SIS Journal of Projective Psychology & Mental Health

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

January 2020 Editorial: Prominent Assessment Instruments in Suicide and PTSD Research on U.S. Veterans Chris Piotrowski 01-05 Why Teach Future Psychotherapists to Administer and Interpret Projective Tests? Well, why teach future physicians and surgeons to perform dissections? Stephen P. Joy 06-11 Using the Rorschach Trauma Content Index (TCI) with Incarcerated Women Jason M. Smith, Carl B. Gacono and Ted B. Cunliffe 12-20 Pain Assessment: Most Prominent Measures/Tests in the Research Literature, 2006-2018 Chris Piotrowski 21-31 Writings as Projective Material Robert B. Williams 32-35 Emotional States and Coping Patterns of Patients with High and Low Post Traumatic Symptoms Rachana Kumari & Anjana Mukhopadhyay 36-42 Utility of SIS-II in Identifying the Therapeutic Change in Pathological Internet Use Prabha Mishra, Manoj K. Pandey and Krishan Kumar 43-49 General Wellbeing and Marital Quality among Spouses of Individuals with Alcohol Dependence Syndrome: A Comparative Study Swarnlata Kumari and Jai Prakash 50-53 An Insight into Psychotherapy: Indian Perspective Padmakali Banerjee and Vikas Sharma 54-56 On the Declining Use of Projective Techniques in School Psychology: A Response to Piotrowski (2019) Nicholas F. Benson, R. G. Floyd, J. H. Kranzler, T. L. Eckert, S. A. Fefer & G. B. Morgan 57-60 Book Review: Inkblot Personality Test - Understanding the Unconscious Mind

Official Publication of the Somatic Inkblot Society www.somaticinkblots.com

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:Property No.4, Block-A, Sector-23, Dwarka, New Delhi-110077, 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/USA SIS Website: http://www.somaticinkblots.com

EDITORIAL Prominent Assessment Instruments in Suicide and PTSD Research on U.S. Veterans Over the past 2 decades, clinicians have expressed extensive research interest in the study of prominent afflictions (Suicide/Suicide Potential; PTSD) affecting veterans in the USA (Bisson et al., 2019; Bohnert et al., 2017; Bush 2012, 2014; Jackson, 2017; Kessler et al., 2017; Shura et al., 2019; Wilson & Keane, 2004; Wisco et al., 2014). From a clinical perspective, both these mental health conditions tend to have high cooccurring rates (DeBeer et al., 2014; Horwitz et al., 2019; Pompili et al., 2013; Watkins et al., 2017). The prospect for efficacious treatment for these conditions resides in the accurate diagnosis and assessment of veterans presenting with various forms of psychopathology and mental health symptoms that may confer either the potential for Suicide (or suicidal ideation) and/or Posttraumatic stress (see Stanley et al., 2019). Thus, the challenges for both mental health providers and VA patients are not only great but indeed potentially life-threatening. In fact, according to VA and government statistics, veterans account for about 20% of all suicides in the USA, over twice the rate of the general population. Moreover, due to the ubiquitous media coverage of ‘veteran suicides’ over the past decade, veterans could be increasingly prone to the effects of ‘suicide contagion’ which can increase the probability of one’s personal risk for suicide (see Wolford- Clevenger et al., 2019). To date, there is an extensive body of extant literature on the topic of Suicide and PTSD. Moreover, research with a focus on the screening and evaluation of these clinical conditions has been advancing at an exponential pace, culminating in copious books and book chapters addressing the specific issue of assessment and testing of veterans (Bongar et al., 2017; Kearney et al., 2017; Kleespies & AhnAllen, 2017). Moreover, several studies have addressed mental health assessment ‘practices’ with regard to Suicide (potential) and PTSD (see Elhai et al., 2005; Pease et al., 2017). Indeed, this emerging literature prompts an interesting question -- Which tests/assessment protocols are most relied upon by researchers when they formulate investigatory research designs for studies screening veterans for these clinical conditions? Unfortunately, the answer to this important issue is rather confounded. In terms of government guidelines, the Joint Commission’s National Patient Goal (NPSG 15) directs suicide risk assessment for patients who present with emotional or behavioral complaints, and all VA facilities are mandated to comply with NPSG 15 (see Doran et al., 2016). However, according to Green et al. (2017, p. 209), there has been little consensus at VA facilities regarding specific assessment protocols for suicide risk screenings (although the VA has recently addressed this issue to some degree); moreover, these screenings do not usually assess for ‘self-harm’ (e.g., physical fighting, self-cutting). In addition, research has shown that military members inconsistently confirm or under-report critical data-points such as suicide-attempt history (Hom et al., 2019). To address this critical issue regarding assessment, the current analysis of the recent mental health literature identified the major tests/ measures/ assessment instruments evident in research studies on the subject areas of Suicide potential and PTSD with a focus on veterans. A Boolean online search of the database PsycINFO, using keywords

(veterans + suicide; veterans + PTSD) for years 2013-2019, produced 323 and 1,098 articles for each condition, respectively. The PsycINFO display offers a scroll-down menu option for tests and measures cited in the search results (in terms of frequency of mentions); for comparison purposes, I replicated the search command for all populations under study (so as to gauge any differences between studies overall versus those limited to veteran populations). Table 1 presents the listing, in rank order, of the top tests/assessment protocols for both these analyses. Table 1. Predominant Measures Used by Researchers in the Study of Suicide/PTSD in Veterans Assessment Instruments (2013-2019) Suicide (n=323) PTSD (n=1,098) Veterans All Populations Veterans All Populations Patient Health Q.-9 Beck Hopelessness Scale Clinician-administered PTSD Scale Clinician-administered PTSD Scale Beck Depression Inv. Beck Depression Inv. PTSD Checklist-Military Version PTSD-Civilian Version Beck Scale for Suicide Ideation Mini International Neuropsychiatric Interview Beck Depression Inventory Beck Depression Inventory-II Interpersonal Needs Q. Beck Scale for Suicide Ideation PTSD Checklist PTSD Checklist PTSD Checklist-Military Version Hamilton Rating Scale for Depression Mini International Neuropsychiatric Interview Structured Clinical Interview (DSM) Mini International Neuropsychiatric Interview Structured Clinical Interview (DSM-Axis 1) Patient Health Q.-9 Mini International Neuropsychiatric Interview Columbia-Suicide Severity Rating Scale Patient Health Q.-9 Alcohol Use Disorders Identification Test Patient Health Q.-9 Suicidal Behaviors Questionnaire-Revised Columbia-Suicide Severity Rating Scale Structured Clinical Interview (DSM) BDI Alcohol Use Disorders Identification Test Interpersonal Needs Q. PTSD Checklist-Civilian PTSD Checklist-Military Version Beck Hopelessness Scale BDI-2 Deployment Risk & Resilience Inventory Structured Clinical Interview (DSM-Axis I) Table 1 illustrates the most prominent assessment measures for Suicide potential and/or PTSD used by researchers in the study of veteran populations. These results indicate that several measures are relied upon frequently by these researchers on investigations for both these clinical conditions, i.e., the PTSD Checklist-Military Version, the Beck Depression Inventory, the Mini International Neuropsychiatric Interview, the Patient Health Questionnaire-9, and the Alcohol Use Disorders Identification Test. Several of these instruments have been found to be among the most popular evaluation techniques reported by practitioner samples (Piotrowski, 2018; Stolberg & Bongar, 2009; Wright et al., 2017). A recent survey of assessment practices by VA psychologists reported that the PTSD Checklist is used by 30% of the sample (Russo, 2018).

Interestingly, these most relied upon tests/measures in research seem to contrast to some degree the most popular tests used specifically by PTSD/trauma clinicians in practice. Although the current findings confirm practitioners’ survey data reported by Elhai et al. (2005) with regard to reliance on the PTSD Checklist, Clinician-Administered PTSD Scale and Structured Clinical Interview for DSM, the Elhai et al. sample favored use of several instruments not found popular in the current analysis of researchers (i.e., Trauma Symptom Inventory, Posttraumatic Stress Diagnostic Scale, the MMPI-2-Keane PTSD Scale, the Impact of Event Scale, the SCL-90 Revised-PTSD Scale). The reason for this discrepancy is not readily apparent, other than that investigators may find some assessment instruments more amenable to research. Although not listed in the current analysis, the Primary Care-PTSD Screen is currently a standard screening tool used in VA facilities (Calhoun et al., 2010). Noteworthy, the development of novel PTSD measures seems to be an active area of research endeavor (e.g., Del Vecchio et al., 2011), as well as perennial modifications to practice guidelines for the treatment of PTSD conditions (see Courtois & Brown, 2019). With regard to the issue of suicide, it is somewhat difficult to interpret the current listing of assessment methods used by researchers, as there is a dearth of prior testusage studies in this clinical area. However, several of the measures used in suicide studies (listed in Table 1) are also used frequently in PTSD research. Apparently, the Columbia Suicide Severity Rating Scale has reportedly been adapted as a tool for the assessment of suicide risk in some VA facilities (Green et al., 2017). In addition, researchers are also focusing on the impact of combat exposure on suicide potential in veterans; the Combat Experiences Scale and the Combat Exposure Scale are most noteworthy in this regard (Corona et al., 2019; Kopacz et al., 2016). At the same time, researchers continue to publish a myriad of assessment approaches in the study of suicidology (Forkmann et al., 2018), including suicide ideation measures specific to veteran populations (Hom et al., 2019). Current psychological assessment protocol at VA facilities mandate the use of the modified PC- PTSD, which includes an item on ‘self-harm’. Undoubtedly, the clinical utility of such a brief screener prompts concerns regarding ‘false negatives’ and the need for a more comprehensive evaluation of suicidal ideation for veterans in need of mental health treatment (Simons et al., 2019). In conclusion, it appears that researchers, studying veteran samples, tend to rely on both traditional (e.g., Beck scales; see Piotrowski & Lubin, 1990) and domain-specific measures in the study of Suicide and PTSD. It must be noted that more rigorous research on suicide risk assessment is urgently needed, particularly since the current state of the research science in this domain (i.e., risk factors) offers limited diagnostic assistance to practitioners (see Sommers-Flanagan & Shaw, 2017). Moreover, co-morbidity factors in suicidal ideation are a much underresearched area of study (see Cheref et al., 2019; Riblet, 2019). Further, the contemporary ‘social networking’ milieu may provide an additional data-source in the assessment of suicide potential for researchers and treatment personnel to consider (Cero & Witte, 2019). Finally, future research efforts should focus on the PTSD- Suicide link, where extant research on efficacious intervention and treatment for posttraumatic states could make a significant contribution in addressing and reducing suicide rates of military veterans.

References: Bisson, J.I., et al. (2019). The International Society for Traumatic Stress studies guidelines for the prevention and treatment pf posttraumatic stress disorder: Methodology and developmental process. Journal of Traumatic Stress, 1-9. Bohnert, K.M., et al. (2017). Substance use disorders and the risk of suicide mortality among men and women in the US Veterans Health Administration. Addiction, 112, 1193-1201. Bongar, B., et al. (2017). Handbook of military and veteran suicide: Assessment, treatment, and prevention. New York, NY: Oxford University Press. Bush, S.S. (2014). Psychological assessment of veterans. New York, NY: Oxford University Press. Bush, S.S. (2012). Neuropsychological practice with veterans. New York, NY: Springer. Calhoun, P.S., et al. (2010). Clinical utility of the Primary Care-PTSD Screen among U.S. veterans who served since September 11, 2001. Psychiatry Research, 178, 330-335. Cero, I., & Witte, T.K. (2019). Assortativity of suiciderelated postings on social media. American Psychologist, in press. Cheref, S., et al. (2019). Refining psychological, substance abuse, and sociodemographic predictors of suicide ideation and attempts in a national multiethnic sample of adults, 2008-2013. Journal of Nervous and Mental Disease, 207(8), 675-682. Corona, C.D., et al. (2019). Meaning in life moderates the association between morally injurious experiences and suicide ideation among U.S. combat veterans: Results from the National Health and Resilience in Veterans Study. Psychological Trauma, in press. Courtois, C.A., & Brown, L.S. (2019). Guideline orthodoxy and resulting limitations of the APA’s Clinical Practice Guideline for the Treatment of PTSD in Adults. Psychotherapy, 2019, 56(3), 329-339. DeBeer, B.B., et al. (2014). Combined PTSD and depressive symptoms interact with postdeployment social support to predict suicidal ideation in Operation Enduring Freedom and Operation Iraqi Freedom veterans. Psychiatry Research, 216, 357-362. Del Vecchio, N., et al. (2011). Enhancing self-report assessment of PTSD: Development of an item bank. Journal of Traumatic Stress, 24(2), 191- 199. Doran, N., et al. (2016). The validity of a brief risk assessment tool for predicting suicidal behavior in veterans utilizing VHA mental health care. Suicide and Life-Threatening Behavior, 46(4), 471-484. Elhai, J.D., et al. (2005). Which instruments are most commonly used to assess traumatic event exposure and posttraumatic effects? A survey of traumatic stress professionals. Journal of Traumatic Stress, 18(5), 541-545. Forkmann, T., et al. (2018). Assessing suicidality in real time: A psychometric evaluation of self-report items for the assessment of suicidal ideation and its proximal risk factors using ecological momentary assessments. Journal of Abnormal Psychology, 127(8), 758-769. Green, J.D., et al. (2017). The Direct and Indirect Self- Harm Inventory (DISH): A new measure for assessing high-risk and self-harm behaviors among military veterans. Psychology of Men & Masculinity, 18(3), 208-214. Hom, M.A., et al. (2019). Investigating the reliability of suicide attempt history reporting across five measures: A study of US military service members at risk of suicide. Journal of Clinical Psychology, 75, 1332-1349. Horwitz, A.G., et al. (2019). Prospective associations between DSM-5 PTSD symptom clusters and suicidal ideation in treatment-seeking veterans. Psychological Services, 16(2), 321-328. Jackson, C. (2017). Veterans and suicide: Risk factors, assessment, and treatment. In J. Beder (Ed.), Caring for the military: A guide for helping professionals (pp. 157-171.). New York, NY: Routledge. Kearney, L.K., et al. (2017). Psychological assessment in the Veterans Health Administration (VHA) model of integrated primary care. In M.E. Maruish (Ed.), Handbook of psychological assessment in primary care settings (2nd ed., pp. 709-731). New York, NY: Routledge. Kessler, R.C., et al. (2017). Developing a practical suicide risk prediction model for targeting high-risk patients in the Veterans Health Administration. International Journal of Methods in Psychiatric Research, 26, e1575. Kleespies, P.M., & AhnAllen, C.G. (2017). Evaluating and managing suicide risk in veterans. In P.M. Kleespies (Ed.), Oxford handbook of behavioral emergencies and crises (pp. 165-184.). New York, NY: Oxford University Press. Kopacz, M.S., et al. (2016). Suicidal behavior and spiritual functioning in a sample of veterans diagnosed with PTSD. Journal of Injury and Violence Research, 8(1), 1-9.

Pease, J.L., et al. (2017). How Veterans Health Administration suicide prevention coordinators assess suicide risk. Clinical Psychology and Psychotherapy, 24, 401-410. Piotrowski, C. (2018). The status of the Beck inventories (BDI, BAI) in psychology training and practice: A major shift in clinical acceptance. Journal of Applied Biobehavioral Research, 23(3), e12112. 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. Pompili, M., et al. (2013). Posttraumatic stress disorder and suicide risk among veterans: A literature review. Journal of Nervous and Mental Disease, 201(9), 802-812. Riblet, N.B., et al. (2019). Health care processes contributing to suicide risk in veterans during and after residential substance abuse treatment. Journal of Dual Diagnosis, in press. Russo, A.C. (2018). A practitioner survey of Department of Veterans Affairs psychologists who provide neuropsychological assessments. Archives of Clinical Neuropsychology, 33, 1046-1059. Shura, R.D., et al. (2019). Relationship between traumatic brain injury history and recent suicidal ideation in Iraq/Afghanistan-era veterans. Psychological Services, 16(2), 312-320. Simons, G.J., et al. (2019). Drop-in suicide prevention group decreases suicidal ideation among veterans. Military Psychology, 31(1), 18-25. Sommers-Flanagan, J., & Shaw, S.L. (2017). Suicide risk assessment: What psychologists should know. Professional Psychology: Research and Practice, 48(2), 98-106. Stanley, I.H., et al. (2019). The Military Suicide Research Consortium common data elements: An examination of measurement invariance across current service members and veterans. Assessment, 26(6), 963-975. Stolberg, R.A., & Bongar, B. (2009). Assessment of suicide risk. In J.N. Butcher (Ed.), Oxford handbook of personality assessment (pp. 501- 526). New York, NY: Oxford University Press. Watkins, L.E., et al. (2017). Co-occurring aggression and suicide attempt among veterans entering residential treatment for PTSD. Journal of Psychiatric Research, 87, 8-14. Wilson, J.P., & Keane, T.M. (Eds.). (2004). Assessing psychological trauma and PTSD (2nd ed.). New York, NY: Guilford. Wisco, B.E., et al. (2014). Posttraumatic stress disorder in the US veteran population: Results from the National Health and Resilience in Veterans Study. Journal of Clinical Psychiatry, 75(12), 1338-1346. Wolford-Clevenger, C., et al. (2019). A preliminary validation of the Suicidal Behavior Exposure Scale. Psychology of Violence, 9(4), 442-450. Wright, C.V., et al. (2017). Assessment practices of professional psychologists: Results of a national survey. Professional Psychology: Research and Practice, 48(2), 73-78. Chris Piotrowski, Ph.D. Senior Editor University of West Florida, USA, Email:cpiotrowski@uwf.edu Email: piotrowskichris@hotmail.com

Personality tests, long a mainstay of clinical training, comprise a diminishing portion of the graduate school curriculum despite increasing evidence of their validity. While defensible given the expanded assessment toolkit and other innovations of contemporary clinical practice, this trend has some limitations. For example, the openended verbal productions elicited by sentence stems and story prompts closely resemble the material generated by clients in therapy. Mastery of systematic approaches to the coding of sentence completions and TAT stories enables students to develop interpretive skills that will serve them well in standard clinical practice. This paper highlights several rationales to support this conclusion. The purpose of this commentary is to develop an argument in favor of a renewed focus on performance-based (or projective) methods of personality assessment in clinical training. This proposal is based less on the importance of projective methods in daily clinical practice than on their value as tools for the refinement of our students’ clinical skills. Let me begin with a brief outline of the major problem faced by aficionados of performance-based assessment. Most of my points in this section should be familiar to readers of this journal, but they are rarely integrated into a cohesive framework – and their cumulative impact is, indeed, potentially cataclysmic. It took half a century for the debate surrounding projective methods to move from extreme viewpoints (“X-Ray of the Psyche” vs. “tea leaves”) to something resembling an acceptable scientific discussion. Any sensible psychologist, whose mind was not closed decades ago, should agree that some performance-based personality assessment methods yield valid information (Mihura et al., 2017; Piotrowski, 2015a); likewise, that there are legitimate grounds for questioning (and investigating) whether these instruments offer adequate incremental validity (after interviews and self-report inventories are administered) to justify the investment of professional time and expertise involved in their use. Given the facts that projective methods correlate weakly with self-reported characteristics and that the two approaches predict distinct (albeit overlapping) behaviors, it is likely that the final scientific verdict will be more favorable than otherwise (Schultheiss et al., 2009). But even as their scientific foundation is strengthened, the place of projective tests in the assessment ecosystem is endangered. Long a central component of training in clinical psychology and related fields (Belter & Piotrowski, 2001), signs of a diminishing status began to emerge a generation ago (Piotrowski & Zalewski, 1993), a trend that has accelerated in the present century (Piotrowski, 2015b; Stedman, Essery, & McGeary, 2018). By the time the science fully demonstrates their value, expertise in their use may be functionally extinct (Piotrowski, 2017). The declining use of performance-based personality measures by today’s psychologists stems from the convergence of several factors. First, we must recognize the bitter historical feud between tough-minded, nomothetically inclined, statistically savvy academic psychologists and tender-minded, idiographically inclined, relationally focused practitioners. This was an “even fight” for some years, but in the end, the academics (being mostly in charge of training each new generation of practitioners, hence the more “fertile” group) were statistical favorites to emerge victorious. The sluggish initial response of the psychoanalytically fixated but psychometrically challenged practitioners to this challenge did not help matters, either for projective tests or for the psychodynamically

Why Teach Projective Tests?: 07 informed therapies with which they had become associated. Second, the advent of managed care towards the end of the 20th century forced practitioners to place greater emphasis on short-term, readily measured behavioral change than on in-depth understanding of human individuality (Piotrowski, 1999). It is difficult to justify devoting hours to formal assessment when treatment will be limited to, say, 10 sessions. (The therapeutic assessment movement pioneered by Finn [1996] represents an interesting adaptive response to this challenge.) Third, the emergence of important new methods of assessment (notably semistructured interviews, clinical rating scales, and behavior checklists) made for a more “crowded” assessment curriculum, and clinical trainers needed to reconsider the place of traditional tests in their syllabi. Fourth, as computer-based test scoring became more widely available and sophisticated, selfreports grew even easier to use relative to labor-intensive projective techniques. This last trend combined with advanced computerdriven forms of data analysis and on-line sampling to make brief self-report measures even more appealing to researchers. (How far this is owing to the need to keep up with an accelerating pace of professional life and how far to a disinclination to engage in effortful mental tasks is uncertain. There are clear advantages to having a billable report largely composed by the ghost in the machine, and when clever multivariate manipulations enable a study based on a few dozen closed-ended items to be published in a mid-ranking personality journal, how many tenure-hungry assistant professors will resist?) It can be argued that a narrow focus on measures that are easily administered, scored, and analyzed represents an evolutionary dead end for clinical and personality psychology alike. We have long known that the human capacity for reasoned information processing is quite limited relative to that of algorithmic, actuarial decision rules. The end result of our present single-minded devotion to complex statistics will, in all likelihood, be our professional obsolescence. (I wish to emphasize that I am by no means unfriendly either to nomothetic science or statistical analysis – far from it! But I am concerned by our retreat from the attempt to understand people qua people.) Paul Meehl (1973), whose dissertation first confronted us with the superiority of actuarial (vs. clinical) prediction, also wrote presciently about the value of the clinician: as a fellow human being, a psychologist commands a highly evolved capacity to perceive certain qualities in her or his conspecifics, a capacity beyond the ken of even the most powerful computers. Our ability to work with client responses to ambiguous stimuli under open-ended instructions is a case in point. Still, no matter how great our superiority over computers or poorly-trained technicians in the interpretation of projective material may be, and no matter how strong the evidence grows that performance-based methods yield useful information not readily obtained via other means (see Meyer et al., 2018), the fact remains that the role of performance-based personality assessment will remain relatively circumscribed for the foreseeable future. Given this stark reality, it is reasonable for directors of clinical training programs to ask (as they do!): “why should we devote substantial amounts of precious instructional time to a skill that is popular neither in clinical nor research settings?” Allow me to introduce my response to that question with an anecdote. When I attended a Boulder-model clinical psychology program, one of the senior professors remarked that today’s psychologists seemed much more skilled at producing change in clients, but much less skilled at decoding their personality patterns: excellent interventionists, but not always understanding the nature of the psychic territory in which they meddled. And this was a quarter-century ago; the trend has accelerated since. Whenever we produce change without understanding the wider system in which our work is embedded, we risk unanticipated complications. Pesticides kill pollinators; antibiotics kill benign

symbiotes; antipsychotics trigger metabolic syndrome. Now, consider the nature of medical training. We do not place a first-year student in an operating room with a hemorrhaging gunshot victim and tell her or him to save the patient. To do so would condemn said patient to inept care, even iatrogenic injury. We begin with laboratory exercises in anatomy and physiology; dissection of infrahuman animals giving way in time to detailed work with cadavers. In this way, students acquire familiarity with the various anatomical and physiological processes, quick to recognize what they are dealing with and confident in their ability to navigate the complex internal space of the body. No more should we place beginning trainees in counseling and psychotherapy, whose background to date is all based on textbooks and lectures, in settings where they must identify and cope with the psychic traumas of living, breathing patients. The internal space of the mind is no less complex than that of the physical body, and just as easily damaged by a clumsy intervention. Yes, we have students practice interviewing skills with one another and observe themselves on tape, but this interpersonal sparring (valuable as it may be!) is only a shadow of the reality that awaits in the clinic: the live-action engagement with conflicted and suffering humanity. We want our graduate students to learn how to perceive and interpret the meanings of client utterances – to recognize the nuances of individual statements – to discern the underlying narrative structure of memories, fantasies, and (perchance) dreams. Where are we to find the preserved remains of complex psychic phenomena? What is our equivalent of the frog, the fetal pig, the cadaver? I suggest that certain forms of performancebased (or projective) material are ideally suited for this purpose. In particular, I would like to call for a renewed emphasis, in clinical training and research alike, on two projective methods: sentence completions and the picture-story exercise exemplified by the Thematic Apperception Test (TAT). These provide us with samples of verbal behavior, extracted from actual people under controlled conditions and preserved intact for our continued examination and study. Consider, first, sentence completion tests. Here, “stems” may be constructed ranging from highly ambiguous (e.g., “I think…”) to highly structured (e.g., “When a woman is put in charge…”) depending on the focus of the test designer’s interest. The most open-ended stems will elicit maximally varied responses and allow for flexible scoring and interpretation, while more specific prompts will “pull” for narrowly defined response categories, useful when one is investigating a particular construct. Each response can be scored independently. Since the responses are succinct, a relatively large number of items can be included. These factors enhance reliability. But from a clinical training perspective, each response represents a distinct personal statement of the sort that clients in therapy often make. As clinical students learn the possible meanings of the many responses offered up that begin with, say, “I think,” they are learning how to “read into” the statements or clinical material their future clients may actually provide in treatment. We already possess reliable, well-validated scoring systems enabling us to extract a wide variety of meanings from sentence completions. The most widely used clinical test of this type, the Rotter Incomplete Sentences Blank (RISB; Rotter, Lah, & Rafferty, 1992), features a well-articulated system whereby we may evaluate the level of Adjustment (vs. Maladjustment) exhibited by any given response. The system balances positive responses against conflictual ones, so that strengths and vulnerabilities both may be incorporated into our case formulations. Also, because of the inherent flexibility of the method, it is possible to develop additional scoring systems that can be applied to the same test protocols. To take just three examples, it is possible to use RISB protocols to assess defense mechanisms (Johnson &

Why Teach Projective Tests?: 09 Gold, 1995), cognitive distortions (Lehnert, Overholser, & Adams, 1996), and major personality traits (Joy, 2017). Less frequently seen in clinical settings, but the subject of an even more impressive body of research, is Loevinger’s Washington University Sentence Completion Test (WUSCT; Hy & Loevinger, 1996), which rejoices in an elaborate, well-validated system for evaluating one’s level of ego development, from primitive impulsive characters up to highly integrated and differentiated identities. Aside from these two measures, most of the remaining sentence completion tests are not well known and have, in many cases, fallen largely into disuse (Rohde [1947], used to evaluate motives, is a good example) – though there have been encouraging signs of interest in developing specialized contemporary measures of this type to assess depression (Barton et al., 2005), vulnerability to bipolar disorder (Dempsey, Gooding, & Jones, 2014), psychopathy (Endres, 2004), and poor performance in military training (Picano et al., 2002). My point is that in training students to discern the significances underlying sentence completions, we are not merely training them to score more-or-less obscure personality tests. Rather, we are refining their clinical sensibilities, teaching them to master the skill of finding meaning in the many personal statements made by clients during intake interviews and subsequent therapeutic sessions. And we are doing so in an entirely safe environment. The statements lie before us as on the anatomist’s dissection table, there to be studied at leisure and shorn of any risk. Misinterpretations will harm nobody as the professor circulates among the students, gently guiding their perceptions. We may progress from analysis of well-studied protocols supplied by the professor (psychological autopsies, as it were) to case material obtained by the students. With practice, the students will become swift and sure, able to intuit meaning in real time during clinical interviews. As the sentence completion method is mastered, attention may be shifted onto the more complex TAT-type measures. Here, the individual samples of verbal behavior are much larger and the challenge of extracting meaning in a principled, reliable fashion much greater. But the potential rewards are concomitant with the effort required. For what we are presented with are complete narratives: representations of the social cognitive structure of the respondent’s mind. Murray’s original idea may have been that fantasy can substitute for dream material as a way of exploring the psyche, but the picturestory method also parallels episodic memory, especially those episodic memories found most important by the reflective, self-creating human mind. Memories, dreams, waking fantasy, anticipated futures: these are the stuff of which we are made. I do not think most clinicians – or most researchers – fully appreciate the extent to which the entire narrative approach to personality derives from the use of TAT-type measures. Nor are most aware of the range of uses to which such measures have been put. We tend to tell a story that begins (appropriately) with Murray’s (1938) “needs and press” model, maybe including some remarks along lines of how the interaction of needs and press, leading to a given outcome, constitutes a simple thema. We then consider either the purely clinical tradition of TAT use (e.g., Bellak, 1996) or its applications in pure research (as, for example, in McClelland’s classic studies of power and achievement motivation). If we are a bit more sophisticated, we consider both traditions and lament the lack of meaningful bridges uniting the two. There is nothing incorrect about such an approach, but it fails to do justice to the history of testing. Variations on the picture-story exercise have been used in cross-cultural studies by anthropologists (including classic work conducted in Japan, in Latin America, and among southwestern Native American tribes). Scoring systems have been validated not only for Murray-style needs, motives, or central

concerns (Smith, 1992), but also for primary process thinking (Holt, 2008), defense mechanisms (Cramer, 1991), and social cognition/object relations (Westen, 1995). The failure of clinical psychology faculty to teach such approaches (many of which are reviewed by Jenkins, 2015) contributed much to the method’s gradual decline in popularity. But there is more. It should be remembered that Silvan Tomkins, whose script theory (1995; Sedgwick & Frank, 1995) forms the foundation for today’s narrative models of personality, began as one of Murray’s research associates. His analysis of personality in terms of nuclear episodes, scenes that slowly transmute into the scripts by which we live, stems directly from his earlier work analyzing TAT stories. Without Tomkins we would not have the contemporary researchers (e.g., McAdams, 2016) who have explored the narrative structure of self: identity as constructed on the basis of affectively charged self-defining memories. For any approach taken to the study of TAT stories can also be applied to other narrative forms: dreams, yes, but also recollections of early childhood or simple accounts of last week’s family outing. In short: as clinical students master the craft of decoding the many layers of meaning inherent in TAT protocols (or any similar narrative samples, such as early memories), these future practitioners are becoming more adept at discerning the abstract essence of people’s stories. And stories are the working material of psychotherapy as of human life more generally. (This work, conducted in assessment classes and workshops, would unfold in parallel with the cultivation of interviewing skills in psychotherapy methods courses.) It may not much matter whether they will make extensive use of the TAT or its cousins in their later clinical practice. What matters is that by studying these stories, duly recorded and safely ensconced in the laboratory, they are developing crucial clinical skills. Grotesque as the metaphor may appear: if sentence completions are the fetal pigs of personology, fantasies and memories are our cadavers. Even if nothing new were ever to be discovered using these methods, any more than new discoveries are likely when wellknown creatures are placed on the dissection table, their use in clinical training would be more than justified. But I will go further, and assert that it is through the study of people’s free responses to structured but open-ended prompts that we are likely to make new findings. Closed-ended questionnaires, for all their very real value, operate as closed systems, enabling us to test well-formed hypotheses but never introducing anything unexpected. Neither object relations theory nor the narrative approach to personality could possibly have emerged from a generation of psychologists schooled only in the statistical analysis of self-report data. If we want the next generation to be capable of fresh insights into human nature, we need to give them every opportunity to explore the ways in which our inner worlds are revealed by our expressive behaviors. Training in projective methods such as the use of sentence completion and storytelling tasks is one of the principal means by which this important aspect of our mental life may be achieved. References: Barton, S., Morley, S., Bloxham, G., Kitson, C., & Platts, S. (2005). Sentence completion test for depression: An idiographic measure of depressive thinking. British Journal of Clinical Psychology, 44, 29-46. Bellak, L., & Abrams, D.M. (1996). The T.A.T., the C.A.T., and the S.A.T. in clinical use (6th ed.). Boston, MA: Allyn & Bacon. Belter, R.W., & Piotrowski, C. (2001). Current status of doctoral-level training in psychological testing. Journal of Clinical Psychology, 57(6), 717-726. Cramer, P. (1991). The development of defense mechanisms: Theory, research, and assessment. New York: Springer-Verlag. Dempsey, R.C., Gooding, P.A., & Jones, S.H. (2014). Assessing the specificity of autobiographical memory in individuals at a trait-based vulnerability to bipolar disorder using a sentence completion task. Memory, 22, 222-231.

Why Teach Projective Tests?: 11 Endres, J. (2004). The language of the psychopath: Characteristics of prisoners’ performance on a sentence completion task. Criminal Behaviour and Mental Health, 14, 214-226. Finn, S.E. (1996). Manual for using the MMPI-2 as a therapeutic intervention. Minneapolis, MN: University of Minnesota Press. Holt, R.R. (2008). Primary process thinking: Theory, measurement, and research. Lanham, MD: Jason Aronson. Hy, L.X., & Loevinger, J. (1996). Measuring ego development (2nd ed.). Mahwah, NJ: Lawrence Erlbaum Associates. Jenkins, S.R. (Ed.). (2015). A handbook of clinical scoring systems for Thematic Apperception Techniques. New York: Routledge. Johnson, N.L., & Gold, S.N. (1995). The Defense Mechanism Profile: A sentence completion test. In H. R. Conte & R. Plutchik (Eds.), Ego defenses: Theory and measurement (pp. 247-262). Oxford, UK: Wiley. Joy, S.P. (2017). Reading personality: Assessing “Big Three” traits with the sentence completion method. Current Issues in Personality Psychology, 5, 215-231. Lehnert, K.L., Overholser, J.C., & Adams, D.M. (1996). The Cognition Rating Form: A new approach to assessing self-generated cognitions in adolescent sentence completions. Psychological Assessment, 8, 172-181. McAdams, D. (2016). The art and science of personality development. New York: Guilford Press. McClelland, D.C., Koestner, R., & Weinberger, J. (1989). How do self-attributed and implicit motives differ? Psychological Review, 96, 690-702. Meehl, P. (1973). Psychodiagnostics: Selected papers. Minneapolis, MN: University of Minnesota Press. Meyer, G.J., Katko, N.J., Mihura, J.L., Klag, M.J., & Meoni, L.A. (2018). The incremental validity of selfreport and performance-based methods for assessing hostility to predict cardiovascular disease in physicians. Journal of Personality Assessment, 100, 68-83. Mihura, J.L., Roy, M., & Graceffo, R.A. (2017). Psychological assessment training in clinical psychology doctoral programs. Journal of Personality Assessment, 99, 153-164. Murray, H. (1938). Explorations in personality. New York: Oxford University Press. Picano, J.J., Roland, R.R., Rollins, K.D., & Williams, T.J. (2002). Development and validation of a sentence completion measure of defensive responding in military personnel assessed for nonroutine missions. Military Psychology, 14, 279-298. Piotrowski, C. (2017). The linchpin on the future of projective techniques: The precarious status of personality assessment in the (overcrowded) professional psychology curriculum. Journal of Projective Psychology and Mental Health, 24, 71-73. Piotrowski, C. (2015a). 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. (2015b). On the decline of projective techniques in professional psychology training. North American Journal of Psychology, 17, 259-266. Piotrowski, C. (1999). Assessment practices in the era of managed care: Current status and future directions. Journal of Clinical Psychology, 55(7), 787-796. Piotrowski, C.,& Zalewski, C. (1993). Training in psychodiagnostic testing in APA-Approved PsyD and PhD clinical psychology programs. Journal of Personality Assessment, 61, 394-405. Rohde, A.R. (1947). Sentence Completions Test Manual. New York: Author. Rotter, J.B., Lah, M.I., & Rafferty, J.E. (1992). Rotter Incomplete Sentences Blank Manual (2nd ed.). San Antonio, TX: The Psychological Corporation. Schultheiss, O. C., Yankova, D., Dirlikov, B., & Schad, D. J. (2009). Are implicit and explicitmotive measures statistically independent? A fair and balanced test using the picture story exercise and a cue- and response-matched questionnaire measure. Journal of Personality Assessment, 91, 72–81. Sedgwick, E.K., & Frank, A. (Eds.). (1995). Shame and its sisters: A Silvan Tomkins reader. Durham, NC: Duke University Press. Smith, C.P. (Ed.). (2008). Motivation and personality: Handbook of thematic content analysis. Cambridge, UK: Cambridge University Press. Stedman, J.M., Essery, J., & McGeary, C.A. (2018). Projective personality assessment: Evidence for a decline in training emphasis. Journal of Projective Psychology and Mental Health, 25, 54-59. Tomkins, S.S. (1995). Exploring affect: Selected writings (Edited by E.V. Demos). New York: Cambridge University Press. Westen, D. (1995). Social Cognition and Object Relations Scale: Q-sort for projective stories (SCORS-Q). Unpublished manuscript.

histories of incarcerated women (N = 180). The TCI was significantly correlated with total reported trauma events, reported sexual abuse, other Rorschach scores (AgPast, ROD), and scales on both the Personality Assessment Inventory and the Trauma Symptom Inventory-2. The TCI may be related more to sexual abuse than physical abuse and the traumatic intrusions appear to be related to borderline features and dependency in this sample. These results suggest that the TCI facilitates our understanding of trauma in the lives of incarcerated women. While the number of incarcerated prisoners has declined, the percentage of female offenders has increased slightly (Carson, 2018; Green et al., 2016). Female offenders have exhibited higher rates of psychopathology (including mood and anxiety disorders), trauma, and borderline personality disorders than male offenders (Bronson & Berzofsky, 2017; Fazel, Hayes, Bartellas, Clerici, & Trestman, 2016; Smith, Gacono, Kivisto, & Cunliffe, 2019). Females tend to have higher rates of Posttraumatic Stress Disorder (PTSD) than males (Prins, 2014). Incarcerated females have even higher rates of PTSD (from 12% to as high as 54%; Green et al., 2016) than both incarcerated males and non-incarcerated females (Briere, Agee, & Dietrich, 2016; Harner, Budescu, Gillihan, Riley, &Foa, 2015). High incidents of sexual abuse and interpersonal violence are common traumatic historical events related to the development of PTSD and substance use within female offenders (Bowles, DeHart, & Webb, 2012; Briere et al., 2016; DeCou, Lynch et al., 2016; Rowan-Szal, et al., 2012;MacDonald, 2013;Tolin&Foa, 2006; Tripodi & Pettus- Davis, 2013). Rorschach Measures of Trauma Personality assessment measures for trauma are common and the Comprehensive System (CS) Rorschach (RIM) variables have been used extensively (Armstrong,2002; Armstrong & Loewenstein, 1990; Ephraim, 2002; Gacono & Meloy, 1994; Gravenhorst, 2002; Kaser- Boyd & Evans, 2008; Piotrowski, 2017; Sloan, Arsenhault, & Hilsenroth, 2002; Viglione, Towns, & Lindshield, 2012). The RIM assesses psychological variables beyond those measured by self-report. The interpersonal nature of the testing situation also allows the respondent to indirectly communicate trauma issues (Gacono & Meloy, 1994; Levin & Reis, 1997). The Trauma Content Index (TCI; Armstrong & Loewenstein, 1990) has been used specifically as a Rorschach measure to assess trauma. The TCI is correlated with personal traumatic history and intrusive traumatic imagery (Armstrong & Loewenstein, 1990; Zukerman, Ben-Itzchak, Fostick, & Armony-Sivan, 2017). The TCI is calculated by summing Rorschach responses that contain: 1) Blood (Bl), 2) Anatomy (An), 3) Sex (Sx), 4) Morbid (MOR; i.e., something is torn, broken, damaged) and 5) Aggressive Movement (AG). This score is divided by the total number of Rorschach responses. Exner’s (2003) Comprehensive System is used to calculate the TCI. Recently, another Rorschach scoring system, (Rorschach Performance Assessment System; R-PAS; Meyer, Viglione, Mihura, Erard, & Erdberg, 2011) was proposed whereby a Critical Contents (CritCont%) score

was used to include contents identified in the TCI as well as Explosion (Ex), Fire (Fi), and X-ray (Xy; this score is included in the An in R-PAS; a separate Xy score is not included in R-PAS) responses. This score is highly correlated with the TCI (Viglione et al., 2012). While, some investigators have questioned the validity of the TCI, stating the traumatic content categories of the TCI are broad, encompass images related to other types of psychopathology or non-traumatic issues, and are related to exaggerating (Viglione et al., 2012), most research has supported its validity (Armstrong & Loewenstein, 1990; Zukerman et al., 2017). High scores on the Trauma Content Index have been related to sexual abuse, dissociation, physiological responses, higher levels of arousal, and those diagnosed with PTSD produce high scores (Armstrong & Loewenstein, 1990; Arnon, et al., 2011; Brand, et al., 2009; Goldfinger, Amdur, & Liberzon, 1998; Nordström & Carlsson, 1997; Zukerman et al., 2017). A mean of 0.25 has shown specificity and sensitivity for trauma, while mean scores greater than 0.30 have been suggested to indicate traumatic intrusions and has been proven to differentiate traumatized and non-traumatized patients (Armstrong, 2002; Arnon et al., 2011; Kamphuis, Kugeares, & Finn, 2000; Kamphuis et al., 2008; Smith et al., 2010).Investigators have also found that the TCI and Aggressive Past responses (AgPast; tendency to view selfas a victim; Gacono & Meloy, 1994) are highly correlated in traumatized patients (Kamphuis et al., 2000). With offenders, TCI scores have been higher in debt collectors than those that have committed homicides or had low levels of violence (Nørbech, Grønnerød & Hartmann, 2016). Females high in psychopathy (M = 0.37; Smith, Gacono, Cunliffe, Kivisto,& Taylor, 2014) and female sexual offenders tend to have had high TCI scores as well (M = 0.23; Smith, Gacono, Kivisto, & Cunliffe, 2019). Method: Participants: We used archival data in this study. The females (N = 180) were part of separate research projects conducted by Doctoral Level Psychologists at various medium sized state prisons in the United States (California, Wyoming, and Kentucky). Due to the nature of female prisons in the USA, the security levels of the women ranged from camp to maximum. Instant offenses for the population were: 72% (130), were drug related, 10 % (18) had a violent crime, 5% had a sex offense (9), 13% (23) had another type of crime. All participants randomly received a flyer requesting their participation and all inmates volunteered for participation in the various studies. They signed informed consent forms to be included in research. They did not receive any monetary incentives and participation did not affect their sentence. The research studies were approved by the various institutions. Table 1. Descriptive Statistics for Entire Sample M SD Range Age 35.49 9.62 20-70 IQ 97.15 12.41 80-155 Total Traumatic Events 5.66 2.77 0-12 Total Physical Abuse Events 1.78 1.00 0-4 Total Sexual Abuse Events 1.27 0.97 0-7 Rorschach Responses 21.39 7.92 14-55 Lambda 0.77 0.56 0.06-4.33 TCI 0.26 0.19 .00-.93 CritCont% 0.30 0.20 .00-1.07 ROD 0.21 0.12 .00-.57 AgPast 1.69 2.04 0-15 TSI-2 IE 66.05 10.40 39-82

M SD Range TSI-2 DA 63.51 7.90 41-93 TSI-2 DIS 60.67 10.93 41-93 TSI-2 AA-H 60.80 9.35 35-77 TSI-2 SOM 52.66 11.73 32-80 TSI-2 TRB 62.79 13.86 41-100 TSI-2 TRAUMA 64.00 8.72 37-84 PAI ICN 53.52 7.78 34-76 PAI INF 58.32 10.06 40-86 PAI NIM 59.04 8.85 44-73 PAI PIM 36.05 10.51 15-68 PAI SOM 62.84 13.08 40-109 PAI DEP 72.90 14.13 41-107 PAI BOR 76.67 12.07 44-99 PAI ALC 64.53 19.09 41-105 PAI DRG 87.07 18.61 42-114 PAI AGG 65.51 15.32 32-97 PAI PAR-H 72.06 11.88 42-98 PAI ARD-T 81.47 14.01 41-99 PAI BOR-A 68.57 12.75 36-91 PAI BOR-I 69.95 11.14 36-89 Note. M = mean; SD = standard deviation; TSI = Trauma Symptom Inventory; PAI = Personality Assessment Inventory; CritCont%; = Critical Contents; TCI = Trauma Content Index; ROD = Rorschach Oral Dependency; AgPast = Aggressive Past; IE = Intrusive Experiences; DA = Defensive Avoidance; DIS = Dissociation; ICN = Inconsistency; INF = Infrequency; NIM = Negative Impression Management; PIM = Positive Impression Management; SOM = Somatic Complaints; AA-H = Hyperarousal; TRB = Tension Reduction Behavior; DEP = Depressive Symptoms; BOR = Borderline Features; ALC = Alcohol; DRG = Drugs; AGG = Aggression; PAR-H = Hyperarousal; ARD-T = Traumatic Stress; BOR-A = Affective Instability; BOR-I = Identity Problems. The ethnicities for the entire sample (N = 180) were White (N = 112; 62.2%), Black (N = 47; 26.1%), Hispanic (N = 15; 10.98.3%), Asian (N = 3; 1.7%), Native American (N = 2; 1.1%), and Other (N = 1; 0.6%). Diagnoses were part of the archival records and had been provided by a Clinical Psychologist. Overall, 80 (44.4%) met criteria for PTSD and 19 (10.6%) met criteria for Unspecified Trauma- and Stressor- Related Disorder (UTSRD; 55% had a trauma-related diagnosis). In terms of Personality Disorders, 107 (59.4%) were diagnosed with Antisocial Personality Disorder (ASPD) and 68 (37.8%) were diagnosed with Borderline Personality Disorder (BPD). Age, IQ, Rorschach responses, and Lambda scores are available in Table 1. Further, mean, standard deviations, and ranges for all variables included in the correlational analyses are available in Table 1. Those diagnosed with PTSD had a TCI of 0.27. Measures: The Shipley Institute of Living Scale (SILS; Shipley & Zachary, 1986) or the Shipley-2 (Shipley, Gruber, Martin, & Klein, 2009), Trauma Symptom Inventory-2 (TSI-2; Briere, 2011),Personality Assessment Inventory (PAI; Morey, 1991), Stressful Life Events Screening Questionnaire (SLESQ; Goodman, Corcoran, Turner, Yuan, & Green, 1998), and Rorschach Inkblot Test (Exner, 2003; Rorschach, 1921/1942) were administered in accordance with procedures outlined in the test manuals. All measures were completed by Doctoral Level Psychologists (Ph.D. or Psy.D.) with extensive training in the scoring, administration, and interpretation of these measures. The SILS/Shipley-2 was used to provide an estimate of intelligence. The Shipley measures crystallized intelligence with the

Vocabulary scale and fluid intelligence with either the Abstraction or Block Pattern scale. The Shipley has been shown to correlate with the WAIS-R Full Scale IQ between .85 and .87 (Shipley & Zachary, 1986). It is important to utilize a cognitive measure when using the Rorschach as low IQ can contribute to a constricted Rorschach protocol (Gacono, 2019; Smith, Gacono, Fontan et al., 2018). The Stressful Life Events Screening Questionnaire (SLESQ; Goodman et al., 1998) is a 13-item self-report measure to assesses lifetime exposure to traumatic events which was used to identify traumatic events. It has been found to have good testretest reliability and appropriate levels of concurrent and discriminant validity (Goodman et al., 1998). The Trauma Symptom Inventory-2 (TSI-2; Briere, 2011) is a 136 item self-report measure. It measures trauma-relevant symptomology with two validity scales, four factor scores, 12 clinical scales and 12 clinical subscales. The TSI-2 has shown to have concurrent, discriminant, construct, criterion, and factorial validity as well as high test-retest reliability and internal consistency (Briere, 2011). It has been validated on incarcerated women (Briere, 2011). Protocols were considered valid if they had T scores below 75 on the Response Level (RL) scale and had a raw score below 15 on the Atypical Response (AR) scale. The Personality Assessment Inventory (PAI; Morey, 1991) is a 344 item self-report measure. It examines psychopathology and personality characteristics. It contains validity, clinical, treatment, and interpersonal scales. When examining the validity of a protocol, participants were retained for analyses only if they obtained an Infrequency (INF) score below 75T, an Inconsistency (ICN) score below 73T, and a Negative Impression Management (NIM) score lower than 77T (Morey, 1991). All the Rorschach protocols were administered and scored per the Exner Comprehensive System Guidelines (Exner, 2003). Exner’s (2003) Comprehensive System was used to calculate the TCI. All Rorschach variables (TCI, CritCont%, ROD, & AgPast) were scored using CHESSSS (Fontan et al., 2013). All have shown to have good reliability and validity (Armstrong, 2002; Bornstein & Masling, 2005; Gacono & Meloy, 1994; Viglione et al., 2012). Kappa coefficients for the Rorschach scores ranged from .75 to 1.00 (all in the excellent range [Meyer, 1999]). Twenty protocols were scored by two raters and inter-rater reliability was calculated from these protocols. Procedure: The total sample consisted of incarcerated females. Thirty-six of the 180 were excluded as 24 had PAI INF, INC, and/or NIM scores above the cutoff and 12had an IQ < 80. The following were used in the correlational analyses: 1) total traumatic events; total physical abuse events; total sexual abuse events; 2) Rorschach: TCI; CritCont%; ROD; AgPast; 3) TSI-2 scales: IE (Intrusive Experiences); DIS (Dissociation); AA-H (Hyperarousal); DA (Defensive Avoidance); SOM (Somatic Preoccupations); TRB (Tension Reduction Behavior); TRAUMA (Constellation of TSI-2 Trauma Scales); 4) PAI scales: SOM (Somatic Complaints); DEP (Depressive symptoms); BOR (Borderline features); AGG (Aggression); ALC (Alcohol); DRG (Drug); PAR-H (Hypervigilance); BOR-A (Affective Instability); BOR-I (Identity Problems); ARD-T (Traumatic Stress). The Statistical Package for Social Sciences (SPSS) version 22, was used for all calculations. The data were analyzed for means, standard deviations, and ranges. Due to the nature of the Rorschach variables selected (unequal distribution, J-Shaped curves; Exner, 1995), these variables were examined with non-parametric statistics (Spearman rho; Viglione, 1995).

Results: Table 2. TCI Correlational Analyses TCI Total Traumatic Events 0.294** Total Physical Abuse Events 0.114 Total Sexual Abuse Events 0.299** CritCont% 0.955** ROD 0.178* AgPast 0.482** TSI-2 IE 0.175 TSI-2 DA 0.279* TSI-2 DIS 0.115 TSI-2 AA-H 0.106 TSI-2 SOM 0.097 TSI-2 TRB 0.079 TSI-2 TRAUMA 0.209 PAI SOM 0.148 PAI DEP 0.036 PAI BOR 0.333** PAI ALC 0.200 PAI DRG 0.130 PAI AGG 0.296** PAI PAR-H 0.093 PAI ARD-T -0.002 PAI BOR-A 0.325** PAI BOR-I 0.239* Note.Correlations = ρ (Spearman); * = p < .05; ** = p < .01. TSI = Trauma Symptom Inventory; PAI = Personality Assessment Inventory; TCI = Trauma Content Index; CritCont%; = Critical Contents; ROD = Rorschach Oral Dependency; AgPast = Aggressive Past; IE = Intrusive Experiences; DA = Defensive Avoidance; DIS = Dissociation; SOM = Somatic Complaints; AA-H = Hyperarousal; TRB = Tension Reduction Behavior; DEP = Depressive symptoms; BOR = Borderline Features; ALC = Alcohol; DRG = Drugs; AGG = Aggression; PAR-H = Hyperarousal; ARD-T = Traumatic Stress; BOR-A = Affective Instability; BOR-I = Identity Problems. The TCI correlational analyses found 10 significant correlations (see Table 2). These included total traumatic events (ρ [107] = .294, p = .002), total sexual abuse events (ρ [106] = .299, p = .002), CritCont% (ρ [168] = .955, p < .001), ROD (ρ [166] = .178, p = .022), AgPast (ρ [167] = .482, p < .001), TSI-2 DA (ρ [73] = .279, p = .017), PAI BOR (ρ [92] = .333, p = .001), PAI BOR-A (ρ [92] = .325, p = .002), PAI BOR-I (ρ [92] = .239, p = .022), and PAI AGG (ρ [92] = .296, p = .004). Though there was not a significant correlation with the TSI-2 TRAUMA scale, there was a positive trend (ρ [73] = .209, p = .062).CritCont% was significantly correlated with the TSI-2 TRAUMA scale (ρ [73] = .261, p = .026). Discussion: In our study, the TCI had several noteworthy correlations. The TCI was significantly correlated with the total number of reported traumatic events and total reported sexual abuse events but not total reported physical abuse events. This suggests that the index may be tapping into intrusive traumatic imagery from these events (there was a positive trend with m responses which measures intrusive intrusions). However, it appears that it may be more related to sexual rather than physical abuse as previously seen (Kamphuis et al., 2000; Nordström & Carlsson, 1997). Not surprisingly, the CritCont% was highly correlated with the TCI. The CritCont% was significantly correlated with a constellation of TSI-2 trauma scales suggesting it is measuring trauma symptomology (TCI had a positive trend). Though the overall sample had a TCI with a mean of 0.26 (less than the .30 signifying traumatic intrusions; Armstrong, 2002), it does appear the individuals within the sample are suffering from traumatic intrusions. For forensic populations, clinicians need to be mindful of exaggeration or malingering which is a possibility on the TCI (Viglione et al., 2012). However, in this forensic sample, none of the validity scales on the self-report measures were significantly correlated with the TCI. When examining the TCI components, the contents suggest aggression, a damaged sense of self, sexual preoccupations, blood, and anatomy responses. The significant relationship between AgPast and the TCI suggests that the female offenders identify with a damaged view of self in part due to the fact that they were victims of aggression or traumatic events (also PAI AGG scale). In our sample, the victims of aggression become the victimizers (prone to aggression; Gacono &

Meloy, 1994; Goldenson, Geffner, Foster, & Clipson, 2007; Smith, Gacono, & Cunliffe, in press [a]) which would relate to Rorschach Aggressive Movement (AG) responses (part of the TCI). Avoidance is a key symptom of PTSD and from clinical experience, this unhealthy coping strategy is common among female offenders with past traumatic experiences. Therefore, the TCI appears to be related to their use of avoidance, specifically intentional effort to deter and fend off unwanted internal experiences and physical environments that could trigger a memory (TSI-2 DA). While trauma, PTSD, and Borderline Personality Disorder (BPD) differ, they overlap in central symptomology (Cloitre, Garvert, Weiss, Carlson, & Bryant, 2014). The TCI is significantly correlated with the PAI Borderline features scales in our sample. Both PTSD and BPD are prominent within incarcerated women, with 49 (27.2%) having a trauma diagnosis (PTSD or UTSRD) and a co-morbid BPD diagnosis in this sample (Bronson &Berzofsky, 2017; Fazel et al., 2016; Prins, 2014; Smith et al., 2019). Perhaps the measures are assessing symptoms from both disorders. Examining the PAI BOR scales, BOR-A examines affective instability and heightened emotionality which has been described as a differentiating factor between male and female offenders/psychopaths (Cunliffe & Gacono, 2005, 2008; Cunliffe et al., 2016; Gacono, 2016; Gacono & Meloy, 1994; Smith, Gacono, & Cunliffe, 2018). This leads the female offender to be prone to dissociation, avoidance, and traumatic intrusions and the emotionality may be the driving force of symptom presentation and antisocial behavior (Smith, Gacono, Kivisto et al., 2019). The TCI and ROD scales were also significantly correlated suggesting that traumatic intrusions may relate to higher levels of dependency in the sample. Abnormal attachment/bonding is common with victims of sexual abuse especially in early childhood (common in incarcerated women; Smith, Gacono, & Cunliffe, in press [b]). Consequently, it is not surprising our women would have higher levels of dependency related to an excessive need for nurturance (ROD & PAI BOR scores). The findings show that when validating a Rorschach variable, externally assessed criteria (e.g., diagnoses; real-world data [traumatic events]) may be better than introspectively assessed criteria (e.g., selfreport measures). Research findings have found externally assessed criteria rather than introspectively assessed criteria are better at validating Rorschach indices (Mihura, Meyer, Dumitrascu & Bombel, 2013; Smith, Gacono, Fontan et al., 2018; Smith, Gacono, & Cunliffe, 2019). This may, in part, explain the lack of significant correlations between the TCI and many of the TSI-2 and PAI scales assessing traumatic events. Conclusions: The Rorschach remains a valuable instrument in psychological assessment. Though it is not meant to make diagnoses, it can provide information about personality characteristics not accessible with self-report measures. This provides clinicians with a more thorough understanding when it comes to trauma especially in forensic contexts. A multimethod assessment approach including the Rorschach is recommended. This is paramount since the high levels of psychopathology in forensic settings necessitates treatment. Future trauma-related research with the Rorschach would benefit by investigating the relationship between the TCI and other popular measures of PTSD (see Piotrowski, 2020). References: Armstrong, J. G. (2002). Deciphering the broken narrative of trauma: Signs of traumatic dissociation on the Rorschach. Rorschachiana, 25(1), 11-27. Armstrong, J.G., & Loewenstein, R.J. (1990). Characteristics of patients with multiple personality and dissociative disorders on psychological testing. Journal of Nervous and Mental Disease, 178, 448–454.

Arnon, Z., Maoz, G., Gazit, T., & Klein, E. (2011). Rorschach indicators of PTSD: A retrospective study. Rorschachiana, 32(1), 5-26. Bornstein, R. F., & Masling, J. M. (2005). The Rorschach Oral Dependency Scale. In R. F. Bornstein & J. M. Masling (Eds.), Scoring the Rorschach: Seven validated systems (pp. 135-157). Mahwah, NJ: Lawrence Erlbaum Associates Publishers. Bowles, M.A., DeHart, D. & Webb, J.R. (2012). Family influences on female offenders’ substance use: The role of adverse childhood events among incarcerated women. Journal of Family Violence, 27(7), 681-686. Brand, B. L., Armstrong, J. G., Loewenstein, R. J. & McNary, S. W. (2009). Personality differences on the Rorschach of dissociative identity disorder, borderline personality disorder, and psychotic inpatients. Psychological Trauma: Theory, Research, Practice, and Policy, 1(3), 188–205. doi:10.1037/a0016561 Briere, J. (2011). Trauma Symptom Inventory–2 (TSI–2). Odessa, FL: Psychological Assessment Resources. Briere, J., Agee, E., & Dietrich, A. (2016). Cumulative trauma and current posttraumatic stress disorder status in general population and inmate samples. Psychological Trauma: Theory, Research, Practice, and Policy, 8(4), 439-446. http://dx.doi.org/10.1037/tra0000107 Bronson, J., &Berzofsky, M. (2017). Indicators of mental health problems reported by prisoners and jail inmates, 2011-12 (Bureau of Justice Statistics Bulletin). Washington, DC: U.S. Department of Justice. Carson, E.A. (2018). Prisoners in 2016 (Bureau of Justice Statistics Bulletin). Washington, DC: U.S. Department of Justice. Cloitre, M., Garvert, D.W., Weiss, B., Carlson, E.B., & Bryant, R.A. (2014). Distinguishing PTSD, Complex PTSD, and Borderline Personality Disorder: A latent class analysis. European Journal of Psychotraumatology, 5 (1). DOI: 10.3402/ejpt.v5.25097 Cunliffe, T.B., & Gacono, C.B. (2005). A Rorschach investigation of incarcerated antisocial personality disordered female offenders. International Journal of Offender Therapy and Comparative Criminology, 49, 530-547. Cunliffe, T.B., & Gacono, C.B. (2008). A Rorschach understanding of antisocial and psychopathic women. In C. B. Gacono, F.B. Evans, N. Kaser- Boyd, & L.A. Gacono (Eds.), The handbook of forensic Rorschach assessment (pp. 361-378). New York, NY: Routledge. Cunliffe, T.B., Gacono, C.B., Smith, J.M., Kivisto, A.J., Meloy, J.R., & Taylor, E.E. (2016). Assessing psychopathy in women. In C.B. Gacono (Ed.), The clinical and forensic assessment of psychopathy: A practitioner’s guide (2nd ed., pp. 167-190). New York, NY: Routledge/Taylor & Francis Group. DeCou, C.R., Lynch, S.M., DeHart, D.D., & Belknap, J. (2017). Evaluating childhood and adulthood victimization as predictors of psychotic disorders: Findings from a nationwide study of women in jail. Psychosis, 9(3), 282-285. DOI: 10.1080/17522439.2017.1325512 Ephraim, D. (2002). Rorschach trauma assessment of survivors of torture and state violence. Rorschachiana, 25(1), 58-76. http://dx.doi.org/10.1027/1192-5604.25.1.58 Exner, J. E. (Ed.). (1995). Issues and methods in Rorschach research. Mahwah, NJ: Erlbaum. Exner, J.E. (2003). The Rorschach: A Comprehensive System (4th ed.). New York: Wiley. Fazel, S., Hayes, A. J., Bartellas, K., Clerici, M., & Trestman, R. (2016). Mental health of prisoners: prevalence, adverse outcomes, and interventions. The Lancet: Psychiatry, 3(9), 871- 881. Fontan, P., Andronikof, A., Nicodemo, D., Al Nyssani, L., Guilheri, J., Hansen, K. G., Kumasaka, S., & Nakamura, N. (2013). CHESSSS: A free software solution to score and compute the Rorschach Comprehensive System and Supplementary Scales. Rorschachiana, 34(1), 56-82. http://dx.doi.org/10.1027/1192-5604/a000040 Gacono, C.B. (2016). Introduction. In C. B. Gacono (Ed.), The clinical and forensic assessment of psychopathy: A practitioner's guide (pp. 3-13). New York, NY, US: Routledge/Taylor & Francis Group. Gacono, C.B., & Meloy, J.R. (1994). The Rorschach assessment of aggressive and psychopathic personalities. Hillsdale, NJ: Erlbaum. Goldenson, J., Geffner, R., Foster, S.L., & Clipson, C.R. (2007). Female domestic violence offenders:

Their attachment security, trauma symptoms, and personality organization. Violence and Victims, 22, 532-545. Goldfinger, D.A., Amdur, R.L., & Liberzon, I. (1998). Psychophysiologic responses to the Rorschach in PTSD patients, noncombat and combat controls. Depression and anxiety, 8 (3), 112-20. Goodman, L., Corcoran, C., Turner, K., Yuan, N., & Green, B. (1998). Assessing traumatic event exposure: General issues and preliminary findings for the Stressful Life Events Screening Questionnaire. Journal of Traumatic Stress, 11(3), 521-542. Gravenhorst, M. C. (2002). Rorschach psychodiagnosis of psychic trauma in sexually abused children. Rorschachiana, 25(1), 77-85. http://dx.doi.org/10.1027/1192-5604.25.1.77 Green, B. L., Dass-Brailsford, P., Hurtado de Mendoza, A., Mete, M., Lynch, S. M., DeHart, D. D., & Belknap, J. (2016). Trauma experiences and mental health among incarcerated women. Psychological Trauma: Theory, Research, Practice, and Policy, 8(4), 455-463. Harner, H. M., Budescu, M., Gillihan, S. J., Riley, S., & Foa, E. B. (2015). Posttraumatic stress disorder in incarcerated women: A call for evidence-based treatment. Psychological Trauma: Theory, Research, Practice, and Policy, 7(1), 58-66. Kamphuis, J.H., Kugeares, S.L., & Finn, S.E. (2000). Rorschach correlates of sexual abuse: Trauma content and aggression indices. Journal of Personality Assessment, 75, 212–224. Kamphuis, J.H., Tuin N., Timmermans, M., &Punamäki, R.L. (2008). Extending the Rorschach Trauma Content Index and Aggression Indexes to dream narratives of children exposed to enduring violence: An exploratory study. Journal of Personality Assessment, 90 (6), 578-584. DOI: 10.1080/00223890802388558 Kaser-Boyd, N. & Evans, F. B. (2008). Rorschach assessment of psychological trauma. In C. B. Gacono & F. B. Evans (Eds.), The handbook of forensic Rorschach assessment (pp. 255–277). New York, NY: Routledge. Levin, P., & Reis, B. (1997). Use of the Rorschach in Assessing Trauma. In J.P. Wilson & T.M. Keane (Eds.), Assessing psychological trauma and PTSD (pp. 529–541). New York: Guilford. MacDonald, M. (2013). Women prisoners, mental health, violence and abuse, International Journal of Law and Psychiatry, 36 (3–4), 293-303. Meyer, G. J. (1999). Simple procedures to estimate chance agreement and kappa for the interrater reliability of response segments using the Rorschach Comprehensive System. Journal of Personality Assessment, 72, 230-255. Meyer, G., Viglione, D.J., Mihura, J.L., Erard, R.E., & Erdberg, P. (2011). A Manual for the Rorschach Performance Assessment System. Toledo, OH: R-PAS. Mihura, J.L., Meyer, G.J., Dumitrascu, N., & Bombel, G. (2013). The validity of individual Rorschach variables: Systematic reviews and meta-analyses of the comprehensive system. Psychological Bulletin, 139, 548-605. Morey, L. C. (1991). Personality Assessment Inventory professional manual. Odessa, FL: Psychological Assessment Resources. Nørbech, P.C.B., Grønnerød, C., & Hartmann E. (2016). Identification with a violent and sadistic aggressor: A Rorschach study of criminal debt collectors. Journal of Personality Assessment, 98 (2), 135-145. Nordström, K., & Carlsson, A. M. (1997, March). Rorschach comparison of borderline patients with and without a history of childhood sexual abuse. Paper presented at the annual meeting of the Society for Personality Assessment, San Diego, CA. Piotrowski, C. (2020). Prominent assessment instruments in suicide and PTSD research on U.S. veterans. Journal of Projective Psychology & Mental Health, 27(1), 1-5. Piotrowski, C. (2017). Rorschach research through the lens of bibliometric analysis: Mapping investigatory domain. Journal of Projective Psychology & Mental Health, 24(1), 34-38. Prins, S.J. (2014). Prevalence of mental illnesses in US state prisons: A systematic review. Psychiatric Services, 65(7), 862-872. Rorschach, H. (1921/1942). Psychodiagnostik. Bern: Bircher (translation Hans Huber Verlag, 1942). Rowan-Szal, G.A., Joe, G.W., Bartholomew, N.G., Pankow, J., & Simpson, D.D. (2012). Brief trauma and mental health assessments for female offenders in addiction treatment, Journal of Offender Rehabilitation, 51(1-2), 57-77.

Shipley, W.C., Gruber, C.P., Martin, T.A., & Klein, A.M. (2009). Shipley-2 manual. Los Angeles, CA: Western Psychological Services. Shipley, W. C., & Zachary, R. A. (1986). Shipley Institute of Living Scale. Los Angeles, CA: Western Psychological Services. Sloan, P., Arsenault, L., & Hilsenroth, M. (2002). Use of the Rorschach in the assessment of war-related stress in military personnel. Rorschachiana, 25(1), 86-122. Smith, J.M., Gacono, C.B., & Cunliffe, T.B. (2019). Understanding the Rorschach Egocentricity Index with incarcerated women. Archives of Assessment Psychology, 9(1), 139-155. Smith, J.M., Gacono, C.B., & Cunliffe, T.B. (2018). Comparison of male and female psychopaths on select CS Rorschach variables. SIS Journal of Projective Psychology and Mental Health, 25(2), 138-155. Smith, J.M., Gacono, C.B., & Cunliffe, T.B. (in press[a]). Female psychopathy and aggression: A study with incarcerated women and Rorschach aggression scores. Journal of Aggression, Maltreatment, and Trauma. Smith, J.M., Gacono, C.B., & Cunliffe, T.B. (in press[b]). Trauma and dependency in incarcerated women. Criminal Justice & Behavior. Smith, J.M., Gacono, C.B., Cunliffe, T.B., Kivisto, A.J., & Taylor, E.E. (2014). Psychodynamics in the female psychopath: A PCL-R/Rorschach investigation. Violence and Gender, 1(4), 176-187. Smith, J.M., Gacono, C.B., Fontan, P., Taylor, E.E., Cunliffe, T.B., & Andronikof, A. (2018). A scientific critique of Rorschach research: Revisiting Exner's (1995) Issues and Methods in Rorschach Research. Rorschachiana, 39(2), 180-203. Smith, J.M.,Gacono, C.B., Kivisto, A.J., & Cunliffe, T.B. (2019). A PCL-R, Rorschach, and PAI investigation of females with sex offenses against minors and a Rorschach comparison with male pedophiles. Archives of Assessment Psychology, 9(1), 113-137. Smith S.R., Chang, J., Kochinski, S., Patz, S., &Nowinski, L.A. (2010). Initial validity of the logical Rorschach in the assessment of trauma. Journal of Personality Assessment, 92(3), 222-231. DOI: 10.1080/00223891003670174 Tolin, D. F., &Foa, E. B. (2006). Sex differences in trauma and posttraumatic stress disorder: A quantitative review of 25 years of research. Psychological Bulletin, 132(6), 959-992. Tripodi, S.J., & Pettus-Davis, C. (2013). Histories of childhood victimization and subsequent mental health problems, substance use, and sexual victimization for a sample of incarcerated women in the US, International Journal of Law and Psychiatry, 36 (1), 30-40. Viglione, D.J. (1995). Basic considerations regarding data analysis. In J.E. Exner (Ed.), Issues and methods in Rorschach research (pp. 195-226). Hillsdale, NJ, US: Lawrence Erlbaum Associates, Inc. Viglione, D. J., Towns, B., & Lindshield, D. (2012). Understanding and using the Rorschach Inkblot Test to assess post-traumatic conditions. Psychological Injury and Law, 5(2), 135-144. http://dx.doi.org/10.1007/s12207-012-9128-5 Zukerman, G., Ben-Itzchak, E., Fostick, L., &Armony- Sivan, R. (2017). Information processing of the Rorschach's Traumatic Content Index in traumaexposed adults: An Event Related Potential (ERP) study. Biological Psychology, 127, 108- 122. 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

The issue of pain measurement and assessment has attracted intense clinical and research attention, particularly over the past three decades. Hence, pain assessment has become a) a central feature in the study of pain across a myriad of health care disciplines (i.e., medicine, rehabilitation, psychology, nursing, social work, quality of life, and public health), b) a major component of comprehensive pain management, and c) a burgeoning area of applied research. Given the vast landscape of this literature: Where is the practicing mental health clinician to turn in identifying the major pain assessment instruments reported in the recent scholarly literature? To that end, the aim of the current study is to identify the most prominent methods (i.e., measures, scales, inventories, tests) in research, reported in studies with a focus on pain or pain states, 2006-2018. Hence, an extension of a similar study design reported by Piotrowski (2007). Based on a bibliometric examination of the literature, including assessment measures noted in major texts on pain, nearly 200 assessment instruments were identified and determined to be the most visible scales/tests related to the issue of pain. Next, the author conducted an online search in the ProQuest database (restricted to years 2006-2018). Using a Boolean logic search strategy on these instruments, individual searches produced the total number of scholarly articles for each assessment method that was noted in the Abstract of primary articles. This procedure identified 130 measures that were the focus of study in at least 5 articles. Of these, 49 tests appeared in study abstracts more than 100 times. Noteworthy, several of these ‘popular’ tests were measures of psychopathology, outside the specific domain of Pain, such as the Beck Depression Inventory, the STAI, and the MMPI series. Moreover, many of the most popular scales reflect general health assessment and quality of life issues. In addition, the assessment of functional disability was well represented in the top ranked scales/measures (e.g., Oswestry Disability Index, the DASH Questionnaire). Other prominent assessment methods were, the Visual Analogue Scale, the Health Assessment Questionnaire, the Numerical Rating Scale, Brief Pain Inventory, the McGill Pain Questionnaire, the Hospital Anxiety & Depression Scale, the SF-36 Health Survey, the Pittsburgh Sleep Quality Index, and the PROMIS. These findings should provide a seminal template for mapping the extant scholarship regarding preferred methods or assessment techniques used in research on pain. Furthermore, the current analysis points to the vast array of measures and scales on which research findings in pain scholarship are based, which prompts the problematic concern regarding the lack of investigatory cohesion in this rapidly expanding literature and fragmentation of research streams across this multidisciplinary field. Historically, the myriad of pain conditions and the deleterious experience of chronic pain have continued to inflict an onerous impact on the human condition, designating ‘pain’ as a major public health problem and vital-sign metric (Gaskin & Richard, 2012; Melzack, 1983; Turk & Gatchel, 2018). More recently, the Biopsychosocial paradigm, reflected in the modern era of clinical practice and research scholarship in the healthcare field (Castelnuovo, 2017; Porter-Moffitt et al., 2006), has been well-incorporated in the study of pain (Deer & Ray, 2015; Eisenberger, 2012; Flor & Turk, 2011; Gatchel et al., 2007; Gatchel& Turk, 1999; Hickling et al., 1995; Huzmeli & Melek, 2017; Riva et al., 2011). Accordingly, the extant literature on various pain states is voluminous and growing at an exponential rate (Gatchel, 2005; Jensen & Turk, 2014). In mental health practice, complaints regarding pain or experience of chronic pain are a ubiquitous symptom presented to the clinician (Fillingim et al., 2016; Gaskin & Richard, 2012; Jensen & Turk, 2014; Lee et al., 2017; Wallace et al., 2018). Thus, it follows that the study of pain, particularly the area of pain assessment, has been and continues to be a prominent topic of scholarly

investigation in the mental health field, exemplified by well-cited textbooks (Gatchel & Weisberg, 2000; Keller & Butcher 1991; Turk & Gatchel, 2002; Turk & Melzack, 2011). Evaluation and Assessment of Pain: Within this clinical domain, comprehensive evaluation of the ‘patient-in-pain’ is considered a critical, central component in the treatment of the myriad of pain conditions (Epker, 2013; Gatchel et al., 2017; Mikail et al., 1993; Ruben et al., 2018). Based on the voluminous body of extant research, the issue of pain measurement and assessment has attracted intense investigatory attention from both clinicians and scholars (Bruns & Disorbio, 2015; Kovatch et al., 2017; Turk & Okifuji, 2002). Moreover, co-morbidity factors play a significant role in the study of pain (Reist et al., 2017; Turk & Gatchel, 2018). Hence, pain assessment has become a) a central feature in the study of pain across a multitude of clinical health care disciplines (Medicine, rehabilitation, psychology, nursing, quality of life, and public health), b) a major component of chronic pain management, and c) a burgeoning area of clinical and applied research. Interestingly, there have been limited reviews of the literature regarding the clinical usage of specific pain measures and scales, beyond confirmation on the popularity of the MMPI (all revisions) in the assessment protocol used with pain patients in professional practice (see Andrasik et al., 1989; Piotrowski, 2018; Piotrowski & Lubin, 1990; Porter-Moffitt et al., 2006). In fact, in a seminal study, Piotrowski (1998) reported on the top-ranked tests used by clinicians in the pain field, i.e., the MMPI (all versions), the Beck Depression Inventory, McGill Pain Questionnaire, SCL-90, the Multidimensional Pain Inventory, and the Millon MCMI. From an evaluation perspective, the pain experience is usually conceptualized along several domains: nociception, neuropathic, psychological factors, personality strengths, emotion regulation, pain beliefs, coping resources, functional capacity, social/ interpersonal milieu. Yet, practicing clinicians, with limited exposure (due to lack of training and hands-on experience) with the copious array of pain assessment instruments usually rely on pain measures like the McGill Pain Questionnaire and/or broadband mental health tests of psychopathology (see Piotrowski, 2018, 1998). Rationale for the Current Study: In a recent review, based on the extant body of literature on pain studies, Piotrowski (2017) found that projective techniques have garnered limited clinical interest in this area. In an earlier bibliometric study, the most noted assessment instruments on the topic of pain were: the McGill Pain Questionnaire, Beck Depression Inventory, the Multidimensional Pain Inventory, the Coping Strategies Questionnaire, and the Low Back Pain Questionnaire (Piotrowski, 2007). Thus, an updated analysis of the pain literature is urgently needed. The salient issue is: Where is the practicing mental health clinician to turn in identifying the major pain assessment instruments available and discussed in the recent scholarly literature? Moreover, having an awareness of the most prominent measures in the study of pain should facilitate professional communication in consultancy with specialists or multidisciplinary pain treatment teams (Gatchel et al., 2014; Townsend et al., 2006). To that end, the aim of the current study is to identify the most prominent methods (i.e., measures, scales, inventories, tests) in the research literature, reported in studies with a focus on pain or pain states, 2006-2018. Hence, an extension of a similar study design reported by Piotrowski (2007, 2019). Method: The design followed the parameters of a bibliometric ‘Content Analysis’ of the literature (see Krippendorff, 2004), which has been recently applied in the study of pain states (Piotrowski, 2014). The initial challenge was

to obtain a listing of the major evaluation measures, tests, and scales in the field of pain assessment. To that end, researchers have utilized systematic reviews of the extant literature to identify key instruments with high visibility in research studies (e.g., Zijlema et al., 2013). For the current analysis, a 3-prong procedure was applied: 1) scanning test coverage in several recent textbooks on the topic of pain and mental health assessment (e.g., Marchand et al., 2014; Sajatovic, 2012), 2) identifying listings of top tests noted in review articles on the measurement of pain states (i.e., Banerjee et al., 2017; Epker, 2013; Piotrowski, 2007) and quality of life (e.g., Hall et al., 2011), and 3) scanning the results of a bibliometric search (see De Bellis, 2009) of the recent mental health literature on the topic of pain (PsycINFO database; a menu tab displays the most frequently cited assessment instruments across specific ‘pain’ domains). This systematic approach yielded nearly assessment instruments determined to be the most visible scales/tests discussed in the literature regarding the topic of Pain. Next, the author conducted an online search in the ProQuest database, restricted to years 2006-2018. This repository of extensive literature indexes scholarly studies across the medical, health, psychological, and social sciences, containing over 125 billion digital pages. In order to determine which measures were the main focus of study, the search option ABSTRACT was used in order to identify which scales/tests were specifically noted by investigators. Using Boolean logic (name of test/questionnaire/scale/measure/ inventory + pain) on each of the instruments, individual searches produced the total number of scholarly articles where the test was noted in the Abstract. A running frequency tabulation was maintained during all online searches which identified the 130 measures/scales that appeared in at least 5 articles. This scoring template then illustrated the ranking of individual assessment techniques, based on frequency distribution. Findings: First, the most striking observation of the data analysis is the vast scope, comprehensive nature, and impressive number of measures which serve as part of the methodology across the research spectrum in the pain literature. In and of itself, this finding may have both positive and negative implications. One possibility is that such a voluminous foundation of measurement techniques and methods may reflect the robustness of the burgeoning literature of a multidisciplinary field; on the other hand, the vast array of distinct methods and assessment tools may be an indicator of disparate investigatory interests and research designs which, to some extent, contribute to a lack of conceptual cohesion and clinical consensus regarding both research focus and relevance of research findings. Thus, advances in scholarship in the study of pain may be stymied or side-tracked by fragmentation in investigatory streams, leading to an opaque sense of direction for future research. Table 1 displays, in rank order, the most mentioned or cited scales/measures used in studies on the evaluation of pain across a myriad of pain states and conditions since 2006. While this listing is rather exhaustive (encompassing 130 assessment tools), a select 49 appeared in study abstracts more than 100 times. Moreover, several of these ‘popular’ tests were measures of psychopathology, outside the specific domain of ‘Pain’, such as the Beck Depression Inventory, the Geriatric Depression Scale, the State-Trait Anxiety Inventory, and the MMPI series (Banks & Kerns, 1996; Lee et al., 2017; Piotrowski, 2018). Apparently, researchers who are involved in the study of pain have a strong clinical interest in mental health comorbidity factors, particularly levels of depression and anxiety, and related general psychological indices of pain patients (see Bair et al., 2003; Morgan, 2009; Okifuji & Turk, 2014 for discussion). Furthermore, many of the most prominent scales, noted in Table 1, reflect general health assessment and quality of life issues. In addition, the

assessment on the extent of functional disability is well represented in the top ranked scales/measures (e.g., Oswestry Disability Index, the DASH Questionnaire). The issue of chronic pain has been a major area of research concentration (e.g., Alschuler & Otis, 2014; Dansie & Turk, 2013; Dysvik et al., 2013), exemplified by the vast number of measures with the specific aim to evaluate patients experiencing and coping with longterm pain. In this regard, prior research studies suggest that common psychological features, evident in chronic pain sufferers, support the characterization of the ‘pain personality’ in the clinical evaluation of these patients (Doherty et al., 2017; Kennedy et al., 2011; Naylor et al., 2017; Zhang, 2002). Moreover, in the aggregate, Quality-of-Life issues appear to be a major emerging assessment area in the study of chronic pain populations (Dezutter et al., 2013; Dusova & Cseszarova, 2008; Trost et al., 2015), evident by the proliferation of Quality-of-Life scales noted in the current analysis. Conclusion: Table 1 should be relied upon as a handy clinical assessment reference guide in the treatment of pain patients. While this list of measures appears rather extensive, new assessment tools in the area of pain assessment continue to be introduced in the literature (e.g., Meyer et al. 2016). Thus, staying abreast of the emerging literature in the study of pain will surely be challenging. The current content analysis exercise provided the opportunity to deduce several key developments regarding recent investigatory research streams in pain scholarship: *Despite the popularity of tests of psychopathology such as the MMPI and Millon inventories (Frauenhoffer et al., 1998), these broadband measures seem to be used selectively in pain-related research. Perhaps, as health care providers become more familiar with the efficacy of these robust instruments in pain-related conditions, there use may increase in the future (see Gatchel et al., 2006; Haggard et al., 2008; Marek & Ben Porath, 2017; Tarescavage et al., 2015; Vendrig, 2000). *With the aging U.S. population, there should be more research attention devoted to the study of pain, particularly chronic pain states, in the elderly; such robust investigatory emphasis has been quite evident over the past decade (Buffum et al., 2007; Gagliese, 2009; Jacobs et al., 2006; Kang & Demiris, 2016; Molton & Terrill, 2014; Sofaer-Bennett et al., 2007; Tse et al., 2013; Yohannes & Caton, 2010). In this regard, ‘Collateral’ assessment of family and other caretakers of long-term pain patients will be a critical factor in mental health evaluations (see Leonard et al., 2006). *Whereas the issue of suicidal ideation has been discussed in the extant literature with regard to chronic pain patients (Edwards et al., 2006; Reist et al., 2017), few measures that tap suicide potential or cognitions in pain populations were evident in the current analysis. *Interestingly, there is a dearth of research focus on racial and ethnic factors in pain assessment (Tait & Chibnall, 2014). *While the study of pain states in children has been a bourgeoning area of research (e.g., Azize et al., 2014; Gorodzinsky et al., 2011; Lollar et al., 1982; McGrath et al., 2013; Stefanatou & Bowler, 1997), the availability and range of assessment measures specifically designed for this unique clinical population (including adolescent-age patients) are somewhat limited. *The recent emphasis on patient-reported outcomes in mental health assessment (i.e., PROMIS) has application in the comprehensive assessment of pain patients (Holmes et al., 2017). *The role of the health provider in the pain assessment process has been a neglected area of research (see Ruben et al., 2018).

Future Research: This study, by design, was limited to published journal articles in the database ProQuest. Although journal coverage was multidisciplinary, further research efforts should concentrate on scholarly literature files and repositories such as MEDLINE and related health care databases. In addition, bibliometric studies on pain assessment regarding specific clinical conditions or specialty-area journals (e.g.cancer, headache, musculoskeletal, orofacial, fibromyalgia) should not only be informative, but also introduce a template for mapping the extant scholarship on pain assessment while providing directions for future research on these clinical conditions. Table 1. Measures in Abstract of Scholarly Articles on Pain in ProQuest Database (2006-2018) Measure/Test/Scale # of Mentions Visual Analogue Scale 13551 Oswestry Disability Index 3818 Numerical Rating Scale 2607 Brief Pain Inventory 2123 McGill Pain Questionnaire 1550 Health Assessment Questionnaire 1518 Hospital Anxiety and Depression Scale 1420 Beck Depression Inventory 1229 Roland-Morris Disability Questionnaire Short-Form-36 Health Survey Pittsburgh Sleep Quality Index State-Trait Anxiety Inventory PROMIS Shoulder Pain and Disability Index Faces Pain Scale Disabilities of the Arm, Shoulder and Hand Questionnaire (DASH) Health Assessment Questionnaire European Org. for Research & Treatment of Cancer QoLQ Functional Assessment of Cancer Therapy Barthel Index Nottingham Health Profile PHQ-9 Fear-Avoidance Beliefs Questionnaire Health Assessment Questionnaire-Disability Index Tampa Scale for Kinesiophobia General Health Questionnaire Geriatric Depression Scale CES-D Multidimensional Pain Inventory (West Haven-Yale) SCL-90 Functional Independence Measure Coping Strategies Questionnaire Edmonton Symptom Assessment System Pediatric Quality of Life Inventory Migraine Disability Assessment (MIDAS) Disability Status Scale

Profile of Mood States (POMS) WOMAC Osteoarthritis Index Health Utilities Index Memorial Symptom Assessment Scale Pain Drawing Headache Impact Test (HIT) Pediatric Quality of Life Inventory Hamilton Rating Scale for Depression Neuropathic Pain Symptom Inventory Oswestry Low Back Pain Disability Questionnaire Pain Self-Efficacy Questionnaire Chronic Pain Acceptance Questionnaire MMPI Graded Chronic Pain Scale Pain Anxiety Symptoms Scale Neuropathic Pain Scale Sickness Impact Profile Toronto Alexithymia Scale Montgomery-Asberg Depression Rating Scale Arthritis Self-Efficacy Scale Short-Form-12 Health Survey Pain Coping Inventory EORTC Quality of Life Questionnaire Hamilton Anxiety Rating Scale Start Back Screening Tool Symptom Distress Scale Fear of Pain Questionnaire Arthritis Impact Measurement Scale Pain Catastrophizing Scale Fatigue Impact Scale Functional Disability Inventory GAD-7 Children’s Depression Inventory Back Beliefs Questionnaire MD Anderson Symptom Inventory Musculoskeletal Pain Screening Questionnaire SOAPP-R Chronic Pain Coping Inventory WHO-5 Well-Being Index Pain Coping Questionnaire Box Scale PASS-20 MSQoL Survey of Pain Attitudes Child Behavior Checklist (CBCL) Functional Movement Screen Euro-QoL-5D Scale Beck Hopelessness Scale

Injustice Experience Questionnaire Multidimensional Health Locus of Control Geriatric Pain Measure Pain and Impairment Relationship Scale Chronic Pain Self-Efficacy Scale Somatic Perception Questionnaire Behavioral Risk Factor Surveillance System (HRQoL) Pain Stages of Change Questionnaire Pain DETECT Questionnaire Pain Beliefs Questionnaire Low Back Pain Questionnaire Vanderbilt Pain Management Inventory ID Migraine Zung Self-Rating Anxiety Scale Headache Disability Inventory Pain Discomfort Scale Cornell Musculoskeletal Discomfort Questionnaire Pain Beliefs & Perceptions Inventory Medical Outcomes Study Social Support Survey Positive & Negative Affect Scale Battery for Health Improvement McMaster Health Index Questionnaire Life Satisfaction Index Breakthrough Pain Assessment Tool Pain Experience Scale Fibromyalgia Rapid Screening Tool PPMQ-R Pediatric Pain Questionnaire MOBID-2 Health Anxiety Inventory Psychological General Well-Being Index Illness Behavior Questionnaire Quality of Well-Being Scale Social Support Questionnaire Avoidance-Endurance Questionnaire Headache Management Self-Efficacy Scale Duke Health Profile Millon MCMI Functional Status Index Depression Anxiety & Personal Outlook Scale (DAPOS) Personal Health Questionnaire Radboud Skills Questionnaire Ferrans and Powers Quality of Life Index Medical Outcomes Study Pain Measures Child Pain Anxiety Symptoms Scale Multidimensional Pain Readiness to Change Questionnaire Note. Measures with less than 5 mentions are not listed.

References: Alschuler, K.N., & Otis, J.D. (2014). An examination of the impact of clinically significant levels of posttraumatic stress disorder symptomatology on the classification of pain as mild, moderate, or severe in a sample of veterans with chronic pain. Psychological Services, 11(3), 273-280. Andrasik, F., Piotrowski, C., & Packard, R.C. (1989, June). Psychological testing patterns: A survey of headache clinicians. Paper presented at the annual meeting of the American Association for the Study of Headache, Boston. Azize, P.M., Endacott, R., Cattani, A., & Humphreys, A. (2014). Cultural responses to pain in UK children of primary school age: A mixed-methods study. Nursing & Health Sciences, 16(2), 186-192. Bair, M.J., Robinson, R.L., Katon, W., & Kroenke, K. (2003). Depression and pain comorbidity: A literature review. Archives of Internal Medicine, 163, 2433-2445. Banerjee, A., Hendrick, P., Bhattacharjee, P., & Blake, H. (2017). A systematic review of outcome measures utilized to assess self-management in clinical trials in patients with chronic pain. Patient Education and Counseling, in press. Banks, S.M., & Kerns, R.D. (1996). Explaining high rates of depression in chronic pain: A diathesis-stress framework. Psychological Bulletin, 119(1), 95- 110. Bruns, D., & Disorbio, J.M. (2015). The psychological assessment of patients with chronic pain. In T.R. Deer, M.S. Leong, & A.L. Ray (Eds.), Treatment of chronic pain by integrative approaches: The American Academy of Pain Medicine textbook on patient management (pp. 61-82). New York, NY: Springer Science. Buffum, M.D., Hutt, E., Chang, V.T., Craine, M.H., & Snow, A.L. (2007). Cognitive impairment and pain management: Review of issues and challenges. Journal of Rehabilitation Research & Development, 44(2), 315-329. Castelnuovo, G. (2017). New and old adventures of clinical health psychology in the 21stcentury.Frontiers in Psychology, 8, 1214. Dansie, E.J., & Turk, D.C. (2013). Assessment of patients with chronic pain. British Journal of Anesthesia, 111, 19-25. De Bellis, N. (2009). Bibliometrics and citation analysis. New York, Scarecrow Press. Deer, M.S., & Ray, A.L. (Eds.). (2015). Treatment of chronic pain by integrative approaches. New York, NY: Springer Science. Dezutter, J., Casalin, S., Wachholtz, A., Luyckx, K., Hekking, J., & Vandewiele, W. (2013). Meaning in life: An important factor for the psychological wellbeing of chronically ill patients. Rehabilitation Psychology, 58, 334-341. Doherty, E.M., Walsh, R., Andrews, L., & McPherson, S. (2017). Measuring emotional intelligence enhances the psychological evaluation of chronic pain. Journal of Clinical Psychology in Medical Settings, 24, 365-375. Dusova, B., & Cseszarova, M. (2008). An overview of the quality of life of clients with chronic pain. Primary Health Care, 18(1), 25-29. Dysvik, E., Natvig, G.K., & Furnes, B. (2013). A narrative approach to explore grief responses and treatment adherence in people with chronic pain after participation in a pain-management program: A 6-year follow-up study. Patient Preference and Adherence, 7, 751-759. Edwards, R., Smith, M.T., Kudel, I., & Haythornthwaite, J. (2006). Pain-related catastrophizing as a risk factor for suicidal ideation in chronic pain. Pain, 126(1), 272-279. Eisenberger, N. (2012). The pain of social disconnection: Examining the shared neural underpinnings of physical and social pain. Nature Reviews Neuroscience, 13(6), 421-434. Epker, J. (2013). Psychometric methods for measuring pain. The Clinical Neuropsychologist, 27(1), 30- 48. Flor, H., & Turk, D.C. (2011). Chronic pain: An integrated biobehavioral approach. Seattle, WA: IASP Press. Fillingim, R.B., et al. (2016). Assessment of chronic pain: Domain, methods, and mechanisms. Journal of Pain, 17(9, Suppl.), T10-T20. 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. Gagliese, L. (2009). Pain and aging: The emergence of a new subfield of pain research. Journal of Pain, 10, 343-353.

Gaskin, D.J., & Richard, P. (2012). The economic costs of pain in the United States. Journal of Pain, 13(8), 715-724. Gatchel, R.J. (Ed.). (2005). Clinical essentials of pain management. Washington, DC: APA. Gatchel, R.J., Mayer, T.G., & Eddington, A. (2006). MMPI Disability Profile: The least known, most useful screen for psychopathology in chronic occupational spinal disorders. Spine, 31, 2973- 2978. Gatchel, R.J., McGeary, D., McGeary, C., & Lippe, B. (2014). Interdisciplinary chronic pain management: Past, present, and future. American Psychologist, 69, 119-130. Gatchel, R.J., Peng, Y., Peters, M.L., Fuchs, P.N., & Turk, D.C. (2007). The biopsychosocial approach to chronic pain: Scientific advances and future directions. Psychological Bulletin, 133, 581-624. Gatchel, R.J., Robinson, R.C., Block, A.R., & Benedetto, N.N. (2017). Assessment of pain in primary care settings. In M.E. Maruish (Ed.), Handbook of psychological assessment in primary care settings (2nded., pp. 441-428). New York, NY: Routledge. Gatchel, R.J., & Turk, D.C. (Eds.). (1999). Psychosocial factors in pain: Critical perspectives. New York, NY: Guilford Press. Gatchel, R.J., & Weisberg, J.N. (2000). Personality characteristics of patients with pain. Washington, DC: APA. Gorodzinsky, A.Y., Hainsworth, K.R., & Weisman, S.J. (2011). School functioning and chronic pain: A review of methods and measures. Journal of Pediatric Psychology, 36(9), 991-1002. Haggard, R.A., Stowell, A.W., Bernstein, D., &Gatchel, R.J. (2008). Relationship between the MMPI-2 and psychosocial measures in a heterogeneous pain population. Rehabilitation Psychology, 53(4), 471-478. Hall, T., Krahn, G.L., Horner-Johnson, & Lamb, G. (2011). Examining functional content in widely used health-related quality of life scales. Rehabilitation Psychology, 56(2), 94-99. Hickling, E.J., Sison, G.F., & Holtz, J.L. (1985). Role of psychologists in multidisciplinary pain clinics: A national survey. Professional Psychology: Research and Practice, 16(6), 868-880. Holmes, M.M., et al. (2017). The impact of patientreported outcome measures in clinical practice for pain: A systematic review. Quality of Life Research, 26(2), 245-257. Huzmeli, E.D., & Melek, I. (2017). Neuropathic pain’s biopsychosocial effects. Neurological Science, 38, 1993-1997. Jacobs, J.M., Hammerman-Rozenberg, R., Cohen, A., & Stessman, J. (2006). Chronic back pain among the elderly: Prevalence, associations, and predictors. Spine, 31(7), 203-207. Jensen, M.P., & Turk, D.C. (2014). Contributions of psychology to the understanding and treatment of people with chronic pain. American Psychologist, 69, 105-118. Kang, Y., & Demiris, G. (2016). Self-report pain assessment tools for cognitively intact older adults: Integrative review. International Journal of Older People Nursing, 1-19. Keller, L.S., & Butcher, J.N. (1991). Assessment of chronic pain patients with the MMPI-2. Minneapolis, MN: Univ. of Minnesota Press. Kennedy, C.E., Moore, P.J., Peterson, R.A., Katzman, M.A., Vermani, M., & Charmak, W.D. (2011). What makes people anxious about pain? How personality and perception combine to determine pain anxiety responses in clinical and non-clinical populations. Anxiety, Stress, & Coping, 24(2), 179-200. Kovatch, M., Feingold, D., Elkana, O., & Lev-Ran, S. (2016). Evaluation and comparison of tools for diagnosing problematic prescription opioid use among chronic pain patients. International Journal of Methods in Psychiatric Research, 26, e1542. Krippendorff, K. (2004). Content analysis: An introduction to its methodology (2nded.). Thousand Oaks, CA: Sage. Lee, R.R., et al. (2017). Chronic pain assessments in children and adolescents. Pain Research and Management, article# 7603758. Lee, W., Hong, K., Lim, S., Kim, D.H., & Yoon, J. (2017). The association between symptomatic and diagnostic depression and pain among the elderly population in South Korea. Journal of Nervous & Mental Disease, 205(9), 699-704. Leonard, M.T., Cano, A., & Johansen, A.B. (2006). Chronic pain in a couples context: A review and integration of theoretical models and empirical evidence. Journal of Pain, 7(6), 377-390.

Lollar, D.J., Smits, S.J., & Patterson, D.L. (1982). Assessment of pediatric pain: An empirical perspective. Journal of Pediatric Psychology, 7(3), 267-277. Marchand, S., Saravane, D., & Gaumond, I. (Eds.). (2014). Mental health and pain: Somatic and psychiatric components of pain in mental health. New York, NY: Springer. Marek, R.J., & Ben-Porath, Y.S. (2017). Using the MMPI-2- RF in behavioral medicine settings. In M.E. Maruish (Ed.), Handbook of psychological assessment in primary care settings (2nded., pp. 631-662). New York, NY: Routledge. McGrath, P.J., Stevens, B.J., Walker, S.M., & Zempsky, W.T. (Eds.). (2013). Oxford textbook of paediatric pain. New York, NY: Oxford University Press. Melzack, R. (Ed.). (1983). Pain measurement and assessment. New York: Raven Press. Meyer, K., Klipstein, A., Oesch, P., Jansen, B., Kool, J., & Niedermann, K. (2016). Development and validation of a pain behavior assessment in patients with chronic low back pain. Journal of Occupational Rehabilitation, 26, 103-113. Mikail, S.F., DuBreuil, S., & D’Eon, J.L. (1993). A comparative analysis of measures used in the assessment of chronic pain patients. Psychological Assessment, 5(1), 117-120. Molton, I.R., & Terrill, A.L. (2014). Overview of persistent pain in older adults. American Psychologist, 69, 197-207. Morgan, B.D. (2009). Managing pain in patients with cooccurring addictive disorders. Journal of Addictions Nursing, 20(1), 41-48. Naylor, B., Boag, S., &Gustin, S.M. (2017). New evidence for a pain personality? A critical review of the last 120 years of pain and personality. Scandinavian Journal of Pain, 17, 58-67. Okifuji, A., & Turk, D.C. (2014). Assessment of patients with chronic pain with and without comorbid mental health problems. In S. Marchand, D. Saravane, & I. Gaumond (Eds.), Mental health and pain: Somatic and psychiatric components of pain in mental health (pp. 227-259). New York, NY: Springer- Verlag. Piotrowski, C. (2019). Fibromyalgia, low back pain, osteoarthritis, myofascial pain, and complex regional pain syndrome: Predominant assessment measures in research. Journal of Projective Psychology & Mental Health, 26(1), 23-29. Piotrowski, C. (2018). MMPI-related pain research through the lens of bibliometric analysis: Mapping investigatory domain. North American Journal of Psychology, 20(1), 151-158. 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. (2017). The utility of projective techniques in pain assessment: An historical review. Journal of the Indian Academy of Applied Psychology, 43(2), 189-197. Piotrowski, C. (2014). Chronic pain in the elderly: Mapping the mental health literature. Journal of Instructional Psychology, 41(1), 16-18. Piotrowski, C. (2007). Review of the psychological literature on assessment instruments used with pain patients. North American Journal of Psychology, 9(2), 303-306. Piotrowski, C. (1998). Assessment of pain: A survey of practicing clinicians. Perceptual & Motor Skills, 86, 181-182. Piotrowski, C., & Lubin, B. (1990). Assessment practices of health psychologists: Survey of APA Division 38 clinicians. Professional Psychology: Research and Practice, 21, 99-106. Porter-Moffitt, S., Gatchel, R.J., Robinson, R.C., Deschner, M., Posamentier, M., Polatin, P., & Lou, L. (2006). Biopsychosocial profiles of different pain diagnostic groups. Journal of Pain, 7(5), 308-318. Reist, C., et al. (2017). Assessment of psychological pain in suicidal veterans. PLoS ONE, 12(5), e0177974. Riva, P., Wirth, J.H., & Williams, K. (2011). The consequences of pain: The social and physical pain overlap on psychological responses. European Journal of Social Psychology, 41(6), 681-687. Ruben, M.A., et al. (2018). To know another’s pain: A meta-analysis of caregivers’ and healthcare providers’ pain assessment accuracy. Annals of Behavioral Medicine, 52(8), 662-685. Sajatovic, M. (2012). Rating scales in mental health (3rded.). Baltimore, MD: Johns Hopkins Press.

Sofaer-Bennett, B., Walker, J., Moore, A., Lamberty, J., Thorp, T., & O’Dwyer, J. (2007). The social consequences for older people of neuropathic pain: A qualitative study. Pain Medicine, 8(3), 263-271. Stefanatou, A., & Bowler, D. (1997). Depiction of pain in the self-drawings of children with sickle cell disease. Child: Care, Health and Development, 23(2), 135-155. Tait, R.C., & Chibnall, J.T. (2014). Racial/ethnic disparities in the assessment and treatment of pain: Psychosocial perspectives. American Psychologist, 69(2), 131-141. Tarescavage, A.M., Scheman, J., & Ben-Porath, Y.S. (2015). Reliability and validity of the MMPI-2-RF in evaluations of chronic low back pain patients. Psychological Assessment, 27(2), 433-446. Townsend, C.O., Bruce, B.K., Hooten, W.M., & Rome, J.D. (2006). The role of mental health professionals in multidisciplinary pain rehabilitation programs. Journal of Clinical Psychology: In Session, 62(11), 1433- 1443. Trost, Z., Agtarap, S., Scott, W., et al. (2015). Perceived injustice after traumatic injury: Associations with pain, psychological distress, and quality of life outcomes 12 months after injury. Rehabilitation Psychology, 60(3), 213-221. Tse, M., Wan, V., & Vong, S. (2013). Health-related profile and quality of life among nursing home residents: Does pain matter? Pain Management Nursing, 14(4), 173-184. Turk, D.C., & Gatchel, R.J. (Eds.). (2018). Psychological approaches to pain management: A practitioner’s handbook (3rded.). NY: Guilford Press. Turk, D.C., & Melzack, R. (Eds.). (2011). Handbook of pain assessment (3rded.). New York, NY: Guilford Press. Turk, D.C., & Okifuji, A. (2002). Psychological factors in chronic pain: Evolution and revolution. Journal of Consulting and Clinical Psychology, 70(3), 678- 690. Vendrig, A.A., Derksen, J., & de Mey, H.R. (1999). Utility of selected MMPI-2 scales in the outcome prediction of patients with chronic back pain. Psychological Assessment, 11(3), 381-385. Wallace, M.S., et al. (2018). An integrated quantitative index for measuring chronic multisite pain: The Multiple Areas of Pain (MAP) Study. Pain Medicine, 19(7), 1425-1435. Yohannes, A.M., & Caton, S. (2010). Management of depression in older people with osteoarthritis: A systematic review. Aging & Mental Health, 14(6), 637-651. Zhang, G. (2002). A cluster analysis of the Personality Assessment Inventory with chronic pain patients. Unpublished doctoral dissertation, Wisconsin School of Professional Psychology. Zijlema, W.L., Stolk, R.P., Lowe, B., et al. (2013). How to assess common somatic symptoms in large-scale studies: A systematic review of questionnaires. Journal of Psychosomatic Research, 74, 459- 468. SIS Abstracts Download The soft copies of the abstracts of published papers of all issues in SIS Journal of Projective Psychology and Mental Health commencing from Volume 1 (Launching year 1994) to the current year can be downloaded free of cost from the website of Somatic Inkblot Society on following URL: SIS Abstracts: http://somaticinkblots.com/abstracts/ Copyright ©1994. SIS Center, India

discussed. Criterion to produce written projective materials is limited to individuals with adequate reading and writing abilities. Clinical tools/approaches noted are: (1) Sentence Completion Method and Incomplete Sentences Test; (2) clients’ writing thoughts and reflections on therapy sessions and how issues are being faced between sessions; and (3) writing as discussing things with oneself—meanings, values, relationships, life, and one’s future. Written projective material from a young woman’s journal expressing suicidal intentions that were eventually fulfilled is also shared. Projective techniques are regarded as ―clinical tools‖ (Anastasi, 1982, p.590). Among the areas they have assisted clinicians in learning about are ―. . . latent needs, sentiments, feelings, and attitudes which the subject would be unwilling or unable to recognize or to express in direct communication‖ (Rohde, 1946, p. 169). The variety of projective clinical tools have been found to be useful with most client groups. Also, projective techniques as clinical tools ―. . . are especially helpful in evaluating those having limited language and verbal skills such as children, foreign born or new immigrants, native people, the learning disabled or the mentally sub-normal‖ (Dubey, Banerjee, & Dubey, 2019, p. 42). Among the many projective clinical tools there are a select few that involve reading and writing referred to as ―verbal techniques‖ (Anastasi, 1982, p.575). They assume satisfactory reading and writing levels in the language of the clinical tool and beyond. A formal example of such a clinical tool has been labeled variously as the Sentence Completion Method (Holsopple, & Miale, 1954; Payne, 1928; Rohde, 1946) or Incomplete Sentences Test (Rotter & Willerman, 1947). Writings as projective material for caring and therapy: The instructions on an early version of the Incomplete Sentences Test are as follows: ―Complete these sentences to express your real feeling. Try to do everyone. Be sure to make a complete sentence!‖ (Rotter & Willerman, 1947, p. 44). Some examples of sentence stems from the Rotter and Willerman (1947) version of the test are: ―2. The happiest time . . . . ; 11. A mother . . . . ; 13. My greatest fear . . . . ; 23. My mind . . . .‖ (p.44). Incomplete/sentence completion tests involving writings resulting in projective material have been regarded as helpful and of interest over many years. This is supported in studies that: ―. . . consistently find that sentence completion tests (SCTs) are among the most commonly used personality assessment instruments‖ (Holaday, Smith, & Sherry, 2000, p. 371). Some data confirming this trend are that, ―sentence completion tests were the most widely used projective measures, reportedly used by 26% [342] of [1317] school psychologists‖ (Benson et al., 2019, p.42). Writings as a source of useful projective material also occurs during treatment. Some clinicians encourage clients to write their thoughts and reflections about their therapy sessions and how they are working at issues between the sessions. A colleague of mine always provided clients with 2-part carbonless lined sheets at the end of each session. The intention was that clients would produce two copies of their reflections in writing with one to be shared to inform the therapy process and then filed by the clinician for consideration in subsequent sessions. In the contexts noted here, writings as projective material are being obtained for caring and therapy.

One person’s projective writings to fulfillment: Writings as projective material was especially recognized by Prescott (1957). He observes that among adolescents, ―Writing is a way of discussing things with themselves, seeking meanings, clarifying values, considering their own relationships with the world, and pondering the meaning of life and its implications for their own future‖ (Prescott, 1957, p. 188). When such writings have been available, they have been studied by psychologists (e.g., Frank, 1953; Haviland & Kramer, 1991). Here we examine the writings from the journal of a young woman, Ashley Smith, incarcerated at the New Brunswick Youth Centre (NBYC) from April 2003 to October 2006 (Ombudsman ..., 2008, p. 17). This excerpt is as it was written by Ashley at age 18 on September 4, 2006 when she was worrying about being transferred to an adult jail: ―Mom, If I die then I will never have to worry about upsetting my Mom again. Itwould have been nice today to stick myhead in the lawn mower blade. F***, I really did have to hold back the urge.Maybe next time I will give it a try. Most people are scared to die. It can’t be any worse than living a life like mine. Being dead I think would just suit mefine. I wonder when the best time to do itwould be. I’m not going to get locked because then I’m back on checks and theywill expect me to act up then. Iwill call my Mom before bed and have one more chat. Somehow, I have to let herknow that none of this is her fault.I don’t knowwhy I’m like I am but I know she didn’t do it to me. People say there is nothingwrong with me. Honestly, I think they need to f*** off because they don’t knowwhat goes on in my head. When I use to try to hang myself, I was just messingaround trying to make them care and pay attention. Now it’s different. I wantthem to f*** off and leave me alone. It’s no longer a joke. It’s kind of scares tothink that they might catch me before it’s done and then I will be a vegetable for the rest if my life. That’s why the most importantthing right now is to stayunlocked so they don’t think anything is up. It’s over. Maybe I will use a brand-new pair of socks. Fresh for me. No I don’t f****ngdeserve a new pair of socks. I will use the old dirty ugly ones. Ha Ha that kind of explains me. Dirty and ugly. Two peas in a pot (sic). F*** THIS WORLD!!! HaHa. When [name omitted] told me she took me off fifteen-minute checks I almosts**t myself. Can she help me anymore. I should ask her for a razor blade. Maybeshe will give me that to. Joke of the day. Ashley Smith is no longer on checks. 1 2 3 4 5 what the f*** is the point of being alive? [Name omitted] said she doesn’t know if I will be allowed to have another apartment visit because I waxed myeyebrow. How about this one. ―I can’t have another apartment visit because I’mf****ng DEAD!‖ I want to die. I went to court yesterday and I thought he wasgoing to send me to adult! Time is running out. My chances are getting fewer andfewer. F***. I give up! I’m done trying‖ (Ombudsman ..., 2008, pp. 23-24). To appreciate this writing sample as an example of ―projective material‖ it will be helpful to know about Ashley’s mental health and behavior. On March 4, 2003, Ashley was referred for psychological, psychiatric, and educational assessments. At the time of the assessments, Ashley was 15 years old. The diagnostic impression of the psychiatric report indicated ―learning disorder, attention deficit hyperactivity disorder, and borderline personality disorder.‖ ―Depression‖ was ruled out. ―Narcissistic personality traits‖ were added to the psychiatric report in an addendum. What is meaningful about the diagnostic impressions reported is that they were likely based on Ashley’s behaviors and symptoms close to the time she came from the community. The psychology report recommended that Ashley’s parents participate in sessions to deal with an ―oppositional defiant‖ youth. Finally, recommendations were made for ongoing monitoring, evaluation, counseling, and medication.

Ashley arrived at NBYC in April 2003 with these diagnoses. Among them, it was borderline personality disorder that was confirmed by her ongoing behavioral symptoms and especially diagnostic criterion 5—recurrent suicidal behavior, gestures, or threats, or self-mutilating behavior (American Psychiatric Association, 2000). During her stay at NBYC, Ashley had many and recurring attempts at self-injury. The record documents 168 self-injury attempts—some from very mild to two that were nearly fatal (Ombudsman ..., 2008, p. 35). During September 2006, the month before transfer to an adult facility, there were 16 self-injury attempts by Ashley—a rate higher than at any other time. Prior to her transfer on October 5, 2006 to a provincial adult facility [St. John Regional Correctional Centre], while still at NBYC, on October 1st, Ashley composed: My Life My life I no longer love I’d rather be set free above Get it over with while the time is right Late some rainy night Turn black as the sky and as cold as the sea Say goodbye to Ashley Miss me but don’t be sad I’m not sad I’m happy and glad I’m free, where I want to be No more caged up Ashley Wishing I was free Free like a bird (Ombudsman . . ., 2008, p. 2). This poem can be seen as serious projective material in writing. By October 31, 2006, Ashley was transferred to federal jurisdiction. During 11.5 months of federal incarceration Ashley was segregated/ isolated and instigated approximately 150 security incidents. Many involved self-harm— self-strangulation using ligatures, incidents of head-banging, and superficial cutting of her arms (Sapers, 2008, para. 17). These recurring behavioral incidents ended with Ashley’s self-strangulation death with a ligature on October 19, 2007 at Grand Valley Institution for Women near Kitchener- Waterloo, Ontario, Canada. Regarding Ashley’s diagnoses, a somewhat recent study reports that individuals manifesting borderline personality disorder with narcissistic personality traits tend to be at increased risk for persistent suicidal behavior (Ansell et al., 2015; Williams, 2018). Finally, in the documentation reviewed it is not clear that any of Ashley Smith’s writings shared here informed the therapy or care she received. References: American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (4th ed. text rev.). Washington, DC: Author. Anastasi, A. (1982). Psychological testing (5th ed.). New York: Macmillan. Ansell, E. B., Wright, A. G., Markowitz, J. C., Sanislow, C. A., Hopwood, C. J., Zanarini, M. C., Pinto, A., McGlashan, T. H., & Grilo, C. M. (2015). Personality disorder risk factors for suicide attempts over 10 years of follow-up. Personality Disorders, 6, 161-167. http://dx.doi.org/10.1037/per0000089 Benson, N. F., Floyd, R. G., Kranzler, R. G., Eckert, T. L., Fefer, S. A., & Morgan, G. B. (2019). Test use and assessment practices of school psychologists in the United States: Findings from the 2017 National Survey. Journal of School Psychology 72, 29–48. doi.org/10.1016/j.jsp.2018.12.004 Dubey, B. L., Banerjee, P., & Dubey, A. (2019). Inkblot Personality Test: Understanding the unconscious mind. New Delhi, India: Sage Publications India. Frank, A. (1953). Anne Frank: The diary of a young girl. New York: Simon and Schuster. Haviland, J. M., & Kramer, D. A. (1991). Affect-cognition relationships in adolescent diaries: The case of Anne Frank. Human Development, 34, 143-159. Holaday, M., Smith, D. A., and Sherry, A. (2000). Sentence completion tests: A review of the literature and results of a survey of members of the Society for Personality Assessment. Journal of Personality Assessment, 74(3), 371–383. doi: 10.1207/S15327752JPA7403_3. Holsopple, J. Q., & Miale, F. R. (1954). Sentence completion: A projective method for the study of personality. Springfield, IL: Thomas.

Ombudsman and Child and Youth Advocate (2008, June). Ashley Smith: A Report of the New Brunswick Ombudsman and Child and Youth Advocate on the services provided to a youth involved in the youth criminal justice system. Fredericton, NB: Author. Available at: https://www.cyanb.ca/images/AshleySmith-e.pdf Payne, A. F. (1928). Sentence completions. New York Guidance Clinic. Prescott, D. H. (1957). The child in the educative process. New York: McGraw-Hill Book Co. Rohde, A. R. (1946). Explorations in personality by the sentence completions method. Journal of Applied Psychology, 30, 169-181. Rotter, J. B., & Willerman, B. (1947). The Incomplete Sentences Test as a method of studying personality. Journal of Consulting Psychology, 11(1), 43-48. Sapers, H. 2008. A Preventable Death. Ottawa, Ontario: Correctional Services of Canada. Available at: https://www.oci-bec.gc.ca/cnt/rpt/pdf/oth-aut/othaut20080620-eng.pdf Williams, R. B. (2018). A possible preventable death: If the lethality of the diagnosis known now was known then. 29th International Congress of Applied Psychology (ICAP2018), June 28th, 2018, Montreal, Canada. Page 238, Poster Session I, Listing #70 38014. SIS JOURNAL OF PROJECTIVE PSYCHOLOGY AND MENTAL HEALTH (An Official Publication of Somatic Inkblot Society) Published Regularly Twice a Year in January and July First Volume Published in 1994 All Volumes of the SIS Journal are also available in PDF Format Individuals/Institutions can become Member of Somatic Inkblot Society by Submitting Membership Application Form Given in the Journal and Receive Print Version/Soft Copy of the Journal Published After the Date of Membership Free of Cost Bankey L. Dubey, Ph.D., DPM, DM&SP, Editor Emeritus, SIS Journal of Projective Psychology and Mental Health, E-mail: bldubey@gmail.com

A traumatic event is one that threatens injury or the physical integrity of self or others and also causes horror, terror or helplessness at the time it occurs. A variety of personal and environmental factors may lead to enduring post traumatic difficulties. The aim of the present study was to investigate the emotional states and coping patterns of patients with high and low post traumatic symptoms. The present investigation selected 12 high and 12 low trauma-affected adult (18 to 40 years) patients, both male and female cases, from various trauma centers of Varanasi. The level of trauma symptoms was assessed with the PTSD checklist civilian version (PCL-C). Emotional state was measured with Eight State Questionnaire and coping pattern was assessed with the Coping Strategies Scale. As hypothesized the emotional states of high trauma affected patients reported significantly high level of emotional states viz. anxiety, stress, depression, regression, fatigue, guilt than the low trauma affected patients. Extraversion and arousal, the two sociable and alert emotional states, however, reported a significantly lower mean among the high trauma subjects contrary to the assumption. The coping strategies of high traumaaffected subjects reported low level of coping pattern than their low traumatic group counterparts and established the hypothesis. The human response to psychological trauma is one of the most important public health hazards in the world. Traumatic events such as family and social violence, rapes and assaults, disasters, wars, accidents and predatory violence confront people with such horror and threat that it may temporarily or permanently alter their capacity to cope, their biological threat perception, and their concepts of themselves. Traumatized individuals frequently develop post-traumatic stress disorder (PTSD), a disorder in which the memory of the traumatic event comes to dominate the victims' consciousness, depleting their lives of meaning and pleasure (vanderKolk & vanderHart, 1991). A variety of personal and environmental factors may lead to enduring post-traumatic difficulties. The emotional toll of psychological trauma is a particularly distressing aspect of the suffering caused by global terrorism, genocide, and war. Psychological trauma also affects millions of people who have survived mass disasters such as hurricanes, cyclones, tsunamis, tornadoes, floods, industrial explosions, and epidemic illnesses, and perhaps tons and million more people who suffer “private disasters” due to deaths, devastating injuries, or threats to themselves and their loved ones‟ lives and safety as a result of life-threatening accidents or illnesses, childhood or elder abuse and neglect, or violence in their families or communities. Psychological trauma may occur during a single traumatic event (acute) or as a result of repeated (chronic) exposure to overwhelming stress (Terr, 1992). Ehlers and Clark (2000) opined some special characteristics of traumatic memories. These are experienced with full force, frozen in time (i.e. time does not easily fade them), the new memories do not update the old ones, these experiences have no temporal context and are voluntarily recalled as if experienced now. Stressful events have subjective meanings, such as loss, threat, and fear, which are important in the etiology of depression (Kendler et al. 1998), anxiety, specific phobias, post-traumatic stress disorder (PTSD), and other psychiatric disorders. However, research on trauma (i.e., exceptionally frightening and threatening events, with or without physical injury) has largely focused on PTSD. Even so, it has repeatedly been observed in general population studies (Breslau et al. 1991 &

Kessleret al. 1995) and in studies of disasters (McFarlane & Papay, 1992 & Green et al. 1992), combat (Bleich et al. 1997), and other types of trauma (Shalev et al. 1998) that depression, phobic avoidance, substance abuse, and other psychiatric problems are also frequent outcomes. Anxiety emerges because the person experiences the injury as a dangerous situation that re-awakens basic fears and threats encountered during early childhood development. It may be related to a traumatic injury in various ways. After trauma, most of the patients do not perceive themselves as being fully intact. The feelings of independence and self-sufficiency are felt lacking. In the hospital, the patients have to depend upon caregivers, who are strangers for them, for all their physical needs. This generates stranger anxiety. The patients have to stay away from their family and friends. They are also worried about their physical appearance and fear losing love and respect of their near and dear ones. Patients may also suffer from symptoms such as post-traumatic stress, depression and anxiety, symptoms that can affect recovery (Andersson et al 1997; Bryant et al 1999). In a large cohort study, Carroll and colleagues (2006) examined the duration of depressive symptoms in whiplash patients. They found that patients frequently reported these symptoms in the acute phase and the symptoms often persisted one year after the injury. Guilt is a common response following loss and/or traumatic experiences with significant victimization (e.g., after terrorist acts, war, personal victimization). Following traumatic events, guilt may be a complicated part of traumatic response; it is among the symptoms associated with more pronounced traumatic reactions. Guilt may intensify or complicate trauma and/or grief reactions (Nader et al., 1990; Schwarz & Kowalski, 1992). It also may result in hopelessness, depression and other problems such as selfharm, suicidal feelings, and substance abuse. Regression is reversion to an earlier developmental stage. Patients may behave in a very dependent manner even when capable of doing things for themselves. Simultaneously they may also have guilt feelings about this child-like behavior. Coping is described as the constantly changing and behavioral efforts to manage specific external or internal demands that are appraised as taxing or exceeding the resources of the person. A coherent aggregate of varied coping behavior is known as coping strategy. Coping strategies can fulfill two functions,firstly, they can focus efforts on the cause of stress (problemoriented coping),and secondly, they can reduce the individual‟s emotions resulting from the stress-inducing situation (emotionoriented coping). Most people possess several coping strategies for dealing with stress-inducing situations, but have a preference for one type of coping strategy. Literature suggests that seeking social support for everyday stressors is almost associated with poor coping styles (Monroe & Steiner, 1986). The reasons for this are unknown but may revolve around negative reactions from others (Rook, 1998) and are indicative of poor networks or catastrophizing coping style. While seeking support is associated with poorer outcomes in trauma situations, disclosures to others is linked to both short and long-term outcomes (Smythe, 1998). However, the reaction of others in the social environment may moderate this relationship. In particular individuals who experience negative reactions from others may have worse outcomes than individuals who do not disclose (Silver, Holman & Gil- Rivas, 2000). Hopper et.al. (2010) defined trauma as „an experience that creates a sense of fear, helplessness, or horror, and overwhelms a person‟s resources for coping‟. The impact of traumatic stress can be devastating and longlasting in vulnerable individuals who may develop depression or post-traumatic stress disorder. A trauma victim is required to provide medical attention at the earliest and the psychological setbacks manifested in behaviors like

pessimism, depression, anxiety or avoidance of reminding the event are necessary to be handled by counseling. Behavioral interventions designed to encourage the use of existing social supports and discourage social withdrawal and isolation may help to reduce protracted and severe grief reactions. Hypotheses: 1. The high trauma-affected subjects would score high on eight emotional states viz. anxiety, stress, depression, regression, fatigue, guilt, extraversion and arousal than their low trauma-affected counterparts. 2. The high trauma-affected subjects would score high on avoidance coping strategy and low on planned approach pattern than their low trauma-affected counterparts. Method: Sample: The initial sample of the present study was comprised of 74 subjects (both male and female) age ranging from 18 to 40 years. Patients admitted in hospitals/trauma centers after facing some automobile accidents, explosions, fires, earthquakes, sexual assaults or other terrifying experiences and undergoing treatment for at least 6 weeks were considered for screening the cases. PTSD Checklist-civilian version (PCL-C) was administered on the total sample. On the basis of PTSD checklist, 24 trauma-affected subjects were screened out in terms of intensity of symptoms ie. high trauma affected and low trauma affected groups. Final distribution of group stands with the following sample size viz. high trauma (N=12) and low trauma (N=12). Measures: PTSD Checklist-Civilian Version (PCL-C) (Weathers et al., 1993): The PCL is a standardized self-report rating scale for PTSD comprising 17 items that correspond to the key symptoms of PTSD. Respondents indicate how much they were bothered by a symptom over the past month on a 5-point scale, encircling their responses ranging from “1”not at all to “5” extremely. Eight State Questionnaire Hindi version (Kapoor & Bhargav,1990): Indian adaptation of the scale consisting of 96 items was used to assess the dominant mood states of the trauma affected subjects. The eight emotional or mood states covered by the scale are anxiety, stress, depression, regression, fatigue, guilt, extraversion and arousal of the adult. The items are rated on a scale of 4 point response pattern from always to never. The reliability coefficients of the subscales ranged between 0.88 to 0.96. Coping Strategies Scale (Srivastava, 2001): The scale was used to measure the coping pattern of the subjects. It is a five-point rating scale containing 50 items covering behavioral approach, cognitive approach, cognitive behavioral approach, behavioral avoidance and cognitive avoidance approach. The reliability coefficient of the scale is 0.92. Procedure: PTSD Checklist-Civilian Version (PCL-C) was administered on the total sample of seventy four subjects. On the basis of PTSD checklist, 24 trauma-affected subjects were screened out and two groups were assigned (high trauma and low trauma) on the basis of decided cut-off scores. In the 17 items of the PTSD Checklist, response categories 3-5 (Moderately or above) were regarded as symptomatic and responses 1-2 (below Moderately) were regarded as nonsymptomatic. PTSD checklist used the DSM criteria for a diagnosis i.e. Symptomatic response to at least 1 “B” item (Questions 1- 5), Symptomatic response to at least 3 “C” items (Questions 6-12), and Symptomatic response to at least 2 “D” items (Questions 13-17). Trauma-affected subjects who fulfilled the criteria for the B,C and D categories of items only formed the clinical sample for the study. Eight State Questionnaire Hindi version and Coping Strategies Scale were administered on both the groups, namely, high trauma (N=12) and low trauma (N=12) affected patients.

Results: Table 1: Means, SDs and t-values of eight states of the two groups of high and low trauma-affected patients Mood States High trauma (N=12) Low trauma (N=12) t-value Anxiety M 26.33 10.33 8.831** SD 3.55 5.17 Stress M 23.92 14.75 5.072** SD 4.81 4.00 Depression M 25.75 11.92 8.056** SD 3.95 4.44 Regression M 25.08 10.58 9.819** SD 3.36 3.84 Fatigue M 24.33 13.58 6.118** SD 3.86 4.69 Guilt M 28.83 12.75 6.757** SD 3.76 7.33 Extraversion M 7.50 19.83 8.645** SD 2.39 4.32 Arousal M 9.08 21.58 7.768** SD 3.60 4.25 **p<.01 Table 1 represents that high trauma group has reported significantly high score (t<0.01) on the six dimensions of mood states than their low trauma counterparts in support of hypothesis1. The two dimensions of mood states, ie. extraversion and arousal, however reported significantly low mean scores than their low trauma counterparts leading to partial rejection of hypothesis 1. Table 2: Means, SDs and t-values of coping strategies of the high and low trauma-affected patients Patterns of Coping Strategies High trauma(N=12) Low trauma (N=12) t-value Behavioural approach M 26.00 30.83 1.999* SD 6.17 5.65 Cognitive approach M 11.41 14.58 2.369* SD 3.02 3.50 Cognitive behavioural approach M 12.58 20.66 4.871** SD 4.48 3.60 Behavioural avoidance M 25.83 13.66 4.143** SD 7.55 6.81 Cognitive avoidance M 13.83 11.66 1.725* SD 2.32 3.67 *p<.05, **p<.01 Table 2 reflects that as hypothesized high trauma group has reported significantly low scores on all the three patterned coping approach than their low trauma counterparts. It establishes the hypothesis 2 by reporting significantly high t-values in support of avoidance coping strategies for the high trauma-affected patients. The obtained result

thus substantiated the hypothesis that high trauma subjects have scored high on six mood states viz, anxiety, stress, depression, regression, fatigue and guilt than their low trauma counterparts. Further, in support of the second hypothesis the high trauma subjects rely more on avoidance coping strategy patterns and less on planned behavioral or cognitive coping patterns than their low trauma counterparts. Discussion: The findings of the present study revealed that highly traumatic patients are poor in six important emotional states or moods in comparison to the low trauma subjects out of eight categories of emotional states measured, namely, anxiety, stress, depression, regression, fatigue and guilt. The high trauma group again scored significantly lower mean scores on extraversion and arousal than their low trauma counterparts supporting the poor quality of emotional states. It means that highly traumatic patients have an underlying feeling of worry, nervousness, or unease, typically about an imminent event or something with an uncertain outcome. The patient has a physical, mental, or emotional response to events that causes bodily or mental tension. People cope with their environmental and endogenous anxieties by a coordinated complex system of defenses (Schnaper, 1975). Traumatized patients also react by using various types of defense mechanisms (Blumenfield & Schoeps, 1993). Most patients feel anxious or worried and show emotional reactions, which are usually of short duration (Malt & Olafsen, 1992); (Schnyder & Malt, 1998). On the basis of the findings of the present study, the patient has a high score on depression. It is a condition of mental disturbance typically with energy, and difficulty in maintaining concentration or interest in life. Depression can arise from loss or threatened loss of body function and of family and work roles. In more serious cases, the patients may experience a decrease in self-esteem, sense of worthiness and usefulness for their families and society (Blumenfield & Schoeps, 1993). Highly traumatic patients have scored high on regression. It relates to a return to an earlier stage of life, or a means of escaping from problems. Findings of the present study indicate that in highly traumatic patients, fatigue is also present. Fatigue is extreme tiresomeness, typically resulting from mental or physical exertion or illness. According to the present study, guilt is found in highly traumatic patients. It is a feeling of culpability especially for imagined offences or from a sense of inadequacy. Guilt may prevent someone from facing other key issues or intense emotions, and, in that sense, may serve as an unrecognized method of avoidance (Chaplin, 1975; Nader, 1997). Unresolved guilt impedes recovery and produces further difficulties. Guilt can be adaptive when it leads to improvements in character and behavior (Schiraldi, 2000). Unprocessed guilt can make recovery difficult. Therapeutic assistance is important for persistent and/or intense guilt as well as other trauma symptoms that disrupt life. Present study indicates that traumatic patients have low score on the dimension of extraversion and arousal and both are highly significant. Extraversion is a state of sociable, outgoing, adventuresome, talkative, and enthusiastic mood condition. Arousal is a state of alert, keyed up, excited, and stimulated condition with keen and sharp senses. Extraversion and arousal of emotional states however reported significantly lower mean scores among high trauma subjects contrary to the assumption. Coping is a cognitive and behavioral process involving a choice of strategies that help an individual handle an identified problem and the attached emotions. Thus, coping is conceptualized as a process that may mediate or moderate the relationship between the stressful event and the outcomes of the event. The findings of the present study revealed that highly traumatic subjects are poor in comparison to the low trauma subjects

in the categories of coping strategies such as behavioral approach, cognitive approach, and cognitive-behavioral approach. Coping refers to a person‟s cognitive and behavioral efforts to manage stressful situations and accompanying negative emotions. In response to a stressful situation an individual uses a variety of coping strategies (Folkman et.al, 1986). The combinations or patterns of coping strategies may vary across individuals or groups of individuals with certain personality characteristics. The response to the stressor is coping; the individual chooses a specific manner to deal with the stimulus. Healthy coping pattern never depends upon avoidance of cognition or manner. Higher mood states like anxiety, depression, regression, guilt etc. along with faulty coping pattern thus can be detected behind the high traumatic symptoms and are required to be intervened for maintaining sound quality life. Conclusion: The findings indicate that healthy coping pattern never depends upon avoidance of cognition. Various intervention programs and better understanding of coping strategies used by the trauma-affected subjects may be useful in developing a behavior modification. Higher emotional states like anxiety, stress, depression, regression, fatigue, guilt along with faulty coping pattern thus can be detected behind the high traumatic symptoms and are required to be intervened for maintaining a healthy quality life. References: Andersson,A. L., Bunketorp, O., & Allebeck, P.(1997). High rates of psychosocial complications after road traffic injuries.Injury,28, 539-543. Bleich, A., Koslowsky, M., Dolev, A.,& Lerer, B.(1997). Post-traumatic stress disorder and depression. British Journal of Psychiatry, 170, 479-482. Blumenfield, M., &Schoeps, M. M. (1993). Psychological care of the burn and trauma patients. pp. 1-147. Baltimore: Williams and Wilkins. Breslau, N., Davis, G. C., & Peterson, E. (1991). Traumatic events and post-traumatic stress disorder in an urban population of young adults. Archives of General Psychiatry,48, 216-222. Bryant, R.A., Marosszeky, J.E.,& Crooks, J.(1999). Interaction of post-traumatic stress disorder and chronic pain following traumatic brain injury. Journal of Head Trauma Rehabilitation. 14, 588- 594. Carroll, L. J., Cassidy, J. D.,& Cote, P. (2006). Frequency, timing, and course of depressive symptomatology after whiplash. Spine, 31, 551- 556. Chaplin, J. P. (1975). Dictionary of Psychology. New York: Dell Publishing. Ehlers, A.,& Clark, D. M. (2000). A cognitive model of post-traumatic stress disorder Behavior Research and Therapy, 38, 319-345. Folkman, S., Lazarus, R.S., Gruen, R.J., & DeLongis, A. (1986). Appraisal, coping, health status and psychological symptoms. Journal of Personality and Social Psychology. 50, 571-579. Green,B. L.,Lindy, J. D., Grace, M. C., &Leonard, A. C. (1992). Chronic posttraumatic stress disorder and diagnostic comorbidity in a disaster sample. Journal of Nervous and Mental Disease. 180, 760-766. Kapoor, M., & Bhargava, M. (1990). Eight state questionnaire. New Delhi: The Psycho-Centre. Kendler, K. S., Karkowski, L.M., &Prescott, C. A. (1998).Stressful life events and major depression: Risk period, long-term contextual threat, and diagnostic specificity. Journal of Nervous and Mental Disease. 186, 661-669. Kessler, R. C., Sonnega, A., Bromet, E., Hughes, M., &Nelson, C. B. (1995). Posttraumatic stress disorder in the National Comorbidity Survey. Archives of General Psychiatry, 52, 1048-1060. Hopper, E. K., Bassuk, E. L., & Olivet, J. (2010). Shelter from the storm: Trauma-informed care in homeless service settings. The Open Health Services and Policy Journal, 3, 80-100. Malt, U. F., & Olafsen, O. M. (1992).Psychological appraisal and emotional response to physical injury: A clinical, phenomenological study of 109 adults. Psychiatry Medicine, 10,117-134. McFarlane, A. C., & Papay, P. (1992). Multiple diagnoses in post-traumatic stress disorder in the victims of a natural disaster. Journal of Nervous and Mental Disease, 180, 498-504.

Monroe, S. M., & Steiner, S. C. (1986). Social support and psychopathology: Interrelations with preexisting disorder, stress, and personality. Journal of Abnormal Psychology, 95, 29-39. Nader, K., Pynoos, R., Fairbanks, L., &Frederick, C. (1990). Children‟s PTSD reactionsone year after a sniper attack at their school. American Journal of Psychiatry, 147,1526- 1530. Nader, K. (1997). Treating traumatic grief in systems. In Figley, C. R., Bride, B. E. and Mazza, N. (eds.), Death and Trauma: The Traumatology of Grieving, London: Taylor and Francis, pp. 159-192. Rook, K. S. (1998). Investigating the positive and negative sides of personal relationships: Through a lens darkly? In B. H. Spitzberg and W. R. Cupach, (Eds.), The dark side of close relationships (369-393). Erlbaum Associates: Mahwah, NJ, . Schiraldi, G. R. (2000). The Post-Traumatic Stress Disorder Source Book. Los Angeles: Lowell House. Schnaper, N. (1975).The psychological implications of severe trauma: Emotional sequelae to unconsciousness. Journal of Trauma and Acute Care Surgery, 15, 94-98. Schnyder, U., & Malt, U. F.(1998). Acute stress response patterns to accidental injuries. Journal of Psychosomatic Research, 45,419-424. Schwarz, E. D.,& Kowalski, J. M. (1992). Personality characteristics and post-traumatic stress symptoms after a school shooting. Journal of Nervous and Mental Diseases, 180, 735-737. Shalev,A. Y., Freedman, S., Peri, T., Brandes, D., Sahar, T., Orr, S. P., &Pitman, R. K.(1998).Prospective study of posttraumatic stress disorder and depression following trauma. American Journal of Psychiatry, 155, 630-637. Silver, R. C., Holman, E. A., & Gil-Rivas, V. (2000). Social responses to discussion of traumatic life events. Paper presented at the University of California Intercampus Health Psychology Conference, Lake Arrowhead, CA. Smythe, J. M. (1998). Written emotional expression: Effect sizes, outcome types, and moderating variables. Journal of Consulting and Clinical Psychology, 66, 174-184. Srivastava, A. K. (2001). Coping strategies scale. Varanasi: Rupa Psychological Centre. Terr, L. (1992). Too scared to cry: Psychiatric trauma in childhood. New York: Basic Books. vanderKolk, B. A., & vanderHart, O.(1991). The intrusive past: The flexibility of memory and the engraving of trauma. American Imago, 48, 425-454. Weathers, F., Litz, B., Herman, D., Huska, J., & Keane, T. (1993). The PTSD Checklist (PCL): Reliability, Validity, and Diagnostic Utility. Paper presented at the Annual Convention of the International Society for Traumatic Stress Studies, San Antonio, TX. 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, SIS Email: bldubey@gmail.com Dr. Naveen Gupta Editor-in-Chief Email: dr_naveengupta@yahoo.com Cell: 91-9627182913

Adicción a las Tecnologías de la información y la comunicación) having English translation as Individualized Psychotherapeutic Program for Addiction to the Technologies of the Information and Communication] as a therapeutic module to deal with Pathological Internet Use (PIU), which was basically developed for individuals suffering from Internet Gaming Disorder. The former is a more generalized problem. In addition, other objective of this study was to see the utility of SIS-II in detecting personality problems (pretreatment) and to identify the posttherapeutic changes in PIU patient. This case study was a unique attempt in its sense that to the best of the knowledge of authors, SIS-II was rarely used in the case of PIU or internet addiction, especially to check out its utility to find out therapeutic change. Results of the study revealed that PIPATIC was quite effective in reducing the PIU, which is more generalized problem than internet gaming disorder and this therapeutic module brought positive changes in intra-interpersonal aspects of the patient. The study further revealed that use of SIS-II is quite helpful either in assessing personality of people with PIU and/or applying it to detect the therapeutic change. Moreover, it was also noticed in this study that SIS-II guides the therapists about unnoticed/remaining areas of difficulty in patients even after the completion of therapy. Prevalence of Pathological Internet Use (PIU) in India is reported to be 19.85% (Gedam, et al, 2019). In another study involving1086 college students (aged 18-21), it was seen that 27.1% had mild, 9.7% had moderate and 0.4% had severe level of internet addiction. PIU was found to have adverse effect on the academic progress (Anand et al., 2018). PIU is observed in various studies either affecting or associated with stress, anxiety and depression (Tran et al., 2017), physical health issues (sleep disturbance, back/neck pain), and degradation in academic efforts (Saisan, et al, 2013; Shaw & Black, 2008). A meta-analysis found that it causes problems in areas of scholastic, occupational, interpersonal, financial and physical spheres of life (Douglas et al., 2008). Griffiths (2005) had proposed six salient features of it i.e., salience, mood modification, tolerance, withdrawal, conflict and relapse, which are primary indicators of PIU. Particularly in this era of digitalization, where all activities of life is associated with internet, the adults are at greater risk of developing PIU. It seeks attention of mental health professionals to accept the challenge and manage the changing scenario. In this continuum, the present study aimed at managing (using standard therapeutic modules) the severity of PIU and associated problems in a case of a 21-year male. The Somatic Inkblot Series-II (SIS-II) was administered to detect the underlying unconscious phenomena and identify the pretreatment and post-treatment changes in the patients after the intervention. The literature on the topic using SIS looks scanty, and it would be an interesting attempt towards managing such growing problems. Clinical History: Index patient, Mr. X, aged 21 years, male, undergraduate student, visited Post-Graduate Institute of Behavioral& Medical Sciences, Raipur, (India) with parents, having the complaints of excessive use of internet through Smartphone. He had noticed deterioration in academic performance. He was getting aggressive, abusive and at times destructive when prevented from using internet. He foundit difficult in initiating and

continuing interpersonal interactions with teachers, fellow students, friends and others. These complaints started since August2014, when he was in 11th standard. In 10th standard he obtained 91.20% marks, which dropped down to 75% in 12th standard and he failed under-graduation first year. As per the patient, he was not able to control the urge to use internet in his Smartphone. He had been using internet since last 6 years for almost 6 to 8 hours per day. He used internet for entertainment (playing games, viewing pornography, superhero movies and music), establishing and continuing online relationship and chatting. He also reported that he had excessive concern about his health and had difficulty in accepting other viewpoints, which became the main reason of conflicts in the family. As per background history, he had a sevenyear older brother pursuing his masters. He belongs to a nuclear middle-class family. Premorbid history revealed that he was a selfabsorbed and shy person who was always preoccupied with studies, had no close friends to share things, and had no interest in outdoor activities. Because of his solitary attitude, he was many times bullied by his classmates, which he could never retaliate and needed to call parents to stop such incidents. He used to play video games in leisure time. He had been a person with perfectionist attitude. Method: Design: The study was conducted using a case study method with qualitative and quantitative analysis. Tools: 1. Demographic data sheet: This was used (a self-prepared semi-structured sheet) to collect demographic details and details of his internet usage. 2. Online Cognition Scale (OCS): It was developed by Davis, Flett, and Besser (2002).The OCS is a 36-item questionnaire that measures PIU. Respondents rate the agreeableness on a seven-point Likert scale for each item. The scale has high internal consistency as a total measure of problematic Internet use (α=0.94) and for each of the four OCS dimensions: social comfort (α=0.87), loneliness/depression (α=0.77), diminished impulse control (α=0.84), and distraction (α=0.81). Item-total correlations were highly significant, ranging from 0.47 to 0.77 for social comfort, 0.49 to 0.81 for loneliness/depression, 0.50 to 0.76 for diminished impulse control, and 0.55 to 0.80 for distraction. 3. Somatic Inkblot Series (SIS-II): It consists of 62 inkblot images. There is also a sample image in the beginning to make the subject comfortable. The test was administered, scored and interpreted following Cassell & Dubey (2003). Intervention Package: Considering the different areas of problems (i.e., PIU, interpersonal relationship difficulties, poor emotional control such as anger outburst, excessive health concerns, poor social skills, perfectionist attitude and self-absorbedness)in the patient, special management package, PIPATIC (ProgramaIndividualizadoPsicoterapéutico para la Adicción a las Tecnologías de la información y la comunicación),having English translation as Individualized Psychotherapeutic Program for Addiction to the Technologies of the Information and Communication, was used in present case management, which was primarily developed by Torres-Rodriguez & Carbonell (2017). They basically prepared this program for and tested it on Internet Gaming Disorder.

Table 1: Therapeutic modules of PIPATIC 1. Psycho-educational module: individual and family psycho-education, motivational interviewing, choosing goals and objectives (three sessions) 2. Standard CBT addiction intervention module: stimulus control, learning appropriate coping responses, cognitive restructuration, problem solving related to addiction, exposure (five sessions) 3. Intrapersonal module: psychotherapeutic work on identity, self-esteem, self-control, emotionalintelligence, and anxiety control (five sessions) 4. Interpersonal module: encouraging adaptive communication skills, assertiveness, and increasing communication skills (two sessions) 5. Familiar module: family communication, limits, and affect (three sessions) 6. Development of a new lifestyle module: self-observation of improvement, alternative activities, and relapse prevention (two sessions) (cited inTorres-Rodriguez, Griffiths, Carbonell, &Oberst, 2018) Procedure: Patient went through the baseline assessment (preceded by clinical interview) using demographic data sheet, OCS and SIS-II before beginning of the therapeutic sessions. Same assessments were repeated at the completion of three months (23 sessions; 2 sessions per week) of therapeutic intervention. Therapists followed the therapeutic modules, PIPATIC (table 1), with modification of some components in terms of their presentation in a sequence, inclusion or exclusion of certain techniques or modules as per the requirement of the patient‟ problems. Each session was structured, in which revision of homework assignments, measuring change/mood check (through 10- point rating scale) and homework assignment till next session were key parts. The entire therapy was divided into four major sections. Their descriptions are given below: First three sessions: • In these sessions, therapy began with psychoeducation to educate patient and family members about illness, method of treatment, role of family members in treatment and prognosis. • Motivational interviewing (active listening to patient‟s statements, expressing empathy, rolling with resistance) was conducted to work on his resistance to accept PIU as an illness/problem. In addition to attract him to therapy sessions, negotiation technique, persuasion and cost-benefit analysis was done. • In order to reduce the anger and conflict with family members, parents and brother were educated using metaphors and self-disclosure. They were advised to avoid using provoking words such as „addicted‟ and „dumb.‟ Such words used to provoke anger in the said patient. They were also educated to notice small desired changes (usually family members expect major change in patient as therapy starts) in use of internet and other reported complaints and were asked to reinforce positively by simply praising at the contingent to that change. Next eight sessions: • These sessions were targeted at controlling/reducing PIU. Initially behavioral techniques were applied followed by cognitive therapy techniques. • To control the craving, mental imagery and abdominal breathing were used and the patient found mental imagery of positive past events (pleasurable events, achievement, visit etc.) more beneficial. In addition, distraction techniques i.e., leaving Smartphone and either going to kitchen to help mother or watching T.V. or reading books of his interest or listening to music or playing outdoor games were applied. However, later distraction techniques were not given much emphasis. • To monitor the PIU, self-register techniques (using internet use diary and/or an in-built app in phone “Action Dash”) were used. To control/reduce the use of internet gradually,

self-observation (through body scan and mindful seeing) and self-instruction training (self-talk that „OK I will use internet after a gap of 15 minutes,‟ and others) were used. A small reduction in terms of frequency/time duration (in seconds/minutes) was positively reinforced by the therapist and parents. Family members were advised to observe the patient for his usage in terms of hours/frequency and to report therapist on phone without knowledge of patient. • Patient was advised these activities to continue till the end of therapy sessions and in the beginning of each session internet use was recorded by the therapist in collaboration with patient. • Later on, in the sessions, to reduce/solve the different problems and maladaptive cognitions related to PIU, inputs from cognitive therapy were used i.e., Socratic questioning, cost-benefit analysis, generating alternative views, downward arrow technique, behavioral experiment, taking others as reference points etc. were used. • Next eight sessions: • These sessions were basically focused on dealing with intrapersonal aspects/difficulties of the patient such as anger, guilt, and poor self-esteem due to PIU and poor academic outcomes. Some of the cognitive techniques discussed above were also used in this phase of therapy. These sessions were both cognition and problem-focused. The patient was encouraged to make an activity scheduling to restructure his daily routine, which was grossly disturbed. A mastery and pleasure technique was added and trained for his self-reinforcement with a successful achievement of any task in the schedule. Maladaptive thoughts for self were dealt with above mentioned cognitive techniques. During these sessions‟ patient reported much delay and difficulty in making decisions. He was again trained how to use cost-benefit analysis in this context. He appeared and reported capable of making relatively quick decisions. Next four sessions: • These sessions were targeted on interpersonal problems/difficulties which the patient and parents reported. He had been shy, had difficulty in initiating and maintaining interpersonal interaction and establishing meaningful relationships. Therapist also noticed lack of proper eye-contact and head being down during the sessions. Despite these, he reported difficulty in accepting other viewpoints that caused frequent family conflicts. For these problems, he was trained activities related to assertiveness, communication skills and in-therapy role play. These were repeated in each of the four sessions by dividing fixed time for each activity and homework was given. For the problem of difficulty in accepting other viewpoints, he was trained in using others as reference point techniques. Socratic questioning and creating ability to generate alternative viewpoints on his own were also applied to deal with associated maladaptive thoughts related to this problem. Results: Table 2. Pre-to-post intervention change in PIU on OCS Sr. No. OCS Dimensions Scale Mean Score (Healthy individuals) Patient’s Score Pre-Intervention Post- Intervention Loneliness/depression 16.05 (6.50) Diminished impulse control 27.17 (10.29) Distraction 24.86 (8.17) Social comfort 34.45 (12.09) Note: PIU= Pathological Internet Use; OCS= Online Cognition Scale

Table 3. Pre-to-post intervention change in SIS-II Indices Sr. No. SIS-II Indices Pre-Intervention Post-Intervention Total Response Human response Animal response Anatomical Response Sex response Movement response Most typical response Typical response Atypical response Rejection 1 (3 B) 1 (A 27) Pathological response A 1. Pathological anatomy (1 A & 10 B) Absent B Depression 2 (28A) Absent C Hostility & aggression 1 (15 B) Absent D Paranoia None None Table 4.Pre-to-post intervention change in content of selected responses on SIS-II Images Pre intervention Post intervention A1 Looks like a deflated heart with blood pouring out it Looks like a heart and its mirror image A4 Looks like a glass with some type of alcohol Looks like a lemon piece in a glass A6 A teddy bear and a man kicking a ball A man doing something and a teddy bear A8 Looks like a conclave lens Looks like a happy man A10 Looks like a blurred face of a man A face of a man A13 Human hand Looks life human hand coming out of hole A14 Looks like an abnormal food canal and stomach A food pipe and stomach A21 Leafs Looks like a tortoise A24 Big ugly flower Looks like tribal people helping each other being around the fire A27 An ultrasound Rejection of image A28 A woman‟s face, sad one Looks like an arm A29 Two guns Looks like a cliff B3 Rejection of image Looks like two people saying something B4 A man blowing out cigarette Looks like two human faces B5 A man, a girl Looking like two people sitting in chairs and talking B10 An ugly dog (burnt face) A dog B14 Human heart Looks like an apple B23 Unknown insects A big spider B28 An alien mother and her offspring Looks like a mother and child B29 A human with missing leg Looks like a person running B31 A family of humans Looks like a human family

Discussion: This case study was aimed at primarily on two objectives. First, to see the applicability of PIPATIC program on PIU and second to see to what extent the SIS-II is apt to identify the therapeutic change. PIPATIC was found effective on reducing severity of PIU in terms of score on OSC (table 2) and daily use hours as reported by patient, monitored through inbuilt mobile app (Action Dash) and corroborated by parents. Before the beginning of therapy, he used to cling to Smartphone more than 6 to 8 hours per day; now after therapy, it came down to 2 hours to 2 hour 15 minutes per day. It is a remarkable reduction that appeared to enhance the patient‟s selfconfidence and self-efficacy (subjectively reported by patient). Parents reported around 80% improvement in his anger, interpersonal difficulties, increased hours of study, involvement with outdoor games i.e., playing badminton, regularly attending gym, and helping in household chores. One extraordinary change the parents reported that post-therapy the client used to sit and interact with guests at home, which earlier he used to avoid. Earlier studies found PIPATIC was effective in reducing internet gaming disorder, resolving intra-interpersonal problems, co-morbid conditions and family relations (Torres-Rodriguez, Griffiths, & Carbonell, 2017; Torres-Rodriguez, Griffiths, Carbonell & Oberst, 2018). However, in the current study therapists applied it to check to what extent it is applicable to PIU in general. It was found to have promising outcomes in this case study. Authors further suggest using it in random control trials for individuals with PIU to further extend its efficacy in generalized pathological internet use. Regarding the second objective of this case study i.e., to explore the utility of SIS-II in identifying therapeutic change in a case of PIU. Results of pre-to-post difference in both SIS-II Indices (table 3) and content analysis of responses (table 4) revealed noticeable changes in positive direction, which corroborate with reduction in severity of PIU, reports from parents and therapist observations. At pre-intervention assessment, rejection of image B3 is suggestive of improper interpersonal skills in the patient. After intervention on same image patient perceived a typical response. In few other responses which were indicative of certain inner emotional turmoil in the patient, postintervention the responses appeared to be more positive. On image A28 (a woman‟s face, sad one turned into looks like arms), on image A8 (Looks like a conclave lens turned into looks like a happy man), on image A10 (Looks like a blurred face of a man turned into a face of a man) and on image B29 (a human with missing leg turned into looks like a person running). These post-therapy changes in content of responses are suggestive of the fact that therapy was helpful in creating positive affectivity and enhanced self-image and SIS-II successfully picked up and projected the changes. Moreover, content change on A13 (human hand turned into looks like human hand coming out of hole) is indicative of patient is trying to fight with his emotional and behavioral difficulties and appears to come out of these. Content change on image A14 (Looks like an abnormal food canal and stomach turned into a more typical response i.e, a food pipe and stomach) is suggestive of reduction in somatic concerns as reported by patient in the intake history. On image A29 (two guns turned into looks like a cliff) symbolizes reduction in anger but at the same time he appeared to have a feeling of difficultly to achieve life goals or problems in his life. Moreover, with improvement in different problem areas in the patient and simultaneous changes in SIS-II response contents, SIS-II further guides the therapist about remaining areas of difficulties which can be target of therapy in boost-up sessions. A rejection of image A27 (in post therapy assessment record) guides the therapist work into the area

of sexual content. Patient appeared to have certain conflict in that area. Similarly, on image B 31(looks like a human family; in posttherapy assessment record) appeared to be an atypical response, which directs therapist to work in family integration or greater interpersonal integration in the psyche of patient (Cassell & Dubey, 2003, Dubey, Banerjee and Dubey, 2019). Overall, this case report suggested that PIPATIC was helpful to bring positive changes in different areas of the patient‟s problems and simultaneously SIS-II was quite appropriate in detecting the problems in the patient‟s personality and was effective to detect and reflect the therapeutic changes in him. It further guided the therapist about the unnoticed/unresolved problem areas, which could play major role in relapse prevention of the patient. References: Anand, N., Jain, P. A., Prabhu, S., Thoman, C., Bhatt, A., Prathyusha, P. V., Bhatt, S. U., Young, K., Cherian, A. V. (2018). Internet use patterns, internet addiction, and psychological distress among engineering university students: A study from India. Indian Journal of Psychological Medicine, 40, 458-67. Cassell, W. A. & Dubey, B. L. (2003). Interpreting inner world through somatic imagery: Manual of the somatic inkblot series. Alaska, USA: Somatic Inkblot Center. Davis, R. A., Flett, G. L., & Besser, A. (2002). Validation of a New Scale for Measuring Problematic Internet Use: Implications for Pre-Employment Screening. Cyber Psychology and Behavior, 5, 4, 331-345. Douglas, A. C., Mills, J. E., Niang, M., Stepchenkova, S., Byun, S., Ruffini, C., Lee, S. K., Loutfi, J., Lee, J., Atallah, A., & Blanton, M. (2008). Internet Addiction: Meta-Synthesis of Qualitative Research for the Decade. Journal on Computers in Human Behavior, 24, 3027-3044. Dubey, B.L., Banerjee, P. and Dubey Anand (2019) Inkblot Personality Test test-Understanding the unconscious Mind, Sage Publications Inc. New Delhi. Gedam, S. R., Ghosh, S., Modi, L., Goyal, A., & Mansharamani, H. (2019). Study of internet addiction: Prevalence, pattern, and psychopathology among health professional undergraduate. Indian Journal of Social Psychiatry, 33, 305-11. Griffiths, M. A. (2005). „Components‟ Model of Addiction within a Bio-psychosocial Framework. Journal of Substance Use, 10, 191-7. Saisan, J., Smith, M., Robinson, L., & Segal, J. (2013).Internet and Computer addiction: Signs, Symptoms,andTreatment.Retrievedfromhttp://ww w.helpguide.org/mental/internet_cybersex_addicti on. Shaw, M., & Black, D. W. (2008). Internet Addiction. CNS Drugs, 22, 5, 353-365. Torres-Rodriguez, A., & Carbonell, X. (2017). Update and proposal of treatment for Internet Gaming Disorder: PIPATIC program. Revista de Psicoterapia, 28(107), 317–33 6. Torres-Rodríguez, A., Griffiths, M. D., & Carbonell, X. (2017). The treatment of internet gaming disorder: a brief overview of the PIPATIC program. International Journal of Mental Health and Addiction. https://doi.org/10.10 07/s114 69- 017-9825-0 Torres-Rodriguez, A., Griffiths, M. D., Carbonell, X. & Oberst, U. (2018).Treatment efficacy of a specialized psychotherapy program for Internet Gaming Disorder. Journal of Behavioral Addictions 7 (4), 939-952. Tran, B. X., Huong, L. T., Hinh, N. D., Nguyen, L. H., Le, B. N., Nong, V. M., Thuc, V. T. M., Tho, T. D., Latkin, C., Zhang, M. W. B., & Ho, R. C. M. (2017). A Study on the Influence of Internet Addiction and Online Interpersonal Influences on Health-Related Quality of Life in Young Vietnamese. BMC Public Health, 17:138. doi 10.1186/S12889-016-3983.

. General Wellbeing and Marital Quality among Spouses of Individuals with Alcohol Dependence Syndrome: A Comparative Study Swarnlata Kumari and Jai Prakash Alcoholism is the most severe form of alcohol abuse and involves the inability to manage drinking habits. It is also commonly referred to as alcohol use disorder. Excessive use of alcohol affects the mental and behavioral health of the user and his family members. Spouses of alcoholics are more likely to be victims of domestic violence, may suffer emotional harm, and become socially withdrawn. The aim of the present study was to examine the quality of life, psychological wellbeing and marital quality among spouses of individuals with alcohol dependence syndrome and spouses of normal control subjects. The study was conducted at Ranchi Institute of Neuropsychiatry and Allied Sciences, Kanke, Ranchi. The sample consisted of 75 participants (50 spouses of individuals with alcohol dependence syndrome and 25 spouses of normal control subjects) fulfilling the inclusion and exclusion criteria. It was purposive sampling which was followed. WHO quality of life scale, PGI general wellbeing, and marital quality scale were administered to all participants. Findings indicated high psychosocial impairment among spouses of individuals with alcohol dependence syndrome than normal controls. Alcohol has an adverse effect on health and is one of the prominent social problems all over the world (WHO, 2004). As per 2010 statistics, 7.5% of the world population indulges in heavy episodic alcohol use and the worldwide alcohol per capita consumption is equal to 6.2L of alcohol per person over the age of 15 years (WHO, 2009). It's usually seen that the wives of alcoholics must take the responsibility of both parents and may develop certain mental and physical illness (Tiwari, 2010). Several studies have found that spouses of alcoholic partner suffer from mental and physical problems, low social activity and poor marital satisfaction (Moos et al., 1990). The use of alcohol is also associated with marital dissatisfaction, negative interaction and marital violence (Marshall, 2003). Kishor et al. (2013) reported 43% of spouses of alcoholic men have a major depressive disorder (MDD) and a significant correlation of severity of alcohol use is associated with depression. A higher incidence of negative social consequences ranging from poor selfesteem, low socio-economic status, disturbed family relations, social and recreational problems have been reported among the spouses of alcoholics (Parthasarthy, 2013). Repeatedly hospitalized patients are found to be have significantly poor Marital Quality in the domains of Understanding, Rejection, Satisfaction, Affection, Despair, Decision Making, Dominance, Self-Disclosure, Trust and Role Functioning when compared to first time admitted patients (Jose, et al, 2017). Poor marital quality is also reported as a major source to abuse alcohol (Williams 2003; Bagul et al. 2015). Quality of life covers all aspect of individual life including psychological health, physical health. The good interpersonal relationship, financial condition, stresses in life, social support and emotional support play a significant role in improving the quality of an individual's life. Material and Method: The study was hospital-based and crosssectional in nature having two independent groups; it was conducted at RINPAS, Kanke, Ranchi. The sample consisted of participants (50 spouses of individuals with alcohol dependence syndrome and spouses of normal control subjects) using purposive sampling. Written informed consent

had been taken from the participants after explaining the purpose of the study. The Socio-Demographic Data Sheet, WHO Quality of Life, PGI General Wellbeing and Marital Quality Scale were administered to all participants for gathering data. Results: The age range of spouses of alcohol dependence syndrome and spouses of normal controls were 25 to 45 years. Fiftyfour of the spouses were educated up to higher secondary. Forty-two spouses belonged to rural domicile, and 41 were home makers. Duration of marriage ranged from 4 years to 25 years. Forty spouses belonged to nuclear family. Both the groups were matched on their socio-demographic variables. Table: 1 showing Quality of life of Spouses of Individuals with Alcohol Dependence Syndrome and Spouses of Normal Control on WHO BRIEF Quality of life scale. QOL Variables Spouses of Individuals with Alcohol Dependence Syndrome (N = 50) Spouses of Normal Control Subjects (N = 25) df t-value Mean SD Mean SD Physical Health 14.64 2.78 14.76 2.71 .178 Psychological Health 11.20 3.55 19.44 2.63 10.26** Social Relations 5.82 3.95 12.48 1.58 8.07** Environment 11.46 3.17 12.92 2.58 1.99 Total quality of life score 43.12 7.10 59.60 4.33 10.63** Table: 2 showing Marital Quality and PGI General Well Being of Spouses of Individuals with Alcohol Dependence Syndrome and Spouses of Normal Control Subjects on Marital Quality of life scale. Scale Spouses of Individuals with Alcohol Dependence Syndrome (N = 50) Spouses of Normal Control Subjects (N = 25) df t-value Mean SD Mean SD Marital quality of life 180.86 12.07 75.44 13.75 34.02** PGI general well being 6.34 2.12 17.32 1.67 22.54** Table: 3 showing relationship between Socio Demographic, clinical variables and Quality of life of Spouses of Individuals with Alcohol Dependence Syndrome. QOL Variables Age No of Family Members Duration of Marriage Duration of Alcohol Intake Age Started Taking Alcohol Physical Health -.177 .052 -.247 -.258 .278 Psychological Health .156 -.386** -.016 .116 .040 Social Relations .177 -.155 -.113 .088 .154 Environmental .093 -.052 .188 -.064 ..337* **Significance at the 0.01 level (2-tailed), *Significance at the 0.05 level (2-tailed)

Discussion: The present study was conducted in order to find out how alcohol abuse affects the marital quality, psychological wellbeing, and quality of life of their spouses. The total quality of life score indicates poor quality of life of spouses of alcohol dependence group. It is apparent because excess use of alcohol leads to anger outburst, unpredicted violence and stressed home environment. The findings are supported by several studies (Sharon,2014; Tiwari, et.al, 2010). Two domains of quality of life were found to be significantly different in each group. However, physical health and environment did not differ significantly when the two groups of individuals were concerned. Psychological health was found to be most unpleasant among the spouses of alcohol dependence group. The spouses of alcohol dependence group feel less happy, less satisfied with their life, feel depressed as compared to the spouses of the normal control group. One is aware of how alcoholics mess the environment of the family while they are in the influence of alcohol. This is supported by Moos at al. (2010), Tempier et al, (2006). Spouses of alcohol dependence syndrome significantly differed from spouses of normal subjects on “Social relations” as well as on “Environment”. Spouses of alcohol dependence syndrome feel less secure have poor health facility, poor financial condition, poor interpersonal relationship, poor sexual satisfaction, and a narrow social network compared to the spouses of normal control. The present finding is further supported by other studies (Homish et al., 2006; Waldron et al., 2011).Marital quality of the spouses of alcohol dependence syndrome was also found to be very poor as compared to the spouses of normal controls. This is because individuals with alcohol dependence drain their money and time to get alcohol and have less time to spend with their partners. Alcohol abuse (dependence) brings several medical complications for which many clients need to spend their time in hospitalization. All these factors affect their interpersonal relationships with their spouses. This finding is supported by other studies (Moos et al., 1990; Parsons, 2003; Marshall, 2009). The scores on General Wellbeing were found to be on the lower side among the spouses of alcohol dependence syndrome as compared to the spouses of normal control subjects. General wellbeing was found to be directly associated with how well a person is satisfied in his or her life, how healthy is his interpersonal relationship and how much he is happy in his life. However, this is not possible with the spouses of alcohol dependence syndrome. The finding was supported by Malini & Ravindran (2014). Psychological health is positively correlated with the number of members in the family. A family with large number is likely to have more adverse effect on the family atmosphere. Alcohol abuse directly affects the quality of sleep, anxiety in family members, and the aggressive and abusive behavior of the abuser. The environment is positively correlated with age in which the individual starts taking alcohol. Spouses of alcohol abuse often find themselves difficult to cope with their situation. Often, they have less social support, and poor financial condition. Early alcohol abuse has adverse prognostic outcome than those starting at higher age. Conclusion: Alcohol dependence syndrome is one of the leading psychosocial hazards which affect the physical, mental, social, emotional and financial condition of the family. The spouses of alcoholics become the primary victim because of the strained physical, sexual, and mental abuse by the partner. The poor marital quality, poor quality of life and diminished general wellbeing induce an adverse home environment. Several studies indicating depression, anxiety and fear as well as an obsession with unpleasant consequences are associated with the spouses of alcohol dependence syndrome. It can be concluded that substance dependence in the field of

clinical research has become pivotal and intervention on the individual as well as the family should be the primary call for the clinicians. As a mental health professional, it is our responsibility to promote health education and social reform to control alcohol abuse. References: Shah, A. (1995).Clinical validity of Marital Quality Scale. NIMHANS Journal, 13(1),23-31. Bagul, K. R., Deshmukh, S. B., Bagul., M. K., Deshmukh, P. S. (2015). Psychiatric Morbidity and Marital Quality among Wives of Patients with Alcohol Dependence Syndrome. Journal of Evidencebased Medicine and Healthcare, 22(2), 3284- 3295. Department of Mental Health, Substance Abuse, & World Health Organization. (2004). Global status report: alcohol policy. WHO. Gelder, M. G., Juan,J., & Nancy,A. (2004). New Oxford textbook of Psychiatry, Vol 1.Oxford Univ. Press. Homish, G. G., Leonard, K. E., & Kearns-Bodkin, J. N. (2006). Alcohol use, alcohol problems, and depressive symptomatology among newly married couples. Drug and alcohol dependence, 83(3), 185-192. Jose, K., Khess, C. R., & Uvais, N. A. (2017). Marital quality in alcohol dependence syndrome: A comparative study between first time and repeatedly hospitalised patients. International Journal of Research in Medical Sciences, 5(12), 5301. Kishor, M., Pandit, L. V., & Raguram, R. (2013).Psychiatric morbidity and marital satisfaction among spouses of men with alcohol dependence. Indian Journal of Psychiatry, 55(4), 360. Moos, R. H., Brennan, P. L., Schutte, K. K., & Moos, B. S. (2010). Spouses of older adults with late-life drinking problems: health, family, and social functioning. Journal of Studies on Alcohol and Drugs, 71(4), 506-514. Moos, R. H., Finney, J. W., & Cronkite, R. C. (1990). Alcoholism treatment: Context, process, and outcome. Oxford University Press. Parsons, T. (2003).Alcoholism and its effect on the family .AllPsych Journal, 14. Prathsarathi.K. (2013).Psychological problems of the wives of alcoholics. International Journal of Scientific Research,5(2), 574-575. Saxena, S., Chandiramani, K., & Bhargava, R. (1998). WHOQOL-Hindi: A questionnaire for assessing quality of life in health care settings in India. National Medical Journal of India, 11, 160-165. Tempier, R., Boyer, R., Lambert, J., Mosier, K., & Duncan, C. R. (2006).Psychological distress among female spouses of male at-risk drinkers. Alcohol, 40(1), 41-49. Tiwari, R., Srivastava, A. S., & Kaushik, S. S. (2010). Presumptive stressful life events among spouse of alcoholics. Indian Journal of Social Science Research, 7(1), 41-6. Verma, S. K., Dubey, B. L., & Gupta, D. (1983). PGI General Well Being Scale: Some correlates. Indian Journal of Clinical Psychology. Waldron, M., Heath, A. C., et al. (2011). Alcoholic marriage: later start, sooner end. Alcoholism: Clinical and Experimental Research, 35(4), 632- 642. Williams, K. (2003). Has the future of marriage arrived? A contemporary examination of gender, marriage, and psychological well-being. Journal of Health and Social Behavior, 44(4), 470. World Health Organization. Substance Abuse Department, World Health Organization. World Health Organization. (2009). Global health risks: mortality and burden of disease attributable to selected major risks. Geneva: WHO.

Psychotherapeutic interventions are becoming increasingly important in India. Indian literature is full of information related to existence of knowledge about psychotherapy. The current study reviews the literature related to psychotherapy in Indian cultural context. The training of professionals is largely based on western models. Ancient treatment methods and cultural values need to be combined with modern approaches. This integration will enhance the psychotherapeutic effectiveness. The incorporation of cultural factors in psychotherapy will facilitate the adherence and acceptability. Psychology and psychotherapies have a long history in India. The ancient scriptures are full of descriptions pertaining to psychological sciences. Systematic attempts have been made to study these concepts in the light of modern western psychology (Manickam, 2010). Triguna theory, Bhagwad Gita, Asharam system are few of the numerous illustrations which reflect and emphasize various notions of personality, psychotherapy and developmental stages. Ayurveda underlined the importance of emotions in physical and mental health. The harmony between body, mind and soul was considered to be a pre-requisite for healthy existence which was exemplified by yogic system. Consequently, Indian system conceptualized health and ill health in holistic manner. As per the ancient approaches mental illness is managed by a combination of occult, spiritual and medicinal techniques. Moreover, physical exercises, practicing ethical and moral practices and dietary discipline were also highlighted. According to Balodhi (1991),western methods although being more scientific, focused on specific aspects whereas eastern approaches were more holistic. An effort has been made to investigate the basic tenets of the Indian culture which have a bearing on the conceptualization and practical application of psychotherapy in the Indian setting (Bhargava, Kumar & Gupta, 2017). With this background, Girindrasekar Bose, the founder of the Indian Psychoanalytic society started practicing western psychotherapy in India. The role of cultural and contextual factors is often neglected in Psychoanalysis. In the present context, Tummala-Narra (2015) emphasized recognition of cultural competence and socio- cultural factors in psychotherapy. The Indian perspectives in the approach were subsequently added (Kakar, 1989, 2003; Nagpal, 2011). The behavioral and cognitive behavioral therapies are increasingly gaining prominence in India. The adaptation of cognitive behavior therapy to the belief system of individual makes it applicable in various cultures (Dattilio & Bahadur, 2005). The cognitive-behavioral interventions are supported by empirical studies across various clinical conditions and cultures. In Indian context, cognitive behavioral therapy needs to incorporate philosophical and cultural aspects with more instructive and dyadic style by the therapist in the initial stages of therapy (Kumar & Gupta, 2012). The applicability of western psychotherapy models in India, without necessary modifications, considering cultural and contextual factors, may not yield maximum benefits. According to Neki (1975) western psychotherapy hardly addresses the majority and is applicable to elite population staying in metropolitan cities. Psychotherapeutic Relationship: The therapist and patient relationship in India which is determined by the traditional cultural

values is not like the west. In contrast to the west, Indian patients accept dependency relationships, are less willing to accept intrapsychic explanations, are ready to discard ego boundaries and involve the therapist in direct role relationships (Surya & Jayaram, 1964). The Guru-Chela relationship as a model of psychotherapy (Neki, 1973) was proposed for Indian population. The surrenderance and faith are very much embedded in such a relationship. The western model, however, construes therapeutic relationship from the collaborative framework. Ancient literature, Mythology and Indigenous Psychotherapeutic Paradigms: Ancient Indian scriptures have anecdotes which are useful in psychotherapy (Avasthi, Kate & Grover, 2013). The mythology may be meaningfully utilized with Indian patients. Wig (2004) highlighted the ‘Hanuman Complex’ from Ramayana which is a common problem in many psychiatric disorders. The Bhagwad gita is an ancient Indian treatise which explained the origin of psychological problems and its successful resolution. The document pertains to modes of behavior, temperament, frailties and strengths, ego agonies and the supreme art of counseling (Rao,1980).The yogic practices described in ancient texts may be integrated with the contemporary psychotherapeutic practices. These practices are considered significant for physical, mental and spiritual health. The yoga involves breath regulation, relaxation, physical exercises and mindful awareness which have resemblance to many western therapies. The researchers have found that yoga can be beneficial in the management of various psychological problems (e.g., Vahia, 1972; Grover, et al, 1994). More scientific research studies in yogic methods will pave way for its application in psychotherapeutic practice. The mindful meditation is an important component of optimism attitude model (Banerjee, 2018). Cultural factors: The cultural factors play an important role in psychotherapy (Seiden,1999; Asnaani & Hofmann, 2012). The factors may be related to symptom manifestation, coping mechanisms and help-seeking behaviors. In India, cultural factors have a bearing on psychotherapeutic relationship. The consideration of these elements will facilitate positive results from psychotherapy and make it more acceptable. Summary and Way Forward: The review indicates that the traditional wisdom on psychotherapy in India should be integrated with the modern psychotherapies to make the interventions more effective and acceptable. The cultural values embedded in our psychic realities necessitate consideration of such factors in psychotherapeutic interventions. The interdependence, belief in rebirth, fatalism and ritualistic treatment are factors specific to India. Opinions have ranged from total suitability of odd western models of psychotherapy to absolute necessity for indigenous psychotherapy for Indian patients. The researcher suggests combining both the approaches in a scientific manner. References:

Asnaani, A., & Hofmann, S. G. (2012). Collaboration in multicultural therapy: Establishing a strong therapeutic alliance across cultural lines. Journal of Clinical Psychology, 68(2), 187-197. Avasthi, A., Kate, N., & Grover, S. (2013). Indianization of psychiatry utilizing Indian mental concepts. Indian Journal of Psychiatry, 55(Suppl 2),136-144. Balodhi, J. P. (1991). Holistic approach in psychiatry: Indian view. NIMHANS Journal, 9(2), 101-104. Banerjee, P. (2018). The Power of Positivity: Optimism and the Seventh Sense. SAGE Publishing India. Bhargava, R., Kumar, N., & Gupta, A. (2017). Indian perspective on psychotherapy: cultural issues. Journal of Contemporary Psychotherapy, 47(2), 95-103. Dattilio, F. M., & Bahadur, M. (2005). Cognitivebehavioral therapy with an East Indian family. Contemporary Family Therapy, 27(3), 367-382. Grover, P., Varma, V. K., Pershad, D., & Verma, S. K. (1994). Role of yoga in the treatment of neurotic disorders: current status and future directions. Indian Journal of Psychiatry, 36(4), 153-162.

Kakar, S. (1989). The maternal-feminine in Indian psychoanalysis. International Review of Psychoanalysis, 16, 355-362. Kakar, S. (2003). Psychoanalysis and Eastern spiritual healing traditions. Journal of Analytical Psychology, 48(5), 659-678. Manickam, L. S. S. (2010). Psychotherapy in India. Indian Journal of Psychiatry, 52l(1), 366-370. Nagpal, A. (2011). A Hindu reading of Freud’s Beyond the Pleasure Principle. On Freud's" Beyond the Pleasure Principle", 230-239. Neki, J. S. (1973). Gurū-Chelā relationship: The possibility of a therapeutic paradigm. American Journal of Orthopsychiatry, 43(5), 755-766. Neki, J. S. (1975). Psychotherapy in India: past, present, and future. American Journal of Psychotherapy, 29(1), 92-100. Rao, A. V. (1980). Gita and mental sciences. Indian Journal of Psychiatry, 22(1), 19-31. Seiden, D. (1999). The Effect of Research on Practice in Cross-Cultural Behavior Therapy: A Single Case Study. Behaviour Therapist, 22(10), 200-201. Surya, N. C., & Jayaram, S. S. (1964). Some Basic Considerations in the practice of Psychotherapy in the Indian Setting. Indian Journal of Psychiatry, 6(3), 153-156. Tummala-Narra, P. (2015). Cultural competence as a core emphasis of psychoanalytic psychotherapy. Psychoanalytic Psychology, 32(2), 275-292. Vahia, N. S. (1972). Experience in the management of psychiatric and psychosomatic disorders with yoga. Journal of Yoga Institute, 18, 80-83. Wig, N. N. (2004). Hanuman complex and its resolution: An illustration of psychotherapy from Indian mythology. Indian Journal of Psychiatry, 46(1), 25-28. 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, Director SIS Center,7490 coon club Road, Medina, OH 44256 (USA) Email: bldubey@gmail.com

This article is a response to the recent editorial by Piotrowski (2019). In our article (Benson et al., 2019), we reported results from a national survey of the tests and assessment practices used by contemporary school psychologists in the United States. We appreciate Piotrowski’s (2019) acknowledgement of our results as offering ―a keen perspective on the emerging status and breadth of assessment practices, specific to the field of school psychology‖ (p. 75). Our article focused on a wide range of assessment practices, and Piotrowski’s concerns pertained largely to our presentation and discussion of results regarding projective techniques. First, Piotrowski (2019) lamented that we downplayed the use of projective techniques and suggested that we cast them as moribund. Specifically, he objected to our statement that, ―today, few projective tests of any kind are used‖ (Benson et al., 2019, p. 43) in school psychology. The word few means not many persons or things. Although it is true that 32% of participants in our study reported using at least one projective technique during the past year, 93% of those who used them did so less than once per month, on average (M = 0.39, SD = 1.36). Thus, Piotrowski’s criticism appears to be based on conflation of the percent of practitioners using these techniques with the average frequency of their use. According to our results, projective techniques are administered only about once every three months by school psychologists, on average. This is certainly not many. Moreover, although we did not ask respondents to indicate how they interpreted the tests they administered, other surveys regarding projective test usage found they were used for alternative purposes, such as establishing rapport (Holaday, Smith, & Sherry, 2000; Kennedy, Faust, Willis, & Piotrowski, 1994), and not to exclusively test projective hypotheses. In any case, our results showed a dramatic decline in the use of projective techniques in school psychology relative to results from the previous comprehensive assessment surveys we cited that were conducted more than 20 years ago.1 As our results showed, the administration of projective techniques is no longer standard practice in school psychology. Second, Piotrowski (2019) expressed concern that we ―singled-out‖ (p. 75) projective techniques as rarely used instruments while minimizing the infrequent use of narrow-band, symptom-specific measures like the Children’s Depression Inventory (CDI; Kovacs, 2010) and Revised Children’s Manifest Anxiety Scale, Second Edition (RCMAS-2; Reynolds & Richmond, 2008). Although we did not explicitly label narrowband instruments as rarely used, we noted that they ―are used relatively sparingly‖ and that the CDI and RCMAS-2 are used ―less than once per month, on average‖ (Benson et al., 2019, p. 45). Our results can reasonably be interpreted as indicating that narrow-band self-report instruments are sparingly used by practitioners in school settings. Furthermore, we also noted the decline in use of tests of perceptual and motor functioning in the same paragraph in question, as our intent was to note trends evident across surveys conducted over time and not to single out specific classes of instruments for criticism. Third, Piotrowski (2019) took issue with our claim that the results presented in our article are consistent with the evidence-based practice movement (i.e., a movement toward

use of assessment and intervention practices with demonstrated research support; Gross, Farmer, & Ochs, 2018; Kratochwill, 2007). Although there are certainly examples of empirically supported instruments that are rarely used by school psychologists, we believe that the less frequent use of projective techniques by school psychologists can be attributed largely to a mismatch between the constructs measured by these instruments and the purposes of assessments conducted in school settings. Most assessments in schools are conducted as part of the eligibility determination process for special education under the Individuals with Disabilities Education Act (IDEA, 2004), and most referrals occur during childhood rather than during adolescence. Thus, some of Piotrowski’s examples of instruments that have solid empirical support but did not rank highly based on frequency of use, such as the Millon Adolescent Clinical Inventory (Millon, 1993) and the Minnesota Multiphasic Personality Inventory-Adolescent- Restructured Form (Archer, Handel, Ben- Porath, & Tellegen, 2016), are not surprising. Moreover, the top 50 tests in our list consist mostly of those with extensive evidence of reliability and validity to support their use for school-based assessment purposes. With respect to projective techniques, our data are consistent with Piotrowski’s conclusion that their use ―for assessment may be somewhat limited‖ (p. 75) — at least in the field of school psychology. Evidence-based practice involves using procedures supported by empirical research demonstrating their utility in guiding decisions about when intervention is warranted, what the targets of intervention should be, and what specific interventions should be used (Youngstrom& Van Meter, 2016). At the current time, there is a paucity of evidence supporting the utility of scores derived from projective techniques for the determination of eligibility for special education and the design of interventions in school settings (Nelson-Gray, 2003; Whitcomb, 2017). In our view, the critiques levied by Lilienfeld, Wood, and Garb (2000), which Piotrowski (2019) cited, were fair, objective, and constructive. In fact, Lilienfeld et al. reported that they found empirical support for some of the Rorschach Inkblot Test and Thematic Apperception Test indexes. They suggested that suboptimal design and construction of projective techniques likely contributed to the empirical shortcomings of other indexes and provided constructive recommendations for addressing these limitations. Specifically, these authors recommended the following principles: (a) aggregation across multiple items, (b) relevance of stimuli to the construct of interest, and (c) iterative, self-correcting test construction. These recommendations fit well with the current definition of validity in the Standards for Educational and Psychological Testing: ―Validity refers to the degree to which evidence and theory support the interpretations of test scores for proposed uses of tests‖ (American Educational Research Association [AERA], American Psychological Association [APA], & National Council on Measurement in Education [NCME], 2014, p. 11). Per this definition, reliability and validity are not properties of tests. Rather, evidence needs to be collected and marshalled for each score that is proffered for interpretation and use. To facilitate this process, it is important that projective techniques be designed to measure clearly defined attributes, evidence supports the derived scores as accurate representations of intended attributes, and the number of scores derived from the test does not exceed the number of attributes the test is designed to measure (Mari, Carbone, & Petri, 2015). Nonetheless, the now decades-old cautions against using projective techniques for clinical and forensic purposes offered by Lilienfeld et al. (2000) still hold true today. Although we noted the marked decline in the use of projective techniques by school psychologists in our article, those who use projective techniques can take solace in the fact that scholarship focusing on their use is alive and

A Response to Piotrowski (2019): 59 well, as evidenced by data presented by Piotrowski (2019; see Table 2). It is possible that multiple projective techniques may be viewed as evidence-based if they are designed and constructed appropriately and subjected to strong programs of construct validation consistent with the Standards for Educational and Psychological Assessment (AERA, APA, & NCME, 2014). Certainly, we welcome assessment innovations based on scientific methods, focusing on children and adolescents, for the determination of special education eligibility, and linked to the design of interventions in school settings. Last, Piotrowski (2019) hypothesized that the sharp decline in the use of projective tests in the field of school psychology over the past 20 years is due to the lack of faculty interest. This is quite plausible, although the apparent lack of faculty interest is most likely related to limited research supporting the validity and utility of projective techniques in the schools. Because our study focused on the test use and assessment practices of practitioners in the field, we did not survey faculty in school psychology training programs. Results of our survey therefore did not shed light on whether school psychology programs are currently meeting the training needs of future practitioners with regard to assessment. Moreover, results of our survey do not explain why the observed changes in the field occurred, particularly regarding the use of projective techniques. Further research on the content and scope of assessment curricula in school psychology training programs is obviously needed. We suspect that projective tests are currently given little attention in most training programs, consistent with findings from a summary review of survey results regarding coverage of drawing techniques in graduate-level clinical, counseling, and school psychology programs (Piotrowski, 2016). Note:1Piotrowski (2019) discussed the results of two surveys that were not included in our literature review: Kennedy, Faust, Willis, and Piotrowski (1994) and Whitney (2011). Although it was not possible to review and cite every survey relevant to our study, we generally limited our review to national surveys that were conducted on the comprehensive assessment practices of school psychologists and published in peerreviewed journals. The study by Kennedy et al. focused solely on socio-emotional assessment practices, and the study by Whitney is an unpublished doctoral dissertation. References: American Educational Research Association, American Psychological Association, & National Council on Measurement in Education. (2014). Standards for educational and psychological testing (4th ed.). Washington, DC: Authors. Archer, R. P., Handel, L., Ben-Porath, Y. S., & Tellegen, A. (2016). MMPI-A-RF interpretive manual. Minneapolis, MN: University of Minnesota Press. Benson, N. F., Floyd, R. G., Kranzler, J. H., Eckert, T. L., Fefer, S. A., & Morgan, G. B. (2019). Test use and assessment practices of school psychologists in the United States: Findings from the 2017 National Survey. Journal of School Psychology, 72, 29-48.

doi:10.1016/j.jsp.2018.12.004 Gross, T. J., Farmer, R. L., & Ochs, S. E. (2018). Evidence-based assessment: Best practices, customary practices, and recommendations for field-based assessment. Contemporary School Psychology. https://doi.org/10.1007/s40688-018- 0186-x Holaday, M., Smith, D. A., & Sherry, A. (2000). Sentence completion tests: A review of the literature and results of a survey of members of the Society for Personality Assessment. Journal of Personality Assessment, 74, 371.383. doi:10.1207/s15327752jpa7403_3 Individuals with Disabilities Education Act (2004). Pub. L. No. 108–446. Kennedy, M. L., Faust, D., Willis, W. G., & Piotrowski, C. (1994). Social-emotional assessment practices in school psychology. Journal of Psychoeducational Assessment, 12, 228–240. doi:10.1177/073428299401200302 Kovacs, M. (2010). The Children's Depression Inventory (2nd ed.). Toronto, ON: Multi-Health Systems.

Kratochwill, T. (2007). Preparing psychologists for evidence-based school practice: Lessons learned and challenges ahead. American Psychologist, 62, 829–843. doi:10.1037/0003-066x.62.8.829. Lilienfeld, S. O., Wood, J. M., & Garb, H. N. (2000). The scientific status of projective techniques. Psychological Science in the Public Interest, 1(2), 27–66. doi:10.1111/1529-1006.002. Mari, L., Carbone, P., & Petri, D. (2015). Fundamentals of hard and soft measurement. In A. Ferrero, D. Petri, P. Carbone, & M. Catelani (Eds.), Modern measurements: Fundamentals and applications (pp. 203–262). Hoboken, NJ: Wiley-IEEE Press. Millon, T. (with Millon, C. & Davis, R. D.). (1993). Millon Adolescent Clinical Inventory manual. Minneapolis, MN: National Computer Systems. Nelson-Gray, R. O. (2003). Treatment utility of psychological assessment. Psychological Assessment, 15, 521–531. doi:10.1037/1040-3590.15.4.421 Piotrowski, C. (2016). Drawing techniques in assessment: A summary review of 60 survey-based studies of training and professional settings. Journal of the Indian Academy of Applied Psychology, 42, 220- 236. Piotrowski, C. (2019). Projective techniques are not moribund: Comment on the Benson et al. (2019) assessment practices article. SIS Journal of Projective Psychology and Mental Health, 26, 73–76. Reynolds, C. R., & Richmond, B. O. (2008). Revised Children's Manifest Anxiety Scale (2nd ed.). Los Angeles, CA: Western Psychological Services. Whitcomb, S. A. (2017). Behavioral, social, and emotional assessment of children and adolescents (5th ed.). New York, NY: Routledge. Whitney, S. R. (2011). Assessment practices of school psychologists (Unpublished doctoral dissertation), City University of New York, New York, NY. Youngstrom, E. A., & Van Meter, A. (2016). Empirically supported assessment of children and adolescents. Clinical Psychology: Science & Practice, 23, 327–347. doi:10.1111/cpsp.12172. 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

Book Review The book “Inkblot Personality Test - Understanding the Unconscious Mind” written by Bankey Lal Dubey, Padmakali Banerjee and Anand Dubey is a comprehensive book on Inkblot Tests- Rorschach, Holtzman and Somatic Imagery Test. It is published by SAGE Publications in September 2019, runs into 479 pages. The foreword is written by Prof. Wayne H. Holtzman, Hogg Professor emeritus of Psychology, University of Texas, Austin (USA). The book has 12 Chapters devoted to the historical development of three inkblot technique: the Rorschach Inkblot Test, Holtzman Inkblot test and Somatic Inkblot test. The theory of Rorschach test “Percept Analysis” postulated by Dr. Zygmut Piotrowski along with theories of Somatic Inkblot test- “Somatic Imagery Theory”, “Theory of Body Symbolism”, and “Theory of Inner Cry” have been described very well. Prominent research studies conducted on Rorschach, Holtzman and Somatic Inkblots, during last 70 years in India, in the area of normal population and clinical groups, have been mentioned in detail. The administration, scoring and interpretation of the Rorschach Test (Klopfer, Beck and Exner system), Holtzman Inkblot test and Somatic Inkblots Test is described in length. Quantitative indices-based interpretation along with Qualitative interpretation and psychoanalytic interpretation is described with the help of case studies. Fifteen cases on different diagnosis such as migraine, exhibitionism, somatic grief, dream symbolism, sex abuse, trans sexual, sexual problems and hypnosis, psychosomatic problems, anxiety, depression, body phobia, suicide survivors, dissociative convulsion disorders are interpreted using content analysis and psycho-analytic interpretation. Chapter 11 on the “Application of Inkblots test in business organization” is specially presented to HR personnel engaged in the selection and promotion of executives in business organizations and industries. Certain personality traits such as interpersonal relationship, ego/self, healthy body imagery, erotic imagery, hostility aggression, insecurity and Team building have been found very effective for the success of people in industry, are highlighted with application. The Somatic Imagery test (SIT) has emerged as online cloud based individual as well as group-administered test. The SIT brings to surface the information that individual fails to report in a standard interview process. Indian norms and clinical indicators on various diagnostic groups will help HR personnel and psychologists/clinical psychologists, counselors, psychiatrists, psychotherapists and all those interested in understanding and modifying the human behavior. Advance praise of the book have been made by eminent international professors and clinical psychologists such as Profs Wayne H. Holtzman, Ph.D. (USA), Robert B. Williams, Ph.D. (Canada), Silvia Daini, M.D. (Rome), AiloUhinki, Ph.D. (Finland),Rui C. Campos,Ph.D. (Portugal), George Savage, D. tech. (South Africa), Carina Coulacoglou, Ph.D. (Greece) and Greesh C. Sharma, Ph.D. (USA). I personally feel this book will help all professionals and clinicians using projective technique, particularly the inkblots test for personality assessment and therapeutic intervention. The book “Inkblot Personality Test - Understanding the Unconscious Mind” must be on their desk. Rakesh Jain, Ph.D. Head, Department of Clinical Psychology Institute of Mental Health and Hospital Agra (India) Author: Rorschach Inkblot Test: A Guide to Modified Scoring System

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. Rakesh Kumar, Ph.D. Sandhya R. Mohanty, Ph.D. K.N.Ojha, Ph.D. Manoj Pandey, M.Phil. AmitaPuri, 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,7490 coon club Road, Medina, OH 44256 (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 AJAY PRINTING CENTRE, 3, JANKI DEVI MARKET, CHILLI INT ROAD,AGRA-282003

SOMATIC INKBLOT SOCIETY Journal of Projective Psychology & Mental Health Institution/Library Subscription Form Subscription Year:

Name of Institution/College

Name, Designation and Phone No. of Contact Person

Full Mailing Address with PIN/ZIP at which Journal is to be delivered

Email ID:

Phone No. with Country Code:

Institutional Annual Membership (Foreign) US $100 (subscription fee) US$ 20 (Postage Amount) Institutional Annual Membership (Indian) Rs.1500/- (subscription fee) Rs. 100/- for receipt of journal by Registered Post {Total Amount Rs. 1600/- only} Pay Subscription Fee through Bank Deposit

Name of Account: SIS Journal of Projective Psychology & Mental Health Account Number. 32297525238 IFS Code: SBIN0032182 Type of Bank Account: Saving Bank Bank Name and Address: State Bank of India, Property No.4, Block-A, Sector-23, Dwarka, New Delhi- 110075. Pay Subscription Fee through DD/ Multi-city Cheque payable to SIS Journal of Projective Psychology and Mental Health. Payable at New Delhi Submit Scanned Subscription Application Form through Email Dr. B.L. Dubey, Ph.D. Editor Emeritus, Email:bldubey@gmail.com Copy to Prof. Naveen Gupta, Ph.D., Director. Editor-in-Chief, Email: dr_naveengupta@yahoo.com Or Submit Print Version of Subscription Application Form by Speed Post to Prof. Naveen Gupta, Ph.D. Director, Hindustan Institute of Management and Computer Studies, Farah, Mathura-281122, India Mention Subscription Fee Deposit Details:

Any Other Information: Signature of Authorized Signatory with Date: Note: 1. Please submit subscription before the month of December. 2. Two Issues of the Journal are published in January and July every year. For SIS Official Use: Subscription Receipt Date: Subscription No.

SOMATIC INKBLOT SOCIETY Membership Application Form Membership Type:

Full Name:

Mailing Address with PIN/ZIP:

Email:

Cell with Country Code:

Date of Birth

Education: (Degree, Year, Institution, Major Field of Study)

Employment: Current position, employer, dates (Graduate Students indicate area of study and degree toward which you are working).

Training and Experience in Personality Assessment

Sponsor (Name Address cell and Email)

Mention whether you need Print Version or Only Soft Copy the Journal

Types of Memberships and Fee Details Individual Annual Membership (Foreign) US $50 Individual Life Membership (Foreign) US $300 Fellow Member- After 10 Years Life Membership (Foreign) US $150 Institutional Annual Membership (Foreign) US $100 Individual Annual Membership (Indian) Rs. 1000/- Individual Life Membership (Indian) Rs. 5000/- Fellow Member-After 10 Years Life Membership (Indian) Rs. 2500/ Institutional Annual Membership (Indian) Rs.1600/- (With Regd Postage) Institutional Life Membership (Indian) Rs. 10,000/- Pay Membership Fee through Bank Deposit

Bank Name and Address: State Bank of India, Property No.4, Block-A, Sector-23, Dwarka, New Delhi-110077. Name of Account: SIS Journal of Projective Psychology &Mental Health Account Number. 32297525238 IFS Code: SBIN0032182 Type of Bank Account: Saving Bank Pay Membership Fee through Cheque payable to SIS Journal of Projective Psychology and Mental Health Submit Membership Application Form through Email Dr. B.L. Dubey, Ph.D. Editor Emeritus, Email:bldubey@gmail.com Copy to Prof. Naveen Gupta,Ph.D., Director. Editor in Chief, Email: dr_naveengupta@yahoo.com Or Submit Print Version of Membership Application Form by Speed Post to Prof. Naveen Gupta, Ph.D. Director, Hindustan Institute of Management and Computer Studies, Farah, Mathura-281122, India Mention Fee Deposit Details:

Declaration by Applicant: I certify that the information provided above is accurate and correct. Signature of the Applicant with Date: Affix Your Photograph

SIS JOURNAL OF PROJECTIVE PSYCHOLOGY &MENTALHEALTH: ACHIEVEMENTS Journal in WHO’sListing 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 RevistaBrasileria de Psiquiatria Brazil Eng.,Spani.,Portuguese Arquivos de Neuro-psiquiatria Brazil Portuguese ActaPsiquiatricaypsicologica de AmerciaLaina Argentina Spanish Journal of the Medical Association of Thailand Thailand English, Thai British Journal of Psychiatry UK English ActaPsychiatricaScandinavica Denmark English SaludMentale Mexico Spanish Vertex Argentina Spanish Journal of Personality and Clinical Studies India English Social Psychiatry and Psychiatric Epidemiology Germany English RevistaMedica de Chile Chile Spanish South African Journal of Psychology South Africa Afrikaans, English Psychological Reports USA English South African Medical Journal South Africa Afrikaans, English The Australian & New Zealand Jr. of Psychiatry Australia English International Journal of Social Psychiatry U. K. English Psychiatry Research Ireland English Social Science & Medicine U. K. English Revista De SaudePublica Brazil Portuguese International Journal of Geriatric Psychiatry U. K. English 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 SIS Journal of Projective Psychology & Mental Health Jan 2020

EDITORS EMERITUS: Wilfred A. Cassell, MD, FAPA, E-Mail: siswilfredacassell@yahoo.com

Bankey L. Dubey, Ph.D., Director SIS Center, 7490 coon club Road, Medina, OH 44256 (USA) 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, 7490 coon club Road, Medina, OH 44256 (USA) 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

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

PUBLICATION MANAGER: Brijesh.K.Gupta, MBA Hindustan Inst. of Mgt.& Computer Studies, Farah, Mathura-281122(India) EDITORIAL CONSULTANTS: Abhilasha Singh, Ph.D. AiloUhinki, Ps.D. AmitaPuri, 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. Bhavana Arya, 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. J.V. Weissenberg, M.Sc. Jashobanta Mahapatra,Ph.D. Jayanti Basu, Ph.D. Krishan K. Sony, Ph.D. LSS Sam Manickam, Ph.D. M.P.Singh, Ph.D. Manisha Dasgupta, Ph.D. ManojK. Pandey, M.Phil. Nalini Mishra, Ph.D. Padma Dwivedi, M.A. Padmakali Banerjee, Ph.D. Prasant K. Roy. M.Phil. RadheShyam, 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.