on this image brings back the conflicting mother-son relationship particularly during childhood which was also indicated on A27. B31 "One family –mummy, papa, son and daughter" is very good response on the last image of the test. It further indicates his feelings towards happy family and sign of good prognosis.

Discussion A useful feature of the somatic inkblot test is the inclusion of structured images capable of stimulating male and female body imagery. Case of gender identity was taken to assess the sexual conflict of the client and it brought out on surface underlying unconscious conflict particularly in relationship area. He gave more somatic percept on SIS indicating having anxiety and somatic preoccupation. CBT was found useful in this case, helped in reducing anxiety and develop new strategies cope with his gender identity issue. Reference: Becker, I., Nieder, T. O., Cerwenka, S., Briken, P., Kreukels, B. P., Cohen-Kettenis, P. T., & Richter- Appelt, H. (2016). Body image in young gender dysphoric adults: A European multi-center study. Archives of Sexual Behavior, 45(3), 559-574. Cassell, W, A. & Dubey, B. L. (2003). Interpreting Inner World through Somatic Imagery: Manual of Somatic Inkblot Series. Anchorage (USA): SIS Center. Cash, T. F., Maikkula, C. L., & Yamamiya, Y. (2004). Baring the body in the bedroom‖: Body image, sexual self-schemas, and sexual functioning among college women and men. Electronic Journal of Human Sexuality, 7, 1-9. Dubey, B.L., Ajith, C., Gupta, Somesh, & Kumar, B. (2004). Role of Somatic Inkblot Series in Psychosexual Disorder in India, SIS J. of Proj. Psych. & Mental Health, 11(2), 115-120. Grant, C. E., Bailey, T. L., & Noble, W. S. (2011). FIMO: scanning for occurrences of a given motif. Bioinformatics, 27(7), 1017-1018. Iantaffi, A., & Bockting, W. O. (2011). Views from both sides of the bridge? Gender, sexual legitimacy and transgender people's experiences of relationships. Culture, Health & Sexuality, 13(03), 355-370. Karasic, D., & Drescher, J. (2006). Sexual and Gender Diagnoses of the Diagnostic and Statistical Manual (DSM) A Reevaluation. Journal of Psychology & Human Sexuality, 17(3-4), 1-5. Klopfer, B.: Anisworth, M.D.: Klopfer, W.G. & Holt. R.R. (1954). Developments in the Rorschach Technique. Vol. 1. Technique and Theory. World Book Coy, New York. Nuttbrock, L., Bockting, W., Mason, M., Hwahng, S., Rosenblum, A., Macri, M., & Becker, J. (2011). A further assessment of Blanchard‘s typology of homosexual versus non-homosexual or autogynephilic gender dysphoria. Archives of Sexual Behavior, 40(2), 247-257. Richter-Appelt, H. (2016). Body image in young gender dysphoric adults: a European multi-center study. Archives of Sexual Behavior, 45(3), 559-574. Van de Grift, T. C., Elaut, E., Cerwenka, S. C., Cohen- Kettenis, P. T., De Cuypere, G., Richter-Appelt, H., & Kreukels, B. P. (2017). Effects of medical interventions on gender dysphoria and body image: a follow-up study. Psychosomatic Medicine, 79(7), 815. 25 Years Abstracts SIS Journal of Projective Psychology and Mental Health Receive a soft copy of compiled abstracts of 25 years 2004 -2018 (Volume-1 to Volume 25) of SIS Journal of Projective Psychology and Mental Health. Submit an email request Bankey L. Dubey Director, Somatic Inkblot Centre Email: bldubey@gmail.com

Somatic Inkblot Society

Office Bearers:

President: Bankey L.Dubey, Ph.D. Vice President: Brig. D.Saldanha, M.D. Vice President: Rakesh Pandey, Ph.D. Editor-In-Chief: Naveen Gupta, Ph.D. Gen. Secretary: Shweta Sharma, M.Phil. Joint Secretary: Abhilasha Singh, Ph.D. Treasurer: Padma Dwivedi, M.A. Executive Editor: Rakesh Kumar, Ph.D.

Executive Members :

Anand Dubey, MBA. Satyadhar Dwivedi, M.Phil. Sandhya R. Mohanty, Ph.D. K.N.Ojha, Ph.D. Manoj Pandey, M.Phil. Amita Puri, Ph.D. Greesh Sharma, Ph.D. M.P.Singh, Ph.D. Riju A. Singh, MBA.

Past Editors-in-Chief:

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

Amool R. Singh, Ph.D., Prof. Dept of Clin. Psy, RINPAS, Kanke, Ranchi-834006 (India) E-mail:sisamool@yahoo.com (2006-2012)

Rakesh Pandey, Ph.D. Prof. Dept of Psy.,Banaras Hindu University,Varanasi-221005 Email: rpan_in@yahoo.com (2013-2015)

Statement Showing Ownership and Other Particulars About Somatic Inkblot Society’s Journal of Projective Psychology & Mental Health Place of Publication: Mathura-281122 Periodicity of Publication: Half Yearly Editor: Dr. Naveen Gupta Nationality: Indian Address: Hindustan Institute of Management and Computer Studies, Farah, Mathura-281122 U.P. Owner: Somatic Inkblot Society Printer’s/Publisher’s Name: Shaji Joseph I, Dr. Naveen Gupta, hereby declare that the particulars given above are true to the best of my knowledge and belief. Sd/ Dr. Naveen Gupta, Editor-in-Chief Journal of Projective Psychology & Mental Health Published by Dr. Naveen Gupta, on behalf of Somatic Inkblot Society at IMPERIAL COMPUGRAPHICS 2/12, Swadeshi Bima Nagar, Civil Lines, M.G. Road, Agra – 2 Email : imperialprintersagra@yahoo.com Phone No. 0562-4045083

SIS JOURNAL OF PROJECTIVE PSYCHOLOGY & 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 Psiquiatricay psicologica de Amercia Laina Argentina Spanish Journal of the Medical Association of Thailand Thailand English, Thai British Journal of Psychiatry UK English Acta Psychiatrica Scandinavica Denmark English Salud Mentale Mexico Spanish Vertex Argentina Spanish Journal of Personality and Clinical Studies India English Social Psychiatry and Psychiatric Epidemiology Germany English Revista Medica de Chile Chile Spanish South African Journal of Psychology South Africa Afrikaans, English Psychological Reports USA English South African Medical Journal South Africa Afrikaans, English The Australian & New Zealand Jr. of Psychiatry Australia English International Journal of Social Psychiatry U. K. English Psychiatry Research Ireland English Social Science & Medicine U. K. English Revista De Saude Publica Brazil Portuguese International Journal of Geriatric Psychiatry U. K. English Journal of Projective Psychology & Mental Health India English Journal Brasilerio de Psiquiatria Brazil Portuguese Psychiatry and Clinical Neurosciences Australia English

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

Abstracted in “APA” Psyc INFO Regd. No. 71632/99, RNI Delhi UGC Journal No.: 48979 SIS Journal of Projective Psychology & Mental Health July 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

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. Deapti Mishra, 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. Manoj Pandey, M.Phil. Nalini Mishra, Ph.D. Padma Dwivedi, M.A. Padmakali Banerjee, Ph.D. Paola Nicolini, M.A. Prasant K. Roy. M.Phil. 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. Yogesh K. Arya, Ph.D.