SIS Journal of Projective Psychology & Mental Health

Editorial: Research on Love: Neglected Areas of Scientific Inquiry

Love is one of a handful of emotions that is a common core affective state experienced by humans. It is ubiquitous, universal, yet perplexing. Moreover, love can be directed toward fellow human beings, animals, inanimate objects, ideas, or just about anything. Yet it seems at times elusive, ephemeral, yet residing within us and outside us. This intense, at times overwhelming emotion is accorded special status, and can be challenging to define or, at times, comprehend (but we know it when we see it or feel it). From an academic point of view, not surprisingly, Love is a popular topic of scholarly interest (e.g., Cruces et al. 2015; Fehr et al., 2014; Fink, 2015; Knox, 2007; Song et al., 2015; Sussman, 2010; Sternberg & Barnes, 1988;Tatkin, 2012; Zsok et al., 2017). Undoubtedly, love remains a central feature of interpersonal and marital relationships (Anderson, 2014; Paludi, 2012; Sternberg & Barnes, 1988). A search of the literature confirms the fact that the topic of love has attracted extensive scholarly attention for over a century. A keyword search of the database PsycInfo indicates that the subject matter of love has served as a central focus of investigatory interest by researchers, represented by a voluminous body of literature (6,191 peer-reviewed articles, 975 books/chapters, 878 dissertations). Yet few studies have focused on the intellectual structure and investigatory expanse of this extensive repository of scholarship. Moreover, given that this body of literature spans across a myriad of disciplines, it would be instructive to determine topical areas that attract little research interest regarding the subject of love. Such findings would elucidate our understanding of investigatory areas involving the issue of love. Hence, the aim of the current exercise is to perform a bibliometric content analysis of studies on love reported in the recent mental health literature and determine topical domains that are largely neglected by researchers as the main focus of study. Bibliometric analysis is a recognized and valid means in gaining a lucid canvas regarding research trends on a select body of scholarship (Krippendorff, 2004; Piotrowski, 2021, 2012; Piotrowski & Watt, 2022).For the current analysis of recent literature (2012-2021), the repository source of scholarship was the database PsycInfo. An online search in PsycInfo was conducted on November 1, 2021, which specified the term ‘Love’ as part of the Title of articles. The search identified 1,781 peer-reviewed articles. Of these, 219 were excluded (i.e., editorials, erratum/corrections, book reviews). Thus, the final dataset for the analysis was 1,562 articles. This procedure confirmed that the search strategy produced primary research with a central focus on the topic of love. Based on extensive experience conducting bibliometric analyses on various research topics and individual journals, I reviewed each study and determined the major topical focus of the article. The specific aim was to determine the main topic/issue under study. Each article reference was coded with only 1 topical designation. A running-tab was maintained until all 1,562 articles were categorized which culminated in a rank-ordering of researched topics based on frequency. The parameters for ‘neglected’ domains were those topics with less than 1% of the dataset of 1,562 studies (i.e., 10 or less articles). Table 1. Areas with Sparse Research Attention in Studies on the Topic of Love Trust Jealousy Loneliness Love addiction Love-at-first-sight Divorce Dreams Emotion regulation Well-being Control issues Anxiety Love-triangle/Open marriage Depression Love between siblings Suicide/suicide ideation Love of pets/dogs Forgiveness Relationship ‘break-ups’ Adopted children/fostering Financial issues Teaching about love

Exploitation Military samples Workplace romance Erotica/sexting Rape Substance abuse Mindfulness ‘Tough Love’ Work-Family balance Creativity/Poetry Grief Cognitive style Love from a distance Love of nature Love of science/Books Love of country Love of food Love of sports Based on this content analysis of primary research, Table 1 lists copious topical areas which have received rather limited investigatory attention over the past 10 years. The lack of research focus on several of these subject areas is quite surprising, given the high visibility of some of these topics in the popular media and in the general psychological literature. For example, loneliness, divorce, emotion regulation, suicide, conflict in relationships, workplace romance, and jealousy. One possibility is the lack of consensus on the definition of the construct of love (Gawda, 2019; Hatfield et al., 2012; Skold & Roald, 2020; Watts & Stenner, 2014); hence, some researchers may consider love an opaque variable to study, and thus, shy-away from venturing on investigating this rather illusive topic in the context of other psychological issues. Yet, other researchers rely on a variety of measures on the topic of love readily available in the published literature. Table 2 lists prominent tests and measures that reflect or encompass the construct of love. Several of these scales couch the issue of love in the context of romantic relationships (Natoli et al., 2021; Piotrowski, 1999). Perhaps, as these measures on the construct of love present satisfactory scientific evidence of psychometric credibility (see Aghedu et al., 2019; Bishop et al., 2016; Costa et al., 2021; Kapusta et al., 2018; Trent et al., 2020), investigators will incorporate the study of love in their research designs. Table 2. Prominent Measures in Research Studies on Love Passionate Love Scale Love Addiction Inventory Triangular Love Scale Love Attitudes Scale Universal Love Scale Capacity to Love Inventory (CTL-Inventory) Multidimensional Evaluation of Love Scale Individual and Relational Role Balance Scale Satisfaction with Life Scale Relationship Assessment Scale Dyadic Adjustment Scale

References: Aghedu, F.C., et al. (2019). The Multidimensional Evaluation of Love (MEVOL) Scale: Development and preliminary validation. TPM- Testing, Psychometrics, Methodology in Applied Psychology, 26(2), 249-269. Anderson, S.B. (2014). Identity, continuity, and love. Issues in Psychoanalytic Psychology, 36, 11. Bishop, J.L., et al. (2016). The Individual and Relational Role Balance Scale (IRRBS). College Student Journal, 50(4), 531-550. Costa, S., et al. (2021). The Love Addiction Inventory: Preliminary findings of the development process and psychometric characteristics. International Journal of Mental Health and Addiction, 19, 651-668. Cruces, J., et al. (2015). Interpreting variability of the experience of falling in love. International Journal of Psychology and Psychotherapy, 15(1), 87-100. Fehr, B., et al. (2014). Compassionate love in romantic relationships. Journal of Social and Personal Relationships, 31(5), 575-600. Fink, B. (2015). Love and or in psychoanalysis. Psychoanalytic Review, 102(1), 59-91.

Gawda, B. (2019). The structure of the concepts related to love spectrum. Journal of Psycholinguistic Research, 48, 1339-1361. Hatfield, E., et al. (2012). A brief history of social scientists’ attempts to measure passionate love. Journal of Social and Personal Relationships, 29(2), 143-164. Kapusta, N.D., et al. (2018). Measuring the capacity to love: Development of the CTL-Inventory. Frontiers in Psychology, 9, Article 1115. Knox, D. et al. (2007). College men and jealousy. College Student Journal, 41(2), 494-498. Krippendorff, K. (2004). Content analysis: An introduction to its methodology (2nd ed.). Thousand Oaks, CA: Sage. Natoli, A.P., et al. (2021). A multimethod investigation of sex, romantic relationships, and interpersonal dependency. Archives of Sexual Behavior, 50, 2621-2629. Paludi, M.A. (Ed.). (2012). The psychology of love. Santa Barbara, CA: Praeger. Piotrowski, C. (2021). Personality psychology research: A bibliometric analysis of investigatory domain. Journal of Projective Psychology & Mental Health, 28(1), 47-52. Piotrowski, C. (2012). Occupational health psychology: Neglected areas of research. Journal of Instructional Psychology, 39(3), 131-135. Piotrowski, C. (1999). Use of tests and measures in marital and family research. Psychological Reports, 84, 1251-1252. Piotrowski, C., & Watt, J.D. (2022). Contemporary boredom research: A bibliometric analysis of investigatory domains. North American Journal of Psychology, 24(1), 127-134. Skold, A.B., & Roald, T. (2020). An existential structure of love. The Humanistic Psychologist, in press. Song, H., et al. (2015). Love-related changes in the brain: A resting-state functional magnetic resonance imaging study. Frontiers in Human Neuroscience, 9, Article 71. Sternberg, R.L.,& Barnes, M.L. (Eds.), The psychology of love. New Haven, CT: Yale University Press. Sussman, S. (2010). Love addiction: Definition, etiology, treatment. Sexual Addiction & Compulsivity, 17(1), 31-45. Tatkin, S. (2012). Wired for love. Oakland, CA: New Harbinger. Trent, N.L., et al. (2020). Preliminary development and validation of a scale to measure universal love. Spirituality in Clinical Practice, 7(1), 51-64. Watts, S., & Stenner, P. (2014). Definitions of love in a sample of British women: An empirical study using Q methodology. British Journal of Social Psychology, 53, 557-572. Zsok, F., et al. (2017). What kind of love is love at first sight? An empirical investigation. Personal Relationships, 24, 869-885.

Chris Piotrowski, PhD Senior Editor University of West Florida Email: piotrowskichris@hotmail.com

The use of psychological instruments prior to them being fully validated is never justified. The consequences can be serious in terms of psychometric credibility. The push to utilize a new Rorschach scoring system, the Rorschach Performance Assessment System (R-PAS; Meyer, Viglione, Mihura, Erard, and Erdberg, 2011), is worth examining from this perspective. Is its use scientifically justified, or, even necessary? We informally polled several colleagues regarding frequently asked questions when comparing the CS/CS-R and the R-PAS (Gacono and Smith, 2021a). This article explores practitioners’ responses to 10 of those questions.

Introduction: The use of psychological instruments prior to them being fully validated is never justified. The consequences for both practice and research can be serious. For example, the Psychopathic Personality Inventory-Revised (PPI-R; Lilienfeld & Widows, 2005) is a self-report measure normed primarily on college populations. It has only low to moderate correlations with the PCL-R (only Factor 2). Yet, after its introduction it was used almost immediately in studies as an independent measure for forming ―psychopathy‖ groups, when it should have continued as a dependent measure related to assessing its validity. This impacted research results, created confusion in the psychopathy literature, and eventually, the PPI-R found its way into applied usage with some forensic cases where it was misused for ―diagnosing‖ and/or making inferences about psychopathy (a problematic leap; Gacono, 2016). Scrutiny is needed before clinicians apply what they read in journals or what is offered by test developers. Bias does exist in journal editors and reviewers. They tend to be employed in academia and/or influenced by academic research where their conceptual knowledge may stem from a few recent studies (rather than a historically established line of theory). Many studies are also informed by a perspective that lacks Step 1 of the scientific method (direct observation or relevant exposure [active applied work] to the population studied; Cunliffe, Gacono, and Smith, 2021). This glaring omission can create a partial understanding of conceptual issues. Note a statement from the website of the late PPI-R developer: ―Please note that (despite my interests in psychopathic personality) I do not accept graduate students whose principal interests lie in criminal justice, criminology, or psychology-law given that the focus on our lab is on basic personality/psychopathology research rather than on applied criminal justice or forensic work. Nevertheless, students with secondary interests in these applied areas are certainly more than welcome to apply. (psychology.emory.edu/home/ people/faculty/Lilienfeld-scott.html., retrieved August 6, 2020; our emphasis added).‖ Once in print, findings from poorly designed studies are interpreted as valid and inform future studies. Consequently, theoretical offerings from these sources can represent a seemingly plausible house of cards that rests on a foundation of bias and flawed methodology. This partial conceptual understanding also translates to how instruments are discussed and used. Counterintuitive findings from these conceptually limited studies create apparent controversies where none exist (Gacono, 2019, 2021) and have contributed to what Bob Hare has termed an ―armchair‖ quality to the literature. Unchallenged, the obvious is often ignored. How can one offer opinions about psychopathy without having spent enough time working with actual psychopaths? How can one offer opinions about the Rorschach without having utilized the instrument enough times in an applied context?

A push to utilize the new Rorschach scoring system, the Rorschach Performance Assessment System (R-PAS; Meyer, Viglione, Mihura, Erard, and Erdberg, 2011), is worth examining from this same perspective. Is its use scientifically justified, or, even necessary? We informally polled several colleagues and received questions from LinkedIn members regarding comparative issues with the CS/CS-R and R-PAS (Gacono and Smith, 2021a). A few key references were also provided to serve as guides for more in-depth analysis. Many of these articles can be found on our Research Gate or LinkedIn pages. 1) Has the Comprehensive System ―been frozen in time‖ and by inference in need of replacement? Answer: NO. It is alive, well, and evolving. Andrea Priddy (Director of Rorschach Workshops and John Exner’s daughter) in partnership with the International Rorschach Institute (IRI) will be providing the Comprehensive System-Revised in 2022 (CS-R; Fontan & Andronikof, 2022). This has been discussed in recent videos1 by the IRI (2022). An erratum is also offered here—Gacono has never thought that the CS was frozen in time (Kivisto, Gacono, & Medoff, 2013). 2) Is altering the CS administration procedures, in any significant way, desirable or warranted? Answer: NO. A large body of social science research establishes the impact of such things as instructions, response style and so forth on test performance (Gacono & Smith, 2021b). This is a critical issue related to both test construction and admissibility. The Mihura, Meyer, Dumitrascu, and Bombel (2013) meta-analyses excluded studies that deviated from standard CS procedures. Yet, this issue is ignored when attempting to justify the validity of the R-PAS based on CS studies. What did Rorschach say about administration procedures? He stated, ―An attempt is made to get at least one answer to every plate, thought suggestion in any form is, of course, avoided.‖ (1921/1942; p. 16). Compare this to the R-PAS instructions, ―Try to give two responses ... or maybe three, to each card. That is, for each card try to see two different things; possibly three‖ (Meyer et al., 2011, p. 8) The CS-R procedures are consistent with Rorschach’s intentions/cautions, the R-PAS procedures are not. R-PAS instructions are not based on any sound conceptual premise but rather on a statistical based choice to control R (Gacono & Smith, 2021b, 2022). Pure and simple, the alteration in administration procedures has created a ―new‖ test which differs from Rorschach’s intent (the CS/CS-R instructions follow Rorschach’s intent; Tibon-Czopp & Weiner, 2016). The R-PAS requires validation with protocols administered with these new instructions (Gacono & Smith, 2021a). Statistically manipulated CS administered protocols used to develop comparative data for a new system are not sufficient. This is not to say that some inferences from the CS are not appropriate. 3) Is it desirable to control Responses (R) beyond what CS or CS-R guidelines already do? Answer: NO. Variations in R are useful clinically and in research (Gacono & Gacono, 2008; Young, Erdberg, & Justice, 2008). R can elevate or constrict related to the personality of the individual. In certain populations (some sex offender groups [Gacono, Meloy, & Bridges, 2000, 2008]) internal press can result in elevated R. Decreased R can result from characterological constriction. Even a 13 response protocol may be interpretively useful (Gacono, 1997; Gacono & Gacono, 2008; Gacono & Meloy, 1994, p. 5;). While a one-to-one interpretation of the constellation cut-off score may be questionable, the data may otherwise be accurate and adequate for describing the individual and contributing to the personality formulation (Gacono & Smith, 2021b, 2022). Envision a rich 13 response protocol, with 8 DRs, a Lambda less than .50, 4 reflections, an elevated WSum6, etc., when compared to a 20 response protocol with a Lambda over 2.00. In either case, the frequency of R should be interpreted not controlled (Tibon-Czopp & Weiner, 2016).

1https://www.youtube.com/watch?v=-eFF-kf0Ejg& https://www.youtube.com/watch?v=x2gTntCIQ7I

Most importantly is a study by one of the R-PAS originators (Young, Erdberg, & Justice, 2008) that compared Lambda, X-% and WSum6 between psychiatric inmates with < 14 and > 13 protocols. These variables were not significantly different (these were the only variables statistically compared). A comparison of the group data also suggests that many other essential variables would not be significantly different (i.e., M means, 2.61, 2.79; EA means, 4.86, 4.57). While the rate for low R protocols (even after re-administration) was fairly high (38 out of 240) here is what Young et al. (2008, p. 419) stated, ―… at least for this group of psychiatrically hospitalized inmates, Rorschach records with R < 14 can be useful for clinical interpretation, a finding also suggested by Gacono and Gacono … It is also noteworthy that inmates with low response Rorschach records were significantly more likely to demonstrate low intellectual functioning (p = .001) and impaired executive functioning (p =.01).‖ The reduced R, as in so many cases, in this study is an accurate reflection of the patient’s personality functioning (Gacono & Gacono, 2008). Meyer (1992) has written about controlling R for over 30 years. His arguments are based on a statistical approach to the Rorschach without a conceptual acknowledgement or research established validation of the actual pros and cons when the test is used in actual assessment (clinically relevant). This line of reasoning does not include careful consideration for what is interpretively lost in sequence analysis and interpreting the variation in R. 4) Is controlling R beyond the CS-R instructions necessary? Answer: NO. When experienced clinicians establish rapport and administer the test as part of a battery the rate of low R protocols (R < 14) or having to re-administer the test is less than 4% (Gacono & Meloy, 1994, p. 5). Gacono recalls only 2 protocols that required re-administration during three decades of adult Rorschach administration. Dr. Barton Evan’s shared, ―In 20 years of forensic child custody evaluations, I cannot remember the need to re-administer the CS because of R< 13‖ (Personal Communication, March 4, 2022). In a study of re-administration in 3 samples (clinical, forensic, & students) looking for R< 14 on the first administration, the rate of < 14 was found to be less than 5% (Exner, Fontan, & Andronikof, 2022). High percentages of R< 14 protocols can occur in certain samples administered by skilled clinicians, but when these do, the low R coincides with the personality functioning of the subjects (Gacono & Gacono, 2008; Young et al., 2008). Quoting a 10% rate creates a straw person fallacy where one does not exist (Cunliffe et al., 2021; Gacono & Smith, 2021a, 2021b, 2022). A 10% “rejection rate” is not factual. 5) Do the validity findings from the CS/CS-R translate directly to the R-PAS? Answer: Unknown, likely some do, some do not. Further study is warranted. What we do know is that the CS/CS-R has been utilized in many clinical and nonclinical populations and found to accurately represent the patients or nonpatients evaluated. This cannot be confirmed for the R-PAS (Gacono & Smith, 2021a). 6) Does the main Mihura et al. (2013) meta-analyses used to support the R-PAS justify its conclusions? Answer: NO. See Smith et al. (2018) and Smith, Gacono, Fontan, Cunliffe, and Andronikof (2020) for an in-depth analysis of the problems with these meta-analyses. Of additional concern is that when Smith et al. requested that the data from the study be offered for several Rorschach examiners to review and subject our own analysis, we were told thatdatawere no longer available in ―their original format.‖One must consider that this reference to unavailable data is one of the primary sources used to support R-PAS validity. 7) Are all the variables eliminated based on the meta-analyses’ desirable? Answer: NO. Consider that the CS-R determinants, variables, etc. have a robust conceptual basis. Some of these may be produced infrequently in non-clinical populations; however, this does not negate their usefulness in certain

clinical groups. For example, the Hx content was eliminated from the R-PAS based on their analysis of non-patient protocols (statistically manipulated CS protocols). Yet we found this to be a signature coding with female psychopaths in supporting the presence of their malignant hysterical style (Smith, Gacono, & Cunliffe, 2021). Using a statistical chopping block with non-clinical protocols (as opposed to a wide range of clinical and non-clinical protocols) for eliminating Rorschach variables is neither valid science nor does it create a better Rorschach system. 8) Are there adequate normative, clinical, or forensic R-PAS administered samples to justify its usage? Answer: NO. The R-PAS has been available for 11 years and still does not have R-PAS normative data. It relies on statistical manipulated CS data for its normative sample. R-PAS newsletters for years have asked for help in collecting normative data in the USA and other countries, but no data have been presented as of Spring 2022. The R-PAS manual reports a mixed adolescent and adult forensic sample of 45 persons. The only substantial R-PAS forensic norms with actual R-PAS administration were presented in Erard, Singer, and Viglione (2017) with 376 child custody litigants from several US states. Compare this to the over 4000 nonpatient, clinical, and forensic protocols available with the CS/CS-R. 9) Were the developers of the R-PAS and/or the Rorschach Council anointed or endorsed by John Exner? Answer: NO. In fact, quite the contrary. John Exner’s daughter and CEO of Rorschach Workshops, Andrea Priddy, stated: In 2006 [John Exner] had planned on discontinuing his Rorschach Research Council … he felt it was less productive than he wanted …he was frustrated with the Council and he said more often than not were interested in their own projects rather than furthering the Comprehensive System and the tasks at hand that he had presented to them … upon his death he didn’t make any arrangements to continue the Council … he did not feel that would be a productive move‖ (IRI, 2022). 10) Is the R-PAS admissible in court? Answer: NO. Review the above as well as McCann and Evans (2008). The R-PAS lacks sufficient comparative data, the meta-analyses are not adequate for its conclusions nor are the data from it still available in its ―original format.‖ The R-PAS lacks the longitudinal test-retest reliability that has been determined with the CS for certain variables and determinants (EB, Y, etc.). These speak to its ―validity.‖ Additionally, as noted by McCann and Evans (2008)2: The presence of a standard method in administering, scoring, and interpreting data for a psychometric instrument is one of the main criteria that has been set forth in the professional guidelines for forensic use of psychological tests …The most widely used system is Exner’s Comprehensive System … Moreover, there are clinical norms available for a variety of diagnostic groups as well as nonpatient adults, adolescents, and children (p. 63). The need for administration procedures to be linked directly to comparative data and validity studies are the key issues. Additionally, the R-PAS is not widely ―accepted‖ by Rorschach users. In fact, as contrasted with the CS Rorschach that was challenged primarily by a group of individuals who did not use the test, did not conduct original research with the instrument, and were not assessment experts, critics of the R-PAS have been uniformly Rorschach experts (Gacono & Smith, 2021a; CSIRA) whose criticisms of the system remain unaddressed.

2 See McCann and Evans (2008) Admissibility of the Rorschach for a detailed analysis of these issues. Also see The Handbook of Forensic Rorschach Assessment Section I (Scientific and Legal Foundations) as a guide to understanding these issues (Gacono & Evans, 2008).

One final issue involves the question of the extent to which each system over or under assesses psychopathology (Tibon-Czopp & Weiner, 2016). While an in-depth discussion of this issue is beyond the scope of this commentary, the following provides a context. 1) It is proven that the CS Rorschach, when interpreted properly, accurately describes an individual’s personality functioning. Additionally, in many cases the CS-R now offers an examiner the option to compare the examinee’s data with their corresponding national norms (e.g., an Algerian citizen can be compared to Algerian norms). This cannot be said for the R-PAS. 2) Reasonable discussion about this issue cannot be couched within a ―sign‖ approach to Rorschach interpretation. For example, believing Fr equals psychopathy or an X-% score equals schizophrenia is, at best, naïve. It is akin to suggesting that one would diagnose schizophrenia based solely on a MMPI elevated Scale 8. Attempting to reduce the Rorschach yield in this manner (sign approach), as opposed to interpreting the test by comparing patterns of variables within an individual protocol have been vigorously challenged since the test’s inceptions (Gacono & Meloy, 1994; Gacono & Smith, 2021b, 2022; Lindner, 1946). Once adequate R-PAS comparative data are obtained (with R-PAS administered procedures) a more fruitful line of research is to determine what is lost and what is gained with the newer system. In this commentary we have provided one specific example (Hx) of what is lost when variables are cut on a statistical chopping block using non-clinical protocols, and mentioned other areas, such as sequence analysis and R as a dependent measure (where variations need interpretation, not control), for which the impact has yet to be fully assessed. Examiners know what they have with the CS and the CS-R (see Piotrowski, 1996). The CS and CS-R are proven, useful, and admissible in court, not in need of replacement. Until the R-PAS has adequate comparative data generated with its administration procedures and additional validity research with R-PAS administered protocols the same cannot be said for this version of the Rorschach. Despite the claims of several of the R-PAS proponents, the R- PAS does not meet the criteria for admissibility in court and can be easily challenged. The Rorschach has survived the Wood et al. era where true criticisms have been addressed and false ones debunked (Gacono & Evans, 2008; Khadivi & Evans, 2012; Piotrowski, 2015), to find itself facing the challenges outlined in this commentary. Likely it will survive this new challenge. Ultimately solid research will determine the answer to questions that arise. However, truly the buyer must beware and in no other times than the present have Exner’s ominous words----―a huge number of published investigations … are clearly marked by errors in design, implementation, and/or analysis‖ (1995, p. 3)—been more relevant. The issues with the R- PAS have not been addressed to date and is not fully validated. As always, we encourage Rorschachers to read the original sources, review the facts, and analyze the data. In this regard, consultation is offered through maverickpsychology.com to aid in sorting out and examining these issues. Acknowledgements: Thanks to Drs. Ted Cunliffe, Barton Evans, Chris Mulchay and several anonymous members of our LinkedIn sites for their helpful comments. Disclosure statement: While Jason Smith is part of a company (IRI) that sells CS-R manuals, CHESSSS-2®, and associated products, most importantly, Carl Gacono is not.

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Erard, R. E., Singer, J. S., & Viglione, D. J. (2017). The Rorschach in multimethod custody evaluations. In R. E. Erard & F. B. Evans (Eds.), The Rorschach in multimethod forensic assessment: Conceptual foundations and practical applications (pp. 210–241). Routledge/Taylor & Francis Group. Exner, J. E. (1995). Introduction. In J. E. Exner (Ed.), Issues and methods in Rorschach research (pp. 1–24). Mahwah, NJ: Erlbaum. Exner, J.E., Fontan, P., & Andronikof, A. (2022). Rorschach: The Comprehensive System-Revised, Interpretation & Technical Manual. Fort Mill, SC: Rorschach Workshops. Fontan, P., & Andronikof, A. (2022, July). Introduction to the Rorschach Comprehensive System Revised (CS-R) and CHESSSS 2®. Workshop given at the XXIII Congress of the International Society of the Rorschach and Projective Methods, Genova, Switzerland. Gacono, C. B. (1997). Borderline personality organization, psychopathology, and sexual homicide: The case of Brinkley. Contemporary Rorschach interpretation, 217-238. Gacono, C. B. (Ed.). (2016). The clinical and forensicassessment of psychopathy: A practitioner’s guide (2nd ed.). New York, NY, US: Routledge/Taylor & Francis Group. Gacono, C. B. (2019). The importance of Lambda to the generalizability of Rorschach findings reported in the literature. SIS Journal of Projective Psychology and Mental Health, 26(2), 104-106. Gacono, C. B. (2021). Introduction. In J. M. Smith, C. B. Gacono, and T. B. Cunliffe (Authors). Understanding Female Offenders: Psychopathy, Criminal Behavior, Assessment, and Treatment (pp. 1–32). Academic Press. Gacono, C. B., & Evans, F. B. (Eds.). (2008). The LEA series in personality and clinical psychology. The handbook of forensic Rorschach assessment (N. Kaser-Boyd & L. A. Gacono, Collaborators). New York, NY: Routledge/Taylor & Francis Group. Gacono, C.B., & Meloy, J.R. (1994). The Rorschach assessment of aggressive and psychopathic personalities. Hillsdale, NJ: Erlbaum. Gacono, C. B., Meloy, J. R., & Bridges, M. R. (2000). A Rorschach comparison of psychopaths, sexual homicide perpetrators, and nonviolent pedophiles: Where angels fear to tread. Journal of Clinical Psychology, 56(6), 757–777. Gacono, C. B., Meloy, J. R., & Bridges, M. R. (2008). A Rorschach understanding of psychopaths, sexual homicide perpetrators, and nonviolent pedophiles. In C. Gacono, B. Evans, N. Kaser-Boyd, & L. Gacono (Eds.), The Handbook of Forensic Rorschach Assessment (pp. 379–402). Mahwah, NJ: Lawrence Erlbaum. Gacono, C.B., & Smith, J.M. (2021a). Essential issues to consider prior to using the R-PAS in a forensic context. SIS Journal of Projective Psychology & Mental Health, 28(1), 4-13. Gacono, C.B., & Smith, J.M. (2021b). Some comments on the importance of comparative group data for interpreting Rorschach findings. SIS Journal of Projective Psychology & Mental Health, 28(2), 67-73. Gacono, C.B., & Smith, J.M. (2022). Some comments on the idiographic interpretation of Rorschach findings. SIS Journal of Projective Psychology & Mental Health, 29(1), 4-14. Gacono, L.A., & Gacono, C.B. (2008). Some considerations for the Rorschach assessment of forensic psychiatric outpatients. In C.B. Gacono, F.B. Evans, N. Kaser-Boyd, & L.A. Gacono (Eds.), The handbook of forensic Rorschach assessment (pp. 421-444). New York: Lawrence Erlbaum Associates. International Rorschach Institute (IRI). (2022). International Rorschach Institute YouTube channel. https://www.youtube.com / channel/UCNkM1J9lo9bohJn7NVNFSxA Khadivi, A., & Evans, F. B. (2012). The brave new world of forensic Rorschach assessment: Comments on the Rorschach special section. Psychological Injury and Law, 5(2), 145-149. Kivisto, A. J., Gacono, C., & Medoff, D. (2013). Does the R-PAS meet standards for forensic use? Considerations with introducing a new Rorschach coding system. Journal of Forensic Psychology Practice, 13(5), 389–410. Lindner, R.M. (1946). Content analysis in Rorschach work.Rorschach Research Exchange, 10, 121-129. Lilienfeld, S. O., & Widows, M. R. (2005). Psychopathic personality inventory-revised: Professional manual. Lutz, Florida: Psychological Assessment Resources, Inc. McCann, J. T., & Evans, F. B. (2008). Admissibility of the Rorschach. In C. B. Gacono, F. B. Evans (Eds.) & N. Kaser-Boyd, L. A. Gacono (Collaborators), The handbook of forensic Rorschach assessment (pp. 55–78). Routledge/Taylor & Francis Group. Meyer, G. J. (1992). Response frequency problems in the Rorschach: Clinical and research implications with suggestions for the future. Journal of Personality Assessment, 58(2), 231–244.

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Historically, the effects of color have generated extensive scholarly interest in the field of psychology and allied disciplines (Elliot et al., 2015). Yet, the majority of this body of research has appeared in journals outside of the sub-specialty of psychological assessment. As 5 of the 10 Rorschach cards have chromatic characteristics, the significance of individuals’ reactions to color on these inkblots seems critical to the assessment process. In the initial phase of Rorschach administration, the sole color on cards II and III is red. The aim of the current study is to highlight the critical importance and impact of the color Red on human perception and cognitive processes, with direct implications for the Rorschach method. A review of the empirical research on this issue confirms that the color Red has the potential to influence visual selection, perceptual processes, avoidance motivation, and psychological inhibitions. Moreover, the color Red has been found to elicit strong emotional reactivity and disruptive effects on cognitive processes. Overall, the preponderance of experimental findings supports the position that of all the different hues, the color Red seems to have a) high arousal properties and b) a detrimental influence on cognitive-perceptual performance. Moreover, research suggests that cognitive processing style in response to the color Red can occur unconsciously. Of interest to the assessment process, several studies on the impact of the color Red specific to Rorschach chromatic plates corroborate this general conclusion. Further research on the significance of the color Red in Rorschach assessment is sorely needed. An extensive bibliography that serves as a basis for this review is provided.

Introduction: Color plays a significant part in the human experience, and whether consciously or unconsciously, is rather ubiquitous. Hence, color has a fundamental role in human perception and cognition regarding the world around us (Elliot et al., 2015). While colors engender attributes such as chroma and hue, these features also possess connotative meaning both intra-individually and socially (Briki & Hue, 2016; Elliot, 2015). Indeed, the field of psychology has embraced the scientific study on the role and impact of color for over a century (e.g., Wells, 1910). The importance of color serves a central role in the works of Carl Jung. Current scholarly interest in the study of colors is evidenced by the publication of a chapter on color psychology in the rather prestigious publication Annual Review of Psychology (see Elliot & Maier, 2014). A recent review (de Villemor - Amaral & Yazigi, 2022) verifies the significance of color in psychological assessment, particularly with regard to projective techniques. Since color is a central aspect of the assessment process on the Rorschach test, it seems worthwhile to study the role of different color hues in this process (Piotrowski, 2017, 2018). The present focus will be specifically on the color Red. Thus, the current study presents a conceptual framework that addresses the significance of the color Red in the assessment enterprise, with particular application regarding the Rorschach. The Rorschach and Color: Prior studies assert that while colors can convey psychological ‘meaning’, individuals rarely have insight into the influence of color on their affective, cognitive, and perceptual functioning (Fetterman et al., 2014; Gil & Le Bigot, 2017). Thus, it is imperative that researchers/clinicians need to account for the ‘functional’ aspect of color, particularly with regard to perception and cognitive processes (see Elliot & Aarts, 2011). Of all the hues, the color Red has received extensive research attention in the general scientific literature (e.g., Berthold et al., 2017; Dolezalova et al., 2021; Lehmann et al., 2018; Gruber, 2018; Hong et al., 2020; Steele & Rash, 2021; Wu et al., 2018). Moreover, Elliot and Maier (2014) argue that based on experimental research the influence of

color Red on mental functioning varies by ‘psychological context’ and has been shown to have a keen impact on psychological responding via emotion-based associations. These findings support extensive research regarding the significant effect that the color Red has on human emotions (Bertrams et al., 2020; Fetterman et al., 2011; Kuhbandner & Pekrun, 2013; Kuniecki et al., 2015; Mentzel et al., 2017; Ou et al., 2004; Sutton & Altarriba, 2016; Young et al., 2013), including studies on children (Gil & Le Bigot, 2017). Historically, it is not surprising that color has attracted much attention from assessment researchers as 5 of the 10 Rorschach cards have chromatic characteristics (Lazarus, 1949; Pasto & Kivisto, 1956; Potter & Sarason, 1947; Ryan et al., 1971; Siipola, 1950; Siipola et al., 1950). Interestingly, there is but sparse research on Rorschach cards II and III, where the color Red is a prominent feature (see Jimenez Gomez et al., 1994). Pertaining to the Rorschach, Guidetti et al. (1986) found ‘shock’ specific to the color Red. Hence, the open question is: What is the significance of the color Red on these Rorschach plates with regard to the attentional / perceptual processes and psychological reactance to these two cards? An examination of experimental and clinical findings on the psychological impact of the color Red may provide some insights towards a clinical framework in addressing this issue. In the assessment process, the Rorschach is considered a perceptual-cognitive task. Several key studies call our attention to the role of the color Red regarding a perception-cognitive link. Shih and Sperling (1996) found that the color Red has an impact on selective attention during visual search. Meier et al. (2012) conclude that exposure to the color Red has motivational, as well as symbolic implications for human perception. Seminal studies (i.e., Aaronson, 1964; Jacobs & Hustmyer, 1974; Wilson, 1966) identified the high arousal potential for the color Red, whereas Wallen (1948) found an aversive association between the color Red on the Rorschach to blood. Later, Crane and Hicks (1989), in testing arousal theory, reported that the color Red elicits high arousal potential. Maurizi (1988) asserts that the color Red prompts heightened visual impact. These findings have been corroborated by subsequent research (see Briki & Hue, 2016; Mehla et al., 2017). Due to the negative connotation attributed to the color Red (Elliot & Meier, 2014; Piotrowski, 2012), researchers have shown that the color Red can activate ‘avoidance’ motivation (Tanaka & Tokuno, 2011; Thorstenson, 2015). Perhaps this is due to ratings for the color Red as an unpleasant experience (see Jacobs & Suess, 1975; Lewinski, 1938). In this regard, Drechsler (1960) reported that colors (including red) can have a disruptive effect on ongoing thought processes, whereas Martin (2017) found that the color Red inhibits cognitive performance. Perhaps, these latter findings can be explained by visual sensitivity to the color Red which has been confirmed by prior research studies (Conners & Kinney, 1962; Hansen et al., 2009; Tseng et al., 2010). In this context, investigators have also noted that color hues have a differential neurodynamic effect, with the color Red harboring a high level of physiological complexity (see Roy et al., 2021; Smets, 1969). Of particular interest to Rorschach assessment, Payen et al. (2011) and Nakshian (1964) found that the color Red elicits inhibition, and several researchers have suggested that cognitive processing style to the color Red can occur unconsciously (Li et al., 2021; Lichtenfeld et al., 2009). Overall, this body of research findings suggests that the color Red can have a detrimental role regarding the cognitive-perceptual performance on the Rorschach. However, contrary findings have been reported. For example, Caldwell and Jones (1985) question the assumption that ‘warm’ colors (such as red) are more arousing. Bertrams et al. (2015) found that individual difference factors (e.g., ego strength) can moderate the detrimental effect of color Red on cognitive performance, whereas Smajic et al. (2014) found no relationship between the ‘Red’ effect and anxiety with regard to performance. In a cautionary note, Whitfild and Whiltshire (1990) claim that laboratory research on

color preference is not translational to real world context. Table 1 highlights several recent studies that may have implications for Rorschach assessment in the context of the current discussion. Table 1. Research Studies on the Color Red and Personality Factors Study Major Finding

Mehta et al. (2017) In a study on personality factors (i.e., sensationseeking), authors found that the color Red has the capability to induce arousal. Fetterman et al. (2014) For a sample of undergraduates, the authors studied the link between the color Red and hostility; Findings showed that hostile individuals are prone to see (perceive?) the color Red more frequently than nonhostile people. Xia et al. (2018) Investigating Color-in-Context theory, the authors found that the color Red intensifies the initial attention to emotion-congruent conditions, particularly anger. Singg & Whiddon (2000) In this study on personality, using the Luscher Color Test, the authors found that internal locus of control was associated with the color Red . Wolf & Schutz (2019) In this study on the impact of color Red on performance, the authors found limited support for the effect of font color on personality trait self-ratings. Colt et al. (2003) Based on NEO (5 factor) data, findings indicated that color preference was moderated based on individuals’ views toward specific color-pairings. Silva & Ferreira (2017) Color and form quality on the Rorschach were investigated in children; Authors reported that the color Red produced poor form responses. Briki & Hue (2016) In a study on color perception, the color Red was associated with dominance and arousal. Conclusion: This paper summaries key findings from the extant literature on the potential detrimental effect of the color Red on both perceptual and cognitive functions. The author argues that this body of scholarship should be incorporated as a critical framework for clinical consideration regarding the assessment process specific to the Rorschach Method, as a foundation for further research investigations. This review prompts several issues that need to be addressed and elucidated by future research, in light of the fact that projective techniques continue as popular clinical tools (Piotrowski, 2022). Does the ‘color shock’ of the color Red on Rorschach cards II and III have an immediate influence on number of responses and perceptual attention specific to these 2 plates? If so, how does this process impact an individual’s response or protocol to all remaining cards? Indeed, how does this initial response to the color Red impact the Structural

Summary? Moreover, individual personality difference factors (see Katz & Ziffo, 1975; Schmidt et al., 1955) in responding to the color Red on cards II and III need to be examined further. Would presentation of an ‘achromatic’ version of cards II and III deviate significantly from the traditional administration? Finally, based on vision research: a) the issue of color contrast sensitivity (Ennis et al., 2014) needs to be systematically investigated using the Rorschach, and b) the link between various mental disorders and disturbances of color perception seems a fruitful area for further research (see Keane et al., 2018; Pevzner, 1969; Warner, 1949). Advances in our understanding on the differential role of the color Red based on age group, i.e., children, adults, the elderly (Baldelli et al., 1991; Gil & Le Bigot, 2017; Gnambs et al., 2015), as well as the study of the positive attributes of the color Red to the human experience (e.g., Pazda et al., 2021; Pontes & Hoegg, 2020; Rook, 2014) are sorely needed. Moreover, measurement issues related to color perception (see Gelineau, 1981; Roy et al., 2021) need to be addressed by future research. Overall, the thrust of the current discussion highlights the importance of the translational link between the findings of basic experimental research and the clinical assessment process regarding the Rorschach.

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Research in psychoanalytic personality assessment has involved the development and validation of affect-laden representations of self and others, i.e., object relations, which are substrates of interpersonal variables assessed by selfreport and performance-based personality measures. With both self-report and performance-based elements, sentence completion measures such as the Rotter Incomplete Sentences Blank (RISB) offer an alternative method of assessing personality (mal) adjustment by eliciting and scoring completions of a respondent’s feelings to short sentence stems (Rotter & Rafferty, 1950; Rotter et al., 1992). The current study sought to develop and evaluate an object relations (OR) measure for the RISB. RISB sentence stems related to self and others were selected to develop the OR scale (15 stems) and self- and other-representation subscales (9 stems and 6 stems, respectively). Several test score reliability and validity analyses were undertaken following contemporary psychometric guidelines. Inter-rater reliability coefficients for outpatient mental health clients (N = 50) were r = .80 (Self subscale), r = .88 (Other subscale), and r = .88 (Total scale). Internal consistency reliabilities for outpatients (N = 123) demonstrated medium-to-large alpha (α = .77; α = .54; α = .77) and omega (ω = .79; ω = .55; ω = .78) coefficients. Test-retest reliabilities (r = .71; r = .65; r = .64) using a college student sample (N = 20) demonstrated moderate temporal stability of the scales. External validity evaluations examined correlations between RISB OR scale scores and relevant Rorschach (N = 84) and MMPI-2 (N = 111) scale scores of outpatient clients. Convergent validity correlations were in the small-to-large effect size range with several MMPI-2 interpersonal scales but were minimal in relation to Rorschach variables. Discriminant validity was most clearly shown with Rorschach variables but not MMPI-2 scales. In addition, results showed significant differences in mean RISB OR scale scores of outpatients and college students (N = 50 each), but not between personality disordered and non-personality disordered outpatients (N = 45 each). The findings of this study suggest adequate psychometric standing of the RISB OR scales and subscales as measures of object relations. Implications and future directions are discussed.

Introduction: The assessment of relatedness in the psychoanalytic tradition involves appraisal of a person’s internal object relations. These intrapsychic relational structures shape the quality and tenor of interpersonal functioning. Maladaptive object relations are found among persons with dependent personalities (Bornstein, 2003), eating disorders (Heesacker et al., 1990), schizophrenia (Spear & Sugarman, 1984), borderline personality disorder (Yeomans et al., 2015), and narcissistic personality disorder (Diamond et al., 2022). Broad-band self-report and performance-based clinical personality tests typically contain variables assessing facets of interpersonal functioning, albeit not necessarily assessing object relations directly. Sentence Completion tests (SCTs) call for completion of short sentence stems and contain both performance-based and self-report elements. SCTs represent an alternative technique for assessing personality dynamics, including representations of self and others that can be considered to constitute object relations. One well-known SCT is the Rotter Incomplete Sentences Blank (RISB; Rotter & Rafferty, 1950; Rotter et al., 1992). The RISB has been the most widely used SCT (Haak, 2003; Hojnoski et al., 2006; Holaday et al., 2000), and has standardized norms and scoring procedures. It has been applied to the assessment of psychosocial functioning (Weis et al., 2008) including the detection of dependency patterns (Dunlap, 1951, as cited in Rotter et al., 1992; Fitzgerald, 1958, as cited in Rotter et al., 1992), the ability to predict social behavior (Chance, 1958), social conduct based on trust and popularity (Jessor et al., 1963), anxiety, inhibited interpersonal styles,

and hostility (Geller, 1966, as cited in Rotter et al., 1992; Geller, 1968, as cited in Rotter et al., 1992; Renner et al., 1962; Torstrick et al., 2015), social introversion (Vernallis et al., 1970), (un)conscious relational needs in borderline personality pathology (Schiltz & Schiltz, 2016), and perceptions of self and others (Janda, 1998). Some researchers have devised special scoring systemsfor the RISB including measures assessing attitudes toward the law and the criminal justice system (Hulin & Maher, 1959, as cited in Rotter et al., 1992), selfacceptance, self-description, and acceptance of others (Shepard, 1979, as cited in Rotter et al., 1992), perceptual accuracy of healthcare staff among inpatients (Watts, 1973, as cited in Rotter et al., 1992), and a cognition rating form (Lehnert et al., 1996). Social cognitive elements revealed by the RISB render this hybrid method of direct and indirect responding useful in assessing interpersonal functioning. However, unlike commonly used performance-based methods such as the Rorschach and Thematic Apperception Test, the RISB does not contain a specific index related to interpersonal functioning. The current study focused on the development and initial psychometric evaluation of an object relations measure for the RISB. In this endeavor, we drew from a contemporary understanding of object relations as “units composed of a representation of the self and a representation of another, linked by an affect related to or representing a drive” (Yeomans et al., 2015, pp. 3-4). Test score reliability evaluation included inter-rater, internal consistency, and test-retest reliability analyses. Construct validity evaluation consisted of convergent and discriminant validity with relevant scales and indices from the Rorschach (Exner, 2001; Meyer et al., 2011) and Minnesota Multiphasic Personality Inventory-2nd edition (MMPI-2; Butcher et al., 1989). Methods: Participants: Samples of outpatient clients and college students were used in this study. Participants in the outpatient sample were N = 123 adult clients (n = 70 women, 56.9%, n = 53 men, 43.1%) who had previously received psychological services from a university-affiliated community mental health clinic in Central Florida. Inclusion was based on the following criteria: (a) age 18 years or older; (b) completion of a RISB; (c) provision of a mental health diagnosis; and (d) having received psychotherapy services. The sample was predominantly Caucasian (85.5%), followed by Hispanic (8%), Asian American (4%), and African American (2.4%) participants. The mean age was 37.8 (SD = 14.36; range = 18-69). Relationship status was as follows: single = 78 (63.4%), married = 15 (12.2%), divorced and/or separated = 21 (17%), in a relationship = 7 (5.7%) or widowed = 2 (1.6%). Primary diagnoses were mood disorders (48%), substance use disorders (13.8%), bipolar disorders (8.0%), schizophrenic disorders (2.4%) and personality disorders (36.6%), with some co-occurring diagnoses. Participants in the college sample consisted of N = 50 students (n = 26 women, 52%; n = 24 men, 48%) who were: (a) 18 years of age or older; and (b) consented to complete the RISB. The sample was predominantly Caucasian (60.0%), with smaller frequencies of African American (18.0%), Asian American (16.0%), and Hispanic (6.0%) students. The mean age of the college participants was 22.8 (SD = 7.4; range = 18-54). Relational status consisted of single = 35 (70%), married = 3 (6%), divorced = 2 (4%) and in a relationship = 10 (20%). Eight (16%) participants had prior mental health diagnoses and eleven (22%) were receiving psychotherapy at the time of this study. Additional data for the college sample included number of close friends (M = 6.3; SD = 4.8), subjective appraisal on level of adjustment to college on a scale of one to five (M = 4.0; SD = 0.8) and level of satisfaction with their relationships on a scale of one to five (M = 3.9; SD = 0.9).

Instruments: RISB. The primary instrument of interest in this study was the RISB, adult form. Following the RISB manual’s scoring instructions, each item was scored on a 7-point scale with higher scores representing psychological maladjustment (6 = severe conflict) and lower scores representing psychological adjustment (0 = strong positive). Prior studies involving the entire RISB protocol have found strong inter-rater reliabilities with correlation coefficients ranging from .72 to .99 (Rotter et al., 1992). With reference to internal consistency reliability, Rotter et al. (1992) reported that RISB items “are not designed to be equivalent” and as such, “assessing the internal consistency is not strictly applicable” (p. 41). Nevertheless, studies assessing the internal consistency of the entire RISB protocol showed coefficients ranging from .69 to .86 (Catanzaro 1988, as cited in Rotter et al., 1992; Rotter et al., 1949; Rotter et al., 1954; Torstrick et al., 2015). The RISB manual reports temporal stability for this instrument is “sensitive to personality adjustment,” and “falls somewhere in the middle of the state-trait continuum – reflecting change but also maintaining moderate stability over time” (Rotter et al., 1992, p. 43). Construct validity evaluations with the RISB demonstrated significant correlations with severe anxiety, chronic psychosis, personality disorders, and severe substance use (Rotter et al., 1992). In addition, Lah (1989) found significant correlations between maladjustment, as measured by the Overall Adjustment Score (OAS), and sociometric indices of unhappiness, non-self-acceptance, nervousness, and humorlessness. Rorschach. Rorschach variables selected for convergent validity analyses of the RISB included the Coping Deficit Index (CDI), Good Human /Poor Human Representational responses (GHR/PHR), Oral Dependent Language (ODL), and Mutuality of Autonomy/Mutuality of Pathology (MAH/MAP). The information processing efficiency index (Zd) and the illogical/incoherent thinking index (WSum6) were used to evaluate discriminant validity. The CDI measures “social ineptness as well as an unrewarding or chaotic interpersonal history,” and can indicate vulnerabilities in coping with social stressors (Krishnamurthy et al., 2011, p. 304), executive function errors among adult inpatients (r = .30; Ilonen et al., 2016), and an inability to manage one’s emotions (r = -.49; Vishwakarma et al., 2016). The GHR/PHR variables are measures of interpersonal involvement that correlate with histories of healthy or conflictual interactions with others. More frequent PHR responses are indicative of a proneness to respond to others in ill-advised or undesirable ways (Exner, 2000, pp. 322-326, as cited in Weiner, 2003). Soenning et al. (2010) found higher frequencies of PHR among rejected, aggressive children, whereas “popular” children had higher frequencies of GHR. The ODL index has been found to correlate with help seeking behaviors (r = .85), dependency (r = .58), and insecure attachment (r = .19) (Bornstein, 1996). Lastly, the MAH/MAP indices have gained support as measures of object relational interplay (Bombel et al., 2009; Graceffo et al., 2014; Monroe et al., 2013). MMPI-2. MMPI-2 scales related to self/interpersonal functioning included Low Self-Esteem (LSE), Social Discomfort (SOD), Self-Alienation (Pd5), and Social Alienation (Pd4) for convergent validity analyses. Schizophrenia (Sc) and Type A (TPA) scales were used for discriminant validity analyses. The LSE scale has correlated inversely with measures of global self-worth (r = -.54) and sociability (r = -.49) among undergraduate students (Brems & Lloyd, 1995). SOD has correlated inversely with measures of sociability (r = -.25; Hathaway & McKinley, 1989) and paranoia/mistrust when interacting with others (r = .35; Sellbom et al., 2005). Self-Alienation (Pd5) has been found to have an inverse correlation with a measure of social potency (r = -.38; Lilienfeld, 1999) and positive correlation with a lack of self-integration (r = .29; Wrobel, 1991), and reflects feeling misunderstood, guilty, unhappy, and self-reproaching (Nichols, 2011, as cited in Friedman et al., 2015). The Social Alienation (Pd4) subscale of the MMPI-2 has positive correlations with measures of feeling isolated or ungratified in social relations (r = .18; Wrobel, 1991), a lack of belongingness (r = .28; Wrobel, 1991), and externalization of blame (r = .60; Lilienfeld, 1999).

Procedures: Archival data from the records of outpatient clinic clients evaluated between 2013 and 2020 were extracted to yield a N = 123 outpatient sample. In addition, with provision of informed consent, a sample of N = 50 college students enrolled at two private universities in the southern United States was collected, who were tested with the RISB between November 2020 and September 2021. External validity analyses involved indices and scales from N = 84 available Rorschach protocols and N = 111 MMPI-2 profiles from the outpatient sample. To assess if the RISB OR scales could differentiate between diagnostic categories, the outpatient sample was divided into n = 45 personality disordered versus n = 45 randomly selected non-personality disordered participants. Similarly, the RISB OR scales’ ability to differentiate scores of outpatients and controls was assessed using n = 50 randomly selected outpatients and N = 50 college students. Lastly, two supplemental analyses compared randomly selected subsamples of n = 42 outpatients with n = 42 college students who had never received a mental health diagnosis, as well as n =39 outpatients with n =39 college students who were not receiving psychotherapy at the time of RISB testing. Scale Development: RISB OR scale items were chosen based on their social cognitive stems that elicit a representation of self and others. Fifteen stems were selected that elicited self- and other representations, thus constituting the total OR scale (see Table 1). Nine of the fifteen stems were allocated to the Self-representation subscale due to their elicitation of associations related to images of the self (e.g., “My mind,” “I am very,” “I need,” “I wish”); six were allocated to the Other-representation subscale due to their elicitation of generalizations and/or personalized images of others (e.g., “Men,” “Other people,” “My father,” “A mother”). The RISB’s emphasis on expressing “your real feelings” steeps sentence completions in affect, thus prompting the RISB OR measure to correspond with the contemporary definition of object relations. Table 1. RISB Object Relations Subscale(s) Self-representation subscale (Item #)

Other-representation subscale (Item #)

I feel (12)

Men (7)

I can’t (15)

People (10)

I suffer (20)

A mother (11)

I failed (21)

Other people (19)

My mind (23)

My father (35)

I need (25)

Most women (40)

I am very (32)

I wish (34)

I (37)

Results: Preliminary analyses yielded the following means and standard deviations for the RISB OR scales among N = 50 college student participants: Total scale M = 46.6 (SD = 9.7), Self-subscale M = 29.2 (SD = 6.8), and Othersubscale M = 17.4 (SD = 5.1). Likewise, the means and standard deviations for N = 123 outpatient participants were: Total scale M = 60.1 (SD = 11.2), Self-subscale M = 37.5 (SD = 7.8), and Other- subscale M = 22.6 (SD = 5.4). The OR scales were significantly intercorrelated and achieved medium-to-large intercorrelations in both samples, as shown in Table 2.

Table 2. Pearson Correlations between RISB OR Scales Scales

Outpatient

College

Self Other Total Self Other Total Self-subscale - .42** .90** - .31* .87** Other -subscale .42** - .78** .31* - .74** Total scale .90** .78** - .87** .74** - *p < .05 **p < .01 Inter-rater reliability. Inter-rater reliability analyses of the RISB OR scales were derived from ratings by the first author and a trained clinical psychology graduate student following the test’s manual’s item-scoring guidelines, using a n = 50 randomly selected outpatient subsample. Results showed the following ICCs for the OR scales: Total Scale r = .88, Self-subscale r = .80, and Other -subscale r = .88, demonstrating strong interrater reliability and aligning with prior ICCs observed for the entire RISB protocol (Rotter et al., 1992). Internal consistency reliability. Internal consistency reliability using N = 123 outpatients were measured using Cronbach’s alpha (α) as well as MacDonald’s Omega (ω) as the subscales measure different facets of the OR construct: self- and other representations. The internal consistency reliabilities of the OR Total scale (α =.77; ω = .78) and the Self subscale (α = .77; ω = .79) were strong, representing large effect sizes, and was at an acceptable, medium-effect size level for the other subscale (α = .54; ω = .55). Additional post-hoc analyses were conducted to determine if alternative item combinations would improve the internal consistency reliability of the other subscale, but none achieved an alpha or omega greater than .54. Test-retest reliability. Test-retest reliability analysis used a n = 20 college student subsample retested over a 2–3-week interval, with blind scoring by the first author. Results demonstrated moderate coefficients for the Total scale (r = .64; p< .05), Self-subscale (r = .71; p< .01), and other- subscale (r = .65; p< .05). Results from all reliability analyses of the RISB OR scales are summarized in Table 3. Table 3. Reliability Analyses of RISB OR Scales

Reliability type N Self subscale Other subscale Total scale Inter-rater r .80 .88 .88 Internal Consistency

Alpha (α) .77 .54 .77

Omega (ω) .79 .55 .78 Test-Retest r .71** .65* .64* *p< .05 **p< .01 Construct Validity. Convergent validity analyses with N = 84 Rorschach protocols achieved one small significant correlation (r = .23; p< .05) between the Self subscale and MAP. Discriminant validity was most clearly demonstrated for Zd, with correlations under .10 across all three of the OR scales. Given the limited evidence for convergent validity with Rorschach indices based on the variables selected, the reach was extended in a post-hoc analysis to Rorschach variables that are one-step removed from the self- and other-representation constructs. Rorschach variables selected for post-hoc convergent validity analysis included the Isolation Index, SumT, SumV, SumY, morbid (MOR), aggressive movement (AG), fictional and part human representations ((H)+Hd+(Hd)), depression index (DEPI), coping ability (EA), current stressors (es), and distorted human

movement (M-). Populars (P) and Intellectualization Index (Intel) were selected for discriminant validity analysis. Only one of the convergent validity variables achieved statistically significant, meaningful correlations with OR scale scores: Morbid (MOR) with the Total scale (r = .24) and Other subscale (r = .22), whereas fictionalized/part human representations correlated inversely with the Total scale (r = -.23) and Self subscale (r = -.23). Discriminant validity was demonstrated with Populars (P) and Intellectualization Index (Intel) as both achieved effect sizes below .10 with all three RISB OR scales. All results related to the Rorschach are shown in Table 4. Table 4. Pearson Correlations of RISB OR Scales Scores and Rorschach Indices (N = 84)

Rorschach Index Self Subscale Other Subscale Total Scale

CDI .10 -.02 .05

GHR -.07 -.07 -.08

PHR -.14 -.15 -.17

MAP .23* .06 .18

MAH .03 .13 .08

ODL -.07 .05 -.03

ISOL .17 -.13 .06

SumT .14 .07 .13

SumV .09 .11 .11

SumY .01 .03 .02

MOR .21 .22* .24*

AG .07 .13 .11

(H) + Hd + (Hd) -.23* -.17 -.23*

DEPI .03 .02 .03

EA .09 .03 .08

es .08 .08 .09

M- -.11 -.01 -.08

Zd .07 .05 .07

WSum6 .13 .06 .12

Populars -.05 -.03

Intellectualization Index .02 -.08 -.02 *p< .05 Convergent validity analyses using N = 111 MMPI-2 profiles achieved the strongest and most consistent convergence with OR scale scores. The Self subscale and Total scale achieved correlations with all four MMPI- 2 scales chosen for initial validity analyses. The Other subscale achieved no correlations with these four MMPI- 2 scales. Acceptable discriminant validity levels below .10 were not demonstrated with Sc and TPA. In uniformity with procedures used with Rorschach indices, the reach was extended in a post-hoc analysis to MMPI-2 scales that are one-step removed from self- and other-representation constructs. MMPI-2 scales Sc1 (Social Alienation), Sc3 (Lack of Ego Mastery, Cognitive), DEP3 (Self-Deprecation), Subjective Depression (D1), Familial Discord (Pd1), Authority Problems (Pd2), Family Problems (FAM), Welsh’s A, Psychasthenia (Pt), and Social Introversion (Si) were selected for convergent validity analysis. MMPI-2 scales Sc6 (Bizarre Sensory Experiences) and Obsessiveness (OBS) were chosen for discriminant validity analysis. Several of these post-hoc MMPI-2 scales reached statistical significance with small-to-medium effect size correlations with

respective RISB OR scales. Discriminant validity was most clearly demonstrated with Sc6 in relation to the Self subscale, with a correlation under .10. The full set of results are shown in Table 5. Table 5. Pearson Correlations of RISB OR Scales Scores and MMPI-2 Scale Scores (N = 111) MMPI-2 Scale Self Subscale Other Subscale Total Scale

LSE .37** .14 .45**

SOD .35** .17 .41**

Pd4 .27** .17 .42**

Pd5 .29** .15 .40**

Sc1 .29** .41** .39**

Sc3 .22* .30** .30**

DEP3 .35** .34** .40**

D1 .46** .33** .47**

Pd1 .17 .27** .24*

Pd2 -.05 .05 -.01

FAM .13 .25** .21*

Welsh’s A .35** .31** .39**

Pt .37** .30** .40**

Si .43** .30** .44**

Sc .19* .21* .33**

TPA .14 .18 .24*

Sc6 .06 .28** .17

OBS .30** .25** .32** *p < .05 **p < .01 Group comparisons. Four analyses of variance (ANOVAs) were conducted to compare RISB OR scores between diagnostic categories as well as outpatients versus controls. The first ANOVA between n = 45 personality disordered and n = 45 randomly selected non-personality disordered outpatients displayed nonsignificant results. In contrast, the second ANOVA between n = 50 randomly selected outpatients and N = 50 college students achieved significant results for all three RISB OR scales: Total scale, F(1, 49) = 14.1, p< .001; Self subscale, F(1, 49) = 13.4, p< .001; Other subscale, F(1, 49) = 17.2, p< .001, with outpatients scoring significantly higher than college students. The third ANOVA assessed the mean differences in scores between n = 42 college student participants who had never received a mental health diagnosis and n = 42 randomly selected outpatient participants with diagnoses at the time of RISB completion. Results were significant for all three scales: Total scale, F(1, 83) = 32.3, p< .001; Self subscale, F(1, 83) = 27.5, p< .001; Other subscale, F(1, 83) = 17.8, p< .001, with higher mean scores for outpatient participants. The final ANOVA was conducted with n = 39 college student participants who were not receiving psychotherapy at the time of this study and n = 39 randomly selected outpatient participants who were receiving psychotherapy at the time of RISB completion. The results demonstrated significant differences for all three scales: Total scale, F(1, 77) = 30.7, p< .001; Self subscale, F(1, 77) = 20.6, p< .001; Other subscale, F(1, 77) = 22.4, p< .001, with higher mean scores for outpatient participants. Discussion: Object relations theorists’ position self- and other-representations linked by affects as the foundations of relating that persist throughout the lifespan and occur with minimal conscious amendment (Diamond et al.,

2022; Yeomans et al., 2015). As such, these affect-laden templates for relationships are of particular interest in the assessment of interpersonal (mal)adjustment. Performance-based and self-report measures assess features of interpersonal functioning in indirect and direct ways, respectively. The RISB operates as a hybrid method with direct responding in terms of what the examinee chooses to write, and thus, in what is revealed. This SCT method, however, is unique in that across stems it retains an indirect injection of interpersonal nuance evidenced in themes, complexity of the completions, and affective associations to particular stems. Such indirect features in RISB completions include themes of social orientation, identification, psychological adjustment, perceptual attitudes, and social schemas (Lomax & Lam, 2011; Wollitzer et al., 1973). The current study capitalized on the current trends in object relations (OR) assessment by developing and evaluating an OR measure for the RISB. Of the 40 RISB stems, 15 were selected for the RISB OR Total scale. These scales achieved medium-to-large effect size intercorrelations ranging from .31 to .90 across outpatient and college student participants, suggesting reasonable coherence in assessing dysfunction across self- and otherrepresentations. The first reliability analysis of this study focused on evaluating the inter-rater reliability of the RISB OR scales. Each scale achieved ICCs at r >.80, demonstrating acceptable inter-rater agreement. Examination of the psychometric adequacy of the OR scales also rested on demonstrating additional evidence of score reliability. Internal consistency reliabilities were strong for the Total scale and Self subscale, but moderate for the Other subscale. The lower alpha and omega values for the Other subscale may be accounted for by a couple of factors. First, the Other subscale has the fewest items, thus requiring each item’s scores to carry a greater weight. Second, the manner by which representations are elicited by key Other subscale items (“A mother,” “My father,” “People,” “Other people,” “Most women,” “Men”) is unique. Two stems prompt respondents to shift from a subjective to an objective characterization of the figures (“A mother” vs. “My father;” “People” vs. “Other people”). This shift to objectivity is associated with greater reflective capacity and higher ego functioning (Pronin et al., 2004), and thus, elicits responses modified by a cognitive-perceptual buffer. Despite these considerations, the content of these stems is relevant to object relations and could still prove insightful when the contents of completions are examined. The final component of reliability analysis involved test-retest reliability, which demonstrated moderate stability of OR scores. These coefficients were smaller than those found in prior studies using a two-week time interval (Arnold & Walter, 1957, as cited in Rotter et al., 1992; Richardson & Soucar, 1971, as cited in Rotter et al., 1992). On the other hand, all three OR scales achieved higher coefficients than a previous test-retest study using intervals greater than two weeks (Churchill & Crandall, 1955). Overall, our results suggest the RISB OR scales have adequate temporal stability based on similarities to stability coefficients obtained in other test-retest studies using the entire protocol (Rotter et al., 1992). The second half of the study focused on evaluating the external validity of the RISB OR scales. In the RISB and Rorschach analyses, the Self subscale achieved a small, significant correlation with the Rorschach MAP variable, indicating the scale’s correlation with a harmful or destructive visions of relationships. Of the Rorschach variables selected in this study for post-hoc analyses, only two correlated significantly with OR scales. The Rorschach Morbid (MOR) variable had a small yet significant positive correlation with the Total scale and other subscale. This finding suggests a sensitivity of these RISB OR scales to detect maladjusted, if not damaged or flawed, self-representations. Furthermore, the Rorschach fictionalized human representation variable achieved small negative correlations with the Total scale and Self subscale, suggesting the scales may reflect the degree to which the examinee bases his/her other-representations on real life people. Discriminant validity analyses with the Rorschach demonstrated effect sizes under .10 for the Populars (P) and

Intellectualization Index variables, thus demonstrating the OR scales do not align with unrelated constructs of perceptual conventionality and reasoning devoid of affective influence. In the RISB and MMPI-2 analyses, the initial four MMPI-2 scales achieved statistically significant medium effect size correlations with the Total scale. In relation to the Self subscale, Pd4 and Pd5 reached statistically significant small-to-medium effect sizes, whereas LSE and SOD achieved statistically significant medium effect sizes. The significant correlations with the Self subscale and Total scale indicate the scales’ detection of self- and other representations as they relate to the participants’ appraisal of, and relationship with, themselves and others. A post-hoc method similar to that with the Rorschach was extended to MMPI-2 scales to further assess self/other constructs of the RISB OR scales; the results were promising. Ten MMPI-2 scales selected for the post-hoc convergent analyses involved direct appraisal of self and others, and seven correlated significantly with the Self subscale. The numerous significant correlations paralleled prior findings demonstrating that RISB scores correlate positively with relevant MMPI scale scores (Rotter et al., 1992). Furthermore, the effect size magnitudes for the RISB Self and Other subscales in relation to MMPI-2 scales supported their differentiated constructs. Post-hoc discriminant validity analyses with targeted effect sizes below. 10 was only achieved with the Self subscale and Sc6. Therefore, discriminant validity was not substantially demonstrated. The results from the current study appeared to replicate findings from Schlicht et al. (1969) in obtaining minimal convergent correlations with the Rorschach, but discriminant validity findings were more promising. On the other hand, as noted earlier, our results showed favorable convergent validity with several MMPI-2 scales but limited evidence of discriminant validity with this self-report measure. These findings appear to demonstrate that a SCT measure such as the RISB is truly a hybrid of self-report and performance-based approaches of personality assessment, particularly in evaluating maladjusted self- and other-representations. Overall, the reliability and validity of the RISB OR scales achieved psychometric results commensurate with prior RISB studies involving the entire protocol. Despite these promising results, the temporal stability of the OR scales needs further validation with a larger sample, and the internal consistency of the Other subscale may also need enhancement. The RISB OR scales do not convincingly correlate with Rorschach variables that measure interpersonal features. Nonetheless, small-to-medium correlations with noteworthy variables (MOR and MAP) are suggestive of the scales’ ability to detect pessimistic or pathological social cognitive components of object relations representations in a manner like the Social Cognition and Object Relations Scale (SCORS) for the TAT (Stein et al., 2011). Furthermore, a multitude of correlations with MMPI-2 scales of self/interpersonal functioning indicate the RISB OR scales elicit features of object relations (i.e., self-esteem, social alienation, interpersonal wariness, and self-regard). As such, the construct validity of the RISB OR scales can be most accurately conceived of as measures of (mal)adjustment in self- and other representations. Prior studies of convergence analyses between self-report and performance-based tasks reveal low convergences between corresponding constructs across measures (Archer & Krishnamurthy, 1993a, 1993b; Meyer, 1997). However, Meyer (1996) asserted that such cross-method disagreement is not emblematic of test score invalidity and may, in fact, enhance interpretation. Sentence completion methods are hybrid measures as they have more structure than the Rorschach but less than self-report measures such as the MMPI-2 (Watson, 1978). Since the RISB involves the completion of moderately ambiguous sentence stems to express personal feelings, it may be considered to have unique method variance compared to the highly ambiguous Rorschach stimuli and less ambiguous, verbally mediated MMPI-2 items.

This study also compared mean scores for the OR scales between two broad diagnostic subgroups within the outpatient sample. Significant differences with the OR scales were not observed between outpatients with and without personality disorders. Nevertheless, all the score floors for the OR scales among the personality disordered sample were higher than the non-personality disordered sample, suggesting a greater likelihood for personality disordered persons to trend towards maladjustment. Statistically significant differences in RISB OR scale scores were, however, found in other comparisons. Specifically, mean scores from all RISB OR scales differed significantly between college students and outpatient participants in the expected direction. In addition, statistically significant score differences were observed between college students not receiving mental health treatment and outpatients actively receiving mental health treatment at the time of RISB completion. Similarly, statistically significant differences were found between student participants who had never received a prior mental health diagnosis andoutpatient clients who had a diagnosis at the time of RISB testing. These results indicate the RISB OR scale scores were successful in differentiating clinical from non-clinical samples. Limitations: The limitations of this study are noted. First, the internal consistency reliabilities for the Other-representation subscale did not achieve coefficient levels similar to prior RISB studies and were notably lower than the Selfrepresentation subscale and Total scale. Therefore, continued refinement of the Other-representation subscale’s internal consistency is warranted. Second, the sample size of the control group was limited. Due to this relatively small sample size, as well as their demographics as college students, replication studies with more diverse participants are needed. Replication studies might extend the validity and reliability analyses of the RISB OR scales with samples of different ages, socioeconomic and cultural backgrounds. A third limitation of this study concerns the Rorschach variables used for external validity comparisons. These variables were coded by graduate students in supervised practicum training. As such, errors in coding may have occurred, which may have impacted the strength of correlations. Future research extending the construct validity of object relations within the RISB OR scales might involve correlations with the SCORS and/or Bell Object Relation and Reality Testing Inventory (BORRTI; Bell, 1995). Contributions: This study served to develop a measure for the RISB that detects object relations, and it produced promising findings. To the best of our knowledge, a measure for the RISB has not been developed for nearly 26 years, since Lehnert et al. (1996), thus making this work an advancement in accordance with contemporary psychometric standards. In addition, this study marks the first time in nearly 45 years the temporal stability of the RISB was evaluated, since Rabinowitz and Shouval (1977). The internal reliability for the RISB OR scales is adequate, and the construct validity findings suggest the scales are sufficient measures of (mal)adjusted selfand other-representations constituting object relations. Moreover, the internal validity results for the OR scales generally corresponded to those of prior RISB studies involving an entire protocol, suggesting these results may operate as a partial replication. Our study also examined correlations between selected RISB items, MMPI-2 scales, and Rorschach variables. Such comparisons have not been studied in over 50 years (cf. Schlicht et al., 1969; Snow, 1972). SCTs have been popular assessment tools in clinical practice for nearly eight decades. Although interest in their use has declined recently (Piotrowski, 2018), the capacity of the RISB to elicit aspects relevant to object relations advocates for the relevancy of an object relations scale for this measure. As such, this set of RISB OR

scales serve as potentially useful measures of object relations in clinical personality assessments and may serve to rejuvenate interest in clinical and research applications of SCTs. Acknowledgments: We offer our thanks to the Society for Personality Assessment for providing dissertation grant support for the first author; Karina Guerra-Guzman, graduate research assistant for the second author for her scoring assistance; and Scott A. Gustafson, Ph.D. for permitting data extraction from the psychology clinic archives.

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Projective tests open a window into the inner depth of the unconscious and help in accessing the suppressed and repressed material causing undesirable behavior, unlike the Questionnaire and Rating Scale method. This suppressed and repressed material is brought to the surface in the form of responses and dreams and needs symbolic interpretation and introspection. This paper highlights the efficacy of Somatic Inkblot Test – online version (Dubey et. Al., 2019, Dubey & Dubey, 2021) in two cases: first is a case of major depressive disorder (single episode, mild severity, with anxious distress-mild severity- Code: DSM-5, 296.21), and second is a case of Somatic Symptom Disorder, having mild, predominant pain, with panic attack (Code: DSM-5, 300.82)

Case 1. The Index Client is a 35-year-old para-medical professional, she is a college graduate, single and lives in an urban Indian joint family. Her family consists of her elder parents, a younger brother and his wife and a younger sister. She complains about insomnia, suicidal thoughts, irritability, loss of interest in professional work, night-time crying, feelings of aloofness and depressive mood. These symptoms have been ongoing for the past four to five months. She was administered the Somatic Inkblot test on September 1, 2022. The client reports of a distressed and disturbed family environment, frequent financial arguments between her brother and mother, internal family conflict between “brother’s wife” and the rest of the family. As per the client, her tension and stress got compounded by the loss of her older sister and confidante to a medical illness. The client also reported the failure of a nine-year romantic and physical relationship with a male co-worker. The client had hidden this relationship from her family and chose to reveal it to her younger sister after the breakup. Her sister chose to share this secret with her parents even though the client had requested privacy in the matter. The client's family, though upset with her decisions nonetheless provided her with emotional support and encouragement to help her move on and address her mental health issues. The client reports feeling fine till April 2022. The client started feeling sad all day and stopped taking care of herself and was no longer interested in routine home chores. She even stopped spending time with her 3-year-old nephew who was very close to her. She also reported loss of appetite even to the food of her choice. She has lost about 3 Kilogram since then. She stopped visiting her workplace in June 2022 and was advised to start work or resign. She started keeping distance from her colleagues and friends even on social media because she was feeling irritated, annoyed, tense, and restless even on petty things. Finally, she lost her job. She has joined another hospital and has been working since August 2022. In the month of July, she started feeling discomfort in lower abdomen and fear of having pain from an Ovarian Cyst for which she consulted a Gynecologist. After investigation, the Doctor diagnosed it as a case of “hydrosalpinx” and advised that it may affect her pregnancy in future if remain untreated. She has not reported any injury, serious illness, seizures, use and abuse of substance. She has not reported suspicion and any kind of hallucination. Provisional Diagnosis: Major depressive disorder, single episode, mild severity, with anxious distress-mild severity. Code: 296.21 (DSM-5) Her responses on 30 images of online SIT are interpreted following content / psychoanalytic interpretation (Cassell & Dubey, 2003; Dubey, et al, 2019; Phillips & Smith, 1953; Schafer, 1954).

Image 1: “I see a dog”. The response indicates passive dependency with aggression. Image 2: It looks like a “Jesus’ cross”. It may indicate innocence and denial of guilt as defense against superego conflict (Schafer, 1954). It further indicates that the person is seeking spiritual support to control the adverse situation she is facing and to save her ego from breakdown particularly in cases of depression and maladjustment. Image 3: It looks like a “Smiling person”. It may indicate her happy mood. Image 4: “Person wants to play with a sad teddy”. Sad teddy bear may indicate her unhappy childhood. Sad Teddy bear may represent the client herself, and her depressive childhood. Special note regarding inquiry of any traumatic experience during childhood may be further conducted during therapy sessions. Image 5: I see “A Lady dancing and an Apple”. Both responses are the most common perceptions and indicate her happy mood. Image 6: Her response on this image was “A boy likes a girl, and the girl does not like the boy”. It may indicate a conflicting relationship between a male and a female. It looks like her own projection of a conflicting relationship with her male partner. Image 7: I see a “Fetus”. Normally people see an ear on this image and the “fetus” may indicate her anxiety and fear of pregnancy. Image 8: Looks like “A hand is coming out after breaking the ice. Also there looks like many small pigs”. It indicates her suffering and her efforts to escape from this suffering. Many small pigs may indicate her timidity, dependency, passive-receptive attitude, rejection of adult role and sign of fertility. Image 9: She saw “Two happy penguins”. It indicates her wishful thinking to have a happy life with her friend which looks far away from the present reality. Image 10: I see a “A lady's body with a broken heart”. Heart is a natural symbol of Interpersonal relationship; however, broken heart indicates broken love relations, which is confirmed from her case history. Image 11. Looks like “Lizard's mouth on the top and a dog”. Image of lizard and dogs indicates a conflicting relationship, it might be about her own love relationship. Mouth of Lizard may indicate male phallic symbol and libidinal conflict (Schafer, 1954). Image 12: “Two ovaries with blocked urethra”. This response may indicate a kind of fear that the fallopian tube is blocked to control pregnancy. This could also indicate her fear of blocked urethra, after using fertility pills to control pregnancy, which she shared during inquiry. Image 13: “A happy God gives his love and blessings to his male and female children”. This may indicate seeking spiritual help to resolve her issues. Image 14: Looks like a “spinal column”, is a normal response. Image 15: “Female phallic organ” may indicate healthy body imagery. Image 16: It looks like “Two babies in the womb and blessing to each other”. It indicates her wishful thinking to get blessings to have a good interpersonal relationship with her boyfriend. Image 17: “A half-naked breast”. It indicates active phallic content and her involvement and fantasy in erotic relationship. Image 18: “Two young people talking against each other”. It may indicate their conflict and disturbed interpersonal relationship particularly with her boyfriend. A couple/male and female talking is the common response in this image.

Image 19: “A lady loves her child”. It indicates a smooth interpersonal relationship with her mother and a kind of tension with father or father figure. Normally people perceive a father in this image, which she has avoided; this may indicate her poor relationship with father. This could also be due to the poor relationship with her boyfriend. Image 20: “A couple chatting”. It may indicate her wishful thinking, to have a good interpersonal relationship with her friend. Image 21: Looks “Too many sharp objects”. This may indicate her passive aggression. Image 22: I see “A lovely heart which diminishes his color and shape”. It Indicates her frustration and anxiety in her relationship. Image 23: “A penis inserted in some lake full of waves”. It may indicate her fantasy and active erotic involvement. Image 24: It looks like “Heart within ovum which is broken and too much sperm wants to enter in that heart. The responses may indicate active erotic involvement and a desire to become mother. The broken heart clearly indicates a broken love relationship. Image 25: It looks like “A gun with defective head”. This may indicate her passive aggressiveness and withdrawal from the situation. She might not be in a position to express her aggression towards her boyfriend. Image 26: “A dead man's soul is coming out”. It is a normal response in this image. Image 27: “A child talking with an unborn child”. It may indicate a kind of regression where she feels she was much better and secure while in the mother’s womb. Image 28: It looks like “A lady loves her child”. It’s a normal response indicating a loving relationship with her mother. Image 29: “A man who has lost half of his leg and is still running”. This may indicate her ego strength to save her from breakdown after such odd happenings. It is also a sign of good prognosis. Psychotherapy works better with such clients. Image 30: Looks like “A happy couple kisses each other with their two children” It may indicate her memory of a happy childhood with her parents.

Indices based Quantitative Analysis: The Indices’ based interpretation is more like counting the number and percentage of responses and their ratios. The high and low percentages have been interpreted ahead: Her total number of responses (R= 46) indicates high productivity and functioning intelligence. The high percentage of Human responses (H= 17, 36.96%) may indicate her smooth interpersonal relationship with other people. It is also an indicator of high self-esteem and good interpersonal skills. High percentage of Human responses are observed in team-makers and normal subjects. The moderate number of Most typical responses (MT= 12) further supports the contention of high Human percentage and indicates coherent, logical thinking and an ability to keep up with the demands of society. The person with 12 MT responses may agree with others after little persuasion and can change their opinion easily. They also show good adjustment in most of the situations. Very low percentage of Animal responses (A= 5, 10.87%) may indicate withdrawal from the surroundings, aloofness, loneliness, and isolated outlook towards life. Such people may behave in an egocentric manner and invite tension. Often such persons may exhibit frustration and suppressed aggression. The Anatomical responses (At = 11, 23.91%) are slightly more than average range but normal for the persons belonging to the discipline of physiology / medical sciences. The Typical responses: 17 (36.95%) are in normal range. The high Movement responses (M= 18, 39.13%) supports the contention of high Human responses and

indicates her active involvement and creativity. The percentage of Sex response (Sex= 3, 6.52%) Hostility Aggression (HAS=0), Depression (D= 3), and Paranoia (P=0), are within normal range. Other indices are found within normal range. The qualitative / Psychoanalytic interpretation: The qualitative/psychoanalytic interpretation gives emphasis on projection, symbolism, and content analysis. Overall, the responses given by the client indicate the presence of good Interpersonal relationship with her mother (Image 19/28). Her responses on Image 3/5/15/29 indicate her healthy body imagery. She is happy with her body imagery and able to protect herself and her ego strength. She has a desire to keep a happy life and it is a sign of good prognosis. Her responses on Image 2/8/13 indicates that she is seeking spiritual support to control the adverse situation and resolve issues which she is facing presently. Her spiritual bent saves her ego from breakdown. Small pigs indicated her timidity and her weakness to face reality. She has projected suppressed aggression towards someone (Images 1/21/25), perhaps her boyfriend, which must be addressed during therapy sessions. Her response on Image 4 indicates that the projection of the sad teddy bear is her own perception of depressive childhood. It seems pertinent to inquire any traumatic experience if she can recollect during childhood particularly before the age six years during the therapy sessions. Her responses on Image 6/10/11//24 indicate a conflicting relationship between her and her partner/friend. Perceiving the heart is a natural symbol of good Interpersonal relationship, however, a broken heart indicates broken love relations or a kind of frustration which she has shared while talking about the broken relationship with her boyfriend. The responses also projected active erotic involvement and a desire to become mother. Her response on Image 12 indicates a kind of fear that the fallopian tube is blocked. This might be because of the use of fertility pills to control pregnancy, which she has shared during inquiry. Her responses on image 15/17/23 may indicate her active involvement and fantasy in sexual relationship. Her responses on Image 9/16/30 are indicative of her wishful thinking to have a happy life and happy family. She also feels neglected by her father. The Somatic Inkblot images brought on surface her frustration, suppressed aggression, erotic conflict, and depressive contents. Her spiritual bent and positive look towards life is a positive sign of good prognosis. Case 2: The Client is a 16-year-old female, unmarried, studying in 11th standard, belonging to urban family of middle socio-economic status, referred by her treating general physician for psychological help and psychotherapy, with major complaints of pain in lower abdomen and excessive worry about the illness for the last seven months. She took an online Somatic Inkblot test on 28 January 2022. The client reported that on 26th June 2021, she went to attend the birthday party of one of her female friends. There were two couples, her female friend with her boyfriend and another couple. They consumed alcohol and booked three separate rooms in a hotel. She was surprised to see the ex-boyfriend of her female friend (celebrating her birthday), knocking at her door. She invited him inside her room. They sat for a while and shared a cigarette, after which they came close to each other and had an intimate relationship. The client pushed him away after some time, and shouted at him, asking him to leave the room. He left the room after which she started sobbing and called her friend to drop her home. She stays with her maternal grandfather because her mother is a divorcee. On the chatting platform, the next morning, she received an apology from the boy with clarification that all that happened was because of her consent. After that she started feeling pain in her lower abdomen. She informed her mother about the incident and pain in stomach for which she advised her to meet a professional nurse who is a good friend of her mother. Next morning, she met the Nurse and shared all that happened in the night because she was afraid of getting pregnant. She was advised to take a contraceptive pill to avoid risk of pregnancy. She did not get any relief and visited another doctor who advised ultrasound and other investigations, which turned out to be normal. She could still feel pain for which the doctor started treating her for gastrointestinal problems. She was hospitalized for two days for the treatment of stomach pain before the “Unit test examination of school”. The treating doctor advised her mother to take help from a psychiatrist because they did not find any reason for her pain.

Provisional Diagnosis: Somatic Symptom Disorder, mild, with predominant pain, with panic attack (Code: 300.82). Her Responses on Somatic Inkblot test have been interpreted following content / psychoanalytic interpretation: Image 1: Looks like a “A monkey”. The response monkey symbolizes ambivalence towards domineering father, (domineering authority), antisocial personality (psychopathy), derisive attitudes and ineffectuality (Phillips & Smith, 1953). This may also project the domination of her perpetuator. Image 2: “A boy sitting over someone’s head” may be the direct projection of domination and overpowering of the perpetuator. Image 3: “A person dancing and a heart”, indicates her ego strength, good interpersonal relationship, and happy mood. Image 4: “Teddy bear”. It is a normal response, indicating her happy childhood. Image 5: Looks like “A clever man dancing and an apple”. Instead of seeing a woman dancing, she has seen a dancing man. The clever man may represent her perpetrator who is feeling happy and enjoying. If a female is unable to perceive a dancing lady, it may indicate that the happiness from her life has gone away. Image 6: “Two women” may indicate good interpersonal relations. Image 7: Looks like “A mouse”. The mouse may represent “cautious interpersonal relations, lethargy, and timidity (Schafer, 1954). Image 8: “Hand - must be in some kind of suffering”. She wanted to share her suffering and needed help from the therapist. This is also a sign of good prognosis. Image 9: I see “a heart between two animals”. Two birds interacting / playing is the normal response. Persons having conflicting relationships with opposite sex often do not see birds playing/ interacting. She has projected her hatred and frustration towards the perpetuator. Image 10: “Skeleton”. She has avoided perceiving hearts, which may indicate her frustration in a relationship. The skeleton may also indicate somatic anxiety. Image 11: “Dear”. She avoided perceiving “heart”; another common perception on this image may indicate frustration with depressive contents. The theme of images 9, 10, 11 is projected on this image, strongly indicating somatic anxiety. Image 12: I see “Trees within the Lungs”. Kidney/Lungs is the most common normal response to this Image. Seeing trees within lungs may indicate tension and anxiety. Image 13: “A huge man in black clothes dancing with 2 children”. Huge man in black clothes symbolizes an authoritarian father. She left her father’s home after the divorce of her mother; she has no contact with her father. It may also indicate her wishful thinking of having a good relationship with her father. Image 14: “Utensils piled up”. Rejection of spinal column may indicate physical injury to the spine or sexual conflict. Females with sexual trauma may reject this image because it symbolizes male phallic region. Image 15: Looks like “Fish mouth with a church sign”. The fish mouth symbolizes erotic content. Female phallic organ is the common response in this image. The Church may indicate spiritual support to resolve her conflict. It may also indicate her guilt feelings and spiritual support. Image 16: “A baby girl who is crying”. Fetus is a common normal response. The “baby girl crying” may be the reflection of her suffering and fear of pregnancy. This may also indicate her pensive mood.

Image 17: “Someone is trapped”. The response may indicate a feeling of being trapped and helpless. Breast is the most common normal response in this image. Rejection of breast may indicate deprivation/ conflict with her mother during childhood. Those who lost their mother during childhood, lived away from their parents, or reared by grandparents, often reject this image. A female having sexual trauma may also reject this image. She has left her father’s home and stayed with her maternal grandpas for many years. Image 18: “A woman and a man with brains''. The brains may indicate arguments and conflict between father and mother, which the client has witnessed during her childhood. Image 19: “Two people.” Normally people perceive father and son- a healthy response. Avoiding perceiving a father may indicate her deep-rooted conflict with her father which should be addressed during therapy sessions. Such feelings, if not addressed, may lead to hatred towards male partners in future. Image 20: Looks like “Two people are sitting and having conversation” is a normal response. It may also indicate her smooth relationship with others. Image 21: I see “knives” may indicate aggression. Image 22: “Heart” is a normal response and sign of healthy body imagery and good interpersonal relationship. Image 23: “Water waves with a fish”. It is Freudian symbolism indicating active erotic involvement. It should be addressed during therapy sessions. Image 24: I see “Broken Earth with heart”. The response may indicate frustration and a broken love relationship. Image 25: “Gun” may indicate passive aggression. Image 26: “A person lying down with thoughts”. Normal response Image 27: “A baby seeing his reflection” looks like a normal response. Image 28: “A mother with baby hugging” indicates a caring mother with a very happy interpersonal relationship. Image 29: “A sad man is kicking something” may indicate her pensive mood and aggressive behavior. This may also indicate her revenge to punish the perpetuator. Image 30: “Fourpeople holding each other, two adults and two small”. She failed to perceive “A family of father, mother and two children'.' The most common response in this image may indicate poor interpersonal relationships between parents and children or among close family members. The theme of conflict with the father shown on image 19 is supported by her response in this image also. This should be addressed during the therapy session. Indices based Quantitative Analysis: Her total number of responses are R = 40, indicating high productivity and functioning intelligence. The presence of a high percentage of Human responses 17 (42.5%) (more than 25 %) may indicate that the person can maintain a smooth interpersonal relationship with others. The low number of Animal 6 (15%) responses may restrict outlet of aggression. The Most Typical responses (MT=11) are just on the border. Such people show poor adjustment. Often, they invite conflict because they are misunderstood by others. The Anatomical responses: 6 (15%) are within normal range. The preponderance of more than 10 percent of other contents 11 (27%) may indicate anxiety. It may also be an indicator of evading reality and psychological disturbances. She has avoided perceiving male or female phallic contents which may be because of her traumatized encounter. A high number of Movement responses are associated with high fantasy, creativity, functioning intelligence, and active involvement. High M response is also correlated with an introverted personality. Her score on Depression scale (D=3) may indicate mild depressive symptoms. Other scores on PAS, HAS, Paranoia are within normal range.

The qualitative / Psychoanalytic interpretation: Overall, the SIT responses indicate good interpersonal relationships with mother-figure and colleagues (images 18/20/28), She has projected libidinal conflict, somatic anxiety, sexual assault, and repugnant emotion (Images 2/7/10/14/16). Poor interpersonal relationship with father, parental deprivation, family conflict or family disintegration, authoritarian parenting is reflected (Images 13/19/30). Her responses also indicate loss of happiness from life, sufferings, feeling of helplessness and sexual assault. She finds herself in a situation that she is unable to cope with and attempts to seek spiritual support (Image 5/8/15/17). She has also projected desires to have intimate relations, conflicting relationships with partner/friend, and frustration in broken love relationships (Image 9/23/24).

Conclusion: The interpretation of indices-based analysis and content analysis does not go hand to hand. The indices could indicate basic personality of the person whereas content analysis/ psychoanalytic interpretation brought to the surface her suffering and repressed unconscious materials needed for processing during therapy sessions. Both cases are advised to undergo at least 10-15 sessions of psychotherapy. The first case has reported significant improvement after 4 sessions of psychotherapy. The second case has reported improvement after 3 sessions of psychotherapy.

References: Boland R., Verduin, M. & Pedro Ruiz, P. (2015). Kaplan and Saddock”sSynopsis of Psychiatry, Eleventh Edition, Wolters Kluwer Publication, Philadelphia, p. 497 Cassell, W, A. and Dubey, B. L. (2003). Interpreting Inner World through Somatic Imagery: Manual of Somatic Inkblot Series. SIS Center, Anchorage, (USA) Compagnoni, N. and Dubey, B.L. (2020). Somatic Imagery Test (SIT) as a Measure of Trauma Resolution in a Case of Abortion (2020) SIS J. Projective Psychology & Mental Health, 27(2), 105-111. Dubey B. L., Banerjee P. & Dubey Anand (2019). Inkblot Personality Test: Understanding the Unconscious Mind, SAGE NY. Dubey, B.L., Cassell, W. A., Manickam, L.S.S. and Singh., A. R. (2005). Efficacy of Somatic Inkblot Test in Personality Assessment, Diagnostic Evaluation and Therapeutic Intervention. Indian J. of Clinical Psychology, 31, 10 -23. Dubey, B.L and Dubey, Anand. (2012). Application of SIS in Business Organization, SIS Journal of Projective Psychology & Mental. Health, 19: 43-47. Dubey B.L. & Dubey A. (2018). Manual of Somatic Imagery test. Dubay Healing Center, 7490 Coon Club Rd. Medina, OH 44256 (USA) Dubey, B.L. & Dubey, Anand. (2021). Manual of Somatic Imagery Test, SIS Journal of Proj. Psych & Mental. Health, 28: 2, 83-112. Dubey, B.L.; Kumar, R. and Dubey, Anand. (2018). Somatic Inkblot Series and the Journal of Projective Psychology & Mental Health: Inception to Silver Jubilee, SIS Journal of Projective Psychology & Mental Health, 25: 1, 5-34. Philips L & Smith J. (1953). Rorschach Interpretation- Advance technique, New York, Grune Schaefer, R. (1954). Psychoanalytic Interpretation in Rorschach Testing.Grune & Stratton, Inc., New York. Singh, S. and Dubey, B.L. (2020). Therapeutic Intervention through Somatic Imagery Test - A Case Study (2020) SIS J. Projective Psychology & Mental Health, 27(2), 112-115. Singh, S. & Dubey, A. (2021). Somatic Imagery Test as a tool for Assessment of Hostility and Aggression: Case Analyses. SIS Journal of Projective Psychology & Mental. Health, 28: 1, 53-57. Singh, S. & Dubey, B.L. (2022). Intervention using Somatic Inkblot Test in Sexual Deviance - A Case Study, SIS Journal of Projective Psychology & Mental. Health, 29: 1, 51-56.

This paper explored the effect of variation of post-hypnotic suggestion on the management if dissociative conversion disorder in an adult woman. These suggestions were individualized for the patient using findings from the projective tests like Thematic Apperception Test and Sentence Completion Test. The tests were done during baseline phase and postintervention phase. The patient had significantly lesser conflicts, improved attitude towards parents, greater selfconfidence, and improved compassion towards herself during the post-intervention phase. Also, 9 sessions of hypnosis were done to reach complete recovery, but the patient showed significant improvement in the symptoms of dissociative conversion just after 2 sessions of hypnosis. Secondary gain also needed to be controlled during the final phase of the psychotherapy session in order to achieve completely recovery from dissociative conversion. The patient was followed up for 8 months thereafter. Currently, the patient is no longer having dissociative conversion attacks.

Introduction: Patients having dissociative conversion are more susceptible to hypnosis compared to control group. Also, the more intense the symptoms of conversion, the higher is the hypnotic susceptibility of such patients. Hypnosis in combination with Rational Emotive Behavior Therapy has been used to treat patients having panic attacks. Sixteen sessions were done with the patient and the patient had only one panic attack after 3 years since completion of treatment (Singh & Banerjee, 2002). Moene et. al (2002) could successfully treat dissociative motor conversion using regular treatment methods in a randomized controlled trial and concluded a comprehensive psychotherapeutic program is more beneficial in treating symptoms of motor conversion, irrespective of the application of hypnosis. Lynn et. al (2002) demonstrated that there is an ambivalent relationship between hypnotic suggestibility and psychotherapeutic outcomes of dissociative conversion. Sengar et. al (2003) have treated male erectile dysfunction successfully using hypnotherapy. Oakley (2006) used hypnosis as a tool in experimental psychopathology research and found that for patients having dissociative motor conversion, during hypnotically induced motor paralysis of patient’s leg, neurological reading showed that patient genuinely tried to move the leg but was unable to do so. Iglesias & Iglesias (2009) used information about motor conversion from patients by interviewing them using the Hypnotic Diagnostic Interview for Hysterical Disorders and used this data to effectively manage the conversion symptoms. Indian research has also applied hypnotherapy in treating anxiety, post-traumatic stress disorders, panic attack, phobia, substance abuse, psychogenic impotence, psychogenic amnesia, nocturnal enuresis and erectile dysfunction (Singh, 2016). According to Bell et al. (2011), hypnotic trance results in a constellation of perceptual and cognitive alterations which are characterized by disruptions in otherwise intricate and integrated psychological systems. These disruptions are responsible for creating higher acceptance to suggestibility in patient. Also, individuals having dissociative disorders may have impaired working memory and lack of cognitive control. Hence, they respond to verbal suggestions with poorer cognitive resources resulting of poorer executive functioning control (Terhune et. al, 2017). Thus, post-hypnotic suggestion during the hypnotic trance works well in strengthening cognitive control and higher order executive functioning. Hypnotherapy is also effective in producing positive outcomes in psychological blindness and deafness due to conversion disorder (Kundalia, Agila & Chandrani, 2019). Wieder et. al (2022) showed that increased hypnotic suggestibility leads to better treatment outcome in dissociative conversion disorder. However, these previous studies have not shown how the nature of post-hypnotic suggestion sometimes needs to be varied between sessions in order to fit the needs of the patient and help to manage the patient better. Hence this study is being reported as a single case study to show the effect of variation in post-hypnotic suggestion to manage a patient

having dissociative conversion. Also, in most studies, hypnosis is usually used as an adjunct to other cognitive and behavioral therapies. However, in the current study hypnosis was used as a standalone treatment method. Case report: The index patient, Ms. A. K., 25 years old, female, Hindu, Hindi speaking, belonging to the urban area of Jamshedpur, currently pursuing Graduation, unmarried, unemployed was brought to RINPAS Stress Management Clinic with complaints of losing consciousness multiple times every day, increased palpitations, pain and heaviness in chest, dryness in mouth, decreased appetite for 6 months. Family history did not reveal any psychiatric illness. However, personal history revealed that the patient was having strained relationship with her father. She practiced switchboard communication with her father involving her mother into it to avoid direct confrontation and criticisms. Her mother was mostly indifferent to patient’s symptoms. As reported by her parents, the patient was not on any psychotropic medication for her symptoms. Findings of assessment: Sack’s Sentence Completion Test (SSCT): This test was administered to assess the interpersonal conflicts and attitudes of the index patient. It was found that the patient has been significantly disappointed with her father because “she wanted her father to let her study more instead of getting her married off”. It was also found that she wanted to establish herself as a professional but felt sad since she perceived her family as unsupportive which hindered her progress in professional field. Thematic Apperception Test (TAT): The TAT was administered to assess the dynamics of personality of the index patient. In the TAT it was found that the patient perceived herself to be helpless and lacking in confidence. It was also found that she found herself to be subjugated by her father, because of which she perceived her environment to be mostly dominating. As a result of this, she also had a Need for Aggression towards her father as found from the analysis of her responses to TAT cards. Mother was perceived to be mostly unsupportive towards her and she had an ambivalent attitude towards her mother. She also felt that her parents put more importance to her sibling’s needs and demands than hers, because of which she perceived her environment to be depriving. There was a need for succorance and a need for affiliation as well. Her anxieties revealed fears of deprivation and lack or loss of love and being deserted. Conflicts revealed autonomy versus compliance which was evident as she learned to take autonomy from the perceived authoritarian father while being submissive to him at the same time. In view of above findings, the post-hypnotic suggestions focused on building a sense of self-efficacy in the patient (you do whatever is right for you no matter what others say…you are a strong woman). Her perception towards her parents was altered from being perceived as punitive to being perceived as supportive so that she could auto-suggest herself to stand up for her rights and be assertive about her own needs and demands from her family, especially her father. Stanford Hypnotic Clinical Scale: She scored a plus in the items – Hand Lowering, Arm Rigidity, Dreams, Age Regression, and Posthypnotic response. She did not score plus in auditory hallucination suggestion. Overall, these indicated that she had adequate susceptibility to hypnosis. Method and outcome of treatment: Nine sessions were conducted with the patient. Treatment modalities consisted of – A. Hypnosis and Post-hypnotic suggestion B. Controlling Secondary Gain

Initial sessions: Sessions were conducted at an interval of two weeks. During the baseline phase, she was having dissociative conversion episodes, that is, she was losing consciousness thrice to four times in a day. However, just after two sessions of hypnosis and post-hypnotic suggestion, the frequency of the conversion episodes decreased to around thrice to four times in a month. After the third session of hypnosis, the frequency decreased even further to once to none in a month as per the reports of her parents. The intensity of the dissociative symptoms also decreased after hypnosis – during the baseline phase, she remained unconscious for 2 to 3 hours at a stretch. However, after the third session of hypnosis, the duration of remaining unconscious decreased to around 20 minutes. Standardized instructions given for Induction and Deepening stages by Brann, Owens, Williamson (2012) were used to induce hypnotic trance in the patient. After deepening was done, it was checked to see if it was induced properly by giving ideo-motor suggestion of lifting her hand to the patient. After she lifted the hand above 6 inches, could hold it for a minute and put it down again, the following post-hypnotic suggestion was given – “….And now you are at a place where any suggestions you give yourself will sink deep down into your mind and begin to exert an effect on how you think….how you feel…how you behave….so that each time you use these techniques it will help you become more relaxed….now in a few moments…I invite you to consider yourself to be someone who is very strong and bold… You are expressing your own difficulties assertively to other people…you are standing up for your own rights to others…. You are an independent, strong woman….You do whatever you feel is right for you no matter what others say….You express your opinions and perspectives clearly to the other person….You take decisions for yourself....You communicate to your parents that you would marry only when you want to marry....You complete your studies at the earliest…start working. And then you might marry as you wish it to be…You express this wish clearly to your parents…your parents are your well-wishers…They are supportive in your decisions with marriage and career…And henceforth, you will not lose consciousness during conflicting times….You feel comfortable in communicating your needs and desires to your parents assertively….You will not lose consciousness anymore from now on in the event of a conflicting situation….(post-hypnotic suggestion ends here)…And take a deep breath in and breathe out….another deep breathe in…and exhale… and Now you are completely relaxed…Take a few more deep breaths…” The post-hypnotic suggestion was given for 5 minutes at a stretch. Thereafter, the patient’s attention was gradually brought back to the present situation, and she woke up. However, after three more subsequent sessions, it was seen that, the patient progress ceased to happen. That is, even after repeated application of hypnosis and controlling secondary gain she was still having at least one or two conversion episodes for 15 to 20 minutes in a month and had significant anxiety in the form of palpitations, dry mouth. Hence it was decided that now the narrative of post-hypnotic suggestion has to be changed in order to now guide her towards a sense of recovery and instill relaxation in her. Final Sessions: During the final phase of the treatment, 4 more session were conducted. As has been already mentioned, the post-hypnotic suggestion was now changed to – “….And now you are at a place where any suggestions you give yourself will sink deep down into your mind and begin to exert an effect on how you think….how you feel…how you behave….so that each time you use these techniques it will help you become more relaxed….now in a few moments….I invite you to realize that now you are completely out of all your difficulties… You are having a pleasant state of mind now….and now

that you are completely relieved you strive to realize your academic potential…to the maximum of your capability…and you continue to exercise the autonomy that you have gained…to complete your studies in the way that you have planned….and standing up to your parents, especially your father…in expressing your needs regarding your career and academics….and you will reach to the point in life where you want to reach…gaining financial independence….having a well-paying job as a teacher in school as you had always wanted…And you experience a feel-good thing about yourself engaging into this new venture….You are more confident about yourself now…..Discovering yourself in a new light…Being self-reliant and confident about yourself….Keeping the past behind and looking towards a bright future that lies ahead of you….Letting yourself eventually marry a man who suits your needs while building a career of your choice….marriage and building a career are not conflicting goals in life…..letting yourself pursue both simultaneously….Willing to work even after marriage…Finding a man who suits your preferences regarding career and views about life…Stating this need to your family, your father….(post-hypnotic suggestion ends here)…And in a few moments…Taking a few deep breaths in and out….Again breathe in and out….again…” This post-hypnotic suggestion was again given for 5 minutes after which the patient was gradually brought back to consciousness into the present moment. Also, during the final phase of the therapeutic regime, it was seen that the patient’s parents still served to maintain some secondary gain out of parental concern, as they still attended her and cared for her when she lost unconscious. This was serving to maintain her residual symptoms and was hindering her recovery. Hence, the parents were psycho-educated again to not pay any attention or offer any interpersonal care to the patient while she lost consciousness as that would come as a reinforcement for the patient and would serve to maintain her residual symptoms for longer durations. They were also psycho-educated that such behavior would also hinder the development of her sense of independence. Hence, after 9 hypnosis sessions and better control secondary gain simultaneously, it was found that the patient had no dissociative conversion episodes, as reported by patient herself and her parents. TAT and SSCT were done again during the post-intervention phase and the findings suggested that the patient had better sense of self-control, regained sense of autonomy and self-efficacy, viewed herself in a more favorable light than earlier, became more assertive and forthcoming than before and presented herself to others with more confidence than earlier. She also developed more favorable and more empathetic attitude towards her parents and became more compassionate towards herself after the psychotherapy. Thereafter, three in-person and four telephonic follow-up sessions were conducted. The patient herself, and her family again reported that she was maintaining well and did not have any episodes of dissociative conversions, palpitations, and anxiety for up to 8 months since follow up. It has been three months now since the last followup and she is currently maintaining well. Discussion: Hypnosis is a very common method for treating dissociative conversion disorder and is often considered as a first line treatment for dissociative disorders. There have been many studies till date showing its efficacy in such patients. The psychodynamic model states that patients having dissociative conversion experience have emotional conflicts but are unable to express them verbally or otherwise. Hence these emotional conflicts are repressed in their unconscious and later on expressed in the form of conversion symptoms (Peeling & Muzio, 2022). Hypnosis lowered the patient’s conscious inhibition so that the clinician had access to her unconscious while she was in the hypnotic trance state. During this time, the clinician accessed her emotional conflicts and interpersonal inhibitions and in the post-hypnotic phase suggested her to be forthcoming about her needs in an assertive way, stand up for her own rights and to not lose consciousness in a conflicting situation. These

suggestions got ingrained in her sub-conscious mind and thus she could auto-suggest the same to herself outside session. This brought about a decrease in her symptoms. Gironell et. al (2021) assessed the efficacy of clinical hypnosis in a case series taking 50 patients having functional neurological disorder or conversion disorder. He used indirect hypnotic suggestions like puns, questions and implications which caused interruptions and disruptions in the patients’ direct consciousness and facilitated them to accept direct suggestions. Usually, hypnosis is usually suggested to be used as an adjunct to other cognitive and behavioral therapies. However, in the current study hypnosis was used as a standalone treatment and the behavioral intervention to control secondary gain was in fact used as an adjunct to hypnosis. There are various kinds of dissociations namely dissociation of identity, memory, and consciousness. Since dissociative conversion disorder is a disorder defined by the dissociation of consciousness, hence accessing the patient’s sub-conscious and unconscious by taking her to hypnotic trance to treat the conversion symptoms was efficacious in decreasing the patient’s psychopathology (Singh & Kumar, 2020). Rafiq & Zaheer (2018) used Circle therapy in hypnosis. Only two sessions of hypnosis were conducted in this study and the symptoms of conversion completely and the patient maintained well for 11 months thereafter. This is like the current study where the patient showed significant improvement after only two sessions of hypnosis. To explain the findings of the study neurologically, the activation of alpha waves during hypnotic trance might have lowered cognitive inhibition in the patient, making her suggestible to external suggestion from the clinician. However, gamma waves are activated in the brain during hypnotic trance especially when there is focal cortical activation in the brain (Lamb, 2011). Hence, there might have been focal cortical activity in the brain resulting in gamma wave activation during the post-hypnotic suggestion (Jensen, Adachi & Hakimian, 2015). However, a conclusive statement about the nature of brain waves could not be drawn from the present study because EEG could not be used to measure the same. However, a distinct feature of the current study is that here, the narrative of post-hypnotic suggestion was changed and individualized in the final or later phase of the study to meet the patient’s needs. That is, the posthypnotic suggestion narrative was formulated in a way such that it alleviated the need for cognitive control to maintain submissiveness to her father and instead instilled the sense of autonomy. This sense of autonomy in turn might have helped her to gain conscious control over academic potential, confidence, helped her to be assertive about her needs and direct suggestion was also given about the same as individuals who go through hypnosis exhibit greater cognitive control than control patient. This is like an Indian study where hypnosis was used in conjunction with rational emotive behavior therapy to treat panic attacks and the results showed increased sense of control, improved self-confidence, and elimination of pathological psycho-physiological symptoms (Singh & Banerjee, 2002). The mechanism of cognitive control in hypnosis is also used in similar other illnesses like irritable bowel syndrome and psychosomatic disorders. The suggestive effects also work with the effectiveness of placebo psychotropic medicines in symptom relief or pain reduction. Hypnosis also works similarly as a non-deceptive placebo effect (Terhune et al., 2017). The results of this study can be used in psychosomatic illnesses like somatoform disorders, anxiety disorders, acute stress reactions and even in behavioral syndromes like eating disorders, sleep disorders and sexual dysfunctions. The post-hypnotic suggestion may be varied in its nature of delivery and its content at every stage of the progress of the treatment to achieve maximum treatment efficacy in the individuals. In future, it is therefore recommended to use hypnosis as a primary mode of treatment in suggestible individuals to treat the mental disorders mentioned above to have longer lasting effects. Also, the current study showed how hypnosis produces quick and effective results in treating dissociative illness which might be a promising finding for its use in further research with patients susceptible to hypnosis. However, EEG was not used in the current study to monitor the patient’s brain waves during different stages of hypnosis.

References: Bell, V., Oakley, D. A., Halligan, P. W., & Deeley, Q. (2011). Dissociation in hysteria and hypnosis: evidence from cognitive neuroscience. Journal of neurology, neurosurgery, and psychiatry, 82(3), 332–339. https://doi.org/10.1136/jnnp.2009.199158 Franny C. Moene, Philip Spinhoven, Kees A.L. Hoogduin & Richard Van Dyck (2002) A Randomized Controlled Clinical Trial of a Hypnosis-Based Treatment for Patients with Conversion Disorder, Motor Type, International Journal of Clinical and Experimental Hypnosis, 51:1, 29-50, DOI: 10.1076/iceh.51.1.29.14067 Gironell, A., Badosa, J. M., Roig, A., Tuccillo, R., Marconi, G., Muñoz, M., Ribosa, R., Camino, A., Juan, E., Ripol, A., Camino Vallhonrate, A., Juan Linares, E., Ripol Puig, A. Feixas, G. (2021). Efficacy of Clinical Hypnosis in Functional Neurological Disorders: Experience in a Consecutive Series of 50 Patients. [Eficacia de la hipnosisclínicaenlostrastornosneurológicos funcionales: Experienciaenunaserieconsecutiva de pacientes]. Revista de Psicoterapia, 32(119), 113-127. https://doi.org/10.33898/rdp.v32i119.472 Iglesias, A., Iglesias, A. (2009). The Hypnotic Diagnostic Interview for Hysterical Disorders, Pediatric Form. American Journal of Clinical Hypnosis. 52: 1. Pp 35-43 Jensen, M. P., Adachi, T., & Hakimian, S. (2015). Brain Oscillations, Hypnosis, and Hypnotizability. The American journal of clinical hypnosis, 57(3), 230–253. https://doi.org/10.1080/00029157.2014.976786 Kundalia, ChiragAshok & Agila, C & Chandrani, KalpeshV. (2019). Hypnotherapy in the treatment of conversion disorder blindness and deafness type. Annals of Indian Psychiatry. 3. 10.4103/aip.aip_23_19 Lamb, C.S. (2011) Hypnotically-Induced Deconditioning: Reconstruction of Memories in the Treatment of Phobias; American Journal of Clinical Hypnosis, 28:2, 56-62, DOI: 10.1080/00029157.1985.10402635 Lynn, S. J., Shindler, K., Meyer, E. (2003) Hypnotic Suggestibility, Psychopathology and Treatment Outcome. Sleep and Hypnosis. 5(1):17-25 Peeling, J.L., Muzzio, M.R. (2022). Conversion Disorder. Bookshelf ID: NBK551567PMID: 31855394, https://www.ncbi.nlm.nih.gov/ books/NBK551567/ Rafiq, M., Zaheer, S. (2018) Management of non-epileptic seizures through hypnosis – A Case Study. Pakistan Journal of Neurological Sciences. Vol. 14, Issue 1. Pp: 37-41 Roelofs, K., Hoogduin, K. A., Keijsers, G. P., Näring, G. W., Moene, F. C., & Sandijck, P. (2002). Hypnotic susceptibility in patients with conversion disorder. Journal of abnormal psychology, 111(2), 390–395. https://doi.org/10.1037//0021-843x.111.2.390 Sengar, K.S., Singh, A. & Manjhi, K. C. Chakaraborty, P.K. (2003). Treating acquired male erectile dysfunction with hypnotherapy – A Case Report. Indian Journal of Clinical Psychology, 30 (1&2). 79-82 Singh, A.R. & Banerjee, K.R. (2002). Treating panic attack with hypnosis in combination with Rational Emotive Therapy-A Case Report, Singh, A.R. (2016). The Induction of Hypnosis: A New Method. Indian Journal of Clinical Psychology. Vol. 43, No.2, pp: 78-84 Terhune, D. B., Cleeremans, A., Raz, A., & Lynn, S. J. (2017). Hypnosis and top-down regulation of consciousness. Neuroscience and biobehavioral reviews, 81(Pt A), 59–74. https://doi.org/10.1016/j.neubiorev.2017.02.002 Wieder, L., Brown, R. J., Thompson, T., Terhune, D. B. (2022). Hypnotic suggestibility in dissociative and related disorder: A metaanalysis. Neuroscience and Biobehavioral Reviews. 139 (104751). https://doi.org/10.1016/j.neubiorev.2022.104751

Understanding and treating OCD can be one of the greatest challenges facing mental health professionals. Experts recommend cognitive- behavioral therapy (CBT), which includes a heavy component of exposure and response prevention (ERP), the first- line treatment of choice for mild to moderate cases of obsessions and compulsions. Since, traditional ERP is mostly based on western philosophies, mindfulness strategies, which are more relatable to the Indian population, has been used as an adjunct to ERP and cognitive restructuring for the treatment of OCD. The present study aimed to examine the effect of mindfulness as an adjunct to ERP and cognitive restructuring on individuals diagnosed with OCD. The individuals (n= 4) were assessed in the domains of thought control using the Thought Control Questionnaire (TCQ), emotional schema using the Leahy Emotional Schema Scale II (LESS II), quality of life using WHOQOL - BREF, dysfunctional attitude by the Dysfunctional Attitude Scale –Short Form 1 and Y- BOCS total score, pre and post therapeutic intervention.It was found that mindfulness as an adjunct to CBT led to improved thought control, better quality of life, lower dysfunctional attitude and lesser severity of symptoms. It further highlights the need for developing therapeutic strategies more suitable for the Indian culture which would have a wider applicability.

Introduction: Understanding and treating OCD is a challenging task to mental health practitioners. OCD has an estimated lifetime prevalence of 2.3 % (Ruscio et al., 2010). An epidemiological study from India found the lifetime prevalence of OCD to be 0.6% (Reddy et al., 2010). A long-term follow-up study by Skoog and Skoog (Skoog & Skoog, 1999) demonstrates that OCD tends to take a chronic course, with a waxing and waning of symptoms over a lifetime. Although it is difficult to reach a definitive conclusion about the natural course of OCD, it may be said that most individuals with the disorder experience an early but insidious onset in adolescence or early adulthood, with a mixture of obsessive and compulsive symptoms that build during periods of stress and possibly subside during intervals of relative stability. This pattern of waxing and waning symptoms can continue over several years until their severity progresses to the point where the person finally seeks treatment (Clark, 2006). People with OCD may have symptoms of obsessions, compulsions, or both. These symptoms can interfere with all aspects of life, such as work, school, and personal relationships. Obsessions are unwanted, unacceptable intrusive and repetitive thoughts, images, or impulses that are associated with subjective resistance, are difficult to control, and generally produce distress even though the person having such thoughts may recognize their senselessness (Rachman et al., 1971). Their content often focuses on troubling, repugnant, or even nonsensical themes about dirt and contamination, aggression, doubt, unacceptable sexual acts, religion, and orderliness, symmetry, and precision. Compulsions, on the other hand, are repetitive, stereotyped behaviors or mental acts that are usually performed in response to an obsession to prevent or reduce anxiety or distress (APA, 2000). A compulsion is generally accompanied by an especially strong urge to carry out the ritual resulting in a diminished sense of voluntary control over the ritual (Rachman, 1993). Subjective resistance is often present, but the person eventually gives in to the overpowering urge to perform the ritual. Washing, checking, repeating specific behaviors or phrases,

ordering (rearranging objects to restore balance or symmetry), hoarding, and mental rituals (i.e., repeating certain superstitious words, phrases, or prayers) are the most common compulsions. Despite its effectiveness, some qualifications must be noted about ERP. Foa and colleagues, as well as other investigators (Foa, 2010), found support for the behavioral model from which ERP is derived. In their first trial with 21 patients (Foa & Goldstein, 1978), 86% had stopped ritualizing after treatment, but only 57% improved substantially on obsessions, suggesting that compulsions responded more to ERP than obsessions. Approximately 25 % of individuals refuse ERP, and another 3-12% will not complete therapy (Foa et al., 1984). If a conservative estimate of 30% is used for refusers and dropouts, then the post treatment efficacy of ERP is reduced to 63% of patients seeking treatment for their OCD. The term “mindfulness” has been used to refer to a psychological state of awareness, a practice that promotes this awareness, a mode of processing information, and a character logical trait (Brown et al., 2007; Katz, 2014; Kostanski & Hassed, 2008; Siegel, 2009). The word mindfulness originally comes from the Pali word sati, which means having awareness, attention, and remembering (Bodhi, 2000). According to Hershfield and Nicely, (“Jon Hershfield and Shala Nicely - Everyday Mindfulness for OCD,” 2017) authors of „Everyday Mindfulness for OCD‟, mindfulness meditation is very similar to the ancient Indian practice of Vipassana. They cite that there is no one perfect way to meditate for OCD, but the vipassana tradition is probably the most appropriate for these purposes. Vipassana is a Pali word that can be translated as „insight meditation‟. In this type of meditation, we gain insight in part by focusing on the body and its sensations, and most commonly, on the breath. In a larger sense, vipassana is a series of philosophical and moral perspectives, but one of the tools used to achieve this perspective is a form of meditation that involves training the mind to become aware of when it is distracted by thoughts or feelings and to remain attentive to the present moment (Goldstein, 2016). While it may be assumed that all meditation practices equally benefit the practitioner, research rather intriguingly suggests that different styles of meditation practice elicit different brain activity patterns (Cahn & Polich, 2009; Cahn & Polich, 2006; Lutz et al., 2007; Valentine & Sweet, 1999). For example, mindfulness meditation more than concentrative forms of meditation (e.g., focusing on a mantra) has been shown to stimulate the middle prefrontal brain associated with both self-observation and metacognition (Cahn & Polich, 2006; Siegel, 2009) and foster specific attentional mechanisms (Valentine & Sweet, 1999). With the advancement of neurological technology, mindfulness researchers are examining distinct components of mindfulness meditation such as focused attention, open monitoring (nonjudgmental moment-to-moment observation of one‟s experience), and loving-kindness compassion practice and their specific physiological outcomes (Lutz et al., 2008; Lutz et al., 2007). Training in mindfulness has been incorporated into mindfulnessbased interventions (MBIs) in recent years (Segal et al., 2002); (Kabat-Zinn, 2005). There is increasing evidence that MBIs have positive consequences for psychological (Brown et al., 2007; Keng et al., 2011) and physical health (Grossman et al., 2004), in a broad range of mental health (Chiesa et al., 2015; Hofmann & Gómez, 2017; Strauss et al., 2018) and non- clinical (Eberth & Sedlmeier, 2012) population. A mindfulness- based approach has the potential to reduce drop- out from ERP and to improve ERP task management with an emphasis on accepting difficult thoughts, feelings, and bodily sensations and on becoming more aware of urges, rather than automatically acting on them (Strauss et al., 2015). Despite this wealth of literature, there is a paucity of research of MBIs for OCD (Hale et al., 2013). However, a mindfulness- based approach might be expected to enhance engagement with ERP for three reasons.

First, exposure during ERP elicits intrusive thoughts that the person would typically attempt to eliminate by engaging in compulsive behaviors. It has long been established that intrusive thoughts are common throughout the general population and are not generally problematic (Rachman & de Silva, 1978). Mindfulness- based interventions (MBIs) teach people to allow such thought into awareness without attempting to suppress them and to attend to them non- judgmentally (Segal et al., 2002). Therefore, a mindfulness- based approach to ERP would be expected to enable people to be better able to accept the intrusive thoughts elicited following exposure to triggering situations and to remain engaged in the ERP task despite these thoughts. Second, it is also well established that people with OCD show a heightened intolerance of anxiety (Cougle et al., 2011). Just as with thoughts, MBIs teach people to notice and accept unpleasant physical sensations and anxiety and to disengage from attempts to avoid or eliminate them (Segal et al., 2002). It would be expected, therefore, that a mindfulness- based approach would help people to attend to and accept the physical sensations of anxiety that come about during ERP tasks and to, nevertheless, remain engaged with the tasks. Third, MBIs encourage people to notice the range of behavioral choices they can make in response to an event, rather than reacting to such events automatically (Segal et al., 2002). A mindfulness- based approach to ERP should, therefore, support people to better recognize their urges to engage in compulsive behaviors and to make the choice to resist these urges during ERP tasks. An exploration in combining mindfulness with CBT found that „far from undermining the process, mindfulness complements or even enhances [CBT]” (Fairfax, 2008). Hershfield, director of The OCD and Anxiety Center of Greater Baltimore in Hunt Valley and Corboy, founder of the OCD Center of Los Angeles specialize exclusively in the treatment of OCD and related anxiety-based conditions by focusing entirely on the integration of traditional CBT with the principles of mindfulness and acceptance. They have both been mentors of various patients suffering from OCD and have successfully helped them cope with their disorder. They along with many other therapists and mindfulness experts have laid down various strategies by which mindfulness and CBT can be integrated and applied as therapy to patients suffering from OCD. In India, most people tend to seek treatment from alternative systems of medicine such as Ayurveda, Homoeopathy, Yoga and visit a psychiatrist only if the problem persists. People who are comfortable seeking professional mental health services, still, largely confuse between psychiatrists and psychologists and prefer quick medicine-based cures rather than talking therapy (Kumar & Gupta, 2012). Indians tend to favor treatment that is directive, structured and short term. In the Indian set up, therapists are usually viewed as an expert and the client is generally used to expecting and accepting authority (Kumar & Gupta, 2012). Thus, CBT being structured, goal- directed and time limited may be considered suitable for the Indian population. However, to be effective, CBT must build on an understanding of the Indian value system, the cultural heritage and life events of Indian clients. Keeping this in mind, it is assumed that the Indian population will be better able to identify with the therapeutic process when mindfulness techniques are incorporated within CBT rather than the implementation of traditional CBT which is mostly based on western philosophies. Method: The work has been carried out in the department of Clinical Psychology Center of University of Calcutta. The sample consisted of two males and two females, all with average intellectual functioning and diagnosed with OCD (mild- moderate category as assessed by Y- BOCS). They were assessed on the domains of thought control, emotional schema, quality of life, dysfunctional attitude, and their overall Y- BOCS scores were calculated. After obtaining consent, the individuals were invited to take part in psychotherapeutic intervention comprising of CBT and mindfulness, after which they were again assessed in the above-mentioned domains (i.e., thought control, emotional schema, quality of life, dysfunctional attitude) and their overall Y- BOCS

scores. The pre and post intervention scores were then compared on the Kruskal Wallis Test in order to assess the effect of the therapeutic intervention. Scales administered: Thought Control Questionnaire (TCQ) by Wells & Davies (1994); Leahy Emotional Schema Scale II (LESS II), Revised by Leahy, 2012; The World Health Organization Quality of Life (WHOQOL) - BREF by WHO (1996); Dysfunctional Attitude Scale –Short Form 1 (DAS- SF1) by Beevers et al. (2007); Yale- Brown Obsessive Compulsive Scale (Y-BOCS) - Self- Report by Goodman et al., (1989a, 1989b). Therapy procedure (Mindfulness training and Cognitive Behavior Therapy): Basic framework for therapy: A total of 15 psychotherapy sessions were conducted. Duration of sessions excluding Exposure Response Prevention (ERP) was 30 minutes. Duration of session including ERP was either 90 minutes/ or until anxiety of the client dissipated completely, whichever occurred earlier (Kozak & Foa, 1997). Session 1: Case History and Mental Status Examination of the clients were conducted and noted down, simultaneously. Pre- intervention measures were obtained. Appropriate rapport was established and consent for therapeutic intervention was taken from the clients. Session 2: The client was psycho educated about OCD in the following areas, i.e., signs and symptoms, epidemiology, lifetime prevalence rate, how the client‟s symptoms matched with that of the disorder, treatment available and why pharmacological treatment along with psychotherapy was required. The rationale for selecting ERP and Cognitive Behavior Therapy as mode of intervention was explained. The treatment was presented as a focused, time- limited intervention comprising 15 sessions and the need for acquisition of skills for coping more effectively with obsessive and compulsive complaints was emphasized. The rationale for including mindfulness principles and practice were explained. Session 3: The Obsessive- Compulsive Cycle was explained. The concept of mindfulness was explained to the client using imagery techniques and he/she was made to engage in a 10- minute mindfulness practice using the breath as an anchor. A 10- minute mindfulness practice was assigned as homework. Session 4: Homework was reviewed. The client was made to engage in mindfulness meditation using breath and body as anchors for 20- minutes and the same was assigned as homework for every subsequent session. Session 5: Homework was reviewed. The process of ERP was explained to the client. The client was explained how mindfulness could play a significant role in bringing awareness to current experiences and could facilitate engagement in ERP tasks. A list of compulsions was made collaboratively with the client and arranged according to their increasing level of distress, to form a compulsive hierarchy. The client was encouraged to design his/her own ERP tasks, i.e., tasks that would elicit maximum levels of anxiety which they were willing to tolerate in relation to specific OCD areas of difficulty. This task was also assigned as homework. Sessions 6-11: Homework was reviewed; the client was engaged in one or more ERP tasks during the therapy session which was preceded by a 10- minute mindfulness exercise; during in- session ERP tasks, ratings of anxiety were recorded after a regular interval of 15 minutes for every client on a blank paper to observe the rise and fall in anxiety during the task. Following this, each client was asked to identify three ERP tasks to conduct each day between therapy sessions and to record daily engagement in these tasks using a diary. In addition, the clients were encouraged to engage in unplanned ERP tasks in daily life when facing obsessional cues, that is, to take as many opportunities to apply the ERP approach to OCD as possible, and this included both planned ERP weekly tasks and unplanned ERP tasks when the opportunity arises.

Session 12-14: Homework was reviewed; the client was engaged in 10- minute mindfulness practice, which was followed by a 20- minute Socratic inquiry about the practices in order to draw out learning, with particular emphasis on the following three areas: non- judgmental acceptance of (intrusive) thoughts; non- judgmental acceptance of physical sensations (of anxiety); a recognition that it is possible to choose whether or not to follow behavioral urges (to engage in compulsive behaviors). Session 15: Post- intervention measures were taken. These were then compared to their respective preintervention measures and the client was adequately informed about the changes. Further inputs from the client were also encouraged. Session 16 and onwards: Further plans of intervention were made based on the post- intervention measures of each client. The following therapeutic elements were planned and carried out based on the client‟s individual needs: to once again review the client on the nature and course of OCD; to ensure realistic treatment expectations including, the presence of residual symptoms and to ensure a clear understanding of the CBT model, ERP and mindfulness; to elicit dysfunctional assumptions and core beliefs, if required, depending upon the suitability of the client, through downward arrow technique and to help him/her elicit alternative ways of thinking; to provide written instructions on response to a relapse of obsessions; to instruct the client to be vigilant about reemerging avoidance, reassurance seeking, or other compulsive and neutralizing responses. Results: Graph 1: Comparison of pre- post intervention measures with respect to thought control i.e., distraction, social control, punishment, worry, re- appraisal, as obtained on TCQ

Graph 2: Comparison of pre- post intervention measures with respect to emotional schema

Graph 3: Comparison of pre- post intervention measures with respect to quality of life i.e., physical health, psychological health, social relations, and environment as obtained on (WHOQOL) – BREF

Graph 4: Comparison of pre- post intervention measures with respect to dysfunctional attitude as obtained on DAS- SF1 and Y- BOCS total score

Discussion: It can be observed from Graph 1, that the clients tend to use more distraction techniques of thought control post intervention as compared to prior intervention. They also tend to use lesser social control, punishment, worry and re- appraisal techniques in the post intervention phase as compared to the pre intervention phase. It can be observed from Graph 2, that the clients tend have an increased validation of their emotions, a better ability to comprehend their emotions, lesser guilt about their emotions, a better ability to understand complicated emotions, assign a greater value to their emotions, a better control of emotions, a greater richness of emotional experience, a more rational self-understanding of emotions, perceive a shorter duration of their emotions, normalizing one‟s emotions, a lesser suppression of unwanted thoughts, lesser degree of rumination, greater expression of emotions and a lesser degree of blaming others post intervention as compared to pre intervention. From Graph 3, it can be observed that the clients tend to experience better quality of life in terms of physical health, psychological health, social relations, and environment post intervention as compared to pre intervention. From Graph 4, it can be observed that the clients tend to have lower dysfunctional attitude and lesser severity of symptoms of OCD post intervention as compared to prior intervention. It was found that mindfulness training

along with CBT would lead to an increase, among clients, in the degree of non- judgmental awareness and acceptance of the various cognitive, behavioral, and affective challenges associated with OCD. Simultaneously, the cognitive and behavioral technique of ERP was found to help clients restructure their cognitive distortions and helped them to reduce their fear of facing anxiety on not performing a compulsion. Limitations: The intervention has been done on a very small set of clients. A large sample size would validate the findings of this study. Conclusion: From the above study, it was concluded that an adjunct of mindfulness strategies and ERP could result in more effective coping with a wide range of intrusive thoughts and anxiety provoking situations. It further highlights the need for developing therapeutic strategies more suitable for the Indian culture which would have a widespread applicability.

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SIS JOURNAL OF PROJECTIVE PSYCHOLOGY AND MENTAL HEALTH (An Official Publication of Somatic Inkblot Society)

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What is the Somatic Inkblot Test (online version)? The Somatic Inkblot test (SIT) is a semi-structured, projective, diagnostic instrument and an adjunct to psychotherapy. The SIT is available at www.dubayhealingcenter.com, with 30 images, was released for quick assessment, after 30 years of intense data collection on clinical, organizational, and normal groups. Researchers have reported high reliability and validity of the test (Dubey et al, 2019) The papers published in the international journal, “SIS Journal of Projective Psychology and Mental Health''(www.somaticinkblots.com) clearly show the advantages of the SIT both in the “individual” as well as “group administration” settings. The SIT automates the entire “psychological test life-cycle” including administration, scoring, interpretation, reporting and diagnostic collaboration. In addition to quantitative analysis, the SIT facilitates and emphasizes content analysis, psychoanalytic interpretation, and symbolic interpretation via a database of research made available as “hints”, “Artificial Intelligence” and case studies. It takes about 30 minutes to complete the test. The technique is based on spontaneous, individually generated responses to semi-ambiguous figures, which elicit intrapsychic associations specific to the person presented with them. The SIT images evoke symbolism and meanings unique to the responding individual. The test responses (Total R, Human, Animal, Anatomical, Sex, Most Typical, Movement, Rejection and Pathological responses) can be differentiated from peer norms and clinical indices and can be analyzed according to internationally recognized psychodiagnostic criteria. The procedure is an adjunct to psychotherapy because responses can be further explored to create a more effective treatment plan, and can be re-addressed in later discussions, providing opportunities to elicit deeply defended material. During the administration of the SIT procedure, clients may abreact emotional conflict raised to consciousness by the images, which can be a therapeutic experience (Cassell and Dubey, 2003). The SIT has an amazingly simple 11 scoring indices common to Rorschach, such as R, H, A, At, Sex, MT/P, Movement, Rejection and Pathological responses (PAS, HAS, Depression and Paranoia). It is less complicated than existing inkblot tests since it emphasizes content analysis. The Test was administered to different clinical groups – Anxiety, Depression, PTSD, Schizophrenia, Sex perpetuators, Criminals, Neurotics, Marital maladjustment, and the findings were very encouraging. The images take the client back in time and helps to verbalize the repressed material lying down in the storage of unconscious mind. Such verbalization is very useful during therapy session. The Test was administered to business executives in different situations and as expected, the data revealed several higher mental functions. These were as follows: productivity, imaginative ability, controlled emotionality, good adjustment, and group conformity. Please visit our website: http://www.dubayhealingcenter.comand take the test to see its simple administration, scoring and interpretation (Quantitative and Content analysis). Please see the Manual of the Test and book “Inkblot Personality Test -Understanding the Unconscious Mind, Dubey, B.L., Banerjee, P. and Dubey Anand (2019) Sage Publications Inc. Please feel free to write for more information and help on our email given below:

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President: Amool Ranjan Singh, Ph.D. Vice President: Anand Dubey, MBA. Editor-In-Chief: Naveen Gupta, Ph.D. Gen. Secretary: Masroor Jahan, Ph. D. Treasurer: Padma Dwivedi, M.A. Joint Secretary: Abhilasha Singh, Ph.D. Editor Emeritus: Bankey L.Dubey, Ph.D.

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Dharmendra K. Singh, Ph.D. Jokaitluangi, Aizawl, Ph.D. K. S. Sengar, Ph.D. Neha Sayeed, Ph.D. N.Premika. Devi, Ph.D. P.K. Gupta, Ph.D. Riju A. Singh, Ph.D. Sanjukta Das, Ph.D. Shivani Tiwari, LL.B. Sweta Bajpayee, Ph.D.

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-ail: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)

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