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Journal of Projective Psychology and Mental Health: Volume 27, Number 1, Jan 2020 Editorial

1. Editorial: Prominent Assessment Instruments in Suicide and PTSD Research on U.S. Veterans, pages 1-5.

Over the past 2 decades, clinicians have expressed extensive research interest in the study of 2 prominent afflictions (Suicide/Suicide Potential; PTSD) affecting veterans in the USA (Bisson et al., 2019; Bohnert et al., 2017; Bush 2012, 2014; Jackson, 2017; Kessler et al., 2017; Shura et al., 2019; Wilson & Keane, 2004; Wisco et al., 2014). From a clinical perspective, both these mental health conditions tend to have high co-occurring rates (DeBeer et al., 2014; Horwitz et al., 2019; Pompili et al., 2013; Watkins et al., 2017). The prospect for efficacious treatment for these conditions resides in the accurate diagnosis and assessment of veterans presenting with various forms of psychopathology and mental health symptoms that may confer either the potential for Suicide (or suicidal ideation) and/or Post-traumatic stress (see Stanley et al., 2019). Thus, the challenges for both mental health providers and VA patients are not only great but indeed potentially life-threatening. In fact, according to VA and government statistics, veterans account for about 20% of all suicides in the USA, over twice the rate of the general population. Moreover, due to the ubiquitous media coverage of ‘veteran suicides’ over the past decade, veterans could be increasingly prone to the effects of ‘suicide contagion’ which can increase the probability of one’s personal risk for suicide (see Wolford-Clevenger et al., 2019).

To date, there is an extensive body of extant literature on the topic of Suicide and PTSD. Moreover, research with a focus on the screening and evaluation of these clinical conditions has been advancing at an exponential pace, culminating in copious books and book chapters addressing the specific issue of assessment and testing of veterans (Bongar et al., 2017; Kearney et al., 2017; Kleespies & AhnAllen, 2017). Moreover, several studies have addressed mental health assessment ‘practices’ with regard to Suicide (potential) and PTSD (see Elhai et al., 2005; Pease et al., 2017). Indeed, this emerging literature prompts an interesting question -- Which tests/assessment protocols are most relied upon by researchers when they formulate investigatory research designs for studies screening veterans for these clinical conditions?

Unfortunately, the answer to this important issue is rather confused. In terms of government guidelines, the Joint Commission’s National Patient Goal (NPSG 15) directs suicide risk assessment for patients who present with emotional or behavioral complaints, and all VA facilities are mandated to comply with NPSG 15 (see Doran et al., 2016). However, according to Green et al. (2017, p. 209), there has been little consensus at VA facilities regarding specific assessment protocols for suicide risk screenings (although the VA has recently addressed this issue to some degree); moreover, these screenings do not usually assess for ‘self-harm’ (e.g., physical fighting, self-cutting). In addition, research has shown that military members inconsistently confirm or under-report critical data-points such as suicide-attempt history (Hom et al., 2019).

To address this critical issue regarding assessment, the current analysis of the recent mental health literature identified the major tests/measures/assessment instruments evident in research studies on the subject areas of Suicide potential and PTSD with a focus on veterans. A Boolean online search of the database PsycINFO, using keywords (veterans + suicide; veterans + PTSD) for years 2013-2019, produced 323 and 1,098 articles for each condition, respectively. The PsycINFO display offers a scroll-down menu option for tests and measures cited in the search results (in terms of frequency of mentions); for comparison purposes, I replicated the search command for all populations under study (so as to gauge any differences between studies overall versus those limited to veteran populations).

Interestingly, these most relied upon tests/measures in research seem to contrast to some degree the most popular tests used specifically by PTSD/trauma clinicians in practice. Although the current findings confirm practitioners’ survey data reported by Elhai et al. (2005) with regard to reliance on the PTSD Checklist, Clinician-Administered PTSD Scale and Structured Clinical Interview for DSM, the Elhai et al. sample favored use of several instruments not found popular in the current analysis of researchers (i.e., Trauma Symptom Inventory, Posttraumatic Stress Diagnostic Scale, the MMPI-2-Keane PTSD Scale, the Impact of Event Scale, the SCL-90 Revised-PTSD Scale). The reason for this discrepancy is not readily apparent, other than that investigators may find some assessment instruments more amenable to research.

Although not listed in the current analysis, the Primary Care-PTSD Screen is currently a standard screening tool used in VA facilities (Calhoun et al., 2010). Noteworthy, the development of novel PTSD measures seems to be an active area of research endeavor (e.g., Del Vecchio et al., 2011), as well as perennial modifications to practice guidelines for the treatment of PTSD conditions (see Courtois & Brown, 2019).

With regard to the issue of suicide, it is somewhat difficult to interpret the current listing of assessment methods used by researchers, as there is a dearth of prior test-usage studies in this clinical area. However, several of the measures used in suicide studies (listed in Table 1) are also used frequently in PTSD research. Apparently, the Columbia Suicide Severity Rating Scale has reportedly been adapted as a tool for the assessment of suicide risk in some VA facilities (Green et al., 2017). In addition, researchers are also focusing on the impact of combat exposure on suicide potential in veterans; the Combat Experiences Scale and the Combat Exposure Scale are most noteworthy in this regard (Corona et al., 2019; Kopacz et al., 2016). At the same time, researchers continue to publish a myriad of assessment approaches in the study of suicidology (Forkmann et al., 2018), including suicide ideation measures specific to veteran populations (Hom et al., 2019). Current psychological assessment protocol at VA facilities mandates the use of the modified PC-PTSD, which includes an item on ‘self-harm’. Undoubtedly, the clinical utility of such a brief screener prompts concerns regarding ‘false negatives’ and the need for a more comprehensive evaluation of suicidal ideation for veterans in need of mental health treatment (Simons et al., 2019).

In conclusion, it appears that researchers, studying veteran samples, tend to rely on both traditional (e.g., Beck scales; see Piotrowski & Lubin, 1990) and domain-specific measures in the study of Suicide and PTSD. It must be noted that more rigorous research on suicide risk assessment is urgently needed, particularly since the current state of the research science in this domain (i.e., risk factors) offers limited diagnostic assistance to practitioners (see Sommers-Flanagan & Shaw, 2017). Moreover, comorbidity factors in suicidal ideation are a much under-researched area of study (see Cheref et al., 2019; Riblet, 2019). Further, the contemporary ‘social networking’ milieu may provide an additional data-source in the assessment of suicide potential for researchers and treatment personnel to consider (Cero & Witte, 2019). Finally, future research efforts should focus on the PTSD-Suicide link, where extant research on efficacious intervention and treatment for posttraumatic states could make a significant contribution in addressing and reducing suicide rates of military veterans.

Chris Piotrowski, Ph.D., Senior Editor, University of West Florida, USA, Email: cpiotrowski@uwf.edu

2. Why Teach Future Psychotherapists to Administer and Interpret Projective Tests? Well, why teach future physicians and surgeons to perform dissections? Stephen P. Joy, pages 6-11.

Personality tests, long a mainstay of clinical training, comprise a diminishing portion of the graduate school curriculum despite increasing evidence of their validity. While defensible given the expanded assessment toolkit and other innovations of contemporary clinical practice, this trend has some limitations. For example, the open ended verbal productions elicited by sentence stems and story prompts closely resemble the material generated by clients in therapy. Mastery of systematic approaches to the coding of sentence completions and TAT stories enables students to develop interpretive skills that will serve them well in standard clinical practice. This paper highlights several rationales to support this conclusion.

3. Using the Rorschach Trauma Content Index (TCI) with Incarcerated Women Jason M. Smith, Carl B. Gacono and Ted B. Cunliffe, pages 12-20.

Based on findings from prior research studies, trauma histories have been found to be ubiquitous in psychopathic women. In this study, the Rorschach Trauma Content Index (TCI) was used to better understand the trauma histories of incarcerated women (N = 180). The TCI was significantly correlated with total reported trauma events, reported sexual abuse, other Rorschach scores (AgPast, ROD), and scales on both the Personality Assessment Inventory and the Trauma Symptom Inventory-2. The TCI may be related more to sexual abuse than physical abuse and the traumatic intrusions appear to be related to borderline features and dependency in this sample. These results suggest that the TCI facilitates our understanding of trauma in the lives of incarcerated women.

4. Pain Assessment: Most Prominent Measures/Tests in the Research Literature,2006-2018 Chris Piotrowski, pages 21-31.

The issue of pain measurement and assessment has attracted intense clinical and research attention, particularly over the past three decades. Hence, pain assessment has become a) a central feature in the study of pain across a myriad of health care disciplines (i.e., medicine, rehabilitation, psychology, nursing, social work, quality of life, and public health), b) a major component of comprehensive pain management, and c) a burgeoning area of applied research. Given the vast landscape of this literature: Where is the practicing mental health clinician to turn in identifying the major pain assessment instruments reported in the recent scholarly literature? To that end, the aim of the current study is to identify the most prominent methods (i.e., measures, scales, inventories, tests) in research, reported in studies with a focus on pain or pain states, 2006-2018. Hence, an extension of a similar study design reported by Piotrowski (2007). Based on a bibliometric examination of the literature, including assessment measures noted in major texts on pain, nearly 200 assessment instruments were identified and determined to be the most visible scales/tests related to the issue of pain. Next, the author conducted an online search in the ProQuest database (restricted to years 2006-2018). Using a Boolean logic search strategy on these instruments, individual searches produced the total number of scholarly articles for each assessment method that was noted in the Abstract of primary articles. This procedure identified 130 measures that were the focus of study in at least 5 articles. Of these, 49 tests appeared in study abstracts more than 100 times. Noteworthy, several of these ‘popular’ tests were measures of psychopathology, outside the specific domain of Pain, such as the Beck Depression Inventory, the STAI, and the MMPI series. Moreover, many of the most popular scales reflect general health assessment and quality of life issues. In addition, the assessment of functional disability was well represented in the top ranked scales/measures (e.g., Oswestry Disability Index, the DASH Questionnaire). Other prominent assessment methods were, the Visual Analogue Scale, the Health Assessment Questionnaire, the Numerical Rating Scale, Brief Pain Inventory, the McGill Pain Questionnaire, the Hospital Anxiety & Depression Scale, the SF-36 Health Survey, the Pittsburgh Sleep Quality Index, and the PROMIS. These findings should provide a seminal template for mapping the extant scholarship regarding preferred methods of assessment techniques used in research on pain. Furthermore, the current analysis points to the vast array of measures and scales on which research findings in pain scholarship are based, which prompts the problematic concern regarding the lack of investigatory cohesion in this rapidly expanding literature and fragmentation of research streams across this multidisciplinary field.

5. Writings as Projective Material Robert B. Williams, pages 32-35.

How writing has been and continues to be a relevant clinical tool and potential source of projective material is discussed. Criterion to produce written projective materials is limited to individuals with adequate reading and writing abilities. Clinical tools/approaches noted are: (1) Sentence Completion Method and Incomplete Sentences Test; (2) clients’ writing thoughts and reflections on therapy sessions and how issues are being faced between sessions; and (3) writing as discussing things with oneself—meanings, values, relationships, life, and one’s future. Written projective material from a young woman’s journal expressing suicidal intentions that were eventually fulfilled is also shared.

6. Emotional States and Coping Patterns of Patients with High and Low Post Traumatic Symptoms Rachana Kumari & Anjana Mukhopadhyay, pages 36-42

A traumatic event is one that threatens injury or the physical integrity of self or others and causes horror, terror or helplessness at the time it occurs. A variety of personal and environmental factors may lead to enduring post traumatic difficulties. The aim of the present study was to investigate the emotional states and coping patterns of patients with high and low post traumatic symptoms. The present investigation selected 12 high and 12 low trauma-affected adult (18 to 40 years) patients, both male and female cases, from various trauma centers of Varanasi. The level of trauma symptoms was assessed with the PTSD checklist civilian version (PCL-C). Emotional state was measured with Eight State Questionnaire and coping pattern was assessed with the Coping Strategies Scale. As hypothesized the emotional states of high trauma affected patients reported significantly high level of emotional states viz. anxiety, stress, depression, regression, fatigue, guilt than the low trauma affected patients. Extraversion and arousal, the two sociable and alert emotional states, however, reported a significantly lower mean among the high trauma subject’s contrary to the assumption. The coping strategies of high trauma affected subjects reported low level of coping pattern than their low traumatic group counterparts and established the hypothesis.

7. Utility of SIS-II in Identifying the Therapeutic Change in Pathological Internet Use Prabha Mishra, Manoj K. Pandey and Krishan Kumar, pages 43-49.

The present case study was an attempt to apply PIPATIC [(ProgramaIndividualizadoPsicoterapéutico para la Adicción a las Tecnologías de la información y la comunicación) having English translation as Individualized Psychotherapeutic Program for Addiction to the Technologies of the Information and Communication] as a therapeutic module to deal with Pathological Internet Use (PIU), which was basically developed for individuals suffering from Internet Gaming Disorder. The former is a more generalized problem. In addition, another objective of this study was to see the utility of SIS-II in detecting personality problems (pretreatment) and to identify the post therapeutic changes in PIU patients. This case study was a unique attempt in its sense that to the best of the knowledge of authors, SIS-II was rarely used in the case of PIU or internet addiction, especially to check out its utility to find therapeutic change. Results of the study revealed that PIPATIC was quite effective in reducing the PIU, which is a more generalized problem than internet gaming disorder and this therapeutic module brought positive changes in intra-interpersonal aspects of the patient. The study further revealed that use of SIS-II is quite helpful either in assessing personality of people with PIU and/or applying it to detect the therapeutic change. Moreover, it was also noticed in this study that SIS-II guides the therapists about unnoticed/remaining areas of difficulty in patients even after the completion of therapy.

8. General Wellbeing and Marital Quality among Spouses of Individuals with Alcohol Dependence Syndrome: A Comparative Study Swarnlata Kumari and Jai Prakash, pages 50-53.

Alcoholism is the most severe form of alcohol abuse and involves the inability to manage drinking habits. It is also commonly referred to as alcohol use disorder. Excessive use of alcohol affects the mental and behavioral health of the user and his family members. Spouses of alcoholics are more likely to be victims of domestic violence, may suffer emotional harm, and become socially withdrawn. The aim of the present study was to examine the quality of life, psychological wellbeing and marital quality among spouses of individuals with alcohol dependence syndrome and spouses of normal control subjects. The study was conducted at Ranchi Institute of Neuropsychiatry and Allied Sciences, Kanke, Ranchi. The sample consisted of 75 participants (50 spouses of individuals with alcohol dependence syndrome and 25 spouses of normal control subjects) fulfilling the inclusion and exclusion criteria. It was purposive sampling which was followed. WHO quality of life scale, PGI general well being, and marital quality scale were administered to all participants. Findings indicated high psychosocial impairment among spouses of individuals with alcohol dependence syndrome than normal controls.

9. An Insight into Psychotherapy: Indian Perspective Padmakali Banerjee and Vikas Sharma, pages 54-56.

Psychotherapeutic interventions are becoming increasingly important in India. Indian literature is full of information related to the existence of knowledge about psychotherapy. The current study reviews the literature related to psychotherapy in Indian cultural context. The training of professionals is largely based on western models. Ancient treatment methods and cultural values need to be combined with modern approaches. This integration will enhance psychotherapeutic effectiveness. The incorporation of cultural factors in psychotherapy will facilitate the adherence and acceptability.

10. On the Declining Use of Projective Techniques in School Psychology: A Response to Piotrowski (2019) Nicholas F. Benson, R. G. Floyd, J. H. Kranzler, T. L. Eckert, S. A. Fefer & G. B. Morgan, pages 57-60.

This article is a response to the recent editorial by Piotrowski (2019). In our article (Benson et al., 2019), we reported results from a national survey of the tests and assessment practices used by contemporary school psychologists in the United States. We appreciate Piotrowski’s (2019) acknowledgement of our results as offering ―a keen perspective on the emerging status and breadth of assessment practices, specific to the field of school psychology‖ (p. 75). Our article focused on a wide range of assessment practices, and Piotrowski’s concerns pertained largely to our presentation and discussion of results regarding projective techniques.

11. Book Review: “Inkblot Personality Test - Understanding the Unconscious Mind” Rakesh Jain, pages 61.

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