The Unconscious Life of the Child with Obsessive-Compulsive Disorder Tamarin Epstein A Research Report submitted to the Faculty of Humanities, University of the Witwatersrand, Johannesburg, in partial fulfillment of the requirements for the degree of Master of Arts in Education (Educational Psychology). Johannesburg, 2006. ABSTRACT This qualitative study explores the unconscious life of four children diagnosed with Obsessive-Compulsive Disorder (OCD) specifically related to self-concept, personality, and psychopathology using a case study approach. A review of literature on childhood OCD is presented and the study is located within a psychodynamic theoretical framework. Findings indicate that the children are emotionally maladjusted, with high levels of anxiety and psychopathology. They have low self- esteem and poor body images, mostly tending towards immaturity. Two of the children have personality disturbances (neurotic, hysterical personalities). All the children have disturbed superegos (harsh or neurotic). Although their symptoms are currently mild, and some have ceased, analysis suggests they have been repressed and continue to affect them. They are sexually preoccupied and conflicted due to the unsuccessful resolution of the Oedipus complex. They have poor impulse control and considerable anger and aggression (mostly overt). They experience their environment as unstable and frightening and have anxieties about physical injury and being watched. The boys have regressed sex drives and homosexual tendencies, and have not identified with their fathers. The girls have identified with their mothers but experience masturbation guilt and blocked sexual drives, causing anxiety and moodiness. The children are all highly defended and escape from feelings of helplessness, inadequacy, and isolation, and discharge anxiety and aggressive instincts by using the defenses of undoing, reaction formation, acting-out, fantasy (sometimes violent), projection, displacement, and intellectualisation. Their strong dependency needs suggest fixation in the oral stage of psychosexual development. They tend towards self-directed aggression and depression. Most have family histories of mood disorders (particularly depression), and obsessions linked to fears of economic hardship due to parental illness or death. Most have histories of anxiety disorders or anxiety-related problems, and family histories of anxiety disorders and/paternal OCD. They all experienced a personally traumatic event precipitating the onset of OCD. i They perceive disconnectedness, conflict, and communication difficulties in their families. They need more parental attention, try to involve family members in their rituals, and leave their parents feeling exhausted and frustrated. There is sibling rivalry in the case of the children with siblings (Mike, Daniel and Jane), and tension has increased between their siblings and themselves since they presented with OCD. They experience social isolation, are hypersensitive to social opinion (especially criticism), and have an exaggerated sense of personal responsibility for events around them, suggesting emotional hypersensitivity. All the children have long experienced difficulty with social skills as a result of their personality styles, and have trouble adjusting to school. Three of the children are introverted and excessively shy. The other child is extroverted and excessively domineering. Their predominant personality tendencies have intensified since the onset of OCD, resulting in further social difficulties. All the children have concentration difficulties and disorders/problems with implications for learning and school achievement. The results of the research make a contribution to knowledge in the area of understanding OCD from the unique perspective of the child?s unconscious life. Impairments in self-concept, psychosocial functioning, family, and peer relationships, and educational adjustment and learning abilities linked to the presence of OCD are indicated. ii DECLARATION I declare that this research report is my own unaided work. It is submitted for the degree of Master of Arts in Education (Educational Psychology) at the University of the Witwatersrand, Johannesburg. It has not been submitted before for any other degree or examination at any other university. Tamarin Epstein day of 2006. iii ACKNOWLEDGEMENTS This research report is dedicated to all people who live with Obsessive-Compulsive Disorder. I would like to thank my supervisor, Dr Gavin Ivey, for his guidance and encouragement. I am grateful to Daryl, for his support, and to Michaela Rose, for sharing her mother?s time and energy with the children who participated in this study. I wish to extend my thanks and appreciation to all who participated in this study. iv CONTENTS CHAPTER 1 INTRODUCTION 1.1. Research Aim 1 1.2. Research Questions 1 1.3. Research Rationale 2 CHAPTER 2 CHILDHOOD-ONSET OBSESSIVE-COMPULSIVE DISORDER (OCD) 2.1. Introduction 6 2.2. Epidemiology of OCD 6 2.3. Clinical Subtypes of OCD 8 2.4. Course and Prognosis of Childhood-onset OCD 9 2.5. Gender and Childhood-onset OCD 10 2.6. Primary Symptoms of Childhood-onset OCD 11 2.7. Effects of Childhood-onset OCD on the child, family and social environment 14 2.8. Differential Diagnosis of OCD 17 2.9. Comorbidity with OCD 18 2.10. Aetiology of OCD 2.10.1. Genetic theories 20 2.10.2. Neurological theories 21 2.10.3. Psychosocial theories 23 2.10.4. Cognitive-behavioural theories 25 2.10.5. Biopsychosocial models 26 2.10.6. Psychodynamic theories 27 2.11. Psychological Assessment and Diagnosis of OCD in Children 2.11.1. Diagnostic difficulties 30 2.11.2. Assessment and diagnostic procedures 31 2.12. Conclusion 35 CHAPTER 3 RESEARCH METHODOLOGY 3.1. Theoretical Framework 3.1.1. Psychoanalytic theory of the unconscious 40 3.2. Sample and Sampling 41 3.3. Procedure 3.3.1. Research design 44 3.3.2. Data gathering instruments and procedure 3.3.2.1. Projective tests 45 3.3.2.2. Biographical questionnaire 47 3.4. Data Analysis 48 3.5. Ethical Considerations 3.5.1. Voluntary participation 50 3.5.2. No harm to participants 50 3.5.3. Confidentiality 51 3.5.4. Informed consent 52 3.5.5. Analysis and reporting 53 CHAPTER 4 ANALYSIS 4.1. Subject A ? ?Mike? 4.1.1. Introduction 55 4.1.2. Age-related norms for human figure drawing (HFD) analyses 58 4.1.3. HFD analyses 4.1.3.1. D-A-P drawing 1 a) Introduction 59 b) Emotional indicators: Self-concept Personality Psychopathology 60 62 66 4.1.3.2. D-A-P drawing 2 a) Introduction 68 b) Emotional indicators: Self-concept Personality Psychopathology 69 71 74 4.1.3.3. D-A-P drawing 3 a) Introduction 76 b) Emotional indicators: Self-concept Personality Psychopathology 77 79 82 4.1.3.4. K-F-D a) Introduction 84 b) Emotional indicators: Self-concept Personality Psychopathology 86 92 95 4.1.4. TAT analysis 97 4.2. Subject B ? ?Daniel? 4.2.1. Introduction 106 4.2.2. Age-related norms for HFD analyses 109 4.2.3. HFD analyses 4.2.3.1. D-A-P drawing 1 a) Introduction 111 b) Emotional indicators: Self-concept Personality Psychopathology 112 114 118 4.2.3.2. D-A-P drawing 2 a) Introduction 120 b) Emotional indicators: Self-concept Personality Psychopathology 121 123 126 4.2.3.3. D-A-P drawing 3 a) Introduction 128 b) Emotional indicators: Self-concept Personality Psychopathology 129 131 135 4.2.3.4. K-F-D a) Introduction 138 b) Emotional indicators: Self-concept Personality Psychopathology 139 142 147 4.2.4. TAT analysis 160 4.3. Subject C ? ?Jane? 4.3.1. Introduction 158 4.3.2. Age-related Norms for HFD Analyses 159 4.3.3. HFD Analyses 4.3.3.1. D-A-P Drawing 1 a) Introduction 162 b) Emotional Indicators: Self-concept Personality Psychopathology 163 165 168 4.3.3.2. D-A-P Drawing 2 a) Introduction 171 b) Emotional Indicators: Self-concept Personality Psychopathology 172 174 176 4.3.3.3. K-F-D a) Introduction 179 b) Emotional Indicators: Self-concept Personality Psychopathology 180 183 186 4.3.4. TAT Analysis 190 4.4. Subject D ? ?Anne? 4.4.1. Introduction 195 4.4.2. Age-related Norms for HFD Analyses 197 4.4.3. HFD Analyses 4.4.3.1. D-A-P Drawing 1 a) Introduction 199 b) Emotional Indicators: Self-concept Personality Psychopathology 201 203 207 4.4.3.2. D-A-P Drawing 2 a) Introduction 211 b) Emotional Indicators: Self-concept Personality Psychopathology 212 214 217 4.4.3.3. K-F-D a) Introduction 221 b) Emotional Indicators: Self-concept Personality Psychopathology 222 225 229 4.4.4. TAT Analysis 233 CHAPTER 5 DISCUSSION 5.1. Interpretation of Mike?s internal world 240 5.2. Interpretation of Daniel?s internal world 248 5.3. Interpretation of Jane?s internal world 257 5.4. Interpretation of Anne?s internal world 265 CHAPTER 6 CONCLUSIONS 6.1. Conclusions of the Research 6.1.1. Mike?s internal world 274 6.1.2. Daniel?s internal world 276 6.1.3. Jane?s internal world 279 6.1.4. Anne?s internal world 280 6.1.5. Interpretative themes 6.1.5.1. Psychological adjustment 283 6.1.5.2. OCD symptoms 283 6.1.5.3. Oedipus complex 285 6.1.5.4. Defenses 291 6.1.5.5. Oral fixation 292 6.1.5.6. Personality factors 293 6.1.5.7. Psychosocial factors 294 6.1.5.8. Precipitating events 296 6.1.5.9. Genetic factors and comorbidity 297 6.2. Research Limitations 6.2.1. External validity a) Population validity and sampling bias b) Third variable effects 299 300 6.2.2. Internal validity a) Experimenter effects b) Content validity c) Self-reported data 301 303 305 6.3. Avenues for Future Research 305 REFERENCES 306 APPENDICES Appendix A DSM-IV-TR Diagnostic Criteria for 300.3 Obsessive- Compulsive Disorder (OCD) Appendix B Introductory Letter Appendix C Subject Information Sheet Appendix D Subject Biographical Questionnaire Appendix E Child Assent Form Appendix F Subject A (?Mike?) D-A-P 1 Drawing Appendix G Subject A (?Mike?) D-A-P 1 Questions and Answers Appendix H Subject A (?Mike?) D-A-P 2 Drawing Appendix I Subject A (?Mike?) D-A-P 2 Questions and Answers Appendix J Subject A (?Mike?) D-A-P 3 Drawing Appendix K Subject A (?Mike?) D-A-P 3 Questions and Answers Appendix L Subject A (?Mike?) K-F-D Drawing Appendix M Subject A (?Mike?) K-F-D Questions and Answers Appendix N Subject A (?Mike?) TAT Transcript and Short Form for Recording and Analysing TAT (adapted from Bellak, 1975) Appendix O Subject B (?Daniel?) D-A-P 1 Drawing Appendix P Subject B (?Daniel?) D-A-P 1 Questions and Answers Appendix Q Subject B (?Daniel?) D-A-P 2 Drawing Appendix R Subject B (?Daniel?) D-A-P 2 Questions and Answers Appendix S Subject B (?Daniel?) D-A-P 3 Drawing Appendix T Subject B (?Daniel?) D-A-P 3 Questions and Answers Appendix U Subject B (?Daniel?) K-F-D Drawing Appendix V Subject B (?Daniel?) K-F-D Questions and Answers Appendix W Subject B (?Daniel?) TAT Transcript and Short Form for Recording and Analysing TAT (adapted from Bellak, 1975) Appendix X Subject C (?Jane?) D-A-P 1 Drawing Appendix Y Subject C (?Jane?) D-A-P 1 Questions and Answers Appendix Z Subject C (?Jane?) D-A-P 2 Drawing Appendix AA Subject C (?Jane?) D-A-P 2 Questions and Answers Appendix BB Subject C (?Jane?) K-F-D Drawing Appendix CC Subject C (?Jane?) K-F-D Questions and Answers Appendix DD Subject C (?Jane?) TAT Transcript and Short Form for Recording and Analysing TAT (adapted from Bellak, 1975) Appendix EE Subject D (?Anne?) D-A-P 1 Drawing Appendix FF Subject D (?Anne?) D-A-P 1 Questions and Answers Appendix GG Subject D (?Anne?) D-A-P 2 Drawing Appendix HH Subject D (?Anne?) D-A-P 2 Questions and Answers Appendix II Subject D (?Anne?) K-F-D Drawing Appendix JJ Subject D (?Anne?) K-F-D Questions and Answers Appendix KK Subject D (?Anne?) TAT Transcript and Short Form for Recording and Analysing TAT (adapted from Bellak, 1975) Appendix LL Interpretative themes (diagrammatic representation) Chapter 1 Introduction 1.1. Research Aim The aim of the study is to explore the unconscious psychological life of children diagnosed with obsessive-compulsive disorder (OCD), as defined by the Diagnostic and Statistical Manual of Mental Disorders 4th ed., text-revision (DSM-IV-TR) of the American Psychiatric Association (APA, 2000). Specific areas of exploration relate to the self-concept of the child, the personality of the child, and diagnostic indicators of psychopathology. The presence of OCD in childhood is an area of relevance to educational psychology. This is because children with OCD frequently experience impairments in psychosocial functioning (Waters, Barrett & March, 2001), and may develop educational difficulties in the form of nonverbal learning disability (NVLD) (March & Mulle, 1998, as cited in Adams & Burke, 1999). Much of the research on OCD focuses on gathering quantitative data, with little emphasis on understanding the subjective, inner experience of children with OCD. Consequently, the study aims to make a contribution to knowledge in the area of understanding OCD qualitatively, from the unique perspective of the child?s unconscious life. 1.2. Research Questions The research question of the study addresses the nature and content of the unconscious world of the child with OCD. The specific areas investigated are indicators of the child?s self-concept, personality, and psychopathology. 1.3. Research Rationale The DSM-IV-TR (APA, 2000) categorises OCD as an anxiety disorder, characterised by intrusive, repetitive thoughts (obsessions) and/or senseless, ritualistic, repetitive behaviours (compulsions), resulting in significantly impaired functioning. The onset of OCD is commonly in childhood, and a significant interest has consequently arisen in the area of paediatric OCD (Robinson, 1998). From the perspective of educational psychology, the presence of OCD in childhood is of special interest. This is because children with OCD commonly develop educational difficulties, in the form of nonverbal learning disability (NVLD) (March & Mulle, 1998, as cited in Adams & Burke, 1999), as well as impairments in psychosocial functioning (Waters et al., 2001). The presence of NVLD places the child at risk for experiencing difficulties in nonverbal areas, such as visual-spatial abilities, even though reading and language abilities are intact. Impairments in the area of nonverbal learning may lead to problems with handwriting, mathematics, and the processing of socio-emotional information (March & Mulle, 1998, as cited in Adams & Burke, 1999). Recent research has established that children with OCD experience impairments in verbal and nonverbal episodic memory, which relate to difficulties in using effective strategies for learning. This may explain why dysfunctional memory performance is a consistent feature of OCD in adults (Henin, Savage, Rauch & Deckersbach, 2001). Children with OCD frequently experience psychosocial difficulties due to the fact that OCD is a debilitating condition for the child, often resulting in social isolation (Kanner, 1962, as cited in Snider & Swedo, 2000). Peer friendships, family relationships, and academic performance may suffer in deeply negative ways (Waters et al., 2001). OCD has a profound effect on the lives of children who experience it, and there is a great need for further research to improve understanding and treatment of OCD. Despite this need, there are relatively few published clinical and therapeutic studies on children with OCD (Presta et al., 2003). Exploring unconscious processes, in particular, is relevant to psychodynamic theories of OCD. These theories are based on the understanding that OCD, or ?obsessional neurosis?, develops as a result of unconscious conflict (Sechaud, 1998). Although psychodynamic theories of OCD have been challenged (Greist, 1997; Rapoport, 1991; as cited in Adams & Burke, 1999), and some authors deem psychodynamic psychotherapy a contentious and sometimes unsuccessful approach to treating OCD (Jenike, 1990, as cited in Presta et al., 2003), the approach has nonetheless been found to have positive effects on the emotional state, self-esteem, and interpersonal relationships of OCD sufferers (Presta et al., 2003). Because the psychodynamic approach focuses on unconscious processes, its success in helping OCD sufferers to process their emotions and improve their interpersonal relationships, implies that research into the unconscious processes of OCD sufferers ? whether these processes emerge due to OCD itself, or as a result of the anxiety generated by OCD symptoms ? is potentially valuable in understanding and treating OCD. In addition, the nature of obsessions characterising OCD strongly suggests the existence of unconscious content, motivating and maintaining obsessions and underlying obsessional material. This is due to the recurrent, persistent, intrusive, senseless, excessive, bizarre, and negative nature of obsessions (Presta et al., 2003). In addition, some children are unaware of, or can?t explain the obsessions (Swedo, Rapoport, Leonard, Lenane & Cheslow, 1989, as cited in Robinson, 1998) that dominate their mental life (de Silva & Rachman, 1998). Egodystonia (insight into the source of obsessional thoughts as being in their own minds) is commonly absent in children with OCD (Presta et al., 2003). These factors suggest unconscious dynamics underlying obsessions. The fact that obsessions are intensely anxiogenic (anxiety-provoking), causing the child to feel driven to perform compulsions to reduce anxiety, despite their senseless, time consuming and intrusive or distressing nature (APA, 2000), also suggests unconscious forces underlying the symptoms of OCD. From a psychodynamic perspective, anxiety derives from unconscious conflict between sexual and aggressive forces threatening to erupt into consciousness, and efforts to keep them repressed (Sadock & Sadock, 2001). When repression breaks down anxiety is generated, causing unconscious intrapsychic defense to mechanisms emerge (Sadock & Sadock, 2001). ?[A]nxiety is so unpleasant an affect that the need to avoid it acts like a quasidrive?, resulting in the ?substitution of one affect for another to reduce conscious anxiety? (intrapsychic defense mechanisms) (Polansky, 1991, p.33). In OCD, unacceptable or threatening impulses generate feelings of guilt and the defenses of undoing, isolation, and reaction formation emerge to reduce anxiety (Sadock & Sadock, 2001). Undoing refers to using words or behaviour intended to negate or symbolically compensate for unacceptable feelings, thoughts, or actions. Isolation (isolation of affect) is the separating of ideas from the affects originally associated with them. Reaction formation involves substituting unacceptable thoughts and feelings with totally opposed feelings, thoughts, or behaviour (APA, 2000). Obsessions and compulsions are ?ego-alien? and anxiogenic (Sadock & Sadock, 2001, p.150). Anxiety is not always dispelled and may even increase when compulsions are performed (Sadock & Sadock, 2003; Sechaud, 1998), further suggesting that unconscious processes may be operating, as the anxiety driving compulsions must then be deeply rooted. Projective tests, such as the Draw-A-Person test (D-A-P), the Kinetic Family Drawing test (K-F-D), and the Thematic Apperception Test (TAT) purport to be able to tap unconscious emotional content such as self-concept, defenses, aspects of the child?s personality, and interpersonal relationship dynamics (de Bruin, 2001). These tests are also useful as psychopathological diagnostic indicators to generate and investigate hypotheses (Sadock & Sadock, 2001). Thus, the study explores the unconscious processes of children with OCD by using the D-A-P, K-F-D, and the TAT to gain insight into their self-concepts, defenses, personalities, and psychopathology. In this way, the study seeks to make a contribution to research in the area of understanding paediatric OCD, from the perspective of the sufferers themselves. Because their obsessive thoughts and rituals may frighten children, they may not verbalize their feelings. The researcher aims to indirectly give a voice to these children, by providing a medium through which their inner experiences may find expression. The researcher has been unable to find any published studies exploring the unconscious life of children with OCD. This study makes a contribution to understanding paediatric OCD within the context of psychodynamic theory. Chapter 2 Childhood-onset obsessive-compulsive disorder (OCD) 2.1. Introduction Obsessive-compulsive disorder (OCD) is a chronic, disabling psychological condition that may arise in childhood, adolescence, or adulthood (Kaplan & Hollander, 2003; Snider & Swedo, 2000). Adams and Burke (1999) maintained that OCD is a serious, potentially debilitating illness. Because it remains underestimated and under-treated, it represents a primary cause of serious disabilities in childhood and adolescence, sometimes resulting in continued impairments in adult life (Presta et al., 2003). OCD is a common childhood and adolescent disorder (Presta et al., 2003; Snider & Swedo, 2000; Zohar, Pauls, Ratzoni & Apter, 1997). OCD is second only to depression in both children and adults as the most common psychological disorder, requiring early recognition and assessment due to its significant potential effect on global social adjustment in adulthood (Karno, Golding, Sorenson & Burnam, 1988, as cited in Presta et al., 2003). According to Presta et al. (2003), childhood and adolescent OCD have received increased attention over the last few years, promoting a more profound awareness and recognition of this condition and the need for earlier interventions and development of more specific approaches to treatment. 2.2. Epidemiology of OCD In the United States (U.S.), OCD is a common disorder (Snider & Swedo, 2000; Zohar et al., 1997). Once perceived as rare, OCD is the fourth most common psychological disorder among Americans (Rasmussen & Eisen, 1992, as cited in Adams & Burke, 1999). An estimated one in every forty Americans suffers from OCD (Penzel, 1995, as cited in Adams & Burke, 1999). According to the Anxiety Disorders Association of America (ADAA), OCD cost the American government 6 percent of their total mental health bill in 1990, with 3.3 Million adult sufferers (2.3 percent of the population) (ADAA, 2003). Kaplan and Hollander (2003) estimate this figure as between 2 and 3 percent. Earlier epidemiological evaluations between 1992 and 1998 reported incidences in various parts of the world, as ranging from 1 to 5 percent (1 percent in the U.S., 1.3 percent in Denmark, 3.6 percent in Israel, and 5 percent in Japan) (Presta et al., 2003). The researcher was unable to find any published figures for the incidence of OCD in South Africa. According to the ADAA (2003), OCD has equal prevalence among adult men and women. Some studies reflected this finding (Flament et al., 1988; Zohar, Pauls, Ratzoni & Apter, 1992; as cited in Robinson, 1998), and others reported greater frequencies of OCD in males, with ratios of between 2:1 and 3:2 of males to females (Flament et al., 1989; Thomsen & Mikkelsen, 1991; as cited in Robinson, 1998). Although OCD was once believed to be rare in children (Presta et al., 2003; Snider & Swedo, 2000), it is far more common than was previously believed (March & Leonard, 1996, as cited in Adams & Burke, 1999). Epidemiological studies in the U.S. estimated that approximately 1 in every 200 children and adolescents, suffers from OCD (Adams & Burke, 1999; March, Leonard & Swedo, 1995, as cited in Robinson, 1998; Waters, Barrett & March, 2001). The 2001 British nationwide survey of child mental health reported prevalence rates for OCD of 0.25 percent (but puts this figure as high as 12 percent, when subsyndromal forms are included) (Presta et al., 2003). Flament et al. (1988, as cited in Robinson, 1998) reported a 1.9 percent lifetime prevalence rate for OCD in a sample of adolescents. Later studies reported higher rates of between 2 and 3 percent (Robinson, 1998; Snider & Swedo, 2000; Zohar et al., 1992, as cited in Robinson, 1998; Zohar et al., 1997). Childhood prevalence rates may actually be higher than the figures reflect, due to the fact that OCD is frequently misdiagnosed or unrecognised in children (Clarizio, 1991; Rasmussen & Eisen, 1992; as cited in Adams & Burke, 1999). 2.3. Clinical Subtypes of OCD Due to an increase in the frequency of OCD diagnosis during the 1980?s and early 1990?s, researchers were stimulated to distinguish subtypes of OCD (Zohar et al., 1997). Research established that OCD is a clinically heterogeneous disorder with a bimodal distribution regarding age at onset, with one peak between the ages of 10 and 14 years and another peak between the ages of 20 and 22 years (Rasmussen & Tsuang, 1986, as cited in Henin, Savage, Rauch & Deckersbach, 2001). Henin et al. (2001) proposed that these two profiles of onset may be associated with two subtypes of the disorder, viz. early or childhood-onset (before the age of 18 years) and late or adult-onset (at the age of 18 years or older). A significant proportion (30 to 50 percent) of adults with OCD experienced childhood- onset of the disorder (March & Leonard, 1996, as cited in Adams & Burke, 1999; Presta et al., 2003; Robinson, 1998). The ADAA (2003) reported this figure as one- third. Observable obsessive-compulsive manifestations frequently emerge in early childhood, as early as at the age of 3 years (Robinson, 1998). Chronological age and age at onset of OCD are important factors in predicting the future course of the disorder, and the development of different comorbidity patterns (Presta et al., 2003). Childhood-onset OCD is distinguished from adult-onset OCD by heavier familial loading, male predominance, higher frequencies of neurological symptoms and tic-like compulsions (Henin et al., 2001), and higher frequencies of sensory phenomena and comorbid tic disorders (Rosario-Campos et al., 2001). Research suggests the existence of different subtypes of OCD in adults (non-familial, familial with tic disorder, and familial without tics). Similarly, clinical impressions suggest that different course-based subtypes are identifiable in children with OCD (Presta et al., 2003). Although OCD is generally a chronic condition, there have been cases of acute manifestation (Abramowitz, Moore, Carmin, Wiegartz & Purdon, 2001). Retrospective studies concluded that some women experience an acute onset of OCD during pregnancy or within the first few weeks after giving birth (Williams & Koran, 1997, as cited in Abramowitz et al., 2001), a phenomenon referred to as acute postpartum- onset OCD. The most common features of this condition are intrusive, egodystonic, anxiogenic, obsessive thoughts about harming the newborn baby, and avoidance of situations that evoke these thoughts (Abramowitz et al., 2001). 2.4. Course and Prognosis of Childhood-onset OCD When OCD appears in childhood it frequently begins either between 5 and 8 years of age, or during adolescence (Swedo, Leonard & Rapoport, 1990, as cited in Adams & Burke, 1999). The mean age of onset in childhood is somewhere between 9 and 10 years (Robinson, 1998). Presta et al. (2003) reported that greater numbers of obsessions and compulsions are associated with pre-pubertal onset of OCD than with pubertal-onset Little is known about the longitudinal course of OCD symptoms in adults (Mataix-Cols et al., 2002). Although OCD is relatively persistent in adulthood, a comprehensive literature review showed a 10 to 50 percent complete remission rate of childhood- onset OCD by late adolescence (Snider & Swedo, 2000). According to Presta et al. (2003), between 10 and 15 percent of adult OCD patients experienced an episodic course with periods of full remission. This percentage tended to increase during childhood (Apter & Tyano, 1988, as cited in Presta et al., 2003), and rapid improvements took place without treatment in one-third of cases (Flament et al., 1990; Thomsen & Mikkelsen, 1995; as cited in Presta et al., 2003). The symptoms of adults with OCD are generally relatively stable across time, with some symptoms waxing and waning within symptom dimensions, but rarely shifting between dimensions (Mataix-Cols et al., 2002). Subclinical OCD develops into the full-blown disorder relatively frequently (Presta et al., 2003). OCD symptoms are significantly unstable in presentation during childhood (Presta et al., 2003). Adams and Burke (1999) pointed out that OCD symptoms may range in severity, both between individuals and within one individual, depending on the setting (e.g. between home and school environments). In 85 percent of cases the child experiences symptom changes, generally in the form of different obsessions and compulsions existing simultaneously, with the most recent symptoms increasingly dominating the ones that began earlier (Presta et al., 2003). The severity of OCD in childhood is a major contributing factor to a poor prognosis, but is not necessarily predictive thereof (Thomsen, 1995, as cited in Presta et al., 2003). A poor prognosis appears instead to be associated with comorbid tics or odd cluster personality disorders (Presta et al., 2003). Childhood-onset OCD may be preceded and/or followed by other anxiety disorders (such as separation anxiety disorder, panic disorder with agoraphobia, social phobia or pavor nocturnus), mood disorders (bipolar and unipolar depression), eating disorders (anorexia), psychotic disorders (usually schizophreniform or atypical psychoses), or attention-deficit/hyperactivity disorder (AD/HD) (Bulik, Sullivan, Fear & Joyce, 1997; Cassidy, Allsopp & Williams, 1999; Thomsen & Mikkelsen, 1995; as cited in Presta et al., 2003). 2.5. Gender and Childhood-onset OCD Research suggests that boys tend to have an earlier age of onset than girls (Robinson, 1998). According to Swedo, Rapoport, Leonard, Lenane & Cheslow (1989, as cited in Presta et al., 2003), the onset of OCD generally takes place during puberty (at approximately the age of 11) in girls, whereas boys are more likely to display an earlier, pre-pubertal onset (at approximately the age of 9). A number of adult studies supported these results (Burke, Burke & Regier, 1990, as cited in Robinson, 1998). Hanna (1995, as cited in Robinson, 1998) reported relationships between gender, symptom severity, and mean age of onset, with symptoms tending to be more severe in males with onset before the age of ten and in females with onset after the age of ten. Some studies revealed that young boys had more severe symptoms than young girls, and suggested that OCD tends to be more persistent in boys than in girls (Presta et al., 2003). To this end, Thomsen and Mikkelsen (1995; as cited in Presta et al., 2003) found that the symptoms of adolescent girls with OCD are more likely to improve independently of treatment, than those of boys. Boys are more inclined to present with a comorbid tic disorder and to have a family history of either OCD or tic disorders (Presta et al., 2003). Studies indicate that aggressive obsessions may be related to male gender, and cleaning compulsions to female gender (Presta et al., 2003). This suggests that gender-related factors associated with biology or gender role socialization, or both, may affect the nature of OCD symptoms. 2.6. Primary Symptoms of Childhood-onset OCD OCD is characterised by intrusive, repetitive cognitions (obsessions) and/or complex, senseless, ritualistic, repetitive, and time-consuming behaviours (compulsions), resulting in significantly impaired functioning. The defining feature of OCD is the grossly excessive nature of obsessive ideation and compulsive ritual (Dinn, Harris & Raynard, 1999). By definition, OCD is diagnosable only if symptoms are distressing and protracted, or if they significantly interfere with daily functioning (APA, 2000). The clinical definition of an ?obsession? refers to intrusive thoughts, images, or impulses (APA, 1994, as cited in Adams & Burke, 1999). Although much of the general population experience unpleasant, intrusive thoughts, individuals with OCD attach unwarranted significance to thems (Rachman 1993; as cited in Dinn et al., 1999). Individuals with OCD are preoccupied, or obsessed, with ideas and events related to danger and catastrophe (Dinn et al., 1999). The nature of their obsessions is variable, ranging from unreasonable fears of contamination or an excessive moral conscience, to bizarre, unrealistic thought patterns (Presta et al., 2003), e.g. a child with OCD may be consumed with worries about germ-infested door handles, a fire that may harm the family, or going to hell because of an immoral thought (Adams & Burke, 1999). Common childhood obsessions include contamination (fears of dirt, germs, or illness), aggression (fears of causing harm or death to self or others), and fears of making mistakes with tragic consequences. Other common childhood obsessions include scrupulosity (fears of thinking or acting in immoral ways, or displeasing God, frequently relating to sex), obsessive thinking regarding symmetry, exactness, and numbers, and magical thinking (the belief that engaging in certain behaviour can prevent something bad from happening) (Francis & Gragg, 1996; Hanna, 1995; as cited in Robinson, 1998). Salzman and Thaler (1981, as cited in Dinn et al., 1999) characterised the phenomenon of magical thinking as a common feature of OCD. Marks (1987, as cited in Dinn et al., 1999) explained that many beliefs associated with this phenomenon possess magical or superstitious qualities. This conviction that one's thoughts can magically prevent negative events from occurring provides the rationale for compulsive activities, explaining their irrational quality (Dinn et al., 1999). Obsessions can also assume the form of pathological self-doubting (Adams & Burke, 1999), where an individual may doubt his or her own sensory perceptions or memory (Rapoport, 1991, as cited in Adams & Burke, 1999). This pattern of self-doubting can be extremely intense (Adams & Burke, 1999). Consequently, such individuals are extremely cautious and doubtful, as they tend to estimate high probabilities for negative outcomes to take place. This anxiogenic cognitive process is referred to as abnormal risk assessment, and involves selectively attending to, and exaggerated appraisal of, risk and threat (Dinn et al., 1999). The irrepressible, disturbing nature of their thoughts leads many sufferers of OCD to feel frightened that they are going insane (Adams & Burke, 1999). However, interestingly, most people with OCD have insight as to the source of these thoughts being in their own minds (?egodystonia?) (APA, 2000). Some studies reported that most children have insight into their disorder, realising that what they are thinking is irrational, excessive, and unreasonable (March & Leonard, 1996; Johnston & March, 1992; as cited in Adams & Burke, 1999), while other studies reported that children rarely experience this insight (Presta et al., 2003). Children with OCD may not understand their own actions and might feel embarrassed if asked to explain how their repeated actions can influence events (Johnston & March, 1992, as cited in Adams & Burke, 1999). Young children may try to explain obsessions by saying someone outside of them is placing thoughts in their heads, or telling them to do things (Adams & Burke, 1999). Even when insight is present, children with OCD still experience high levels of anxiety and fear due to the distressing content of their obsessions (APA, 2000). Obsessions assume such powerful meaning for individuals with OCD that they feel compelled to engage in debilitating cognitive and behavioural rituals (?compulsions?) to control, dispel or neutralise their obsessions, and reduce the anxiety generated by them (APA, 2000). Whereas obsessions arise only in the mind, compulsions manifest as ritualised, and often stereotyped, behaviour - either covert (mental and internal) or overt (physical and behavioural) (Adams & Burke. 1999). Thus, compulsions constitute risk-aversive behaviour, serving to lessen anxiety by reducing the subjective probability of a negative outcome (Carr, 1974, as cited in as cited in Dinn et al., 1999). Common childhood behavioural compulsions include excessive cleaning activities (hand washing, showering, and cleaning), repetition of actions, checking (doors, locks, windows, or other objects), counting, ordering and arranging, touching or tapping objects, excessive collecting or hoarding, and the 'just right' phenomenon (Adams & Burke, 1999; Presta et al., 2003). The ?just right? phenomenon refers to the compulsion to repeat an action until it feels right, e.g. a child may arrange and re- arrange a pile of books until he or she gets it ?just right? (Swedo, 1990, as cited in Snider & Swedo, 2000). Mental compulsions include praying and the mental repetition of words, songs, or poems, over and over again (March & Leonard, 1996; Hanna, 1995; as cited in Robinson, 1998). Compulsive behaviour, then, may manifest in a child washing his or her hands so much that they become chapped, cracked, or even bleed, frequently checking his or her body for signs of illness, or mentally reciting a prayer ten times over (Adams & Burke, 1999). Compulsions are often shaped by obsessional content, e.g. for children who obsess about germs on door handles, the corresponding compulsion may manifest as wrapping their hands prior to touching the handle or immediately after contact with it, or as total avoidance of touching it. In some cases, however, obsessions and compulsions are paired in ways evading logical explanation. For example, a child may read and re-read a sentence over and over again, believing that this will somehow prevent the death of his or her parents (Adams & Burke, 1999). Although OCD classically and usually presents as a combination of obsessions and compulsions, a small percentage of OCD sufferers experience only either obsessions or compulsions (March & Leonard, 1996, as cited in Adams & Burke, 1999). According to Presta et al. (2003), individuals with very early-onset OCD are more likely to have compulsions than obsessions. The majority of children with OCD, however, typically have both obsessive and compulsive symptoms, and frequently experience multiple obsessions and compulsions concurrently (Adams & Burke, 1999). Swedo et al. (1989, as cited in Presta et al., 2003) found that although ?pure obsessiveness? was rare (only 4 percent of the sample), ?pure ritualizers? were not uncommon among children and adolescents with OCD. Zohar et al. (1992, as cited in Robinson, 1998) reported that no significant age- related trends correspond with any one OCD symptom. According to the American Academy of Child and Adolescent Psychiatry (AACAP, 1998, as cited in Adams & Burke, 1999), no specific symptomatology is applicable to all cases, as the precise content of children?s obsessions and compulsions is likely to change over time. Symptom severity also tends to change over time (Hanna, 1995, as cited in Presta et al., 2003). 2.7. Effects of Childhood-onset OCD on the Child, Family and Social Environment OCD has a profound impact on the lives of the children and adults who experience it. All anxiety disorders are associated with an impaired quality of life (QOL) relating to family life and activities of daily living, but OCD is acknowledged to be the most debilitating in this regard. Children with more severe OCD, or comorbid depression, experience a particularly low QOL (Lochner et al., 2003). Because the child with OCD is preoccupied with constant obsessions and rituals, little time and energy remains for family and friends (Adams & Burke, 1999). OCD often affects the child?s family relationships, peer friendships, and academic performance in profoundly negative ways (Waters et al., 2001). Families of children with OCD are frequently highly involved in the child?s symptoms. Such family involvement is widely recognised as a factor in reinforcing and maintaining the child?s symptoms (Amir, Freshman & Foa, 2000; Waters et al., 2001), as it allows the child to continue functioning with their incapacitating illness and delays the seeking of appropriate intervention (Rutter, Taylor & Hersov, 1994, as cited in Snider & Swedo, 2000). This involvement manifests in the form of family members making an effort to accommodate the child?s obsessive-compulsive behaviour, by helping with or participating in rituals, providing reassurance, and facilitating the child?s avoidance of feared stimuli (Waters et al., 2001). For example, the child may insist that a parent check doors, or wash clothing over and over again (Adams & Torchia, 1998; as cited in Adams & Burke, 1999). Parents may compensate for the child?s contamination obsessions by serving foods that the child believes are safe, or accommodating his or her increasingly frequent and prolonged trips to the bathroom (Rutter et al., 1994, as cited in Snider & Swedo, 2000). Parental patterns of witnessing, or feeling pressure to participate in, the child's rituals, may result in stress within the family. Consequently, potentially debilitating family stress is a frequent accompaniment to OCD. Parents may experience stress due to many other factors besides being involved in the child?s rituals, including feeling guilty for having caused or transmitted the disorder. Another source of family stress lies in the frustration experienced by many parents when the child expends extensive energy to control compulsions outside the home, only to unleash a frenzy of compulsive behaviour when returning home. This situation may cause conflict between the parents and the school, as the family feel drained by the child's symptoms, while no problems are observed in the school environment (Adams & Torchia, 1998, as cited in Adams & Burke, 1999). Another source of family stress is the considerable frustration often experienced by siblings of children with OCD. Siblings may be subject to ridicule because of their brother or sister?s odd behaviour, and may feel reluctant to invite friends home. Siblings may also feel neglected by their parents as parents often spend vast amounts of time and energy on the child with OCD (Adams & Torchia, 1998, as cited in Adams & Burke, 1999). Siblings might also harbour secret concerns around developing OCD themselves (Adams & Torchia, 1998, as cited in Adams & Burke, 1999). Studies suggest that OCD is likely to significantly impair the affected child?s social functioning, particularly within a school environment. The child may experience difficulties in forming and maintaining friendships. When OCD symptoms are observable to peers, the child may be the object of ostracism and teasing, leading to social isolation (Clarizio, 1991, as cited in Adams & Burke, 1999). Because children with OCD are frequently aware that their thoughts and behaviours are strange and socially unacceptable, they may make efforts to hide the disorder from their peers, resulting in further social isolation (Adams & Burke, 1999). Because obsessions and mental compulsions absorb the child, his or her ability to pay attention at school reduces, often resulting in a decreased learning capacity (Adams, Waas, March & Smith, 1994, as cited in Adams & Burke, 1999). Schoolwork and grades may thus suffer as a result. Teachers may consider the child to be inattentive, lazy, or defiant and, if the child perceives the classroom as an intimidating environment, absenteeism from school may result (Clarizio, 1991, as cited in Adams & Burke, 1999). The child?s self-esteem may suffer, as he or she becomes more and more frustrated and ashamed, with continuing to fail to live up to parental and teacher expectations (Adams & Burke, 1999). 2.8. Differential Diagnosis of OCD The diagnostic criteria for OCD in children are the same as those for adults (APA, 2000), as the essential characteristics of OCD are similar for both groups (Swedo et al., 1989, as cited in Robinson, 1998). Clinical criteria in the DSM-IV-TR stipulate recurrent obsessions and/or compulsions, which cause marked distress and/or interference in the child's functioning. The DSM-IV-TR also requires that adults have insight into the excessiveness of their symptoms. Although this is not a requirement for children, the designation ?poor insight type? is still applied as a specifier in cases of children who lack insight into their disorder, as it is with adults (APA, 2000). Health care professionals often overlook or incorrectly identify OCD (Flament et al., 1988, as cited Robinson, 1998). This may be due to the fact that a number of psychiatric and non-psychiatric disorders can display obsessive and compulsive symptoms (Hollander, 1993, as cited in Robinson, 1998; Presta et al., 2003). One such group of disorders is organic diseases. Stereotypical behaviour related to mental retardation or brain damage may sometimes resemble OCD rituals. OCD rituals are, however, usually more complex in nature (Presta et al., 2003). Autism and asperger?s syndrome also share some similarities with OCD, as egodystonia is also absent and interpersonal relationships are significantly impaired. Both the repetitive childhood behaviours that characterise asperger's syndrome and the stereotypes found in autism are distinguishable from OCD, because they are not associated with obsessions, but function rather as endeavours to maintain a stable environment. Early schizophrenia or 'schizo-obsessive' syndromes are distinguishable from pure OCD by their psychotic features (Presta et al., 2003). Although other anxiety disorders share symptoms of anxiety with OCD, the intense worrying characterising generalized anxiety disorder and the aggressive fears usually associated with separation anxiety disorder and panic disorder are not accompanied by compulsions, as they are with OCD (Presta et al., 2003). Simple phobias are particularly difficult to differentiate from OCD (Swedo et al., 1989, as cited in Robinson, 1998). As with OCD, they are characterised by excessive fears however the fears do not generally involve germs and frequently tend to decrease in the absence of specific stimuli (Presta et al., 2003). Mood disorders (especially depressive episodes) share obsessive brooding and rumination with OCD. However, the content thereof is not senseless, as it is with OCD, but relates to the person?s life experience (Presta et al., 2003). Although children with AD/HD may present with compulsive rituals, these rituals are not associated with obsessions, as they are with OCD, but rather serve to compensate for distraction (Presta et al., 2003). Eating disorders share obsessive-compulsive type behaviour with OCD, in the obsessive and compulsive monitoring of food intake and physical exercise that characterises anorexia nervosa and bulimia nervosa. However, these behaviours are differentiated from the symptoms of OCD, in that they focus entirely on food. Similarly, body dysmorphic disorder is differentiated from OCD as the focus is purely on body image (Presta et al., 2003). 2.9. Comorbidity with OCD The appropriate identification and treatment of comorbid conditions are important diagnostic considerations for OCD (Presta et al., 2003). According to Snider and Swedo (2000), there are multiple patterns of comorbidity in children with OCD. Both chronological age and age at onset are predictive of distinct comorbidity patterns (Presta et al., 2003). Kaplan and Hollander (2003) maintained that up to two-thirds of all adults, adolescents, and children with OCD have comorbid psychological disorders. Comorbid disorders are thus relatively common in children with OCD, particularly depressive disorders and other anxiety disorders (Robinson, 1998). In a study of children with OCD, comorbidity was frequent, with only one participant diagnosed as having ?pure? OCD (Waters et al., 2001). Major depressive disorder is the most frequently reported comorbid disorder with OCD (Kaplan & Hollander, 2003). Frequently observed comorbid anxiety disorders include overanxious disorder, simple phobias (Swedo et al., 1989, as cited in Snider & Swedo, 2000), social anxiety disorder, and panic disorder. OCD is also often comorbid with the mood disorder referred to as bipolar II disorder (Thomsen, 2000, as cited in Presta et al., 2003), as well as with adjustment disorder with depressed mood (Swedo et al., 1989, as cited in Snider & Swedo, 2000). OCD is frequently comorbid with a number of childhood-onset conditions, such as AD/HD, attention-deficit disorder (ADD), and separation anxiety disorder (SAD) (Adams & Burke, 1999). Other childhood-onset disorders frequently comorbid with OCD include disruptive behaviour disorders (especially conduct disorder) and tic disorders (particularly tourette?s syndrome) (Robinson, 1998). Other frequently reported comorbid childhood-onset disorders include learning disorders, particularly reading disorder, expressive language disorder (Robinson, 1998), and nonverbal learning disability (NVLD) (Adams & Burke, 1999). OCD is also frequently comorbid with substance abuse disorders (Robinson, 1998), particularly alcohol and marijuana abuse (Thomsen, 2000, as cited in Presta et al., 2003). 2.10. Aetiology of OCD While the precise aetiology of OCD remains unclear, recent medical and psychological research has contributed greatly to the understanding and treatment of childhood OCD (Adams & Burke, 1999). Research suggests the possible existence of an obsessive-compulsive spectrum of disorders (Presta et al., 2003). The disorders comprising this spectrum include anxiety disorders (SAD, early-onset panic disorder, and OCD), somatoform disorders (body dysmorphic disorder and hypochondriasis), eating disorders, tic disorders (such as tourette's syndrome), and impulse control disorders (such as trichotillomania) (Goodwin, Lipsitz, Chapman, Mannuzza & Fyer, 2001, as cited in Presta et al., 2003). 2.10.1. Genetic theories A leading aetiological theory relates to a genetic predisposition for OCD, based on findings that diagnostic rates for OCD are higher in family members of individuals with OCD than in the general population (Swedo et al., 1990, as cited in Adams & Burke, 1999; Waters et al., 2001; de Silva & Rachman, 1998). Several family studies reported a high incidence of OCD in the first-degree relatives of individuals with OCD (de Silva & Rachman, 1998; Dinn et al., 1999; Robinson, 1998). According to Hettema, Neale and Kendler (2001), panic disorder, generalized anxiety disorder, phobias, and OCD all have significant familial aggregation. The role of genetic factors in OCD has also been evaluated in numerous twin studies (Snider & Swedo, 2000), which showed concordance rates of up to 87 percent of OCD symptoms in monozygotic twins, and up to 47 percent in dizygotic twins (Presta et al., 2003). Genetic vulnerability seems to be complex, due to strong research evidence showing the existence of different subtypes of OCD (Presta et al., 2003). In addition, the finding that some cases of OCD involved identifiable familial components, but others did not, is relevant in this regard (Robinson, 1998). According to de Silva and Rachman (1998), a review of the research suggested that what appears to be inherited is a general emotional oversensitivity, or neurotic tendency, which can serve to predispose one to developing an anxiety disorder. Although genetic studies suggested familial vulnerability to OCD, there is controversy over the validity of research findings, as a result of variations in the diagnostic criteria used in studies and methodological differences between studies (Presta et al., 2003). One example of a type of study that has potential methodological difficulties is a segregation study. Although segregation studies have generated evidence for a genetic aetiology of OCD, this type of study is limited in its capacity to distinguish genetic effects from environmental ones. In support of genetic theories, however, the particular symptoms a child presents with differ from those of the first-degree relative with the disorder, suggesting that symptoms are not mimicked or socially learned from the child?s environment (Robinson, 1998). Substantial research evidence indicates that there is a high degree of general psychopathology in the families of children with OCD (Hoover & Insel, 1984; McKeon & Murray, 1987; Toro, Cervera, Osejo & Salamero, 1992; as cited in Dinn et al., 1999). Hoover and Insel (1984, as cited in Dinn et al., 1999) reported that almost 12 percent of the first-degree relatives of children with OCD received psychiatric hospitalisation. Psychological disorders, including depression, other anxiety disorders, and TS are common among family members of children with OCD (Dinn et al., 1999). Hoover and Insel (1984, as cited in Dinn et al., 1999) reported the presence of multiple psychological disorders, including affective illness, suicidal behaviour, and alcoholism, among the first, second, and third degree relatives of adults with OCD. Nestadt, Samuels, Romanoski, Folstein and McHugh (1994, as cited in Dinn et al., 1999) found that the presence of obsessions and compulsions in their community sample were associated with a family history of suicidal behaviour and alcoholism. 2.10.2. Neurological theories According to March et al. (1995, as cited in Robinson, 1998), OCD is increasingly considered to be a neurological disorder. Neuropsychological studies have found strong evidence linking OCD with distinct patterns of cognitive impairment and brain dysfunction (Adams & Burke, 1999; Henin et al., 2001). Four main lines of neurochemical evidence provide the basis of neurological theories of OCD. The first line of evidence relates to the identification of an immune-related subtype of OCD (Poststreptococcal Childhood-Onset OCD) (Presta et al., 2003; Robinson, 1998). This theory is based on findings that infection is a factor in the aetiology of OCD as, in a small percentage of children, sudden-onset OCD or an abrupt worsening of existing OCD symptoms may result from bacterial or viral infections (Dinn et al., 1999). According to this theory, antibodies produced to ward off the infections cause inflammation in certain areas of the brain, which may result in OCD symptoms (Allen, Leonard & Swedo, 1995, as cited in Dinn et al., 1999). A second line of neurological research implicates greater than normal volumes of certain brain structures in the aetiology of OCD (Presta et al., 2003; Rauch, Bates & Grachev, 1997, as cited in Adams & Burke, 1999). This is based on the finding that adults who experienced early-onset of OCD displayed reduced volume in the left caudate. Research has shown smaller than normal striatal and ventricle volumes, as well as larger than normal third ventricle volumes in individuals with OCD (Presta et al., 2003). Presta et al. (2003) also discussed research findings on children with OCD, which indicated less total white matter, but greater volumes of the total operculum, correlating with the severity of their disorder. A third area of neurological research relates to investigations into the neurochemistry of OCD, emphasising the role of abnormalities in central serotonergic metabolism (Barr, Goodman, Price, McDougle & Charney, 1992; Winslow & Insel, 1990; as cited in Adams & Burke, 1999). In this respect, several lines of research evidence (cerebrospinal fluid serotonin metabolite studies, meta-chlorophenylpiperazine challenge studies and drug response studies) suggested that OCD is associated with hyperserotonergic activity (Dinn et al., 1999). The anti-obsessional action of Selective Serotonin Reuptake Inhibitors (SSRI?s) provides persuasive evidence that OCD symptoms are affected by fluctuations in serotonergic activity (Flament, Rapoport, Murphy, Berg & Lake, 1987, as cited in Dinn et al., 1999). However, Presta et al. (2003) argued that the fact that a significant percentage of OCD patients do not respond to SSRI?s provides a challenge to serotonergic hypotheses for OCD. A fourth line of neurological research implicates highly select neurocognitive impairment in a specific circuit in the brain in the aetiology of OCD (Dinn et al., 1999). A source of evidence for this theory derives from studies involving brain injury or infection (Robinson, 1998). Ramsay and Fahy (1995) observed increased obsessive- compulsive symptoms following head injuries and encephalitis. Although structural brain imaging studies failed to reveal consistent abnormalities in individuals with OCD (Ramsay & Fahy, 1995), some findings strongly suggested the possible existence of a dysfunction in the orbitofrontal-limbic network or basal ganglia circuitry (Dinn et al., 1999; Presta et al., 2003; Ramsay & Fahy, 1995; Robinson, 1998). Dinn et al. (1999) contended that the struggle individuals with OCD experience in resisting their compulsive urges is the result of orbitofrontal hypermetabolism. Hypermetabolism of this circuit produces intense levels of anxiety, resulting in compensatory mechanisms to reduce anxiety, such as compulsive behaviour. Thus, the excessive quality of obsessive-compulsive behaviour represents an effort to achieve equilibrium, with compulsive rituals serving as strategies to compensate for increased neuronal activity in the orbitofrontal system (Dinn et al., 1999). Research conducted by Henin et al. (2001) suggested that the memory deficits characterising OCD in adults may emerge developmentally in a child with OCD, due to abnormal maturation of the frontal-striatal system, as research has revealed abnormalities in the brain morphology of both children and adults with OCD. However, it is important to note that cognitive impairment has not been detected in children with OCD on a consistent basis (Henin et al., 2001). Clinical studies have associated OCD with numerous neurological disorders and diseases, such as epilepsy (Levin & Duchowny, 1991, as cited in Robinson, 1998), TS (Robinson, 1998), and Sydenham's chorea (Rapoport, 1998). Because these associated disorders are linked to developmentally evolved basal ganglia abnormalities or disease, the hypothesis that OCD is a peripheral manifestation of abnormalities in neuronal circuitry, viz. the cortico-striatal-thalamo-cortical circuitry (March et al., 1995; Insel, 1992; as cited in Robinson, 1998). 2.10.3. Psychosocial theories Psychosocial explanations for OCD focus largely on research evidence regarding the role played by traumatic or negative life events in precipitating the onset of OCD symptoms (Dinn et al., 1999). Because negative cognitive intrusions increase under anxiety-provoking circumstances (Marks 1987, as cited in Dinn et al., 1999), traumatic childhood experiences increase the intensity and frequency of naturally occurring negative thought intrusions (Dinn et al., 1999). The onset of childhood OCD can frequently be linked to a particular, usually traumatic life event (such as a loved one?s death, a divorce, a change in schools, unhappiness at school, or moving home) (Rapoport, 1990), generating extreme levels of anxiety and prompting the use of compensatory strategies to reduce arousal to controllable levels (Dinn et al., 1999). Studies found that 38 percent children with OCD reported a precipitating event prior to the onset of their OCD. Most frequently reported events were stressful family circumstances or fears related to a program on television. Although subsequent OCD symptoms are unrelated to the precipitating event, and become more generalized, the initial symptom is often related to the precipitant (Robinson, 1998). Exposure to traumatic events in childhood has been associated with the development of the cognitive patterns of magical thinking, superstition, and paranormal beliefs that characterise OCD. Although even normal adults often resort to ritual or magical beliefs under circumstances of uncontrollable threat, for people who experience childhood trauma, paranormal or magical beliefs become ingrained in the premorbid OCD child's conceptual framework, due to their ability to engender a sense of intellectual mastery, control, and predictability under conditions of threat or chaos. Because stressful events indicate vulnerability and helplessness, and the unpredictable, threatening nature of such events is anxiogenic, compulsive rituals emerge as salient defenses for the child (Dinn et al., 1999). Anthropological observations on the role of magic and ritual in many cultures revealed that these cognitions provide a sense of control over threatening, uncontrollable situations. In this way they function to reduce anxiety in situations in which appropriate threat- reducing action is not an option (Carr, 1974, as cited in Dinn et al., 1999). However, as Dinn et al. (1999) pointed out, this trauma-based theory for OCD may only explain the development of OCD in a subset of patients. A related psychosocial theory suggests that significant adults in the immediate environment of the premorbid OCD child may generate and reinforce the child?s superstitious pathogenic thinking and behaviour. One such line of evidence relates to findings that the relatives of patients with OCD are more superstitious than matched controls. Significantly higher than normal prevalence rates of psychopathology in the families of individuals with OCD are well established by research. Thus, exposure to conditions of pathological thinking within the family environment may exert strong pathogenic pressures on the child?s patterns of thinking. To this end, children who are enmeshed in this state of chronic insecurity within the home environment may respond by becoming highly sensitive and vigilant towards threat-related stimuli and acquiring a deep-rooted sense of vulnerability. These children may develop a keen awareness of subtle cues, indicating a change in the mood or behaviour of their parents, and thus become skilled at detecting and evading potentially detrimental outcomes. In this way, OCD symptoms emerge as an adaptation to conditions of genuine prolonged threat (Dinn et al., 1999). A further psychosocial theory for OCD is provided by Rachman (1993, as cited in Dinn et al., 1999), who observed that obsessive-compulsive phenomena may arise, in part, due to fears of criticism and an exaggerated sense of personal responsibility. This hypersensitivity to criticism may reflect an intense concern over achieving social acceptance. Checking compulsions may serve as an attempt to prevent criticism, and the themes of obsessions (such as worries related to aggressive and sexual behaviour, and social norms and standards) commonly focus on behaviours and impulses that would generate considerable criticism if acted upon. Thus, in accordance with this model, OCD represents a gross distortion of adaptive behaviours in an effort to achieve social acceptance (Rachman, 1993, as cited in Dinn et al., 1999). 2.10.4. Cognitive-behavioural theories Not only are acute childhood traumas implicated in the aetiology of OCD, but prolonged conditions of threat also seem to function as a predisposing factor for OCD. Psychological stress produces compulsions, with the stress of chronic, intense anxiety, serving as a cultural channel for the operant conditioning of potentially enduring symptoms (Pitman, 1993, as cited in Dinn et al., 1999). In support of this theory, studies have found that adult females with histories of childhood sexual assault showed higher incidences of obsessive-compulsive symptoms (Dinn et al., 1999). In addition, the results of Pitman?s (1993, as cited in Dinn et al., 1999) study of a Vietnam War combat veteran who presented with comorbid post-traumatic stress disorder (PTSD) and OCD, suggested that combat-related trauma is a factor in the development of post-traumatic OCD. This theory is further supported by the finding of the National Vietnam Veterans Readjustment Study that the prevalence of OCD rises dramatically among soldiers exposed to combat (Dinn et al., 1999). Another cognitive-behavioural explanation for OCD is the inferential confusion model. According to this theory, some types of thought-action fusion patterns symptomatic of OCD occur as a result of inferential confusion. Inferential confusion occurs when an individual mistakes an imagined possibility for a real probability, explaining the recurrent, egodystonic nature of obsessions (the person acts as if the imagined negative inference is probable, and unsuccessfully attempts to modify the imaginary probability within the context of reality). This model focuses primarily on the role of the imagination in OCD (O'Connor & Aardema, 2003). 2.10.5. Biopsychosocial models Dinn et al. (1999) presented a three-factor causal model of OCD, which posited that exposure to long-term, non-specific traumatic stress generates an excessive amount of anxiety during the psychological development of the premorbid OCD child. These individuals with OCD experience alterations in brain metabolism, as a result of the exposure to protracted threat. These alterations affect the basal ganglia-orbitofrontal circuit of the brain, which enters into a state of enhanced responsiveness over time, drastically reducing the threshold for stimulation. In this way, the child becomes hypersensitive to cues that signify potential harm or danger, both external and internal, referred to as ?exaggerated threat appraisal? (Dinn et al., 1999). Further to the theory that childhood exposure to traumatic events leads to the development of the magical thinking, superstition and paranormal beliefs of OCD, the three-factor causal model postulated that the child evolves a distinct cognitive style, characterised by exaggerated threat appraisal and thought suppression (Dinn et al., 1999). Thought suppression refers to efforts to block out obsessions, leading to a paradoxical increase in their intensity and frequency (Rachman 1978; Salkovskis, 1989; Salkovskis & Campbell, 1994; as cited in Dinn et al., 1999). Because these negative, intrusive thoughts and obsessions arouse extremely high levels of anxiety or disgust, this serves to further intensify their frequency and severity, resulting in a feedback loop. The individual adapts to this hypersensitivity and anxiety by using a variety of strategies constituting the symptoms of OCD (Dinn et al., 1999). 2.10.6. Psychodynamic theories Psychodynamic explanations for OCD are based on Freud?s psychoanalytic conceptualisation of OCD as ?obsessional neurosis?, one of two major neurotic conditions (Sechaud, 1998). Freud (1913) provided evidence for his theory of obsessional neurosis from post-hypnotic experiments and psychoanalytic work with individuals suffering from neuroses. From his initial research into hypnotic suggestion as a useful treatment for hysterical illnesses, based initially on the progress in this area of French physicians such as Charcot and Janet, Freud began to explore the psychological origins of neurosis. In his clinical practice he developed the psychoanalytic technique of ?free association? (Polansky, 1991) and the therapeutic procedure of ?catharsis? (Freud, 1905a) for the treatment of neuroses. Freud (1905a, pp.77, 85) expressed that all his clinical experience revealed that the ?psychoneuroses? (obsessional neurosis, dementia praecox, hysteria and paranoia) arise from repressed libidinal impulses. Neurosis originates as a result of instinctual conflicts surrounding the resolution of the Oedipus complex, which is a crucial part of healthy psychological development (Sechaud, 1998). The child is unable to relinquish Oedipal phantasies and libido becomes ?fixated? (stuck) on his or her infantile love objects (Mitchell & Black, 1995). The Oedipus complex consists of a significant unconscious psychological developmental challenge for children, in which the child falls in love with the opposite sex parent and wants to eliminate the same sex parent, who is perceived as a rival for the exclusive affections of the same-sex parent (Polansky, 1991). A girl suffers from ?penis envy?, in the form of anger towards her mother for not giving her a penis. Penis envy plays a necessary role in loosening the girl?s ties to her mother (her primary love object) and the development of her femininity (Freud, 1925). Her desire for a penis is replaced by the desire to have a child by her father. In this way, her father becomes her love object and she becomes jealous of her mother (Freud, 1925). A boy suffers from ?castration anxiety?, in the form of a fear that his father will find out about his desires for his mother and cut off his penis as punishment (Lemma, 2002). The Oedipus complex is resolved through fears of punishment or retaliation (castration) from the opposite sex parent (in the case of boys), and identification with the same sex parent (in the case of boys and girls) (Freud, 1925; Mitchell & Black, 1995). In girls, the Oedipus complex is either abandoned or becomes repressed. In boys, the Oedipus complex is ?not simply repressed, it is literally smashed to pieces by the shock of threatened castration? (Freud, 1925, p.341). The process of identification emerges with the successful resolution of the Oedipus complex and involves the formation of the superego, by incorporation (internalisation) of the values, attitudes and sexual orientation of the same sex parent (Lemma, 2002). The anxiety generated by the challenges of resolving the Oedipus complex is immense, with the child caught between a libidinal desire to possess the mother or father and fear of punishment from the other parent, and prove to be overwhelming for individuals who develop OCD (Stafford-Clark, 1965). The characteristics of the Oedipus complex depend largely on how previous psychosexual developmental stages were resolved by the child (Mitchell & Black, 1995). In OCD, psychosexual development is inhibited and the child regresses to the anal-sadistic phase, an earlier stage of psychosexual development characterised by sadistic and anal-erotic impulses, in which he or she became fixated (Freud, 1913). Intrapsychic conflicts at the anal stage (between the ages of 1 and 3 years old) represent a major predicament for the child, as he or she needs to adapt to or resist parental control (Lemma, 2002). In this phase, fear and helplessness towards the adored parent are transformed by a reaction formation into the exact opposite: aggression and phantasies of omnipotence, which are displaced onto all secondary love objects succeeding the parents (Stafford-Clark, 1965). Freud (1905a) hypothesised that OCD symptoms result due to these repressed mental processes, desires and wishes, which obtain discharge via conversion or substitution. In this way these intense, harmful affects are displaced onto alternative, harmless representations of the primary love object (Sechaud, 1998). The superego represents an ?internalisation of parental values that accompanies the resolution of the Oedipal struggle and holds infantile sexuality in check? (Mitchell & Black, 1995, p.15). In OCD, Oedipal fears of punishment from the same sex parent remain unresolved and are adopted by the superego, resulting in conflict based on ambivalent feelings of love and hate. As this conflict is repressed, the affects of guilt and moral distress subsist (Sechaud, 1998). OCD symptoms are defensive reactions to the huge anxiety produced by these conflicting impulses, and serve to prevent or allay fears of harming, contaminating, destroying, or illicitly becoming sexually involved with, the mother or father, or both (Stafford-Clark, 1965). This accounts for what Freud (1913) described as the extraordinary part played in OCD symptoms by impulses of hatred and anal-eroticism, and results in the defensive retreat in the face of prevailing, anxiogenic Oedipal desires, constituting the symptoms of OCD (Sadock & Sadock, 2003). Thus, the superego of individuals with OCD is particularly harsh and feelings of inferiority persist, due to a strong sense of guilt that is ?over-strongly conscious?, generating anxiety (Freud, 1923, p.932). Freud conceptualised OCD as one of a group of disorders (transference neuroses) characterised by high levels of anxiety (Stafford-Clark, 1965). The DSM-IV-TR classification of OCD as an anxiety disorder (APA, 2000) still supports this premise. Anna Freud (1981) proposed that innate dispositional factors (such as quantities of sexual or aggressive instincts) underlie development, and can result in fixation at a particular pregenital psychosexual stage. Freud (1913) maintained that some individuals are dispositionally predisposed to developing a particular kind of neurosis, such as OCD. Freud (1913, p.135) acknowledged the role of an ?external disturbance? (precipitating event) in triggering the onset of OCD symptoms. Anna Freud (1981) also acknowledged that environmental factors, such as individual growth patterns and family circumstances, play a role in psychological development and psychopathology. 2.11. Psychological Assessment and Diagnosis of OCD in Children 2.11.1. Diagnostic difficulties It is estimated that an average of 8 years elapse before psychological help is sought for children suffering from OCD (Presta et al., 2003). This is partly because they are more likely to come to the attention of medical professionals, often resulting in a delay before they are referred for psychological treatment (Snider & Swedo, 2000). Children may come to the attention of paediatricians (for encopresis or secondary enuresis, because of contamination obsessions that lead to a refusal to use the toilet), or dermatologists (for skin conditions, such as eczema from excessive hand washing, or focal lesions from compulsive skin picking). Dentists may be consulted (due to excessive teeth cleaning, resulting in gum lacerations and bleeding), or neurologists (in cases where tics are present). Children may come to the attention of plastic surgeons (as a result of somatic obsessions or dysmorphophobic fears). Depression or generalized anxiety in children, resulting from their disturbing thoughts and behaviours, may lead the family to consult a family physician (Snider & Swedo, 2000). Most children make an effort to suppress or ignore their obsessions (March & Leonard, 1996, as cited in Adams & Burke, 1999). This leads to another factor contributing to delays in diagnosing childhood OCD - the fact that parents are often unaware of the child?s symptoms, either because children tend to become skilled at hiding or disguising them, or due to the common absence of egodystonia in children (Presta et al., 2003). Children frequently perform rituals for 6 months before parents notice the behaviour (Swedo et al., 1989, as cited in Robinson, 1998). Parents also frequently find it difficult to distinguish voluntary behaviour in their children from the involuntary behaviour related to OCD (Adams & Torchia, 1998, as cited in Adams & Burke, 1999). Consequently, parents may only seek help when the behaviours cause significant disruption in the life of the child or family or when the child?s social and educational functioning has become seriously impaired (Rapoport, 1989; Zohar et al., 1992; as cited in Robinson, 1998). Unfortunately, even when the child gains access to appropriate psychological help, OCD is not an easily diagnosable condition and diagnostic errors are frequently made (Presta et al., 2003). According to Robinson (1998), the majority of cases are misdiagnosed as depression or other anxiety disorders. Children frequently present with a large number of complaints, requiring careful consideration in order to identify comorbid and potentially related or unrelated conditions. Neurological assessment and laboratory studies may need to be undertaken (Robinson, 1998). 2.11.2. Assessment and diagnostic procedures It is crucial to obtain a thorough, developmentally sensitive history of the child?s present and past illnesses, in assessing and diagnosing OCD (Robinson, 1998). A complete history of the nature and extent of OCD symptoms must be obtained from the child, in the form of a description of the urges or worries accompanying the rituals, and how symptoms interfere in his or her daily life. However, children often try to hide their disorder to avoid appearing bizarre or different, and when asked why they have obsessive thoughts or perform rituals, most say that they don?t know (Swedo & Rapoport, 1989, as cited in Robinson, 1998). Because children, especially younger ones, may be averse to discussing their symptoms, it is recommended to consult multiple sources of collateral information (Robinson, 1998). Distress may be ascertained by the extent of interference in the child?s schoolwork, social activities, and interpersonal relationships (March & Leonard, 1996). It is important to consider the child?s developmental stage, when assessing and treating any psychological illness. A developmental perspective to the assessment of OCD allows other areas of functioning requiring further or alternative interventions to be identified and addressed. Important areas to consider include the presence of comorbid mood and anxiety disorders, individual learning difficulties, and other psychological disorders (Robinson, 1998). Obsessive-compulsive phenomena were previously believed to simply constitute a transitory childhood pattern of development (Presta et al., 2003). Most, if not all, children exhibit normal levels of obsessive-compulsive behaviours as a function of appropriate development. Such developmentally appropriate behaviours occur early in childhood, enhancing socialization and advancing development (Adams & Burke, 1999). In general, developmental rituals cause little disruption to the child's life and provide some comfort. Examples might include lining up stuffed animals as part of a bedtime ritual or wearing ?lucky? socks for an important game (Snider & Swedo, 2000). Piaget (1950, as cited in Robinson, 1998) described the normative presence of obsessive-compulsive behaviour in childhood development as playing an important role in cognitive maturation and the psychological issues of mastery and control, e.g. mastery of separation anxiety is encouraged by bedtime rituals and childhood games (Adams & Burke, 1999). Obsessive-compulsive symptoms must therefore be differentiated from developmentally appropriate ritualised behaviours (Presta et al., 2003). However, it may be a complex task to distinguish normal childhood rituals and repetitive behaviours from abnormal compulsions (Robinson, 1998). Leonard et al. (1990, as cited in Robinson, 1998) found that normal ritualised play begins between the ages of 3 and 5 years, starting with individualised play and progressing to group games with more complex rules. From the age of six through pre-adolescence, children generally continue to make use of elaborate rules that include the elements of prohibitions, contamination, and avoidance (Leonard et al., 1990, as cited in Robinson, 1998). Leonard et al. (1990, as cited in Robinson, 1998) noted the similarities between OCD and normal childhood rituals, with regard to counting, lucky numbers, and the ?just right? phenomenon. Although bedtime emerges as a common time for rituals, by 8 years of age most night time fear-related rituals normally diminish. Collecting behaviour normally begins during the developmental stage of latency, although this is differentiated from the hoarding behaviours of OCD because the objects collected are meaningful and sentimental (Leonard et al., 1990, as cited in Robinson, 1998). According to Zohar and Bruno (1997, as cited in Robinson, 1998), obsessive- compulsive behaviour declines during the normative process of development. Zohar and Bruno (1997, as cited in Robinson, 1998) found that children with OCD differed from their peers by early adolescence, because their obsessive-compulsive behaviours persisted and their anxiety levels were higher. Obsessive-compulsive behaviours are distinguished from normal rituals by their later mean age of onset, the intensely distressing feelings they evoke when not performed, their egodystonic quality, the emotional exhaustion they generate, the interference they produce in the child's life, the dysfunction produced (rather than a sense of mastery or socialization), and the fact that they appear bizarre to adults and other children, if not to the affected child (Leonard, 1989, as cited in Adams & Burke, 1999). Thus, although behaviours such as doubting, checking, and repeating constitute a normal part of daily functioning, in children with OCD they are performed in excess (Adams & Burke, 1999). There are a number of structured psychological assessment instruments available to aid in identifying obsessions and compulsions, and establishing their severity (Robinson, 1998). Aside from the DSM-IV-TR diagnostic criteria for OCD (APA, 2000), numerous semi-structured diagnostic interview diagnostic scales have been developed for use with children. These measures include the Children's Yale-Brown Obsessive-Compulsive Scale (CY-BOCS), the Yale Schedule for Tourette?s Syndrome and Other Behavioural Disorders, the Leyton Obsessional Inventory-Child Version (LOI-CV), the Multidimensional Anxiety Scale for Children, the Anxiety Disorders Interview Schedule for Children, the U.S. National Institute of Mental Health (NIMH) Global Severity Scale, and the Children's Global Assessment Scale (CGAS). The CY-BOCS provides a checklist to identify past and present obsessions and compulsions, and order them according to content. On this scale, the most prominent symptoms (target symptoms) are rated on a 5-point anchored scale, providing measurements of symptom severity. The severity scale provides a validated means to assess and monitor the child?s progress at intervals during the treatment process (Adams & Burke, 1999). The Yale Schedule for Tourette?s Syndrome and Other Behavioural Disorders provides subscales to measure the total severity of compulsions and subscales for obsessions, in the form of violent images and impulses scales (Zohar et al., 1997). The Multidimensional Anxiety Scale for Children is used to assess anxiety in children of 8 years or older. The test is useful to determine the presence and severity of an anxiety disorder and to establish whether a disorder constitutes OCD. The scale contains an Obsessive-Compulsive Screen (MASC OC-Screen) for assessing the presence of specific obsessive-compulsive symptoms. The Anxiety Disorders Interview Schedule for Children is another scale used to diagnose OCD, and the NIMH Global Severity Scale broadly assesses the clinical severity of OCD symptoms (Waters et al., 2001). The CGAS is useful to measure general functioning and symptom-related difficulties and, although scores are based on clinical judgment, the test has demonstrated inter-rater reliability and validity (Adams & Burke, 1999). Other assessment measures used to assess OCD in children include the Wechsler Intelligence Scale for Children (WISC), the Complex Figure Test, the Beck Depression Inventory (BDI), the Children's Depression Inventory (CDI), the State- Trait Anxiety Inventory, attention tests, and projective tests. The McMaster Family Assessment Device assesses functioning within the context of the child?s family. The Family Accommodation Scale for Obsessive-Compulsive Disorder assesses family involvement in the child's symptoms, by measuring the level at which parental and family routines have been modified to accommodate the child?s OCD symptoms (Adams & Burke, 1999). Structured psychological assessment instruments, such as those referred to above that aid in identifying obsessions and compulsions, were not used in the study, as the aim of the study was not to assess and diagnose OCD (the subjects had already been diagnosed with OCD). The aim of the study was to focus on exploring the internal world of children with OCD and thus the assessment measures used were projective tests, as these are designed to investigate unconscious processes, and a biographical questionnaire based on the DSM-IV-TR diagnostic criteria for OCD (APA, 2000) and data about OCD collected in the literature review of this study, to provide a context within which the children?s projective test data could be analysed. 2.12. Conclusion OCD is a relatively common psychological disorder in both children and adults (Presta et al., 2003; Snider & Swedo, 2000; Zohar et al., 1997). The diagnostic criteria for OCD stipulate recurrent obsessions and/or compulsions, which cause marked distress and/or interference in the individual?s functioning (APA, 2000). The defining feature of OCD is the grossly excessive nature of obsessive ideation and compulsive ritual (Dinn, Harris & Raynard, 1999). Most people with OCD have insight as to the source of these thoughts being in their own minds, but even when insight is present, children with OCD still experience high levels of anxiety and fear due to the distressing content of their obsessions (APA, 2000). Common childhood obsessions include contamination, aggression, fears of making mistakes with tragic consequences, scrupulosity, obsessive thinking with regard to symmetry, exactness and numbers, magical thinking (Francis & Gragg, 1996; Hanna, 1995; as cited in Robinson, 1998), and pathological self-doubting (Adams & Burke, 1999). Obsessions assume such intense meaning for individuals with OCD that they feel compelled to perform debilitating cognitive and behavioural rituals (compulsions) to control, dispel or neutralise their obsessions, and reduce anxiety generated by them (APA, 2000). Common childhood compulsions include excessive cleaning activities, repetition of actions, checking, counting, ordering and arranging, touching or tapping objects, excessive collecting or hoarding, and the 'just right' phenomenon (Adams & Burke, 1999; Hanna, 1995; March & Leonard, 1996; as cited in Robinson, 1998; Presta et al., 2003). Compulsions are frequently, but not always, shaped by the content of obsessions (Adams & Burke, 1999). OCD usually presents as a combination of obsessions and compulsions, however a small percentage of sufferers experience only either obsessions or compulsions (March & Leonard, 1996, as cited in Adams & Burke, 1999). Although OCD is generally a chronic condition, there are cases of acute manifestation, such as in acute postpartum-onset OCD (Abramowitz et al., 2001). OCD symptoms are generally relatively stable across time in adults (Mataix-Cols et al., 2002), but unstable in presentation during childhood (Presta et al., 2003). The disorder is relatively persistent in adulthood, but less so in childhood (Snider & Swedo, 2000). Symptom severity is likely to change over time (Hanna, 1995, as cited in Presta et al., 2003), and according to the setting (Adams & Burke, 1999), particularly in children (Presta et al., 2003). Although the severity of OCD in childhood is a major contributing factor to a poor prognosis (Thomsen, 1995, as cited in Presta et al., 2003), comorbid tics or odd cluster personality disorders are the most significant factors associated with a poor prognosis (Presta et al., 2003). Two clinical subtypes of OCD have been differentiated, early-onset (before the age of 18 years) and late-onset (at the age of 18 years or older). The mean age of onset in childhood is between 9 and 10 years, tending to be earlier in boys (at approximately the age of 9) than in girls (at approximately the age of 11) (Robinson, 1998). Boys tend to have more severe and persistent symptoms, than girls (Presta et al., 2003). Other anxiety disorders may precede and/or follow childhood-onset OCD (Presta et al., 2003). Comorbid disorders are fairly common in children with OCD, especially depressive disorders and other anxiety disorders (Robinson, 1998), with major depressive disorder as the disorder most often comorbid with OCD (Kaplan & Hollander, 2003). Anxiety disorders frequently comorbid with OCD include overanxious disorder, simple phobias (Swedo et al., 1989, as cited in Snider & Swedo, 2000), social anxiety disorder, and panic disorder. OCD is often comorbid with Bipolar II Disorder (Thomsen, 2000, as cited in Presta et al., 2003), adjustment disorder with depressed mood (Swedo et al., 1989, as cited in Snider & Swedo, 2000), and substance abuse disorders (Robinson, 1998). OCD is often comorbid with childhood-onset conditions, particularly AD/HD, ADD, SAD (Adams & Burke, 1999), disruptive behaviour disorders (notably conduct disorder), tic disorders (especially TS) (Robinson, 1998), and learning disorders (particularly reading disorder, expressive language disorder, and NVLD (Adams & Burke, 1999; Robinson, 1998). Children with OCD are likely to come to the attention of medical professionals first (Snider & Swedo, 2000), and an average of 8 years elapse before psychological treatment is sought (Presta et al., 2003). The diagnosis of OCD is often overlooked or incorrectly identified by health care professionals (Flament et al., 1988, as cited Robinson, 1998), possibly because many disorders can display obsessive and compulsive symptoms (Hollander, 1993, as cited in Robinson, 1998; Presta et al., 2003). Thus, it is crucial to obtain a thorough, developmentally sensitive history of the child?s present and past illnesses, in assessing the child (Robinson, 1998). Obsessive-compulsive symptoms must be differentiated from developmentally appropriate ritualised behaviours, often a difficult task (Presta et al., 2003). A number of measures may be used in the psychological assessment of children for OCD, including semi-structured diagnostic interview scales that aid in identifying obsessions and compulsions, and establishing their severity (Robinson, 1998). OCD has a profound impact on the lives of children and adults who experience it. Children with more severe OCD, or comorbid depression, experience a particularly low quality of life (Lochner et al., 2003). The child?s family relationships, peer friendships, and academic performance are often affected in deeply negative ways by OCD (Waters et al., 2001). Potentially debilitating family stress frequently accompanies OCD. OCD is likely to significantly impair the child?s social functioning, particularly at school, often resulting in social isolation (Adams & Burke, 1999). The child?s learning capacity is decreased due to OCD symptoms (Adams, Waas, March & Smith, 1994, as cited in Adams & Burke, 1999), and absenteeism from school may occur (Clarizio, 1991, as cited in Adams & Burke, 1999). The child?s self-esteem may suffer, due to increasing frustration and shame over failing to live up to parental and teacher expectations (Adams & Burke, 1999). Although the precise aetiology of OCD remains unclear, recent research contributed greatly to the understanding and treatment of childhood OCD (Adams & Burke, 1999), and suggested the possible existence of an obsessive-compulsive spectrum of disorders (Presta et al., 2003). Aetiological theories include genetic, neurological, psychosocial, cognitive-behavioural, and biopsychosocial models. A leading theory relates to a genetic predisposition for OCD, based on findings that diagnostic rates for OCD are higher in family members of individuals with OCD than in the general population (de Silva & Rachman, 1998; Swedo et al., 1990, as cited in Adams & Burke, 1999; Waters et al., 2001). Research findings indicated high degrees of general psychopathology in families of children with OCD (Hoover & Insel, 1984; McKeon & Murray, 1987; Toro, Cervera, Osejo & Salamero, 1992; as cited in Dinn et al., 1999). What is inherited appears to be a general emotional oversensitivity, which can predispose one to developing an anxiety disorder (de Silva & Rachman, 1998). There is increasing research evidence of a neurological basis for OCD (March et al., 1995, as cited in Robinson, 1998), with strong evidence linking OCD with cognitive impairment and brain dysfunction (Adams & Burke, 1999; Henin et al., 2001). Psychosocial explanations for OCD focus largely on research evidence on the role of traumatic or negative life events in precipitating OCD. These events generate extremely high levels of anxiety, prompting compulsive rituals to reduce anxiety. A related psychosocial theory suggests that significant adults in the child?s immediate environment may generate and reinforce the child?s pathogenic superstitious thinking and behaviour. A further psychosocial theory is that OCD may arise partly due to fears of criticism and an exaggerated sense of personal responsibility. This hypersensitivity to criticism may reflect concerns over achieving social acceptance, and OCD symptoms represent gross distortions of adaptive behaviours in efforts to achieve this acceptance (Rachman, 1993, as cited in Dinn et al., 1999). Cognitive-behavioural theories for OCD implicate childhood traumas, particularly prolonged psychological stress, in the aetiology of the disorder. This stress produces compulsions, and the ongoing nature of the stress results in operant conditioning of potentially enduring symptoms (Pitman, 1993, as cited in Dinn et al., 1999). The inferential confusion model provides another cognitive-behavioural explanation for OCD, in which the individual confuses an imagined possibility for a real probability. Their unsuccessful attempts to modify the imaginary probability within the context of reality constitute OCD symptoms (O'Connor & Aardema, 2003). Biopsychosocial Models for OCD include a three-factor causal model, which contends that exposure to long-term, non-specific, traumatic stress during the child?s development generates excessive anxiety. Alterations in brain metabolism result, causing ?exaggerated threat appraisal? (hypersensitivity to cues of potential harm or danger). The child evolves a cognitive style typified by the exaggerated threat appraisal and thought suppression that characterise OCD (Dinn et al., 1999). Psychodynamic explanations for OCD are based on Freud?s understanding of OCD as arising from repressed instinctual conflicts in relation to resolving the Oedipus complex (Sechaud, 1998). When a child is unable to relinquish Oedipal phantasies, libido becomes ?fixated? on primary love objects (Mitchell & Black, 1995). Children with OCD became fixated in the anal-sadistic stage of psychosexual development (between the ages of one and three), and regress to this stage as a defense against the anxiety generated by these Oedipal desires. Regression to this stage manifests as the symptoms of OCD (Freud, 1913; Sadock & Sadock, 2003). Chapter 3 RESEARCH METHODOLOGY 3.1. Theoretical Framework 3.1.1. Psychoanalytic theory of the unconscious Freud postulated the concept of the unconscious mind as a level of consciousness that lies below the realm of conscious awareness. He claimed that most human psychological functioning exists within the dimension of the unconscious. He justified his theory of the unconscious with evidence from hypnotic experiments, particularly those involving post-hypnotic suggestion, and his psychoanalytic work using the technique of free association (Freud, 1915). Other evidence that the mind contains much material that is unconscious emerged from slips of the tongue, humour, and dreams (Polansky, 1991). The unconscious is ruled by the ?pleasure principle? of the id (the most basic, instinctual part of the mind) and its processes are ?timeless? (Freud, 1915, p.191). Thus in the realm of the unconscious, time and reality do not exist and the focus is on the primary processes of seeking pleasure and avoiding ?unpleasure? (psychic pain). The instincts of sex (?life instinct?) and destruction (?death instinct?) find psychological representation in the form of impulses within the unconscious. Repressed material forms part of the unconscious, containing material that is unacceptable to the superego and so is censored and hidden from consciousness (Freud, 1915). From a psychoanalytic perspective, all disturbances in behaviour and personality are best understood by exploring the unconscious mind, as this is where they originate. Freud was the first to identify and make an effort to conceptualise and understand OCD (?obsessional neurosis?) and the misery it evokes in the lives of sufferers and those around them. He came to understand OCD as driven by unconscious forces, in response to the repression of anxiogenic sexual instincts during psychosexual development, specifically linked to the unsuccessful resolution of the Oedipus complex (Stafford-Clark, 1965). Thus, the concept of the unconscious mind is central to a psychoanalytic understanding of OCD, as it is of most psychological disorders. Since the researcher seeks to explore the unconscious life of children with OCD, the study assumes the existence of the unconscious and makes use of data gathering and analysis procedures designed to investigate unconscious processes. 3.2. Sample and Sampling The sample was drawn from the local population of children who have been diagnosed and treated for OCD. By definition, the sample was constituted by individuals who had experienced early-onset OCD, defined by Henin et al. (2001) as a clinical sub-type of OCD in which symptoms emerge before the age of 18 years. As very early-onset OCD is defined as symptoms emerging before the age of 6 years (Presta et al., 2003), children who had very early-onset OCD were eligible for inclusion in the sample. The sample was drawn from the population of children aged between 6 and 12 years of age, or what Freud (1905b) defined as latency-age children. Because latency is a phase of socialization (Freud, 1905b), children in this psychosexual developmental stage were identified as suitable candidates for the study as it was expected that they had developed a sense of self in relation to family and the outside world. The researcher gained access to a small sample of four participants. This sample size was selected for two reasons. Firstly, a small sample was more manageable for the purposes of the study because qualitative analysis of the data gathered is time- consuming and rigorous in nature. Secondly, a small group of subjects is adequate for the purposes of the study because it does not aim to generalize findings to the larger population, but focuses on gaining a rich and detailed understanding of the subjects? inner worlds. The sampling technique used was non-probability, convenience sampling. This method was selected because the study relates to a specific population, and it was only possible (ethically and practically) to gain access to a sample of this population via convenience sampling. For these purposes, the researcher approached a psychologist who specializes in working with children with OCD and a child psychiatrist. Both professionals agreed to assist the researcher by identifying potential sample members drawn from their clients and forwarding an introductory letter from the researcher (see Appendix B) to the parents. As time went by, the researcher approached further psychologists working in private practice or for organisations, institutions, and schools. Some of them agreed to forward an introductory letter from the researcher to the parents of children who met the criteria for eligibility to participate in the study, although most of them did not have any clients eligible for inclusion in the sample. The introductory letter explained the purpose of the research and requested the participation of the parents and their children in the study. The researcher?s contact details appeared on the introductory letter, and if the parents wished to participate in the study they contacted the researcher telephonically. The researcher handed or faxed copies of the introductory letter to the professionals who agreed to assist her and/or placed a copy on their notice boards with their consent. For ethical reasons, the researcher was not privy to any details about potential participants who received the introductory letter. Only four parents contacted the researcher telephonically, and all agreed to participate in the study. The researcher made appointments to meet with the parents at their homes to discuss their participation and address any questions or concerns. Those who agreed to participate completed the biographical questionnaire (see Appendix D), which gathered biographical data about the child. The questionnaire contained a separate consent form, which parents signed to consent to their and their children?s participation. The researcher then requested a second meeting with the parents and their children at their homes to collect the completed biographical questionnaires, establish rapport with the children, and explain the procedure for the psychological testing to the children. The researcher explained to the children that she is studying at university and doing a project about children who have OCD, because she is interested in understanding them and knowing more about them, and that the way she is doing this is by asking children to draw pictures, tell her about their pictures, and make up some stories about picture cards. The researcher explained that she would like to spend a few hours alone with the children, so that they could do the drawings and make up the stories. She explained to the children that they could choose whether or not they wanted to do the drawings and make up the stories, and that they didn?t have to if they didn?t want to, and nobody would mind if they didn?t want to. The children were requested to indicate their assent to participating in the study, by signing an assent form that was co-signed by their parents (see Appendix E). The researcher explained to the children that, should they feel uncomfortable with the testing at any point, testing would be terminated with no adverse consequences for themselves. Thereafter the researcher requested a session of up to two hours alone with the children, in a quiet room, with a table or desk and chairs, in order to individually administer the D-A-P, K-F-D and TAT to them. The researcher requested that the session take place in their homes, to help the children feel as safe and comfortable as possible in a familiar environment. In the introductory letter, the researcher had stated that, in the event that testing was not completed in the first session, she would request a further session of up to one hour with the child. However, a second session was not required with any of the participants. The researcher allowed the participants rest breaks between tests and whenever they appeared tired. She observed and recorded their behaviour during the testing process. This data is presented in the introduction to each subject and in the introduction to each test in the analysis chapter of the research report. 3.3. Procedure 3.3.1. Research design The research design is purely qualitative in nature as it seeks to understand the psychological life of children with OCD. The purpose of qualitative research is not to explain the human behaviour in question, but rather to seek detailed descriptions and understandings thereof by observing and analysing individuals. The approach seeks to understand how an individual uniquely perceives and comprehends his or her world (Babbie & Mouton, 1998). The study is exploratory in nature and there is no research hypothesis as the approach is inductive. This means that the researcher did not approach the study with existing hypotheses as to what results would emerge, but rather used the data generated by the study to derive understandings and theories (Babbie & Mouton, 1998). The aim of the study is to generate a detailed interpretive understanding of the child?s subjective emotional state, unconscious conflicts and defenses, personality, and psychopathology by analysing the child?s projective drawings and TAT stories. These findings were contextualised with reference to the child?s symptomatology and personal history, in accordance with the principles of qualitative research described by Babbie and Mouton (1998). These principles relate to the primary tasks of qualitative researchers in terms of describing the behaviour in detail and attempting to understand it within its context (Babbie & Mouton, 1998). Thus, the qualitative researcher captures and discovers meaning in the data by becoming immersed in it (Neuman, 1997). The study aims for specificity and seeks to interpret a particular issue or problem. A case study approach was selected as it lends itself to the gathering of detailed, rich, subjective data. The researcher is a fundamental part of this process (Banister, Burman, Parker, Taylor & Tindall, 1994). This means that the researcher?s interpretation and understanding of the data generated from this study are factors acknowledged as integral aspects of the research process and subsequent results. 3.3.2. Data gathering instruments and procedure There were four instruments used to gather data. Three of these were projective assessment tests, administered to the children. These were the Machover Draw-A- Person test (D-A-P), the Kinetic Family Drawing Test (K-F-D) and the Thematic Apperception Test (TAT). The fourth instrument was a biographical questionnaire about the child, constructed by the researcher and completed by the parents or guardians of the children. 3.3.2.1. Projective tests Three projective assessment tests were administered to the children in the study. Two of these tests took the form of Human Figure Drawing (HFD) tests, viz. the D-A- P and K-F-D. The third projective test administered was the TAT. The rationale behind the use of projective tests to assess individuals is referred to as ?the projective hypothesis?. This hypothesis holds that all responses made by the subject in the testing condition to test stimuli or the tester are reflections or projections of his or her inner world (Tallent, 1992). The projective use of drawings, particularly human figure drawings, emerged partly from studies based on the application of classical psychoanalytic theory (Mortensen, 1991). Ogden (2001, p.72) maintained that HFD is ?widely held to represent the drawer?s perception of himself or herself, and his or her body image?, reflecting both self-concept and body image. Machover (1949, as cited in Mortensen, 1991) maintained that the process of HFD involves a practice of selection and integration, which necessitates the process of identification through projection and introjection. In this way, the individual?s ?body image? is expressed in the drawing in terms of the associated needs and conflicts (Machover, 1949, as cited in Mortensen, 1991, p.52). These may be expressed either directly or indirectly, thus exposing the operation of the individual?s defense mechanisms. Although Koppitz (1968, as cited in Mortensen, 1991) did not agree with Machover?s argument that HFD is expressive of body image, she did propose that these drawings express the self-concept of the individual, and that the child directly expresses either his or her conflicts and attitudes, a ?wishdream?, or a combination of both. HFD is used to describe the personality of the individual, with special relevance to his or her psychosexual identification and development, aggressive and sexual impulses, defense mechanisms, and anxieties (Mortensen, 1991). Machover (1949, as cited in Tallent, 1992) proposed that HFD, as creative expression, indicates the individual?s conflicts and needs, and that the figure drawn is intimately connected to the personality of the person creating the drawing. Ogden (2001) explained that personality characteristics are obtained from HFD, regardless of artistic ability or training. A study conducted by Marques et al. (2002) found that the DAP showed a high degree of reliability, in the form of emotional indicators. According to Reynolds (1978), empirical research generally supports the validity of the Kinetic Family Drawing (K-F-D) for personality assessment. HFD tests are useful as psychopathological diagnostic indicators, to generate hypotheses for further exploration (Ogden, 2001; Sadock & Sadock, 2001; Swensen, 1969, as cited in Ogden, 2001). Machover (1949, as cited in Tallent, 1992) explained that, although some of the assumptions behind the interpretation of HFD may lack experimental verification, their clinical validity has been proven. At the very least, the interpretative techniques for HFD, such as the D-A-P, ?provide a rich source of hypotheses to be responsibly evaluated in the context of the data mix of a battery? (Tallent, 1992, p.167). For the purposes of this study, the D-A-P was used as a projective measure. Thus it was not administered according with the instructions in Harris? (1963) test manual (as these were designed to measure intellectual maturity), but in accordance with the administration instructions provided by Machover (1949, as cited in Tallent, 1992). The K-F-D was administered in accordance with the procedure proposed by Burns and Kaufman (1972). Ogden (2001) pointed out the importance of considering the subject?s verbalizations about his or her drawing, in conjunction with the hypotheses and signs contained within the drawing itself. For these purposes, some researchers make use of a second phase of administration, involving a series of questions (Tallent, 1992). The researcher incorporated this narrative phase into the process of administering the D- A-P and K-F-D tests, thereby enriching the study. Morgan and Murray?s Thematic Apperception Test (TAT) was developed to aid in obtaining fantasy material from psychoanalytic patients (Morgan & Murray, 1935, as cited in Cohen & Swerdlik, 2001). Thus, as is the case with HFD tests, the TAT is a projective technique that makes use of pictures as projective stimuli (Bellak, 1975). Analysis of the stories created by testees in response to the TAT cards provides a source of interpretive hypotheses about the individual?s emotional state of mind and perceptions, and attitudes toward the self, family, and outside world (Bellak, 1975). Furthermore, such analyses generate deeper information about the individual?s thought processes, personality characteristics, and repressed unconscious material (such as conflicts, needs, desires, and defenses) (Bellak, 1975). The TAT is utilised extensively in both research and clinical settings and can generate rich data about an individual. According to Kaplan and Saccuzzo (2001, p.463), although some experts consider the psychometric properties of the TAT to be questionable, empirical data reveals that interpretative data on some variables, such as the achievement need of the individual, produced ?respectably high reliability figures?. Although criterion-related evidence as to the TAT?s validity has not been easy to document, there is consensus among most experts that sufficient evidence exists as to its content-related validity, to support its use in the evaluation of human personality (Kaplan & Saccuzzo, 2001). In the study, the TAT was administered according to the administration instructions contained in the test 3.3.2.2. Biographical questionnaire The biographical questionnaire (see Appendix D) contains questions about the child, his or her symptoms and treatment, the family, and the effect of the child?s OCD symptoms on the child and family. The questionnaire is based on the DSM-IV-TR diagnostic criteria for OCD (APA, 2000) and data about OCD gathered in the literature review of this study. The questionnaire aimed to provide a context within which the children?s test data could be analysed. 3.4. Data Analysis Analysis of qualitative research data consists of capturing themes from the evidence and organising the data, to present a sound, coherent picture (Neuman, 1994). Research results were obtained by interpreting the emotional and diagnostic indicators provided by the children?s D-A-P drawings, K-F-D drawings and TAT stories. These findings were considered within the context of data obtained from the biographical questionnaire. To this end, the researcher consulted a wide variety of interpretative systems relating to HFD interpretation to ensure that the interpretations were as rich and multifaceted as possible. Thus, the D-A-P and K-F-D drawings were analysed using the theoretical frameworks and guidelines provided by relevant authors addressing the psychodiagnostic, intrapsychic, emotional and relational indicators revealed in Human Figure Drawings. Hammer, Machover, and Levy have been prominent contributors to literature on these subjects. Other contributing authors include Beck, Halpern, Alschuler, Hattwick, Mira, Lehner, Gunderson, Bender, Buck, Krout, Fisher, Elkisch, and Jolles (Gilbert, 1980). The researcher found the various interpretative systems relating to HFD interpretation mostly complemented one another, with many prominent authors agreeing on the meanings of emotional indicators. Where there were discrepancies, the researcher interpreted the emotional indicators in the context of the child?s drawing, his or her other drawings, her observations and impressions of the child, and the data obtained about the child from the biographical questionnaire. Reynolds (1978) provided a guide for the interpretation of K-F-D clinical indicators, which was also consulted. The K-F-D drawings were also interpreted and analysed in accordance with the criteria outlined by Burns and Kaufman (1972), incorporating both the subjective analytic perceptions of the researcher, together with objective criteria for the analysis of components within the drawings. The interpretative guidelines provided by Handler (1996) for emotional indicators and interpretation of structure, content, and body parts were also utilised. The interpretative criteria elaborated upon by Ogden (2001) for emotional and personality assessment using projective drawing tests also served as guidelines in analysing the D-A-P and K-F-D drawings. The quantitative intelligence quota-based scoring system of Machover?s administration technique (Machover, 1949, as cited in Tallent, 1992) was not utilised. The drawings were rather interpreted qualitatively according to the criteria referred to above. The TAT stories were analysed using Bellak?s (1973) Short Form of the TAT Blank and Analysis Sheet and the interpretative guidelines proposed by Bellak (1975). The biographical questionnaire contains both closed and open-ended questions. The open-ended questions were analysed using thematic content analysis. Content analysis involves arranging unstructured raw data, in order to make valid, meaningful inferences (Henwood, 1996). As much as possible, the researcher refrained from editing the raw data, reporting it verbatim in the research report whenever it was meaningful, feasible and sensible to do so, followed by her interpretations thereof. At times, the researcher had to use her initiative in analysing the data according to the themes, e.g. regarding the open-ended questions requiring details of the children?s OCD symptoms. Data gathered from the biographical questionnaires is incorporated in the introduction to each subject, in the analysis chapter of the research report. In keeping with the principles of qualitative data analysis, as outlined by Henning (2004), the researcher proceeded to identify themes in the rich, complex data generated by analysis of projective test data in the context of biographical information. As the study is qualitative in nature, the researcher is an important part of the process of data interpretation (Banister et al., 1994). It is acknowledged that the data analysis is contextualised within and coloured by the subjective personal perceptions and understandings of the researcher herself. Because the researcher has extensive personal experience of spending time with individuals with OCD, it is possible that she may have inadvertently tended to ?over-analyse? some of the children?s behaviour, interpreting her observations as potentially symptomatic behaviours in instances when they may not have been, as a consequence of relating the behaviour to her own personal experiences. In addition, because the researcher has a child of her own, she may have unconsciously made comparisons between the participants and her own child, e.g. in terms of what constituted developmentally appropriate behaviour, and inadvertently projected these judgements in her interpretations. 3.5. Ethical Considerations Babbie and Mouton (1998) outlined the most important professional ethical codes of conduct pertaining to conducting social scientific research. These ethical standards relate to the areas of voluntary participation, causing no harm to participants, anonymity, confidentiality, the deceiving of subjects, and data analysis and reporting practices (Babbie & Mouton, 1998). Aspects of these ethical guidelines pertaining to the study are discussed below. 3.5.1. Voluntary participation Participation in the study was entirely voluntary and no reward was offered for participation. No coercion was used in gaining access to subjects for the study. Although, fortunately, no participants (children or parents) withdrew from the study, they were allowed to do so at any point in the research process with no adverse consequences, which was explained to them. 3.5.2. No harm to participants Although no harm was anticipated as a result of participation in the study, the researcher offered to provide the children?s referring mental health practitioners with copies of their D-A-P and K-F-D drawings and transcribed TAT stories, with the written consent of their parents. The biographical questionnaire provided for parents to indicate whether or not they consented to this. Thus, should the children have experienced any adverse effects due to participating in the study, their mental health practitioners would have been provided with data to assist them in providing the children with appropriate support. Potential adverse effects may have included anxieties related to test performance or the disclosure of data of a personal nature to the researcher. For ethical reasons of confidentiality, informed written parental consent was thus required to release this data to the children?s mental health practitioners. However no parents who participated in the study elected to consent to this release of data. 3.5.3. Confidentiality The researcher undertook to keep identifying data pertaining to the research subjects confidential. All data gathered by the study was used for research purposes only and only the researcher, her supervisor, and examiners were privy to identifying data. In the research report, the researcher made use of pseudonyms at all times to refer to participants and anyone mentioned by name by the participants. No identifying data was gathered by the biographical questionnaire. Upon completion of the research, the questionnaires will be destroyed. The children?s drawings were not destroyed, as photocopies of these are attached to the research report for purposes of evaluation of the researcher?s analyses thereof. This is important for the purposes of validating the results of the study. However the researcher photocopied the original drawings after removing identifying details such as names and replacing them with pseudonyms. The original drawings will be destroyed on completion of the study. The researcher has attached copies of the transcribed questions asked about the children?s drawings and their answers to the research report, after removing identifying details, for the purposes of validation of the results of the study. The original transcripts will be destroyed on completion of the study. Similarly, the researcher has attached copies of the transcribed TAT stories to the research report for the purposes of validation of the results of the study. The researcher removed identifying details from transcripts and will destroy original transcripts on completion of the study. 3.5.4. Informed consent The aims, procedure and implications of the study were briefly explained to the parents in the introductory letter. The researcher explained these aspects in more detail when she was contacted telephonically by the parents, and again on meeting with them. She also provided them with a subject information sheet, attached to the biographical questionnaire, which offered a more detailed explanation of the study. Feedback to the parents of the children who participated in the study was offered on request in the form of a summary page of the results of the study. For ethical reasons no individual feedback was offered by the researcher, as she is not suitably qualified to provide such feedback. In addition, the researcher is not in possession of sufficient data about the child, to effectively address or manage any concerns and queries parents may have about their children, or the children may have about themselves. The researcher referred parents to their child?s mental health professional, who is in a position to debrief participants and provide support in the event of any individualised queries or concerns. The subject information sheet explained the purpose of the research and requested consent for parents and their children to participate in the study. It provided the researcher?s contact details and an offer on the part of the researcher to answer any questions and address any concerns that parents may have. This offer was also communicated to the parents by the researcher on meeting them. The questionnaire provided for the parents or guardian to give consent to participate in the study themselves and for their children?s participation. The questionnaire also contained a child assent form for the children to provide their assent to participating in the study, which the children completed with the assistance of their parents or guardian. 3.5.5. Analysis and reporting Data gathered by the administration of the projective tests was analysed according to the criteria for analysis provided by the relevant authors referred to in the data analysis section of the research report. This ensured that the researcher complied with the accepted technical standards for projective test analysis, a proviso made by Babbie and Mouton (1998). The researcher presented an analysis of each subject?s test data in the context of data gathered from the biographical questionnaire and her observations and subjective impressions of the subject, to ensure that the analysis is as rich and multifaceted as possible. As there was a large quantity of data to analyse and the objective was to understand the subjective, inner world of each child as fully as possible, the analysis for each subject is presented separately. In the introduction to each subject, the researcher presented her observations and subjective impressions of the subject and the data from the biographical questionnaire. The age-related norms for HFD applicable to each subject were applied in the analysis and are presented after the introduction to the subject. The HFD analyses are then presented, each one introduced by the researcher?s observations of the subject as s/he drew. The emotional indicators contained in the drawings were extracted and presented under the categories of self-concept, personality, and psychopathology. These categories were chosen to enable the data to be categorized and ordered in a manner appropriate to the aims of the study. Each category contains sub-categories to further organize the data in an orderly and meaningful way. Where relevant, the researcher?s impressions and observations and data from the biographical questionnaire are incorporated and integrated to enrich the analysis. Analysis of the subjects? TAT stories is presented as an analysis of the stories to each individual card, as each card explores one or more particular themes. A full analysis adapted from Bellak?s (1975) TAT Transcript and Short Form for Recording and Analysing TAT is presented as a separate appendix for each subject. The discussion chapter of the research report presents the researcher?s interpretation of the internal world of each subject. In this chapter, data from the biographical questionnaire, the test data, and the researcher?s observations and impressions are integrated against a background of theory gathered in the literature review of the research report that pertains to the discussion. Themes that emerged in the analysis are discussed. In the conclusions chapter of the research report, the main themes that emerged in the discussion chapter are summarized for each subject. Interpretative themes for all the subjects are then presented. The findings for the subjects are compared and contrasted. The findings of the study are integrated with relevant psychodynamic theory and other appropriate theories and data gathered in the literature review of the research report. Photocopies of the children?s drawings, transcripts of questions and answers to their drawings, and transcribed TAT stories are attached to the research report (after the removal of identifying data), for the purposes of marker evaluation of the analyses and to allow the results of the study to be validated by other researchers. This ensures the transparency of research findings and the researcher?s accountability for the results of the study. Babbie and Mouton (1998) proposed that the researcher should indicate the methodological and theoretical limitations of findings on conclusion of the study. The researcher has discussed these limitations in the conclusions chapter of the research report. Chapter 4 Analysis 4.1. Subject A ? ?Mike? 4.1.1. Introduction Mike presented as a bright, shy boy of 11 years and 5 months. Although tall for his age, he appeared physically frail with delicate features. His early developmental milestones were normal except for difficulties with handwriting and social skills (excessive shyness). He presented with Separation anxiety disorder (SAD) when he started school. His parents are divorced and he has two half-siblings from his father?s previous marriage, a sister aged 18 and a brother aged 21 who live with Mike?s father. Mike lives with his mother, whom he is very close to. Mike was 7 years and 2 months old when his mother first noticed symptoms of obsessive-compulsive Disorder (OCD). Treatment was sought from the family doctor and he was referred to a psychiatrist for treatment at the age of 7 years and 8 months. His first symptoms were worries about contamination by germs (?not wanting to share a glass or spoon with his mother?), repeated doubting (worrying whether his mother had locked the house and that she had left the stove on), ordering (having to personally place his toys and books ?just right? in his room), aggressive or socially- unacceptable impulses (?frequently interrupting and saying out loud what he thought of guests?), recurrent thoughts or worries about sex/?bad thoughts? (thinking that sex is a bad thing and ?not liking to think that his mother has sex?), cleaning rituals (hand- washing and ?chewing the clothing he wore?), observable repeating or counting rituals (counting things over and over, building floors or tiles on the floor while repeatedly counting, repeating lines and accents from movies, licking his lips repeatedly, shaking his head repeatedly to fall asleep), mental repeating or counting rituals (counting repetitively to fall asleep), and demanding reassurance (to the point of having panic attacks due to unnecessary worrying that something bad was going to happen). Just prior to the onset of these symptoms a traumatic event happened in Mike?s life, viz. his parents? divorce. Since the divorce, he has seen very little of his father and there is still much conflict between his parents. His father recently invited him to stay over every second Saturday night, which he now does. Although he enjoys this, he reportedly often feels anxious about going. There is a family history of OCD (Mike?s father, his father?s brother and sister, and his paternal grandfather, are or were OCD sufferers). Mike has been diagnosed with three comorbid psychological conditions, viz. separation anxiety disorder (SAD), attention-deficit disorder (ADD), and tourette?s syndrome (TS). Mike is still receiving psychological treatment. Nowadays, his mother classifies his symptoms as ?mild? in severity (one or two aspects of his life are mildly impaired but he generally copes well with life). He no longer displays worries about contamination, aggressive or socially unacceptable impulses, or recurrent thoughts and worries about sex (?bad thoughts?). However, the symptoms of repeated doubting, ordering, cleaning rituals, observable repeating or counting rituals, mental repeating or counting rituals, and demanding reassurance, remain. Mike?s temperament and life have changed since he started displaying symptoms of OCD. His symptoms wear him out and he is often tired as a result. He has become more depressed, withdrawn, and shy. He behaves aggressively (?acts-up?) more than before, and has trouble making friends at school. He is teased and ridiculed at school because of his strange behaviour. He has trouble concentrating in class, and sometimes doesn?t want to go to, or misses, school. He tries to hide his OCD symptoms from teachers and other children at school, and his symptoms are minimal at school but very bad at home, although he tries to hide them at home as well. He also tries to hide his symptoms when out in public, and is embarrassed and ashamed by the way he acts. He has low self-esteem and is frustrated and upset because he can?t always manage to do what people expect. Family life has changed since Mike started displaying OCD symptoms. Mike needs more parental attention, and tries to involve family members in his rituals. Coping with Mike leaves his parents feeling more exhausted and frustrated than previously and there is generally more tension in the family than before. There is more tension between Mike and his siblings than before. His siblings feel jealous and neglected because the parents spend extra time with him. They are embarrassed by Mike?s strange behaviour and don?t like inviting friends home any more. Mike?s mother appears to be very supportive and understanding regarding his symptoms and makes an effort to seek and keep up-to-date with new information on his disorders. She and Mike frequently talk openly about his symptoms, and she refers to them as ?his habits?. She has explained his symptoms to his teachers and Mike himself has recently started to take the initiative in explaining his symptoms to any new teachers. Mike was friendly and co-operative with the researcher and performed all tasks requested of him willingly. During testing, he displayed occasional motor tics (in the form of snarling), fidgeted almost constantly, and occasionally tapped his fingers repetitively. When he became anxious he tended to breathe heavily, and he became increasingly fatigued, expressing his discomfort with becoming more and more tired to the researcher from time to time. During rest breaks, Mike interacted very little with the researcher and seemed to prefer to be left alone to sit quietly and rest. He sometimes got up from his chair and wandered around the room. The researcher had a sense that he was avoiding conversing with her. Mike was generally quite defended in the answers he provided to questions about his Draw-A-Person (D-A-P) and Kinetic Family Drawing (K-F-D) drawings, e.g. when asked who the favourite and least favourite people of the figure depicted in his first D- A-P drawing are, he replied ?his best friend? and ?his enemy? respectively. However, he was far less guarded in the telling of his Thematic Apperception Test (TAT) stories, some of which expressed violent fantasies. 4.1.2. Age-related norms for human figure drawing (HFD) analyses Mike?s first and third D-A-P figures measure 4.7 and 3.7 inches in height respectively. This classifies them as small figures, as normal sized figures are between 6 and 7 inches tall (paper size is A4, which is roughly the same as Letter size upon which this norm is based) (Handler, 1996; Urban, 1963, as cited in Ogdon, 2001). However, as small drawings may be considered normal among children (particularly school-age boys) (Hammer, 1958; Lakin, 1956; Machover, 1960; as cited in Ogdon, 2001), small figure size has not been interpreted as an emotional indicator in Mike?s D-A-P drawings. The tallest figure in Mike?s K-F-D is his father (3.4 inches in height). Mike is the smallest figure (a mere 1.4 inches high). Figure size is interpreted as an emotional indicator in the analysis of the K-F-D but only in a qualitative manner, regarding the relative sizes of the figures to one other. The pencil pressure in all Mike?s drawings is slightly heavy. However it is normal for boys between the ages of 8 and 14 years to use heavier pencil pressure when drawing than girls (Fellows & Cerbus, 1969, as cited in Ogdon, 2001). Thus, heavy pencil pressure has not been interpreted as an emotional indicator, although interpretations based on firm pencil pressure have been used. Although the gender drawn with the larger head is often interpreted as the one perceived to be socially dominant by the subject (Cook, 1951, Machover, 1949; as cited in Ogdon, 2001), normal children often draw opposite sex figures larger (Weider & Noller, 1953, as cited in Ogdon, 2001). Thus the fact that Mike?s second D-A-P drawing is much larger than his two drawings of males has not been interpreted as an emotional indicator. Interpretations relating to inconsistent treatment by children of male and female drawings have however been used. Ears are omitted from Mike?s second D-A-P drawing and from the figures of his mother and sister in the K-F-D. However, as omission of ears is considered normal especially in children (Buck, 1950; Buck & Warren, 1992; Handler, 1985; Jolles, 1964; Machover, 1949; Urban, 1963; as cited in Ogdon, 2001), these omissions have not been interpreted as emotional indicators. As a heavy line or other emphasis on the waist may be normal in children?s drawings (Machover, 1960, as cited in Ogdon, 2001), the presence of this feature in Mike?s drawings has not been interpreted as an emotional indicator. All Mike?s D-A-P figures meet the expected normative content criteria listed by Koppitz (1968, as cited in Handler, 1996) for a boy of his age. All the figures in the K- F-D meet these criteria with the exception of the figures of Mike himself (from which a nose, hair, and feet are omitted) and his father (from which feet are omitted). In the context of Mike?s D-A-P drawings, it is considered that these omissions in the K-F-D are best interpreted as emotional indicators. 4.1.3. HFD analyses 4.1.3.1. D-A-P drawing 1 a) Introduction Mike seemed slightly nervous when asked to draw a person. He hesitated for a few moments and began drawing. He looked up at the researcher briefly a few times, fidgeted his legs a lot and tapped his fingers a few times, but asked no questions nor appealed for reassurance or encouragement. He drew a male figure in the centre of the left-hand side of the page, starting with the front of the head and facial features. He left the back of the head open. He then drew the neck, shoulders, upper arms and torso, then added arms and hands. He drew the belt, legs, feet, and shoes, then completed the back of the head and added hair. He drew from left to right and the pace of his drawing increased steadily. The drawing took 1 minute and 25 seconds to complete, at which time he stopped drawing and looked up at the researcher. b) Emotional indicators Self-concept Self-esteem and body image The name Mike gave to the figure in his drawing was ?Bean?. Although it is unknown what this name means to Mike, it is possible that ?Bean? may refer to a ?Mr Bean?-like character from the television series by the same name, in which case ?Bean? refers to a person who is very awkward in social situations and is laughed at in his role as a funny, silly, odd-looking, unintelligent man. ?Bean? may also refer to the vegetable, in which case it may denote intellectual dullness. In both of these tentative interpretations, Mike may perceive himself as intellectually dull and thus liable to be socially isolated and ridiculed by others, thereby indicating a psychological conflict in the area of self-esteem. Mike stated that he wouldn?t really like to be ?Bean?, which may indicate dissatisfaction with himself. The drawing contains multiple indicators of low self-esteem and feelings of inadequacy. These are a small trunk (Buck, 1950; Buck & Warren, 1992; Handler, 1985; Jolles, 1964; Urban, 1963; as cited in Ogdon, 2001), a thin trunk (Jolles, 1952; Machover, 1949; as cited in Ogdon, 2001), tiny shoulders (Buck, 1950; Handler, 1985; Jolles, 1964; Urban, 1963; as cited in Ogdon, 2001), frail, thin arms (Brown, 1953; Buck, 1966; Buck & Warren, 1992; Hammer, 1997; Handler, 1985; Jolles, 1964; Lezak, 1983; Machover, 1949; Mitchell, 1993; Mursell, 1969; Reznikoff &Tomblen, 1956; Urban, 1963; Wolk, 1969; as cited in Ogdon, 2001), and fewer than five fingers (Schildkrout, 1972, as cited in Ogdon, 2001). Mike stated that the worst thing about ?Bean? is ?that he?s got a pointy nose? and that what makes ?Bean? happy is his ?cool hair? and that his hair is the best thing about ?Bean?. These narratives may indicate conflict or insecurity with the image Mike feels he projects to others. There are indications that Mike feels a sense of social isolation, uneasiness, or hostility. These are the profile head with a full-face body (Machover, 1949, as cited in Gilbert, 1980; Urban, 1963, as cited in Ogdon, 2001), withdrawn, vacant facial expression (Machover, 1949; Hammer, 1954; as cited in Gilbert, 1980), a broad, flared, hooked nose (Hammer, 1954; Levy, 1958; as cited in Gilbert, 1980), and a long neck (Handler, 1985; Machover, 1949; as cited in Ogdon, 2001). Sexuality and gender identity Although some indicators of sexual awareness may be age-appropriate considering Mike is approaching the age of puberty, the presence of quite a number of sexually- oriented indicators suggests a preoccupation or conflict with sexuality. These indicators are emphasized hair (Buck, 1950; DiLeo, 1970; Hammer, 1954; Handler, 1985; Jolles, 1964; Levy, 1958; Machover, 1951; Roback, 1968; Urban, 1963; as cited in Ogdon, 2001), elongated anatomical areas/phallic symbols (nose, neck, feet) (Hammer, 1950, as cited in Gilbert, 1980), elongated feet (Buck, 1966; Buck & Warren, 1992; Hammer, 1953; Handler, 1985; Jolles, 1964; Mitchell, 1993; Urban, 1963; Wysocki & Wysocki, 1977; as cited in Ogdon, 2001), phallic feet (Machover, 1949, as cited in Gilbert, 1980), and an emphasized belt (Buck, 1966; Buck & Warren, 1992; Jolles, 1964; Machover, 1949; Urban, 1963; as cited in Ogdon, 2001). Infantile, regressed sex drives are indicated by the emphasized hair (Buck, 1950; Handler, 1985; Levy, 1958; as cited in Ogdon, 2001; Machover, 1949, as cited in Gilbert, 1980), small trunk (Buck, 1950; Buck & Warren, 1992; Handler, 1985; Jolles, 1964; Urban, 1963; as cited in Ogdon, 2001), and rounded trunk (Gurvitz, 1951; Handler, 1985; Levy, 1950; Machover, 1949; as cited in Ogdon, 2001). Castration anxiety/masturbation guilt is suggested by short arms (Handler, 1985; Jolles, 1964; as cited in Ogdon, 2001), and the presence of an omitted/overextended finger (Machover, 1949, as cited in Gilbert, 1980). There are indications that Mike is preoccupied or conflicted with gender identity or sexual orientation. While masculine assertion or a need for it, is indicated by the marked directional preference for vertical movement (Alschuler & Hattwick, 1947; Handler, 1985; Levy, 1958; as cited in Ogdon, 2001) and strong nose (Machover, 1949, as cited in Gilbert, 1980), there are numerous indicators of homosexual tendencies/effeminacy. These include hair that is given much attention (Hammer, 1950, as cited in Gilbert; Levy, 1958, as cited in Ogdon, 2001), a rounded trunk (Gurvitz, 1951; Handler, 1985; Levy, 1950; Machover, 1949; as cited in Ogdon, 2001), a wasp waist (Levy, 1958, as cited in Ogdon, 2001), tapering arms and legs (Machover, 1949, as cited in Gilbert, 1980), small ankles and wrists (Machover, 1949, as cited in Gilbert, 1980), overdetailed feet (Buck, 1966; Jolles, 1964; Urban, 1963; as cited in Ogdon, 2001), overdetailed shoes or laces (Buck & Warren, 1992; Levine & Sapolsky, 1969; Machover, 1949; Urban, 1963; as cited in Ogdon, 2001), and a high heel (male figure, male subject) (DeMartino, 1954; Hammer, 1968; Rabin, 1968; Urban, 1963; as cited in Ogdon, 2001; Machover, 1949, as cited in Gilbert, 1980). Personality Introversion/extroversion There are indicators suggesting Mike tends toward introversion and self- consciousness. These include stroking in towards the body (Hammer, 1954; Levy, 1950; as cited in Gilbert, 1980), placement of the drawing on the left-hand side of the page (Levy, 1950; Machover, 1949; Mitchell, 1993; Urban, 1963; as cited in Ogdon, 2001), an enlarged head (Hammer, 1954; Levy, 1950; as cited in Gilbert, 1980), closed eyes (Handler, 1985; Machover, 1949; as cited in Ogdon, 2001), and an emphasized body (underclothed) (Machover, 1949, as cited in Gilbert, 1980). Defenses There are indications of tendencies toward shyness, inhibition, defensiveness, and evasion. These include long pencil strokes (Handler, 1996), an increase in the length of stroke movement (Hammer, 1954; Mira, 1943; as cited in Gilbert, 1980), placement of the drawing high on the page (Buck, 1950; Hammer, 1958; Handler, 1985; Jolles, 1964; Urban, 1963; as cited in Ogdon, 2001), the head drawn in profile (Handler, 1996) with a full-face body (Machover, 1949; Urban, 1963; as cited in Ogdon, 2001), rigid posture (Hammer, 1958; Levy, 1958; as cited in Gilbert, 1980), and a small trunk (Buck, 1950; Buck & Warren, 1992; Handler, 1985; Jolles, 1964; Urban, 1963; as cited in Ogdon, 2001). Reaction- formations or compensatory defenses to defend against feelings of insecurity, are suggested by placement of the figure high on the page (Machover, 1949, as cited in Gilbert, 1980), placement of the figure on the left-hand side of the page (Machover, 1949, as cited in Ogdon, 2001), broken lines (at the back of the head, left arm, and left ankle) (Buck, 1950; Hammer, 1954; as cited in Gilbert, 1980), a placating facial expression (Hammer, 1958; Machover, 1949; as cited in Gilbert, 1980), limp arms at the sides (Levy, 1950; Machover, 1949; Rierdan et al., 1982; as cited in Ogdon, 2001), small hands (DiLeo, 1973, as cited in Odon, 2001; Handler, 1996), and large feet (Modell & Potter, 1949; Urban, 1963; as cited in Ogdon, 2001). The enlarged head suggests tendencies toward the use of intellectualisation and fantasy as defenses (Buck, 1950; Buck & Warren, 1992; Handler, 1985; Jolles, 1964; Urban, 1963; as cited in Ogdon, 2001; Hammer, 1954; Levy, 1958; as cited in Gilbert, 1980), as does the placement of the drawing high on the page (Buck, 1950; Buck & Warren, 1992; Hammer, 1958; Handler, 1985; Jolles, 1969; Jolles & Beck, 1953; Urban, 1963; as cited in Ogdon, 2001). Intellectualisation is the unconscious process of controlling or minimizing anxiogenic feelings by excessive abstract thinking. Fantasy (autistic fantasy) refers to the unconscious process of excessive daydreaming to substitute for relationships with other people, taking action, or solving the problem (APA, 2000). Autonomy/dependency Ambivalence regarding strivings for independence and achievement versus dependency needs is indicated by feet pointing in opposite directions (Buck & Warren, 1992; Jolles, 1964; Urban, 1963; as cited in Ogdon, 2001), and by the presence of both three indicators of ambition and three indicators of a lack of ambition. Ambition/drive/future-orientation is suggested by the firm line quality (Hammer, 1954; Levy, 1958; as cited in Gilbert, 1980), placement of the drawing high on the page (Levy, 1950, as cited in Ogdon, 2001), and an enlarged head (Buck, 1966; Buck & Warren, 1992; Hammer, 1954; Handler, 1985; Jolles, 1964; Koppitz, 1984; Levy, 1958; Machover, 1951; Urban, 1963; as cited in Ogdon, 2001). Lack of drive/ambition/energy/achievement is suggested by drooping shoulders (Hammer, 1954, as cited in Gilbert, 1980), short arms (Buck, 1966; Buck & Warren, 1992; Handler, 1985; Jolles, 1964; Machover, 1949; Schildkrout, 1972; Urban, 1963; Wolk, 1969; as cited in Ogdon, 2001), and thin, weak arms (Machover, 1949, as cited in Ogdon, 2001). When asked what animal ?Bean? would most like to be, Mike replied that he would like to be a ?cheetah?. Yet he stated that ?Bean??s least favourite activities are ?doing nothing? and ?running?, which are two activities of cheetahs and are also opposing activities. The discrepancy between these answers may indicate a psychological conflict between dependency and inactivity on the one hand, and an ambitious striving or need for independence and activity on the other. In this regard Mike?s statements that ?Bean??s favourite activity is ?going to parties? and that ?he parties? on weekends may also refer to a need for autonomy, activity, and social contact. This may be supported further by Mike?s assertion that when ?Bean? is being good, he ?just sits down? but when he is being bad ?he?s bashing something?, and if ?Bean? were invisible he?d ?play pranks on people?, suggesting a conflict between what ?Bean? does and what he may want to do (activity/autonomy versus inactivity/dependency). Indicators of dependency and helplessness suggest that Mike is currently overwhelmed by these needs and feelings. These are an enlarged head (Goodman & Kotkov, 1953; Handler, 1985; Machover, 1951; as cited in Ogdon, 2001), short arms (Handler, 1985; Koppitz, 1968; as cited in Ogdon, 2001), small hands (Hammer, 1954; Handler, 1985; as cited in Ogdon, 2001), fewer than five fingers (Hammer, 1958, as cited in Gilbert, 1980), and a belt buckle (Machover, 1949; as cited in Gilbert, 1980). Impulse control There are indications that Mike is struggling to control his behaviour and emotions. While controlled behaviour and emotional control are indicated by the rigid posture of the figure (Hammer, 1950; Levy, 1958; as cited in Gilbert, 1980), and long pencil strokes (Alschuler & Hattwick, 1947; Hammer, 1954; as cited in Gilbert, 1980), poor impulse control is suggested by feet pointing in opposite directions, and striped clothing (shoes) (Schildkrout, 1972, as cited in Ogdon, 2001). Repressed aggression is indicated by the single line mouth (Hammer, 1954; Levy, 1958; as cited in Gilbert, 1980), and mitten hands (Buck, 1950; Handler, 1985; Jolles, 1964; Machover, 1949; Urban, 1963; as cited in Ogdon, 2001). Overt anger and aggressive tendencies are indicated by the straight lines (Hammer, 1958; Krout, 1950; as cited in Gilbert, 1980), large head (Gurvitz, 1951; Handler, 1985; Levy, 1958; Urban, 1963; Wysocki & Whitney, 1965; Wysocki & Wysocki, 1977; as cited in Ogdon, 2001), emphasized hair (Handler, 1985; Shneidman, 1958; as cited in Ogdon, 2001), shaded hair (Machover, 1949, as cited in Gilbert, 1980), long neck (Hammer, 1950; Levy, 1958; as cited in Gilbert, 1980), and emphasized feet (Hammer, 1954; Machover, 1958; Schildkrout, 1972; Shneidman, 1958; Urban, 1963; as cited in Ogdon, 2001). Assaultiveness is implied by emphasized hair (Handler, 1985; Shneidman, 1958; as cited in Ogdon, 2001), reinforced hair (Hammer, 1954, as cited in Gilbert, 1980), and emphasized feet (Hammer, 1954; Machover, 1949; as cited in Gilbert, 1980). A psychological conflict between ?Bean??s ?good? and ?bad? sides may be indicated by Mike?s narratives that when ?Bean? is being good he ?just sits down? but when he is being bad ?he?s bashing something?, and if ?Bean? were invisible, he?d ?play pranks on people?. Thus, ?Bean??s ?bad? side seems to contain anger and aggressive, assaultive urges. Interestingly, Mike often presented with a motor tic resembling the snarling of an angry animal during testing. Psychopathology Although Mike?s creation of the drawing in normal succession indicates adequate contact with reality (Machover, 1949, as cited in Gilbert, 1980), the moderate distortions (head much larger than body) suggest poor adjustment (Koppitz, 1966; Mitchell, 1993; Vane & Eisen, 1962; as cited in Ogdon, 2001). There are numerous indicators of psychopathology in the drawing. Depression is indicated by decreased pace and productivity as the drawing continued (Hammer, 1954, as cited in Gilbert, 1980), placement of the figure on the left-hand side of the page (Buck, 1950; Buck & Warren, 1992; Hetherington, 1952; Jolles, 1964;Mitchell, 1993; Urban, 1963; as cited in Ogdon, 2001), rigid posture (Olch, 1971, as cited in Ogdon, 2001), and drooping shoulders (Hammer, 1954, as cited in Gilbert, 1980). Anxiety is suggested by broken lines (Buck, 1956; Hammer, 1954; as cited in Gilbert, 1980), placement of the drawing on the left-hand side of page (Machover, 1949, as cited in Gilbert, 1980), an unbalanced stance (Machover, 1949, as cited in Gilbert, 1980), rigid posture (Jacks, 1969; Schildkrout, 1972; as cited in Ogdon, 2001), an unusually large head (Mogar, 1962; Wysocki & Whitney, 1965; as cited in Ogdon, 2001), shading (hair) (Machover, 1949; Hammer, 1958, Levy, 1958; as cited in Gilbert, 1980), a simplified trunk (Riethmiller & Handler, 1997, as cited in Ogdon, 2001), arms close to the body (Machover, 1949, as cited in Gilbert, 1980), moderate distortions (Handler & Reyher, 1966, as cited in Ogdon, 2001), and excessive detail (Machover, 1949, as cited in Gilbert, 1980). Neurosis is indicated by the enlarged head (Handler, 1985; Machover, 1951; Urban, 1963; as cited in Ogdon, 2001), and excessive detail (Machover, 1949, as cited in Gilbert, 1980). Obsessiveness is suggested by excessive detail (Machover, 1949, as cited in Gilbert, 1980). Obsessive-compulsivity is implied by excessive detail (Buck, 1966; Buck & Warren, 1992; Deabler, 1969; Hammer, 1969; Handler, 1985; Jacks, 1969; Kahn & Giffen, 1960; Levy, 1958; Machover, 1949; McElhaney, 1969; Reynolds, 1978; as cited in Ogdon, 2001), overdetailed feet (Buck, 1966; Jolles, 1964; Urban, 1963; as cited in Ogdon, 2001), overdetailed shoes or laces (Buck & Warren, 1992; Levine & Sapolsky, 1969; Machover, 1949; Urban, 1963; as cited in Ogdon, 2001; Hammer, 1954; Levy, 1958; as cited in Gilbert, 1980), and striped clothing (shoes) (Schildkrout, 1972, as cited in Ogdon, 2001). Paranoia is revealed by the enlarged head (Machover, 1949, as cited in Gilbert, 1980), and rigid posture (Kahn & Giffen, 1960, as cited in Ogdon, 2001). Hyperactivity is suggested by the marked directional preference for vertical movement (Alschuler & Hattwick, 1947; Handler, 1985; Levy, 1958; as cited in Ogdon, 2001). Conflict or somatisation in the head area is suggested by a line break at the back of the head (Machover, 1949, as cited in Gilbert, 1980), the enlarged head (Hammer, 1954; Levy, 1958; as cited in Gilbert, 1980), distortion of the head (Hammer, 1954; Levy, 1958; as cited in Gilbert, 1980), and shaded hair (Hammer, 1954; Levy, 1958; Machover, 1949; as cited in Gilbert, 1980). Conflict or somatisation in the throat area is indicated by the long neck (Hammer, 1954, as cited in Gilbert, 1980; Levy, 1958, as cited in Ogdon, 2001). Conflict or somatisation in the eye area is suggested by the omission of eyeballs (Hammer, 1954; Levy, 1958; Machover, 1949; as cited in Gilbert, 1980). Mike stated that ?Bean? is ?looking? but that it makes him sad that ?he doesn?t have any eyeballs?. This may indicate a psychological conflict associated with the eyes (what is seen or unseen perhaps). Schizoid tendencies are revealed by the self-preoccupied facial expression (Machover, 1949, as cited in Gilbert, 1980), a closed eye (Machover, 1949, as cited in Gilbert, 1980), a long neck (Hammer, 1954; Levy, 1958; as cited in Gilbert, 1980), the tight stance (Machover, 1949, as cited in Gilbert, 1980), and the long, narrow trunk (Buck & Warren, 1992; Handler, 1985; Jolles, 1964; Urban, 1963; as cited in Ogdon, 2001). Narcissistic tendencies are suggested by the enlarged head (Handler, 1985; Machover, 1951; Urban, 1963; as cited in Ogdon, 2001), hair given much attention (Hammer, 1954, as cited in Gilbert, 1980; Handler, 1985; Levy, 1958; Machover, 1949; as cited in Ogdon, 2001), and overdetailed feet (Buck, 1966; Jolles, 1964; Urban, 1963; as cited in Ogdon, 2001). Organicity is indicated by the enlarged head (Burgemeister, 1962; Hammer, 1977; Jolles, 1952; Kahn & Giffen, 1960; Levy, 1958; Machover, 1951; Urban, 1963; as cited in Ogdon, 2001), and asymmetrical arms (Hammer, 1969; Koppitz, 1968; Machover, 1949; Mundy, 1972; Urban, 1963; as cited in Ogdon, 2001). 4.1.3.2. D-A-P drawing 2 a) Introduction Mike seemed more relaxed when drawing the second picture. He did not look up at the researcher while drawing and continued to fidget his legs and tap his fingers now and then. Again, he asked no questions nor required reassurance or encouragement from the researcher. He drew a female figure on the top half of the page, slightly to the right, starting with a head, facial features and hair. He added the neck and the left shoulder, left arm, hand and left side of the torso as one continuous curvy line. He did the same with the right side and drew the left side of the skirt down to the hemline and up the right side of the skirt, as another continuous set of straight lines. He drew lines on the skirt and drew the left leg and foot with shoe and shoe details. He added the right leg, foot, shoe, and shoe details. He added detail to the hair. He drew from left to right and the pace of his drawing increased steadily. The drawing took 1 minute and 33 seconds to complete, at which point he stopped drawing and looked up at the researcher. b) Emotional indicators Self-concept Self-esteem and body image The name Mike gave to the figure in his drawing was ?Shanon?. He stated that she reminds him of a girl at school and he would not like to be her. He expressed that the best thing about ?Shanon? is her name and the worst thing about her is her ?funny face?. From this data, it is apparent that Mike may not like ?Shanon?, or the way she looks. It is possible that these attitudes may be a projection of his own low self- esteem, or that they may project an attitude toward women/girls or simply towards ?Shanon? herself. Mike expressed that what ?Shanon? dislikes the most is ?when her hair gets ugly? and the worst thing about her is her ?funny face?. These narratives may indicate a psychological conflict associated with self-esteem and the image of oneself projected to others. Mike expressed that the person ?Shanon? dislikes the most is ?the person that doesn?t choose her?. Similarly, this may relate to a psychological conflict around self-esteem and social acceptance. Interestingly, Mike stated that ?Shanon? would most like to be a ?dog?cos that?s what she likes?, which may reveal a need for nurturance, a wish to be loved and accepted unconditionally and not to have many expectations placed on him, as in a relationship between a dog and its owner. As in the previous drawing, this drawing contains numerous indicators of low self- esteem and feelings of inadequacy. These are a small trunk (Buck, 1950; Buck & Warren, 1992; Handler, 1985; Jolles, 1964; Urban, 1963; as cited in Ogdon, 2001), a thin trunk (Jolles, 1952; Machover, 1949; as cited in Ogdon, 2001), tiny shoulders (Buck, 1950; Handler, 1985; Jolles, 1964; Urban, 1963; as cited in Ogdon, 2001), frail, thin arms (Brown, 1953; Buck, 1966; Buck & Warren, 1992; Hammer, 1997; Handler, 1985; Jolles, 1964; Lezak, 1983; Machover, 1949; Mitchell, 1993; Mursell, 1969; Reznikoff &Tomblen, 1956; Urban, 1963; Wolk, 1969; as cited in Ogdon, 2001), fewer than five fingers (Schildkrout, 1972, as cited in Ogdon, 2001), and a larger female figure with wide stance, while the same-sex figure was puny (Levy, 1958; McElhany, 1969; Mitchell, 1993; Pollitt, 1964; as cited in Ogdon, 2001). As in the previous drawing, there are indications of a sense of social isolation, uneasiness or hostility. These are a withdrawn, vacant facial expression (Hammer, 1954; Machover, 1949; as cited in Gilbert, 1980), and sharply pointed feet (Hammer, 1954; Jacks, 1969; Mitchell, 1993; Schildkrout, 1972; Urban, 1963; as cited in Ogdon, 2001). Sexuality and gender identity As in the first drawing, a preoccupation or conflict with sexuality is suggested. Indicators are emphasized hair (Buck, 1950; DiLeo, 1970; Hammer, 1954; Handler, 1985; Jolles, 1964; Levy, 1958; Machover, 1951; Roback, 1968; Urban, 1963; as cited in Ogdon, 2001), elongated anatomical areas/phallic symbols (nose, neck and feet) (Hammer, 1954, as cited in Gilbert, 1980), and a phallic foot (Machover, 1949, as cited in Gilbert, 1980). Infantile, regressed sex drives are indicated by emphasized hair (Buck, 1950; Handler, 1985; Levy, 1958; as cited in Ogdon, 2001; Machover, 1949, as cited in Gilbert, 1980), a small trunk (Buck, 1950; Buck & Warren, 1992; Handler, 1985; Jolles, 1964; Urban, 1963; as cited in Ogdon, 2001), and a rounded trunk (Gurvitz, 1951; Handler, 1985; Levy, 1950; Machover, 1949; as cited in Ogdon, 2001). Castration anxiety/masturbation guilt is indicated by short arms (Handler, 1985; Jolles, 1964; as cited in Ogdon, 2001), and an omitted/overextended finger (Machover, 1949, as cited in Gilbert, 1980). As in Mike?s first drawing, there are indicators of a preoccupation or conflict with gender identity/sexual orientation. While masculine assertion or a need for it, is suggested by a marked directional preference for vertical movement (Alschuler & Hattwick, 1947; Handler, 1985; Levy, 1958; as cited in Ogdon, 2001), there are numerous indicators of homosexual tendencies/effeminacy. These are hair given much attention (Hammer, 1954, as cited in Gilbert, 1980; Levy, 1958, as cited in Ogdon, 2001), the female figure drawn as larger and with a wide stance, while the same-sex figure is puny (Levy, 1958; McElhany, 1969; Mitchell, 1993; Pollitt, 1964; as cited in Ogdon, 2001), a rounded trunk (Gurvitz, 1951; Handler, 1985; Levy, 1950; Machover, 1949; as cited in Ogdon, 2001), a wasp waist (Levy, 1958, as cited in Ogdon, 2001), small ankles and wrists (Machover, 1949, as cited in Gilbert, 1980), overdetailed feet (Buck, 1966; Jolles, 1964; Urban, 1963; as cited in Ogdon, 2001), and overdetailed shoes or laces (Buck & Warren, 1992; Levine & Sapolsky, 1969; Machover, 1949; Urban, 1963; as cited in Ogdon, 2001). Personality Introversion/extroversion As in his previous drawing, there are indications that Mike tends towards introversion and self-consciousness, viz. placement of the drawing on the right-hand side of the page (Buck, 1950; Hammer, 1969; Jolles, 1964; Wolff, 1946; as cited in Ogdon, 2001), and omission of pupils (empty eyes) (Hammer, 1968; Kahn & Giffen, 1960; Levine & Sapolsky, 1969; Machover, 1949; Mitchell, 1993; Schildkrout, 1972; Urban, 1963; as cited in Ogdon, 2001) Defenses As in his previous drawing, tendencies towards shyness, inhibition, defensiveness, and evasion are suggested. These are placement of the drawing high on the page (Buck, 1950; Hammer, 1958; Handler, 1985; Jolles, 1964; Urban, 1963; as cited in Ogdon, 2001), placement of the drawing on the right-hand side of page (Buck, 1950; Hammer, 1969; Jolles, 1964; Wolff, 1946; as cited in Ogdon, 2001), long pencil strokes (Handler, 1996), increasing length of stroke movement (Hammer, 1954; Mira, 1943; as cited in Gilbert, 1980), omission of pupils (empty eyes) (Hammer, 1968; Kahn & Giffen, 1960; Levine & Sapolsky, 1969; Machover, 1949; Mitchell, 1993; Schildkrout, 1972; Urban, 1963; as cited in Ogdon, 2001), rigid posture (Hammer, 1954; Levy, 1958; as cited in Gilbert, 1980), and a small trunk (Buck, 1950; Buck & Warren, 1992; Handler, 1985; Jolles, 1964; Urban, 1963; as cited in Ogdon, 2001). Reaction formations or compensatory defenses to defend against feelings of insecurity are indicated, as in his previous drawing, Indicators are placement of the figure high on the page (Machover, 1949, as cited in Gilbert, 1980), a placating facial expression (Hammer, 1954; Machover, 1949; as cited in Gilbert, 1980), the wide stance (Buck, 1950; Buck & Warren, 1992; Hammer, 1969; Jolles, 1964; Machover, 1949; Urban, 1963; as cited in Ogdon, 2001), limp arms at the sides (Levy, 1950; Machover, 1949; Rierdan et al., 1982; as cited in Ogdon, 2001), and small hands (DiLeo, 1973, as cited in Odon, 2001; Handler, 1996). As in Mike?s previous drawing, tendencies toward introspection and the use of fantasy and intellectualisation as defenses, are suggested by placement of the drawing high on the page (Buck, 1950; Buck & Warren, 1992; Hammer, 1958; Handler, 1985; Jolles, 1969; Jolles & Beck, 1953; Urban, 1963; as cited in Ogdon, 2001). Autonomy/dependency Ambivalence toward striving for independence and achievement versus dependency needs is again evident in this drawing. This is indicated by feet pointing in opposite directions (Buck & Warren, 1992; Jolles, 1964; Urban, 1963; as cited in Ogdon, 2001), unequally sized legs (Buck, 1950; Buck & Warren, 1992; Jolles, 1964; as cited in Ogdon, 2001), and by the presence of equal numbers of indicators of ambition and a lack of ambition. Ambition/drive/future-orientation is suggested by the firm line quality (Hammer, 1954; as cited in Gilbert, 1980; Levy, 1958, as cited in Ogdon, 2001), placement of the figure high on the page (Levy, 1950, as cited in Ogdon, 2001), and placement of the figure on the right-hand side of page (Buck, 1950; Buck & Warren, 1992; Jolles, 1952; Mitchell, Trent & MacArthur, 1993; as cited in Ogdon, 2001). Lack of drive/ambition/energy/achievement is indicated by drooping shoulders (Hammer, 1950, as cited in Gilbert, 1980), thin, weak arms (Machover, 1949, as cited in Ogdon, 2001), and short arms (Buck, 1966; Buck & Warren, 1992; Handler, 1985; Jolles, 1964; Machover, 1949; Schildkrout, 1972; Urban, 1963; Wolk, 1969; as cited in Ogdon, 2001). However, as is the case in his first drawing, the presence of multiple indicators of dependency and helplessness indicate that Mike is presently overwhelmed by these needs and feelings. These indicators are the female figure drawn as larger with a wide stance, while the same-sex figure is puny (Levy, 1958; McElhany, 1969; Mitchell, 1993; Pollitt, 1964; as cited in Ogdon, 2001), short arms (Handler, 1985; Koppitz, 1968; as cited in Ogdon, 2001), small hands (Hammer, 1954; Handler, 1985; as cited in Ogdon, 2001), and fewer than five fingers (Hammer, 1954, as cited in Gilbert, 1980). Mike stated that ?Shanon? is ?standing? and that ?dancing? makes her happy and is the activity she likes the most. He stated that she goes ?horse riding? on the weekend. Mike said that when ?Shanon? is being good, she is ?sleeping? but when she is being bad, she is partying. The discrepancy between these answers may indicate a psychological conflict between dependency, inactivity, and social withdrawal on the one hand, and an ambitious striving or need for independence, activity, and social contact on the other. Impulse control As in his previous drawing, there are indications that Mike is battling to control his behaviour and emotions. While controlled behaviour and emotional control are indicated by placement of the drawing on the right-hand side of the page (Buck, 1950; Buck & Warren, 1992; Hammer, 1969; Handler, 1985; Jolles, 1964; Jolles & Beck, 1953; Marzolf & Kirchner, 1972; Mitchell, at. al., 1993; Urban, 1963; as cited in Ogdon, 2001), rigid posture (Hammer, 1954; Levy, 1958; as cited in Gilbert, 1980), and long pencil strokes (Hammer, 1954; Alschuler & Hattwick, 1947; as cited in Gilbert, 1980), poor impulse control is suggested by feet pointing in opposite directions and striped clothing (shoes) (Schildkrout, 1972, as cited in Ogdon, 2001). As in Mike?s first drawing, both repressed and overt aggression are expressed. Repressed aggression is indicated by the single line mouth (Hammer, 1954; Levy, 1958; as cited in Gilbert, 1980). Overt anger and aggressive tendencies are indicated by the straight lines (Hammer, 1958; Krout, 1950; as cited in Gilbert, 1980), emphasized hair (Handler, 1985; Shneidman, 1958; as cited in Ogdon, 2001), wide stance (Buck, 1950; Buck & Warren, 1992; Hammer, 1969; Jolles, 1964; Machover, 1949; Urban, 1963; as cited in Ogdon, 2001), asymmetrical legs (Hammer, 1969; Koppitz, 1968; Machover, 1949; Mundy, 1972; Urban, 1963; as cited in Ogdon, 2001), and emphasized feet (Hammer, 1954; Machover, 1958; Schildkrout, 1972; Shneidman, 1958; Urban, 1963; as cited in Ogdon, 2001). Assaultiveness is suggested by emphasized hair (Handler, 1985; Shneidman, 1958; as cited in Ogdon, 2001), reinforced hair (Hammer, 1954, as cited in Gilbert, 1980), and emphasized feet (Hammer, 1954; Machover, 1949; as cited in Gilbert, 1980). A psychological conflict between ?Shanon??s good and bad sides and much frustration, repressed sadness, or anger, may be revealed by Mike?s statement that if ?Shanon? were invisible she would ?scream?when no-one can hear her?. The fact that she would scream unheard may also relate to fears of negative judgement or consequences to emotional expression. Feelings of guilt are expressed by the figure?s drooping shoulders (Hammer, 1954, as cited in Gilbert, 1980). Psychopathology As in his previous drawing, Mike drew in normal succession, suggesting adequate contact with reality (Machover, 1949, as cited in Gilbert, 1980). However, again there are multiple indicators of psychopathology. There are only half as many indicators of anxiety as in his first drawing but more indicators of depression. There are no indicators of conflict/somatisation in the head or throat areas, as there were in his first drawing. Depression is suggested by decreased pace and productivity as the drawing continues (Hammer, 1954, as cited in Gilbert, 1980), placement of the drawing on the right-hand side of the page (Levy, 1950, as cited in Ogdon, 2001), a single, unsmiling line for a mouth (Handler, 1985; McElhaney, 1969; as cited in Ogdon, 2001), a narrow neck (Hammer, 1954; Levy, 1958; as cited in Gilbert, 1980), drooping shoulders (Hammer, 1954, as cited in Gilbert, 1980), and rigid posture (Olch, 1971, as cited in Ogdon, 2001). Anxiety is indicated by the large size of the drawing (inconsistent treatment of male and female drawings) (Haworth, 1962, as cited in Ogdon, 2001), an unbalanced stance (Machover, 1949, as cited in Gilbert, 1980), rigid posture (Jacks, 1969; Schildkrout, 1972; as cited in Ogdon, 2001), a simplified trunk (Riethmiller & Handler, 1997, as cited in Ogdon, 2001), and excessive detail (Machover, 1949, as cited in Gilbert, 1980). Neurosis is suggested by the omission of pupils (empty eyes) (Hammer, 1968; Kahn & Giffen, 1960; Levine & Sapolsky, 1969; Machover, 1949; Mitchell, 1993; Schildkrout, 1972; Urban, 1963; as cited in Ogdon, 2001), and excessive detail (Machover, 1949, as cited in Gilbert, 1980). Obsessiveness is revealed by the large size of the drawing (inconsistent treatment of male and female drawings) (Haworth, 1962, as cited in Ogdon, 2001), and excessive detail (Machover, 1949, as cited in Gilbert, 1980). Obsessive-compulsivity is indicated by excessive detail (Buck, 1966; Buck & Warren, 1992; Deabler, 1969; Hammer, 1969; Handler, 1985; Jacks, 1969; Kahn & Giffen, 1960; Levy, 1958; Machover, 1949; McElhaney, 1969; Reynolds, 1978; as cited in Ogdon, 2001), overdetailed feet (Buck, 1966; Jolles, 1964; Urban, 1963; as cited in Ogdon, 2001), overdetailed shoes or laces (Buck & Warren, 1992; Levine & Sapolsky, 1969; Machover, 1949; Urban, 1963; as cited in Ogdon, 2001; Hammer, 1954; Levy, 1958; as cited in Gilbert, 1980), and striped clothing (shoes) (Schildkrout, 1972, as cited in Ogdon, 2001). Paranoia is indicated by the rigid posture (Jacks, 1969; Schildkrout, 1972; as cited in Ogdon, 2001). Hyperactivity is implied by a marked directional preference for vertical movement (Alschuler & Hattwick, 1947; Handler, 1985; Levy, 1958; as cited in Ogdon, 2001). Conflict or somatisation in the eye area is suggested by the omission of eyeballs (Hammer, 1954; Levy, 1958; Machover, 1949; as cited in Gilbert, 1980). Schizoid tendencies are suggested by a self-preoccupied facial expression (Machover, 1949; as cited in Gilbert, 1980), omission of pupils (empty eyes) (Hammer, 1968; Kahn & Giffen, 1960; Levine & Sapolsky, 1969; Machover, 1949; Mitchell, 1993; Schildkrout, 1972; Urban, 1963; as cited in Ogdon, 2001), and the long, narrow trunk (Buck & Warren, 1992; Handler, 1985; Jolles, 1964; Urban, 1963; as cited in Ogdon, 2001). Narcissistic tendencies are suggested by the hair given much attention (Hammer, 1954, as cited in Gilbert, 1980; Handler, 1985; Levy, 1958; Machover, 1949; as cited in Ogdon, 2001), and overdetailed feet (Buck, 1966; Jolles, 1964; Urban, 1963; as cited in Ogdon, 2001). Organicity is indicated by asymmetrical legs (Hammer, 1969; Koppitz, 1968; Machover, 1949; Mundy, 1972; Urban, 1963; as cited in Ogdon, 2001). 4.1.3.3. D-A-P drawing 3 a) Introduction Mike seemed anxious about drawing a picture of himself. He drew a small male figure on the upper left-hand side of the page. First he drew the face, hair, and facial features, while fidgeting and breathing heavily. He added the neck and drew the left shoulder, left arm, hand, and left side of the torso, as one continuous curvy line. He did the same with the right side, and then drew the right side of the hip area continuing on to the right, the left leg and up the left side of the lower body to the hip area, as one continuous set of straight lines. He drew the right foot with shoe and shoe details, and the left leg, foot, shoe and shoe details. He then added laces to the shoes, in a neat bow, first on top of the right then the left shoes. He added more detail to the right shoelace and finally added eyebrows to the facial features. He drew from left to right in the beginning, and then changed to a right to left sequence, and the pace of his drawing increased steadily. The drawing took 1 minute and 58 seconds to complete. b) Emotional indicators Self-concept Self-esteem and body image The drawing is a self-portrait as requested by the researcher. As in Mike?s previous two drawings, this drawing contains numerous indicators of low self-esteem and feelings of inadequacy. These are a small trunk (Buck, 1950; Buck & Warren, 1992; Handler, 1985; Jolles, 1964; Urban, 1963; as cited in Ogdon, 2001), a thin trunk (Jolles, 1952; Machover, 1949; as cited in Ogdon, 2001), and fewer than five fingers (Schildkrout, 1972, as cited in Ogdon, 2001). As in the previous two drawings, there are indications that Mike feels a sense of social isolation, uneasiness, or hostility. These are a withdrawn, vacant facial expression (Machover, 1949; Hammer, 1954; as cited in Gilbert, 1980), a hostile, angry facial expression (Machover, 1949, as cited in Gilbert, 1980), large eyes (Handler, 1985; Machover, 1949; as cited in Ogdon, 2001), raised eyebrows (Machover, 1949; Urban, 1963; as cited in Ogdon, 2001), and frowning eyebrows (McElhaney, 1969, as cited in Ogdon, 2001). Once again, the theme of hair emerged when Mike expressed that the best thing about himself is ?my hair?. This suggests the theme of outward appearance as being more important than intrinsic qualities. He also stated that the person he dislikes the most is ?people that don?t like me?, what makes him the saddest is ?when people ignore me?, and that the activity he likes doing the least is ?stuff that makes me boring?. These answers suggest feelings of social isolation and low self-esteem. The theme of wanting to be a dog re-emerged, when Mike stated that he would most like to be a ?dog?cos dogs are cool?. This may again reveal a need for nurturance, a wish to be loved and unconditionally accepted and not to have many expectations placed upon him. It seems apt to mention again that Mike frequently presented with a motor tic resembling the snarling action of an animal during testing. Sexuality and gender identity As in Mike?s previous drawings, preoccupation or conflict with sexuality is indicated. Indicators are emphasized hair (Buck, 1950; DiLeo, 1970; Hammer, 1954; Handler, 1985; Jolles, 1964; Levy, 1958; Machover, 1951; Roback, 1968; Urban, 1963; as cited in Ogdon, 2001), elongated anatomical areas/phallic symbols (nose, neck and feet) (Hammer, 1950, as cited in Gilbert, 1980), elongated feet (Buck, 1966; Buck & Warren, 1992; Hammer, 1953; Handler, 1985; Jolles, 1964; Mitchell, 1993; Urban, 1963; Wysocki & Wysocki, 1977; as cited in Ogdon, 2001), phallic feet (Machover, 1949, as cited in Gilbert, 1980), and an emphasized belt (Buck, 1966; Buck & Warren, 1992; Jolles, 1964; Machover, 1949; Urban, 1963; as cited in Ogdon, 2001). Infantile, regressed sex drives are suggested by emphasized hair (Buck, 1950; Handler, 1985; Levy, 1958; as cited in Ogdon, 2001; Machover, 1949, as cited in Gilbert, 1980), a small trunk (Buck, 1950; Buck & Warren, 1992; Handler, 1985; Jolles, 1964; Urban, 1963; as cited in Ogdon, 2001), and a rounded trunk (Gurvitz, 1951; Handler, 1985; Levy, 1950; Machover, 1949; as cited in Ogdon, 2001). Castration anxiety/masturbation guilt is indicated by an omitted/overextended finger (Machover, 1949, as cited in Gilbert, 1980). As in his previous drawings, there are indications of a preoccupation or conflict with gender identity or sexual orientation. While masculine assertion or a need for it, is suggested by a marked directional preference for vertical movement (Alschuler & Hattwick, 1947; Handler, 1985; Levy, 1958; as cited in Ogdon, 2001), there are multiple indicators of homosexual tendencies or effeminacy. These are hair given much attention (Hammer, 1950, as cited in Gilbert; Levy, 1958, as cited in Ogdon, 2001), large eyes (Geil, 1944; Levy, 1958; Machover, 1949; Urban, 1963; as cited in Ogdon, 2001), a rounded trunk (Gurvitz, 1951; Handler, 1985; Levy, 1950; Machover, 1949; as cited in Ogdon, 2001), a wasp waist (Levy, 1958, as cited in Ogdon, 2001), overdetailed feet (Buck, 1966; Jolles, 1964; Urban, 1963; as cited in Ogdon, 2001), overdetailed shoes or laces (Buck & Warren, 1992; Levine & Sapolsky, 1969; Machover, 1949; Urban, 1963; as cited in Ogdon, 2001), and a high heel (male figure, male subject) (DeMartino, 1954; Hammer, 1968; Rabin, 1968; Urban, 1963; as cited in Ogdon, 2001; Machover, 1949, as cited in Gilbert, 1980). Personality Introversion/extroversion As in Mike?s previous two drawings, there are indications of tendencies toward introversion and self-consciousness. These are placement of the drawing on the left- hand side of the page (Levy, 1950; Machover, 1949; Mitchell, 1993; Urban, 1963; as cited in Ogdon, 2001), omission of pupils (empty eyes) (Hammer, 1968; Kahn & Giffen, 1960; Levine & Sapolsky, 1969; Machover, 1949; Mitchell, 1993; Schildkrout, 1972; Urban, 1963; as cited in Ogdon, 2001), and an emphasized body (underclothed) (Machover, 1949, as cited in Gilbert, 1980). Defenses As in Mike?s previous drawings, there are numerous indicators of tendencies toward shyness, inhibition, defensiveness, and evasion. These are long pencil strokes (Handler, 1996), increasing length of stroke movement (Hammer, 1954; Mira, 1943; as cited in Gilbert, 1980), placement of the drawing high on the page (Buck, 1950; Hammer, 1958; Handler, 1985; Jolles, 1964; Urban, 1963; as cited in Ogdon, 2001), omission of pupils (empty eyes) (Hammer, 1968; Kahn & Giffen, 1960; Levine & Sapolsky, 1969; Machover, 1949; Mitchell, 1993; Schildkrout, 1972; Urban, 1963; as cited in Ogdon, 2001), rigid posture (Hammer, 1958; Levy, 1958; as cited in Gilbert, 1980), and a small trunk (Buck, 1950; Buck & Warren, 1992; Handler, 1985; Jolles, 1964; Urban, 1963; as cited in Ogdon, 2001). As in his previous drawings, reaction formations or compensatory defenses to defend against feelings of insecurity are suggested. These are indicated by placement of the figure high on the page (Machover, 1949, as cited in Gilbert, 1980), placement of the figure on the left-hand side of the page (Machover, 1949, as cited in Ogdon, 2001), limp arms at the sides (Levy, 1950; Machover, 1949; Rierdan et al., 1982; as cited in Ogdon, 2001), fewer than five fingers (Hammer, 1958, as cited in Gilbert, 1980), large feet (Modell & Potter, 1949; Urban, 1963; as cited in Ogdon, 2001), and a belt buckle (Machover, 1949; as cited in Gilbert, 1980). As in his previous drawings, tendencies toward introspection and the use of fantasy and intellectualisation as defenses, are suggested, by placement of the drawing high on the page (Buck, 1950; Buck & Warren, 1992; Hammer, 1958; Handler, 1985; Jolles, 1969; Jolles & Beck, 1953; Urban, 1963; as cited in Ogdon, 2001). Autonomy/dependency Mike?s ambivalence toward striving for independence and achievement versus dependency needs is again evident in this drawing. This is indicated by feet pointing in opposite directions (Buck & Warren, 1992; Jolles, 1964; Urban, 1963; as cited in Ogdon, 2001), and by the presence of both indicators of ambition and lack of ambition. While ambition/drive/future-orientation is suggested by firm line quality (Hammer, 1954; Levy, 1958; as cited in Gilbert, 1980), and placement of the drawing high on the page (Levy, 1950, as cited in Ogdon, 2001), lack of drive/ambition/energy/achievement is indicated by drooping shoulders (Hammer, 1954, as cited in Gilbert, 1980). However, as is the case in his previous two drawings, indicators of dependency and helplessness suggest that Mike is preoccupied with these needs. These indicators are fewer than five fingers (Hammer, 1954, as cited in Gilbert, 1980), and a belt buckle (Machover, 1949, as cited in Gilbert, 1980). Impulse control As in Mike?s previous two drawings, there are indications that he is battling to control his behaviour and emotions. While controlled behaviour and emotional control is indicated by long pencil strokes (Alschuler & Hattwick, 1947; Hammer, 1954; as cited in Gilbert, 1980), and rigid posture (Hammer, 1950; Levy, 1958; as cited in Gilbert, 1980), poor impulse control is indicated by feet pointing in opposite directions (Schildkrout, 1972, as cited in Ogdon, 2001). As in his previous two drawings, both repressed and overt aggression is expressed. Repressed aggression is indicated by the single line mouth (Hammer, 1954; Levy, 1958; as cited in Gilbert, 1980). Mike?s statement that he would most like to ?call people names? if he were invisible, may reflect repressed anger and feelings of helplessness. His statement that what makes him the saddest is ?when people ignore me? may lend support to the notion that he feels helplessness and not always heard or understood by others. Feelings of guilt are expressed by drooping shoulders (Hammer, 1954, as cited in Gilbert, 1980). Anger and overt aggressive tendencies are indicated by straight lines (Hammer, 1958; Krout, 1950; as cited in Gilbert, 1980), emphasized hair (Handler, 1985; Shneidman, 1958; as cited in Ogdon, 2001), shaded hair (Machover, 1949, as cited in Gilbert, 1980), a short, heavy line mouth (Machover, 1949, as cited in Ogdon, 2001), a wide stance (Buck, 1950; Buck & Warren, 1992; Hammer, 1969; Jolles, 1964; Machover, 1949; Urban, 1963; as cited in Ogdon, 2001), asymmetrical arms (Hammer, 1969; Koppitz, 1968; Machover, 1949; Mundy, 1972; Urban, 1963; as cited in Ogdon, 2001), large fingers (Handler, 1985; Shneidman, 1958; as cited in Ogdon, 2001), and emphasized feet (Hammer, 1954; Machover, 1958; Schildkrout, 1972; Shneidman, 1958; Urban, 1963; as cited in Ogdon, 2001). Assaultiveness is suggested by emphasized hair (Handler, 1985; Shneidman, 1958; as cited in Ogdon, 2001), reinforced hair (Hammer, 1954, as cited in Gilbert, 1980), large fingers (Handler, 1985; Shneidman, 1958; as cited in Ogdon, 2001), and emphasized feet (Hammer, 1954; Machover, 1949; as cited in Gilbert, 1980). Psychopathology Mike expressed that the worst thing about himself is ?TS? (tourette?s syndrome) and that ?I don?t like it?. This indicates that he is acutely aware of his disorder and that it causes him significant distress. It suggests that he feels different to other people. The themes of ?standing? and ?sleeping? re-emerged when Mike stated that he is ?standing there? in the drawing and that ?sleeping? makes him happy. These answers imply an inactive, socially withdrawn state, and may also relate to his answer to the question of what he does when he is being good (?just sit around?). Mike also stated that he likes ?sleeping and hanging out with friends on the weekend? and that his favourite activity is ?sitting with family?. These answers are in sharp contrast with what Mike said he does when he is being bad, which is to ?get hyper?. These alternating themes of inactivity and social withdrawal on the one hand, and hyperactivity on the other, may indicate a psychological conflict between these two behavioural extremes. As in his previous drawings Mike drew in normal succession, suggesting adequate contact with reality (Machover, 1949, as cited in Gilbert, 1980). However, the moderate distortions (arms different widths, and legs short compared to the trunk) suggest poor adjustment (Koppitz, 1966; Mitchell, 1993; Vane & Eisen, 1962; as cited in Ogdon, 2001). As in his two previous drawings there are multiple indicators of psychopathology. Although there are fewer indicators of anxiety than in the first drawing, there are still numerous such indicators. In this drawing, there are no indicators of conflict/somatisation in the throat area, as there were in his first drawing. However, conflict in the head area is indicated, as in the first drawing. Depression is indicated by decreased pace and productivity as drawing continued (Hammer, 1954, as cited in Gilbert, 1980), placement of the figure on the left-hand side of the page (Buck, 1950; Buck & Warren, 1992; Hetherington, 1952; Jolles, 1964; Mitchell, 1993; Urban, 1963; as cited in Ogdon, 2001), a single, unsmiling line for a mouth (Handler, 1985; McElhaney, 1969; as cited in Ogdon, 2001), rigid posture (Olch, 1971, as cited in Ogdon, 2001), and drooping shoulders (Hammer, 1954, as cited in Gilbert, 1980). Anxiety is suggested by placement of the drawing on the left-hand side of the page (Machover, 1949, as cited in Gilbert, 1980), shading (hair) (Hammer, 1954; Levy, 1958; Machover, 1949; as cited in Gilbert, 1980), large eyes (Machover, 1958, as cited in Ogdon, 2001), rigid posture (Jacks, 1969; Schildkrout, 1972; as cited in Ogdon, 2001), a simplified trunk (Riethmiller & Handler, 1997, as cited in Ogdon, 2001), moderate distortions (Handler & Reyher, 1966, as cited in Ogdon, 2001), and excessive detail (Machover, 1949, as cited in Gilbert, 1980). Neurosis is indicated by the omission of pupils (empty eyes) (Hammer, 1968; Kahn & Giffen, 1960; Levine & Sapolsky, 1969; Machover, 1949; Mitchell, 1993; Schildkrout, 1972; Urban, 1963; as cited in Ogdon, 2001), and excessive detail (Machover, 1949, as cited in Gilbert, 1980). Obsessiveness is suggested by excessive detail (Machover, 1949, as cited in Gilbert, 1980). Obsessive-compulsivity is implied by excessive detail (Buck, 1966; Buck & Warren, 1992; Deabler, 1969; Hammer, 1969; Handler, 1985; Jacks, 1969; Kahn & Giffen, 1960; Levy, 1958; Machover, 1949; McElhaney, 1969; Reynolds, 1978; as cited in Ogdon, 2001), overdetailed feet (Buck, 1966; Jolles, 1964; Urban, 1963; as cited in Ogdon, 2001), overdetailed shoes or laces (Buck & Warren, 1992; Levine & Sapolsky, 1969; Machover, 1949; Urban, 1963; as cited in Ogdon, 2001; Hammer, 1954; Levy, 1958; as cited in Gilbert, 1980), and striped clothing (shoes) (Schildkrout, 1972, as cited in Ogdon, 2001). Paranoia is suggested by rigid posture (Kahn & Giffen, 1960, as cited in Ogdon, 2001), and large eyes (Deabler, 1969; Griffith & Peyman, 1959; Hammer, 1968; Handler, 1985; Jacks, 1969; Kahn & Giffen, 1960; Levy, 1958; Machover, 1958; McElhaney, 1969; Reznikoff & Nicholas, 1958; Robins, Blatt & Ford, 1991; Schildkrout, 1972; Shneidman, 1958; Urban, 1963; as cited in Ogdon, 2001). Hyperactivity is indicated by a marked directional preference for vertical movement (Alschuler & Hattwick, 1947; Handler, 1985; Levy, 1958; as cited in Ogdon, 2001). Conflict or somatisation in the head area is revealed by the shaded hair (Hammer, 1954; Levy, 1958; Machover, 1949; as cited in Gilbert, 1980). Conflict or somatisation in the eye area is indicated by the omission of eyeballs (Hammer, 1954; Levy, 1958; Machover, 1949; as cited in Gilbert, 1980). Schizoid tendencies are implied by a long, narrow trunk (Buck & Warren, 1992; Handler, 1985; Jolles, 1964; Urban, 1963; as cited in Ogdon, 2001), tight stance (Machover, 1949, as cited in Gilbert, 1980), self-preoccupied facial expression (Machover, 1949, as cited in Gilbert, 1980), and the omission of pupils (empty eyes) (Hammer, 1968; Kahn & Giffen, 1960; Levine & Sapolsky, 1969; Machover, 1949; Mitchell, 1993; Schildkrout, 1972; Urban, 1963; as cited in Ogdon, 2001). Narcissistic tendencies are revealed by hair given much attention (Hammer, 1954, as cited in Gilbert, 1980; Handler, 1985; Levy, 1958; Machover, 1949; as cited in Ogdon, 2001), and overdetailed feet (Buck, 1966; Jolles, 1964; Urban, 1963; as cited in Ogdon, 2001). Organicity is suggested by asymmetrical arms (Hammer, 1969; Koppitz, 1968; Machover, 1949; Mundy, 1972; Urban, 1963; as cited in Ogdon, 2001). 4.1.3.4. K-F-D a) Introduction Mike asked if he should draw his whole family in the picture, then if he should also draw himself in the picture. He proceeded to draw four figures from left to right in the top left-hand corner of the page. While drawing he fidgeted his legs a lot but asked no further questions. He drew from left to right and the pace of his drawing increased steadily. The drawing took 4 minutes and 36 seconds to complete, at which time he stopped drawing, looked up at the researcher, and said ?OK, done?. The first figure he drew was that of an adult man with no feet (his father). He drew the head first, and then ears, eyes, nose, and a mouth. He drew the right side of the neck, right shoulder, right arm, and right side of the torso, as a single continuous curved line. He drew another continuous curved line to form the left side of the neck, left shoulder, left arm, and left side of the torso, and then drew the left leg. The second figure he drew was that of a female (his mother). He drew the head, hair, eyes, mouth, and a cigarette protruding from the left side of the mouth. Mike went back to the first figure and added the right leg. He returned to drawing the second figure and added the right side of the neck and right shoulder as a single curved line. He paused and then continued to draw the right arm, the left side of the neck, the left arm, and both hands. He drew the torso and skirt, adding vertical lines to the skirt. He drew the left and then right legs and feet, as a continuous line each. He then returned to the first figure and drew a speech bubble protruding from the right side of the mouth containing the words ?ha ha?, and a tiny tuft of hair on the top right corner of the head. Mike began drawing the third figure, that of a girl with messy hair, a short skirt, and outstretched arms with no shoulders (his sister). He drew her head, hair, eyes, and nose. He drew the right side of her neck and her right arm, followed by the left side of her neck. He drew her mouth, followed by her left hand and left arm. He drew her torso, detail on her skirt, and a waistline. Finally, he drew her left leg and foot, right leg and foot, and a speech bubble protruding from the right side of her face containing the phrase ?laa?. The fourth figure (Mike) appeared to be that of a small child or baby with no feet, drawn slightly apart from the other three figures. It lies isolated within a rectangular bed, with a pillow under the head and a set of headphones connected to a radio over the ears. Mike drew the rectangle first, followed by the pillow. He drew the figure?s head, neck, arms, torso, and legs, followed by the ears, eyes, and mouth. He added headphones to the top of the figure?s head and drew horizontal and then vertical lines, within the outline of the bed. Finally, he added a line protruding from the headphones with a radio connected to it. Mike omitted his 21 year-old brother from the drawing. Since, at that stage, the researcher was unaware that he had siblings (as the biographical questionnaire mentioned none), she was unable to question Mike on this omission. Although the reason for this omission is unknown, the researcher later ascertained from Mike?s mother that he had siblings and that he is not close to his brother, which may explain the omission. Since the omission of a family member from the drawing indicates rejection, denial, and subtle conflict with the person (Burns & Kaufman, 1972), Mike?s omission suggests these features in his relationship with his brother. b) Emotional indicators Self-concept Self-esteem and body image Mike drew himself last, indicating low self-esteem and a feeling that he is the least important person in the family (Reynolds, 1978). He depicted himself as a tiny, crudely drawn figure, much like a small child or baby. Depicting himself as the physically smallest figure suggests low self-esteem and feelings of inadequacy within his family context (Alschuler & Hattwick, 1949; Buck, 1948, 1950; Buck & Warren, 1992; Delatte & Hendrikson, 1982; DiLeo, 1973; Gray & Pepitone, 1964; Hammer, 1997; Handler, 1985; Jacks, 1969; Jolles, 1964; Koppitz, 1968; Lakin, 1956; Lehner & Gunderson, 1948; Levy, 1958; Ludwig, 1969; Marzolf & Kirchner, 1972; McElhany, 1969; McHugh, 1966; Michal-Smith & Morgenstern, 1969; Mitchell, 1993; Mundy, 1972; Ottenbacher, 1981; Precker, 1950; Riklan, 1962; Urban, 1963; as cited in Ogdon, 2001; Reynolds, 1978). Mike depicted himself with a small trunk, further suggesting low self-esteem (Buck, 1950; Buck & Warren, 1992; Handler, 1985; Jolles, 1964; Urban, 1963; as cited in Ogdon, 2001). His thin trunk similarly indicates low self-esteem (Jolles, 1952; Machover, 1949; as cited in Ogdon, 2001), and poor self-acceptance is suggested by Mike?s isolation of himself from the rest of the family (Reynolds, 1978). Interpersonal family dynamics The figure of Mike is drawn away from the rest of his family, indicating a sense of isolation from them or rejection by them (Reynolds, 1978). Mike drew himself lying on a bed, with the other family members standing up, drawn with more detail, and appearing more alert. Mike?s encapsulation by his bed expresses isolation and that he cannot express his feelings naturally (Burns & Kaufman, 1972). Isolation of himself from the rest of the family indicates emotional constriction (Reynolds, 1978), as does anchoring of the drawing (figures drawn within one inch of the edge of the page) (Reynolds, 1978). Mike?s depiction of himself as lying in bed wearing headphones may indicate either a wish to withdraw from and ?block out? his family, or an effort to comfort or amuse himself to compensate for feelings of isolation. Hypersensitivity to criticism is suggested by large ears on the figures of Mike and his father (Buck, 1950; Handler, 1985; Jolles, 1964; Machover, 1951; Mitchell, 1993; Mursell, 1969; Urban, 1963; as cited in Ogdon, 2001). Mike?s headphones may represent efforts to ?block out? criticism. He depicted his family as a small unit in the upper left-hand corner of the page, indicating a sense of social isolation and uneasiness (Graham, 1994, as cited in Ogdon, 2001). These feelings are also suggested by the withdrawn, vacant facial expressions on the faces (Hammer, 1954; Machover, 1949; as cited in Gilbert, 1980). Feelings of insecurity are suggested by placement of the drawing in the upper left- hand corner of the page (Buck, 1948; Goodman & Kotkov, 1953; Handler, 1985; Jolles, 1952; Levine & Sapolsky, 1969; Urban, 1963; as cited in Ogdon, 2001), and by anchoring of the drawing (Reynolds, 1978). Insecurity is further indicated by the placating facial expressions (Hammer, 1954; Machover, 1949; as cited in Gilbert, 1980), small hands (DiLeo, 1973, as cited in Odon, 2001; Handler, 1996), and limp arms dangling at the sides of all figures except Mike?s sister (Levy, 1950; Machover, 1949; Rierdan et al., 1982; as cited in Ogdon, 2001). The broken lines on Mike?s bed further suggest insecurity (Hammer, 1954; Buck, 1950; as cited in Gilbert, 1980). There is no sense of warmth or closeness between the family members in the drawing, but rather a sense of disconnectedness, hardness, rigidity, and tension. Nobody is facing anyone else; everyone has a self-preoccupied, vacant, staring, placating facial expression, and rigid posture. There is a lack of connection or kinesthesis between the figures. The only physical contact between family members is smoke from Mike?s mother?s cigarette almost touching his father?s ear, and Mike?s sister?s hand almost touching his mother?s stiff looking hair. The arm to her hand is dawn as much shorter than the other arm, possibly to ensure it does not make contact with Mike?s mother. Mike?s narrative supports the notion that he perceives a sense of disconnectedness within the family, as he stated that the best thing about the family is ?that they all doing something?, but that the worst thing is ?that they all doing different things?. This perception is substantiated by Mike?s response to the question of how the family members get along, to which he pulled a face, paused, and then said ?all right? in a flat tone of voice. A sense of withdrawal of the family members from one another is also suggested by placement of the drawing high on the page (Buck, 1950; Hammer, 1958; Handler, 1985; Jolles, 1964; Urban, 1963; as cited in Ogdon, 2001), and in the upper left-hand corner of the page (Buck, 1948; Goodman & Kotkov, 1953; Handler, 1985; Jolles, 1952; Levine & Sapolsky, 1969; Urban, 1963; as cited in Ogdon, 2001). Inhibition, withdrawal, or restriction within the family is suggested by the long pencil strokes (Handler, 1996), small trunks (Buck, 1950; Buck & Warren, 1992; Handler, 1985; Jolles, 1964; Urban, 1963; as cited in Ogdon, 2001), rigid postures (Hammer, 1958, as cited in Gilbert, 1980), and small figure sizes, with Mike as the smallest of all (Handler, 1996; Handler & Reyher, 1966, as cited in Ogdon, 2001). The family members have barriers between them (speech bubbles and a cigarette). Communication difficulties are suggested by the long necks of Mike?s mother and sister and of Mike himself, indicating conflict in the throat (speech) area (Hammer, 1954, as cited in Gilbert, 1980; Levy, 1958, as cited in Ogdon, 2001). Mike?s sister is drawn as the largest and liveliest looking figure in the family. This may indicate that Mike perceives her as important and visible, as literally ?standing out? within the family. Despite his assertion that she is his favourite person in the family, and the fact that he drew her as the closest figure to himself, Mike expressed that he dislikes her singing. She is depicted as singing in the drawing, with a speech bubble that reads ?laa? and lines coming out from all around her mouth, presumably indicating loud sound. He stated that he is wearing earphones to block out the sound of her singing, and her speech bubble forms a barrier between the two of them, indicating conflict between them. Mike?s sister?s speech bubble, wide open mouth with lines coming from it, and broad, showy stance suggest that Mike perceives her as forcibly making herself heard and seeking attention. His sister?s outstretched arms reflect a desire for interpersonal contact, affection, or help (Handler, 1985; Michal-Smith & Morgenstern, 1969; Schildkrout, 1972; as cited in Ogdon, 2001; Machover, 1949, as cited in Gilbert, 1980), and her long arms express ambition (Machover, 1949, as cited in Gilbert, 1980). She is depicted as more expressive and assertive than Mike in the drawing. Mike perceives her as closer to his parents than himself, as she is positioned standing next to them, while he is alone and encapsulated. The drawing indicates that Mike feels his sister is louder, more expressive and assertive than himself, and receives more parental attention. His sister?s clown-like mouth suggests forced amiability (Machover, 1949, as cited in Gilbert, 1980), while hostility is indicated by her long neck (Handler, 1985; Machover, 1949; as cited in Ogdon, 2001). This may indicate that, although she feels hostile, she ?sticks her neck out? to play the happy, noisy clown, drawing attention to herself and gaining parental attention. There are indicators that Mike perceives the relationship between his parents as strained. There are barriers from both sides between his father and mother (a speech bubble and cigarette respectively) indicating conflict between them (Burns & Kaufman, 1972), and defensiveness (Reynolds, 1978). Interestingly, Mike only added the right leg to the drawing of his father once he had drawn his mother?s cigarette, then later he added the speech bubble and tiny tuft of hair to the drawing of his father once he had drawn his mother?s right foot. It is considered that this sequence of drawing may further indicate conflict between his parents. In reply to the question of how Mike?s father feels about himself, Mike replied that his father ?feels like he?s the boss of everyone?. Anxiety is suggested by Mike?s father?s unbalanced stance (Machover, 1949, as cited in Gilbert, 1980), while his mother?s long neck suggests hostility (Handler, 1985; Machover, 1949; as cited in Ogdon, 2001), and her rigid posture reveals emotional control (Hammer, 1954; Levy, 1958; as cited in Gilbert, 1980). Mike stated that his mother is telling his father something funny and ?feels like she is making my dad laugh?. He expressed that his father is ?laughing at what my mom?s telling him? and drew him with a speech bubble that reads ?ha ha?. Mike?s mother expressed in conversation with the researcher that she frequently uses humour to ease the tension between Mike?s father and herself. The drawing reveals Mike?s awareness of this dynamic between his parents. Sexuality and gender identity The figures of Mike?s mother and sister are imbued with multiple indicators of sexuality and sexual conflict or preoccupation, while frail, demasculated qualities pervade the figures of Mike and his father. Mike?s mother is depicted with a cigarette in her mouth, which is considered a sex symbol (Buck, 1950; Levy, 1958; Machover, 1951; Urban, 1963; as cited in Ogdon, 2001), suggesting sexual preoccupation (Machover, 1949, as cited in Gilbert, 1980). Sexual conflict or preoccupation is further indicated by elongated anatomical areas/phallic symbols (her neck and feet) (Hammer, 1954, as cited in Gilbert, 1980). Her elongated feet in particular suggest sexual conflict or preoccupation (Buck, 1966; Buck & Warren, 1992; Hammer, 1953; Handler, 1985; Jolles, 1964; Mitchell, 1993; Urban, 1963; Wysocki & Wysocki, 1977; as cited in Ogdon, 2001; Machover, 1949, as cited in Gilbert, 1980), as does her emphasized hair (Buck, 1950; DiLeo, 1970; Hammer, 1954; Handler, 1985; Jolles, 1964; Levy, 1958; Machover, 1951; Roback, 1968; Urban, 1963; as cited in Ogdon, 2001). It is considered possible that these emotional indicators of sexual conflict may express Mike?s repressed conflicts and denial around his mother?s sexuality, as one of his first OCD symptoms involved thinking that sex is bad and not wanting to think his mother has sex. Other indicators support this assertion. The cigarette between his mother?s lips is indicative of sophisticated oral eroticism (Machover, 1949, as cited in Gilbert, 1980), while her emphasized hair suggests regressed sex drives (Buck, 1950; Handler, 1985; Levy, 1958; as cited in Ogdon, 2001; Machover, 1949, as cited in Gilbert, 1980), as does her small trunk (Buck, 1950; Buck & Warren, 1992; Handler, 1985; Jolles, 1964; Urban, 1963; as cited in Ogdon, 2001). Her emphasized hair is long but unshaded, indicating ambivalent sexual fantasies (Buck, 1966, as cited in Ogdon, 2001). Sexual preoccupation or conflict is also suggested in the figure of Mike?s sister. She is drawn with messy hair, suggesting sexual immorality (Machover, 1949; as cited in Gilbert, 1980), and sexual conflict or preoccupation (Buck, 1950; DiLeo, 1970; Hammer, 1954; Handler, 1985; Jolles, 1964; Levy, 1958; Machover, 1951; Roback, 1968; Urban, 1963; as cited in Ogdon, 2001). Her elongated feet, neck and right hand are further indicators of sexual preoccupation (Buck, 1966; Buck & Warren, 1992; Hammer, 1953; Handler, 1985; Jolles, 1964; Mitchell, 1993; Urban, 1963; Wysocki & Wysocki, 1977; as cited in Ogdon, 2001; Machover, 1949; as cited in Gilbert, 1980), while her feet pointing in opposite directions suggest poor impulse control (Schildkrout, 1972, as cited in Ogdon, 2001). Her emphasized hair indicates infantile, regressed sex drives (Buck, 1950; Handler, 1985; Levy, 1958; as cited in Ogdon, 2001), as does her small trunk (Buck, 1950; Buck & Warren, 1992; Handler, 1985; Jolles, 1964; Urban, 1963; as cited in Ogdon, 2001). Her very short skirt with a vertical line detail at the genital area gives an impression of sexuality, or sexual conflict or preoccupation. Regressed sex drives are also suggested by hair on the female figures but not on male figures (Machover, 1949, as cited in Gilbert, 1980). There are suggestions of a preoccupation or confusion around gender identity or sexual orientation in the drawing. Although he was drawn first, Mike?s father is depicted as an old, balding, demasculated, frail man, with a thin trunk and no clothing or feet. Balding male figures suggest feelings of masculine insufficiency and a lack of virility (Buck, 1950; Handler, 1985; Mitchell, 1993; as cited in Ogdon, 2001; Hammer, 1954, as cited in Gilbert, 1980). His sparse, unpressured hair further suggests inadequate virility (Machover, 1949, as cited in Gilbert, 1980). His rounded trunk (Gurvitz, 1951; Handler, 1985; Levy, 1950; Machover, 1949; as cited in Ogdon, 2001) and wasp waist (Levy, 1958, as cited in Ogdon, 2001) suggest effeminacy or homosexual tendencies, while the marked directional preference for vertical movement in the drawing indicates masculine assertion, or a need for it (Alschuler & Hattwick, 1947; Handler, 1985; Levy, 1958; as cited in Ogdon, 2001). Personality Introversion/extroversion As is the case in Mike?s previous two drawings, there are indicators of tendencies toward introversion and self-consciousness. These are placement of the drawing on the left-hand side of the page (Levy, 1950; Machover, 1949; Mitchell, 1993; Urban, 1963; as cited in Ogdon, 2001), and Mike?s dim face (Hammer, 1958; Levy, 1958; as cited in Gilbert, 1980). Defenses Mike?s headphones may indicate defensiveness, withdrawal, and self-preoccupation. The drawing as a whole gives a sense that each member of the family is defended, withdrawn, and self-absorbed. The omission of feet from the figures of Mike and his father further indicates withdrawal (Machover, as cited in Gilbert, 1980). Reaction formations or compensatory defenses to defend against feelings of insecurity, are suggested by placement of all figures high on the page (Machover, 1949, as cited in Gilbert, 1980), placement of all figures on the left-hand side of the page (Machover, 1949, as cited in Ogdon, 2001), and the small size of all figures (Alschuler & Hattwick, 1947; Buck, 1950; Buck & Warren, 1992; Delatte & Hendrikson, 1982; DiLeo, 1973; Gray & Pepitone, 1964; Hammer, 1997; Handler, 1985; Jacks, 1969; Jolles, 1964; Koppitz, 1968; Lakin, 1956; Lehner & Gunderson, 1948; Levy, 1958; Ludwig, 1969; Marzolf & Kirchner, 1972; McElhany, 1969; McHugh, 1966; Michal-Smith & Morgenstern, 1969; Mitchell, 1993; Mundy, 1972; Ottenbacher, 1981; Precker, 1950; Riklan, 1962; Urban, 1963; as cited in Ogdon, 2001). Preoccupation with fantasy and intellectualisation is indicated by placement of the drawing in the upper left-hand corner of the page (Buck, 1948; Goodman & Kotkov, 1953; Handler, 1985; Jolles, 1952; Levine & Sapolsky, 1969; Urban, 1963; as cited in Ogdon, 2001), and placement high on the page (Buck, 1950; Buck & Warren, 1992; Hammer, 1958; Handler, 1985; Jolles, 1969; Jolles & Beck, 1953; Urban, 1963; as cited in Ogdon, 2001). Autonomy/dependency All the figures contain indicators of dependency and feelings of helplessness, as they are all small (Hammer, 1968; Machover, 1949; Meyer, Brown & Levine, 1955; Mitchell, 1993; Urban, 1963; as cited in Ogdon, 2001), with small hands (Hammer, 1954; Handler, 1985; as cited in Ogdon, 2001), and fewer than five fingers (Hammer, 1954, as cited in Gilbert, 1980). Mike?s mother and sister are depicted as younger than their ages, suggesting emotional immaturity (Machover, 1949, as cited in Gilbert, 1980; McElhaney, 1969; Meyer; Urban, 1963; as cited in Ogdon, 2001), and dependency needs (McElhaney, 1969; Urban, 1963; as cited in Ogdon, 2001). The large feet on the figure of Mike?s sister also suggest these qualities (Modell & Potter, 1949; Urban, 1963; as cited in Ogdon, 2001). Her feet pointing in opposite directions indicate feelings of ambivalence over striving for independence (Buck & Warren, 1992; Jolles, 1964; Urban, 1963; as cited in Ogdon, 2001). Mike?s mother?s drooping shoulders suggest a lack of drive/ambition (Hammer, 1954, as cited in Gilbert, 1980). Omission of feet on the figure of Mike?s father suggest feelings of constriction, lack of independence, loss of autonomy, and helplessness (Buck, 1966; Buck & Warren, 1992; Evans & Marmorston, 1963; Hammer, 1954; Handler, 1985; Jolles, 1964; Kokonis, 1972; McLachlan & Head, 1974; Mitchell, 1993; Modell & Potter, 1949; Mursell, 1969; Schildkrout, 1972; Urban, 1963; as cited in Ogdon, 2001), as well as discouragement and withdrawal (Machover, 1949, as cited in Gilbert, 1980). However, there is some suggestion of a sense of ambition and future-orientation within the family, as indicated by the firm line quality (Hammer, 1954, as cited in Gilbert, 1980; Levy, 1958, as cited in Ogdon, 2001), and placement of the drawing high on the page (Levy, 1950, as cited in Ogdon, 2001). Impulse control There are few indicators of overt angry aggressive or assaultive tendencies in Mike?s drawing of himself in the K-F-D, as opposed to his D-A-P drawings. The long pencil strokes indicate emotional control (Alschuler & Hattwick, 1947; Hammer, 1954; as cited in Gilbert, 1980), while predominantly straight lines (Hammer, 1958; Krout, 1950; as cited in Gilbert, 1980) suggest aggressive tendencies. Repressed aggression is suggested by Mike?s long neck (Hammer, 1954; Levy, 1958; as cited in Gilbert, 1980), and single line mouth (Hammer, 1954; Levy, 1958; as cited in Gilbert, 1980). Interestingly, Mike has not drawn any feet, shoes, or hair for himself in this drawing. This is in sharp contrast with his D-A-P self-portrait, in which he drew large, detailed feet, shoes, and hair, and may suggest that he feels less aggressive and more dependent within his family context. This implies low self-esteem within his family and may suggest that Mike feels less need for aggression, as he may be resigned to or even comfortable in a dependent, passive, ?baby? role within the family. There are also numerous indicators of anger and aggressive tendencies, both repressed and overt, in the figures of Mike?s family members. The striped clothing (shoes on female figures) suggests difficulty with impulse control (Schildkrout, 1972, as cited in Ogdon, 2001). Repressed aggression is expressed by his father?s single line mouth (Hammer, 1954; Levy, 1958; as cited in Gilbert, 1980), his father?s small trunk (Buck, 1950; Buck & Warren, 1992; Handler, 1985; Jolles, 1964; Urban, 1963; as cited in Ogdon, 2001), his parents? mitten hands (Buck, 1950; Handler, 1985; Jolles, 1964; Machover, 1949; Urban, 1963; as cited in Ogdon, 2001), and his mother?s closed fists, held close to the body (Machover, 1949, as cited in Gilbert, 1980). Overt anger and aggressive tendencies are expressed by his mother and sisters? emphasized hair (Handler, 1985; Shneidman, 1958; as cited in Ogdon, 2001), the wide stances of his father, mother and sister (Buck, 1950; Buck & Warren, 1992; Hammer, 1969; Jolles, 1964; Machover, 1949; Urban, 1963; as cited in Ogdon, 2001), his sister?s angular body (Machover, 1949, as cited in Gilbert, 1980), and his mother and sisters? long necks (Hammer, 1954; Levy, 1958; as cited in Gilbert, 1980). Psychopathology Basic psychological integrity is suggested by the match between the visible actions of the figures, with Mike?s verbal descriptions of what they are doing (Reynolds, 1978). Moderate distortion of all the figures (his father?s arms, trunk, and legs are distorted and feet omitted, his mother?s neck, right arm, hands, trunk and legs are distorted, his sister?s arms, legs and feet are distorted, Mike has tiny legs and no feet, hands, and hair) suggests poor adjustment (Koppitz, 1966; Mitchell, 1993; Vane & Eisen, 1962; as cited in Ogdon, 2001). There are also numerous indicators of psychopathology. The decreased pace and productivity as the drawing continued, suggests depression (Hammer, 1954, as cited in Gilbert, 1980), as does Mike?s isolation of himself from the rest of the family in the drawing (Reynolds, 1978). Furthermore, Mike?s depiction of himself as lying on a bed may reveal feelings of exhaustion or depression. This assertion is supported by Mike?s response to the question of how he feels about himself, to which he replied, ?I think I?m tired?. Anxiety is suggested by placement of the drawing on the left-hand side of the page (Machover, 1949, as cited in Gilbert, 1980), and moderate distortion of all figures, especially that of Mike himself (Handler & Reyher, 1966, as cited in Ogdon, 2001). Anxiety is also indicated by the small size of the figures (Hattwick, 1949, as cited in Gilbert, 1980) with Mike as the smallest, the simplified trunks of all figures, most noticeably of Mike himself (Riethmiller & Handler, 1997, as cited in Ogdon, 2001), and arms close to the body (Mike?s, his father?s, and his mother?s) (Machover, 1949, as cited in Gilbert, 1980). The broken lines on Mike?s bed further indicate anxiety (Hammer, 1954; Buck, 1950; as cited in Gilbert, 1980). Obsessive-compulsivity is suggested by the small figure sizes of the family members, especially the tiny size of Mike himself, and the striped clothing (skirts) of the female figures (Schildkrout, 1972, as cited in Ogdon, 2001). However, there are far fewer obsessive-compulsive indicators than in Mike?s D-A-P drawings, which may express that he experiences his symptoms as less important within his family than in the outside world. This may suggest that his family provide him with a supportive environment in which he feels less ?pathological? than he does in the outside world. Paranoia is indicated by the rigid postures of the figures (Kahn & Giffen, 1960, as cited in Ogdon, 2001), as well as by the unenclosed dots with pressure, which form the eyes on the figure of Mike (Machover, 1949, as cited in Gilbert, 1980). Hyperactivity is suggested by the marked directional preference for vertical movement in the drawing (Alschuler & Hattwick, 1947; Handler, 1985; Levy, 1958; as cited in Ogdon, 2001). Schizoid tendencies are indicated by the self-preoccupied facial expressions of all figures (Machover, 1949, as cited in Gilbert, 1980), the tight stances of Mike and his parents (Machover, 1949, as cited in Gilbert, 1980), the long, narrow trunks of Mike and his parents (Buck & Warren, 1992; Handler, 1985; Jolles, 1964; Urban, 1963; as cited in Ogdon, 2001), and the long necks of Mike, his mother, and sister (Hammer, 1954; Levy, 1958; as cited in Gilbert, 1980). Narcissistic tendencies are revealed by hair parted in middle (Mike?s mother and sister) (Hammer, 1954; Levy, 1958; as cited in Gilbert, 1980), his sister?s hair given the most attention compared to rest of her figure (Hammer, 1954, as cited in Gilbert, 1980; Handler, 1985; Levy, 1958; Machover, 1949; as cited in Ogdon, 2001), and his sister?s akimbo arms (Handler, 1985; Machover, 1949; as cited in Ogdon, 2001). 4.1.4. TAT analysis Card 1 The card elicits themes of relationships with parental figures, aggression, and ADD (Bellak, 1975). In Mike?s story, he perceives the environment and parents as punitive (the object he broke ?smashed in his face?, which may relate to being punished for aggression). He displayed high anxiety over physical punishment or injury and consequently being overwhelmed and helpless, breathing heavily when he became anxious. A conflict between a harsh superego and high levels of overt aggression (a desire to ?bust something? which is carried out) are suggested. ADD is indicated by Mike?s failure to recognise the violin. The defenses of fantasy (a wish for magical powers), acting out, and undoing are revealed. Acting out refers to the unconscious process of dealing with emotional conflict or environmental stressors by actions instead of feelings or reflections. The story indicates high intelligence, a low level of maturity, and inadequate ego integration. Card 2 The card elicits the theme of autonomy versus compliance with the family (Bellak, 1975). Mike?s story suggests conflict between autonomy and compliance in a punitive environment, and difficulty complying and physically coping with familial and environmental demands (?he fell asleep again and didn?t do his homework again, as he had such a hard day at school?). Dependency and nurturance needs are suggested. His sister tries to help him by waking him up but was unable to, implying that she tries to take care of him and be supportive but lacks the capacity to do so. This suggests that Mike needs more support and care from his parents. Anxiety over parental disapproval and punishment and being overwhelmed and helpless against a harsh superego is implied. Depression is suggested (being too tired to do his school work). Regressive tendencies are suggested. The story indicates high intelligence, a low level of maturity, and inadequate ego integration. Card 3BM The card elicits themes of body image, depression, and aggression (Bellak, 1975). Mike?s story suggests a poor body image is (?his head got mashed and then it rained again and it looked like his whole head was crying?). Conflict between autonomy and compliance is implied, and difficulty complying and physically coping with the demands of a punitive environment (?rain?). Dependency and nurturance needs are evident, as well as anxiety over physical harm or injury and consequently being overwhelmed and helpless. Conflict between a harsh superego and powerful aggressive drives is suggested. Depression and fears of being overwhelmed and helpless as a result are implied (trying to hide from the rain, but it falls on him, until ?it looked like his whole head was crying?), and the defense of projection is used. Projection refers to the unconscious process of falsely attributing unacceptable impulses, feelings, or thoughts to another. Regression is indicated. The story indicates high intelligence, a low level of maturity, and inadequate ego integration. Card 3GF The card elicits the theme of depression (Bellak, 1975). Mike?s story reveals depression (?she cried so hard?) but hopefulness for recovery (?she finally got it open and then she stopped crying?). Conflict between autonomy and compliance and difficulty complying and physically coping with the demands of a punitive environment are suggested. The story implies dependency and nurturance needs, regression, and anxiety over physical harm or injury and consequently being overwhelmed and helpless. Conflict between a harsh superego and powerful aggressive drives is evident, and the defenses of acting out and undoing are implied. The story indicates high intelligence, a low level of maturity, and inadequate ego integration. Card 4 The card elicits themes of male-female relationships and male attitudes toward the role of women (Bellak, 1975). Mike?s story suggests conflict between autonomy and compliance in a punitive environment, and a fear of being dominated and physically injured by women, which may be repressed aggression towards his mother. Women are perceived as punitive, stronger, aggressive, and dominating. The story indicates anxiety over being overwhelmed and helpless in the face of physical injury, and conflict between a harsh superego and powerful aggressive drives. The defenses of undoing and projection are implied. The story indicates high intelligence, a low level of maturity, and inadequate ego integration. Card 5 The card elicits the theme of the mother who may be watching (Bellak, 1975). Mike?s story suggests difficulty complying and physically coping with the demands of a punitive environment. Anxiety over being rejected (?thrown away?) by his mother, which may be repressed aggression against her, is evident. She is perceived as aggressive but overwhelmed and not in control of her environment. Fears of maternal illness or death are revealed. The story suggests a conflict between a harsh superego and powerful aggressive drives, and the defenses of acting out and undoing are implied. The story indicates high intelligence, a low level of maturity, and inadequate ego integration. Card 6BM The card elicits the theme of the mother-son relationship (Bellak, 1975). Mike?s story reveals aggression towards his mother (stealing from her pocket and shooting at her), which she punishes (she called the police). Even though she is an ?old woman?, his mother is perceived as dominant and the victor over him in the end, leaving him helpless. Oedipal anxiety over paternal punishment and disapproval (castration anxiety) is suggested. The ?police? who killed him may symbolise his father?s authority. Conflict between a harsh superego and powerful aggressive drives are revealed, and the defenses of acting out and undoing are implied. Regression is indicated. The story indicates high intelligence, a low level of maturity, and inadequate ego integration. Card 7BM The card elicits the theme of the father-son relationship (Bellak, 1975). Mike?s story suggests conflict between autonomy and compliance, with aggression towards his father for imposing his will on Mike and not letting him have what he wants (?He?d like to whip that moustache off his face?). Oedipal anxiety over paternal punishment and disapproval (castration anxiety) is implied, with his father perceived as the victor in the end, leaving Mike helpless. Conflict between a harsh superego and powerful aggressive drives is suggested, as well as a paranoid fear of being unjustly punished (?But then the boss got angry and said he was fired? because he didn?t want to be promoted). The story indicates the defense of fantasy, high intelligence, a low level of maturity, and inadequate ego integration. Card 7GF The card elicits the theme of the mother-child relationship (Bellak, 1975). Mike?s story reveals feelings of abandonment and rejection by his mother (?The two friends were fighting, then she looked away. The other one started to say something, but she didn?t care about her?), dependency and nurturance needs, and anxiety over the loss of maternal love. The story implies high intelligence, a low level of maturity, inadequate ego integration, and a harsh superego. Card 8BM The card elicits themes of aggression and the Oedipal relationship with the father (Bellak, 1975). Mike?s story reveals Oedipal fears of being physical injury at the hands of his father (castration anxiety) and a need for paternal care and nurturance. Paranoid fears of being unjustly punished (?But then they still charged him. But then they made a mistake and still cut him?), and consequently feeling overwhelmed and helpless are revealed. The story suggests conflict between a harsh superego and powerful aggressive drives. Regression and the defense of undoing are indicated. The story indicates high intelligence, a low level of maturity, and inadequate ego integration. Card 9BM The card elicits themes of current male to male relationships and homosexual drives and fears (Bellak, 1975). Mike?s story implies a poor body image (?Then, they put him back on stage again, but he still smelled of rubbish?). Homosexual fears are revealed in the form of anxiety over disapproval, injury, and being overwhelmed and helpless at the hands of other men (?Then they stomped on him and he fell asleep and they chucked him in the bin and took his hat off and shoved it in his mouth?). Homosexual drives are revealed in the form of a need for male acceptance and nurturing (oral needs) (jumping into the crowd of men at a party, men taking his hat off and shoving it into his mouth). The story implies paranoid fears of being unjustly punished, and conflict between a harsh superego and powerful aggressive drives. The story indicates regression and the defense of undoing. High intelligence, a low level of maturity, and inadequate ego integration are suggested. Card 10 The card elicits themes of male-female relationships and homosexual drives (Bellak, 1975). Mike?s story reveals homosexual drives in the form of a need for male acceptance and nurturing (two men embracing, ?happy to see each other, so then they hugged each other?), as well as homosexual fears of punishment, disapproval, loss of love, and feeling overwhelmed and helpless at the hands of other men (?the one guy wasn?t the real guy?was a diamond smuggler and he ran away, cos the other guy was lying?). The story suggests conflict between homosexual drives and a harsh superego, and a paranoid fear of being unjustly punished (?but then they didn?t believe him, and then he went to prison?). The story indicates the defense of undoing, high intelligence, a low level of maturity, and inadequate ego integration. Card 11 The card elicits themes of infantile or primitive fears (Bellak, 1975). Mike?s story reveals conflict between autonomy and compliance (anxiety over parental disapproval, punishment and loss of love, as the price of autonomy), and dependency and nurturance needs (?food?). Anxiety and a paranoid fear of being watched by ?security cameras? are suggested. Security cameras may symbolise parental authority or a harsh internalised parental authority in the form of the superego. Conflict between nurturance needs and a harsh superego is suggested. The story indicates the defense of undoing, high intelligence, a low level of maturity, and inadequate ego integration. Card 12M The card elicits themes of relationships between a younger man and an older man and passive homosexual fears (Bellak, 1975). Mike?s story suggests a poor body image (?a sick person and she fell as in the house?) and latent homosexual drives (the protagonist is depicted as a female and the relationship as a male-female one). Homosexual fears of injury and being overwhelmed and helpless at the hands of an older, stronger male figure (?he waved too hard and hit her?), and conflict between a harsh superego and powerful aggressive drives are revealed. Regression and the defense of undoing are suggested. High intelligence, a low level of maturity, and inadequate ego integration are indicated. Card 13MF The card elicits themes of sexual conflicts and associated feelings of guilt, and obsessive-compulsivity (Bellak, 1975). Mike?s story reveals aggression and Oedipal acquisition needs, in the form of sexual conflicts and feelings of ambivalence towards his mother/women (because she went to sleep when he wanted to talk to her, but ?he didn?t want her to talk cos she was too bad?). Considerable anger and overt aggression towards the mother is expressed (?When she was asleep, he mashed her head?). The woman is perceived as dominant, powerful, and the victor (?she screamed so hard, the book flew out of his hand and she started beating him?). The story suggests Oedipal fears of paternal disapproval, lack of love, physical injury or punishment from his father (castration anxiety), rendering him helpless. Obsessive- compulsivity is suggested by concern with small details (a book). The story indicates conflict between an adequate superego and powerful aggressive drives, and the defenses of acting out, undoing, rationalization, and splitting. Rationalization is the unconscious process of hiding the motivations for feelings, thoughts, or actions by explanations that reassure or are self-serving. Splitting refers to the unconscious process of ?compartmentalizing? opposite feelings and ?failing to integrate the positive and negative qualities of the self or others into cohesive images? (APA, 2000, p.813). Regression is suggested. The story indicates high intelligence, a low level of maturity, and inadequate ego integration. Card 13B The card elicits themes of childhood (Bellak, 1975). Mike?s story reveals conflict between autonomy and compliance (anxiety over parental disapproval, punishment, loss of love, and being overwhelmed and helpless as a result of disobeying his parents, who are perceived as punitive). Anxiety and paranoid fears of being watched by ?security cameras? are revealed. Security cameras may symbolise parental authority or a harsh internalised parental authority (superego). The story indicates the defenses of acting out and undoing, high intelligence, a low level of maturity, and inadequate ego integration. Card 14 The card elicits the theme of suicidal tendencies (Bellak, 1975). Mike?s story suggests conflict between autonomy and compliance, and a need for autonomy at any personal cost (?He had no choice but to jump out the window?). Conflict between a harsh superego, and a desperate need for autonomy with powerful aggressive drives, is revealed (?he broke the curtains?). Suicidal tendencies (jumping out the window) and anxieties over feeling overwhelmed and helpless are expressed. The story suggests anxiety and paranoid fears of being watched (?something was at the window?). The story indicates regression, high intelligence, a low level of maturity, and inadequate ego integration. Card 17BM The card elicits the theme of Oedipal fears (Bellak, 1975). In Mike?s story, the environment and parents are perceived as punitive (he is imprisoned ?for no reason?). The story suggests Oedipal fears of paternal punishment (castration anxiety) and being overwhelmed and helpless against it (police locking him up may symbolise his father?s authority). Conflict between a harsh superego and a need for autonomy with powerful aggressive drives is revealed. The story indicates paranoid fear of being unjustly punished (?he went to prison for no reason?(b)ut then they locked him up again?). The story indicates the defense of undoing, a high intelligence, a low level of maturity, and inadequate ego integration. Card 18BM The card elicits themes around any anxiety (Bellak, 1975). Mike?s story suggests a poor body image (the fantasy of being big and strong but fears that it won?t last: ?Because he was such a big giant, he used up all his energy, so he went small again?) and high anxiety (tapping his fingers and looking worried) over his own physical weakness with feelings of being overwhelmed and helpless (possibly castration anxiety). There is a conflict between the need for physical strength to gain control over his environment (the ?giant?) and the reality principle of the ego (the giant ?went small again?). Regression is suggested. A harsh superego is implied, and the defenses of fantasy and undoing. The story indicates high intelligence, a low level of maturity, and inadequate ego integration. Card 19 Mike?s story suggests Oedipal fears (castration anxiety) (?The shadow ate the burger and everything that was in the fridge?). The shadow may symbolise an elusive, punitive, powerful father, the perceived hunter of Mike?s ?food? (maternal nurturance). The story reveals anxieties over loss of maternal love and nurturance and feeling overwhelmed and helpless in a punitive, uncontrollable environment. Conflict between a harsh superego and nurturance needs is implied. The story suggests paranoia (the ?dark shadow?), regression, and the defense of projection. The story indicates high intelligence, a low level of maturity, and inadequate ego integration. 4.2. Subject B ? ?Daniel? 4.2.1. Introduction Daniel presented as an intense, outgoing, energetic, exceedingly talkative boy of 7 years and 9 months. He was small for his age with large, sparkling eyes. He lives with his parents and has one sibling, a half-sister aged 19 years. His sister has been living with her father (Daniel?s mother?s ex-husband) for the past year but previously lived with Daniel and his parents. His sister?s father is very fond of Daniel and they get along well. Daniel frequently visits his sister and sleeps over at his her home. Daniel?s early developmental milestones were normal except for difficulties with social skills (he tends to be very bossy). At 18 months old he was diagnosed with a growth problem related to an endocrine disorder and received treatment at a clinic. Daniel was bullied at nursery school because he was physically small for his age. His mother believes that he over-compensates for his small stature by aggressive behaviour, trying to be as strong and forceful as possible. Daniel was diagnosed with asthma and related problems at the age of 18 months. Daniel was 4 years old when his mother first noticed symptoms of psychopathology. A family doctor and a dermatologist were consulted, and Daniel was referred to a psychiatrist for treatment at the age of 4 years and 5 months. It is interesting to note that Daniel?s answer to the question of what to name the figure in his first D-A-P drawing included the statement, ??I can remember when I was four!??. Daniel?s first symptoms were cleaning rituals (excessive hand washing), repeated doubting (worrying that his mother would die), ordering (having to make straight lines out of everything and becoming distressed whenever the order became muddled), observable repeating or counting rituals (counting everything but not necessarily in a repetitive manner), mental repeating or counting rituals (silently repeating the words of a song over and over, for hours at a time), and demanding reassurance (that his mother was not going to die). Daniel received psychological treatment until the age of 7 years and 2 months (he terminated therapy 6 months ago). Nowadays his mother classifies his symptoms as ?mild? in severity (one or two aspects of his life are mildly impaired, but he generally copes well with life). He no longer displays repeated doubting or demands reassurance. However his symptoms of excessive hand washing, needing to have things in a specific order, observable repeating or counting rituals, and mental repeating or counting rituals remain. Just prior to the onset of these symptoms a traumatic event happened in Daniel?s life, viz. his sister (then aged 13 years) was admitted to a mental health centre for two months and diagnosed with severe bipolar mood disorder (BMD). There is a family history of psychopathology. Daniel?s father has symptoms of OCD but has not sought treatment. He is also ?a compulsive spender? and presents with bipolar tendencies. Both Daniel?s parents have histories of alcoholism. His mother suffers from depression and has been in therapy and on medication intermittently over the years. Daniel has been diagnosed with one comorbid psychological condition (AD/HD). Daniel?s sister was on medication until the age of 15 and in therapy for BMD until she was 16. She also displayed symptoms of borderline personality disorder (BPD) from the age of 18 years. His mother described how she used to act strangely by smearing her own blood (often when menstruating), and trying to drown her dolls in the bath, frequently in blood. She was preoccupied with knives and engaged in cutting. She engaged in various other forms of unusual behaviour and her speech was frequently very bizarre, often accompanied by hysterical crying. She presented with delusions of persecution, believing that people wanted to kill her. When she tried to commit suicide by strangling herself she was admitted to a mental health centre for a further two months. She copes better with life these days and began attending university after she matriculated last year. Her mother characterises her as highly intelligent, socially withdrawn, and exceedingly moody. She explained that Daniel is very aware of his sister?s moods. Daniel?s temperament and life have changed since he started displaying symptoms of OCD. He has become more depressed and aggressive than before (he is extremely bossy, manipulative, demanding, and overbearing. ?He argues with everybody? and his parents ?struggle to set and maintain boundaries? for him as ?he does not take ?no? for an answer?. He is frequently? rude? and ?sometimes hurts people unintentionally due to his forcefulness?). He has trouble making friends at school and concentrating in class. Family life has changed since Daniel started displaying symptoms of OCD. He needs more parental attention and tries to involve family members in his rituals. There is generally more tension in the family and coping with Daniel leaves his parents feeling more exhausted and frustrated than before. There is more tension and arguing between Daniel and sister than before (although frequent arguing constitutes a part of the family?s communication style). His sister feels jealous and neglected because Daniel?s parents spend extra time with him (especially as she needs a lot of parental attention herself). Daniel?s mother appears to be very supportive and understanding regarding his symptoms and makes an effort to seek and keep up-to-date with new information on his disorders. She and Daniel talk openly about his symptoms and she explained them to his teachers. She expressed that Daniel has always been a highly intelligent child and she enjoys taking him jogging in the mornings and spends a lot of time reading and doing creative activities with him. However she explained that coping with Daniel and his sister is extremely difficult and exhausting for her, to the point where she attends therapy to gain insight and support to help her cope better with her children. Daniel was friendly and generally co-operative with the researcher and performed all tasks requested of him quite willingly. However it was often difficult to get him to start doing the tasks, as he wanted to chat constantly and show things to the researcher. During testing he fidgeted almost constantly and had difficulty concentrating. He sometimes tapped his hands and feet under the table and occasionally scratched his hands over the table vigorously. Occasionally he rubbed his eyes repeatedly. He breathed heavily occasionally. Frequently he seemed very needy for attention and talked, smiled, and laughed in an intense, animated manner. Occasionally he got up from the table to get something to show the researcher and made frequent trips to the bathroom, often just to wash his hands. Occasionally he insisted on playing with the researcher?s stopwatch and tape recorder, frequently asking the researcher to turn off the tape recorder. Occasionally he recited his 11 or 100 times-tables, sometimes insisting that the researcher time him or recite them herself. During rest breaks Daniel always asked for the tape recorder to be turned off, and interacted in a very lively manner with the researcher, initiating as much contact as he could. He seemed very needy for attention and brought photographs of himself from a nearby shelf to show the researcher. He showed her his silkworms in a shoebox and seemed very proud of them and the silk cocoons they had woven. He asked the researcher to come and see his bedroom and showed her some of his toys, most of which were soft toys and books. He brought a children?s book from his bedroom to show the researcher how well he could read. He asked her to read it to him, which she promised to do at the end of the testing session. It was difficult to get him to resume the testing after a break, as he seemed to enjoy interacting informally with the tester more and appeared to want her to be his playmate, rather than to return to the formalities of the testing process. 4.2.2. Age-related norms for HFD analyses Daniel?s D-A-P figures measure 5.3, 4.6, and 5.1 inches in height respectively. This would usually classify them as small figures, as a normal sized figure is between 6 and 7 inches tall. (Handler, 1996; Urban, 1963, as cited in Ogdon, 2001). However because Daniel turned the page horizontally for the drawings, it is considered that the norms for drawing size cannot be applied to them. Thus emotional indicators relating to figure size have not been used, in interpreting the D-A-P drawings. The tallest figure in the K-F-D is Daniel?s father (4.4 inches high) while Daniel is the smallest (3.65 inches high). The emotional indicator of figure size has been used in interpreting the K-F-D in a relative, qualitative manner. As shaded strokes may be seen in the drawings of normal young children (Koppitz, 1968; Machover, 1960; as cited in Ogdon, 2001), the presence of this feature in all Daniel?s drawings has not been interpreted as an emotional indicator. Children especially below the age of seven years normally draw proportionally larger heads, than adults (Koppitz, 1968; Machover, 1960; Michal-Smith & Morgenstern, 1969; Urban, 1963; as cited in Ogdon, 2001). An enlarged head in a child?s drawing does however indicate an emphasis on fantasy (Hammer, 1965; Levy, 1950; as cited in Gilbert, 1980). Thus, the presence of this feature in Daniel?s second and third D-A- P drawings and K-F-D has not been interpreted as an emotional indicator, except regarding the use of fantasy as a defense. Because nose emphasis by children may be normal (Machover, 1960, as cited in Ogdon, 2001), the noses with nostrils in all Daniel?s D-A-P drawings and on the figure of his father in the K-F-D have not been interpreted using emotional indicators relating to emphasized noses. Emotional indicators relating to the presence of strong, phallic noses and nostrils have however been used. Mouth emphasis in children?s drawings may suggest normality (normal dependence and immaturity) (Machover, 1960; Urban, 1963; as cited in Ogdon, 2001), as does a concave mouth (Machover, 1960, as cited in Ogdon, 2001) and a wide upturned line forming a grin (Handler, 1985; Machover, 1949; Urban, 1963; as cited in Ogdon, 2001). Thus, although these three features were present on all figures in Daniel?s drawings, they have not been interpreted as emotional indicators. Ears are omitted from the figures of Daniel?s mother and sister in the K-F-D. However as this omission is considered normal particularly in children (Buck, 1950; Buck & Warren, 1992; Handler, 1985; Jolles, 1964; Machover, 1949; Urban, 1963; as cited in Ogdon, 2001), it has not been interpreted as an emotional indicator. A heavy line or other emphasis on the waist may be normal in children?s drawings (Machover, 1960, as cited in Ogdon, 2001). Thus, although this feature was present in all Daniel?s drawings, it has not been interpreted as an emotional indicator. Because shoulders are frequently omitted from the drawings of children below the age of 8 years (Hammer, 1965; Halpern, 1965; as cited in Gilbert, 1980), these omissions from Daniel?s?s second and third D-A-P drawings and K-F-D have not been interpreted as emotional indicators. Long fingers may be normal in children?s drawings (Hammer, 1997, as cited in Ogdon, 2001). Thus, although this feature was present on all figures in Daniel?s drawings, it has not been interpreted as an emotional indicator. Ambivalence regarding a striving for independence and achievement versus dependency needs is indicated by feet pointing in opposite directions. This feature is present in all Daniel?s D-A-P drawings and on all figures except his mother in his K-F- D (Buck & Warren, 1992; Jolles, 1964; Urban, 1963; as cited in Ogdon, 2001). However the presence of this feature is considered normal in drawings of a child of Daniel?s age, who is still supposed to be very dependent. It has therefore not been interpreted as an emotional indicator. As buttons suggest normal dependency in the drawings of young children (Buck, 1966; Buck & Warren, 1992; Jolles, 1964; Machover, 1960; as cited in Ogdon, 2001), the presence of this feature in the K-F-D has not been interpreted as an emotional indicator. All the figures drawn exceed the expected normative content criteria listed by Koppitz (1968, as cited in Handler, 1996) for a boy of Daniel?s age. 4.2.3. HFD analyses 4.2.3.1. D-A-P drawing 1 a) Introduction Daniel seemed unhappy about drawing a person, saying that he wanted to draw a monster instead. The researcher promised that he could draw a monster at the end of the drawing activities, which he seemed, satisfied with. He turned the page horizontally and drew the figure of a boy (?Michael?) with a wide stance, wide open arms, very detailed clothing with a skull and crossbones detail on a checked shirt and a toothy grin. He drew the head and ears, then explained, ?It?s nearly like a pixie this, its small S?s? as he added an S-shaped detail to each ear. He drew the eyes, nose, mouth and hair, then the neck and left shoulder. He erased the left shoulder and re-drew it, pressing very hard with the pencil. He sat for a few seconds with his hands in tight fists, looking at the drawing. He then drew the left arm, torso, right arm, and shirt with detail on the front. He drew the legs and feet, starting with the left side and added detailing to the trousers and shoes. He drew in the centre of the page, from left to right and the pace of his drawing decreased steadily. The drawing took 5 minutes and 18 seconds to complete. b) Emotional indicators Self-concept Self-esteem and body image Midline emphasis (skull and crossbones detail on shirt) suggests that Daniel has a poor self-concept with feelings of inferiority, especially physical inferiority (Bodwin & Bruck, 1960; Machover, 1949; Rierdan, Koff & Heller, 1982; Urban, 1963; as cited in Ogdon, 2001). The long, strong arms indicate a need for achievement or physical strength (Buck, 1966; Buck & Warren, 1992; Hammer, 1969; Handler, 1996; Jolles, 1964; Koppitz, 1968; Machover, 1958; Urban, 1963; as cited in Ogdon, 2001). The skull and crossbones detail may also represent a need for physical strength. Daniel?s answer to the question of what the best thing about ?Michael? is (?he?s the oldest in the class?) may express Daniel?s sense of being physically small and a wish to be older, bigger, and stronger. This assertion makes sense, in the light of the fact that Daniel has been subjected to bullying at school, as he is small for his age. There are indicators to suggest that Daniel is hypersensitive to social opinion, particularly criticism. These are the large, emphasized eyes (Handler, 1985; Machover, 1958; as cited in Ogdon, 2001), and the large ears (Buck, 1950; Handler, 1985; Jolles, 1964; Machover, 1951; Mitchell, 1993; Mursell, 1969; Urban, 1963; as cited in Ogdon, 2001). There are indicators suggesting that Daniel feels a sense of social isolation, uneasiness or hostility. These are sharply pointed feet (Hammer, 1954; Jacks, 1969; Mitchell, 1993; Schildkrout, 1972; Urban, 1963; as cited in Ogdon, 2001), and large hands (especially as they are very large) (Buck, 1966; Buck & Warren, 1992; DiLeo, 1973; Handler, 1985; Jolles, 1964; Levy, 1958; Machover, 1949; Urban, 1963; as cited in Ogdon, 2001). The outstretched arms and hands suggest a desire for interpersonal contact, help or affection (Handler, 1985; Michal-Smith & Morgenstern, 1969; Schildkrout, 1972; as cited in Ogdon, 2001). When asked what makes the person in his drawing happy, Daniel replied ?condensed milk?. This may express a desire to be nurtured and ?fed? emotionally. Sexuality and gender identity There are numerous sexually-oriented indicators, perhaps more than might be expected at Daniel?s age, suggesting a conflict or preoccupation with sexuality. These are emphasized hair (Buck, 1950; DiLeo, 1970; Hammer, 1954; Handler, 1985; Jolles, 1964; Levy, 1958; Machover, 1951; Roback, 1968; Urban, 1963; as cited in Ogdon, 2001), elongated anatomical areas/phallic symbols (nose, neck and feet) (Hammer, 1954, as cited in Gilbert, 1980), elongated feet (Buck, 1966; Buck & Warren, 1992; Hammer, 1953; Handler, 1985; Jolles, 1964; Mitchell, 1993; Urban, 1963; Wysocki & Wysocki, 1977; as cited in Ogdon, 2001), and phallic feet (Machover, 1949, as cited in Gilbert, 1980). Infantile, regressed sex drives are suggested by the emphasized hair (Buck, 1950; Handler, 1985; Levy, 1958; as cited in Ogdon, 2001; Machover, 1949, as cited in Gilbert, 1980). Daniel?s drawing contains indicators of a preoccupation or conflict with gender identity or sexual orientation. While masculine assertion or a need for it, is suggested by the strong nose (Machover, 1949, as cited in Gilbert, 1980), homosexual tendencies/effeminacy are suggested by the hair given much attention, especially as it is vigorously shaded (Hammer, 1954, as cited in Gilbert, 1954; Levy, 1958, as cited in Ogdon, 2001), large eyes (Geil, 1944; Levy, 1958; Machover, 1949; Urban, 1963; as cited in Ogdon, 2001), emphasized hip (pockets) (DiLeo, 1973; Geil, 1944; Hammer, 1981; Levy, 1950; Machover, 1951; Urban, 1963; as cited in Ogdon, 2001), overdetailed feet (Buck, 1966; Jolles, 1964; Urban, 1963; as cited in Ogdon, 2001), and overdetailed shoes or laces (Buck & Warren, 1992; Levine & Sapolsky, 1969; Machover, 1949; Urban, 1963; as cited in Ogdon, 2001). Personality Introversion/extroversion There are indicators suggesting that Daniel?s personality is imbalanced or disorganised. These are odd details (skull and crossbones detail on a highly detailed chequered shirt, elf-like shoes, S shapes in ears) (DiLeo, 1973, as cited in Ogdon, 2001), and asymmetrical shoulders (Buck, 1950; Buck & Warren, 1992; Jolles, 1964; Urban, 1963; as cited in Ogdon, 2001). Extroversive, socially outgoing tendencies are suggested by the large eyes (Handler, 1985; Machover, 1949; as cited in Ogdon, 2001). Conversely, central placement of the figure indicates a tendency toward self-directed behaviour and egocentricity (Alschuler & Hattwick, 1947; Levy, 1950; as cited in Ogdon, 2001; Hammer, 1954, as cited in Gilbert, 1980). Defenses Resistance is suggested by Daniel?s turning the paper to another orientation than the one presented to him (Hammer, 1997; Jolles, 1964; Mitchell, 1993; as cited in Ogdon, 2001). Daniel?s answer to the question of what the best thing about ?Michael? is suggests either resistance or defensiveness (?That he?s the oldest in the class, in his class. That?s all, that, that. Also a good thing about him is that ? aah, I can?t say anything?). His spontaneous reciting of times-tables and asking to be timed may have constituted efforts to avoid answering the questions. Compensatory defenses such as reaction formations, to defend against feelings of insecurity are suggested by the extreme bilateral symmetry (Hammer, 1958; Machover, 1951; Urban, 1963; as cited in Ogdon, 2001), wide stance (Buck, 1950; Buck & Warren, 1992; Jolles, 1964; as cited in Ogdon, 2001), placating facial expression (Hammer, 1954; Machover, 1949; as cited in Gilbert, 1980), long, strong arms (Buck, 1966; Buck & Warren, 1992; Hammer, 1969; Handler, 1996; Jolles, 1964; Koppitz, 1968; Machover, 1958; Urban, 1963; as cited in Ogdon, 2001), and midline emphasis (Bodwin & Bruck, 1960; Machover, 1949; Rierdan et al., 1982; Urban, 1963; as cited in Ogdon, 2001). The extreme bilateral symmetry of the drawing indicates that Daniel tends to use the defenses of repression and intellectualisation (Hammer, 1958; Machover, 1951; Urban, 1963; as cited in Ogdon, 2001). Repression refers to the unconscious process of ?expelling disturbing wishes, thoughts, or experiences from conscious awareness. The feeling component may remain conscious, detached from its associated ideas? (APA, 2000, p.813). The overemphasis and strong reinforcement of facial features suggest the use of fantasy to compensate for feelings of inadequacy and weakness (Machover, 1949, as cited in Gilbert, 1980). Daniel?s answer to the question of who ?Michael?s? favourite person is, was ?Charlie Chaplin? (not a family member or friend). This may express a sense of isolation and withdrawal into fantasy to meet his nurturance needs. Autonomy/dependency The straight, uninterrupted strokes suggest a quick, decisive, assertive personality (Allen, 1958; Alschuler & Hattwick, 1947; Hammer, 1958; Krout, 1950; Levy, 1958; as cited in Ogdon, 2001). Similarly, the unusually heavy pencil pressure expresses an assertive, persistent, forceful, ambitious personality (Alschuler & Hattwick, 1947; Hammer, 1968; Kadis, 1950; Levy, 1958; Machover, 1949; Urban, 1963; as cited in Ogdon, 2001), as do the determined, unhesitating pencil strokes (Hammer, 1954, as cited in Gilbert, 1980; Levy, 1958, as cited in Ogdon, 2001). The long, strong arms similarly suggest active, aggressive contact with the environment (Buck, 1966; Buck & Warren, 1992; Hammer, 1969; Handler, 1996; Jolles, 1964; Koppitz, 1968; Machover, 1958; Urban, 1963; as cited in Ogdon, 2001). The overemphasis and strong reinforcement of facial features suggest compensation for feelings of inadequacy and weakness by aggressive and socially dominant behaviour (Machover, 1949, as cited in Ogdon, 2001). Daniel?s answer to the question of what makes ?Michael? happy implied impulsive, aggressive competitiveness, ??Can you say the 100 times-table??You can?t do it! Time me.? Dependency and helplessness is suggested by the emphasis on the midline (Machover, 1949, as cited in Gilbert, 1980). Impulse control The drawing strongly suggests that Daniel has considerably high levels of anger and difficulty with impulse control. There is only one indicator of behavioural or emotional control, viz. long pencil strokes (Alschuler & Hattwick, 1947; Hammer, 1958; as cited in Ogdon, 2001). Long pencil strokes also imply inhibition (Alschuler & Hattwick, 1947; Hammer, 1958; Kadis, 1950; Mira, 1943; Urban, 1963; as cited in Ogdon, 2001; Handler, 1996), as do the swollen hands (Machover, 1955, as cited in Ogdon, 2001). However, the tight collar suggests difficulty controlling of anger or primitive drives (Hammer, 1958; Levy, 1958; as cited in Gilbert, 1980), as does the striped clothing (Schildkrout, 1972, as cited in Ogdon, 2001). Impulsivity is indicated by the large hands (especially as they are very large) (Buck, 1966; Buck & Warren, 1992; Jolles, 1952; as cited in Ogdon, 2001), while the central placement of the figure indicates a tendency toward emotional behaviour (Alschuler & Hattwick, 1947; Levy, 1950; as cited in Ogdon, 2001). The heavy pencil pressure suggests high energy levels and excitement (Hetherington, 1952; Kadis, 1950; Levy, 1958; Mitchell, 1993; Precker, 1950; Riethmiller & Handler, 1997; Urban, 1963; as cited in Ogdon, 2001). Overt anger and aggressive tendencies are suggested by a very high number of indicators. In this drawing, the aggression is all overt with none indicated as repressed. Some of the indicators of overt anger and aggressive tendencies are turning the paper to another orientation than the one presented (Hammer, 1997; Jolles, 1964; Mitchell, 1993; as cited in Ogdon, 2001), unusually heavy pencil pressure (Halpern, 1951; Hammer, 1997; Handler & McIntosh, 1971; Jolles, 1964; McElhaney, 1969; Reynolds, 1978; Riethmiller & Handler, 1997; Schneidman, 1958; Urban, 1963; Wysocki & Whitney, 1965; as cited in Ogdon, 2001), straight lines (Hammer, 1958; Krout, 1950; as cited in Gilbert, 1980), drawing in the middle of page (Machover, 1949, as cited in Gilbert, 1980), emphasized hair (Handler, 1985; Shneidman, 1958; as cited in Ogdon, 2001), large, piercing eyes (Deabler, 1969; Griffith & Peyman, 1959; Hammer, 1968; Handler, 1985; Jacks, 1969; Kahn & Giffen, 1960; Levy, 1958; Machover, 1958; McElhaney, 1969; Reznikoff & Nicholas, 1958; Robins et al., 1991; Schildkrout, 1972; Shneidman, 1958; Urban, 1963; as cited in Ogdon, 2001), and teeth showing (Buck, 1966; Buck & Warren, 1992; Goldstein & Rawn, 1957; Halpern, 1965; Hammer, 1965; Handler, 1996; Jolles, 1964; Koppitz, 1968; Levy, 1958; Machover, 1960; McElhaney, 1969, Mitchell, 1993; Rierdan et al., 1982; Schildkrout, 1972; Urban, 1963; as cited in Ogdon, 2001). More indicators of overt anger and aggressive tendencies are nostrils (Machover, 1949, as cited in Gilbert, 1980), a wide stance, especially as the figure is in the middle of the page (Machover, 1949; Shneidman, 1958; Wysocki & Wysocki, 1977; as cited in Ogdon, 2001), long, strong arms (Buck, 1966; Buck & Warren, 1992; Hammer, 1969; Handler, 1996; Jolles, 1964; Koppitz, 1968; Machover, 1958; Urban, 1963; as cited in Ogdon, 2001), large hands, especially as they are very large (Handler, 1985; Shneidman, 1958; as cited in Ogdon, 2001), sharp, spiked/spear fingers (Brown, 1958; Buck, 1966; Buck & Warren, 1992; DiLeo, 1970; Goldstein & Rawn, 1957; Hammer, 1965; Handler, 1985; Jacks, 1969; Jolles, 1964; Machover, 1949; McElhaney, 1969; Mitchell, 1993; Modell & Potter, 1949; Reynolds, 1978; Schildkrout, 1972; Shneidman, 1958; Urban, 1963; Wolk, 1969; Wysocki & Wysocki, 1977; as cited in Ogdon, 2001), emphasized feet (Hammer, 1954; Machover, 1958; Schildkrout, 1972; Shneidman, 1958; Urban, 1963; as cited in Ogdon, 2001), and sharply pointed shoes (Urban, 1963, as cited in Ogdon, 2001). Assaultiveness is indicated by emphasized hair (Handler, 1985; Shneidman, 1958; as cited in Ogdon, 2001), a wide stance, especially as the figure is in middle of the page) (Machover, 1949; Shneidman, 1958; Wysocki & Wysocki, 1977; as cited in Ogdon, 2001), and emphasized feet (Hammer, 1954; Machover, 1958; as cited in Gilbert, 1980). Psychopathology There are multiple indicators to suggest Daniel is normal, stable, reasonably well- adjusted and has adequate contact with reality. These are consistent pencil pressure (Urban, 1963, as cited in Ogdon, 2001), drawing in normal succession (Machover, 1949; as cited in Gilbert, 1980), central placement of the figure (Buck & Warren, 1992; Handler, 1985; Lakin, 1956; Urban, 1963; Wolff, 1946; as cited in Ogdon, 2001), a relaxed standing posture (Urban, 1963, as cited in Ogdon, 2001), and erasing in moderation followed by an improved drawing (Buck & Warren, 1992; Hammer, 1954; Jolles, 1964; Roback, 1968; as cited in Ogdon, 2001). However, there are numerous indicators of psychopathology. Depression is suggested by the narrow neck (Hammer, 1954; Levy, 1958; as cited in Gilbert, 1980). Anxiety is indicated by the unusually heavy pencil pressure (Buck, 1950; Deabler, 1969; Hammer, 1969; Handler, 1996; Handler & Reyher, 1966; Jolles, 1964; Kadis, 1950; Machover, 1955; Reynolds, 1978; Riethmiller & Handler, 1997; Urban, 1963; as cited in Ogdon, 2001), large eyes (Machover, 1958; as cited in Ogdon, 2001), fragmentation inadvertently introduced (by the chequered pattern on the shirt and skull and crossbones detail) (Hammer, 1978; Jacks, 1969; as cited in Ogdon, 2001), and excessive detail (Machover, 1949, as cited in Gilbert, 1980). Neurosis and obsessiveness are suggested by excessive detail (Hammer, 1954, as cited in Gilbert, 1980; Buck, 1966; Buck & Warren, 1992; Deabler, 1969; Hammer, 1969; Handler, 1985; Jacks, 1969; Kahn & Giffen, 1960; Levy, 1958; Machover, 1949; McElhaney, 1969; Reynolds, 1978; as cited in Ogdon, 2001). Obsessive- compulsivity is indicated by the extreme bilateral symmetry (Hammer, 1958; Machover, 1951; Urban, 1963; as cited in Ogdon, 2001), excessive detail (Buck, 1966; Buck & Warren, 1992; Deabler, 1969; Hammer, 1969; Handler, 1985; Jacks, 1969; Kahn & Giffen, 1960; Levy, 1958; Machover, 1949; McElhaney, 1969; Reynolds, 1978; as cited in Ogdon, 2001), overdetailed feet (Buck, 1966; Jolles, 1964; Urban, 1963; as cited in Ogdon, 2001), overdetailed shoes (Buck & Warren, 1992; Levine & Sapolsky, 1969; Machover, 1949; Urban, 1963; as cited in Ogdon, 2001; Hammer, 1954; Levy, 1958; as cited in Gilbert, 1980), and striped clothing (Schildkrout, 1972, as cited in Ogdon, 2001). Daniel?s answer to the question of who ?Michael? doesn?t like may relate to his contamination obsession and resulting hand washing compulsion, he hates Melanie. It?s his, it?s a girl in his class. He hates her because she sucks her finger. And she does, and there?s really a girl in my class that does suck her finger and named Melanie. I don?t like her cos she touches us with that spots. Hysteria is implied by the wide-eyed stare (Schildkrout, 1972, as cited in Ogdon, 2001). Paranoia is indicated by the unusually heavy pencil pressure (Hammer, 1958; Reznikoff & Nicholas, 1958; Roback, 1968; Weiner, 1966; as cited in Ogdon, 2001), large, staring eyes (Deabler, 1969; Griffith & Peyman, 1959; Hammer, 1968; Handler, 1985; Jacks, 1969; Kahn & Giffen, 1960; Levy, 1958; Machover, 1958; McElhaney, 1969; Reznikoff & Nicholas, 1958; Robins et al., 1991; Schildkrout, 1972; Shneidman, 1958; Urban, 1963; as cited in Ogdon, 2001), large, unusual ears (Buck, 1950; Handler, 1985; Jolles, 1964; Machover, 1951; Mitchell, 1993; Mursell, 1969; Urban, 1963; as cited in Ogdon, 2001), very mechanical, formalistic or bizarre extreme bilateral symmetry (Machover, 1949; Urban, 1963; as cited in Ogdon, 2001), and sharp, spiked/spear fingers (Brown, 1958; Buck, 1966; Buck & Warren, 1992; DiLeo, 1970; Goldstein & Rawn, 1957; Hammer, 1965; Handler, 1985; Jacks, 1969; Jolles, 1964; Machover, 1949; McElhaney, 1969; Mitchell, 1993; Modell & Potter, 1949; Reynolds, 1978; Schildkrout, 1972; Shneidman, 1958; Urban, 1963; Wolk, 1969; Wysocki & Wysocki, 1977; as cited in Ogdon, 2001). Schizophrenia/psychosis is suggested by the unusually heavy pencil pressure (Gustafson & Waehler, 1992, as cited in Ogdon, 2001), teeth showing (Machover, 1949; as cited in Gilbert, 1980), large ears (Handler, 1996), and geometric shaped body (Curran & Marengo, 1990; Hammer, 1981; Ries, 1966; as cited in Ogdon, 2001). Schizoid tendencies are indicated by the large ears (Machover, 1949, as cited in Gilbert, 1980), and midline emphasis (Machover, 1949, as cited in Gilbert, 1980). Narcissistic tendencies are suggested by the hair given much attention (Hammer, 1954, as cited in Gilbert, 1980; Handler, 1985; Levy, 1958; Machover, 1949; as cited in Ogdon, 2001), and overdetailed feet (Buck, 1966; Jolles, 1964; Urban, 1963; as cited in Ogdon, 2001). Organicity is indicated by fragmentation inadvertently introduced (Lezak, 1983; McLachlan & Head, 1974; Mitchell, 1993; as cited in Ogdon, 2001), and perseverations (chequered pattern on shirt) (Burgemeister, 1962; Hammer, 1997; Jacks, 1969; as cited in Ogdon, 2001). 4.2.3.2. D-A-P drawing 2 a) Introduction When asked to draw a woman or girl, Daniel said, ?OK, I?ll try draw you, but with plaited hair?. He began drawing and asked, ?Can you turn that thing off?? referring to the tape recorder. He turned the page horizontally and drew a little girl with a wide stance, wide open arms and a very detailed (striped, shaded) skirt. He drew her with high-heeled boots, a toothy grin and four long heavily shaded plaits formed from small circles. He drew the head and hair first, pressing very hard. He drew the neck, sighed and said, ?It?s a most small person?. He drew the rest of the facial features, torso and hands and a heavily shaded skirt with thick vertical lines. He looked up at the researcher before drawing the legs and feet He pointed to the dog lying in the corner of the room, rubbed his eye and asked to go to the bathroom. When he returned he said he didn?t like rubbing his eyes and that he did it because of the dog, as he rubbed his eyes and hair. He filled in the collar of the girl?s T-shirt in his drawing and then began tapping under the table. He drew from left to right in the centre of the page and the pace of his drawing decreased steadily. The drawing took 7 minutes and 48 seconds to complete. b) Emotional indicators Self-concept Self-esteem and body image As in Daniel?s first drawing, overemphasis and strong reinforcement of the facial features suggest feelings of inadequacy and weakness (Machover, 1949, as cited in Ogdon, 2001) and midline emphasis (line down middle of skirt) suggests a poor self- concept with feelings of inferiority, especially physical inferiority (Bodwin & Bruck, 1960; Machover, 1949; Rierdan et al., 1982; Urban, 1963; as cited in Ogdon, 2001). Hypersensitivity to social opinion, particularly criticism, is again suggested by large, emphasized eyes (Handler, 1985; Machover, 1958; as cited in Ogdon, 2001). As in Daniel?s first drawing, there are indicators of a sense of social isolation, uneasiness, or hostility. These are the large hands (Buck, 1966; Buck & Warren, 1992; DiLeo, 1973; Handler, 1985; Jolles, 1964; Levy, 1958; Machover, 1949; Urban, 1963; as cited in Ogdon, 2001), and sharply pointed feet (Hammer, 1954; Jacks, 1969; Mitchell, 1993; Schildkrout, 1972; Urban, 1963; as cited in Ogdon, 2001). as in Daniel?s first drawing, the outstretched arms and hands suggest a desire for interpersonal contact, help, or affection (Handler, 1985; Michal-Smith & Morgenstern, 1969; Schildkrout, 1972; as cited in Ogdon, 2001). Sexuality and gender identity As in Daniel?s first drawing, there are numerous sexually-oriented indicators, implying a conflict or preoccupation with sexuality. These are emphasized hair (Buck, 1950; DiLeo, 1970; Hammer, 1954; Handler, 1985; Jolles, 1964; Levy, 1958; Machover, 1951; Roback, 1968; Urban, 1963; as cited in Ogdon, 2001), elongated anatomical areas/phallic symbols (nose, neck and feet) (Hammer, 1954, as cited in Gilbert, 1980), an unusually high waistline (Handler, 1985; Machover, 1949; as cited in Ogdon, 2001), elongated feet (Buck, 1966; Buck & Warren, 1992; Hammer, 1953; Handler, 1985; Jolles, 1964; Mitchell, 1993; Urban, 1963; Wysocki & Wysocki, 1977; as cited in Ogdon, 2001), and phallic feet (Machover, 1949, as cited in Gilbert, 1980). Infantile, regressed sex drives are suggested by emphasized hair (Buck, 1950; Handler, 1985; Levy, 1958; as cited in Ogdon, 2001; Machover, 1949, as cited in Gilbert, 1980). Once again, Daniel?s drawing contains indicators of a preoccupation or conflict with gender identity or sexual orientation. While masculine assertion or a need for it, is suggested by the strong nose (Machover, 1949, as cited in Gilbert, 1980), homosexual tendencies or effeminacy are indicated by the hair given much attention, especially as vigorously shaded (Hammer, 1954, as cited in Gilbert, 1954; Levy, 1958, as cited in Ogdon, 2001), large eyes (Geil, 1944; Levy, 1958; Machover, 1949; Urban, 1963; as cited in Ogdon, 2001), overdetailed feet (Buck, 1966; Jolles, 1964; Urban, 1963; as cited in Ogdon, 2001), and overdetailed shoes or laces (Buck & Warren, 1992; Levine & Sapolsky, 1969; Machover, 1949; Urban, 1963; as cited in Ogdon, 2001). Daniel stated that the figure is ?doing ballet? and the best thing about her is that ?she?s the ballet dancer of the world?. When asked whether he would like to be the girl in the drawing, he became anxious and replied, ?No?because she?s a girl and I don?t like being a girl?. His answer to the question of who ?Tammy? doesn?t like was ?Johnny Depp. Because she doesn?t like boys?. From these narratives, it is considered possible that Daniel is ambivalent about his gender identity or sexual orientation, struggling against his feminine side and trying to assert his masculinity. Personality Introversion/extroversion As in his first drawing, there is an indicator suggesting personality imbalance or disorganisation, viz. odd details (high heels on young girl) (DiLeo, 1973, as cited in Ogdon, 2001). As in his first drawing, extroversive, socially outgoing tendencies are suggested by the large eyes (Handler, 1985; Machover, 1949; as cited in Ogdon, 2001), and the figure is centred, implying tendencies toward self-directed behaviour and egocentricity (Alschuler & Hattwick, 1947; Levy, 1950; as cited in Ogdon, 2001; Hammer, 1954, as cited in Gilbert, 1980). Defenses As in his previous drawing, turning the paper to another orientation than the one presented to him, suggests resistance (Hammer, 1997; Jolles, 1964; Mitchell, 1993; as cited in Ogdon, 2001). Although the name Daniel gave the figure was ?Tammy? (the researcher), the figure is that of a young girl and his answers to questions do not appear to relate to the researcher. When asked whether the figure reminds him of anyone, Daniel replied, ?Yes. She reminds me of Melanie?. It is thus considered that the figure is that of Melanie (a girl in his class). Daniel?s assertion that he drew the researcher may be an effort to please her or suggest defensiveness or resistance. Although fewer than in his first drawing, there are indicators that Daniel uses compensatory defenses such as reaction formations to defend against feelings of insecurity. These are a placating facial expression (Hammer, 1954; Machover, 1949; as cited in Gilbert, 1980), a wide stance (Buck, 1950; Buck & Warren, 1992; Hammer, 1969; Jolles, 1964; Machover, 1949; Urban, 1963; as cited in Ogdon, 2001), and midline emphasis (Bodwin & Bruck, 1960; Machover, 1949; Rierdan et al., 1982; Urban, 1963; as cited in Ogdon, 2001). As in his first drawing, overemphasis and strong reinforcement of the facial features suggests the use of fantasy to compensate for feelings of inadequacy and weakness (Machover, 1949, as cited in Gilbert, 1980). The enlarged head similarly indicates the use of fantasy as a defense (Hammer, 1965; Levy, 1950; as cited in Gilbert, 1980). Autonomy/dependency As in the previous drawing the straight, uninterrupted strokes suggest a quick, decisive, assertive personality (Allen, 1958; Alschuler & Hattwick, 1947; Hammer, 1958; Krout, 1950; Levy, 1958; as cited in Ogdon, 2001) and the unusually heavy pencil pressure expresses an assertive, persistent, forceful, ambitious personality (Alschuler & Hattwick, 1947; Hammer, 1968; Kadis, 1950; Levy, 1958; Machover, 1949; Urban, 1963; as cited in Ogdon, 2001), as do the determined, unhesitating pencil strokes (Hammer, 1954, as cited in Gilbert, 1980; Levy, 1958, as cited in Ogdon, 2001). Again, over-emphasis and strong reinforcement of the facial features suggest compensation for feelings of inadequacy and weakness by aggressive and socially dominant behaviour (Machover, 1949, as cited in Ogdon, 2001). Again, there is a suggestion of dependency and helplessness, in the form of midline emphasis (Machover, 1949, as cited in Gilbert, 1980). Impulse control As in Daniel?s previous drawing, this drawing strongly suggests considerably high levels of anger and difficulty with impulse control. As in his first drawing, there is only one indicator of controlled behaviour or emotions, viz. long pencil strokes (Alschuler & Hattwick, 1947; Hammer, 1958; as cited in Ogdon, 2001), and again there are indicators of inhibition, which are long pencil strokes (Alschuler & Hattwick, 1947; Hammer, 1958; Kadis, 1950; Mira, 1943; Urban, 1963; as cited in Ogdon, 2001; Handler, 1996), and swollen hands (Machover, 1955, as cited in Ogdon, 2001). As in his first drawing, the tight collar suggests difficulty controlling anger or primitive drives (Hammer, 1958; Levy, 1958; as cited in Gilbert, 1980), as does the striped clothing (Schildkrout, 1972, as cited in Ogdon, 2001). Once again, the heavy pencil pressure suggests high energy levels and excitement (Hetherington, 1952; Kadis, 1950; Levy, 1958; Mitchell, 1993; Precker, 1950; Riethmiller & Handler, 1997; Urban, 1963; as cited in Ogdon, 2001). Again, impulsivity is indicated by the large hands (Buck, 1950, 1966; Buck & Warren, 1992; Jolles, 1952; as cited in Ogdon, 2001), and central placement of the figure suggests emotional behaviour (Alschuler & Hattwick, 1947; Levy, 1950; as cited in Ogdon, 2001). There is only one indicator of repressed aggression, viz. the small trunk (Buck, 1950; Buck & Warren, 1992; Handler, 1985; Jolles, 1964; Urban, 1963; as cited in Ogdon, 2001). As in his previous drawing, overt anger and aggressive tendencies are suggested by a very high number of indicators. Some of these indicators are turning paper to another orientation than the one presented (Hammer, 1997; Jolles, 1964; Mitchell, 1993; as cited in Ogdon, 2001), unusually heavy pencil pressure (Halpern, 1951; Hammer, 1997; Handler & McIntosh, 1971; Jolles, 1964; McElhaney, 1969; Reynolds, 1978; Riethmiller & Handler, 1997; Schneidman, 1958; Urban, 1963; Wysocki & Whitney, 1965; as cited in Ogdon, 2001), straight lines (Hammer, 1958; Krout, 1950; as cited in Gilbert, 1980), drawing in middle of page (Machover, 1949, as cited in Gilbert, 1980), emphasized hair (Handler, 1985; Shneidman, 1958; as cited in Ogdon, 2001), and large, piercing eyes (Deabler, 1969; Griffith & Peyman, 1959; Hammer, 1968; Handler, 1985; Jacks, 1969; Kahn & Giffen, 1960; Levy, 1958; Machover, 1958; McElhaney, 1969; Reznikoff & Nicholas, 1958; Robins et al., 1991; Schildkrout, 1972; Shneidman, 1958; Urban, 1963; as cited in Ogdon, 2001). Other indicators of overt anger and aggressive tendencies are teeth showing (Buck, 1966; Buck & Warren, 1992; Goldstein & Rawn, 1957; Halpern, 1965; Hammer, 1965; Handler, 1996; Jolles, 1964; Koppitz, 1968; Levy, 1958; Machover, 1960; McElhaney, 1969, Mitchell, 1993; Rierdan et al., 1982; Schildkrout, 1972; Urban, 1963; as cited in Ogdon, 2001), nostrils (Machover, 1949, as cited in Gilbert, 1980), a wide stance (especially as figure is in middle of page) (Machover, 1949; Shneidman, 1958; Wysocki & Wysocki, 1977; as cited in Ogdon, 2001), an angular body (Machover, 1949, as cited in Gilbert, 1980), asymmetrical arms (Hammer, 1969; Koppitz, 1968; Machover, 1949; Mundy, 1972; Urban, 1963; as cited in Ogdon, 2001), large hands (Handler, 1985; Shneidman, 1958; as cited in Ogdon, 2001), sharp, spiked/spear fingers (Brown, 1958; Buck, 1966; Buck & Warren, 1992; DiLeo, 1970; Goldstein & Rawn, 1957; Hammer, 1965; Handler, 1985; Jacks, 1969; Jolles, 1964; Machover, 1949; McElhaney, 1969; Mitchell, 1993; Modell & Potter, 1949; Reynolds, 1978; Schildkrout, 1972; Shneidman, 1958; Urban, 1963; Wolk, 1969; Wysocki & Wysocki, 1977; as cited in Ogdon, 2001), emphasized feet (Hammer, 1954; Machover, 1958; Schildkrout, 1972; Shneidman, 1958; Urban, 1963; as cited in Ogdon, 2001), and sharply pointed shoes (Urban, 1963, as cited in Ogdon, 2001). Assaultiveness is indicated by the emphasized hair (Handler, 1985; Shneidman, 1958; as cited in Ogdon, 2001), wide stance (especially as figure is in middle of page) (Machover, 1949; Shneidman, 1958; Wysocki & Wysocki, 1977; as cited in Ogdon, 2001), and emphasized feet (Hammer, 1954; Machover, 1958; as cited in Gilbert, 1980). Psychopathology As in his previous drawing, there are multiple indicators suggesting Daniel is normal, stable, reasonably well-adjusted, and has adequate contact with reality. These are consistent pencil pressure (Urban, 1963, as cited in Ogdon, 2001), drawing in normal succession (Machover, 1949, as cited in Gilbert, 1980), central placement of figure (Buck & Warren, 1992; Handler, 1985; Lakin, 1956; Urban, 1963; Wolff, 1946; as cited in Ogdon, 2001), and a relaxed standing posture (Urban, 1963, as cited in Ogdon, 2001). However there are also numerous indicators of psychopathology. There are no indicators of schizoid tendencies, as there were in the previous drawing. Otherwise, the quantity of indicators for each category of psychopathology, are similar to those present in Daniel?s first drawing. Depression is suggested by the narrow neck (Hammer, 1954; Levy, 1958; as cited in Gilbert, 1980). Anxiety is indicated by unusually heavy pencil pressure (Buck, 1950; Deabler, 1969; Hammer, 1969; Handler, 1996; Handler & Reyher, 1966; Jolles, 1964; Kadis, 1950; Machover, 1955; Reynolds, 1978; Riethmiller & Handler, 1997; Urban, 1963; as cited in Ogdon, 2001), large eyes, especially as they are shaded (Machover, 1958; as cited in Ogdon, 2001), fragmentation inadvertently introduced (by lines on skirt) (Hammer, 1978; Jacks, 1969; as cited in Ogdon, 2001), and excessive detail (Machover, 1949, as cited in Gilbert, 1980). Neurosis and obsessiveness are suggested by excessive detail (Buck, 1966; Buck & Warren, 1992; Deabler, 1969; Hammer, 1969; Handler, 1985; Jacks, 1969; Kahn & Giffen, 1960; Levy, 1958; Machover, 1949; McElhaney, 1969; Reynolds, 1978; as cited in Ogdon, 2001). Obsessive-compulsivity is indicated by excessive detail (Buck, 1966; Buck & Warren, 1992; Deabler, 1969; Hammer, 1969; Handler, 1985; Jacks, 1969; Kahn & Giffen, 1960; Levy, 1958; Machover, 1949; McElhaney, 1969; Reynolds, 1978; as cited in Ogdon, 2001), overdetailed feet (Buck, 1966; Jolles, 1964; Urban, 1963; as cited in Ogdon, 2001), overdetailed shoes (Buck & Warren, 1992; Levine & Sapolsky, 1969; Machover, 1949; Urban, 1963; as cited in Ogdon, 2001; Hammer, 1954; Levy, 1958; as cited in Gilbert, 1980), and striped clothing (Schildkrout, 1972, as cited in Ogdon, 2001). Daniel?s answer to the question of whether he would like to be ?Tammy? ended with the phrase ??And?another thing is that she doesn?t wash her hair?. This statement may relate to his obsession with contamination and related compulsion to hand wash. Hysteria is indicated by the wide-eyed stare (Schildkrout, 1972, as cited in Ogdon, 2001). Paranoia is suggested by the unusually heavy pencil pressure (Hammer, 1958; Reznikoff & Nicholas, 1958; Roback, 1968; Weiner, 1966; as cited in Ogdon, 2001), large, staring eyes (Deabler, 1969; Griffith & Peyman, 1959; Hammer, 1968; Handler, 1985; Jacks, 1969; Kahn & Giffen, 1960; Levy, 1958; Machover, 1958; McElhaney, 1969; Reznikoff & Nicholas, 1958; Robins et al., 1991; Schildkrout, 1972; Shneidman, 1958; Urban, 1963; as cited in Ogdon, 2001), and sharp, spiked/spear fingers (Brown, 1958; Buck, 1966; Buck & Warren, 1992; DiLeo, 1970; Goldstein & Rawn, 1957; Hammer, 1965; Handler, 1985; Jacks, 1969; Jolles, 1964; Machover, 1949; McElhaney, 1969; Mitchell, 1993; Modell & Potter, 1949; Reynolds, 1978; Schildkrout, 1972; Shneidman, 1958; Urban, 1963; Wolk, 1969; Wysocki & Wysocki, 1977; as cited in Ogdon, 2001). Schizophrenia/psychosis is suggested by the unusually heavy pencil pressure (Gustafson & Waehler, 1992, as cited in Ogdon, 2001), teeth showing (Machover, 1949, as cited in Gilbert, 1980), and geometric shaped body (Curran & Marengo, 1990; Hammer, 1981; Ries, 1966; as cited in Ogdon, 2001). Narcissistic tendencies are suggested by the hair given much attention (Hammer, 1954, as cited in Gilbert, 1980; Handler, 1985; Levy, 1958; Machover, 1949; as cited in Ogdon, 2001), and overdetailed feet (Buck, 1966; Jolles, 1964; Urban, 1963; as cited in Ogdon, 2001). Organicity is indicated by the asymmetrical arms (Hammer, 1969; Koppitz, 1968; Machover, 1949; Mundy, 1972; Urban, 1963; as cited in Ogdon, 2001), and fragmentation inadvertently introduced (Lezak, 1983; McLachlan & Head, 1974; Mitchell, 1993; as cited in Ogdon, 2001). 4.2.3.3. D-A-P drawing 3 a) Introduction When asked to draw another picture, Daniel asked, ?Please of a animal?. The researcher agreed to let him draw a picture of an animal once all the activities were completed, to which he agreed. When asked to draw a picture of himself, he laughed and replied, ?Okay! That will be easy?. He hummed happily as he drew. After a few minutes, he asked, ?Can you turn that thing off?? referring to the tape recorder. Daniel turned the page horizontally and drew a boy with a wide stance and wide open arms, wearing a shirt with wide, jagged lapels and bearing a crest. The right arm and hand is large, swollen and in sharp contrast with the left arm and hand, which appear more normal. The figure wears shorts with pockets and detailed, completely shaded shoes. The hair is completely shaded and the face has a large nose, staring eyes, large ears and a wide, toothy grin. Daniel drew the head and hair first, shading the hair completely while pressing very hard. He drew the eyes and nose then erased the nose and re-drew it, thereby erasing part of the right eye. He drew the mouth and ears, torso, shorts, legs, feet and arms. The drawing took 4 minutes and 52 seconds to complete. b) Emotional indicators Self-concept Self-esteem and body image As in his first two drawings, midline emphasis (pockets and V-neck detail) suggests a poor self-concept with feelings of inferiority, especially physical inferiority (Bodwin & Bruck, 1960; Machover, 1949; Rierdan et al., 1982; Urban, 1963; as cited in Ogdon, 2001). When asked what the best thing about him is, Daniel replied, ?That I?m the best junior primary hockey player?. This narrative may represent a striving for physical strength. As in his first two drawings, there are indicators that Daniel is hypersensitive to social opinion, particularly criticism. These are the large, emphasized eyes (Handler, 1985; Machover, 1958; as cited in Ogdon, 2001), and large, unusual ears viewed through transparent hair (Buck, 1950; Handler, 1985; Jolles, 1964; Machover, 1951; Mitchell, 1993; Mursell, 1969; Urban, 1963; as cited in Ogdon, 2001). As in Daniel?s first two drawings, there are indicators of social isolation, uneasiness, or hostility. These are jagged lines (Hammer, 1965; Krout, 1950; Machover, 1951; Urban, 1963; Waehner, 1946; as cited in Ogdon, 2001), large hands (Buck, 1966; Buck & Warren, 1992; DiLeo, 1973; Handler, 1985; Jolles, 1964; Levy, 1958; Machover, 1949; Urban, 1963; as cited in Ogdon, 2001), and sharply pointed feet (Hammer, 1954; Jacks, 1969; Mitchell, 1993; Schildkrout, 1972; Urban, 1963; as cited in Ogdon, 2001). The outstretched arms and hands suggest a desire for interpersonal contact, help or affection (Handler, 1985; Michal-Smith & Morgenstern, 1969; Schildkrout, 1972; as cited in Ogdon, 2001), as in his first two drawings. The need for a protective mother figure is suggested by the long but not particularly muscular arms and hands (Levy, 1958; Machover, 1949; as cited in Ogdon, 2001). Sexuality and gender identity As in Daniel?s previous drawings, there are numerous sexually-oriented indicators, suggesting a conflict or preoccupation with sexuality. These are emphasized hair (Buck, 1950; DiLeo, 1970; Hammer, 1954; Handler, 1985; Jolles, 1964; Levy, 1958; Machover, 1951; Roback, 1968; Urban, 1963; as cited in Ogdon, 2001), elongated anatomical areas/phallic symbols (nose, fingers on right hand, crest on shirt, feet) (Hammer, 1954, as cited in Gilbert, 1980), elongated feet (Buck, 1966; Buck & Warren, 1992; Hammer, 1953; Handler, 1985; Jolles, 1964; Mitchell, 1993; Urban, 1963; Wysocki & Wysocki, 1977; as cited in Ogdon, 2001), and phallic feet (Machover, 1949, as cited in Gilbert, 1980). Infantile, regressed sex drives are suggested by the emphasized hair (Buck, 1950; Handler, 1985; Levy, 1958; as cited in Ogdon, 2001; Machover, 1949, as cited in Gilbert, 1980). Once again, there are indicators of a preoccupation or conflict with gender identity or sexual orientation. While masculine assertion or a need for it, is indicated by the strong nose (Machover, 1949, as cited in Gilbert, 1980), homosexual tendencies/effeminacy are suggested by hair given much attention, especially as vigorously shaded (Hammer, 1954, as cited in Gilbert, 1980; Levy, 1958, as cited in Ogdon, 2001), large eyes (Geil, 1944; Levy, 1958; Machover, 1949; Urban, 1963; as cited in Ogdon, 2001), large, unusual ears viewed through transparent hair (Buck, 1950; Handler, 1985; Jolles, 1964; Machover, 1951; Mitchell, 1993; Mursell, 1969; Urban, 1963; as cited in Ogdon, 2001), emphasized hip (pockets) (DiLeo, 1973; Geil, 1944; Hammer, 1981; Levy, 1950; Machover, 1951; Urban, 1963; as cited in Ogdon, 2001), overdetailed feet (Buck, 1966; Jolles, 1964; Urban, 1963; as cited in Ogdon, 2001), and overdetailed shoes or laces (Buck & Warren, 1992; Levine & Sapolsky, 1969; Machover, 1949; Urban, 1963; as cited in Ogdon, 2001). Daniel said that the worst thing about him is ?that I hate ballet?, followed by ?no no, not that?that I nag a lot?. From these narratives, it is possible that he is trying to assert his masculinity. Personality Introversion/extroversion As in his previous drawings, there is a suggestion that Daniel?s personality is imbalanced or disorganised, in the form of random, scribbled shading (hair and shoes), indicating a neurotic and even hysterical personality (Kahn & Giffen, 1960; Schildkrout, 1972; as cited in Ogdon, 2001). As in Daniel?s previous drawings, extroversive, socially outgoing tendencies are suggested by the large eyes (Handler, 1985; Machover, 1949; as cited in Ogdon, 2001), and the centred figure indicates tendencies toward self-directed behaviour and egocentricity (Alschuler & Hattwick, 1947; Levy, 1950; as cited in Ogdon, 2001). Defenses Once again, turning the paper to another orientation than the one presented to him, suggests resistance (Hammer, 1997; Jolles, 1964; Mitchell, 1993; as cited in Ogdon, 2001). Either resistance or defensiveness is also suggested by some answers Daniel gave to questions about his drawing. He stated that what he most likes doing is ?sums?. This is significant in the light of his answer to the question of what the first D- A-P figure least likes doing (?sums?). He said that the only thing he likes doing is ?my homework?. He expressed with a sigh that if he were invisible, he would like to ?run around invisible, play with my toys?. This is significant in the light of his answer to the same question to his first D-A-P drawing (?he would like?to run through walls and scare people?). It is considered that, because this drawing is a self-portrait and the questions are about him (thus not allowing for projections onto another figure), Daniel may have experienced more resistance. As in Daniel?s previous drawings, this drawing contains indicators of possible compensatory defenses such as reaction formations to defend against feelings of insecurity. These are a placating facial expression (Hammer, 1954; Machover, 1949, as cited in Gilbert, 1980), a wide stance (Buck, 1950; Buck & Warren, 1992; Hammer, 1969; Jolles, 1964; Machover, 1949; Urban, 1963; as cited in Ogdon, 2001), and midline emphasis (Bodwin & Bruck, 1960; Machover, 1949; Rierdan et al., 1982; Urban, 1963; as cited in Ogdon, 2001). Daniel?s reply to the question of who he doesn?t like was ??Bill Gates, I hate him?just because I don?t like him?. Although a reason for his dislike of Bill Gates was not given, it is considered that it may be a reaction -formation because Bill Gates is a powerful man, while Daniel feels small and inadequate. Again, the figure?s enlarged head indicates the use of fantasy as a defense (Hammer, 1965; Levy, 1950; as cited in Gilbert, 1980), and overemphasis and strong reinforcement of facial features (Machover, 1949, as cited in Ogdon, 2001) suggests fantasy as a defense to compensate for feelings of inadequacy and weakness (Machover, 1949, as cited in Gilbert, 1980). Autonomy/dependency As in his Daniel?s previous drawings the straight, uninterrupted strokes suggest a quick, decisive, assertive personality (Allen, 1958; Alschuler & Hattwick, 1947; Hammer, 1958; Krout, 1950; Levy, 1958; as cited in Ogdon, 2001). Again, unusually heavy pencil pressure suggests an assertive, persistent, forceful, ambitious personality (Alschuler & Hattwick, 1947; Hammer, 1968; Kadis, 1950; Levy, 1958; Machover, 1949; Urban, 1963; as cited in Ogdon, 2001), as do firm, determined, unhesitating, pencil strokes (Hammer, 1954, as cited in Gilbert, 1980; Levy, 1958, as cited in Ogdon, 2001). Again, overemphasis and strong reinforcement of the facial features implies compensation for feelings of inadequacy and weakness by aggressive and socially dominant behaviour (Machover, 1949, as cited in Ogdon, 2001). As in his previous drawings, dependency and helplessness are implied by the midline emphasis (Machover, 1949, as cited in Gilbert, 1980). The gross distortions/disproportions in the drawing suggest poor school achievement (Koppitz, 1966; Mitchell, 1993; Vane & Eisen, 1962; as cited in Ogdon, 2001). Impulse control As is the case in his previous drawings, this drawing reveals considerably high levels of anger and difficulty with impulse control. Again, there is only one indicator of behavioural or emotional control, viz. the long pencil strokes (Alschuler & Hattwick, 1947; Hammer, 1958; as cited in Ogdon, 2001) and there are indications of inhibited tendencies, which are long pencil strokes (Goodman & Kotkov; 1953; Handler, 1985; Machover, 1951; as cited in Ogdon, 2001), and swollen hands (Machover, 1955, as cited in Ogdon, 2001). However as in Daniel?s previous drawings, the heavy pencil pressure suggests high energy levels and excitement (Hetherington, 1952; Kadis, 1950; Levy, 1958; Mitchell, 1993; Precker, 1950; Riethmiller & Handler, 1997; Urban, 1963; as cited in Ogdon, 2001; Handler, 1996). Impulsivity is again indicated by the large hands (Buck, 1966; Buck & Warren, 1992; Jolles, 1952; as cited in Ogdon, 2001) and by the jagged lines (hair, lapels, V-neck, lines of clothing, hands, lines on shoes) (Hammer, 1965; Krout, 1950; Machover, 1951; Urban, 1963; Waehner, 1946; as cited in Ogdon, 2001). The tight collar suggests difficulty controlling anger or primitive drives (Hammer, 1958; Levy, 1958; as cited in Gilbert, 1980), as does the striped clothing (shoes, pockets) (Schildkrout, 1972, as cited in Ogdon, 2001). As in the previous drawing there is only one indicator of repressed aggression, viz. the small trunk (Buck, 1950; Buck & Warren, 1992; Handler, 1985; Jolles, 1964; Urban, 1963; as cited in Ogdon, 2001). There are again a very high number of indicators of overt anger and aggressive tendencies. Some of these indicators are turning the paper to another orientation than the one presented (Hammer, 1997; Jolles, 1964; Mitchell, 1993; as cited in Ogdon, 2001), unusually heavy pencil pressure (Halpern, 1951; Hammer, 1997; Handler & McIntosh, 1971; Jolles, 1964; McElhaney, 1969; Reynolds, 1978; Riethmiller & Handler, 1997; Schneidman, 1958; Urban, 1963; Wysocki & Whitney, 1965; as cited in Ogdon, 2001), straight lines (Hammer, 1958; Krout, 1950; as cited in Gilbert, 1980), jagged lines (Hammer, 1965; Krout, 1950; Machover, 1951; Urban, 1963; Waehner, 1946; as cited in Ogdon, 2001), drawing in the middle of the page (Machover, 1949, as cited in Gilbert, 1980), emphasized hair (Handler, 1985; Shneidman, 1958; as cited in Ogdon, 2001), and large, piercing emphasized eyes (Deabler, 1969; Griffith & Peyman, 1959; Hammer, 1968; Handler, 1985; Jacks, 1969; Kahn & Giffen, 1960; Levy, 1958; Machover, 1958; McElhaney, 1969; Reznikoff & Nicholas, 1958; Robins et al., 1991; Schildkrout, 1972; Shneidman, 1958; Urban, 1963; as cited in Ogdon, 2001). Other indicators of overt anger and aggressive tendencies are teeth showing (Buck, 1966; Buck & Warren, 1992; Goldstein & Rawn, 1957; Halpern, 1965; Hammer, 1965; Handler, 1996; Jolles, 1964; Koppitz, 1968; Levy, 1958; Machover, 1960; McElhaney, 1969, Mitchell, 1993; Rierdan et al., 1982; Schildkrout, 1972; Urban, 1963; as cited in Ogdon, 2001), nostrils (Machover, 1949, as cited in Gilbert, 1980), a wide stance (especially as figure is in middle of page) (Machover, 1949; Shneidman, 1958; Wysocki & Wysocki, 1977; as cited in Ogdon, 2001), asymmetrical limbs (Hammer, 1969; Koppitz, 1968; Machover, 1949; Mundy, 1972; Urban, 1963; as cited in Ogdon, 2001), an angular body (Machover, 1949, as cited in Gilbert, 1980), large hands (Handler, 1985; Shneidman, 1958; as cited in Ogdon, 2001), powerful hands (Hammer, 1958, as cited in Gilbert, 1980), sharp, spiked/spear fingers (Brown, 1958; Buck, 1966; Buck & Warren, 1992; DiLeo, 1970; Goldstein & Rawn, 1957; Hammer, 1965; Handler, 1985; Jacks, 1969; Jolles, 1964; Machover, 1949; McElhaney, 1969; Mitchell, 1993; Modell & Potter, 1949; Reynolds, 1978; Schildkrout, 1972; Shneidman, 1958; Urban, 1963; Wolk, 1969; Wysocki & Wysocki, 1977; as cited in Ogdon, 2001), emphasized feet (Hammer, 1954; Machover, 1958; Schildkrout, 1972; Shneidman, 1958; Urban, 1963; as cited in Ogdon, 2001), and sharply pointed shoes (Urban, 1963, as cited in Ogdon, 2001). Assaultiveness is indicated by the emphasized hair (Handler, 1985; Shneidman, 1958; as cited in Ogdon, 2001), wide stance (especially as the figure is in the middle of the page) (Machover, 1949; Shneidman, 1958; Wysocki & Wysocki, 1977; as cited in Ogdon, 2001), and emphasized feet (Hammer, 1954; Machover, 1958; as cited in Gilbert, 1980). Psychopathology As in his previous drawings, there are multiple indicators that Daniel is normal, stable, reasonably well-adjusted and has adequate contact with reality. These are drawing in normal succession (Machover, 1949, as cited in Gilbert, 1980), consistent pencil pressure (Urban, 1963, as cited in Ogdon, 2001), a relaxed standing posture (Urban, 1963, as cited in Ogdon, 2001), and erasing in moderation followed by an improved drawing (Buck & Warren, 1992; Hammer, 1954; Jolles, 1964; Roback, 1968; as cited in Ogdon, 2001). However there are also numerous indicators of psychopathology. Unlike in Daniel?s previous two drawings, there are no indicators of depression. However there are indicators of schizoid tendencies, as in the first drawing. There are more indicators of anxiety, aggressive tendencies and many more indicators of schizophrenia, than in the previous drawings. Otherwise, the quantity of indicators for each category of psychopathology are similar to those present in his previous drawings. Anxiety is suggested by the unusually heavy pencil pressure (Deabler, 1969; Buck, 1950; Hammer, 1969; Jolles, 1964; Handler, 1996; Handler & Reyher, 1966; Kadis, 1950; Machover, 1955; Reynolds, 1978; Riethmiller & Handler, 1997; Urban, 1963; as cited in Ogdon, 2001), jagged lines (Hammer, 1965; Krout, 1950; Machover, 1951; Urban, 1963; Waehner, 1946; as cited in Ogdon, 2001), emphasized eyes, especially as shaded (Machover, 1958; as cited in Ogdon, 2001), large eyes (Deabler, 1969; Griffith & Peyman, 1959; Hammer, 1968; Handler, 1985; Jacks, 1969; Kahn & Giffen, 1960; Levy, 1958; Machover, 1958; McElhaney, 1969; Reznikoff & Nicholas, 1958; Robins et al., 1991; Schildkrout, 1972; Shneidman, 1958; Urban, 1963; as cited in Ogdon, 2001), fragmentation inadvertently introduced (by erasing nose and part of right eye and by clothing that has effect of fragmenting body from arms and legs) (Hammer, 1978; Jacks, 1969; as cited in Ogdon, 2001), and excessive detail (Machover, 1949, as cited in Gilbert, 1980). Neurosis is suggested by random scribbled shading (Kahn & Giffen, 1960; Schildkrout, 1972; as cited in Ogdon, 2001), placement of the drawing low on the page (DiLeo, 1973, as cited in Ogdon, 2001), and excessive detail (Buck, 1966; Buck & Warren, 1992; Deabler, 1969; Hammer, 1969; Handler, 1985; Jacks, 1969; Kahn & Giffen, 1960; Levy, 1958; Machover, 1949; McElhaney, 1969; Reynolds, 1978; as cited in Ogdon, 2001). Obsessiveness is revealed by excessive detail (Machover, 1949; as cited in Gilbert, 1980). Obsessive-compulsivity is indicated by excessive detail (Buck, 1966; Buck & Warren, 1992; Deabler, 1969; Hammer, 1969; Handler, 1985; Jacks, 1969; Kahn & Giffen, 1960; Levy, 1958; Machover, 1949; McElhaney, 1969; Reynolds, 1978; as cited in Ogdon, 2001), overdetailed feet (Buck, 1966; Jolles, 1964; Urban, 1963; as cited in Ogdon, 2001), overdetailed shoes (Buck & Warren, 1992; Levine & Sapolsky, 1969; Machover, 1949; Urban, 1963; as cited in Ogdon, 2001; Hammer, 1954; Levy, 1958, as cited in Gilbert, 1980), and striped clothing (shoes, pockets) (Schildkrout, 1972, as cited in Ogdon, 2001). Daniel?s mother mentioned that he has always loved having pets, preferably unusual ones. Daniel showed the researcher his silkworms in a box and talked about other animals he likes (snakes), previously had as pets (a mongoose), and currently has as a pet (a tortoise). His answer to the question of what makes him sad was ?when one of my pets die?. This was the same answer that he gave to this question about his first D-A-P drawing. Daniel is close to his pets and seems to connect well with animals. It is possible that he finds them easier to connect with than people and that they provide an important source of comfort and stimulation for him. He seems to be very aware of loss by death (his mother stated that one of his first obsessions centred around fears of her dying and Daniel expressed that what makes him sad is when a pets dies). Hysteria is suggested by random scribbled shading (Kahn & Giffen, 1960; Schildkrout, 1972; as cited in Ogdon, 2001), and a wide-eyed stare (Schildkrout, 1972, as cited in Ogdon, 2001). Paranoia is indicated by the unusually heavy pencil pressure (Hammer, 1958; Reznikoff & Nicholas, 1958; Roback, 1968; Weiner, 1966; as cited in Ogdon, 2001), large, staring eyes (Deabler, 1969; Griffith & Peyman, 1959; Hammer, 1968; Handler, 1985; Jacks, 1969; Kahn & Giffen, 1960; Levy, 1958; Machover, 1958; McElhaney, 1969; Reznikoff & Nicholas, 1958; Robins et al., 1991; Schildkrout, 1972; Shneidman, 1958; Urban, 1963; as cited in Ogdon, 2001), large, unusual ears (Buck, 1950; Handler, 1985; Jolles, 1964; Machover, 1951; Mitchell, 1993; Mursell, 1969; Urban, 1963; as cited in Ogdon, 2001), and sharp, spiked/spear fingers (Brown, 1958; Buck, 1966; Buck & Warren, 1992; DiLeo, 1970; Goldstein & Rawn, 1957; Hammer, 1965; Handler, 1985; Jacks, 1969; Jolles, 1964; Machover, 1949; McElhaney, 1969; Mitchell, 1993; Modell & Potter, 1949; Reynolds, 1978; Schildkrout, 1972; Shneidman, 1958; Urban, 1963; Wolk, 1969; Wysocki & Wysocki, 1977; as cited in Ogdon, 2001). Paranoia may also be indicated by Daniel?s frequent requests for the tape recorder to be turned off. Schizophrenia/psychosis is suggested by the unusually heavy pencil pressure (Gustafson & Waehler, 1992, as cited in Ogdon, 2001), teeth showing (Machover, 1949, as cited in Gilbert, 1980), large ears (Handler, 1996), geometric shaped body (Curran & Marengo, 1990; Hammer, 1981; Ries, 1966; as cited in Ogdon, 2001), and wing-like arms (Buck, 1966; Buck & Warren, 1992; Hammer, 1958; Jolles, 1964; Machover, 1958; Urban, 1963; as cited in Ogdon, 2001). Schizoid tendencies are indicated by the large ears (Machover, 1949, as cited in Gilbert, 1980), and midline emphasis (Machover, 1949, as cited in Gilbert, 1980). Narcissistic tendencies are suggested by the hair given much attention (Hammer, 1954, as cited in Gilbert; Handler, 1985; Levy, 1958; Machover, 1949; as cited in Ogdon, 2001), and overdetailed feet (Buck, 1966; Jolles, 1964; Urban, 1963; as cited in Ogdon, 2001). Organicity is suggested by the asymmetrical limbs (Hammer, 1969; Koppitz, 1968; Machover, 1949; Mundy, 1972; Urban, 1963; as cited in Ogdon, 2001), and fragmentation inadvertently introduced (Lezak, 1983; McLachlan & Head, 1974; Mitchell, 1993; as cited in Ogdon, 2001). 4.2.3.4. K-F-D a) Introduction Daniel drew a vertical line down the left-hand side of the page, and then erased it with a sigh. He asked for a ruler to which the researcher replied that she didn?t have one. He drew three vertical lines down the page and a horizontal line near the top of the page, thereby creating four separate quadrants. He drew a boyish figure with a cheeky face and striped jersey, in the far left quadrant (his father). He drew a carton in the left hand and asked, ?how do you spell peanuts??, then wrote the word on the carton. He drew a cold drink bottle in the right hand and wrote the word ?Coke? on it. He commented that he had forgotten to draw feet and added them, then drew horizontal lines on the jersey and down the arms, added detail to the shoes. He drew a girlish figure in the second quadrant from the left (his mother), starting with her head, face and hair. He drew her torso, skirt, arms, hands, legs and feet He drew a garden hose in her right hand, which weaved between her legs. Then he drew the third of a young, carelessly drawn girl in the third quadrant from the left (his sister). He began with her head, hair, and facial features, followed by her neck and torso. He put his hands behind his head and asked, ?Can?t I just leave out me, cos I?ve already drawn myself?unless I only cut out and stick it?? The researcher responded that it would be nice if he could draw himself in the picture, to which he replied, ?Okay, I?ll quickly draw me.? He drew a head, hair and facial features, in the far right quadrant. He drew a neck and shirt with a row of buttons down it, connecting the buttons by vertical lines. He explained, ?This is me after buttons and you?ll see what I?m doing?. He put his hands behind his head and added teeth to the drawing of his sister. He added trousers, hands, and shoes to the figure of himself. In his left hand he drew a doll. He drew groundlines beneath the figures of his father, mother, and himself. He drew his sister?s legs, feet, and hands. He sighed and asked what his sister should be holding, to which the researcher replied that she could hold whatever Daniel likes. He kept looking at the researcher with his hands behind his head, contemplating for almost a minute, then said, ?Let?s see, what should my sister?s doing?. He drew a flower in her right hand and said, ?picking flowers?. He wrote each person?s name on the vertical line above them. He drew from left to right and the pace of his drawing increased steadily. The drawing took 8 minutes and 25 seconds to complete. b) Emotional indicators Self-concept Self-esteem and body image Daniel drew himself last, suggesting low self-esteem and a perception that he is the least important person within his family (Reynolds, 1978). He also drew himself as the smallest figure, further indicating low self-esteem and feelings of inadequacy within his family (Alschuler & Hattwick, 1949; Buck, 1950; Buck & Warren, 1992; Delatte & Hendrikson, 1982; DiLeo, 1973; Gray & Pepitone, 1964; Hammer, 1997; Handler, 1985; Jacks, 1969; Jolles, 1964; Koppitz, 1968; Lakin, 1956; Lehner & Gunderson, 1948; Levy, 1958; Ludwig, 1969; Marzolf & Kirchner, 1972; McElhany, 1969; McHugh, 1966; Michal-Smith & Morgenstern, 1969; Mitchell, 1993; Mundy, 1972; Ottenbacher, 1981; Precker, 1950; Riklan, 1962; Urban, 1963; as cited in Ogdon, 2001; Reynolds, 1978). Other indicators of low self-esteem and feelings of inadequacy are the presence of fewer than five fingers on Daniel?s left hand (Schildkrout, 1972, as cited in Ogdon, 2001), the buttons down his shirt (Hammer, 1958; Levy, 1958; as cited in Gilbert, 1980) and his dishevelled, unkempt figure (Hammer, 1958, as cited in Gilbert, 1980). The overemphasis and strong reinforcement of facial features suggests feelings of inadequacy and weakness (Machover, 1949, as cited in Ogdon, 2001). Low self-esteem and feelings of inadequacy in all family members is suggested by their small trunks (Buck, 1950; Buck & Warren, 1992; Handler, 1985; Jolles, 1964; Urban, 1963; as cited in Ogdon, 2001), and thin trunks (Jolles, 1952; Machover, 1949; as cited in Ogdon, 2001). Their large hands suggest feelings of weakness (Machover, 1949, as cited in Gilbert, 1980). Interpersonal family dynamics The drawing gives a sense of coldness, hardness, and disconnectedness between the family members, with everyone engaged in a separate activity, nobody facing anyone else, and no physical contact between them. The figures are far apart, suggesting a lack of closeness (Hammer, 1968, as cited in Gilbert, 1980). Daniel drew each family member isolated within his or her own compartment. Compartmentalization indicates an attempt to put family members into boxes, isolating them, perhaps because the person compartmentalized threatens or troubles the child (Burns & Kaufman, 1972). Daniel has compartmentalized everyone in the family, indicating their isolation from one another and that every person is a potential source of anxiety or threat to the others. The family members have multiple barriers between them (vertical lines and objects in their hands), further indicating isolation and conflict (Reynolds, 1978). The staring eyes and wide, fixed grins of the figures give a sense of insecurity, rigidity, and tension. There is a lack of movement and flow between the figures. Daniel has drawn separate groundlines for each person, indicating unstable relationships with them (Reynolds, 1978) and a need for help or support (Hammer, 1958; Levy, 1950; as cited in Gilbert, 1980). Arm extensions serve as aids to control the environment (Reynolds, 1978). Every member in Daniel?s family has their own arm extension, suggesting that he perceives them as unstable and needing help to cope with each other and the outside world. This assertion is further supported by the lining at the top of the page, indicating acute anxiety, due to the perception of his environment as scary (Burns & Kaufman, 1972). Feelings of insecurity are suggested by midline emphasis on Daniel?s shirt (Machover, 1949, as cited in Gilbert, 1980), and the groundlines (Buck, 1950; Hammer, 1954; Jolles, 1964; as cited in Ogdon, 2001; Machover, 1949, as cited in Gilbert, 1980). Daniel?s answer to the question of how everyone in his family gets along was ?They do get along, but I don?t know how. They just get along?. This narrative supports the notion of a sense of insecurity within the family. Communication difficulties are suggested by Daniel?s mother?s long neck, indicating conflict in the throat (speech) area (Hammer, 1958; Levy, 1958; as cited in Gilbert, 1980). Forced amiability is suggested by clown-like mouths on the figures (Machover, 1949, as cited in Gilbert, 1980), while their angular bodies indicate a tendency to criticise (Machover, 1949, as cited in Gilbert, 1980). Hypersensitivity to criticism is indicated by Daniel?s large ears (Buck, 1950; Handler, 1985; Jolles, 1964; Machover, 1951; Mitchell, 1993; Mursell, 1969; Urban, 1963; as cited in Ogdon, 2001). Although Daniel, his sister and father are drawn with overextended, reaching arms revealing a desire for affection (Machover, 1949, as cited in Gilbert, 1980), there is some suggestion of nurturance in the figure of his mother, as maternal qualities are implied by her long skirt (Machover, 1949, as cited in Gilbert, 1980). Daniel?s answer to the question about his D-A-P self-portrait, of what makes him happy was ??when I see my sister?. This suggests that he feels close to his sister, as does her placement closest to him in the K-F-D. However she is also positioned closest to Daniel?s parents, indicating that Daniel perceives her as closer to them and perhaps receiving more attention from them. Sexual preoccupation or conflict As in Daniel?s D-A-P drawings, there are a number of sexually-oriented indicators, suggesting a conflict or preoccupation with sexuality. These are emphasized, messy hair on all figures (Buck, 1950; DiLeo, 1970; Hammer, 1954; Handler, 1985; Jolles, 1964; Levy, 1958; Machover, 1951; Roback, 1968; Urban, 1963; as cited in Ogdon, 2001), elongated anatomical areas/phallic symbols (noses on Daniel and his father, fingers on all figures, neck on Daniel?s mother, hosepipe in Daniel?s mother?s hand and weaving between her legs) (Hammer, 1954, as cited in Gilbert, 1980), and the elongated hands of Daniel?s mother and sister (Buck, 1966; Buck & Warren, 1992; Hammer, 1953; Handler, 1985; Jolles, 1964; Mitchell, 1993; Urban, 1963; Wysocki & Wysocki, 1977; as cited in Ogdon, 2001; Machover, 1949, as cited in Gilbert, 1980). Infantile, regressed sex drives are suggested by the small trunks (Buck, 1950; Buck & Warren, 1992; Handler, 1985; Jolles, 1964; Urban, 1963; as cited in Ogdon, 2001; Machover, 1949, as cited in Gilbert, 1980) and emphasized hair on all the figures (Buck, 1950; Handler, 1985; Levy, 1958; as cited in Ogdon, 2001; Machover, 1949, as cited in Gilbert, 1980). As in Daniel?s D-A-P drawings, the K-F-D indicates a preoccupation or conflict with gender identity or sexual orientation. While masculine assertion or a need for it, is suggested by strong noses on the figures of Daniel and his father (Machover, 1949, as cited in Gilbert, 1980), homosexual tendencies/effeminacy are indicated the hair given much attention, especially as vigorously shaded (Hammer, 1954, as cited in Gilbert, 1954; Levy, 1958, as cited in Ogdon, 2001), the hair parted in the middle on the figures of Daniel?s mother and sister (Hammer, 1958; Levy, 1958; as cited in Gilbert, 1980), large eyes (Geil, 1944; Levy, 1958; Machover, 1949; Urban, 1963; as cited in Ogdon, 2001), enlarged ears on figure of Daniel (Hammer, 1958; Levy, 1958; as cited in Gilbert, 1980), curved lines on male bodies (Daniel and father) (Machover, 1949, as cited in Gilbert, 1980), a rounded trunk and narrow waist on a male subject (Daniel) (Hammer, 1958; Levy, 1958; as cited in Gilbert, 1980), an arm and leg distorted or reinforced on the left side (all figures) (Hammer, 1958; Levy, 1958; as cited in Gilbert, 1980), and overdetailed shoes on figure of Daniel?s father (Buck & Warren, 1992; Levine & Sapolsky, 1969; Machover, 1949; Urban, 1963; as cited in Ogdon, 2001). Personality Introversion/extroversion As in Daniel?s D-A-P drawings, there is an indicator that Daniel?s personality is imbalanced or disorganised, in the form of random scribbled shading (hair and shoes), suggesting a neurotic and even hysterical personality (Kahn & Giffen, 1960; Schildkrout, 1972; as cited in Ogdon, 2001). As in his D-A-P drawings extroversive, socially outgoing tendencies are suggested by the large eyes of the figures (Handler, 1985; Machover, 1949; as cited in Ogdon, 2001). There are no indicators of introversive tendencies in this drawing. Defenses There are suggestions of either resistance or defensiveness in some answers Daniel gave to questions about his drawing. When asked what the one best thing about the family is, he paused and replied sharply, ?I can?t answer that?. When asked what the one worst thing about the family is, he paused and said sharply, ?I also can?t answer that. OK, I know the worst thing is that, ok? no the good thing is that we not poor and that we not rich. And the bad thing is well, there is no bad thing?. When asked who the favourite person in the family is, he replied, ?That I like? No- one. I like them all. Did you think it would be that? Did you think I?d say that? Cos I love my whole family?. When asked how he feels about himself, he replied, ?Fantastic?. When asked how his sister feels about herself, he replied sharply, ?I don?t know?. When asked how his mother feels about herself, he quickly and very sharply replied before the researcher had even finished asking the question (?No?I don?t know, and my father, no!?). As in Daniel?s D-A-P drawings, the overemphasis and strong reinforcement of facial features suggests fantasy to compensate for feelings of inadequacy and weakness (Machover, 1949, as cited in Gilbert, 1980). Fantasy to compensate for feelings of inadequacy is also suggested by the drawing filling the page (Hammer, 1954, as cited in Gilbert, 1980). Elevation of the drawing above the midline indicates that fantasy is an important source of satisfaction for Daniel (Buck, 1950; Hammer, 1958; as cited in Gilbert, 1980). Support for the notion that Daniel uses the defense of fantasy, particularly violent fantasy, is also found in his answer to the question of what he would change if he could change one thing about his family, That we had powers. For me, it would be every kind of fire that there is, that includes lava. Err, my sister would be that, OK my father would be?I don?t know what he would be, cos I?or my mother, or well I?d say my mother could be, have water, so she can drown you. My sister would have poison ivy, s?and my father will have?err?thorns. I can burn people, my sister can er poison people, my mother can drown people and my father can kill people, by by stabbing spikes in them. If someone tries to rob them, then or steal us, that?s what we could use to protect ourselves. And I would turn into a wraith?? It?s like a dead person, that?s dressed in this black?I?ll get a, I?ll get a toy! I?ll be a wraith, my sister would be invisible woman, my mother would be flexible lady and my father would be?Mr Incredible. Autonomy/dependency As in Daniel?s D-A-P drawings, straight, uninterrupted strokes suggest a quick, decisive, assertive personality (Allen, 1958; Alschuler & Hattwick, 1947; Hammer, 1958; Krout, 1950; Levy, 1958; as cited in Ogdon, 2001). Again, the unusually heavy pencil pressure implies assertiveness, persistence, forcefulness, and ambition (Alschuler & Hattwick, 1947; Hammer, 1968; Kadis, 1950; Levy, 1958; Machover, 1949; Urban, 1963; as cited in Ogdon, 2001), as do the firm, determined, unhesitating, pencil strokes (Hammer, 1954, as cited in Gilbert, 1980; Levy, 1958, as cited in Ogdon, 2001). Ambition and future orientation are indicated by the firm line quality (Hammer, 1958; Levy, 1958; as cited in Gilbert, 1980). As in Daniel?s D-A-P drawings, the overemphasis and strong reinforcement of facial features imply aggressive and socially dominant behaviour to compensate for feelings of inadequacy and weakness (Machover, 1949, as cited in Ogdon, 2001). However, dependency and helplessness are suggested by midline emphasis on the figure of Daniel (Machover, 1949, as cited in Gilbert, 1980) and the presence of less than five fingers on the left hands of Daniel and his mother (Hammer, 1958, as cited in Gilbert, 1980). Immaturity is suggested by petal fingers on the figures of his mother and sister (Machover, 1949, as cited in Gilbert, 1980). All the members of Daniel?s family besides himself are depicted as younger than their years, suggesting emotional immaturity (Machover, 1949; McElhaney, 1969; Meyer, 1955; Urban, 1963; as cited in Ogdon, 2001) and dependency needs (McElhaney, 1969; Urban, 1963; as cited in Ogdon, 2001). The moderate distortion/disproportion of all the figures suggests poor school adjustment (Koppitz, 1966; Mitchell, 1993; Vane & Eisen, 1962; as cited in Ogdon, 2001). Impulse control As in Daniel?s D-A-P drawings, his K-F-D reveals considerably high levels of anger and difficulty with impulse control. As in his previous drawings, there is only one indicator of controlled behaviour/emotional control, viz. long pencil strokes (Alschuler & Hattwick, 1947; Hammer, 1958; as cited in Ogdon, 2001). As in his D-A-P drawings, there are indicators of inhibited tendencies, which are long pencil strokes (Goodman & Kotkov; 1953; Handler, 1985; Machover, 1951; as cited in Ogdon, 2001), and swollen hands of all figures (Machover, 1955, as cited in Ogdon, 2001). Repressed aggression is suggested by the small trunks of all the figures (Buck, 1950; Buck & Warren, 1992; Handler, 1985; Jolles, 1964; Urban, 1963; as cited in Ogdon, 2001), and Daniel?s mother?s long neck (Hammer, 1954; Levy, 1958; as cited in Gilbert, 1980). However, as in his D-A-P drawings, there are indications of poor impulse control and impulsivity. The tight collars of all the figures suggest difficulty controlling anger or primitive drives (Hammer, 1958; Levy, 1958; as cited in Gilbert, 1980). Poor impulse control is also suggested by the horizontal stripes on Daniel?s father?s jersey (Schildkrout, 1972, as cited in Ogdon, 2001). The heavy pencil pressure suggests high energy levels and excitement (Hetherington, 1952; Kadis, 1950; Levy, 1958; Mitchell, 1993; Precker, 1950; Riethmiller & Handler, 1997; Urban, 1963; as cited in Ogdon, 2001; Handler, 1996). Impulsivity is indicated by the large hands of all figures (Buck, 1966; Buck & Warren, 1992; Jolles, 1952; as cited in Ogdon, 2001), jagged lines (hair, noses, fingers, teeth, hosepipe) (Hammer, 1965; Krout, 1950; Machover, 1951; Urban, 1963; Waehner, 1946; as cited in Ogdon, 2001), and moderate distortions/disproportions on all figures (Oas, 1984, as cited in Ogdon, 2001). As in Daniel?s D-A-P drawings, there are numerous indicators of overt anger and aggressive tendencies. Some of these indicators are the unusually heavy pencil pressure (Halpern, 1951; Hammer, 1997; Handler & McIntosh, 1971; Jolles, 1964; McElhaney, 1969; Reynolds, 1978; Riethmiller & Handler, 1997; Schneidman, 1958; Urban, 1963; Wysocki & Whitney, 1965; as cited in Ogdon, 2001), straight lines (Hammer, 1958; Krout, 1950; as cited in Gilbert, 1980), jagged lines (Hammer, 1965; Krout, 1950; Machover, 1951; Urban, 1963; Waehner, 1946; as cited in Ogdon, 2001), emphasized hair of all figures (Handler, 1985; Shneidman, 1958; as cited in Ogdon, 2001), large, piercing eyes of all figures (Deabler, 1969; Griffith & Peyman, 1959; Hammer, 1968; Handler, 1985; Jacks, 1969; Kahn & Giffen, 1960; Levy, 1958; Machover, 1958; McElhaney, 1969; Reznikoff & Nicholas, 1958; Robins et al., 1991; Schildkrout, 1972; Shneidman, 1958; Urban, 1963; as cited in Ogdon, 2001), teeth showing on all figures (Buck, 1966; Buck & Warren, 1992; Goldstein & Rawn, 1957; Halpern, 1965; Hammer, 1965; Handler, 1996; Jolles, 1964; Koppitz, 1968; Levy, 1958; Machover, 1960; McElhaney, 1969, Mitchell, 1993; Rierdan et al., 1982; Schildkrout, 1972; Urban, 1963; as cited in Ogdon, 2001), and nostrils on the father?s nose (Machover, 1949, as cited in Gilbert, 1980). Other indicators of overt anger and aggressive tendencies are the wide stances (Daniel, father and sister) (Machover, 1949; Shneidman, 1958; Wysocki & Wysocki, 1977; as cited in Ogdon, 2001), the angular bodies of all figures (Machover, 1949, as cited in Gilbert, 1980), the long neck of Daniel?s mother (Hammer, 1958; Levy, 1958; as cited in Gilbert, 1980), the asymmetrical limbs of all figures (Hammer, 1969; Koppitz, 1968; Machover, 1949; Mundy, 1972; Urban, 1963; as cited in Ogdon, 2001), the large hands of all figures (Handler, 1985; Shneidman, 1958; as cited in Ogdon, 2001), the powerful hands of all figures (Hammer, 1958, as cited in Gilbert, 1980), the sharp, spiked/spear fingers of all figures (Brown, 1958; Buck, 1966; Buck & Warren, 1992; DiLeo, 1970; Goldstein & Rawn, 1957; Hammer, 1965; Handler, 1985; Jacks, 1969; Jolles, 1964; Machover, 1949; McElhaney, 1969; Mitchell, 1993; Modell & Potter, 1949; Reynolds, 1978; Schildkrout, 1972; Shneidman, 1958; Urban, 1963; Wolk, 1969; Wysocki & Wysocki, 1977; as cited in Ogdon, 2001), the emphasized feet of the father (Hammer, 1954; Machover, 1958; Schildkrout, 1972; Shneidman, 1958; Urban, 1963; as cited in Ogdon, 2001), and sharply pointed shoes of the mother and father (Urban, 1963, as cited in Ogdon, 2001). Assaultiveness is indicated by the emphasized hair of all figures (Handler, 1985; Shneidman, 1958; as cited in Ogdon, 2001), the wide stances (Daniel, his father and sister) (Machover, 1949; Shneidman, 1958; Wysocki & Wysocki, 1977; as cited in Ogdon, 2001), and the emphasized feet of the father (Hammer, 1954; Machover, 1958; as cited in Gilbert, 1980). Psychopathology As in Daniel?s D-A-P drawings, there are multiple indicators that he is normal, stable, reasonably well-adjusted, and has adequate contact with reality. These are drawing in normal succession (Machover, 1949, as cited in Gilbert, 1980), consistent pencil pressure (Urban, 1963, as cited in Ogdon, 2001), a relaxed standing posture (Urban, 1963, as cited in Ogdon, 2001), and erasing in moderation followed by an improved drawing (Buck & Warren, 1992; Hammer, 1954; Jolles, 1964; Roback, 1968; as cited in Ogdon, 2001). Basic psychological integrity is suggested by the match between the visible actions of the figures with Daniel?s verbal descriptions of what they are doing (Reynolds, 1978). However, there are numerous indicators of psychopathology. There are indicators of schizoid tendencies, as in Daniel?s first and third D-A-P drawings. There are more indicators of depression, anxiety, hysteria and neurosis, than in his D-A-P drawings. There is a large quantity of schizophrenic indicators, as in his third D-A-P drawing. Otherwise, the quantity of indicators for each category of psychopathology is similar to those present in Daniel?s D-A-P drawings. Depression is implied by narrow necks of all figures (Hammer, 1954; Levy, 1958; as cited in Gilbert, 1980), and water spurting from a hosepipe (Burns & Kaufman, 1972). Anxiety is indicated by the unusually heavy pencil pressure (Deabler, 1969; Buck, 1950; Hammer, 1969; Jolles, 1964; Handler, 1996; Handler & Reyher, 1966; Kadis, 1950; Machover, 1955; Reynolds, 1978; Riethmiller & Handler, 1997; Urban, 1963; as cited in Ogdon, 2001), jagged lines (Hammer, 1965; Krout, 1950; Machover, 1951; Urban, 1963; Waehner, 1946; as cited in Ogdon, 2001), large eyes, especially as shaded (Machover, 1958; as cited in Ogdon, 2001), moderate distortion/disproportion of all figures (Handler & Reyher, 1966, as cited in Ogdon, 2001), the unbalanced stances of the mother and sister (Machover, 1949, as cited in Gilbert, 1980), the simplified trunks of all figures (Riethmiller & Handler, 1997, as cited in Ogdon, 2001), fragmentation inadvertently introduced (by stripes on father?s jersey, clothing that has the effect of fragmenting the body from the arms and legs, and lines that cross one another fragmenting body parts) (Hammer, 1978; Jacks, 1969; as cited in Ogdon, 2001), lining at the top of the page (Burns & Kaufman, 1972), and excessive detail (Machover, 1949, as cited in Gilbert, 1980). Neurosis is suggested by the midline emphasis (Machover, 1949, as cited in Gilbert, 1980), and excessive detail (Buck, 1966; Buck & Warren, 1992; Deabler, 1969; Hammer, 1969; Handler, 1985; Jacks, 1969; Kahn & Giffen, 1960; Levy, 1958; Machover, 1949; McElhaney, 1969; Reynolds, 1978; as cited in Ogdon, 2001). Obsessiveness is indicated by excessive detail (Machover, 1949; as cited in Gilbert, 1980). Obsessive-compulsivity is suggested by the small figure sizes (Schildkrout, 1972, as cited in Ogdon, 2001), hair parted in the middle (mother and sister) (Hammer, 1958; Levy, 1958; as cited in Gilbert, 1980), excessive detail (Buck, 1966; Buck & Warren, 1992; Deabler, 1969; Hammer, 1969; Handler, 1985; Jacks, 1969; Kahn & Giffen, 1960; Levy, 1958; Machover, 1949; McElhaney, 1969; Reynolds, 1978; as cited in Ogdon, 2001), unnecessary detailing (father?s shoes, jersey, popcorn and Coke; Daniel?s shirt and action figure in hand (Hammer, 1958; Levy, 1958; as cited in Gilbert, 1980), the overdetailed shoes of the father (Buck & Warren, 1992; Levine & Sapolsky, 1969; Machover, 1949; Urban, 1963; as cited in Ogdon, 2001; Hammer, 1954; Levy, 1958, as cited in Gilbert, 1980), and striped clothing (father?s jersey) (Schildkrout, 1972, as cited in Ogdon, 2001). Hysteria is suggested by the wide-eyed stares of all figures (Schildkrout, 1972, as cited in Ogdon, 2001), and the mother?s long neck (Hammer, 1958; Levy, 1958; as cited in Gilbert, 1980). Paranoia is indicated by the unusually heavy pencil pressure (Hammer, 1958; Reznikoff & Nicholas, 1958; Roback, 1968; Weiner, 1966; as cited in Ogdon, 2001), the large, staring eyes of all figures (Deabler, 1969; Griffith & Peyman, 1959; Hammer, 1968; Handler, 1985; Jacks, 1969; Kahn & Giffen, 1960; Levy, 1958; Machover, 1958; McElhaney, 1969; Reznikoff & Nicholas, 1958; Robins et al., 1991; Schildkrout, 1972; Shneidman, 1958; Urban, 1963; as cited in Ogdon, 2001), the large ears of Daniel (Machover, 1949, as cited in Gilbert, 1980), and the sharp, spiked/spear fingers of all figures (Brown, 1958; Buck, 1966; Buck & Warren, 1992; DiLeo, 1970; Goldstein & Rawn, 1957; Hammer, 1965; Handler, 1985; Jacks, 1969; Jolles, 1964; Machover, 1949; McElhaney, 1969; Mitchell, 1993; Modell & Potter, 1949; Reynolds, 1978; Schildkrout, 1972; Shneidman, 1958; Urban, 1963; Wolk, 1969; Wysocki & Wysocki, 1977; as cited in Ogdon, 2001). Schizophrenia/psychosis is suggested by the unusually heavy pencil pressure (Gustafson & Waehler, 1992, as cited in Ogdon, 2001), teeth showing on all figures (Machover, 1949, as cited in Gilbert, 1980), large ears of Daniel (Handler, 1996), body distortions/disproportions on all figures (Hammer, 1958; Levy, 1958; as cited in Gilbert, 1980), geometric shaped body (Curran & Marengo, 1990; Hammer, 1981; Ries, 1966; as cited in Ogdon, 2001), and the wing-like arms of the sister and mother (Buck, 1966; Buck & Warren, 1992; Hammer, 1958; Jolles, 1964; Machover, 1958; Urban, 1963; as cited in Ogdon, 2001). Schizoid tendencies are implied by the large ears of Daniel (Machover, 1949, as cited in Gilbert, 1980), his mother?s long neck (Hammer, 1958; Levy, 1958; as cited in Gilbert, 1980), and midline emphasis on the figure of Daniel (Machover, 1949, as cited in Gilbert, 1980). Narcissistic tendencies are suggested by hair given much attention on all figures (Hammer, 1954, as cited in Gilbert; Handler, 1985; Levy, 1958; Machover, 1949; as cited in Ogdon, 2001), hair parted in the middle (mother and sister) (Hammer, 1958; Levy, 1958; as cited in Gilbert, 1980), arms of all figures akimbo (Handler, 1985; Machover, 1949; as cited in Ogdon, 2001), and the father?s overdetailed feet (Buck, 1966; Jolles, 1964; Urban, 1963; as cited in Ogdon, 2001). Organicity is suggested by the asymmetrical limbs of all figures (Hammer, 1969; Koppitz, 1968; Machover, 1949; Mundy, 1972; Urban, 1963; as cited in Ogdon, 2001), and by fragmentation inadvertently introduced (Hammer, 1978; Jacks, 1969; as cited in Ogdon, 2001). 4.2.4 TAT analysis Card 1 The card elicits themes of relationships with parental figures, aggression, symbolic sexual responses, achievement needs and ADD (Bellak, 1975). In Daniel?s story, the environment is perceived as a dangerous and unreliable place devoid of parental protection, in which he needs to defend himself and his loved ones against danger. There is an Oedipal fantasy wish replace his father as his sister?s protector and sexual fantasy of taking her as a mate (?he and his sister lived happily ever after?). Aggression is evident (?So all he had to play with was this gun. And one day, these men tried to attack them, then he shot them?), and conflict between an inadequate superego and aggressive drives. There is a sense of economic deprivation (?There?s this one boy that lived in a forest?himself and his sister?he used to go catch birds with his gun, cos he had no toys?), and achievement needs are suggested (to be strong and powerful). Symbolic sexual responses are indicated (playing with a gun as his toy). ADD is suggested (failure to recognise the violin). Anxiety and excitement are revealed by Daniel?s breathlessness. The defenses of projection, acting out, fantasy, and rationalization are indicated. High intelligence, an average level of maturity, and inadequate ego integration are suggested. Card 2 The card elicits Oedipal themes and themes of family relations (Bellak, 1975). In Daniel?s story, the environment is perceived as unpredictable, and his mother as unnurturing. Possible Oedipal themes emerge, of his father being replaced, perhaps by himself as the fantasy ?nice man? who marries his mother or sister (it is unclear which). Conflict between an inadequate superego and Oedipal sexual needs is suggested. A sense of economic deprivation is implied (?Her daughter had to go live somewhere else, cos the house was getting too small for all of them?). The defenses of projection and fantasy are suggested. High intelligence, an average level of maturity, and inadequate ego integration are indicated. Card 3BM The card elicits the theme of aggression (Bellak, 1975). In Daniel?s story, aggression directed at his mother emerges (he kept the goat as a pet despite her warning and it ?ruined their entire house?). There is conflict between an adequate superego and aggressive drives, and between autonomy and compliance with parental authority. His mother is perceived as punitive and unnurturing. (The wish to ?get a, live with a, ?get a goat as a pet? implies unfulfilled nurturance needs). There is anxiety over economic deprivation (?Then one day, he went in the house and ruined their entire house?). The defenses of projection and fantasy are suggested. High intelligence, an average level of maturity, and inadequate ego integration are indicated. Card 3GF The card elicits the theme of depression (Bellak, 1975). In Daniel?s story, the environment is perceived as dangerous, unstable, and depriving. A need to be taken care of by his mother, who is perceived as emotionally unstable and unable to provide for his physical needs, is implied. There is anxiety over maternal depression and fears that physical deprivation will result (?she was so sad that she?lost all her money cos she didn?t go to work?). There is fear of loss through death (mother or sister) and the consequences thereof. There is conflict between a severe superego and aggressive drives. Blocking and the defense of displacement are indicated. Displacement is the unconscious process of ?transferring a feeling about, or a response to, one object onto another (usually less threatening) substitute object? (APA, 2000, p.811). High intelligence, an average level of maturity, and inadequate ego integration are implied. Card 4 The card elicits the theme of male-female relationships (Bellak, 1975). In Daniel?s story, the environment is perceived as a dangerous place devoid of parental protection, in which he needs to engage with danger to make his own money. There is anxiety over economic deprivation (a need to make money: ?Then, he found him and in, he got paid a million Rand and he lived happily ever after!?), and a need to be taken care of by his mother. The defense of fantasy is suggested. High intelligence, an average level of maturity, and inadequate ego integration are indicated. Card 5 The card elicits the theme of the mother who may be watching (Bellak, 1975). In Daniel?s story, the environment is perceived as unstable and foreboding. His mother is perceived as depressed and unstable. The rain that the ?maid? is looking for, even though ?there?s not even the one cloud in the sky? may refer to his mother?s depression, which Daniel wishes he could somehow prevent. The defenses of fantasy and intellectualisation are suggested. High intelligence, an above-average level of maturity, and inadequate ego integration are indicated. Card 6BM The card elicits themes of the mother-son relationship and Oedipal themes (Bellak, 1975). In Daniel?s story, the environment is perceived as dangerous and unstable. Oedipal themes and castration anxiety emerge (man was shot and survived but died). There is anxiety over physical injury and conflict between the superego and aggressive drives. The defenses of fantasy and undoing are suggested. High intelligence, an average level of maturity, and inadequate ego integration are suggested. Card 7BM The card elicits the theme of the father-son relationship (Bellak, 1975). In Daniel?s story, the environment is perceived as an unreliable, unnurturing place. A need to be taken care of by his father, who is perceived as inadequate (demasculated and physically inadequate) and unable to provide for Daniel?s physical needs, emerges. There is a sense of economic deprivation (need to make money: ??he?s, to make money, he decided?to be a businessman, and he got 50 Grand?). There is conflict between a severe superego and aggressive drives, and conflict between autonomy and compliance. The defenses of fantasy and intellectualisation are suggested. High intelligence, an average level of maturity, and adequate ego integration are indicated. Card 7GF The card elicits the theme of the mother-child relationship (Bellak, 1975). In Daniel?s story, a poor body image is indicated (weakness: ?she actually fells down and fainted? and a sense of being broken, as the doll broke). The environment is perceived as an unreliable place, and a need to be taken care of by his mother, who is perceived as an inadequate provider and nurturer, emerges. The girl falling down and fainting may indicate fear of his sister?s weakness or death. There is a sense of economic anxiety (much focus on how rich the hero is: ?She was so rich?(h)er mother was the richest person in the world?). The defenses of fantasy and reaction formation are suggested. High intelligence, an average level of maturity, inadequate ego integration, and a severe superego are indicated. Card 8BM The card elicits themes of aggression, ambition, and the Oedipal relationship with the father (Bellak, 1975). In Daniel?s story, the environment is perceived as a dangerous, unstable place. Oedipal ambivalence toward his father emerges (perhaps aggression in wishing his father dead so that he can replace him, but also avenging his death), and his father is perceived as an inadequate protector. There is anxiety over the loss of his father by death and the effects thereof. There is conflict between aggressive drives and an inadequate superego. The defenses of projection, fantasy, acting out and undoing are suggested. High intelligence, an average level of maturity, and inadequate ego integration are indicated. Card 9BM The card elicits themes of current male to male relationships (Bellak, 1975). In Daniel?s story, the environment is perceived as unstable and depriving. Daniel needs to be taken care of and fears paternal death or abandonment. The defense of displacement is suggested. High intelligence, an average level of maturity, inadequate ego integration, and a severe superego are indicated. Card 11 The card elicits themes of infantile or primitive fears (Bellak, 1975). In Daniel?s story, achievement needs emerge (masculine strivings symbolised by the bulls). Conflict between an inadequate superego and Oedipal sexual/nurturance needs is suggested. Oedipal wishes to possess the mother may be symbolised by ?bags of gold? with which the man escapes safely from the cave. The dragon is a phallic symbol (Bellak, 1975) and may symbolise the father. The fantasy is that the father didn?t punish him for taking his ?gold? (?the dragon didn?t eat him because he was so special?). There is a hero fantasy of economic ambition may be symbolised by the bags of gold, with anxieties over physical injury and deprivation (father?s ability to provide for him and a need to be taken care of). The defense of fantasy is suggested. High intelligence, an average level of maturity, and inadequate ego integration are indicated. Card 12M The card elicits themes of relationships between a younger man and an older man (Bellak, 1975). In Daniel?s story, the environment is perceived as unstable and unpredictable. Depression, possibly paternal, is suggested (the man ?was in bed and he never got out, he was so tired?), with a sense of hopefulness that the depression will end (?Then one day, this angel came and blessed him and then he walked again?). There is a need to be taken care of, and anxiety over a lack or loss of paternal nurturance by abandonment or death. The defense of fantasy is suggested. High intelligence, an average level of maturity, and inadequate ego integration are indicated. Card 13MF The card elicits themes of sexual conflicts and associated feelings of guilt, oral tendencies and economic deprivation (Bellak, 1975). In Daniel?s story, there is an Oedipal wish to have sex with his mother but the knowledge that it is socially unacceptable and punishable (lying to the authority/father figure symbolised by the police represents castration anxiety). There is ambivalence and considerable oral incorporative aggression towards his mother/women, in the form of wanting to marry the woman but also to incorporate her completely (as ?a vampire?he sucked all her blood out?) and ultimately kill her, but feeling remorse (crying afterwards) and knowing it is socially unacceptable to kill her (and so lying to the police about who killed her). There is a realisation that to possess and destroy his mother will lead to his own destruction (as he ?told the police that someone killed them?). ?(T)hem? may refer either to his father or himself. In either case, there would be a negative outcome for him as he would either be orphaned or dead. There is a conflict between an inadequate superego and oral aggressive drives. The defenses of fantasy, reaction formation, and acting out are suggested. High intelligence, an average level of maturity, and inadequate ego integration are indicated. Card 13B The card elicits themes of childhood (Bellak, 1975). In Daniel?s story, there is a wish to be emotionally close to and acknowledged by his father, and a need to be taken care of by his father. The defense of fantasy, high intelligence, an average level of maturity, and adequate ego integration are indicated. Card 14 The card elicits the theme of suicidal tendencies (Bellak, 1975). In Daniel?s story, a poor body image emerges (the wish to ?become a human? instead of being ?so black that not, even at night you couldn?t see him?). He wishes to be seen, acknowledged, and healed of badness (which may be symbolised by the man?s blackness), revealing a need to be loved and accepted. The defense of fantasy, high intelligence, an average level of maturity, and inadequate ego integration are indicated. Card 17BM The card elicits themes of Oedipal fears and body image (Bellak, 1975). In Daniel?s story, a poor body image is suggested (even though the man ?was so strong?, he ?couldn?t break a rope?. The man ?fell down and he became a dwarf?). An outgoing, active personality is revealed by telling a story about climbing up the rope (Bellak, 1975). The defenses of fantasy and reaction formation are suggested. High intelligence, an average level of maturity, inadequate ego integration, and a severe superego are indicated. Card 18BM The card elicits themes around any anxiety, particularly fears of attack of a homosexual nature (Bellak, 1975). In Daniel?s story, the environment is perceived as unpredictable and dangerous. Fears of homosexual attack emerge (?He got kidnapped? by ?these men?). There is a conflict between homosexual drives and fears. The defenses of fantasy and undoing are suggested. High intelligence, an average level of maturity, and adequate ego integration are indicated. Card 19 In Daniel?s story, the environment is perceived as dangerous and unpredictable. There is the feeling that his mother rejects him and wishes him dead (the ?rude? child of the two ?fell in the water and drowned?the other girl lived happily ever after?). Daniel refers to his mother?s dislike of his ?rudeness? in narratives to all his D-A-P drawings. In the parent questionnaire, his mother described Daniel as ?frequently rude?. There is a need to be taken care of (nurturance). The drowning in the ocean may relate to his mother?s depression. Rivalry with his sister for their mother?s affection emerges. High intelligence, an average level of maturity, inadequate ego integration, and a severe superego are indicated. 4.3. Subject C ? ?Jane? 4.3.1. Introduction Jane presented as a shy, quiet, polite, and soft-spoken little girl of 7 years and 2 months, with full features and a sweet, engaging smile. She has two siblings, a brother aged 19 years and a sister aged 12 years. She lives with her parents and both siblings. Jane?s early developmental milestones were normal except for difficulties with social skills (she tends to be very shy and withdrawn), mathematics, and short-term memory. She was five years old when her mother first noticed symptoms of psychopathology. A family doctor was consulted, and Jane was referred to a psychologist for treatment at the age of five and a half years. Her first symptoms were repeated doubting (worrying that someone in her family would die and worrying about family finances), observable repeating or counting rituals (tapping her feet and fingers repetitively, singing the ?A, b, c song? and other songs over and over, and repetitive counting), and demanding reassurance (that something bad wasn?t going to happen or that nobody in the family was going to die). Jane received psychological treatment until the age of six and a half years (she terminated therapy eight months ago). Nowadays, her mother classifies Jane?s symptoms as ?mild? in severity (one or two aspects of her life are mildly impaired but she generally copes well with life) although all her symptoms remain. Just prior to the onset of these symptoms, a traumatic event happened in Jane?s life, viz. the death of her grandfather. There is a family history of psychopathology although not specifically of OCD. Both her parents have suffered for many years from depression and continue to suffer, although they have sought treatment in the past. Jane has been diagnosed with one other comorbid psychological condition, viz. depression Her brother was born with brain damage and suffers from epilepsy and learning disorders. Jane?s temperament and life have changed since she started displaying symptoms of OCD. Her symptoms wear her out and she is often tired as a result. She has become more depressed, withdrawn, shy, and aggressive than before. She has trouble making friends at school and tries to hide her symptoms from teachers and other children at school. She has trouble concentrating in class and learning problems at school (short-term memory problems and difficulty with mathematics). She also tries to hide her symptoms at home and when out in public Family life has changed since Jane started displaying symptoms of OCD. She needs more parental attention and tries to involve family members in her rituals. Coping with Jane leaves her parents feeling more exhausted and frustrated, and there is generally more tension and arguing in the family than before. There is more tension and arguing between Jane and her siblings than before. Jane?s parents feel guilty because they think maybe they have somehow caused or passed on OCD to Jane. Jane was friendly and very co-operative with the researcher and performed all tasks requested of her willingly. Although initially she was very shy and spoke only when spoken to, as testing progressed she seemed more relaxed and interacted spontaneously and more freely with the researcher. During testing, she displayed difficulty concentrating. Occasionally, she tapped her hands and feet on the table. Occasionally, she sang the ?A, b, c song? very softly to herself when she became anxious. During rest breaks, Jane was quiet and interacted very little with the researcher, mostly speaking only when spoken to. She seemed to prefer to sit quietly, staring out the window and appeared to want to avoid interaction with the researcher, as she sometimes tended to get up and wander around the room. 4.3.2. Age-related norms for HFD analyses Jane?s D-A-P figures measure 3.5 and 2.8 inches in height respectively. This classifies them as small figures, as a normal sized figure is between 6 and 7 inches tall (Handler, 1996; Urban, 1963, as cited in Ogdon, 2001). However among children small drawings may be considered normal (Hammer, 1958; Lakin, 1956; Machover, 1960; as cited in Ogdon, 2001), thus, small figure size has not been used as an emotional indicator in analysing Jane?s D-A-P drawings. Indicators relating to inconsistent treatment by children of male and female drawings have however been used. The tallest figure in her K-F-D is Jane?s mother, measuring 2.45 inches in height. Jane and her father are smaller figures of 2 inches high. Because drawing male figures smaller than female ones may be normal in young girls (Machover, 1960; McHugh, 1963; Weider & Noller, 1953; as cited in Ogdon, 2001), this has not been interpreted as an emotional indicator. Thus emotional indicators relating to figure size have only been interpreted in a relative, qualitative manner in the K-F-D analysis. As shaded strokes may be seen in the drawings of normal young children (Koppitz, 1968; Machover, 1960; as cited in Ogdon, 2001), the presence of this feature in all Jane?s drawings has not been interpreted as an emotional indicator. Children particularly below the seven years of age normally draw proportionally larger heads than adults (Koppitz, 1968; Machover, 1960; Michal-Smith & Morgenstern, 1969; Urban, 1963; as cited in Ogdon, 2001), but an enlarged head in a child?s drawing does indicate an emphasis on fantasy (Hammer, 1965; Levy, 1950; as cited in Gilbert, 1980). Thus the presence of this feature in Jane?s first D-A-P drawing has not been interpreted as an emotional indicator, except to represent the use of fantasy as a defense. Ears are omitted from the figure in Jane?s first D-A-P, as well as from all figures in her K-F-D (except for the figure of Jane?s father, which has one ear). However, as this omission is considered normal particularly in children (Buck, 1950; Buck & Warren, 1992; Handler, 1985; Jolles, 1964; Machover, 1949; Urban, 1963; as cited in Ogdon, 2001), it has not been interpreted as an emotional indicator. Because empty eyes may be normal in the drawings of young children (Koppitz, 1968; Machover, 1960; Urban, 1963; as cited in Ogdon, 2001), the presence of this feature in Jane?s second D-A-P drawing has not been interpreted as an emotional indicator. Nose emphasis in children?s drawings may be normal (Machover, 1960, as cited in Ogdon, 2001), thus the large noses on the figures in Jane?s D-A-P drawings and on the figure of her mother in the K-F-D have not been interpreted using indicators relating to emphasized noses. Indicators relating to the presence of a phallic nose have, however, been used. Because drawing a concave mouth (Machover, 1960, as cited in Ogdon, 2001) and feet pointing in opposite directions is considered normal in children, indicating normal dependence and immaturity (Buck & Warren, 1992; Jolles, 1964; Urban, 1963; as cited in Ogdon, 2001), the presence of these features have not been interpreted as emotional indicators. Because a heavy line or other emphasis on the waist may be normal in children?s drawings (Machover, 1960, as cited in Ogdon, 2001), the presence of this feature has not been interpreted as an emotional indicator. Because shoulders are frequently omitted from the drawings of children below the age of 8 years (Hammer, 1965; Halpern, 1965; as cited in Gilbert, 1980), these omissions from all Jane?s drawings have not been interpreted as emotional indicators. As long fingers may be normal in children?s drawings (Hammer, 1997, as cited in Ogdon, 2001), the presence of long or large fingers in Jane?s drawings has not been interpreted as an emotional indicator. Emotional indicators relating to swollen and petal fingers have however been used. Buttons suggest normal dependency in the drawings of young children (Buck, 1966; Buck & Warren, 1992; Jolles, 1964; Machover, 1960; as cited in Ogdon, 2001). Thus the presence of this feature in the K-F-D has not been interpreted as an emotional indicator. Both Jane?s D-A-P figures meet the expected normative content criteria as listed by Koppitz (1968, as cited in Handler, 1996) for a girl of her age. All the figures in her K- F-D meet with these criteria, with the exception her mother (legs and feet are omitted) and father (feet are omitted). In the context of Jane?s D-A-P drawings, it is considered that these omissions in the K-F-D are best interpreted as emotional indicators. 4.3.3. HFD Analyses 4.3.3.1. D-A-P drawing 1 a) Introduction Jane was quite willing to draw a person, proceeding happily with the task. She drew a small figure of a girl with a wide stance, arms close to her sides, a detailed belt, short skirt, and phallic nose. She drew the head, hair, and facial features, followed by the neck, torso, left arm, right arm, left hand, and right hand. She added a large belt with three circles on it, followed by a skirt, the left leg and foot, and the right leg and foot. She asked if she could draw flowers, to which the researcher replied that she may, however she stopped drawing without adding flowers to her picture. She drew the figure slightly left of the centre of the page, at the bottom of the sheet of paper. She drew from left to right and the pace of her drawing remained relatively constant. The drawing took 2 minutes and 30 seconds to complete. b) Emotional indicators Self-concept Self-esteem and body image The drawing is a self-portrait of Jane. Low self-esteem with feelings of inadequacy is suggested by the placement of the figure on the left-hand side of page (Machover, 1949, as cited in Gilbert, 1980), placement of the figure below the midpoint (Hammer, 1958, as cited in Gilbert, 1980), placement of the drawing on the bottom of the paper (Buck, 1950; Hammer, 1958; Handler, 1985; Jolles, 1958; as cited in Ogdon, 2001), disturbed symmetry (Machover, 1949, as cited in Gilbert, 1980), frail, thin arms (Brown, 1953; Buck, 1966; Buck & Warren, 1992; Hammer, 1997; Handler, 1985; Jolles, 1964; Lezak, 1983; Machover, 1949; Mitchell, 1993; Mursell, 1969; Reznikoff & Tomblen, 1956; Urban, 1963; Wolk, 1969; as cited in Ogdon, 2001), arms dangling by the sides, an entreating facial expression, and a tiny same-sex figure (Hammer, 1958, as cited in Gilbert, 1980), and fewer than five fingers (Schildkrout, 1972, as cited in Ogdon, 2001). Dissatisfaction with her body image is indicated by the long neck (DiLeo, 1970, as cited in Ogdon, 2001). This dissatisfaction may also be implied by Jane?s wish to be a tiger ?because tigers are strong?, when asked what animal she would like to be. Conflict between the environment and herself, is suggested by the stiff arms at her sides (Mitchell, 1993, as cited in Ogdon, 2001). There are indicators of a sense of social isolation, uneasiness, or hostility. These are a withdrawn, vacant facial expression (Machover, 1949; Hammer, 1954; as cited in Gilbert, 1980), a broad, flared, hooked nose (Hammer, 1954; Levy, 1958; as cited in Gilbert, 1980), an angular body (Machover, 1949, as cited in Gilbert, 1980), a long neck (Handler, 1985; Machover, 1949; as cited in Ogdon, 2001), and arms pressed to the sides (Hammer, 1958, as cited in Gilbert, 1980). Emphasized eyes (by pressure) suggest that Jane is hypersensitive to social opinion, particularly criticism (Handler, 1985; Machover, 1958; as cited in Ogdon, 2001). Her ill-fitting clothes suggest that she perceives her social status as unsatisfying (Hammer, 1954, as cited in Gilbert, 1980). Sexuality and gender identity There are a number of sexually-oriented indicators, perhaps more than might be expected at Jane?s age, suggesting a conflict or preoccupation with sexuality. These are a large trunk (Buck, 1950; Buck & Warren, 1992; Handler, 1985; Jolles, 1971; Urban, 1963; as cited in Ogdon, 2001), elongated anatomical areas/phallic symbols (nose, neck and fingers) (Hammer, 1954, as cited in Gilbert, 1980), phallic feet (Machover, 1949, as cited in Gilbert, 1980), and an elaborate/emphasized belt (Buck, 1966; Handler, 1985; Jolles, 1964; as cited in Ogdon, 2001). Blocking of sexual and bodily impulses causing tension is suggested by the large trunk (Buck, 1950; Buck & Warren, 1992; Handler, 1985; Jolles, 1971; Urban, 1963; as cited in Ogdon, 2001), reinforced waistline (Machover, 1949; Modell & Potter, 1949; as cited in Ogdon, 2001), and unusually high waistline (Handler, 1985; Machover, 1949; as cited in Ogdon, 2001). An omitted finger indicates masturbation guilt (Machover, 1949, as cited in Gilbert, 1980) as does the inadequate hair (Hammer, 1953; Handler, 1985; as cited in Ogdon, 2001). Jane?s narratives express that she is very fond of and feels close to her ten-year old cousin, Mary. Her answers to some questions suggest that she is parentified and fantasises that she is a mother figure within her family. Her answer to the question of what she does when she is being good was, I takes Mary (her cousin) to shops and she plays and I help with her homework and I take her to sleep and she likes a hug and, when I sleep, I hug her. Sometimes, my brother takes her and he brings her to me and she hugs me. Her answer to the question of who is her favourite person was, Um, my cousin, Mary. I like my cousin because she plays with me. I drawed a picture like this of her at home and I take it with me when I go somewhere?it sleeps with me. I don?t bath it, because it gets wet Put it in the shower in a place where it?s not wet and keep on waving to her. Her answer to the question of what she does when she is being bad was ?I hit her (Mary) and shout at her. When I shout at her, she cries. I like to draw tears on her and then I?m gonna rub them out?. Personality Introversion/extroversion Although extroversive, socially outgoing tendencies are suggested by emphasized eyes (by pressure) (Handler, 1985; Machover, 1949; as cited in Ogdon, 2001), there are a number of indicators that Jane tends toward introversion, shyness, and self- consciousness. These are the placement of the drawing on the bottom of the paper (Handler, 1985; Jolles, 1952; as cited in Ogdon, 2001), placement of the drawing on the left-hand side of the page (Levy, 1950; Machover, 1949; Mitchell, 1993; Urban, 1963; as cited in Ogdon, 2001), the dim face (Hammer, 1958, as cited in Gilbert, 1980), and the small eyes (Machover, 1949, as cited in Gilbert, 1980). Defenses Some of Jane?s answers to the questions suggest either resistance or defensiveness. Her answer to the question of what to name the person she had drawn was ?Can you please choose?I have no idea?mm, me.? Her answer to the question of what makes her sad, was ?Um?nothing?. Her answer to the questions of what are the best and worst things about her, were ?Playing? and ?Um?uh?nothing? respectively. The use of reaction formations or compensatory defenses to defend against feelings of insecurity, is suggested by the uneven line pressure (Hammer, 1958; Levy, 1950; as cited in Gilbert, 1980; Machover, 1949, as cited in Ogdon, 2001), placement of the figure low on the page (Buck, 1950; Buck & Warren, 1992; DiLeo, 1973; Hammer, 1958; Jolles, 1964; Jolles & Beck, 1953; Mitchell, 1993; Mursell, 1969; Urban, 1963; as cited in Ogdon, 2001), placement of the drawing on the bottom of the paper (Buck, 1950; Hammer, 1958; Handler, 1985; Jolles, 1958; as cited in Ogdon, 2001), placement of the figure on the left-hand side of the page (Machover, 1949, as cited in Ogdon, 2001), a placating facial expression (Hammer, 1954; Machover, 1949; as cited in Gilbert, 1980), a wide stance (Buck, 1950; Buck & Warren, 1992; Jolles, 1964; as cited in Ogdon, 2001), a lack of symmetry (Hammer, 1958, as cited in Gilbert, 1980), and limp arms at the sides (Levy, 1950; Machover, 1949; Rierdan et al., 1982; as cited in Ogdon, 2001). Jane?s answer to the question of what she would like to do if she were invisible was ?She (Mary) would like to scare me and I wouldn?t know where?s Mary?. This response suggests a reaction formation to defend against Jane?s own aggressive wish to scare or abandon Mary, or may represent a projection of her own fears of being frightened and alone. Jane?s answer to the question of what she does when she is being bad, was ?I hit her (Mary) and shout at her. When I shout at her, she cries. I like to draw tears on her and then I?m gonna rub them out?. This response suggests the defense of undoing, as Jane ?undoes? or reverses her aggressive acts towards Mary (hitting and shouting at her and making her cry), by drawing and then erasing Mary?s tears. The enlarged head suggests the use of fantasy as a defense (Hammer, 1965; Levy, 1950; as cited in Gilbert, 1980). Jane?s answers to some questions about her drawing also suggest the use of fantasy as a defense. Despite the fact that Jane?s parents are struggling financially and do not have a car, much less money for holidays, her answer to the question of what she likes doing on the weekends was, I like going to Durban and going?l?lot of places and going to the zoo, going to Mauritius and all that stuff. If you say: let?s go to the zoo; I will?mmm?to the car and get in the car! Her answer to the question of what she is doing in the picture was ?Standing and looking at the sun? and to the question of what makes her happy she replied ?The sun and all the flowers?and I love smelling flowers?. These answers may represent a wish to ?re-paint? her world in bright, happy colours. Placement of the drawing on the bottom of the paper suggests that Jane tends to use fantasy and intellectualisation as defenses (Handler, 1985; Jolles, 1952; as cited in Ogdon, 2001). Autonomy/dependency Ambivalence toward striving for independence and achievement versus dependency needs is indicated by the disparity in size of the legs (Buck, 1950; Buck & Warren, 1992; Jolles, 1964; as cited in Ogdon, 2001). Although Jane?s denial of her dependency needs is suggested by the tiny mouth (Handler, 1985; Urban, 1963; as cited in Ogdon, 2001), these needs appear strong. Lack of drive/ambition/energy/achievement is indicated by thin, weak arms (Machover, 1949, as cited in Ogdon, 2001). Dependency and helplessness are indicated by placement of the drawing on the bottom of the paper (Hammer, 1958; Handler, 1985; as cited in Ogdon, 2001), and fewer than five fingers (Hammer, 1958, as cited in Gilbert, 1980). Immaturity is suggested by petal fingers (Machover, 1949, as cited in Gilbert, 1980). Placement of the figure on the bottom of the paper suggests a need for support (Buck, 1950; Hammer, 1958; Handler, 1985; Jolles, 1958; as cited in Ogdon, 2001). A crippling lack of autonomy is suggested by the presence of thin, tiny, wasted, shrunken legs with a full body (Hammer, 1958; Machover, 1949; Mitchell, 1993; Reznikoff & Tomblen, 1956; Urban, 1963; as cited in Ogdon, 2001). Impulse control The drawing suggests that Jane has relatively high levels of anger and some difficulty with impulse control. Variations in pencil pressure suggest moodiness (Machover, 1949, as cited in Gilbert, 1980) and impulsivity (Hammer, 1958; Levy, 1958; as cited in Gilbert, 1980). Impulsivity is also suggested by the moderate distortions/disproportions of the figure (Oas, 1984, as cited in Ogdon, 2001). However, low physical energy levels are suggested by the inadequate hair: (Handler, 1985; Machover, 1955; as cited in Ogdon, 2001), and inhibited tendencies are indicated by swollen hands (Machover, 1955, as cited in Ogdon, 2001). Arms pressed to the sides suggest that Jane uses passivity as a defense due to a fear of her aggressive impulses (Hammer, 1958, as cited in Gilbert, 1980). Repressed aggression is indicated by the single line mouth (Hammer, 1954; Levy, 1958; as cited in Gilbert, 1980). Overt anger and aggressive tendencies are suggested by a marked disturbance of symmetry (Koppitz, 1968, as cited in Ogdon, 2001), a wide stance (Buck, 1950; Buck & Warren, 1992; Hammer, 1969; Jolles, 1964; Machover, 1949; Urban, 1963; as cited in Ogdon, 2001), a long neck (Hammer, 1950; Levy, 1958; as cited in Gilbert, 1980), an angular body (Machover, 1949, as cited in Gilbert, 1980), and asymmetrical arms (Hammer, 1969; Koppitz, 1968; Machover, 1949; Mundy, 1972; Urban, 1963; as cited in Ogdon, 2001). The wide stance suggests assaultiveness (Machover, 1949; Shneidman, 1958; Wysocki & Wysocki, 1977; as cited in Ogdon, 2001). Psychopathology There are indicators suggesting that Jane is normal, stable, reasonably well-adjusted and has adequate contact with reality. These are drawing in normal succession (Machover, 1949; as cited in Gilbert, 1980), and a relaxed standing posture (Urban, 1963, as cited in Ogdon, 2001). However, emotional instability or disturbance is suggested by the fluctuating pencil pressure (Hammer, 1958; Levy, 1958; as cited in Gilbert, 1980), stiff arms at the sides (Koppitz, 1968, as cited in Ogdon, 2001) and the moderate distortion/disproportion of the figure (Koppitz, 1966; Mitchell, 1993; Vane & Eisen, 1962; as cited in Ogdon, 2001). There are numerous indicators of psychopathology. Depression is suggested by the placement of the drawing on the bottom of the paper (Handler, 1985; Jolles, 1952; as cited in Ogdon, 2001), placement of the figure low on the page (Buck, 1950; Buck & Warren, 1992; Halpern, 1965; Hammer, 1958; Handler, 1985; Jolles, 1964; Jolles & Beck, 1953; Levy, 1950; Machover, 1949; Mitchell, 1993; Mursell, 1969; Urban, 1963; as cited in Ogdon, 2001), placement of the figure placement below the midpoint (Hammer, 1958, as cited in Gilbert, 1980), and placement of the figure on the left-hand side of the page (Buck, 1950; Buck & Warren, 1992; Hetherington, 1952; Jolles, 1964;Mitchell, 1993; Urban, 1963; as cited in Ogdon, 2001). Anxiety is indicated by the uneven line pressure (Machover, 1949, as cited in Gilbert, 1980), placement of the drawing on the bottom of the paper (Handler, 1985; Jolles, 1952; as cited in Ogdon, 2001), placement of the drawing on the left-hand side of page (Machover, 1949, as cited in Gilbert, 1980), emphasized eyes (by pressure) especially as shaded (Machover, 1958; as cited in Ogdon, 2001), a simplified trunk (Riethmiller & Handler, 1997, as cited in Ogdon, 2001), arms close to the body (Machover, 1949, as cited in Gilbert, 1980), moderate distortions (head, trunk, legs and feet) (Handler & Reyher, 1966, as cited in Ogdon, 2001), and fragmentation inadvertently introduced (by a belt cutting off the upper torso from the lower part of the body and by wrists cutting off the hands from the arms) (Hammer, 1978; Jacks, 1969; as cited in Ogdon, 2001). Anxiety over verbal and physical aggression is suggested by Jane?s narratives. Her answer to the question of what she does not like doing was ?I don?t like fighting and swearing?. Her reply to the question of who she doesn?t like reveals anxiety over swearing, fighting, and being hit (probably either by her brother or Mary?s brother). Fears of being hit by a car while playing in the street, and of snakes are also revealed. Neurosis is suggested by the placement of the drawing low on the page (DiLeo, 1973, as cited in Ogdon, 2001), and by the elaborate/emphasized belt (Buck, 1969; Handler, 1985; Jolles, 1971; Machover, 1949; as cited in Ogdon, 2001). Obsessive- compulsivity is indicated by the hair parted in the middle (Hammer, 1958; Levy, 1958; as cited in Gilbert, 1980), the tiny mouth (Handler, 1985; Urban, 1963; as cited in Ogdon, 2001), and unnecessary detailing (on the belt) (Hammer, 1958; Levy, 1958; as cited in Gilbert, 1980). Jane displayed one of her OCD observable repeating or counting rituals (singing the ?A, b, c song?) in her answer to the question of whom she does not like. Hysteria is suggested by the long neck (Hammer, 1958; Levy, 1958; as cited in Gilbert, 1980). Paranoia is indicated by the emphasized eyes (by pressure) especially as they are dark and piercing (Deabler, 1969; Griffith & Peyman, 1959; Hammer, 1968; Handler, 1985; Jacks, 1969; Kahn & Giffen, 1960; Levy, 1958; Machover, 1958; McElhaney, 1969; Reznikoff & Nicholas, 1958; Robins et al., 1991; Schildkrout, 1972; Shneidman, 1958; Urban, 1963; as cited in Ogdon, 2001). Schizophrenia/psychosis is suggested by the malformed head (Hammer, 1981; Machover, 1949, as cited in Ogdon, 2001), inadequate hair (Hammer, 1969; Handler, 1985; Holzberg & Wexler, 1950; Hozier, 1959; as cited in Ogdon, 2001), geometric shaped body (Curran & Marengo, 1990; Hammer, 1981; Ries, 1966; as cited in Ogdon, 2001), body distortions/disproportions (Hammer, 1958; Levy, 1958; as cited in Gilbert, 1980), the absence of shoulders (Burton & Sjoberg, 1964; Evans & Marmorston, 1963; Handler, 1985; Holzberg & Wexler, 1950; McLachlan & Head, 1974; Mitchell, 1993; as cited in Ogdon, 2001), and unessential detail emphasized (belt) (Machover, 1949, as cited in Gilbert, 1980). Conflict or somatisation in the throat area is suggested by the long neck (Hammer, 1954, as cited in Gilbert, 1980; Levy, 1958, as cited in Ogdon, 2001). Schizoid tendencies are suggested by the long neck (Hammer, 1958; Levy, 1958; as cited in Gilbert, 1980). Narcissistic tendencies are indicated by the hair parted in the middle (Hammer, 1954; Levy, 1958; as cited in Gilbert, 1980), and the elaborate/emphasized belt (Handler, 1985; Machover, 1949; Mitchell, 1993; as cited in Ogdon, 2001). Organicity is suggested by placement of the drawing on the bottom of the paper (Michal-Smith & Morgenstern, 1969, as cited in Ogdon, 2001), the malformed head (Hammer, 1981; McElhaney, 1969; Schildkrout, 1972; as cited in Ogdon, 2001; Machover, 1949, as cited in Gilbert, 1980), inadequate hair (McLachlan & Head, 1974; as cited in Ogdon, 2001), marked disturbance of symmetry (Koppitz, 1968, as cited in Ogdon, 2001), asymmetrical limbs (Hammer, 1969; Koppitz, 1968; Machover, 1949; Mundy, 1972; Urban, 1963; as cited in Ogdon, 2001), fewer than five fingers (Koppitz, 1968, as cited in Ogdon, 2001), and fragmentation inadvertently introduced (Lezak, 1983; McLachlan & Head, 1974; Mitchell, 1993; as cited in Ogdon, 2001). 4.3.3.2. D-A-P drawing 2 a) Introduction Once again, Jane was quite willing to draw a person and proceeded happily. She drew the small figure of a boy with a wide, unbalanced stance and arms close to his sides. He is drawn with sparse, spiky hair, a phallic nose, vacant eyes, and disproportionate limbs. There are pockets and wavy lines on his trousers and shading in his genital area. Jane drew the head, ears, facial features, and hair first, followed by the neck, torso, left arm and right arm. She added the left and right hands then drew trousers, starting with the left leg. She drew pockets and wavy lines on the trousers and shaded the genital area. As she drew the shading she said, ?I?m drawing a zip, a zip here?, as she pointed to the genital area of the figure. She drew the left ankle and foot and then the right ankle and foot. She drew the figure to the left of the centre of the page, at the bottom of the sheet of paper. She drew from left to right and the pace of her drawing remained relatively constant. The drawing took 4 minutes and 35 seconds to complete. b) Emotional indicators Self-concept Self-esteem and body image Low self-esteem with feelings of inadequacy is suggested by the placement of the figure on the left-hand side of the page (Machover, 1949, as cited in Gilbert, 1980), placement of the drawing on the bottom of the paper (Buck, 1950; Hammer, 1958; Handler, 1985; Jolles, 1958; as cited in Ogdon, 2001), placement of the figure below the midpoint (Hammer, 1958, as cited in Gilbert, 1980), disturbed symmetry (Machover, 1949, as cited in Gilbert, 1980), frail, thin arms (Brown, 1953; Buck, 1966; Buck & Warren, 1992; Hammer, 1997; Handler, 1985; Jolles, 1964; Lezak, 1983; Machover, 1949; Mitchell, 1993; Mursell, 1969; Reznikoff & Tomblen, 1956; Urban, 1963; Wolk, 1969; as cited in Ogdon, 2001), and fewer than five fingers (Schildkrout, 1972, as cited in Ogdon, 2001). Midline emphasis (pockets on trousers, belt and shading in genital area) suggests a poor self-concept with feelings of inferiority, especially physical inferiority (Bodwin & Bruck, 1960; Machover, 1949; Rierdan et al., 1982; Urban, 1963; as cited in Ogdon, 2001). Body image dissatisfaction is suggested by the long neck (DiLeo, 1970, as cited in Ogdon, 2001). The ill-fitting clothes suggest a perception of her social status as unsatisfying (Hammer, 1954, as cited in Gilbert, 1980), Conflict between the self and the environment, is suggested by the stiff arms at the figure?s sides (Mitchell, 1993, as cited in Ogdon, 2001). A sense of social isolation/uneasiness or even hostility is suggested by the withdrawn, vacant facial expression (Machover, 1949; Hammer, 1954; as cited in Gilbert, 1980), a broad, flared, hooked nose (Hammer, 1954; Levy, 1958; as cited in Gilbert, 1980), an angular body (Machover, 1949, as cited in Gilbert, 1980), a long neck (Handler, 1985; Machover, 1949; as cited in Ogdon, 2001), and arms pressed to the sides (Hammer, 1958, as cited in Gilbert, 1980). Jane named the figure in her drawing ?Wilson? (her cousin). Her narratives suggest that she perceives ?Wilson? as aggressive towards Jane and his sister, Mary. Her narratives imply that she assumes a protective role over Mary against ?Wilson?. Sexuality and gender identity There are a number of sexually-oriented indicators, suggesting a conflict or preoccupation with sexuality. These are the large trunk (Buck, 1950; Buck & Warren, 1992; Handler, 1985; Jolles, 1971; Urban, 1963; as cited in Ogdon, 2001), elongated anatomical areas/phallic symbols (nose, neck, fingers and left foot) (Hammer, 1954, as cited in Gilbert, 1980), phallic feet (Machover, 1949, as cited in Gilbert, 1980), and an emphasized trouser fly (McElhaney, 1969, as cited in Ogdon, 2001). Blocking of sexual and bodily impulses causing tension is suggested by the large trunk (Buck, 1950; Buck & Warren, 1992; Handler, 1985; Jolles, 1971; Urban, 1963; as cited in Ogdon, 2001), and reinforced waistline (Machover, 1949; Modell & Potter, 1949; as cited in Ogdon, 2001). An omitted finger indicates masturbation guilt (Machover, 1949, as cited in Gilbert, 1980), as does the inadequate hair (Hammer, 1953; Handler, 1985; as cited in Ogdon, 2001). Jane?s answers to some questions indicate that she is parentified and has fantasies of being a mother figure within her family. Her answer to the question of what ?Wilson? doesn?t like doing was, Fighting with his sister. But his sister doesn?t like and when Wilson hits his sister, she cries and she hits him back and I shout at them. It makes me angry when they fight, cos some of them get hurt. I like gyming and running with them and I run fast with them and I like to hold their hands and run fast and I just make them open their mouths like they?re laughing. Her answer to the question of what ?Wilson? does when he?s being good was, I ask my father to take us to MacDonald?s and I take them with and my father takes us. I like going to MacDonald?s cos you play and you have fun and it?s so close to my house, so I can even walk Wilson and Mary there with my brother. Her answer to the question of what ?Wilson? likes to do on weekends was ?Nothing?I just take him to zoo. My father takes me, Mary and Wilson to the zoo and my brother, my father and my mother??. Her answer to the question of what ?Wilson? does when he?s being bad was ?He shouts at me and I say: Stop it, else you?ll go to bed??. Personality Introversion/extroversion There are indicators to suggest tendencies toward introversion, shyness and self- consciousness. These are placement of the drawing on the bottom of the paper (Handler, 1985; Jolles, 1952; as cited in Ogdon, 2001), placement of the drawing on the left-hand side of the page (Levy, 1950; Machover, 1949; Mitchell, 1993; Urban, 1963; as cited in Ogdon, 2001), a dim face (Hammer, 1958, as cited in Gilbert, 1980), and small eyes (Machover, 1949, as cited in Gilbert, 1980). Defenses Some of Jane?s answers to questions asked about ?Wilson? suggest either resistance or defensiveness. Her answer to the question of what is the best thing about ?Wilson? was ?I don?t know?. To the question of whether ?Wilson? reminds her of anyone, she replied, ?I don?t know?, despite the fact that she had already identified ?Wilson? as her cousin (by stating that her cousin, Mary, is his sister). Possible reaction formations or compensatory defenses to defend against feelings of insecurity are suggested by the uneven line pressure (Hammer, 1958; Levy, 1950; as cited in Gilbert, 1980; Machover, 1949, as cited in Ogdon, 2001), placement of the drawing on the bottom of the paper (Buck, 1950; Hammer, 1958; Handler, 1985; Jolles, 1958; as cited in Ogdon, 2001), placement of the figure low on the page (Buck, 1950; Buck & Warren, 1992; DiLeo, 1973; Hammer, 1958; Jolles, 1964; Jolles & Beck, 1953; Mitchell, 1993; Mursell, 1969; Urban, 1963; as cited in Ogdon, 2001), placement of the figure on the left-hand side of the page (Machover, 1949, as cited in Ogdon, 2001), a placating facial expression (Hammer, 1954; Machover, 1949; as cited in Gilbert, 1980), lack of symmetry (Hammer, 1958, as cited in Gilbert, 1980), a wide stance (Buck, 1950; Buck & Warren, 1992; Jolles, 1964; as cited in Ogdon, 2001), limp arms at the sides (Levy, 1950; Machover, 1949; Rierdan et al., 1982; as cited in Ogdon, 2001), and midline emphasis (pockets on the trousers, belt and shading in the genital area) (Bodwin & Bruck, 1960; Machover, 1949; Rierdan et al., 1982; Urban, 1963; as cited in Ogdon, 2001). Placement of the drawing on the bottom of the paper suggests the use of fantasy and intellectualisation as defenses (Handler, 1985; Jolles, 1952; as cited in Ogdon, 2001). Autonomy/dependency Ambivalence toward striving for independence and achievement versus dependency needs is indicated by the disparity in size of the legs (Buck, 1950; Buck & Warren, 1992; Jolles, 1964; as cited in Ogdon, 2001). Jane?s dependency needs appear to be strong. Lack of drive/ambition/energy/achievement is indicated by thin, weak arms (Machover, 1949, as cited in Ogdon, 2001). A crippling lack of autonomy is implied by thin, tiny, wasted, shrunken legs with a full body (Hammer, 1958; Machover, 1949; Mitchell, 1993; Reznikoff & Tomblen, 1956; Urban, 1963; as cited in Ogdon, 2001). Dependency and helplessness are indicated by placement of the drawing on the bottom of the paper (Hammer, 1958; Handler, 1985; as cited in Ogdon, 2001), and fewer than five fingers (Hammer, 1958, as cited in Gilbert, 1980). Placement of the figure on the bottom of the paper suggests a need for support (Buck, 1950; Hammer, 1958; Handler, 1985; Jolles, 1958; as cited in Ogdon, 2001). Immaturity is indicated by petal fingers (Machover, 1949, as cited in Gilbert, 1980). Impulse control As in her first drawing, this drawing suggests that Jane has relatively high levels of anger and some difficulty with impulse control. Variations in pencil pressure suggest moodiness (Machover, 1949, as cited in Gilbert, 1980) and impulsivity (Hammer, 1958; Levy, 1958; as cited in Gilbert, 1980). Impulsivity is also suggested by the moderate distortions/disproportions of the figure (Oas, 1984, as cited in Ogdon, 2001), and difficulty controlling impulses is indicated by horizontal stripes on the trousers (Schildkrout, 1972, as cited in Ogdon, 2001). However, low physical energy levels are suggested by the inadequate hair (Handler, 1985; Machover, 1955; as cited in Ogdon, 2001), and inhibited tendencies are indicated by swollen hands (Machover, 1955, as cited in Ogdon, 2001). Arms pressed to the sides suggest passivity as a defense due to a fear of her aggressive impulses (Hammer, 1958, as cited in Gilbert, 1980). Repressed aggression is indicated by the single line mouth (Hammer, 1954; Levy, 1958; as cited in Gilbert, 1980), while overt anger and aggressive tendencies are suggested by the marked disturbance of symmetry (Koppitz, 1968, as cited in Ogdon, 2001), wide stance (Buck, 1950; Buck & Warren, 1992; Hammer, 1969; Jolles, 1964; Machover, 1949; Urban, 1963; as cited in Ogdon, 2001), long neck (Hammer, 1950; Levy, 1958; as cited in Gilbert, 1980, angular body (Machover, 1949, as cited in Gilbert, 1980), and asymmetrical arms (Hammer, 1969; Koppitz, 1968; Machover, 1949; Mundy, 1972; Urban, 1963; as cited in Ogdon, 2001). The wide stance indicates assaultiveness (Machover, 1949; Shneidman, 1958; Wysocki & Wysocki, 1977; as cited in Ogdon, 2001). Psychopathology There are indicators that Jane is normal, stable, reasonably well-adjusted, and has adequate contact with reality. These are drawing in normal succession (Machover, 1949; as cited in Gilbert, 1980), and a relaxed standing posture (Urban, 1963, as cited in Ogdon, 2001). However emotional instability or disturbance is suggested by the fluctuating pencil pressure (Hammer, 1958; Levy, 1958; as cited in Gilbert, 1980), stiff arms at the sides (Koppitz, 1968, as cited in Ogdon, 2001) and the moderate distortion/disproportion of the figure (Koppitz, 1966; Mitchell, 1993; Vane & Eisen, 1962; as cited in Ogdon, 2001). There are numerous indicators of psychopathology. There are no indicators of narcissistic tendencies or paranoia, as there were in Jane?s first D-A-P drawing. Otherwise, the quantity of indicators for each category of psychopathology are similar to those present in her first D-A-P drawing. Depression is suggested by the placement of the drawing on the bottom of the paper (Handler, 1985; Jolles, 1952; as cited in Ogdon, 2001), placement of the figure low on the page (Buck, 1950; Buck & Warren, 1992; Halpern, 1965; Hammer, 1958; Handler, 1985; Jolles, 1964; Jolles & Beck, 1953; Levy, 1950; Machover, 1949; Mitchell, 1993; Mursell, 1969; Urban, 1963; as cited in Ogdon, 2001), placement of the figure below the midpoint (Hammer, 1958, as cited in Gilbert, 1980), and placement of the figure on the left-hand side of the page (Buck, 1950; Buck & Warren, 1992; Hetherington, 1952; Jolles, 1964;Mitchell, 1993; Urban, 1963; as cited in Ogdon, 2001). Anxiety is indicated by the uneven line pressure (Machover, 1949, as cited in Gilbert, 1980), placement of the drawing on the bottom of the paper (Handler, 1985; Jolles, 1952; as cited in Ogdon, 2001), placement of the drawing on the left-hand side of the page (Machover, 1949, as cited in Gilbert, 1980), the simplified trunk (Riethmiller & Handler, 1997, as cited in Ogdon, 2001), arms close to the body (Machover, 1949, as cited in Gilbert, 1980), moderate distortions (trunk, arms, legs, hands and feet). (Handler & Reyher, 1966, as cited in Ogdon, 2001), fragmentation inadvertently introduced (by the belt cutting off the upper torso from the lower body, shading in the genital area cutting off the legs from one another, and wrists cutting off the hands from the arms) (Hammer, 1978; Jacks, 1969; as cited in Ogdon, 2001), and inconsistent treatment of male and female drawings (Haworth, 1962, as cited in Ogdon, 2001). Neurosis is suggested by the placement of the drawing low on the page (DiLeo, 1973, as cited in Ogdon, 2001). Obsessiveness is indicated by the inconsistent treatment of male and female drawings (Haworth, 1962, as cited in Ogdon, 2001). Obsessive-compulsivity is suggested by unnecessary detailing (on trousers and left shoe) (Hammer, 1958; Levy, 1958; as cited in Gilbert, 1980), overdetailed shoes (large, square left shoe with heel) (Buck & Warren, 1992; Levine & Sapolsky, 1969; Machover, 1949; Urban, 1963; as cited in Ogdon, 2001; Hammer, 1954; Levy, 1958; as cited in Gilbert, 1980), and striped clothing (trousers) (Schildkrout, 1972, as cited in Ogdon, 2001). Hysteria is suggested by the long neck (Hammer, 1958; Levy, 1958; as cited in Gilbert, 1980). Schizophrenia/psychosis is suggested by inadequate hair (Hammer, 1969; Handler, 1985; Holzberg & Wexler, 1950; Hozier, 1959; as cited in Ogdon, 2001), a geometric shaped body (Curran & Marengo, 1990; Hammer, 1981; Ries, 1966; as cited in Ogdon, 2001), body distortions/disproportions (Hammer, 1958; Levy, 1958; as cited in Gilbert, 1980), and unessential detail emphasized (trouser details, left shoe details) (Machover, 1949, as cited in Gilbert, 1980). Conflict or somatisation in the throat area, is indicated by the long neck (Hammer, 1954, as cited in Gilbert, 1980; Levy, 1958, as cited in Ogdon, 2001). Schizoid tendencies are suggested by the long neck (Hammer, 1958; Levy, 1958; as cited in Gilbert, 1980), and midline emphasis (pockets on the trousers, belt and shading in the genital area) (Machover, 1949, as cited in Gilbert, 1980). Organicity is indicated by the placement of the drawing on the bottom of the paper (Michal-Smith & Morgenstern, 1969, as cited in Ogdon, 2001), inadequate hair (McLachlan & Head, 1974; as cited in Ogdon, 2001), marked disturbance of symmetry (Koppitz, 1968, as cited in Ogdon, 2001), asymmetrical limbs (Hammer, 1969; Koppitz, 1968; Machover, 1949; Mundy, 1972; Urban, 1963; as cited in Ogdon, 2001), fewer than five fingers (Koppitz, 1968, as cited in Ogdon, 2001), and fragmentation inadvertently introduced (Lezak, 1983; McLachlan & Head, 1974; Mitchell, 1993; as cited in Ogdon, 2001). 4.3.3.3. K-F-D analysis a) Introduction Jane drew a small, girlish figure on the left-hand bottom part of the page (her mother). She started with the head, hair, and facial features then added the neck and a long, triangular torso. She drew the left arm and hand, right arm and hand, adding a piece of paper in the left hand with horizontal, wavy lines on it. She drew a knife- like object in the right hand. She omitted legs and feet from the drawing. Then she drew a small, boyish figure in the middle of the bottom area of the page (her father). She experienced some difficulty in drawing the figure, but persisted. She drew the head, hair and facial features, and one ear on the top right side of the head. She drew a long, triangular neck and a square trunk, followed by the left arm and hand and the right arm and hand. She drew a piece of paper in the right hand with horizontal, wavy lines on it. She drew legs, starting with the left side but omitted feet With great difficulty, she drew a distorted chair encapsulating the figure, except for his head. She added numerous carelessly drawn, horizontal lines within the frame of the chair. Finally, she drew the small, babyish figure of a girl (herself) to the right of her father. She drew a face, two dim eyes, a dim mouth, hair, and a crown. She added a neck and a triangular body decorated with flowers and light, wavy horizontal lines. She drew the left arm and hand, the right arm and hand, and a small, shaded rectangular object in the right hand. She drew the left leg and foot and right leg and foot. She said she was finished and that she had forgotten to draw her brother and sister. The researcher placed crosses where she said she would have drawn them (her brother to the left of her mother and sister to the right of herself). She drew from left to right and the pace of his drawing remained relatively constant, except for drawing the figure of her father, which she struggled with and took a long time to draw. The drawing took 8 minutes and 30 seconds to complete. b) Emotional indicators Self-concept Self-esteem and body image Jane drew herself last, suggesting low self-esteem and a perception that she is the least important person within the family (Reynolds, 1978). Other indicators of low self-esteem with feelings of inadequacy are placement of the drawing on the bottom of the paper (Buck, 1950; Hammer, 1958; Handler, 1985; Jolles, 1958; as cited in Ogdon, 2001), placement of all figures below the midpoint (Hammer, 1958, as cited in Gilbert, 1980), disturbed symmetry on all figures (Machover, 1949, as cited in Gilbert, 1980), and clothes too big for Jane?s figure (Buck, 1950; Hammer, 1958; as cited in Ogdon, 2001). Jane?s answer to the question of what she would change about her family if she could change one thing was ?I would change the house and I would change the beds and the dishes and the cars. That?s all.? This implies an awareness of and dissatisfaction with her social status. Indicators to suggest that Jane feels a sense of social isolation, uneasiness or hostility, are the withdrawn, vacant facial expressions of all figures (Machover, 1949; Hammer, 1954; as cited in Gilbert, 1980), and the parents? long necks (Handler, 1985; Machover, 1949; as cited in Ogdon, 2001). Interpersonal family dynamics The drawing as a whole gives a sense of insecurity, rigidity, and coldness. There is a lack of movement between the figures and a sense of disconnectedness. Everyone is engaged in their own activity, no-one is facing anyone else and there is no physical contact between them. The family members have barriers between them (objects in their hands), indicating isolation and conflict (Reynolds, 1978). All the figures have arm extensions (objects in their hands), suggesting that Jane perceives each one as unstable in their own right and as needing help to cope with one other and the outside world (Reynolds, 1978). Placement of the drawing on the bottom of the paper further suggests a need for support (Buck, 1950; Hammer, 1958; Handler, 1985; Jolles, 1958; as cited in Ogdon, 2001). Jane?s parents are drawn far apart from one another, suggesting a lack of closeness (Hammer, 1968, as cited in Gilbert, 1980). Communication difficulties are suggested by their long necks, indicating conflict in the throat (speech) area (Hammer, 1958; Levy, 1958; as cited in Gilbert, 1980). Their angular bodies suggest a tendency to criticise (Machover, 1949, as cited in Gilbert, 1980). The object in Jane?s mother?s hand (a pen) is sharp and angular like a spear and is pointed at Jane?s father?s head. Jane drew her father and herself as the smallest figures in the family, indicating a perception of their inadequacy within the family (Alschuler & Hattwick, 1949; Buck, 1950; Buck & Warren, 1992; Delatte & Hendrikson, 1982; DiLeo, 1973; Gray & Pepitone, 1964; Hammer, 1997; Handler, 1985; Jacks, 1969; Jolles, 1964; Koppitz, 1968; Lakin, 1956; Lehner & Gunderson, 1948; Levy, 1958; Ludwig, 1969; Marzolf & Kirchner, 1972; McElhany, 1969; McHugh, 1966; Michal-Smith & Morgenstern, 1969; Mitchell, 1993; Mundy, 1972; Ottenbacher, 1981; Precker, 1950; Riklan, 1962; Urban, 1963; as cited in Ogdon, 2001; Reynolds, 1978). There are numerous indicators that Jane perceives her father as inadequate, critical and a potential source of anxiety or threat. Feelings of inadequacy are suggested by her father?s frail, thin arms (Brown, 1953; Buck, 1966; Buck & Warren, 1992; Hammer, 1997; Handler, 1985; Jolles, 1964; Lezak, 1983; Machover, 1949; Mitchell, 1993; Mursell, 1969; Reznikoff &Tomblen, 1956; Urban, 1963; Wolk, 1969; as cited in Ogdon, 2001), hanging limply at his sides (Levy, 1950; Machover, 1949; Rierdan et al., 1982; as cited in Ogdon, 2001) and his long neck (DiLeo, 1970, as cited in Ogdon, 2001). His vague, dim hands suggest low self-esteem or a lack of productivity (Coopersmith, Sakai, Beardsley & Coopersmith, 1976; Machover, 1949; as cited in Ogdon, 2001). His dishevelled, unkempt figure suggests a perceived lack of status (Hammer, 1958, as cited in Gilbert, 1980). Social isolation is implied by his withdrawn, vacant facial expression (Machover, 1949; Hammer, 1954; as cited in Gilbert, 1980) and arms pressed to his sides (Hammer, 1958, as cited in Gilbert, 1980). Emphasized eyes (by pressure) suggest hypersensitivity to social opinion, particularly criticism (Handler, 1985; Machover, 1958; as cited in Ogdon, 2001). Jane has compartmentalized her father, which serves to isolate, as she perceives him as a potential source of anxiety or threat to the rest of the family (Burns & Kaufman, 1972). However she has positioned herself next to him, with a hand stretched out towards him, which may indicate a wish to ?reach out? and be closer to him. Jane omitted her 19-year old brother and her 12 year-old sister from the drawing. The researcher ascertained from Jane?s mother that Jane is not close to her siblings. These omissions indicate rejection, denial and/or isolation and subtle conflict with her siblings (Burns & Kaufman, 1972). Jane?s answer to the question of how everyone in the family gets along indicates antagonism between her brother and herself. She expressed that they don?t like one other, frequently fight and that ?He?s the worst, worst brother in the world?. Her relationship with her brother causes her distress (?He makes me so, so sad?cos sometimes I fight with him?). Jane?s narratives to the drawing again express that she feels close to her cousin, Mary. In her answer to the question of who the favourite person in the family is, she expressed that Mary is her favourite person. Sexuality and gender Identity As in Jane?s D-A-P drawings, there are numerous sexually-oriented indicators, suggesting a preoccupation with sexuality. These are messy hair on the parents (Buck, 1950; DiLeo, 1970; Hammer, 1954; Handler, 1985; Jolles, 1964; Levy, 1958; Machover, 1951; Roback, 1968; Urban, 1963; as cited in Ogdon, 2001), large trunks of Jane and her mother (Buck, 1950; Buck & Warren, 1992; Handler, 1985; Jolles, 1971; Urban, 1963; as cited in Ogdon, 2001), elongated anatomical areas/phallic symbols (mother?s pen and nose, necks of parents, arms and fingers of Jane and mother, Jane?s feet) (Hammer, 1954, as cited in Gilbert, 1980), elongated hands on the figures of Jane and her mother (Buck, 1966; Buck & Warren, 1992; Hammer, 1953; Handler, 1985; Jolles, 1964; Mitchell, 1993; Urban, 1963; Wysocki & Wysocki, 1977; as cited in Ogdon, 2001; Machover, 1949, as cited in Gilbert, 1980), and phallic feet on the figure of Jane (Machover, 1949, as cited in Gilbert, 1980). Blocking of sexual and bodily impulses causing tension is suggested by the large trunks of Jane and her mother (Buck, 1950; Buck & Warren, 1992; Handler, 1985; Jolles, 1971; Urban, 1963; as cited in Ogdon, 2001), the reinforced waistline of her father (Machover, 1949; Modell & Potter, 1949; as cited in Ogdon, 2001), and the unusually high waistline of her father (Handler, 1985; Machover, 1949; as cited in Ogdon, 2001). An omitted finger indicates masturbation guilt (Machover, 1949, as cited in Gilbert, 1980), as does the inadequate hair on the figure of Jane (Hammer, 1953; Handler, 1985; as cited in Ogdon, 2001). Jane seems to identify with her mother as their figures are drawn in a similar style (parted hair of similar length, triangular trunks of long dresses, similar arms, large petal fingers, fewer than five fingers). Jane and her mother are drawn with overextended, reaching arms, revealing a desire for affection (Machover, 1949, as cited in Gilbert, 1980). Jane has drawn her mother and herself with long skirts, suggesting that they are mother figures (Machover, 1949, as cited in Gilbert, 1980). These indicators, together with the indications of her father?s inadequacy above, imply that Jane perceives herself as parentified within her family. Jane?s answer to the question of who the favourite person in the family is supports the notion that she is parentified and has fantasies that she is a mother figure within her family. Her answer was ??My favourite is my little cousin, but my cousin?s bigger than me?ten years old and when I go to see her, I play with her?. Personality Introversion/extroversion There are indicators to suggest tendencies toward introversion, shyness, and self- consciousness. These are Jane?s dim face (Hammer, 1958, as cited in Gilbert, 1980) and Jane?s small eyes (Machover, 1949, as cited in Gilbert, 1980). Defenses Some of Jane?s answers to questions about the family suggest either resistance or defensiveness. Her answers to the questions of what are the best and worst things about her family were ?I don?t know? and ?[t]he worstest thing is?I have no idea? respectively. Her answer to the question of what things the family like to do together was ?[t]hey mm, like to play and do all that stuff. I forgot?? and to the question of who the favourite person in the family is, she replied, ?[u]h, no-one?? Possible reaction formations or compensatory defenses to defend against feelings of insecurity, are suggested by the uneven line pressure (Hammer, 1958; Levy, 1950; as cited in Gilbert, 1980; Machover, 1949, as cited in Ogdon, 2001), placement of the figures low on the page (Buck, 1950; Buck & Warren, 1992; DiLeo, 1973; Hammer, 1958; Jolles, 1964; Jolles & Beck, 1953; Mitchell, 1993; Mursell, 1969; Urban, 1963; as cited in Ogdon, 2001), placement of the drawing on the bottom of the paper (Buck, 1950; Hammer, 1958; Handler, 1985; Jolles, 1958; as cited in Ogdon, 2001), the placating facial expressions of all figures (Hammer, 1954; Machover, 1949; as cited in Gilbert, 1980), a lack of symmetry (Hammer, 1958, as cited in Gilbert, 1980), and Jane?s wide stance (Buck, 1950; Buck & Warren, 1992; Jolles, 1964; as cited in Ogdon, 2001). Placement of the drawing on the bottom of the paper suggests the use of fantasy and intellectualisation as defenses (Handler, 1985; Jolles, 1952; as cited in Ogdon, 2001). Autonomy/dependency Ambivalence toward striving for independence and achievement versus dependency needs is indicated by the disparity in size of Jane?s legs (Buck, 1950; Buck & Warren, 1992; Jolles, 1964; as cited in Ogdon, 2001). Although Jane?s denial of her dependency needs is suggested by her tiny mouth (Handler, 1985; Urban, 1963; as cited in Ogdon, 2001), these needs appear very strong. Lack of drive/ambition/energy/achievement is indicated by her thin, weak arms (Machover, 1949, as cited in Ogdon, 2001). A crippling lack of autonomy is suggested by the thin, tiny, wasted, shrunken legs with a full body on the figure of Jane (Hammer, 1958; Machover, 1949; Mitchell, 1993; Reznikoff & Tomblen, 1956; Urban, 1963; as cited in Ogdon, 2001). Omission of legs on the figure of Jane?s mother suggests a feeling of immobility (Buck & Warren, 1992; Michal-Smith & Morgenstern, 1969; Mitchell, 1993; as cited in Ogdon, 2001), as do the short legs of Jane and her father, particularly as they are very short (Buck, 1950; Buck & Warren, 1992; Handler, 1985; Jolles, 1964; Urban, 1963; as cited in Ogdon, 2001). The large hands of Jane and her mother suggest feelings of weakness (Machover, 1949, as cited in Gilbert, 1980). Dependency and helplessness are indicated by placement of the drawing on the bottom of the paper (Hammer, 1958; Handler, 1985; as cited in Ogdon, 2001) and the presence of fewer than five fingers on Jane?s left hand (Hammer, 1958, as cited in Gilbert, 1980). Jane?s parents are depicted as younger than their years, suggesting emotional immaturity (Machover, 1949; McElhaney, 1969; Meyer, 1955; Urban, 1963; as cited in Ogdon, 2001) and dependency needs (McElhaney, 1969; Urban, 1963; as cited in Ogdon, 2001). Immaturity is suggested by the petal fingers (Machover, 1949, as cited in Gilbert, 1980). Impulse control As in Jane?s D-A-P drawings, her K-F-D suggests relatively high levels of anger and some difficulty with impulse control. Although inhibited tendencies are indicated by Jane?s swollen hands (Machover, 1955, as cited in Ogdon, 2001), and dim facial features (Levy, 1958; Machover, 1949; Urban, 1963; as cited in Ogdon, 2001), the variations in pencil pressure suggest moodiness (Machover, 1949, as cited in Gilbert, 1980), and impulsivity (Hammer, 1958; Levy, 1958; as cited in Gilbert, 1980). Impulsivity is also suggested by the moderate distortions/disproportions of the figures (Oas, 1984, as cited in Ogdon, 2001), as well as the large hands on the figures of Jane and her mother (Buck, 1966; Buck & Warren, 1992; Jolles, 1952; as cited in Ogdon, 2001) and the jagged lines the figures (Hammer, 1965; Krout, 1950; Machover, 1951; Urban, 1963; Waehner, 1946; as cited in Ogdon, 2001). Tight collars on all the figures suggest difficulty controlling anger or primitive drives (Hammer, 1958; Levy, 1958; as cited in Gilbert, 1980), as do the horizontal stripes on Jane?s dress (Schildkrout, 1972, as cited in Ogdon, 2001). Repressed aggression is indicated by the single line mouths of all figures (Hammer, 1954; Levy, 1958; as cited in Gilbert, 1980), the small trunk of Jane?s father (Buck, 1950; Buck & Warren, 1992; Handler, 1985; Jolles, 1964; Urban, 1963; as cited in Ogdon, 2001), and the long necks of Jane?s parents (Hammer, 1954; Levy, 1958; as cited in Gilbert, 1980). Overt anger and aggressive tendencies are suggested by the marked disturbance of symmetry (Koppitz, 1968, as cited in Ogdon, 2001), wide stance of Jane (Buck, 1950; Buck & Warren, 1992; Hammer, 1969; Jolles, 1964; Machover, 1949; Urban, 1963; as cited in Ogdon, 2001), long necks of Jane?s parents (Hammer, 1950; Levy, 1958; as cited in Gilbert, 1980), angular bodies of all figures (Machover, 1949, as cited in Gilbert, 1980), asymmetrical limbs of all figures (Hammer, 1969; Koppitz, 1968; Machover, 1949; Mundy, 1972; Urban, 1963; as cited in Ogdon, 2001), large hands on figures of Jane and mother (Handler, 1985; Shneidman, 1958; as cited in Ogdon, 2001), and Jane?s emphasized feet (Hammer, 1954; Machover, 1958; Schildkrout, 1972; Shneidman, 1958; Urban, 1963; as cited in Ogdon, 2001). Assaultiveness is indicated by Jane?s wide stance (Machover, 1949; Shneidman, 1958; Wysocki & Wysocki, 1977; as cited in Ogdon, 2001), and Jane?s emphasized feet (Hammer, 1954; Machover, 1958; as cited in Gilbert, 1980). Psychopathology As with Jane?s D-A-P drawings, there are indicators she is normal, stable, reasonably well-adjusted, and has adequate contact with reality. These are drawing in normal succession (Machover, 1949, as cited in Gilbert, 1980), and a relaxed standing posture (Urban, 1963, as cited in Ogdon, 2001). Basic psychological integrity is suggested by the match between the visible actions of the figures with Jane?s verbal descriptions of what they are doing (Reynolds, 1978). However, emotional instability or disturbance is suggested by fluctuating pencil pressure (Hammer, 1958; Levy, 1958; as cited in Gilbert, 1980) and the moderate distortion/disproportion of the figures (Koppitz, 1966; Mitchell, 1993; Vane & Eisen, 1962; as cited in Ogdon, 2001). There are numerous indicators of psychopathology. As in Jane?s first D-A-P drawing, there are indicators of narcissistic tendencies and paranoia. There are twice as many indicators of obsessive-compulsivity in her K-F-D, as in Jane?s D-A-P drawings. Otherwise, the quantity of indicators for each category of psychopathology are similar to those present in her D-A-P drawings. Depression is suggested by placement of the drawing on the bottom of the paper (Handler, 1985; Jolles, 1952; as cited in Ogdon, 2001), placement of the figure low on the page (Buck, 1950; Buck & Warren, 1992; Halpern, 1965; Hammer, 1958; Handler, 1985; Jolles, 1964; Jolles & Beck, 1953; Levy, 1950; Machover, 1949; Mitchell, 1993; Mursell, 1969; Urban, 1963; as cited in Ogdon, 2001), and placement of the figure below the midpoint (Hammer, 1958, as cited in Gilbert, 1980). In Jane?s answer to the question about how she feels about herself, she expressed that she feels sad because ?a lot of people dying has made me so sad?. This reveals sadness related to the death of loved ones. The researcher ascertained from Jane?s mother that the only death in the family since Jane?s birth was that of Jane?s grandfather when Jane was five years old. His death was the precipitating event prior to the onset of her OCD symptoms. Jane?s statement that there have been ?a lot of people dying? reveals that her grandfather?s death has confused her and affected her deeply and continues to affect her, suggesting depression. Anxiety is suggested by uneven line pressure (Machover, 1949, as cited in Gilbert, 1980), jagged lines (Hammer, 1965; Krout, 1950; Machover, 1951; Urban, 1963; Waehner, 1946; as cited in Ogdon, 2001), placement of the drawing on the bottom of the paper (Handler, 1985; Jolles, 1952; as cited in Ogdon, 2001), emphasized eyes (by pressure) especially as shaded on the figures of Jane?s parents (Machover, 1958; as cited in Ogdon, 2001), the simplified trunks of all the figures (Riethmiller & Handler, 1997, as cited in Ogdon, 2001), the moderate distortion/disproportion of all figures (Handler & Reyher, 1966, as cited in Ogdon, 2001), the unbalanced stance of Jane?s father (Machover, 1949, as cited in Gilbert, 1980), fragmentation inadvertently introduced (by lines of the father?s chair that have the effect of fragmenting his body) (Hammer, 1978; Jacks, 1969; as cited in Ogdon, 2001), inconsistent treatment of male and female figures (Haworth, 1962, as cited in Ogdon, 2001), and excessive detail (Machover, 1949, as cited in Gilbert, 1980). Neurosis is suggested by midline emphasis on the figure of Jane (Machover, 1949, as cited in Gilbert, 1980), and excessive detail (chair over Jane?s father, writing on page in hand of Jane?s mother, Jane?s dress and boots) (Buck, 1966; Buck & Warren, 1992; Deabler, 1969; Hammer, 1969; Handler, 1985; Jacks, 1969; Kahn & Giffen, 1960; Levy, 1958; Machover, 1949; McElhaney, 1969; Reynolds, 1978; as cited in Ogdon, 2001). Obsessiveness is suggested by the inconsistent treatment of male and female figures (Haworth, 1962, as cited in Ogdon, 2001), and excessive detail (Machover, 1949, as cited in Gilbert, 1980). Obsessive-compulsivity is indicated by the small size of all the figures (Schildkrout, 1972, as cited in Ogdon, 2001), hair parted in the middle on the figures of Jane and her mother (Hammer, 1958; Levy, 1958; as cited in Gilbert, 1980), excessive detail (Buck, 1966; Buck & Warren, 1992; Deabler, 1969; Hammer, 1969; Handler, 1985; Jacks, 1969; Kahn & Giffen, 1960; Levy, 1958; Machover, 1949; McElhaney, 1969; Reynolds, 1978; as cited in Ogdon, 2001), unnecessary detailing (Hammer, 1958; Levy, 1958; as cited in Gilbert, 1980), overdetailed shoes on the figure of Jane (Buck & Warren, 1992; Levine & Sapolsky, 1969; Machover, 1949; Urban, 1963; as cited in Ogdon, 2001; Hammer, 1954; Levy, 1958; as cited in Gilbert, 1980), and striped clothing (Jane?s dress) (Schildkrout, 1972, as cited in Ogdon, 2001). Jane?s answer to the question of how she feels about herself reveals an ongoing preoccupation with her grandfather?s death and suggests fears of future deaths in the family. This relates to her OCD symptom of repeated doubting (worrying that someone in her family would die). Hysteria is suggested by the long necks of Jane?s parents (Hammer, 1958; Levy, 1958; as cited in Gilbert, 1980). Paranoia is suggested by the emphasized eyes (by pressure) of the parents (Deabler, 1969; Griffith & Peyman, 1959; Hammer, 1968; Handler, 1985; Jacks, 1969; Kahn & Giffen, 1960; Levy, 1958; Machover, 1958; McElhaney, 1969; Reznikoff & Nicholas, 1958; Robins et al., 1991; Schildkrout, 1972; Shneidman, 1958; Urban, 1963; as cited in Ogdon, 2001). Schizophrenia/psychosis is indicated by Jane?s inadequate hair (Hammer, 1969; Handler, 1985; Holzberg & Wexler, 1950; Hozier, 1959; as cited in Ogdon, 2001), the geometric shaped bodies of all the figures (Curran & Marengo, 1990; Hammer, 1981; Ries, 1966; as cited in Ogdon, 2001), body distortions/disproportions of all the figures (Hammer, 1958; Levy, 1958; as cited in Gilbert, 1980), wing-like arms on the figures of Jane and her mother (Buck, 1966; Buck & Warren, 1992; Hammer, 1958; Jolles, 1964; Machover, 1958; Urban, 1963; as cited in Ogdon, 2001), and unessential detail emphasized (Machover, 1949, as cited in Gilbert, 1980). Conflict or somatisation in the throat area is indicated by the long necks of Jane?s parents (Hammer, 1954, as cited in Gilbert, 1980; Levy, 1958, as cited in Ogdon, 2001). Schizoid tendencies are implied by the long necks of Jane?s parents (Hammer, 1958; Levy, 1958; as cited in Gilbert, 1980), and midline emphasis on the figure of Jane (Machover, 1949, as cited in Gilbert, 2001). Narcissistic tendencies are suggested by hair parted in the middle on the figures of Jane and her mother (Hammer, 1958; Levy, 1958; as cited in Gilbert, 1980), arms akimbo on the figures of Jane and her mother (Handler, 1985; Machover, 1949; as cited in Ogdon, 2001), and Jane?s overdetailed feet (Buck, 1966; Jolles, 1964; Urban, 1963; as cited in Ogdon, 2001). Organicity is indicated by the placement of the drawing on the bottom of the paper (Michal-Smith & Morgenstern, 1969, as cited in Ogdon, 2001), inadequate hair on the figure of Jane (McLachlan & Head, 1974; as cited in Ogdon, 2001), marked disturbance of symmetry (Koppitz, 1968, as cited in Ogdon, 2001), asymmetrical limbs on all figures (Hammer, 1969; Koppitz, 1968; Machover, 1949; Mundy, 1972; Urban, 1963; as cited in Ogdon, 2001), fragmentation inadvertently introduced (Hammer, 1978; Jacks, 1969; as cited in Ogdon, 2001), and fewer than five fingers on the figures of Jane and her mother (Koppitz, 1968, as cited in Ogdon, 2001). 4.3.4 TAT analysis Card 1 The card elicits themes of relationships with parental figures, achievement needs, and ADD (Bellak, 1975). Jane?s story suggests depression (even though ?the boy saw beautiful pictures?, ?(h)e feels sad. I don?t know why?), loneliness, and a need for reassurance (no other figures in the story). Concerns around body image and physical strength (?gyming?), and achievement needs (?gyming? and ?reading?) are suggested. ADD is indicated (failure to recognise the violin). The defense of isolation is suggested. Average intelligence, an average level of maturity, and inadequate ego integration are indicated. Card 3BM The card elicits the theme of depression (Bellak, 1975). Jane?s story implies depression (?The lady?s crying?), sadness, and loneliness. Regression is indicated. Card 3GF The card elicits the theme of depression (Bellak, 1975). Jane?s story suggests depression (?The girl?s crying?) and a need for reassurance, with her mother perceived as a source of support and nurturance (?Maybe she?s fell. She?s gonna tell her mother?). Regression is suggested. Resistance is indicated (Jane turned the card horizontally). Average intelligence, a low level of maturity, adequate ego integration, and a harsh superego are indicated. Card 4 The card elicits themes of male-female relationships and female attitudes towards men (Bellak, 1975). Jane?s story reveals a wish to be acknowledged and nurtured (?The lady?s looking at this man and holding him?). Average intelligence and a low level of maturity are implied. Card 5 The card elicits the theme of the mother who may be watching (Bellak, 1975). Jane?s story suggests anxiety over being observed by her mother (possibly masturbation- related) and paranoid anxiety (??and the lady looks inside when there?s anyone. And she?s gonna get in??). The defense of reaction formation is suggested. Average intelligence and a low level of maturity are indicated. Card 6GF The card elicits the theme of the relationship of females to the father (Bellak, 1975). Jane?s story reveals a feeling of distance in her relationship with her father (the man and lady are talking, but ?I don?t know about what?) and a sense of personal isolation. Average intelligence and a low level of maturity are indicated. Card 7GF The card elicits the theme of the mother-child relationship (Bellak, 1975). Jane?s story suggests a feeling of not being acknowledged, supported, and nurtured by her mother (the girl is sad and about to cry, but ?the mother?s doing something? and is not receptive to the girl?s sadness). The girl is ?looking somewhere?, which may refer to hopes of receiving nurturance from elsewhere. Depression and regression are suggested (sadness and crying). Average intelligence, a low level of maturity, and inadequate ego integration are suggested. Card 9GF The card elicits the theme of depression (Bellak, 1975). Jane?s story indicates depression (?They running away from the water?), average intelligence, and a low level of maturity. Card 10 The card elicits themes of male-female relationships (Bellak, 1975). Jane?s story reveals wish-fulfillment around the family?s economic needs being met (her parents getting a car). Her parents are perceived as a dyad but there is a sense that they are helpless. The defense of fantasy, average intelligence, a low level of maturity, and adequate ego integration are indicated. Card 11 The card elicits themes of infantile or primitive fears (Bellak, 1975). Jane?s story suggests anxiety and paranoid fears of being observed (Jane looked afraid as she said ?someone?s gonna come and someone?s gonna see these?). Obsessive- compulsivity is indicated (focus on small details of a bush, tree, and rocks). Resistance is displayed (turning the card horizontally), and the defense of reaction formation is suggested. Average intelligence, a low level of maturity, and inadequate ego integration are indicated. Card 12F The card elicits the theme of mother figure conceptions (Bellak, 1975). Jane?s story suggests depression, possibly maternal (?This other lady?s talking to her, because she?s sad?). The environment is perceived as unhappy but support and nurturance are available. Average intelligence and a low level of maturity are implied. Card 13MF The card elicits themes of male-female conflicts and obsessive-compulsivity (Bellak, 1975). Jane?s story reveals depression, possibly paternal (?The man?s crying?). Her mother is perceived as unreceptive to her father?s emotional needs. There is a sense of economic deprivation (the man is crying because he can?t find his shoes). Obsessive-compulsivity is suggested (concern with small details, in this case shoes). Regression is indicated. The defense of rationalization is suggested. Average intelligence and a low level of maturity are implied. Card 13B The card elicits themes of childhood (Bellak, 1975). Jane?s story indicates a perception of the environment/parents as punitive (??the boy?s sad. Maybe, um, someone hit him?). Depression is evident (?The boy?s looking outside at the sun and the boy?s sad?). Anxiety about physical injury, loneliness, and sadness is indicated, and a need to be taken care of, nurtured, and supported. Average intelligence and a low level of maturity are implied. Card 14 The card elicits the theme of wish-fulfilment (Bellak, 1975). Jane?s story indicates a wish to be seen and acknowledged (?And he?s seen?He feels?ah?happy?) and anxiety over feelings of loneliness. The defense of reaction formation, average intelligence, and a low level of maturity are indicated. Card 17GF The card elicits the theme of depression (Bellak, 1975). Jane?s story reveals a perception of the environment as unstable, confusing, and lonely. A need to be taken care of, nurtured, and supported is expressed. Depression and regression are indicated (?The lady?s crying and she?s looking for her house?). Average intelligence, and a low level of maturity are implied. Card 18GF The card elicits the theme of how aggression is handled (Bellak, 1975). Jane?s story reveals a perception of environment as unhappy and unsupportive, and a need to be taken care of, nurtured, and supported. Depression is suggested (?The lady?s crying?) and there is a sense of sadness and loneliness. There is denial that an aggressive act is occurring (??this other lady?s sleeping. And, and the lady?s looking at this other lady and this other lady?s holding this other lady?). Average intelligence, a low level of maturity, and regression are indicated. Card 19 Jane?s story suggests depression (?It might be snows there and there?s snow there covering and snow there and it?s raining?). Average intelligence and a low level of maturity are indicated. 4.4. SUBJECT D ? ?Anne? 4.4.1. Introduction Anne presented as an animated and lively, although slightly shy and cautious little girl of 6 years and 1 month. She had fragile features and a shy smile. She has no siblings and lives with her parents. Anne?s early developmental milestones were normal, except for social difficulties (shyness and Separation Anxiety) and minor difficulties with some speech sounds, for which she received speech therapy at the age of four. She was three years old when her mother first noticed symptoms of psychopathology. A family doctor was consulted and Anne was referred to a psychologist for treatment at the age of four and a half years. Her first symptoms were worries about contamination (worrying that she will get germs if she eats or drinks from the same cup or plate as someone else in her family), cleaning rituals (spitting, chewing and sucking on the clothing she wears, chewing and sucking her hair, sucking her fingers, toys, paper and other objects), repeated doubting (worrying that her parents will die and worrying about family finances), ordering (ordering and lining-up her toys in rows when playing, and needing to pack her toys and other possessions into bags), observable repeating or counting rituals (repeatedly grunting, sniffing, snorting or coughing; repeating words to herself softly or in a whisper; tapping or dragging her feet when walking and avoiding cracks in the paving), mental repeating or counting rituals (repeating songs, prayers or words and counting repetitively), and demanding reassurance (worrying that bad things are going to happen to herself or to one or both parents). Just prior to the onset of these symptoms, a traumatic event happened in Anne?s life, viz. starting a new school. There is a family history of psychopathology. Her father has suffered from OCD from the age of 3 years. He also suffers from BMD, as did Anne?s paternal grandfather. Anne?s father also suffers from dyslexia and experienced difficulties with reading and writing at school. Anne?s mother and maternal grandmother suffer from depression and anxiety. Anne has been diagnosed with one other comorbid psychological condition, viz. SAD. She also has difficulty with handwriting skills. Anne received psychological treatment until the age of 5 years and 7 months (she terminated therapy six months ago). Nowadays, her mother classifies Anne?s symptoms as ?mild? in severity (one or two aspects of her life are mildly impaired but she generally copes well with life) although all her symptoms remain. Anne?s temperament and life have changed since she started displaying symptoms of OCD. Her symptoms wear her out and she is often tired as a result. She has become more depressed, withdrawn and shy, and ?acts-up? more than before. She tries to hide her symptoms at home and from teachers and other children at school, and has trouble making friends at school. She is teased and ridiculed at school because of her strange behaviour. She has trouble concentrating in class, and sometimes doesn?t want to go to, or misses, school. She also tries to hide her symptoms when out in public. She is frustrated and upset because she can?t always manage to do what people expect. Family life has changed since Anne started displaying symptoms of OCD. She needs more parental attention, and tries to involve family members in her rituals. Coping with Anne leaves her parents feeling more exhausted and frustrated than previously and there is generally more tension and arguing in the family than before. Anne?s parents feel guilty because they think maybe they have somehow caused or passed on OCD to Anne. Anne was friendly and co-operative with the researcher and performed all tasks requested of her willingly. Although initially she was slightly shy, as testing progressed she seemed a lot more relaxed and interacted quite spontaneously and freely with the researcher. During testing she displayed difficulty concentrating, and fidgeted almost constantly. She occasionally became excitable and jumped up from her chair. She occasionally rocked on her chair. Occasionally, she sucked and chewed on the sleeve of her sweatshirt, or snorted repetitively. She narrated as she drew her pictures, and added to her drawings as questions were asked. There were occasional requests for reassurance. During rest breaks, Anne interacted in quite a lively manner with the researcher, chatting animatedly about her family and her toys while fidgeting and rocking on her chair. 4.4.2. Age-related norms for HFD analyses Anne?s D-A-P figures measure 10.9 and 11.2 inches in height respectively. This classifies them as large figures, as a normal sized figure is between 6 and 7 inches tall (Handler, 1996; Urban, 1963, as cited in Ogdon, 2001). Although unusually large drawings may be normal among children (Koppitz, 1968; Urban, 1963; as cited in Ogdon, 2001), because Anne?s figures are over 9 inches high, the possibility of a reading problem (Stavrianos, 1971, as cited in Ogdon, 2001), or emotional adjusting problem (Koppitz, 1968, as cited in Ogdon, 2001) is indicated. The tallest figure in the K-F-D is Anne?s mother, measuring 7.9 inches in height, while her father is 7.1 inches high. Because drawing male figures smaller than female ones may be normal in young girls (Machover, 1960; McHugh, 1963; Weider & Noller, 1953; as cited in Ogdon, 2001) this has not been interpreted as an emotional indicator. Emotional indicators relating to figure size are used only in a relative, qualitative manner. As gross distortions/disproportions in drawings suggest normal children under stress in children under the age of seven years (Britain, 1970, as cited in Ogdon, 2001), the presence of this feature in all Anne?s drawings has been interpreted as such. As shaded strokes may be seen in drawings of normal young children (Koppitz, 1968; Machover, 1960; as cited in Ogdon, 2001), the presence of this feature in all Anne?s drawings has not been interpreted as an emotional indicator, although indicators relating to random, scribbled shading have been used. Although children particularly below the age of seven years normally draw proportionally larger heads, than adults (Koppitz, 1968; Machover, 1960; Michal- Smith & Morgenstern, 1969; Urban, 1963; as cited in Ogdon, 2001), an enlarged head in a child?s drawing does however indicate an emphasis on fantasy (Hammer, 1965; Levy, 1950; as cited in Gilbert, 1980). Thus the presence of this feature in all Anne?s drawings has not been interpreted as an emotional indicator, except to represent the use of fantasy as a defense. Although ears are omitted from Anne?s first D-A-P drawing and from some figures in her K-F-D, this omission is considered normal especially in children (Buck, 1950; Buck & Warren, 1992; Handler, 1985; Jolles, 1964; Machover, 1949; Urban, 1963; as cited in Ogdon, 2001) and has thus not been interpreted as an emotional indicator. Because empty eyes may be normal young children?s drawings (Koppitz, 1968; Machover, 1960; Urban, 1963; as cited in Ogdon, 2001) the presence of this feature in Anne?s second D-A-P drawing and a figure in her K-F-D have not been interpreted as emotional indicators. Because small circles for eyes is normal in the drawings of young children (Machover, 1949; Urban, 1963; as cited in Ogdon, 2001), the presence of this feature in all Anne?s drawings has not been interpreted as an emotional indicator. Mouth emphasis in children?s drawings may suggest normality (normal dependence and immaturity) (Machover, 1960; Urban, 1963; as cited in Ogdon, 2001), as does a concave mouth (Machover, 1960, as cited in Ogdon, 2001). Thus, although these features are present in all Anne?s drawings, they have not been interpreted as emotional indicators. Because emphasis on the waist may be normal in children?s drawings (Machover, 1960, as cited in Ogdon, 2001) the presence of this feature in Anne?s first D-A-P drawing and K-F-D has not been interpreted as an emotional indicator. Because shoulders are frequently omitted from the drawings of children below the age of 8 years (Hammer, 1965; Halpern, 1965; as cited in Gilbert, 1980), these omissions from all Anne?s drawings have not been interpreted as emotional indicators. Because one dimensional arms and legs are frequently drawn by children below the age of 8 years (Hammer, 1965; Halpern, 1965; as cited in Gilbert, 1980), the presence of frail, thin, stick-like arms and legs in all Anne?s drawings has not been interpreted as an emotional indicator. As long fingers may be normal in children?s drawings (Hammer, 1997, as cited in Ogdon, 2001), the presence of this feature in Anne?s D-A-P drawings has not been interpreted as an emotional indicator. Emotional indicators relating to sharp, spiked/spear fingers have however been used. Because transparent clothing suggests normality in children?s drawings (Machover, 1960; Urban, 1963; as cited in Ogdon, 2001) the presence of this feature in Anne?s second D-A-P drawing has not been interpreted as an emotional indicator. Because drawing genitalia may be normal in young children (Buck & Warren, 1992, as cited in Ogdon, 2001), the presence of a vagina in Anne?s first D-A-P drawing has not been interpreted as an emotional indicator. Both Anne?s D-A-P figures meet the expected normative content criteria as listed by Koppitz (1968, as cited in Handler, 1996) for a girl of her age, with the exception of her first D-A-P drawing from which a nose is omitted. Noses, necks and feet are omitted from the figures drawn in the K-F-D. In the context of her D-A-P drawings, it is considered that these omissions are best interpreted as emotional indicators. 4.4.3. HFD analyses 4.4.3.1. D-A-P drawing 1 a) Introduction Anne seemed excited to draw a person and proceeded happily with the task. She drew a massive figure of a girl, filling the entire page. The girl is depicted as naked with a wide stance and outstretched arms. She has extremely long, heavily shaded and messy hair, reaching to the bottom of the page. She has tiny eyes, a large mouth with teeth and a tongue, a long neck and a small, round torso with a belly button. She holds rounded, heavily shaded objects (baskets of flowers) in each hand. Her fingers and toes are long spears and she has long, stick-like arms and legs. There are three round, heavily shaded objects (bowls of sweets) in the genital area. Grass is drawn as a wavy line beneath the figure, with a flower on either side of the figure. First, Anne drew the head and eyes, and a mouth with two circles on either side. She said, ?It?s so happy that it?s got circles on its cheeks?. She drew eyebrows and hair, explaining that the hair is long ?so everyone knows it?s a girl, so long that it goes to the toes?. She drew the neck and said, ?I?m gonna draw clothes, now I?m gonna draw the tummy circle, then a little circle?, as she drew the torso and belly button. She drew the left arm, right arm, left leg and right leg, then a tiny circle for each hand. As she drew the toes and fingers, she counted ?1, 2, 3, 4, 5?5 toes/fingers!? She drew a small semi-circle at the bottom of the trunk, explaining, ?I?m even gonna draw a vagina?. She said, ?I?m still drawing the hair. It?s so long, it even goes across the arms, even touches the ground?, as she extended the hair to the bottom of the page. She stated, ?Now, I?m gonna draw grass? and drew a wavy groundline at the bottom of the page. She wrote her name in the top left-hand corner of the page while sounding it out, then drew three number 3?s (drawn reversed) at the top of her picture. As she drew she said, ?three? then explained, ?I?m picking flowers, so I must draw a basket and I?m, I draw flowers so she can pick and circles for basket? as she drew a circular object in the left-hand and a flower on the groundline to the left of the figure. She said, ?have to draw another basket, cos I?m picking so much flowers? and drew a basket in the right hand. When asked what she is doing in the picture, she said, ?I?m picking so much flowers. Now, I?m gonna draw another flower? and drew a flower on the groundline to the right of the figure. When asked what makes her happy, she replied, ?Sweeties in a bowl. Must I draw the sweeties?? When told that she may she drew small circular shapes inside the basket on the right, asking ?Can I colour in the petals?? Told that she may, she drew circular shapes inside the other basket and said, ?I?m picking the flowers and now I?m eating my sweeties. I?ve got 150 sweets in there, gonna draw 2 bowls, 3 bowls of sweeties? as she drew three large circles in the genital area, with the middle one covering the vagina. She drew small circular shapes inside each circle, then looked closely at her drawing and asked, ?Do you like the lips? Now, I?m drawing teeth and the tongue? as she drew two rows of teeth and a tongue inside the mouth. She drew the figure slightly right of the centre of the page, filling the whole sheet of paper. She drew from left to right and the pace of her drawing remained relatively constant. The drawing took 3 minutes and 15 seconds to complete. b) Emotional indicators Self-concept Self-esteem and body image The drawing is a self-portrait of Anne. Low self-esteem with feelings of inadequacy is suggested by the overemphasis and strong reinforcement of the facial features (Machover, 1949, as cited in Ogdon, 2001), disturbed symmetry (Machover, 1949, as cited in Gilbert, 1980), the small trunk (Buck, 1950; Buck & Warren, 1992; Handler, 1985; Jolles, 1964; Urban, 1963; as cited in Ogdon, 2001), and the dishevelled, unkempt figure (Hammer, 1958, as cited in Gilbert, 1980). Midline emphasis (belly button) suggests that Anne has a poor self-concept with feelings of inferiority, especially physical inferiority (Bodwin & Bruck, 1960; Machover, 1949; Rierdan et al., 1982; Urban, 1963; as cited in Ogdon, 2001). Dissatisfaction with her body image also is suggested by the long neck (DiLeo, 1970, as cited in Ogdon, 2001). Preoccupations with body processes, development, and pregnancy are suggested by the nude figure (Machover, 1949; Tolor & DiGrazia, 1977; Urban, 1963; as cited in Ogdon, 2001). Such preoccupations may also be implied by the rounded tummy constituting the torso, with a distinct belly button in the centre, and by the presence of a vagina and bowls of sweets in the genital area. Overconcern with outward appearance is suggested by the overemphasis and strong reinforcement of the facial features (Jolles, 1964, as cited in Ogdon, 2001). There are indicators to suggest that Anne feels a sense of social isolation, uneasiness, or hostility. These are jagged lines (teeth, hair, and neck) (Hammer, 1965; Krout, 1950; Machover, 1951; Urban, 1963; Waehner, 1946; as cited in Ogdon, 2001), a withdrawn, vacant facial expression (Machover, 1949; Hammer, 1954; as cited in Gilbert, 1980), raised eyebrows (Machover, 1949; Urban, 1963; as cited in Ogdon, 2001), the nude figure (Hammer, 1968; Holzberg & Wexler, 1950; Machover, 1949; Urban, 1963; as cited in Ogdon, 2001), and a long neck (Handler, 1985; Machover, 1949; as cited in Ogdon, 2001). Emphasized eyes (by pressure) suggest that Anne is hypersensitive to social opinion, particularly criticism (Handler, 1985; Machover, 1958; as cited in Ogdon, 2001). The dishevelled, unkempt figure suggests a perceived lack of status (Hammer, 1958, as cited in Gilbert, 1980). Anne?s narratives suggest that she perceives her mother as the primary source of discipline in the family. Her answer to the question of what makes her feel sad was ?If my mommy takes my sweets away?. Her answers to the questions of what she does when she is being good and bad were ?Do everything that my mommy says? and ?Don?t do what my mommy says?and my daddy? respectively. Sexuality and gender identity There are more sexually-oriented indicators than might be expected at Anne?s age, suggesting a conflict or preoccupation with sexuality. These are emphasized hair, especially as heavily shaded (Buck, 1950; DiLeo, 1970; Hammer, 1954; Handler, 1985; Jolles, 1964; Levy, 1958; Machover, 1951; Roback, 1968; Urban, 1963; as cited in Ogdon, 2001), messy hair (Buck, 1950; DiLeo, 1970; Hammer, 1954; Handler, 1985; Jolles, 1964; Levy, 1958; Machover, 1951; Roback, 1968; Urban, 1963; as cited in Ogdon, 2001), and elongated anatomical areas/phallic symbols (neck) (Hammer, 1954, as cited in Gilbert, 1980). Blocking of sexual and bodily impulses causing tension is suggested by the small trunk (Buck, 1950; Buck & Warren, 1992; Handler, 1985; Jolles, 1964; Urban, 1963; as cited in Ogdon, 2001), and unusually high waistline (Handler, 1985; Machover, 1949; as cited in Ogdon, 2001). Infantile, regressed sex drives are indicated by emphasized hair (Buck, 1950; Handler, 1985; Levy, 1958; as cited in Ogdon, 2001; Machover, 1949, as cited in Gilbert, 1980), the small trunk (Buck, 1950; Buck & Warren, 1992; Handler, 1985; Jolles, 1964; Urban, 1963; as cited in Ogdon, 2001), and the rounded trunk (Gurvitz, 1951; Handler, 1985; Levy, 1950; Machover, 1949; as cited in Ogdon, 2001). Exhibitionistic and autoerotic tendencies are suggested by the nude figure (Gurvitz, 1951; Machover, 1949; as cited in Ogdon, 2001). Femininity is suggested by the figure?s rounded trunk (Machover, 1949, as cited in Gilbert, 1980). Awareness of her gender identity is suggested by Anne?s answer to the question of what animal she would like to be, which was ?Lion, a girl lion?. The presence of a vagina in the drawing further suggests an awareness of her gender identity. Personality Introversion/Extroversion There are indicators that Anne?s personality is imbalanced or disorganised. These are odd details (three round objects at genital area, hair so long it touches the ground, circles at sides of mouth, the number 3 written around head of figure) (DiLeo, 1973, as cited in Ogdon, 2001), and random, scribbled shading (hair) (Kahn & Giffen, 1960; Schildkrout, 1972; as cited in Ogdon, 2001). There are indicators to suggest that Anne tends toward introversion, shyness, withdrawal, inhibition, and self-consciousness. These are the placement of the drawing on the right-hand side of the page (Buck, 1950; Hammer, 1969; Jolles, 1964; Wolff, 1946; as cited in Ogdon, 2001), central placement of the figure (Alschuler & Hattwick, 1947; Levy, 1950; as cited in Ogdon, 2001; Hammer, 1954, as cited in Gilbert, 1980), long pencil strokes (Handler, 1996), small eyes (Machover, 1949, as cited in Gilbert, 1980), omission of a nose (Handler, 1996; Koppitz, 1968; Mitchell, 1993; as cited in Ogdon, 2001), the emphasized body (underclothed) (Machover, 1949, as cited in Gilbert, 1980), the nude figure (Fisher, 1961; Jolles, 1964; Levy, 1958; Machover, 1949; as cited in Ogdon, 2001), the small trunk (Buck, 1950; Buck & Warren, 1992; Handler, 1985; Jolles, 1964; Urban, 1963; as cited in Ogdon, 2001), and doodling of her name (Hammer, 1965, as cited in Gilbert, 1980). A sensitive personality is suggested by the full lips (Machover, 1949; Urban, 1963; as cited in Ogdon, 2001). Submissiveness is indicated by the emphasis on circles in drawing the body (Machover, 1949, as cited in Gilbert, 1980). Defenses There are indicators of tendencies toward defensiveness and evasion. These are the placement of the drawing on the right-hand side of the page (Buck, 1950; Hammer, 1969; Jolles, 1964; Wolff, 1946; as cited in Ogdon, 2001), long pencil strokes (Handler, 1996), a stick figure (Hammer, 1965, as cited in Gilbert, 1980), a nude figure (Hammer, 1968; Holzberg & Wexler, 1950; Machover, 1949; Urban, 1963; as cited in Ogdon, 2001), and a small trunk (Buck, 1950; Buck & Warren, 1992; Handler, 1985; Jolles, 1964; Urban, 1963; as cited in Ogdon, 2001). Possible reaction formations or compensatory defenses to defend against feelings of insecurity are suggested by the uneven line pressure (Hammer, 1958; Levy, 1950; as cited in Gilbert, 1980; Machover, 1949, as cited in Ogdon, 2001), vacillating direction and interrupted strokes (Jacks, 1969; Levy, 1958; Hammer, 1954; Wolff, 1946; as cited in Ogdon, 2001), placement of the drawing on the bottom of the paper (Buck, 1950; Hammer, 1958; Handler, 1985; Jolles, 1958; as cited in Ogdon, 2001), a placating facial expression (Hammer, 1954; Machover, 1949; as cited in Gilbert, 1980), a lack of symmetry (Hammer, 1958, as cited in Gilbert, 1980), the stick figure (Hammer, 1954; Levy, 1950; as cited in Gilbert, 1980), the wide stance (Buck, 1950; Buck & Warren, 1992; Jolles, 1964; as cited in Ogdon, 2001), midline emphasis (Bodwin & Bruck, 1960; Machover, 1949; Rierdan et al., 1982; Urban, 1963; as cited in Ogdon, 2001), the feet on the base of the page (Buck, 1950; Hammer, 1954; as cited in Gilbert, 1980), and the groundline (Buck, 1950; Hammer, 1954; Jolles, 1964; as cited in Ogdon, 2001; Machover, 1949, as cited in Gilbert, 1980). The overemphasis and strong reinforcement of facial features (Machover, 1949, as cited in Ogdon, 2001) suggests feelings of inadequacy and weakness, compensated for by aggressive and socially dominant behaviour (Machover, 1949, as cited in Ogdon, 2001) and fantasy (Machover, 1949, as cited in Gilbert, 1980). The defense of fantasy to compensate for feelings of inadequacy is also suggested by the drawing filling the page (Hammer, 1954, as cited in Gilbert, 1980). Similarly, the use of fantasy as a defense is indicated by the enlarged head (Hammer, 1965; Levy, 1950; as cited in Gilbert, 1980), while placement of the drawing on the bottom of the paper suggests fantasy and intellectualisation (Handler, 1985; Jolles, 1952; as cited in Ogdon, 2001). Autonomy/dependency The straight, uninterrupted strokes suggest a quick, decisive, assertive personality (Allen, 1958; Alschuler & Hattwick, 1947; Hammer, 1958; Krout, 1950; Levy, 1958; as cited in Ogdon, 2001). The unusually heavy pencil pressure similarly indicates an assertive, persistent, forceful, ambitious personality (Alschuler & Hattwick, 1947; Hammer, 1968; Kadis, 1950; Levy, 1958; Machover, 1949; Urban, 1963; as cited in Ogdon, 2001), as do the firm, determined, unhesitating pencil strokes (Hammer, 1954, as cited in Gilbert, 1980; Levy, 1958, as cited in Ogdon, 2001). Assertiveness and determination are suggested by the marked directional preference for vertical movement in the drawing (Alschuler & Hattwick, 1947; Handler, 1985; Levy, 1958; as cited in Ogdon, 2001). Ambition/drive/future-orientation is suggested by the firm line quality (Hammer, 1954; as cited in Gilbert, 1980; Levy, 1958, as cited in Ogdon, 2001), and placement of the figure on the right-hand side of the page (Buck, 1950; Buck & Warren, 1992; Jolles, 1952; Mitchell et al., 1993; as cited in Ogdon, 2001). A conflict between autonomy and compliance is suggested by Anne?s answer to the questions of what she does when she is being good and bad, which were ?Do everything my mommy says? and ?Don?t do what my mommy says?and my daddy? respectively. Despite her assertive, ambitious tendencies, Anne?s dependency needs are also evident, as indicated by the full lips (Machover, 1949; Urban, 1963; as cited in Ogdon, 2001), open mouth (Gurvitz, 1951; Levy, 1950; Modell & Potter, 1949; as cited in Ogdon, 2001), midline emphasis (Machover, 1949, as cited in Gilbert, 1980), and belly button (Machover, 1949; Hammer, 1954; Halpern, 1965; as cited in Gilbert, 1980). Anne?s answer to the question of what makes her happy was ?Sweeties in a bowl??, suggesting a very concrete, oral need for nurturance. The outstretched arms and hands reflect a desire for interpersonal contact, affection or help (Handler, 1985; Michal-Smith & Morgenstern, 1969; Schildkrout, 1972; as cited in Ogdon, 2001; Machover, 1949, as cited in Gilbert, 1980). Placement of the drawing on the bottom of the paper further suggests a need for support (Buck, 1950; Hammer, 1958; Handler, 1985; Jolles, 1958; as cited in Ogdon, 2001). Impulse control The drawing suggests that Anne has considerably high levels of overt anger and great difficulty with impulse control. Although controlled behaviour/emotional control is indicated by placement of the drawing on the right-hand side of the page (Buck, 1950; Buck & Warren, 1992; Hammer, 1969; Handler, 1985; Jolles, 1964; Jolles & Beck, 1953; Marzolf & Kirchner, 1972; Mitchell et al., 1993; Urban, 1963; as cited in Ogdon, 2001) and long pencil strokes (Hammer, 1954; Alschuler & Hattwick, 1947; as cited in Gilbert, 1980), central placement of the figure indicates a tendency toward emotional behaviour (Alschuler & Hattwick, 1947; Levy, 1950; as cited in Ogdon, 2001). Vacillating direction and interrupted strokes suggest moodiness (Jacks, 1969; Levy, 1958; Hammer, 1954; Wolff, 1946; as cited in Ogdon, 2001), as do the variations in pencil pressure (Machover, 1949, as cited in Gilbert, 1980). Heavy pencil pressure suggests high energy levels and excitement (Hetherington, 1952; Kadis, 1950; Levy, 1958; Mitchell, 1993; Precker, 1950; Riethmiller & Handler, 1997; Urban, 1963; as cited in Ogdon, 2001). Impulsivity is indicated by jagged lines (Hammer, 1965; Krout, 1950; Machover, 1951; Urban, 1963; Waehner, 1946; as cited in Ogdon, 2001), and variations in pencil pressure (Hammer, 1958; Levy, 1958; as cited in Gilbert, 1980). Overt anger and aggressive tendencies are suggested by the unusually heavy pencil pressure (Halpern, 1951; Hammer, 1997; Handler & McIntosh, 1971; Jolles, 1964; McElhaney, 1969; Reynolds, 1978; Riethmiller & Handler, 1997; Schneidman, 1958; Urban, 1963; Wysocki & Whitney, 1965; as cited in Ogdon, 2001), straight lines (Hammer, 1958; Krout, 1950; as cited in Gilbert, 1980), jagged lines (Hammer, 1965; Krout, 1950; Machover, 1951; Urban, 1963; Waehner, 1946; as cited in Ogdon, 2001), drawing in middle of page (Machover, 1949, as cited in Gilbert, 1980), emphasized hair (Handler, 1985; Shneidman, 1958; as cited in Ogdon, 2001), teeth showing (Buck, 1966; Buck & Warren, 1992; Goldstein & Rawn, 1957; Halpern, 1965; Hammer, 1965; Handler, 1996; Jolles, 1964; Koppitz, 1968; Levy, 1958; Machover, 1960; McElhaney, 1969, Mitchell, 1993; Rierdan et al., 1982; Schildkrout, 1972; Urban, 1963; as cited in Ogdon, 2001), nostrils (Machover, 1949, as cited in Gilbert, 1980), marked disturbance of symmetry (Koppitz, 1968, as cited in Ogdon, 2001), a wide stance (especially as figure is in middle of page) (Machover, 1949; Shneidman, 1958; Wysocki & Wysocki, 1977; as cited in Ogdon, 2001), a long neck (Hammer, 1950; Levy, 1958; as cited in Gilbert, 1980), asymmetrical arms (Hammer, 1969; Koppitz, 1968; Machover, 1949; Mundy, 1972; Urban, 1963; as cited in Ogdon, 2001), fingers with no hands (Machover, 1949, as cited in Gilbert, 1980), and stick fingers (Machover, 1949, as cited in Gilbert, 1980). Anne?s answer to the question of what she would like to do if she were invisible was ?Give people a fright?, revealing aggressive impulses. Assaultiveness is implied by emphasized hair (Handler, 1985; Shneidman, 1958; as cited in Ogdon, 2001), reinforced hair (Hammer, 1954, as cited in Gilbert, 1980), and a wide stance (Machover, 1949; Shneidman, 1958; Wysocki & Wysocki, 1977; as cited in Ogdon, 2001). Psychopathology There are indicators to suggest that Anne is normal, stable, reasonably well-adjusted and has adequate contact with reality. These are the central placement of the figure (Buck & Warren, 1992; Handler, 1985; Lakin, 1956; Urban, 1963; Wolff, 1946; as cited in Ogdon, 2001), drawing in normal succession (Machover, 1949; as cited in Gilbert, 1980), and a relaxed, standing posture (Urban, 1963, as cited in Ogdon, 2001). However poor emotional adjustment and emotional stress is suggested by the fluctuating pencil pressure (Hammer, 1958; Levy, 1958; as cited in Gilbert, 1980), omission of a nose (Handler, 1996; Koppitz, 1968; Mitchell, 1993; as cited in Ogdon, 2001), the unusually large size of the figure (Koppitz, 1968, as cited in Ogdon, 2001), and the gross distortions/disproportions (extremely long, asymmetrical hair; tiny trunk; large, thick neck; mouth skewed and on left side of face; extremely long legs) (Britain, 1970; Koppitz, 1966; Mitchell, 1993; Vane & Eisen, 1962; as cited in Ogdon, 2001). Emotional constriction is suggested by anchoring of the drawing (Reynolds, 1978). The hair in disarray suggests confusion in thought processes (Levine & Sapolsky, 1969, as cited in Ogdon, 2001), as does the tiptoe stance (Buck & Warren, 1992; Hammer, 1954; Jolles, 1952; Urban, 1963; as cited in Ogdon, 2001). There are numerous indicators of psychopathology. Depression is suggested by the very short, circular, sketchy strokes (Buck, 1950; Gurvitz, 1951; Hammer, 1958; Jolles, 1952; Levy, 1958; Urban, 1963; as cited in Ogdon, 2001), placement of the drawing on the right-hand side of the page (Levy, 1950, as cited in Ogdon, 2001), and the omission of a nose (Handler, 1996; Koppitz, 1968; Mitchell, 1993; as cited in Ogdon, 2001). A perception of maternal depression is suggested in Anne?s answer to the question of what the worst thing about her is, which was ?When my mommy?s sad?. Anxiety is suggested by the unusually heavy pencil pressure (Buck, 1950; Deabler, 1969; Hammer, 1969; Handler, 1996; Handler & Reyher, 1966; Jolles, 1964; Kadis, 1950; Machover, 1955; Reynolds, 1978; Riethmiller & Handler, 1997; Urban, 1963; as cited in Ogdon, 2001), uneven line pressure (Machover, 1949, as cited in Gilbert, 1980), jagged lines (Hammer, 1965; Krout, 1950; Machover, 1951; Urban, 1963; Waehner, 1946; as cited in Ogdon, 2001), vacillating direction and interrupted strokes (Jacks, 1969; Levy, 1958; Hammer, 1954; Wolff, 1946; as cited in Ogdon, 2001), very short, circular, sketchy strokes (Buck, 1950; Gurvitz, 1951; Hammer, 1958; Jolles, 1952; Levy, 1958; Urban, 1963; as cited in Ogdon, 2001), reinforced lines (Buck, 1950; Hammer 1965;as cited in Gilbert, 1980), simplified trunk (Riethmiller & Handler, 1997, as cited in Ogdon, 2001), fragmentation inadvertently introduced (by neck cutting off head from trunk, by hair fragmenting arms and cutting them off from trunk, by three round circles at genital area cutting off trunk from legs) (Hammer, 1978; Jacks, 1969; as cited in Ogdon, 2001), and excessive detail (circles at sides of mouth, the number 3 written around head of figure, tongue and teeth in mouth, extremely long hair, detailed objects in both hands, three round circles at genital area, belly button) (Machover, 1949, as cited in Gilbert, 1980). Neurosis is indicated by the placement of the drawing low on the page (DiLeo, 1973, as cited in Ogdon, 2001), random, scribbled shading (Kahn & Giffen, 1960; Schildkrout, 1972; as cited in Ogdon, 2001), and excessive detail (Machover, 1949, as cited in Gilbert, 1980). Obsessiveness is suggested by excessive detail (Machover, 1949, as cited in Gilbert, 1980). Obsessive-compulsivity is indicated by the hair parted in the middle (Hammer, 1958; Levy, 1958; as cited in Gilbert, 1980), excessive detail (Buck, 1966; Buck & Warren, 1992; Deabler, 1969; Hammer, 1969; Handler, 1985; Jacks, 1969; Kahn & Giffen, 1960; Levy, 1958; Machover, 1949; McElhaney, 1969; Reynolds, 1978; as cited in Ogdon, 2001; Hammer, 1954; Levy, 1958; as cited in Gilbert, 1980), unnecessary detailing (circles at the sides of the mouth, the number 3 written around the head of the figure, a tongue and teeth in the mouth, extremely long hair, detailed objects in both hands, three round circles at the genital area, and a belly button) (Hammer, 1958; Levy, 1958; as cited in Gilbert, 1980), and re-working with the addition of excessive detail (Hammer, 1958; Levy, 1958; as cited in Gilbert, 1980). A preoccupation with the number 3 is suggested by the three bowls of sweets and three number 3?s on the page. Hysteria is suggested by the random, scribbled shading (Kahn & Giffen, 1960; Schildkrout, 1972; as cited in Ogdon, 2001), and long neck (Hammer, 1958; Levy, 1958; as cited in Gilbert, 1980). Paranoia is suggested by the unusually heavy pencil pressure (Hammer, 1958; Reznikoff & Nicholas, 1958; Roback, 1968; Weiner, 1966; as cited in Ogdon, 2001), and sharp, spiked/spear fingers (Brown, 1958; Buck, 1966; Buck & Warren, 1992; DiLeo, 1970; Goldstein & Rawn, 1957; Hammer, 1965; Handler, 1985; Jacks, 1969; Jolles, 1964; Machover, 1949; McElhaney, 1969; Mitchell, 1993; Modell & Potter, 1949; Reynolds, 1978; Schildkrout, 1972; Shneidman, 1958; Urban, 1963; Wolk, 1969; Wysocki & Wysocki, 1977; as cited in Ogdon, 2001). Schizophrenia/psychosis is suggested by the unusually heavy pencil pressure (Gustafson & Waehler, 1992, as cited in Ogdon, 2001), hair in disarray (Mitchell, 1993, as cited in Ogdon, 2001), teeth showing (Machover, 1949; as cited in Gilbert, 1980), body distortions/disproportions (Hammer, 1958; Levy, 1958; as cited in Gilbert, 1980), the nude figure (Hammer, 1968; Holzberg & Wexler, 1950; Machover, 1949; Urban, 1963; as cited in Ogdon, 2001), and unessential detail emphasized (Machover, 1949, as cited in Gilbert, 1980). Conflict or somatisation in the head area is suggested by the line break at bottom left side of head (Machover, 1949, as cited in Gilbert, 1980). Conflict or somatisation in the throat area is indicated by the long neck (Hammer, 1954, as cited in Gilbert, 1980; Levy, 1958, as cited in Ogdon, 2001). Hyperactivity is suggested by a marked directional preference for vertical movement (Alschuler & Hattwick, 1947; Handler, 1985; Levy, 1958; as cited in Ogdon, 2001). Schizoid tendencies are indicated by the nude figure (Hammer, 1968; Holzberg & Wexler, 1950; Machover, 1949; Urban, 1963; as cited in Ogdon, 2001), the long neck (Hammer, 1958; Levy, 1958; as cited in Gilbert, 1980), and midline emphasis (Machover, 1949, as cited in Gilbert, 1980). Narcissistic tendencies are suggested by the hair given much attention (Hammer, 1954, as cited in Gilbert, 1980; Handler, 1985; Levy, 1958; Machover, 1949; as cited in Ogdon, 2001), hair parted in the middle (Hammer, 1954; Levy, 1958; as cited in Gilbert, 1980), the full lips (Machover, 1949; Urban, 1963; as cited in Ogdon, 2001), an emphasis on curves in depicting body (Machover, 1949, as cited in Gilbert, 1980), and arms akimbo (Handler, 1985; Machover, 1949; as cited in Ogdon, 2001). Organicity is suggested by the open mouth (Gurvitz, 1951; Levy, 1950; Modell & Potter, 1949), marked disturbance of symmetry (Koppitz, 1968, as cited in Ogdon, 2001), asymmetrical arms (Hammer, 1969; Koppitz, 1968; Machover, 1949; Mundy, 1972; Urban, 1963; as cited in Ogdon, 2001), fragmentation inadvertently introduced (Lezak, 1983; McLachlan & Head, 1974; Mitchell, 1993; as cited in Ogdon, 2001), and less than two articles of clothing (Evans & Marmorston, 1963; Koppitz, 1968; as cited in Ogdon, 2001). Anne wrote three reversed number 3?s at the top of her picture, suggesting difficulty with reversals or dyslexic tendencies. 4.4.3.2. D-A-P drawing 2 a) Introduction Anne drew a massive figure of a man, filling the entire page. The figure has a narrow stance, outstretched arms and long, curly, messy hair encircling his whole face. He has tiny eyes with lashes and a large mouth with teeth and a tongue. He has a triangular neck and a small, round torso and holds a rounded, heavily reinforced object in each hand. His fingers and toes are long spears and he has long, stick-like arms and legs. Grass is drawn as a wavy line beneath him, with a flower on each side. She drew in the centre of the page, filling the whole sheet of paper. She drew from left to right and the pace of her drawing remained relatively constant. The drawing took 3 minutes and 48 seconds to complete. First, Anne drew the head, eyes, and a mouth with teeth and a tongue. She explained, ?Different mouth, teeth, tongue?different face, cos Daddy?s gonna have eyelashes, 2 eyelashes, now a different mouth. Now, this time I?m drawing ears and I?m gonna draw my daddy?s hair long, as it is?, as she drew ears and hair. She drew a half-circle for the nose and added a circle and a line inside, stating, ?Daddy?s hair is over his nose. I forgot to draw a nose on the other one. Now, I?m gonna draw the neck, nearly like the other one, but not the same?. She drew the neck, explaining, ?Like real people?s neck now?tummy?smaller, now a little bit longer? and drew the torso. She said, ?And arms, five fingers? as she drew the arms and fingers. She drew legs and toes, counting the toes as she drew them, then said, ?Yes?now I?m gonna draw Daddy clothes?a shirt and pants, cos I?ve gotta draw long?finished!? as she shaded the torso and legs heavily. She exclaimed, ?Now, I?ve gotta draw grass? as she drew a wavy groundline at the bottom of the page, then added, ?Flowers?. She drew two flowers on the groundline, one on each side of the figure, then said, ?He?s gonna be a flower boy, but he?s not eating a bowl of sweets, cos he doesn?t want sweets?. She drew an object in each hand of the figure, stating, ?my daddy?s basket?. She wrote a small ?b? in the top left-hand corner of the page, erased it and wrote a ?d? in the same space. She drew a capital ?D? in the top right-hand corner. b) Emotional indicators Self-concept Self-esteem and body image As in Anne?s previous drawing, there are indicators of low self-esteem, with feelings of inadequacy. These are the overemphasis and strong reinforcement of facial features (Machover, 1949, as cited in Ogdon, 2001), disturbed symmetry (Machover, 1949, as cited in Gilbert, 1980), a small trunk (Buck, 1950; Buck & Warren, 1992; Handler, 1985; Jolles, 1964; Urban, 1963; as cited in Ogdon, 2001), the dishevelled, unkempt figure (Hammer, 1958, as cited in Gilbert, 1980), and the clothes too big for the figure (Buck, 1950; Hammer, 1958; as cited in Ogdon, 2001). As in her first drawing, there are indications of dissatisfaction with her body image and social status. The long neck suggests dissatisfaction with her body image (DiLeo, 1970, as cited in Ogdon, 2001). The dishevelled, unkempt figure suggests a perceived lack of status (Hammer, 1958, as cited in Gilbert, 1980), as do the ill-fitting clothes (Hammer, 1954, as cited in Gilbert, 1980). Overconcern with outward appearance is suggested by the overemphasis and strong reinforcement of the facial features (Jolles, 1964, as cited in Ogdon, 2001). Overconcern with outward appearance is also suggested by Anne?s answer to the question of what the best thing about ?Daddy? is, which was: ?His hair, cos I like what his hair looks like?. Although fewer than in her previous drawing, there are indicators of a sense of social isolation, uneasiness, or hostility. These are jagged lines (Hammer, 1965; Krout, 1950; Machover, 1951; Urban, 1963; Waehner, 1946; as cited in Ogdon, 2001), a withdrawn, vacant facial expression (Machover, 1949; Hammer, 1954; as cited in Gilbert, 1980), and a long neck (Handler, 1985; Machover, 1949; as cited in Ogdon, 2001). Sexuality and gender identity As in her previous drawing, there are a number of sexually-oriented indicators, suggesting a preoccupation with sexuality. These are emphasized hair (Buck, 1950; DiLeo, 1970; Hammer, 1954; Handler, 1985; Jolles, 1964; Levy, 1958; Machover, 1951; Roback, 1968; Urban, 1963; as cited in Ogdon, 2001), messy hair (Buck, 1950; DiLeo, 1970; Hammer, 1954; Handler, 1985; Jolles, 1964; Levy, 1958; Machover, 1951; Roback, 1968; Urban, 1963; as cited in Ogdon, 2001), and elongated anatomical areas/phallic symbols (nose, neck) (Hammer, 1954, as cited in Gilbert, 1980). The heavy shading of this opposite sex figure suggests anxiety associated with sexual preoccupations (Schildkrout, 1972, as cited in Ogdon, 2001). Again, blocking of sexual and bodily impulses causing tension is suggested by the small trunk (Buck, 1950; Buck & Warren, 1992; Handler, 1985; Jolles, 1964; Urban, 1963; as cited in Ogdon, 2001), and exhibitionistic tendencies are suggested by the long eyelashes (Machover, 1949; as cited in Gilbert, 1980). As in her previous drawing, infantile, regressed sex drives are indicated by emphasized hair (Buck, 1950; Handler, 1985; Levy, 1958; as cited in Ogdon, 2001; Machover, 1949, as cited in Gilbert, 1980), a small trunk (Buck, 1950; Buck & Warren, 1992; Handler, 1985; Jolles, 1964; Urban, 1963; as cited in Ogdon, 2001), and a rounded trunk (Gurvitz, 1951; Handler, 1985; Levy, 1950; Machover, 1949; as cited in Ogdon, 2001). A sense of conflict with or fear towards her father is suggested by Anne?s response to the question of what the worst thing about ?Daddy? is, which was: ?Um, how, um, how, he, he, he bee?s ugly?that?s it?. Anne?s response to the question of what is ?Daddy? doing was ?He?s being a flower boy?la, la, la?. Taken in the context of Anne?s depiction of herself as a flower girl in her first D-A-P drawing, this narrative suggests Oedipal love fantasies towards her father. Also, Anne?s answer to the questions of what ?Daddy? likes doing most and least, were ?Being, mm, being with me? and ?(n)ot being with me?? respectively, which may imply Oedipal wishes of being at the centre of her father?s world. The rounded trunk suggests femininity (Machover, 1949, as cited in Gilbert, 1980). Personality Introversion/extroversion As in her previous drawing there are indicators that Anne?s personality is imbalanced or disorganised. These are random, scribbled shading (body and legs) (Kahn & Giffen, 1960; Schildkrout, 1972; as cited in Ogdon, 2001), and odd details (circular shape on the nose, objects in the hands) (DiLeo, 1973, as cited in Ogdon, 2001). Again, there are indicators suggesting tendencies toward introversion, shyness, inhibition, withdrawal, and self-consciousness. These are central placement of drawing (Alschuler & Hattwick, 1947; Levy, 1950; as cited in Ogdon, 2001; Hammer, 1954, as cited in Gilbert, 1980), placement of the drawing on the right-hand side of the page (Buck, 1950; Hammer, 1969; Jolles, 1964; Wolff, 1946; as cited in Ogdon, 2001), long pencil strokes (Handler, 1996), small eyes (Machover, 1949, as cited in Gilbert, 1980), the stick figure (Hammer, 1965, as cited in Gilbert, 1980), a small trunk (Buck, 1950; Buck & Warren, 1992; Handler, 1985; Jolles, 1964; Urban, 1963; as cited in Ogdon, 2001), a self-conscious stance (Machover, 1949, as cited in Gilbert, 1980), and the omission of feet (Machover, as cited in Gilbert, 1980). As in her previous drawing, a sensitive personality is suggested by the full lips (Machover, 1949; Urban, 1963; as cited in Ogdon, 2001) and submissiveness is indicated by the emphasis on circles in drawing the body (Machover, 1949, as cited in Gilbert, 1980). Defenses Unlike in Anne?s first D-A-P drawing, there are no indicators of defensive, evasive tendencies in this drawing. However, her answer to the question of what is the worst thing about ?Daddy? was ?Um, how, um, how, he, he, he bee?s ugly?that?s it?, indicating defensiveness and evasion. Although fewer than in her previous drawing, there are indicators of feelings of insecurity with reaction formations or compensatory defenses. These are uneven line pressure (Hammer, 1958; Levy, 1950; as cited in Gilbert, 1980; Machover, 1949, as cited in Ogdon, 2001), vacillating direction and interrupted strokes (Jacks, 1969; Levy, 1958; Hammer, 1954; Wolff, 1946; as cited in Ogdon, 2001), placement of the drawing on the bottom of the paper (Buck, 1950; Hammer, 1958; Handler, 1985; Jolles, 1958; as cited in Ogdon, 2001), a lack of symmetry (Hammer, 1958, as cited in Gilbert, 1980), the stick figure (Hammer, 1954; Levy, 1950; as cited in Gilbert, 1980), the feet on the base of the page (Buck, 1950; Hammer, 1954; as cited in Gilbert, 1980), and a groundline (Buck, 1950; Hammer, 1954; Jolles, 1964; as cited in Ogdon, 2001; Machover, 1949, as cited in Gilbert, 1980). As in her previous drawing there are indications of fantasy and intellectualisation as defenses. The defense of fantasy to compensate for feelings of inadequacy is suggested by the drawing filling the page (Hammer, 1954, as cited in Gilbert, 1980) and the overemphasis and strong reinforcement of the facial features (Machover, 1949, as cited in Gilbert, 1980). The use of fantasy as a defense is also indicated by the enlarged head of the figure (Hammer, 1965; Levy, 1950; as cited in Gilbert, 1980), while placement of the drawing on the bottom of the paper suggests the defenses of fantasy and intellectualisation (Handler, 1985; Jolles, 1952; as cited in Ogdon, 2001). Autonomy/dependency As in her previous drawing there are numerous indicators of an ambitious, assertive personality. The straight, uninterrupted strokes suggest a quick, decisive, assertive personality (Allen, 1958; Alschuler & Hattwick, 1947; Hammer, 1958; Krout, 1950; Levy, 1958; as cited in Ogdon, 2001). The firm, determined, unhesitating pencil strokes suggest a persistent, ambitious personality (Hammer, 1954, as cited in Gilbert, 1980; Levy, 1958, as cited in Ogdon, 2001). Assertiveness and determination are suggested by the marked directional preference for vertical movement (Alschuler & Hattwick, 1947; Handler, 1985; Levy, 1958; as cited in Ogdon, 2001). The overemphasis and strong reinforcement of the facial features suggests feelings of inadequacy and weakness, compensated for by aggressive and socially dominant behaviour (Machover, 1949, as cited in Ogdon, 2001). Again, there are indicators of ambition/drive/future-orientation. These are the firm line quality (Hammer, 1954; as cited in Gilbert, 1980; Levy, 1958, as cited in Ogdon, 2001), placement of the figure on the right-hand side of the page (Buck, 1950; Buck & Warren, 1992; Jolles, 1952; Mitchell et al., 1993; as cited in Ogdon, 2001), and the long arms (Machover, 1949, as cited in Gilbert, 1980). Although fewer than in her previous drawing there are indicators of Anne?s dependency needs. These are full lips (Machover, 1949; Urban, 1963; as cited in Ogdon, 2001), and an open mouth (Gurvitz, 1951; Levy, 1950; Modell & Potter, 1949). Outstretched arms and hands show a desire for interpersonal contact, affection, or help (Handler, 1985; Michal-Smith & Morgenstern, 1969; Schildkrout, 1972; as cited in Ogdon, 2001; Machover, 1949, as cited in Gilbert, 1980). Placement of the drawing on the bottom of the paper further implies a need for support (Buck, 1950; Hammer, 1958; Handler, 1985; Jolles, 1958; as cited in Ogdon, 2001). Impulse control As in her first D-A-P drawing, this drawing suggests considerably high levels of overt anger and great difficulty with impulse control. Although controlled behaviour/emotional control is indicated by the long pencil strokes (Hammer, 1954; Alschuler & Hattwick, 1947; as cited in Gilbert, 1980), central placement of the figure indicates a tendency toward emotional behaviour (Alschuler & Hattwick, 1947; Levy, 1950; as cited in Ogdon, 2001). Heavy pencil pressure suggests high energy levels and excitement (Hetherington, 1952; Kadis, 1950; Levy, 1958; Mitchell, 1993; Precker, 1950; Riethmiller & Handler, 1997; Urban, 1963; as cited in Ogdon, 2001). Impulsivity is indicated by the jagged lines (on body and legs) (Hammer, 1965; Krout, 1950; Machover, 1951; Urban, 1963; Waehner, 1946; as cited in Ogdon, 2001) and variations in pencil pressure (Hammer, 1958; Levy, 1958; as cited in Gilbert, 1980). Variations in pencil pressure also suggest moodiness (Machover, 1949, as cited in Gilbert, 1980), as do the interrupted strokes in vacillating directions (Jacks, 1969; Levy, 1958; Hammer, 1954; Wolff, 1946; as cited in Ogdon, 2001). Overt anger and aggressive tendencies are suggested by numerous indicators. These are unusually heavy pencil pressure (Halpern, 1951; Hammer, 1997; Handler & McIntosh, 1971; Jolles, 1964; McElhaney, 1969; Reynolds, 1978; Riethmiller & Handler, 1997; Schneidman, 1958; Urban, 1963; Wysocki & Whitney, 1965; as cited in Ogdon, 2001), straight lines (Hammer, 1958; Krout, 1950; as cited in Gilbert, 1980), jagged lines (Hammer, 1965; Krout, 1950; Machover, 1951; Urban, 1963; Waehner, 1946; as cited in Ogdon, 2001), drawing in the middle of the page (Machover, 1949, as cited in Gilbert, 1980), the unusually large, centrally placed figure (Machover, 1949, as cited in Ogdon, 2001), a marked disturbance of symmetry (Koppitz, 1968, as cited in Ogdon, 2001), emphasized hair (Handler, 1985; Shneidman, 1958; as cited in Ogdon, 2001), nostrils (Machover, 1949, as cited in Gilbert, 1980), teeth showing (Buck, 1966; Buck & Warren, 1992; Goldstein & Rawn, 1957; Halpern, 1965; Hammer, 1965; Handler, 1996; Jolles, 1964; Koppitz, 1968; Levy, 1958; Machover, 1960; McElhaney, 1969, Mitchell, 1993; Rierdan et al., 1982; Schildkrout, 1972; Urban, 1963; as cited in Ogdon, 2001), a long neck (Hammer, 1950; Levy, 1958; as cited in Gilbert, 1980), asymmetrical arms (Hammer, 1969; Koppitz, 1968; Machover, 1949; Mundy, 1972; Urban, 1963; as cited in Ogdon, 2001), the very long arms extended from the body (Hammer, 1958; Levy, 1958; as cited in Gilbert, 1980), fingers with no hands (Machover, 1949, as cited in Gilbert, 1980), and stick fingers (Machover, 1949, as cited in Gilbert, 1980). Anne?s answer to the question of what ?Daddy? would like to do if he were invisible was ?Give people a shock?, revealing aggressive impulses. Assaultiveness is indicated by the emphasized hair (Handler, 1985; Shneidman, 1958; as cited in Ogdon, 2001) and reinforced legs (Hammer, 1954, as cited in Gilbert, 1980). Psychopathology There are more indicators than in her previous drawing that Anne is normal, stable, reasonably well-adjusted, and has adequate contact with reality. These are drawing in normal succession (Machover, 1949; as cited in Gilbert, 1980), firm, unhesitating, determined pencil strokes (Levy, 1958, as cited in Ogdon, 2001), central placement of figure (Buck & Warren, 1992; Handler, 1985; Lakin, 1956; Urban, 1963; Wolff, 1946; as cited in Ogdon, 2001), a relaxed standing posture (Urban, 1963, as cited in Ogdon, 2001), and erasing in moderation followed by an improved drawing (Buck & Warren, 1992; Hammer, 1954; Jolles, 1964; Roback, 1968; as cited in Ogdon, 2001). However, once again, poor emotional adjustment, emotional stress and emotional constriction are suggested. Poor adjustment and emotional stress is suggested by the fluctuating pencil pressure (Hammer, 1958; Levy, 1958; as cited in Gilbert, 1980), the unusually large size of the figure (Koppitz, 1968, as cited in Ogdon, 2001) and the gross distortions/disproportions (tiny trunk; disproportionate arms; extremely long legs) (Britain, 1970; Koppitz, 1966; Mitchell, 1993; Vane & Eisen, 1962; as cited in Ogdon, 2001). Emotional constriction is implied by anchoring of the drawing (Reynolds, 1978). As in her previous drawing, the hair in disarray suggests confused thought processes (Levine & Sapolsky, 1969, as cited in Ogdon, 2001), as does the tiptoe stance (Buck & Warren, 1992; Hammer, 1954; Jolles, 1952; Urban, 1963; as cited in Ogdon, 2001). There are numerous indicators of psychopathology. There are no indicators of depression or conflict/somatisation in the head area in this drawing. There are fewer indicators of schizoid and narcissistic tendencies than in Anne?s first D-A-P drawing. Otherwise the quantity of indicators for each category of psychopathology, are relatively similar. Anxiety is suggested by the unusually heavy pencil pressure (Buck, 1950; Deabler, 1969; Hammer, 1969; Handler, 1996; Handler & Reyher, 1966; Jolles, 1964; Kadis, 1950; Machover, 1955; Reynolds, 1978; Riethmiller & Handler, 1997; Urban, 1963; as cited in Ogdon, 2001), uneven line pressure (Machover, 1949, as cited in Gilbert, 1980), jagged lines (Hammer, 1965; Krout, 1950; Machover, 1951; Urban, 1963; Waehner, 1946; as cited in Ogdon, 2001), reinforced lines (Buck, 1950; Hammer 1965; as cited in Gilbert, 1980), vacillating direction and interrupted strokes (Jacks, 1969; Levy, 1958; Hammer, 1954; Wolff, 1946; as cited in Ogdon, 2001), the unbalanced stance (Machover, 1949, as cited in Gilbert, 1980), a simplified trunk (Riethmiller & Handler, 1997, as cited in Ogdon, 2001), fragmentation inadvertently introduced (by the neck cutting off the head from the trunk, by shading of the body and legs cutting them off from the head) (Hammer, 1978; Jacks, 1969; as cited in Ogdon, 2001), excessive detail (tongue and teeth in the mouth, objects in both hands, heavily shaded body and legs) (Machover, 1949, as cited in Gilbert, 1980), and inconsistent treatment of male and female figures (Haworth, 1962, as cited in Ogdon, 2001). Neurosis is suggested by the placement of the drawing low on the page (DiLeo, 1973, as cited in Ogdon, 2001), random, scribbled shading (Kahn & Giffen, 1960; Schildkrout, 1972; as cited in Ogdon, 2001), and excessive detail (Machover, 1949, as cited in Gilbert, 1980). Obsessiveness is indicated by excessive detail (Machover, 1949, as cited in Gilbert, 1980), and inconsistent treatment of male and female figures (Haworth, 1962, as cited in Ogdon, 2001). Obsessive-compulsivity is suggested by excessive detail (Buck, 1966; Buck & Warren, 1992; Deabler, 1969; Hammer, 1969; Handler, 1985; Jacks, 1969; Kahn & Giffen, 1960; Levy, 1958; Machover, 1949; McElhaney, 1969; Reynolds, 1978; as cited in Ogdon, 2001), unnecessary detailing (tongue and teeth in the mouth, objects in both hands, heavily shaded body and legs) (Hammer, 1958; Levy, 1958; as cited in Gilbert, 1980), and re-working with addition of excessive detail (Hammer, 1958; Levy, 1958; as cited in Gilbert, 1980). Hysteria is suggested by random, scribbled shading (Kahn & Giffen, 1960; Schildkrout, 1972; as cited in Ogdon, 2001), and the long neck (Hammer, 1958; Levy, 1958; as cited in Gilbert, 1980). Paranoia is suggested by the unusually heavy pencil pressure (Hammer, 1958; Reznikoff & Nicholas, 1958; Roback, 1968; Weiner, 1966; as cited in Ogdon, 2001), and sharp, spiked/spear fingers (Brown, 1958; Buck, 1966; Buck & Warren, 1992; DiLeo, 1970; Goldstein & Rawn, 1957; Hammer, 1965; Handler, 1985; Jacks, 1969; Jolles, 1964; Machover, 1949; McElhaney, 1969; Mitchell, 1993; Modell & Potter, 1949; Reynolds, 1978; Schildkrout, 1972; Shneidman, 1958; Urban, 1963; Wolk, 1969; Wysocki & Wysocki, 1977; as cited in Ogdon, 2001). Schizophrenia/psychosis is indicated by unusually heavy pencil pressure (Gustafson & Waehler, 1992, as cited in Ogdon, 2001), body distortions/disproportions (Hammer, 1958; Levy, 1958; as cited in Gilbert, 1980), hair in disarray (Mitchell, 1993, as cited in Ogdon, 2001), teeth showing (Machover, 1949; as cited in Gilbert, 1980), and unessential detail emphasized (tongue and teeth in mouth, objects in both hands, heavily shaded body and legs) (Machover, 1949, as cited in Gilbert, 1980). Conflict or somatisation in the throat area is suggested by the long neck (Hammer, 1954, as cited in Gilbert, 1980; Levy, 1958, as cited in Ogdon, 2001). Hyperactivity is indicated by a marked directional preference for vertical movement (Alschuler & Hattwick, 1947; Handler, 1985; Levy, 1958; as cited in Ogdon, 2001). Schizoid tendencies are suggested by the long neck (Hammer, 1958; Levy, 1958; as cited in Gilbert, 1980). Narcissistic tendencies are indicated by the hair given much attention (Hammer, 1954, as cited in Gilbert, 1980; Handler, 1985; Levy, 1958; Machover, 1949; as cited in Ogdon, 2001), full lips (Machover, 1949; Urban, 1963; as cited in Ogdon, 2001), and an emphasis on curves in depicting the body (Machover, 1949, as cited in Gilbert, 1980). Organicity is indicated by a marked disturbance of symmetry (Koppitz, 1968, as cited in Ogdon, 2001), an open mouth (Gurvitz, 1951; Levy, 1950; Modell & Potter, 1949), asymmetrical arms (Hammer, 1969; Koppitz, 1968; Machover, 1949; Mundy, 1972; Urban, 1963; as cited in Ogdon, 2001), and fragmentation inadvertently introduced (Lezak, 1983; McLachlan & Head, 1974; Mitchell, 1993; as cited in Ogdon, 2001). Anne wrote the letter ?b? on her drawing, and then erased it, replacing it with the letter ?d?. This suggests difficulty with reversals or dyslexic tendencies. 4.4.3.3. K-F-D a) Introduction When asked to draw her family, Anne said, ?I don?t know what to do. I?m gonna draw an airport, with my whole family waiting for Daddy to come out?, as she drew a large figure (her mother) on the right-hand side of the page. The figure has a large head, a large smiling mouth, large ears and shaded, messy hair. She added a very large, round tummy for the torso with a belly button, then drew the right and left arms with an object at the end of each (flowers). She drew the right and left legs, then said, ?There?s one, that?s me?no, actually that?s not me, that?s my Mommy?now I?m doing me?. She started drawing herself as a smaller, unkempt and anxious looking figure to the left of her mother, stating, ?There?s not enough space. I?m smaller than Mommy, so I got me lower?. She drew herself with a leaning posture and a large belly button. She drew a butterfly at the end of the left arm and a claw-like right hand holding onto her mother?s left leg. She drew a small semi-circular object (a star) in the right hand. She drew a third figure on the left-hand side of the page (her father) with a very large head, large eyes, a smiling mouth, and a small, rounded torso with a belly button. She drew arms with hearts at the ends and legs. As she drew, she explained, Now I?m drawing Uncle John?this is actually Daddy. Look! That?s it. Auntie Bev?s coming out the airport, so my daddy?s holding hearts, my Mom?s holding flowers. I?m holding two different things. I?m holding a star, now I?m holding a butterfly. Done! How much minutes did I take? I don?t believe it. I?m still doing this picture. She drew a wavy groundline at the bottom of the page and added a flower, a heart and a butterfly to the top of the groundline. She explained, ?Now we got Daddy out of the airport, now we outside, there?s the grass and flowers and, on the flowers, hearts and then butterflies. There, I?m done?Look at it. How much minutes did I take? Who must I give this to??. ?I?m still doing the sky?I?m nearly finished. There?s some parts that I gotta colour in?, she explained, as she drew dark, heavily shaded lines at the top of the page and a heart in the sky to the right of her mother. During questioning she added more hair to the figure of her mother and then to those of herself and her father. She added more lines to her mother?s mouth, stating, ?I?ll give Mommy a bigger, smiley face?. She drew from right to left and took 1 minute and 19 seconds to complete her drawing. b) Emotional indicators Self-concept Self-esteem and body image As in Anne?s D-A-P drawings, there are indicators to suggest low self-esteem with feelings of inadequacy. These are disturbed symmetry (Machover, 1949, as cited in Gilbert, 1980), overemphasis and strong reinforcement of facial features (Machover, 1949, as cited in Ogdon, 2001), the small trunks of Anne and her father (Buck, 1950; Buck & Warren, 1992; Handler, 1985; Jolles, 1964; Urban, 1963; as cited in Ogdon, 2001), the omission of hands on all figures (except for Anne, who has a right hand) (Hammer, 1954, as cited in Gilbert, 1980), fewer than five fingers on all figures (Schildkrout, 1972, as cited in Ogdon, 2001), and the dishevelled, unkempt figures (Hammer, 1958, as cited in Gilbert, 1980). Although there are no indicators of body image dissatisfaction, there are again indicators to suggest her dissatisfaction with her social status and concerns over social opinion. The dishevelled, unkempt figures suggest a perceived lack of status (Hammer, 1958, as cited in Gilbert, 1980). Anne?s answer to the question of what she would change about her family, if she could change one thing, was ?Um?being poor?nothing else?. This answer implies an awareness of and dissatisfaction with her social status. Overconcern with outward appearance is suggested by the overemphasis and strong reinforcement of the facial features (eyes on all figures, mother?s mouth) (Jolles, 1964, as cited in Ogdon, 2001). The emphasized eyes (by pressure) of all the figures suggest hypersensitivity to social opinion, particularly criticism (Handler, 1985; Machover, 1958; as cited in Ogdon, 2001), as do the large ears on the figure of her mother (Hammer, 1968; Jolles, 1964; Machover, 1949; as cited in Gilbert, 1980). Once again, there are indicators to suggest that Anne feels a sense of social isolation, uneasiness or hostility. These are the hostile, angry facial expression of figure of Anne (Machover, 1949, as cited in Gilbert, 1980), the nude figures (Hammer, 1968; Holzberg & Wexler, 1950; Machover, 1949; Urban, 1963; as cited in Ogdon, 2001), and jagged lines (Hammer, 1965; Krout, 1950; Machover, 1951; Urban, 1963; Waehner, 1946; as cited in Ogdon, 2001). Interpersonal family dynamics The family members have barriers between them (objects in their hands); indicating isolation and conflict (Reynolds, 1978). The omission of feet from all the figures suggest feelings of constriction and helplessness and a lack of independence or loss of autonomy (Buck, 1966; Buck & Warren, 1992; Evans & Marmorston, 1963; Hammer, 1954; Handler, 1985; Jolles, 1964; Kokonis, 1972; McLachlan & Head, 1974; Mitchell, 1993; Modell & Potter, 1949; Mursell, 1969; Schildkrout, 1972; Urban, 1963; as cited in Ogdon, 2001), as well as discouragement and withdrawal (Machover, 1949, as cited in Gilbert, 1980). Emotional constriction is indicated by anchoring of the drawing (figures are drawn within one inch of the edge of the page) (Reynolds, 1978). There are more indicators of the need for help or support in Anne?s K-F-D than in her D-A-P drawings. The groundline suggests a need for help or support (Hammer, 1958; Levy, 1950; as cited in Gilbert, 1980), as does placement of the drawing on the bottom of the paper (Buck, 1950; Hammer, 1958; Handler, 1985; Jolles, 1958; as cited in Ogdon, 2001). All the figures have arm extensions, suggesting that Anne perceives everyone in her family as unstable and needing help to cope with one other and the outside world (Reynolds, 1978). The outstretched arms of all the figures reflect a desire for interpersonal contact, affection or help (Handler, 1985; Michal-Smith & Morgenstern, 1969; Schildkrout, 1972; as cited in Ogdon, 2001; Machover, 1949, as cited in Gilbert, 1980). As in Anne?s D-A-P drawings, the gross distortions/disproportions in the K-F-D suggest poor school achievement (Koppitz, 1966; Mitchell, 1993; Vane & Eisen, 1962; as cited in Ogdon, 2001). Sexuality and gender identity As in Anne?s D-A-P drawings, there are a number of sexually-oriented indicators, suggesting a preoccupation or conflict with sexuality. These are emphasized hair on all the figures (especially as it is heavily shaded) (Buck, 1950; DiLeo, 1970; Hammer, 1954; Handler, 1985; Jolles, 1964; Levy, 1958; Machover, 1951; Roback, 1968; Urban, 1963; as cited in Ogdon, 2001), messy hair on all figures (Buck, 1950; DiLeo, 1970; Hammer, 1954; Handler, 1985; Jolles, 1964; Levy, 1958; Machover, 1951; Roback, 1968; Urban, 1963; as cited in Ogdon, 2001), the mother?s large trunk (Buck, 1950; Buck & Warren, 1992; Handler, 1985; Jolles, 1971; Urban, 1963; as cited in Ogdon, 2001), and elongated anatomical areas/phallic symbols (mother?s ears and trunk) (Hammer, 1954, as cited in Gilbert, 1980). Blocking of sexual and bodily impulses causing tension is suggested by the mother?s large trunk (Buck, 1950; Buck & Warren, 1992; Handler, 1985; Jolles, 1971; Urban, 1963; as cited in Ogdon, 2001), the small trunks of the other figures (Buck, 1950; Buck & Warren, 1992; Handler, 1985; Jolles, 1964; Urban, 1963; as cited in Ogdon, 2001), the unusually high waistlines of all figures (Handler, 1985; Machover, 1949; as cited in Ogdon, 2001), and the reinforced waistlines of all figures (Machover, 1949; Modell & Potter, 1949; as cited in Ogdon, 2001). Infantile, regressed sex drives are indicated by emphasized hair (Buck, 1950; Handler, 1985; Levy, 1958; as cited in Ogdon, 2001; Machover, 1949, as cited in Gilbert, 1980), the small trunks of all figures except the mother (Buck, 1950; Buck & Warren, 1992; Handler, 1985; Jolles, 1964; Urban, 1963; as cited in Ogdon, 2001), and the rounded trunks of all the figures (Gurvitz, 1951; Handler, 1985; Levy, 1950; Machover, 1949; as cited in Ogdon, 2001). Anne?s answer to the question of what the one worst thing about her family is, suggests Oedipal ambivalence towards her mother, as follows, The worstest thing is?I have no idea. Nothing?actually, um, when I get punishment. I?m just doing hair now . She?s got funny hair now, look at her. You know why I did her hair like that? Cos I wanna decorate it with hearts . Daddy?s got curly hair. Exhibitionistic and autoerotic tendencies are suggested by the nude figures (Gurvitz, 1951; Machover, 1949; as cited in Ogdon, 2001). Preoccupations with body processes, development, and pregnancy are suggested by the nude figures (Machover, 1949; Tolor & DiGrazia, 1977; Urban, 1963; as cited in Ogdon, 2001). These preoccupations may also be implied by the rounded bellies constituting the torsos of all the figures, with distinct belly buttons in the centre. Femininity is suggested by the rounded trunks of the figures (Machover, 1949, as cited in Gilbert, 1980). Gender identification with her mother as a female is suggested by Anne?s narrative while drawing, ?There?s one, that?s me?no, actually that?s not me, that?s my mommy?now I?m doing me?. Personality Introversion/extroversion As in Anne?s previous drawings, personality imbalance is indicated in this drawing. An imbalanced or disorganised personality, which is neurotic and even hysterical is suggested by the random, scribbled shading (hair and clouds) (Kahn & Giffen, 1960; Schildkrout, 1972; as cited in Ogdon, 2001). As in her D-A-P drawings, there are indicators of tendencies toward introversion, shyness, withdrawal, inhibition, and self-consciousness. These are long pencil strokes (Handler, 1996), placement of the drawing on the bottom of the paper (Handler, 1985; Jolles, 1952; as cited in Ogdon, 2001), small eyes (Machover, 1949, as cited in Gilbert, 1980), the omission of noses from all the figures (Handler, 1996; Koppitz, 1968; Mitchell, 1993; as cited in Ogdon, 2001), Anne?s self-conscious stance (Machover, 1949, as cited in Gilbert, 1980), the small trunks of Anne and her father (Buck, 1950; Buck & Warren, 1992; Handler, 1985; Jolles, 1964; Urban, 1963; as cited in Ogdon, 2001), the emphasized bodies (underclothed) (Machover, 1949, as cited in Gilbert, 1980), and the nude figures (Fisher, 1961; Jolles, 1964; Levy, 1958; Machover, 1949; as cited in Ogdon, 2001). Once again, a sensitive personality is suggested by the full lips of the figures (Machover, 1949; Urban, 1963; as cited in Ogdon, 2001) and submissiveness is indicated by the emphasis on circles in drawing the bodies (Machover, 1949, as cited in Gilbert, 1980). Defenses As in Anne?s first D-A-P drawing, there are indicators of tendencies toward defensiveness and evasion. These are long pencil strokes (Handler, 1996), stick figures (Hammer, 1965, as cited in Gilbert, 1980), nude figures (Hammer, 1968; Holzberg & Wexler, 1950; Machover, 1949; Urban, 1963; as cited in Ogdon, 2001), and the small trunks (Buck, 1950; Buck & Warren, 1992; Handler, 1985; Jolles, 1964; Urban, 1963; as cited in Ogdon, 2001). As in her D-A-P drawings, reaction formations or compensatory defenses against feelings of insecurity are suggested by the uneven line pressure (Hammer, 1958; Levy, 1950; as cited in Gilbert, 1980; Machover, 1949, as cited in Ogdon, 2001), vacillating direction and interrupted strokes (Jacks, 1969; Levy, 1958; Hammer, 1954; Wolff, 1946; as cited in Ogdon, 2001), placement of the figure low on the page (Buck, 1950; Buck & Warren, 1992; DiLeo, 1973; Hammer, 1958; Jolles, 1964; Jolles & Beck, 1953; Mitchell, 1993; Mursell, 1969; Urban, 1963; as cited in Ogdon, 2001), placement of the drawing on the bottom of the paper (Buck, 1950; Hammer, 1958; Handler, 1985; Jolles, 1958; as cited in Ogdon, 2001), a lack of symmetry (Hammer, 1958, as cited in Gilbert, 1980), stick figures (Hammer, 1954; Levy, 1950; as cited in Gilbert, 1980), the wide stances of all figures (Buck, 1950; Buck & Warren, 1992; Jolles, 1964; as cited in Ogdon, 2001), midline emphasis (Machover, 1949, as cited in Gilbert, 1980), the fingerless hands of all figures (Machover, 1949, as cited in Gilbert, 1980), and a groundline (Buck, 1950; Hammer, 1954; Jolles, 1964; as cited in Ogdon, 2001; Machover, 1949, as cited in Gilbert, 1980). Anne?s answer to the question of what the worst thing about her family is, implies the use of undoing to defend against her aggressive impulses towards her mother. As in Anne?s D-A-P drawings, the defenses of fantasy and intellectualisation are indicated. Fantasy is indicated by the enlarged heads of Anne?s parents (Hammer, 1965; Levy, 1950; as cited in Gilbert, 1980). Fantasy to compensate for feelings of inadequacy is suggested by the drawing filling the page (Hammer, 1954, as cited in Gilbert, 1980) and the overemphasis and strong reinforcement of the facial features (Machover, 1949, as cited in Gilbert, 1980). Placement of the drawing on the bottom of the paper suggests fantasy and intellectualisation as defenses (Handler, 1985; Jolles, 1952; as cited in Ogdon, 2001). Autonomy/dependency As in Anne?s D-A-P drawings there are indicators of ambitious, assertive personality traits. The straight, uninterrupted strokes suggest a quick, decisive, assertive personality (Allen, 1958; Alschuler & Hattwick, 1947; Hammer, 1958; Krout, 1950; Levy, 1958; as cited in Ogdon, 2001). The firm, determined, unhesitating pencil strokes suggest a persistent, ambitious personality (Hammer, 1954, as cited in Gilbert, 1980; Levy, 1958, as cited in Ogdon, 2001). Ambition/drive/future-orientation is suggested by the firm line quality (Hammer, 1954; as cited in Gilbert, 1980; Levy, 1958, as cited in Ogdon, 2001). There are more indicators of dependency needs in Anne?s K-F-D than in her D-A-P drawings. These are placement of the drawing on the bottom of the paper (Hammer, 1958; Handler, 1985; as cited in Ogdon, 2001), the mother?s full lips (Machover, 1949; Urban, 1963; as cited in Ogdon, 2001), the mother?s open mouth (Gurvitz, 1951; Levy, 1950; Modell & Potter, 1949), belly buttons of all the figures (Machover, 1949; Hammer, 1954; Halpern, 1965; as cited in Gilbert, 1980), the omission of necks on all figures (Machover, 1949, as cited in Gilbert, 1980), and fewer than five fingers on all figures (Hammer, 1954, as cited in Gilbert, 1980). Anne positioned herself leaning next to her mother in the drawing, with a hand stretched out holding onto her mother?s left leg. This stance and positioning gives a sense of ?leaning on? (depending on) her mother for support. Anne?s parents are depicted as younger than their years, suggesting emotional immaturity (Machover, 1949; McElhaney, 1969; Meyer, 1955; Urban, 1963; as cited in Ogdon, 2001) and dependency needs (McElhaney, 1969; Urban, 1963; as cited in Ogdon, 2001). Regression is suggested by the omission of necks from all the figures (Machover, 1949, as cited in Gilbert, 1980). Impulse control As in Anne?s D-A-P drawings, her K-F-D strongly suggests that Anne has considerably high levels of overt anger and great difficulty with impulse control. Unlike in her D-A-P drawings, there are also indicators of repressed aggression in the K-F-D. Although controlled behaviour/emotional control is indicated by the long pencil strokes (Hammer, 1954; Alschuler & Hattwick, 1947; as cited in Gilbert, 1980), the omission of necks from all the figures suggests poor impulse control (Machover, 1949, as cited in Gilbert, 1980). Heavy pencil pressure suggests high energy levels and excitement (Hetherington, 1952; Kadis, 1950; Levy, 1958; Mitchell, 1993; Precker, 1950; Riethmiller & Handler, 1997; Urban, 1963; as cited in Ogdon, 2001). Vacillating direction and interrupted strokes suggest moodiness (Jacks, 1969; Levy, 1958; Hammer, 1954; Wolff, 1946; as cited in Ogdon, 2001), as do the variations in pencil pressure (Machover, 1949, as cited in Gilbert, 1980). These variations also suggest impulsivity (Hammer, 1958; Levy, 1958; as cited in Gilbert, 1980). Impulsivity is also suggested by the moderate distortions/disproportions of the figures (Oas, 1984, as cited in Ogdon, 2001) and the jagged lines (Hammer, 1965; Krout, 1950; Machover, 1951; Urban, 1963; Waehner, 1946; as cited in Ogdon, 2001). Repressed aggression is indicated by the single line mouths of Anne and her father (Hammer, 1954; Levy, 1958; as cited in Gilbert, 1980), and her father?s small trunk (Buck, 1950; Buck & Warren, 1992; Handler, 1985; Jolles, 1964; Urban, 1963; as cited in Ogdon, 2001). Overt anger and aggressive tendencies are suggested by the unusually heavy pencil pressure (Halpern, 1951; Hammer, 1997; Handler & McIntosh, 1971; Jolles, 1964; McElhaney, 1969; Reynolds, 1978; Riethmiller & Handler, 1997; Schneidman, 1958; Urban, 1963; Wysocki & Whitney, 1965; as cited in Ogdon, 2001), a marked disturbance of symmetry (Koppitz, 1968, as cited in Ogdon, 2001), straight lines (Hammer, 1958; Krout, 1950; as cited in Gilbert, 1980), jagged lines (Hammer, 1965; Krout, 1950; Machover, 1951; Urban, 1963; Waehner, 1946; as cited in Ogdon, 2001), the wide stances of all the figures (Buck, 1950; Buck & Warren, 1992; Hammer, 1969; Jolles, 1964; Machover, 1949; Urban, 1963; as cited in Ogdon, 2001), the asymmetrical limbs of Anne and her father (Hammer, 1969; Koppitz, 1968; Machover, 1949; Mundy, 1972; Urban, 1963; as cited in Ogdon, 2001), emphasized hair (Handler, 1985; Shneidman, 1958; as cited in Ogdon, 2001), fingers with no hands on the figure of Anne (Machover, 1949, as cited in Gilbert, 1980), and stick fingers on the figure of Anne (Machover, 1949, as cited in Gilbert, 1980). The overemphasis and strong reinforcement of the facial features (Machover, 1949, as cited in Ogdon, 2001) suggest feelings of inadequacy and weakness, compensated for by aggressive and socially dominant behaviour (Machover, 1949, as cited in Ogdon, 2001). Assaultiveness is indicated by the wide stances of the figures (Machover, 1949; Shneidman, 1958; Wysocki & Wysocki, 1977; as cited in Ogdon, 2001), emphasized hair (Handler, 1985; Shneidman, 1958; as cited in Ogdon, 2001), and reinforced hair (Hammer, 1954, as cited in Gilbert, 1980). Psychopathology As in Anne?s D-A-P drawings there are indicators suggesting that she is normal, stable, reasonably well-adjusted and has adequate contact with reality. These are firm, unhesitating, determined pencil strokes (Levy, 1958, as cited in Ogdon, 2001), drawing in normal succession (Machover, 1949, as cited in Gilbert, 1980), and relaxed standing postures (Urban, 1963, as cited in Ogdon, 2001). Basic psychological integrity is suggested by the match between the visible actions of the figures with Anne?s verbal descriptions of what they are doing (Reynolds, 1978). However as in Anne?s D-A-P drawings her K-F-D indicates poor emotional adjustment and emotional stress, as well as confusion in though processes. Poor emotional adjustment and emotional stress are suggested by the fluctuating pencil pressure (Hammer, 1958; Levy, 1958; as cited in Gilbert, 1980), the unusually large size of the figures (Koppitz, 1968, as cited in Ogdon, 2001), and the gross distortions/disproportions (Britain, 1970; Koppitz, 1966; Mitchell, 1993; Vane & Eisen, 1962; as cited in Ogdon, 2001). The hair in disarray suggests confused thought processes (Levine & Sapolsky, 1969, as cited in Ogdon, 2001). There are numerous indicators of psychopathology. There are no indicators of conflict/somatization in either the head or throat areas or of hyperactivity in this drawing. There are substantially more indicators of anxiety, schizoid tendencies and organicity than in Anne?s D-A-P drawings. As in her first D-A-P drawing there are indicators of depression (more in this drawing). Otherwise, the quantity of indicators for each category of psychopathology are similar to those in her D-A-P drawings. Depression is suggested by the placement of the drawing on the bottom of the paper (Handler, 1985; Jolles, 1952; as cited in Ogdon, 2001), placement of the figure low on the page (Buck, 1950; Buck & Warren, 1992; Halpern, 1965; Hammer, 1958; Handler, 1985; Jolles, 1964; Jolles & Beck, 1953; Levy, 1950; Machover, 1949; Mitchell, 1993; Mursell, 1969; Urban, 1963; as cited in Ogdon, 2001), very short, circular, sketchy strokes (Buck, 1950; Gurvitz, 1951; Hammer, 1958; Jolles, 1952; Levy, 1958; Urban, 1963; as cited in Ogdon, 2001), the omission of noses from all figures (Handler, 1996; Koppitz, 1968; Mitchell, 1993; as cited in Ogdon, 2001), and clouds (Machover, 1949, as cited in Gilbert, 1980). A feeling of discouragement is suggested by the omission of feet from all the figures (Machover, 1949, as cited in Gilbert, 1980). A perception of maternal depression is suggested in Anne?s narrative while drawing, ?I?ll give Mommy a bigger, smiley face?. Anxiety is suggested by the placement of the drawing on the bottom of the paper (Handler, 1985; Jolles, 1952; as cited in Ogdon, 2001), unusually heavy pencil pressure (Buck, 1950; Deabler, 1969; Hammer, 1969; Handler, 1996; Handler & Reyher, 1966; Jolles, 1964; Kadis, 1950; Machover, 1955; Reynolds, 1978; Riethmiller & Handler, 1997; Urban, 1963; as cited in Ogdon, 2001), uneven line pressure (Machover, 1949, as cited in Gilbert, 1980), jagged lines (Hammer, 1965; Krout, 1950; Machover, 1951; Urban, 1963; Waehner, 1946; as cited in Ogdon, 2001), very short, circular, sketchy strokes (Buck, 1950; Gurvitz, 1951; Hammer, 1958; Jolles, 1952; Levy, 1958; Urban, 1963; as cited in Ogdon, 2001), reinforced lines (Buck, 1950; Hammer 1965;as cited in Gilbert, 1980), and vacillating direction and interrupted strokes (Jacks, 1969; Levy, 1958; Hammer, 1954; Wolff, 1946; as cited in Ogdon, 2001). Other indicators of anxiety are the emphasized eyes (by pressure), especially as they are shaded (all figures) (Machover, 1958; as cited in Ogdon, 2001), Anne?s unbalanced stance (Machover, 1949, as cited in Gilbert, 1980), moderate distortion/disproportion of all the figures (Handler & Reyher, 1966, as cited in Ogdon, 2001), the simplified trunks of all the figures (Riethmiller & Handler, 1997, as cited in Ogdon, 2001), fragmentation inadvertently introduced (Hammer, 1978; Jacks, 1969; as cited in Ogdon, 2001), excessive detail (Machover, 1949, as cited in Gilbert, 1980), clouds (Machover, 1949, as cited in Gilbert, 1980), and lining at the top of the page (Burns & Kaufman, 1972). Neurosis is suggested by placement of the drawing low on the page (DiLeo, 1973, as cited in Ogdon, 2001), random, scribbled shading (Kahn & Giffen, 1960; Schildkrout, 1972; as cited in Ogdon, 2001), and excessive detail (butterflies, flowers, hearts, star, dark clouds) (Buck, 1966; Buck & Warren, 1992; Deabler, 1969; Hammer, 1969; Handler, 1985; Jacks, 1969; Kahn & Giffen, 1960; Levy, 1958; Machover, 1949; McElhaney, 1969; Reynolds, 1978; as cited in Ogdon, 2001). Obsessiveness is indicated by excessive detail (Machover, 1949, as cited in Gilbert, 1980). Obsessive- compulsivity is suggested by the hair parted in the middle on the figure of Anne (Hammer, 1958; Levy, 1958; as cited in Gilbert, 1980), excessive detail (Buck, 1966; Buck & Warren, 1992; Deabler, 1969; Hammer, 1969; Handler, 1985; Jacks, 1969; Kahn & Giffen, 1960; Levy, 1958; Machover, 1949; McElhaney, 1969; Reynolds, 1978; as cited in Ogdon, 2001), unnecessary detailing (butterflies, flowers, hearts, star, dark clouds) (Hammer, 1958; Levy, 1958; as cited in Gilbert, 1980), and re- working with the addition of excessive detail (Hammer, 1958; Levy, 1958; as cited in Gilbert, 1980). Anne?s answer to the question of what she would like to change about her family, was ?Um?being poor?nothing else?, which may relate to her OCD symptom of repeated doubting (worrying about family finances), Hysteria is suggested by the random, scribbled shading (Kahn & Giffen, 1960; Schildkrout, 1972; as cited in Ogdon, 2001). Paranoia is suggested by unusually heavy pencil pressure (Hammer, 1958; Reznikoff & Nicholas, 1958; Roback, 1968; Weiner, 1966; as cited in Ogdon, 2001), the emphasized eyes (by pressure) of all figures (Deabler, 1969; Griffith & Peyman, 1959; Hammer, 1968; Handler, 1985; Jacks, 1969; Kahn & Giffen, 1960; Levy, 1958; Machover, 1958; McElhaney, 1969; Reznikoff & Nicholas, 1958; Robins et al., 1991; Schildkrout, 1972; Shneidman, 1958; Urban, 1963; as cited in Ogdon, 2001), and sharp, spiked/spear fingers on the figure of Anne (Brown, 1958; Buck, 1966; Buck & Warren, 1992; DiLeo, 1970; Goldstein & Rawn, 1957; Hammer, 1965; Handler, 1985; Jacks, 1969; Jolles, 1964; Machover, 1949; McElhaney, 1969; Mitchell, 1993; Modell & Potter, 1949; Reynolds, 1978; Schildkrout, 1972; Shneidman, 1958; Urban, 1963; Wolk, 1969; Wysocki & Wysocki, 1977; as cited in Ogdon, 2001). Schizophrenia/psychosis is indicated by unusually heavy pencil pressure (Gustafson & Waehler, 1992, as cited in Ogdon, 2001), body distortions/disproportions of all figures (Hammer, 1958; Levy, 1958; as cited in Gilbert, 1980), disconnected lines and displaced parts (Hammer, 1954, as cited in Gilbert, 1980), hair in disarray (Mitchell, 1993, as cited in Ogdon, 2001), enlarged ears on the figure of the mother (Machover, 1949, as cited in Gilbert, 1980), the nude figures (Hammer, 1968; Holzberg & Wexler, 1950; Machover, 1949; Urban, 1963; as cited in Ogdon, 2001), and unessential detail emphasized (butterflies, flowers, hearts, star, dark clouds) (Machover, 1949, as cited in Gilbert, 1980). Schizoid tendencies are suggested by the nude figures (Hammer, 1968; Holzberg & Wexler, 1950; Machover, 1949; Urban, 1963; as cited in Ogdon, 2001), enlarged ears on the figure of the mother (Machover, 1949, as cited in Gilbert, 1980), midline emphasis (Machover, 1949, as cited in Gilbert, 1980), and omission of feet and hands (Machover, 1949, as cited in Gilbert, 1980). Narcissistic tendencies are indicated by the hair given much attention (Hammer, 1954, as cited in Gilbert, 1980; Handler, 1985; Levy, 1958; Machover, 1949; as cited in Ogdon, 2001), hair parted in the middle on the figure of Anne (Hammer, 1958; Levy, 1958; as cited in Gilbert, 1980), full lips on the figure of the mother (Machover, 1949; Urban, 1963; as cited in Ogdon, 2001), and an emphasis on curves in depicting the bodies (Machover, 1949, as cited in Gilbert, 1980). Organicity is indicated by the placement of the drawing on the bottom of the paper (Michal-Smith & Morgenstern, 1969, as cited in Ogdon, 2001), marked disturbance of symmetry (Koppitz, 1968, as cited in Ogdon, 2001), open mouths (Gurvitz, 1951; Levy, 1950; Modell & Potter, 1949), asymmetrical limbs of all figures (Hammer, 1969; Koppitz, 1968; Machover, 1949; Mundy, 1972; Urban, 1963; as cited in Ogdon, 2001), fragmentation inadvertently introduced (Hammer, 1978; Jacks, 1969; as cited in Ogdon, 2001), fewer than five fingers on all figures (Koppitz, 1968, as cited in Ogdon, 2001), and less than two articles of clothing on all figures (Evans & Marmorston, 1963; Koppitz, 1968; as cited in Ogdon, 2001). 4.4.4 TAT analysis Card 1 The card elicits themes of the relationship toward the parental figures and ADD (Bellak, 1975). Anne?s story suggests anxiety (repetitive snorting and difficulty coming up with a story), a sense of loneliness and a need for nurturance. Defensiveness was evident (Anne?s action of quickly handing the card back, and the telling of an incomplete story that does not match the picture). ADD is suggested (failure to recognise the violin). High intelligence and an average level of maturity are indicated. Card 2 The card elicits the theme of autonomy from versus compliance with the family (Bellak, 1975). Anne?s story suggests school-related anxiety (?she doesn?t want to go to school?), and a conflict between autonomy and compliance. High intelligence, an average level of maturity, and adequate ego integration are indicated. Card 3BM The card elicits themes of depression and aggression (Bellak, 1975). In Anne?s story, the evironment is perceived as unpredictable and scary. Her story suggests oral aggression (having a nightmare after brushing her teeth), and anxiety over feeling overwhelmed and helpless, that takes the form of nightmares (?she went to bed and dreamed of a horrible dream?). Superego anxiety is suggested (?after the horrible dream, she felt better, cos it was the morning. And she said: No, no?), and a conflict between aggressive drives and a harsh superego. The defenses of displacement and undoing (aggressive drives are directed back at the self) are evident. High intelligence, an average level of maturity, and adequate ego integration are indicated. Card 3GF The card elicits the theme of depression (Bellak, 1975). Anne?s story indicates depression and insecurity (?This girl was hanging on the pole and she was going somewhere?). Defensiveness is evident (?What is this one?I don?t know what it is. What was your story, if you had to do the activity? I?m gonna test you after. What can I use to do it??). The defense of displacement is suggested. High intelligence, an average level of maturity, and inadequate ego integration are indicated. Card 4 The card elicits themes of male-female relationships and female attitudes towards men (Bellak, 1975). Anne?s story suggests a perception of men and women as adversaries (possibly parents), with the man as the aggressor (?The man and lady are fighting. He?s angry with her and she said no fighting, and she?s sad?). Awareness of parental conflict is indicated. This may be a projection Anne?s own aggression and ambivalence towards her parents. Conflict between a harsh superego and aggression is suggested. Depression, possibly maternal (?she?s sad?), is suggested. Anxiety over parental disapproval and feeling overwhelmed and helpless by it is evident. The defenses of projection, acting out, and undoing are suggested. High intelligence, a low level of maturity, and inadequate ego integration are indicated. Card 5 The card elicits the theme of the mother who may be watching (Bellak, 1975). Anne?s story indicates insecurity or paranoia (?There?s flowers in the room and the lady?s checking that everything?s OK?). ?(C)hecking? may relate to compulsive checking. Defensiveness is evident (story is incomplete and very brief with a lack of detail), and the defense of projection is suggested. High intelligence, a low level of maturity, and adequate ego integration are indicated. Card 6GF The card elicits the theme of the relationship of females to the father (Bellak, 1975). Anne?s story indicates a perception of communication difficulties between her parents. Defensiveness towards her father, perhaps repressed aggression, is indicated (?trying to read?, while ?the man?s trying to talk with her?). The defense of projection is suggested. High intelligence and an average level of maturity are indicated. Card 7GF The card elicits the theme of the mother-child relationship (Bellak, 1975). Anne?s story indicates defensiveness and anger towards her mother (?her mommy?s trying to talk to her, but she?s too angry to talk to her mom?), and Oedipal wishes (the girl?s doll is a ?baby doll? and she?s angry with her mother). Conflict between superego and aggression is suggested. The defense of isolation is indicated. High intelligence, a low level of maturity, and inadequate ego integration are implied. Card 9GF The card elicits the theme of depression (Bellak, 1975). Although there is no evidence of such from Anne?s story, a sense of connectedness with her mother, who is perceived as nurturing, emerged. High intelligence, an average level of maturity, and adequate ego integration are indicated. Card 10 The card elicits themes of male-female relationships (Bellak, 1975). Anne?s story reveals anxiety over conflict and ambivalence between her parents (?The mommy and daddy were fighting?). The defenses of acting out and undoing are indicated. High intelligence and an average level of maturity are suggested. Card 11 The card elicits themes of infantile or primitive fears (Bellak, 1975). Anne?s story suggests aggression (dragon is ?angry? and ?he?s looking for something to fight with?), and conflict between aggressive drives and an inadequate superego. Anxiety and fears of attack (from the dragon/phallic/father figure) are indicated. The defenses of acting out, fantasy, and projection are suggested. High intelligence, a low level of maturity, and inadequate ego integration are implied. Card 12F The card elicits the theme of mother figure conceptions (Bellak, 1975). Anne?s story reveals a perception of distance in mother-child relationship (because the ?old lady is very old?, whereas ?the young lady is a princess?). High intelligence and a low level of maturity are indicated. Card 13MF The card elicits the theme of sexual conflicts (Bellak, 1975). Anne?s story suggests an aggressive, Oedipal wish for her mother to be dead so that she can replace her, but ambivalence as there is a sense of remorse at her death (??he?s sorry that he did that and he?s crying now?) and an undoing of her death (?But, she?s not really dead?). Her father is perceived as aggressive, threatening and confused (ambivalent) towards the mother. Conflict between aggressive drives and an inadequate superego is suggested. Anxiety and paranoia are indicated, in the form of fears of attack from a male/father figure and of being overwhelmed and helpless against it (?The lady?s sleeping, maybe she?s dead and he?s killed her?). The defenses of acting out, fantasy, undoing, and projection are implied. High intelligence, a low level of maturity, and inadequate ego integration are indicated. Card 13B The card elicits themes of childhood (Bellak, 1975). Anne?s story indicates economic and nurturance concerns (?The little boy?s poor and he doesn?t have anywhere else to live?but, only in a shack, where there?s no food to eat even?). The defense of projection is indicated. High intelligence and an average level of maturity are implied. Card 14 The card elicits the theme of fears related to darkness (Bellak, 1975). Anne?s story reveals anxiety and paranoid fear of darkness or attack (?The man is checking before he puts on the alarm. It?s night time and he?s gonna turn the alarm on, before he goes to sleep?). Fear of physical injury and of feeling overwhelmed and helpless in a scary world, and a need for reassurance (?He should put it on, hey??) are suggested. There is a need to be taken care of and the perception of her father as a protector, although possibly an inadequate one. High intelligence and an average level of maturity are indicated. Card 17GF The card elicits the theme of depression (Bellak, 1975). Anne?s story indicates anxiety and depression (?The lady?s watching the river and she?s really worried?), and the environment is perceived as distressing. The defense of isolation is suggested. High intelligence and a low level of maturity are implied. Card 18GF The card elicits themes of how aggression is handled, and mother-daughter conflicts (Bellak, 1975). Anne?s story reveals Oedipal ambivalence and aggression, possibly in her relationship with her mother (the ladies are fighting, but are ?very, so sad for being fighting?). There is conflict between aggressive drives and an adequate superego. The defenses of acting out and undoing are suggested. High intelligence, an average level of maturity, and adequate ego integration are implied. Card 19 Anne?s story indicates anxiety and paranoid fear of attack (?I think there?s a monster outside?I think they scared of the monster, so they staying inside?). There is a need for reassurance (?That?s a good idea, don?t you think??), and to be taken care of. High intelligence and an average level of maturity are indicated. Chapter 5 Discussion This chapter presents the researcher?s interpretation of the internal world of each subject. Data from the biographical questionnaire, the test data, and the researcher?s observations and impressions are integrated against a background of relevant theory. Themes that emerged in the analysis chapter are discussed. 5.1. Interpretation of Mike?s internal world All Mike?s drawings suggest that although he has adequate contact with reality he is poorly adjusted emotionally. His TAT stories all indicate immaturity and inadequate ego integration. According to Freud (1905a), neurosis results from repressed libidinal impulses arising from instinctual conflicts in resolving the Oedipus complex. Mike?s D-A-P drawings all contain 2 indicators of neurosis. Obsessive-compulsivity is revealed in his story to TAT card 13MF and all his drawings contain 2 to 4 indicators thereof. All Mike?s drawings contain between 5 and 10 indicators of anxiety, and his TAT stories all reveal high levels of anxiety. During testing he exhibited anxiety, breathing heavily whenever he became anxious. Mike has a history of very high levels of anxiety manifesting in anxiety disorders, having suffered from separation anxiety disorder (SAD) when he started school. A child with obsessive-compulsive disorder (OCD) is unable to relinquish Oedipal phantasies and libido becomes ?fixated? (stuck) on his infantile love objects (Mitchell & Black, 1995). Mike?s TAT stories reveal anxiety over the loss of maternal love and maternal abandonment or rejection (Cards 5, 7GF, and 19). Preoccupation and conflict with sexuality are evident in all his drawings and TAT stories (cards 4, 9BM, 10, 12M, 13MF, and 19), and all his drawings reveal infantile, regressed sex drives. OCD involves regression to the anal-sadistic phase of psychosexual development, in which the child became fixated (Freud, 1913). The task of this phase is to adapt to or resist parental control (Lemma, 2002), and fear and helplessness towards the adored parent are transformed by a reaction formation into aggression and omnipotent phantasies and displaced onto all secondary love objects (Stafford-Clark, 1965). Reaction formations are indicated in all Mike?s drawings. By using this defense, Mike transforms his mother and consequently all women from nurturing, desirable love objects into aggressive, domineering, sadistic, and punitive ones. Love has become hatred and fear and helplessness transforms into aggression. All Mike?s D-A-P drawings reveal difficulty controlling his behaviour and emotions. He has a history of difficulty with impulse control, e.g. one of his first OCD symptoms involved irresistible, aggressive, socially unacceptable impulses to interrupt and express out loud what he thought of guests. Mike?s narratives to all his D-A-P drawings indicate a psychological conflict between his ?good? and ?bad? sides. The infantile defense of splitting is implicit in his story to TAT card 13MF. Aggressive tendencies are suggested in all his drawings and TAT stories (cards 1, 3GF, 5, 6BM, 13MF, and 13B), and he behaves more aggressively since the onset of OCD. His D- A-P drawings all contain 1 to 2 indicators of repressed aggression, 5 to 8 indicators of overt anger and aggression, and 3 to 4 indicators of assaultiveness. His TAT stories contain high levels of aggression, with overt aggression expressed in his stories to cards 6BM, 9BM, 10, 12M, and 13MF. Some of these stories express disturbing, violent, highly aggressive fantasies. Freud (1905a) hypothesized that OCD symptoms result due to repressed mental processes, desires, and wishes obtaining discharge via conversion or substitution. Thus intense, harmful affects are displaced onto alternative, harmless representations of the primary love object (Sechaud, 1998). Mike is very close to his mother and his aggressive feelings towards her are intolerable for him and impossible to consciously acknowledge to himself. He thus defends against his ?unacceptable? aggression by projecting it onto secondary love objects (women), in the form of fears of female aggression. Projection is implied in Mike?s TAT stories to cards 3BM, 4, and 19. Some TAT stories reveal both repressed (cards 4 and 5) and overt (cards 6BM and 13MF) aggression towards women. The female figures in his K-F-D are highly sexualised, containing many indicators of sexual preoccupation and conflict, and emotional immaturity. In the drawing the figures of his family members contain 4 indicators of overt aggression, which are mostly in the figures of his mother and sister. Some of his TAT stories reveal sexual conflict and feelings of ambivalence towards women (card 13MF), indicating that he perceives women as stronger, aggressive, dominating, and punitive (cards 4, 6BM, and 13MF). His story to card 4 expresses a fear of being dominated and physically mutilated by a woman. One of his first OCD symptoms was demanding reassurance that his mother wasn?t going to die, to the point of suffering from panic attacks. This symptom represents a transformation of fears of his own considerable aggression towards his mother. Thus Mike feels fear and ambivalence around female sexuality is rooted in obsessions around his mother?s sexuality. Because these Oedipal conflicts are repressed, the affects of guilt and moral distress endure (Sechaud, 1998). Some of Mike?s first OCD symptoms involved ?bad thoughts? (not wanting to think about sex, or that his mother has sex), worries about contamination (germs from his mother), and compulsions to clean or hand wash. Female sexuality has become associated with ?badness? and ?dirtiness?. OCD symptoms are defensive reactions to the huge anxiety generated by conflicting impulses, and emerge to prevent or allay fears of harming, contaminating, destroying, or illicitly becoming sexually involved with, the mother or father, or both (Stafford-Clark, 1965). The defense of undoing is evident in many of Mike?s TAT stories (cards 1, 3GF, 4, 5, 6BM, 8BM, 9BM, 10, 11, 12M, 13MF, 13B, 17BM, and 18BM), often in the form of self-punishment (Mike takes back or takes on the ?bad? woman?s punishment for her, in the form of remorse and/or being punished himself, often by her), OK?the kid was crying cos he saw this woman was sleeping and he told her not to sleep till he got there, cos he wanted to talk to her. But he didn?t want her to talk cos she was too bad. When she was asleep, he mashed her head and she screamed so hard, the book flew out of his hand and she started beating him. (Story to TAT card 13MF). Self-punishment, in the form of self-directed aggression is expressed in Mike?s stories to TAT cards 1, 3BM, 3GF, 4, 7BM, 8BM, 9BM, 12M, and 13MF. Mike has a history of self-directed aggressive tendencies. Some of his first OCD symptoms involved the cleaning ritual of chewing the clothing he wore, mental repeating or counting rituals of licking his lips repeatedly, and shaking his head over and over again to fall asleep. From a psychodynamic perspective, depression constitutes a form of self-punishment, as it is the turning of anger in on the self (Freud, 1917). All Mike?s drawings contain between 2 and 6 indicators of depression and depression is evident in his stories to TAT cards 2, 3BM, and 3GF. Suicidal tendencies are implicit in his story to TAT card 14. Mike has become more depressed since the onset of OCD. Mike uses the defenses of intellectualisation, as suggested in all his drawings and rationalization, as suggested in his story to TAT card 13MF. He also uses the defense of fantasy (as suggested in all his drawings and stories to TAT cards 1, 7BM, and 18BM), to escape from his feelings of isolation and discharge his aggressive instincts, OK, the kid?s bored so that he?s staring at stuff and he wanted to do something, so he found these things. And he wanted to bust something, but it was too hard, so his magic powers broke it and then it smashed in his face ?That?s the end (Story to TAT card 1). According to Freud (1923), the superego of individuals with OCD is particularly harsh and feelings of inferiority persist due to a strong sense of guilt, generating anxiety. Mike has low self-esteem and feels inadequate, as indicated by all his drawings, and his self-esteem has become lower since the onset of OCD. He has a poor body image (stories to TAT cards 3BM, 9BM, 12M, and 18BM) and is self-consciousness and insecure about social acceptance and the image he projects to others, particularly his physical appearance, as indicated by all his drawings. Almost all his TAT stories suggest a harsh superego (cards 2, 3BM, 3GF, 4, 5, 6BM, 7BM, 7GF, 8BM, 9BM, 10, 11, 12M, 13B, 14, 17BM, 18BM, and 19). In boys, the Oedipus complex is normally resolved through castration anxiety and identification with the same sex parent (Freud, 1925), but the anxiety generated in efforts to resolve the Oedipus complex is overwhelming for persons who develop OCD (Stafford-Clark, 1965). Thus in OCD, Oedipal fears of punishment from the same sex parent remain unresolved, causing conflict based on ambivalent feelings of love and hate (Sechaud, 1998). These fears are overwhelming for Mike, and he has been unable to resolve them. His feelings towards his father are ambivalent. The male figures in Mike?s K-F-D are demasculated and inadequate and all his drawings reveal homosexual tendencies. Mike?s drawings all contain 2 to 3 indicators of narcissistic tendencies, which are a component of homosexuality (Freud, 1914). Conflict between homosexual drives and fears is implicit in his TAT stories (cards 9BM, 10, and 12M). This homosexual ambivalence is related to Mike?s ambivalent feelings towards his father. However, Mike is experiencing castration anxiety, as revealed in all his drawings and TAT stories (cards 6BM, 7BM, 8BM, 13MF, 17BM, 18BM, and 19). His perception of his environment as harsh, unstable, punitive, and often scary, as indicated by all his TAT stories, some of which reveal anxiety over physical harm or injury (cards 3BM, 3GF, 4, 8BM, 9BM, and 12M), implies powerful fears of castration. All Mike?s drawings contain 1 to 2 indicators of paranoia and his TAT stories reveal high levels of paranoid anxiety over being watched, mostly by ?security cameras? (cards 11, 13B, 14, and 19), and being unjustly and severely punished, mostly by imprisonment or physical injury (cards 7BM, 8BM, 9BM, 10, and 17BM). Security cameras, imprisonment, the police, and punishment are all symbolic of his father?s authority. In his story to TAT card 19, his father?s authority is symbolised as a ?dark shadow?, Mm..mm, once there was a dark shadow that kept on hunting the burger in the fridge. The person wanted it, but saw holes in it cos of the shadow. He put cameras in, because he didn?t know what was eating it. He saw holes in it and wanted to find the shadow. He couldn?t find the shadow. The shadow ate the burger and everything that was in the fridge and he couldn?t find it. (Story to TAT card 19). All Mike?s drawings indicate conflict between dependency, inactivity, and social withdrawal on the one hand, and an ambitious striving or need for autonomy, achievement, social contact, and activity on the other. His TAT stories reveal a strong, sometimes desperate need for autonomy, but fears of parental disapproval, punishment (particularly physical punishment), and loss of love as a result of not complying with parental rules and expectations (cards 2, 3BM, 3GF, 4, 7BM, 11, 13B, and 14), There was once a boy and he, his parents told him never to go through the door, so he always sat next to the door. But one day, he went out and security cameras saw and he was locked up for not obeying his parents rules, in the prison beyond the door. But he broke even more rules and again and again he got locked up, cos he couldn?t get out of prison to get back behind a door. (Story to TAT card 13B). Identification with the opposite sex parent emerges with the successful resolution of the Oedipus complex, involving superego formation by incorporating the values, attitudes, and sexual orientation of the same sex parent (Lemma, 2002). Although he experiences castration anxiety, Mike has not identified with his father. As a result, he feels physically inadequate and is struggling with his sexuality and gender identity, tending towards homosexuality. His superego is consequently harsh, as revealed by his TAT stories. Anna Freud (1981) explained that innate dispositional factors underlie development, and can result in fixation at a particular pregenital psychosexual stage. Freud (1913) maintained that some individuals are dispositionally predisposed to developing a particular kind of neurosis. Mike?s tests reveal that he generally tends towards hypersensitivity, as he has a highly sensitive, introverted, shy disposition and is hypersensitive to social opinion, particularly criticism. Evidence for this lies in all his drawings, which suggest tendencies toward introversion, introspection, shyness, inhibition, defensiveness, and evasion. During testing, he displayed general defendedness in narratives about his drawings. His drawings all contain 3 to 5 indicators of schizoid tendencies. He has a history of difficulty with social skills at school due to his excessive shyness, and has become even more shy and withdrawn since the onset of OCD. All his drawings reveal feelings of social isolation, uneasiness, and hostility. Since the onset of OCD he has become more socially isolated at school, has more difficulty making friends, and is teased and ridiculed because of his strange behaviour. Sometimes, he doesn?t want to go to, or misses school, and is embarrassed and ashamed by the way he acts, trying to hide his symptoms from teachers and other children at school, and when out in public. His symptoms are very bad at home and minimal at school. This suggests a hypersensitivity to social opinion, especially criticism. This hypersensitivity is also indicated in Mike?s K-F-D and D-A-P narratives. In addition to emotional sensitivity, he also seems to be highly physically sensitive. Some of his TAT stories express difficulty in physically coping with the demands of his environment, and the expectations of his parents (cards 3BM, 3GF, 4, and 5) and school (card 2). During testing he experienced increasing levels of fatigue, expressing discomfort as he became more and more tired. His OCD symptoms cause him excessive tiredness and he feels frustrated and upset when he is unable to meet people?s expectations, Um?the one person fell down, cos he was too tired. But then he had to do his homework. His sister tried to wake him up, but couldn?t. He got into trouble at school?he fell asleep again and didn?t do his homework again, as he had such a hard day at school. (Story to TAT card 2) Mike?s has a strong paternal family history of OCD. He still receives psychological treatment, although his symptoms are currently mild. He no longer displays worries about contamination by germs (not wanting to share a glass or spoon with his mother), aggressive or socially unacceptable impulses (frequently interrupting and saying out loud what he thought of guests), or recurrent thoughts or worries about sex/?bad thoughts? (thinking that sex is a bad thing and not liking to think that his mother has sex). Analysis of his drawings and TAT stories suggests that these fears and impulses persist, but are repressed. Mike?s other initial symptoms of repeated doubting (worrying whether his mother had locked the house and that she had left the stove on), ordering (having to personally place his toys and books ?just right? in his room), cleaning rituals (hand-washing and chewing the clothing he wears), observable repeating or counting rituals (counting things over and over, building floors or tiles on the floor while repeatedly counting, repeating lines and accents from movies, licking his lips repeatedly, shaking his head repeatedly to fall asleep), mental repeating or counting rituals (counting repetitively to fall asleep), and demanding reassurance (to the point of having panic attacks due to unnecessary worrying that something bad was going to happen) remain. Mike?s drawings indicate that he is overwhelmed by strong dependency needs and feelings of helplessness, suggesting regression to the oral stage of psychosexual development. Regression is suggested in Mike?s TAT stories (cards 2, 3BM, 3GF, 6BM, 8BM, 9BM, 12M, 13MF, 14, 18BM, and 19). His TAT stories reveal dependency and nurturance needs (cards 2, 3BM, 3GF, 4, 7BM, 11, 13B, and 14), and indicate anxiety over feeling overwhelmed, helpless, and powerless over his own outcomes or future (cards 2, 3GF, 3BM, 4, 6BM, 7BM, 8BM, 9BM, 10, 12M, 13MF, 13B, 17BM, 18BM, and 19). Mike?s K-F-D reveals a perception of dependency and helplessness in all the family members. Oral and oral incorporative themes related to eating and drinking emerge in his TAT stories (cards 11, 18BM, and 19). Two of Mike?s more persistent OCD symptoms have oral features, viz. chewing the clothing he wears and licking his lips repetitively. Although he tries to hide his symptoms at home they are still very bad. In stark contrast to his D-A-P drawings, the figure of Mike in his K-F-D contains only a single indicator of overt anger and aggression and two indicators of repressed aggression. This suggests that he behaves less aggressively in his family context than elsewhere and that he fulfils a dependent, passive, ?baby? role within the family. Anna Freud (1981) acknowledged the role of environmental factors such as individual growth patterns and family circumstances in psychological development and psychopathology. Mike?s K-F-D indicates that he also feels isolated within his family context. The drawing reveals disconnectedness between the family members, communication difficulties within the family, and conflict between Mike?s parents. There is more tension in the family since the onset of Mike?s OCD symptoms. He needs more parental attention and coping with him leaves his parents feeling more exhausted and frustrated than previously. He tries to involve family members in his rituals. Mike is reportedly not close to his brother and omitted him from his K-F-D. Although he is close to his sister, his K-F-D reveals sibling rivalry (his sister is more outgoing and perceived as being closer to the parents). Since the onset of OCD there has been more tension between Mike and his siblings, who feel jealous and neglected because the parents spend extra time with him, are embarrassed by his strange behaviour, and don?t like inviting friends home any more. Freud (1913) acknowledged the role of an external event in triggering the onset of OCD symptoms. The precipitating event for the onset of Mike?s OCD symptoms was his parents? divorce. Mike has been diagnosed with attention-deficit disorder (ADD). ADD is suggested in his story to TAT card 1. Mike has experienced more trouble concentrating in class since the onset of OCD, and displayed difficulty concentrating during testing. All his drawings contain one indicator of hyperactivity. During testing, he displayed hyperactive behaviour in the form of almost constant fidgeting. This suggests that his ADD may contain a hyperactive component, thus a diagnosis of attention- deficit/hyperactivity disorder (AD/HD) may be considered. Mike has been diagnosed with tourette?s syndrome (TS). During testing he presented with occasional motor tics, in the form of snarling. Mike?s narrative to his third D-A-P drawing revealed acute awareness of his TS and considerable distress as a result of it. 5.2. Interpretation of Daniel?s internal world Daniel?s drawings all suggest that although he has adequate contact with reality, he is poorly adjusted emotionally. Although his TAT stories indicate an average level of maturity, most suggest inadequate ego integration (cards 1, 2, 3BM, 3GF, 4, 5, 6BM, 7GF, 8BM, 9BM, 11, 12M, 13MF, 14, 17BM, and 19). His drawings all indicate personality imbalance or disorganisation and suggest a neurotic, hysterical personality. Personality imbalance is also reflected by the presence of opposing emotional indicators for both introversion and extroversion in his D-A-P drawings, suggesting that his personality contains elements from both personality extremes. Daniel?s family has a history of personality imbalance, with his sister suffering from BPD. All his drawings contain 4 to 9 indicators of anxiety and most of his TAT stories reveal high anxiety levels (cards 1, 3BM, 3GF, 4, 6BM, 7BM, 7GF, 8BM, 9BM, 11, 13MF, 13B, 17BM, 18BM, and 19). During testing he occasionally displayed heavy, anxious breathing. All Daniel?s drawings contain 1 to 3 indicators of neurosis and an indicator of obsessiveness. His drawings all contain 4 to 6 indicators of obsessive-compulsivity. Daniel?s internal world is highly neurotic due to an unresolved Oedipus complex and a strong predisposition to developing psychopathology, particularly neuroses, mood disorders, and personality disorders. Although Daniel?s OCD symptoms are currently mild and he no longer displays the earlier symptoms of repeated doubting (fears of his mother?s death) or demanding reassurance that his mother is not going to die, analysis of his drawings and TAT stories suggests that these fears persist, but have been repressed. Analysis also indicates that Daniel is preoccupied not only with fears of his mother?s death but those of his father and sister as well. His symptoms of cleaning rituals (excessive hand washing), ordering (having to make straight lines out of everything and becoming distressed whenever the order became muddled), observable repeating or counting rituals (counting everything but not necessarily in a repetitive manner), and mental repeating or counting rituals (silently repeating the words of a song over and over, for hours at a time) remain. Freud (1905a) conceptualised neurosis as arising from repressed libidinal impulses due to instinctual conflicts around the resolution of the Oedipus complex. The libido of a child with OCD becomes ?fixated? on infantile love objects due to an inability to relinquish Oedipal phantasies (Mitchell & Black, 1995). All Daniel?s drawings suggest preoccupation and conflict with sexuality (3 to 5 indicators), and infantile, regressed sex drives (1 to 2 indicators). OCD involves regression to the anal-sadistic phase in which the child became fixated (Freud, 1913). In this phase the child must adapt to or resist parental control (Lemma, 2002), and fear and helplessness towards the adored parent are transformed into aggression and omnipotent phantasies by a reaction formation and displaced onto all secondary love objects (Stafford-Clark, 1965). Conflict between the need for autonomy and compliance with parental authority is evident in Daniel?s stories to TAT Cards 3BM and 7BM. Reaction formations are revealed in all his D-A-P drawings (3 to 5 indicators) and some narratives, as well as in his TAT stories (cards 7GF, 13MF, and 17BM). Displacement is suggested in Daniel?s stories to TAT cards 3GF and 9BM, and projection is evident in his stories to cards 1, 2, 3BM, and 8BM. His stories to TAT cards 3BM and 13MF reveal ambivalence and considerable aggression towards his mother/women and his K-F-D suggests that he perceives females as emotionally immature and vulnerable. By reaction formations, Daniel?s feelings of fear and helplessness towards his mother are transformed into aggression, which is displaced onto female sexuality, his sister, and all women. His sister and all women are thus transformed from nurturing, desirable love objects into emotionally immature, sick, weak, vulnerable, or dirty objects. Freud (1905a) hypothesized that OCD symptoms result from repressed mental processes, desires, and wishes, discharged via conversion or substitution. Thus, intense, harmful affects are displaced onto alternative, harmless representations of the primary love object (Sechaud, 1998). Daniel?s aggressive feelings towards his mother are intolerable for him and impossible to consciously acknowledge to himself, especially as he is especially close to her. He defends against his ?unacceptable? aggression by projecting it onto secondary love objects (his sister and other women) in the form of fears of male aggression towards females. In these fantasy scenarios, he projects his unacceptable aggressive affects onto nameless, faceless men, or monsters (such as vampires), sometimes casting himself as the omnipotent fantasy hero figure (often in a protective fatherly or husbandly role) who ?saves? the weak, helpless woman from her attackers, There?s this one boy that lived in a forest. He, he, he lived, himself and his sister, and he, and he used to go catch up, he used to go catch birds with his gun, cos he had no toys. So all he had to play with was this gun. And one day, these men tried to attack them, then he shot them. That?s all. After that, they were sent to jail, the men, and he and his sister lived happily ever after. I can make it up quick! (Story to TAT card 1). Thus, Daniel feels fear and ambivalence around female sexuality, rooted in obsessions around his mother?s sexuality. Because these Oedipal conflicts are repressed, the affects of guilt and moral distress endure (Sechaud, 1998). Some of Daniel?s first symptoms were repeated doubting (worrying that his mother would die) and demanding reassurance (that his mother was not going to die). For Daniel, female sexuality has become associated with illness, weakness, and vulnerability. OCD symptoms are defensive reactions to the huge anxiety produced by conflicting impulses, emerging to prevent or allay fears of harming, contaminating, destroying, or illicitly becoming sexually involved with the mother or father, or both (Stafford- Clark, 1965). All his drawings and narratives to the drawings suggest high levels of resistance. Defensiveness and blocking is indicated in his story to TAT card 3GF. The defense of undoing is indicated in Daniel?s stories to TAT cards 3BM, 6BM, 8BM, and 18BM and serves to punish the hero?s bad deeds, Once upon a time, there was this boy with his mother. He asked his mother could he get a, live with a, could he get a goat as a pet? Then his mother said no, because you?d wreck the house. Then one day, huh, this goat got lost. He looked after it, but he kept it outside. Then one day, he went in the house and ruined their entire house. And then, he, his mother shouted at the boy and then the goats got sent away. (Story to TAT card 3BM). All Daniel?s drawings indicate high levels of anger and aggression and difficulty with impulse control. There are very few indicators of behavioural or emotional control or inhibition and all his drawings reveal difficulty controlling anger or primitive drives, impulsive tendencies, high energy levels, and excitement. All his drawings contain very high quantities of indicators of overt anger and aggression (14 to 17) and indicate assaultiveness. Aggression is also revealed in his TAT stories (cards 1, 3BM, 3GF, 6BM, 7BM, 8BM, and 13MF). Although most of his aggression is overt, a few indicators of repressed aggression appear in his second and third D-A-P drawings. Daniel has become more verbally and physically aggressive since the onset of OCD. During testing, he was unhappy about drawing people and wanted to draw monsters and animals instead, expressing aggressive wishes. Freud (1923) proposed that the superego of individuals with OCD is particularly harsh and feelings of inferiority endure because of strong guilt, generating anxiety. Daniel?s TAT stories yield contradictory impressions of the adequacy of his superego. His stories to cards 1, 2, 8BM, 11, and 13MF suggest an inadequate superego, while a severe superego is implied by stories to cards 3GF, 7BM, 7GF, 9BM, 17BM, and 19. The presence of indicators for both a weak and a severe superego in one individual suggests a neurotic superego (Sadock & Sadock, 2001). All Daniel?s drawings indicate low self-esteem and feelings of inferiority, especially physical inferiority and a need for achievement or physical strength. Daniel?s narratives while drawing his first and second D-A-P figures express a sense of physical inferiority. As he drew his first D-A-P figure he explained, ?It?s nearly like a pixie this??, and he sighed and said, ?It?s a most small person? as he drew his second D-A-P figure. Some of his TAT stories reveal a poor body image (cards 7GF, 14, and 17BM) and a need for physical strength and power (cards 1 and 11), Once upon a time, there was this man. He was so strong, but he couldn?t break a rope. Then one day, he was climbing up this rope. He, he broke it and he fell down and he became a dwarf. The end. (Story to TAT card 17BM). Daniel?s endocrine-related growth problem caused him to be bullied at nursery school as a result. He deals with his feelings of inadequacy and consequent aggressive feelings towards himself by projecting his feelings of weakness onto females or fantasy figures (often characters from a movie). All his drawings and some narratives suggest fantasy to compensate for feelings of inadequacy and weakness (1 to 3 indicators). Fantasy is present in most of his TAT stories (cards 1, 2, 3BM, 4, 5, 6BM, 7BM, 7GF, 8BM, 11, 12M, 13MF, 13B, 14, 17BM, and 18BM). Six of these stories express violent fantasies (cards 1, 3BM, 6BM, 8BM, 13MF, and 18BM). Violent fantasies are also expressed in Daniel?s K-F-D narratives, I can burn people, my sister can er poison people, my mother can drown people and my father can kill people, by by stabbing spikes in them. Depression constitutes a form of self-punishment, as it represents is the turning in of anger on the self (Freud, 1917). Daniel?s first two D-A-P drawings contain an indicator of depression and there are 2 indicators in his K-F-D. He has reportedly become more depressed since the onset of OCD. Daniel?s mother characterises him as extremely rude, argumentative, bossy, manipulative, demanding, and intensely overbearing. Sometimes he is so forceful that he unintentionally hurts people. The researcher?s observations similarly suggest that Daniel has an intense, assertive, persistent, and forceful personality. During testing, his behaviour was often very needy, demanding, intense, and forceful. At times he insisted on playing with the researcher?s stopwatch and tape recorder and demanded that she say times-tables and time him as he said them. Daniel?s K-F-D suggests an extroverted personality, as does his story to TAT card 17BM. All his drawings indicate an assertive, ambitious, autonomous, persistent, and forceful personality. His mother believes that Daniel over-compensates for his small stature by bossy, overbearing, forceful, and aggressive behaviour. Aggressive and socially dominant behaviour to compensate for feelings of inadequacy and weakness is indicated in all his drawings. Other defenses used are intellectualisation (TAT cards 5 and 7BM) and rationalization (TAT card 1). Although the Oedipus complex in boys is normally resolved through castration anxiety and identification with the same sex parent (Freud, 1925), the anxiety generated in resolving it proves overwhelming for persons who develop OCD (Stafford-Clark, 1965). Thus in OCD, Oedipal fears of punishment from the same sex parent remain unresolved and result in conflict based on ambivalent feelings of love and hate (Sechaud, 1998). Daniel is experiencing castration anxiety, as indicated in his stories to TAT cards 6BM and 13MF. His K-F-D indicates acute anxiety due to perceptions of his environment as unstable and scary. His TAT stories reveal anxiety due to perceptions of his environment as unstable, unreliable, unpredictable (cards 1, 2, 3GF, 5, 6BM, 7BM, 7GF, 8BM, 9BM, 12M, 18BM, and 19), dangerous, and scary (cards 1, 3GF, 4, 6BM, 8BM, 18BM, and 19). Anxiety over being physically injured is expressed in his stories to TAT cards 6BM, 11, and 18BM. These anxieties represent a projection of Daniel?s fears of castration. Despite Daniel?s castration anxiety, his TAT stories suggest Oedipal fantasy wishes (hero fantasies) of replacing his father as the protector and mate of his mother or sister (cards 1, 2, 8BM, 11, and 13MF), indicating that castration anxiety has not eliminated his Oedipal fantasies of eliminating his father and possessing his mother. Identification with the opposite sex parent marks successful resolution of the Oedipus complex, involving superego formation by the incorporation of the values, attitudes, and sexual orientation of the same sex parent (Lemma, 2002). Daniel?s story to TAT card 8BM reveals Oedipal ambivalence towards his father. Because Daniel has not identified with his father, his superego is neurotic (as revealed by his TAT stories), he feels physically inadequate, and he struggles with his sexuality and gender identity. All his drawings indicate homosexual tendencies (4 to 8 indicators) and narcissism (2 to 4 indicators), which is a component of homosexuality (Freud, 1914). His story to TAT card 18BM reveals conflict between homosexual drives and fears of homosexual attack. Narratives to his first and third D-A-P drawings indicate conflict and confusion over his gender identity. Masculine strivings for physical strength and power are evident in all his drawings and his stories to TAT cards 1 and 11. Freud (1913) maintained that some individuals are dispositionally predisposed to developing a particular kind of neurosis. Freud (1905a) defined the psychoneuroses as OCD, schizophrenia, hysteria, and paranoia. All Daniel?s drawings indicate schizophrenia/psychosis (3 to 6 indicators). His sister has a history of bizarre speech and behaviour. Daniel?s drawings all contain 1 to 2 indicators of hysteria. His sister has a history of hysterical behaviour. All Daniel?s drawings reveal paranoia (between 3 and 5 indicators) and his requests throughout testing for the tape recorder to be turned off suggest paranoia. His sister has a history of paranoid delusions of persecution. There is a family history of personality disorders, with his sister diagnosed with a severe case of borderline personality disorder (BPD). Her bizarre, disturbing behaviour included a fascination with knives and cutting herself, smearing her own blood (often menstrual), and trying to drown dolls in the bath (often in blood). She also attempted suicide by trying to strangle herself. All Daniel?s drawings also contain 2 indicators of organicity. Thus, Daniel presents with tendencies of all the psychoneuroses, which explains his neurotic, hysterical personality. Anna Freud (1981) explained that innate dispositional factors underlie development, and can result in fixation at a particular pregenital psychosexual stage. Daniel?s tests reveal that he generally tends to be hypersensitive. All his drawings indicate hypersensitivity to social opinion, particularly criticism and reveal a desire for interpersonal contact, help, or affection. His drawings all indicate social isolation, uneasiness, and hostility. He has a history of difficulty with social skills due to his intense bossiness. He has trouble making friends at school and poor school adjustment is indicated in his third D-A-P drawing and K-F-D. In addition to emotional sensitivity, he also seems to be highly physically sensitive, suffering from an endocrine-related growth problem and asthma. Despite his assertive, ambitious personality, all Daniel?s drawings express dependency and helplessness, suggesting regression to the oral stage of psychosexual development. His TAT stories indicate a need to be nurtured and taken care of (cards 1, 3GF, 4, 7BM, 7GF, 8BM, 9BM, 11, 12M, 13B, 14, 18BM, and 19) and regression to the oral stage is suggested by his story to TAT card 13MF. His dependency needs are stronger within his family context as revealed by his K-F-D and suggested by his narrative while drawing the K-F-D, ?This is me after buttons and you?ll see what I?m doing?, shortly after which he drew a doll in his hand. During testing, Daniel was intensely needy for attention, reminding the researcher of a greedy child. His difficulties with bossiness and forcefulness also sound as if they are motivated by a seemingly insatiable neediness and greediness for attention. Daniel?s K-F-D suggests dependency needs in all family members and there is a family history of alcoholism, with both Daniel?s parents as sufferers. Oral and oral incorporative themes related to eating and drinking emerge in narratives to his first D- A-P drawing and K-F-D and in his stories to TAT cards 11 and 13MF, Once upon a time, there was this man. He was a vampire. He married his wife, then one night, he sucked all her blood out and he cried. And then, then he, duh, told the police that someone killed them. The end. (Story to TAT card 13MF). Anna Freud (1981) acknowledged the role of environmental factors such as individual growth patterns and family circumstances in psychological development and psychopathology. Daniel?s K-F-D indicates insecurity, unstable family relationships, and communication difficulties. Each family member is perceived as a potential source of conflict, anxiety, or threat to the others and as unstable, dependent, and needing help to cope with one other and the outside world. Daniel?s mother suffers from depression and his stories indicate that he perceives her as an inadequate nurturer (cards 2, 3BM, and 7GF), and as depressed and unstable (cards 3GF, 5, and 19). Daniel?s father presents with bipolar and obsessive-compulsive tendencies. Daniel?s TAT stories indicate perceptions of his father as inadequate as a provider, protector, and nurturer (cards 7BM, 8BM, 9BM, 11, 12M, and 13B), and as depressed (card 12M). Daniel?s sister suffers from BPD, bipolar mood disorder (BMD), previously attempted suicide, and is withdrawn, and exceedingly moody, of which Daniel is keenly aware. Daniel has been exposed to much psychopathology in his family environment and worries about the health of his parents and sister, fearing their illness, incapacitation, or death, and the financial impact thereof for him as a child. Freud (1913) recognised the role of an external event in triggering the onset of OCD symptoms. The precipitating event for the onset of Daniel?s OCD symptoms was his sister?s admission to a mental health centre. Daniel?s narratives to his drawings suggest acute awareness of loss by death. One of his first obsessions was repeated doubting (fears of his mother?s death). This fear is expressed in his story to TAT card 3GF. This story may also relate to fears of his sister?s death, as may his story to TAT card 7GF. Fears of his father?s death are also contained in his TAT stories (cards 8BM, 9BM, and 12M). His stories reveal anxiety over economic deprivation due to the illness, incapacitation, or death of a family member (cards 1, 2, 3BM, 3GF, 4, 7BM, 7GF, and 11). Daniel?s father is a compulsive spender, which may also contribute towards Daniel?s economic anxieties. Although Daniel?s mother expressed pride in Daniel for being an intelligent child and explained that she enjoys doing activities with him, she struggles to cope with her children and finds it extremely difficult and exhausting. She is currently in psychotherapy to support her in coping with her children. Daniel needs more parental attention since the onset of OCD and tries to involve family members in his rituals. Coping with him leaves his parents feeling more exhausted and frustrated than previously. There is generally more tension in the family since the onset of Daniel?s OCD symptoms. Although he is close to his sister, Daniel?s K-F-D reveals sibling rivalry (his sister is perceived as being closer to the parents than Daniel). Sibling rivalry is also evident in his story to TAT card 19. Since Daniel presented with OCD there has been more tension in his relationship with his sister and she has felt jealous and neglected because of the extra time Daniel?s parents spend with him. Daniel?s self-esteem is especially low within his family context, as indicated by his K- F-D and his narratives as he drew the K-F-D, ?Can?t I just leave out me, cos I?ve already drawn myself?unless I only cut out and stick it??Okay, I?ll quickly draw me?. His K-F-D indicates low self-esteem and feelings of inadequacy in all the figures. The drawing suggests disconnectedness and a lack of closeness between the family members. Communication difficulties and a tendency to criticise within the family are also indicated. Frequent arguing constitutes a part of the family?s communication style. Daniel was diagnosed with AD/HD and has trouble concentrating in class. During testing, he presented with difficulties in concentrating and hyperactive behaviour. All his drawings indicate impulsive tendencies, high energy levels, and excitement. His story to TAT card 1 also reveals high energy levels and excitement. The researcher?s observations suggest impulsivity (getting up from the table to get things to show the researcher), excitability, and high energy levels (almost constant fidgeting and intermittent motor movements, such as tapping his hands and feet under the table, rubbing his eyes, and vigorously scratching his hands over the table). 5.3. Interpretation of Jane?s internal world All Jane?s drawings suggest that although she has adequate contact with reality, she is emotionally unstable. Most of her TAT stories indicate immaturity (cards 3GF, 4, 5, 6GF, 7GF, 9GF, 10, 11, 12F, 13MF, 13B, 14, 17GF, 18GF, and 19), as do all her drawings. Although she was previously in therapy and her OCD symptoms are currently mild, they all remain. They are repeated doubting (worrying that someone in her family would die and worrying about family finances), observable repeating or counting rituals (tapping her feet and fingers repetitively, singing the ?A, b, c song? and other songs over and over, and repetitive counting), and demanding reassurance (that something bad wasn?t going to happen or that nobody in the family was going to die). All Jane?s drawings contain 1 to 2 indicators of neurosis. Her second D-A-P drawing and K-F-D indicate obsessiveness (1 to 2 indicators). Obsessive-compulsivity is indicated in all her drawings (3 to 6 indicators) and stories to TAT cards 11 and 13MF. All Jane?s drawings contain between 8 and 10 indicators of anxiety and many of her TAT stories reveal anxiety (cards 3GF, 7GF, 9GF, 10, 11, 12F, 13MF, 13B, 17GF, and 18GF). Anxiety over being bullied by her brother and her cousin ?Wilson? is expressed in Jane?s narratives to her drawings. Anxieties over being hit by a car and a fear of snakes are expressed in her first D-A-P drawing. One of her first symptoms, which still persists, was observable repeating or counting rituals involving tapping her feet and fingers repetitively and singing the ?A, b, c song?. Occasionally during testing, she tapped her hands and feet on the table or sang the ?A, b, c song? softly to herself when she became anxious. Freud (1905a) conceptualised neurosis as emanating from repressed libidinal impulses due to instinctual conflicts in resolving the Oedipus complex. Because children with OCD are unable to relinquish Oedipal fantasies libido becomes ?fixated? on infantile love objects (Mitchell & Black, 1995). The Oedipus complex involves the child falling in love with the opposite sex parent and wanting to eliminate the same sex parent, who is perceived as a rival (Polansky, 1991). A girl suffers from ?penis envy? in the form of anger towards her mother for not giving her a penis. Her desire for a penis is replaced by a desire to have a child by her father. All Jane?s drawings indicate preoccupation and conflict with sexuality. Her drawings all reveal blocking of sexual and bodily impulses causing tension. All her drawings indicate moodiness and masturbation guilt. In girls, the Oedipus complex is normally resolved by abandonment or repression, and identification with the mother (Freud, 1925). However, the anxiety generated in resolving the Oedipus complex is overwhelming for individuals who develop OCD (Stafford-Clark, 1965). As a result, Oedipal fears of punishment from the same sex parent remain unresolved, producing conflict based on ambivalent feelings of love and hate (Sechaud, 1998). Jane?s feelings towards her mother are ambivalent. Her K-F-D suggests that she identifies with her mother as a fellow mother figure. Her narratives to all her drawings suggest that she is parentified and has fantasies of replacing her mother as the mother figure within her family. This is evident in the motherly role that Jane assumes towards her cousins, Wilson and Mary, even though they are older than she is, I takes Mary to shops and she plays and I help with her homework and I take her to sleep and she likes a hug and, when I sleep, I hug her. Sometimes, my brother takes her and he brings her to me and she hugs me. (Narrative to first D-A-P drawing). Jane?s narratives to all her drawings indicate ambivalence towards her cousin, Mary. Narratives to all her drawings reveal that she is fond of and close to Mary and protective over her. Jane?s second D-A-P drawing and narratives reveal that Mary?s brother, Wilson, is verbally and physically aggressive towards Jane and Mary. Her narratives express that she plays a motherly role towards Mary and protects them both from Wilson?s bullying. However Jane?s narratives to her first D-A-P also suggest that, as nurturing and protective a ?mother? as she is towards Mary and Wilson, she sometimes punishes them and bullies Mary. Her narratives suggest that she perceives her motherly role towards Wilson and Mary as encompassing nurturing Mary, protecting her against Wilson?s aggression, arbitrating their arguments, giving Mary physical affection, helping her with her homework, and sometimes ?taking the children on a fun outing?, but also growing angry and shouting at Wilson, punishing him, and disciplining Mary physically. Her assumption of this motherly role towards Mary and Wilson implies ambivalent feelings of love and hate towards her own mother, projected onto Mary and Wilson, Fighting with his sister. But his sister doesn?t like and when Wilson hits his sister, she cries and she hits him back and I shout at them. It makes me angry when they fight, cos some of them get hurt. I like gyming and running with them and I run fast with them and I like to hold their hands and run fast and I just make them open their mouths like they?re laughing. (Narrative to second D-A-P drawing). OCD involves regression to the anal-sadistic phase of psychosexual development, in which the child became fixated (Freud, 1913). The task of this phase is to adapt to or resist parental control (Lemma, 2002), and fear and helplessness towards the adored parent are transformed by a reaction formation into aggression and omnipotent phantasies and displaced onto all secondary love objects (Stafford-Clark, 1965). All the significant male figures in Jane?s world (her father, brother, and cousin) are portrayed in her drawings and narratives as threatening and aggressive. Her story to TAT card 6GF expresses a perception of distance in her relationship with her father and her K-F-D suggests a wish to be closer to him. However, the drawing indicates that she perceives him as inadequate and critical and as a potential source of anxiety or threat to the other family members. She omitted her brother from the K-F-D and her narratives indicate much dislike, antagonism, and fighting between them causing her sadness and distress. Her narratives imply that he is aggressive towards her, ?it?s only my brother doesn?t like me and I don?t like him too?must I tell you the name? He?s the worst, worst brother in the world. He makes me so, so sad?cos sometimes I fight with him. (Narrative to K-F-D). All Jane?s drawings indicate reaction formations or compensatory defenses to counter feelings of insecurity. Her stories to TAT cards 5 and 11 and her narrative to the first D-A-P drawing indicate reaction formations to defend against her aggressive impulses. By reaction formations, Jane transforms her father and thus all males from nurturing, desirable love objects into inadequate, aggressive, punitive, and threatening ones. Her second D-A-P drawing and K-F-D indicate difficulty with impulse control and all her drawings suggest impulsivity. Each drawing contains 1 to 3 indicators of repressed aggression, 5 to 7 indicators of anger and aggressive tendencies, and 1 to 2 indicators of assaultiveness. The highest quantity of indicators of both repressed and overt aggression is in her K-F-D. Jane behaves more aggressively since the onset of her OCD symptoms. Freud (1905a) hypothesized that OCD symptoms result due to repressed mental processes, desires, and wishes obtaining discharge via conversion or substitution. Thus, intense, harmful affects are displaced onto alternative, harmless representations of the primary love object (Sechaud, 1998). Jane?s aggressive feelings towards her father are intolerable and impossible to consciously acknowledge to herself. She thus defends against this ?unacceptable? aggression by projecting it onto secondary love objects (other males), in the form of her fears of male aggression. Jane?s D-A-P drawings indicate conflict between herself and her environment. Most of her TAT stories reveal that she perceives her environment as an unhappy, unstable, and sometimes scary place (1, 3BM, 3GF, 7GF, 12F, 13MF, 13B, 17GF and 18GF), implying projection of her anxiety, fears, and aggression onto her environment. OCD symptoms are defensive reactions to the huge anxiety generated by conflicting impulses and emerge to prevent or allay fears of harming, contaminating, destroying, or illicitly becoming sexually involved with, the mother or father, or both (Stafford-Clark, 1965). Some of Jane?s first OCD symptoms, which still persist, were repeated doubting (worrying that someone in her family would die) and demanding reassurance that something bad wasn?t going to happen and that nobody in the family was going to die. Her narratives reveal an ongoing preoccupation with her grandfather?s death and suggest fears of future deaths in the family. Her OCD symptoms of repeated doubting and demanding reassurance represent a transformation of fears of her own aggression towards her parents. Jane?s narrative to the her D-A-P drawing indicates the defense of undoing to defend against her aggressive impulses, I hit her (Mary) and shout at her. When I shout at her, she cries. I like to draw tears on her and then I?m gonna rub them out. (Narrative to first D-A-P drawing). Jane uses the defense of intellectualisation, as indicated in all her drawings. Her story to TAT card 13MF suggests rationalization. She uses the defense of fantasy (as suggested in all her drawings, narratives to her first D-A-P drawing, and her story to TAT card 10) to escape from her feelings of isolation and discharge her aggression. Freud (1923) maintained that the superego of individuals with OCD is particularly harsh and feelings of inferiority are persistent due to a strong sense of guilt, generating anxiety. All Jane?s drawings express low self-esteem, feelings of inadequacy, self-consciousness, and dissatisfaction with her body image (feelings of physical inferiority). Narratives to her first D-A-P drawing and her story to TAT card 1 suggest a wish for physical strength. From a psychodynamic perspective, depression constitutes a form of self-punishment, as it represents the turning of anger in on the self (Freud, 1917). Jane has been diagnosed with depression, which has intensified since the onset of OCD. All her drawings contain 3 to 4 indicators of depression and depression is implied in many of her TAT stories, the main themes of which are crying and sadness (Cards 1, 3BM, 3GF, 7GF, 9GF, 12F, 13MF, 17GF, 18GF, and 19). Her OCD symptoms wear her out and she is often tired as a result. Low physical energy levels and feelings of weakness are indicated in all her D-A-P drawings. Anna Freud (1981) proposed that innate dispositional factors underlie development and can result in fixation at a specific psychosexual stage. According to Freud (1913), some individuals are dispositionally predisposed to developing a particular kind of neurosis. Jane?s tests reveal that she generally tends towards hypersensitivity. The tests reveal a sensitive, introverted, shy disposition and the researcher?s observations suggest that she is a shy, soft-spoken child. She is hypersensitive to social opinion, particularly criticism, as indicated in her first D-A-P drawing and K-F-D. Her drawings all indicate communication difficulties and her K-F- D indicates a tendency to criticise within her family. She has a history of difficulty with social skills due to shyness and withdrawal, which have intensified since the onset of OCD. All her drawings indicate a sense of social isolation, uneasiness, and hostility, and contain 1 to 2 indicators of schizoid tendencies. Her TAT stories express feelings of isolation and loneliness (cards 1, 6GF, 14, 17GF, and 18GF). She has had more difficulty making friends at school since the onset of OCD and tries to hide her symptoms from teachers and other children at school and when out in public. Some of her narratives to the first D-A-P drawing and K-F-D suggest either resistance or defensiveness. Resistance is suggested in her stories to TAT cards 3GF and 11 and the defense of isolation is implied in her story to TAT card 1. Although Jane?s first D-A-P drawing and K-F-D indicate a denial of her dependency needs, all her drawings strongly suggest that she is overwhelmed by strong dependency needs and feelings of helplessness, suggesting regression to the oral stage of psychosexual development. Her drawings all strongly suggest immaturity and a need for support and most of her TAT stories reveal immaturity (cards 3GF, 4, 5, 6GF, 7GF, 9GF, 10, 11, 12F, 13MF, 13B, 14, 17GF, 18GF, and 19). Regression is indicated in her TAT stories (cards 3BM, 3GF, 7GF, 13MF, 17GF, and 18GF). Her TAT stories express a need to be acknowledged, nurtured, and taken care of (cards 4, 7GF, 13B, 14, 17GF, and 18GF). Her D-A-P drawings indicate that she uses passivity as a defense, due to fear of her aggressive impulses. Freud (1913) proposed that some individuals are dispositionally predisposed to developing a particular kind of neurosis (OCD, schizophrenia, hysteria, or paranoia). All Jane?s drawings contain 4 to 6 indicators of schizophrenia/psychosis and an indicator of hysteria. Her first D-A-P drawing and K-F-D contain an indicator of paranoia and her stories to TAT cards 5 and 11 reveal paranoid anxiety over being watched. All her drawings contain 6 to 7 indicators of organicity. There is a family history of psychopathology, although not specifically of OCD. Both Jane?s parents have long histories of depression. Her brother was born with brain damage and suffers from epilepsy and learning disorders. Thus, Jane is genetically predisposed to developing psychopathology and all the psychoneuroses have manifested to some degree, suggesting a dispositional predisposition to developing all the psychoneuroses. Anna Freud (1981) acknowledged the role of environmental factors such as individual growth patterns and family circumstances in psychological development and psychopathology. Both Jane?s D-A-P drawings and some narratives to her K-F-D reveal that she perceives her social status as unsatisfying and her TAT stories to cards 10 and 13MF express anxiety over her family?s economic status. Her K-F-D gives a sense that her parents are emotionally immature and dependent, and her story to TAT card 10 indicates that Jane perceives them as helplessness and inadequate as providers. One of Jane?s first OCD symptoms, which persists, was repeated doubting (worrying about family finances). Jane?s K-F-D indicates tension, conflict, and a sense of disconnectedness within her family, and a sense of personal isolation and insecurity within her family context. The drawing also suggests conflict and a lack of closeness between her parents, and her mother and herself as desiring affection. The drawing reveals that she perceives every member of her family as unstable and as needing help to cope with one other and the outside world. The highest quantity of indicators of obsessive-compulsivity is in her K-F-D (6 indicators), implying that she experiences heightened stress and increased symptoms within the context of her family, although she tries to hide her symptoms at home, Playing in the street, cars can bump me. Fighting, swearing, hitting her sister. Snakes?yesterday, my sister brought another snake at home, it?s only a toy one and when you put it down, it shakes. Me and my mother scared of it and so my father threw it away. A, b, c, d, e, f, g (sung softly). (Narrative to first D-A-P drawing). There is more tension in the family since the onset of Jane?s OCD symptoms and Jane needs more parental attention and tries to involve family members in her rituals. Coping with her leaves her parents feeling more exhausted and frustrated than previously. Jane?s K-F-D and narratives imply that she is not close to her siblings. There is more tension between Jane and her siblings since the onset of her OCD symptoms. Jane omitted her sister from the K-F-D and only mentions her once in her narratives. Her narratives indicate much dislike, antagonism, and fighting between her brother and herself. Freud (1913) acknowledged the role of an external event in triggering the onset of OCD symptoms. The precipitating event for the onset of Jane?s OCD symptoms was the death of her grandfather. Jane?s narratives to her K-F-D reveal ongoing depression and sadness over his death, and indicate that his death has confused her and affected her very deeply. Her story to TAT card 17GF implies that she perceives her environment as confusing and unstable and a need for reassurance is expressed in her stories to TAT cards 1 and 3GF. One of Jane?s first OCD symptoms, which still persists, was demanding reassurance that nothing bad was going to happen and that no-one in her family was going to die. Jane suffers from short-term memory problems and difficulties with mathematics at school. She has trouble concentrating in class and experienced concentration difficulties during testing. Her TAT story to card 1 indicates ADD. 5.4. Interpretation of Anne?s internal world All Anne?s drawings suggest that, although she has adequate contact with reality, she is emotionally maladjusted and suffers from emotional stress, constriction, and some confusion in thought processes. All her drawings suggest personality imbalance or disorganisation in the form of a neurotic, hysterical personality. All her drawings indicate a disorganised personality. They strongly suggest a submissive, sensitive, shy, introverted, inhibited, withdrawn personality, but also assertiveness, ambition, and determination. The researcher?s observations suggest that she tends towards shyness, but also towards assertiveness and excitability. Her TAT stories yield contradictory impressions on the adequacy of her superego, with an inadequate superego indicated by her stories to TAT cards 11 and 13MF and a harsh superego suggested by stories to cards 3BM and 4. Sadock & Sadock (2001) explained that the presence of indicators for both a weak and a severe superego in one individual indicates a neurotic superego. Her TAT stories indicate an average to low level of maturity and her K-F-D indicates immaturity. Although she was previously in therapy and her OCD symptoms are currently mild, they all remain. They are worries about contamination (worrying that she will get germs if she eats or drinks from the same cup or plate as someone else in her family), cleaning rituals (spitting, chewing and sucking on her clothing, chewing and sucking her hair, sucking her fingers, toys, paper, and other objects), repeated doubting (worrying that her parents will die and about family finances), ordering (ordering and lining-up her toys in rows when playing and needing to pack her possessions into bags), observable repeating or counting rituals (repeatedly grunting, sniffing, snorting, or coughing, repeating words to herself softly or in a whisper, tapping or dragging her feet when walking, and avoiding cracks in the paving), mental repeating or counting rituals (repeating songs, prayers, or words, and counting repetitively), and demanding reassurance (worrying that bad things are going to happen to her, or to her parents). All Anne?s drawings contain 3 indicators of neurosis, 1 to 2 indicators of obsessiveness, and 3 to 4 indicators of obsessive-compulsivity. Her OCD cleaning ritual of sucking and chewing her clothing was occasionally displayed during testing, as well as her observable repeating or counting ritual of repetitive snorting. There are large quantities of indicators of anxiety (9 to 15) in all her drawings. Anxiety is also expressed in most of her TAT stories (cards 1, 2, 3BM, 4, 5, 7GF, 10, 11, 13MF, 13B, 14, 17GF, 18GF, and 19). She has a history of anxiety manifesting in anxiety disorders, having been diagnosed with SAD when starting school. There is a family history of anxiety disorders, with her father suffering from OCD and her mother and maternal grandmother suffering from anxiety. Neurosis originates from repressed libidinal impulses because of instinctual conflicts associated with the resolution of the Oedipus complex (Freud, 1905a). Because children with OCD are unable to give up Oedipal fantasies libido is ?fixated? on infantile love objects (Mitchell & Black, 1995). Oedipal love fantasies towards her father are suggested in Anne?s narratives to her second D-A-P drawing. The Oedipus complex entails the child falling in love with the opposite sex parent and perceiving the same sex parent as a rival, wanting to eliminate them (Polansky, 1991). A girl experiences anger towards her mother for not giving her a penis (?penis envy?). A desire to have a child by her father replaces her desire for a penis. All Anne?s drawings indicate preoccupation and conflict with sexuality. Her second D-A-P drawing suggests anxiety associated with sexual preoccupations. All her drawings reveal infantile, regressed sex drives, moodiness, and blocking of her sexual and bodily impulses causing tension. In girls, the Oedipus complex is normally resolved by abandonment or repression, and identification with the mother (Freud, 1925). However, the anxiety produced in the process of resolving the Oedipus complex is overwhelming for people who develop OCD (Stafford-Clark, 1965). Thus, Oedipal fears of punishment from the same sex parent remain unresolved, generating conflict based on ambivalent feelings of love and hate (Sechaud, 1998). Anne?s feelings towards her mother are ambivalent. Oedipal ambivalence towards her mother is expressed in her narrative to the K-F-D and in her stories to TAT cards 4, 13MF, and 18GF. Her mother is perceived as distant in her story to TAT card 12, but as nurturing in her story to card 9GF.Her story to card TAT 7GF expresses Oedipal anger towards her mother. The little girl?s got a doll?a baby doll?and her mommy?s trying to talk to her, but she?s too angry to talk to her mom. That?s all. (Story to TAT card 7GF). The girl and her mommy are on holiday, running on the beach?they gonna build sand castles! Like I?at the beach, I love that and swimming! (Story to TAT card 9GF). The defense of undoing to defend against aggressive impulses towards her mother is implied in her narrative to the K-F-D. Undoing is also suggested in her TAT stories (cards 3BM, 4, 10, 13MF, and 18GF), The lady?s sleeping, maybe she?s dead and he?s killed her. But, he?s sorry that he did that and he?s crying now. But, she?s not really dead. (Story to TAT card 13MF). Anne?s first D-A-P drawing and narratives suggest awareness of her gender identity, and her narratives to the K-F-D imply gender identification with her mother. Anne?s drawings all reveal femininity, but suggest exhibitionistic tendencies. Preoccupation with body processes, development, and pregnancy are revealed in her first D-A-P drawing and K-F-D, ?long, hair, so everyone knows it?s a girl, so long that it goes to the toes?I?m gonna draw clothes, now I?m gonna draw the tummy circle, then a little circle?I?m even gonna draw a vagina?I?m still drawing the hair. It?s so long, it even goes across the arms, even touches the ground?. (Narrative to first D-A-P drawing). OCD entails regression to the anal-sadistic phase of psychosexual development, in which the child became fixated (Freud, 1913). The child?s task in this phase is to adapt to or resist parental control (Lemma, 2002), and fear and helplessness towards the adored parent are transformed into aggression and omnipotent phantasies by a reaction formation and displaced onto all secondary love objects (Stafford-Clark, 1965). Anne?s TAT stories reveal anxiety over physical safety and fears of attack (cards 11, 13MF, 14, and 19). Her father is perceived as the aggressor in two of these stories, but as the protector in another. A sense of conflict or fear of paternal aggression is also suggested in Anne?s narratives to her second D-A-P drawing. All her drawings indicate reaction formations or compensatory defenses to counter feelings of insecurity. In this way, she transforms her father from a nurturing, desirable love object into an aggressive, threatening one. She escapes from her feelings of helplessness and isolation and discharges her anxiety and aggressive instincts by using the defenses of projection, reaction formation, undoing, isolation, displacement, intellectualisation, fantasy, and acting out. All Anne?s drawings contain very few indicators of behavioural and emotional control; and relatively more indicators of impulsivity, emotionality, moodiness, and high energy levels and excitement. During testing, she displayed signs of impulsivity and high energy levels. She fidgeted almost constantly and occasionally rocked on her chair or become excitable and jumped up from her chair. She added to her drawings on impulse as questions were asked. She was very active verbally during testing, narrating animatedly as she drew. Her K-F-D is the only drawing indicating repressed aggression (2 indicators), and her story to TAT card 6GF suggests repressed aggression. All her drawings reveal high quantities of overt anger and aggression (9 to 14 indicators) and indicate assaultiveness, and her narratives to the D-A-P drawings imply aggressive impulses. Aggression is also expressed in her TAT stories (cards 4, 11, 13MF, and 18GF). She behaves more aggressively since the onset of OCD. Aggressive and socially dominant behaviour to compensate for feelings of inadequacy and weakness is indicated in all her drawings. OCD symptoms are defensive reactions to the huge anxiety produced by conflicting impulses and function to prevent or allay fears of harming, contaminating, destroying, or illicitly becoming sexually involved with, the mother or father, or both (Stafford- Clark, 1965). Freud (1905a) hypothesized that OCD symptoms emerge from repressed mental processes, desires, and wishes obtaining discharge via conversion or substitution. In this way, intense, harmful affects are displaced onto alternative, harmless representations of the primary love object (Sechaud, 1998). Anne?s aggressive feelings towards her father are intolerable and impossible to consciously acknowledge to herself. She defends against her anxiety and this ?unacceptable? aggression by projecting them onto her environment, other males, or fantasy figures (such as dragons and monsters) in the form of her fears of physical injury or attack. A perception of her environment as unpredictable and scary is indicated in Anne?s stories to TAT cards 3BM and 17GF. Concerns around physical safety and fears of attack are revealed in her TAT stories (cards 11, 13MF, 14, and 19). Projection is indicated in her TAT stories (cards 4, 5, 6GF, 10, 11, 13MF, and 13B). Some of her first OCD symptoms were repeated doubting (worrying that her parents will die) and demanding reassurance (worrying that bad things are going to happen to her, or to one or both parents). These symptoms are still present and represent a transformation of fears of her own aggression towards her parents. Freud (1923) maintained that the superego of OCD sufferers is especially harsh, resulting in persistent feelings of inferiority due to a strong sense of guilt, which generates anxiety. All Anne?s drawings indicate low self-esteem and feelings of inadequacy. A poor body image is revealed in her D-A-P drawings. All her drawings contain many indicators of self-consciousness and an indicator of overconcern with outward appearances. This overconcern is also revealed in her narrative to the second D-A-P drawing. All her drawings contain 4 indicators of fantasy to compensate for feelings of inadequacy. Fantasy is also indicated in her stories to TAT cards 11 and 13MF. From a psychodynamic perspective, depression constitutes a form of self-punishment, representing anger turned in on the self (Freud, 1917). Depression is indicated in Anne?s first D-A-P drawing, K-F-D, and stories to TAT cards 3GF, 4, and 17GF. She has become more depressed since the onset of OCD. Defensive, evasive tendencies are implied in her first D-A-P drawing and K-F-D and defensiveness is suggested in her TAT stories (cards 1, 3GF, 5, 6GF, and 7GF), Is this a girl or a boy? It?s a girl! I?m still thinking about the story . I?m thinking. I think I came up with a idea . This little girl was watching TV and it was a cartoon. That?s all it is. Here?s your card back. (Story to TAT card 1). All Anne?s drawings contain 8 to 9 indicators of withdrawal and inhibition, and she has become more withdrawn since the onset of OCD. The defense of isolation is implied in her stories to TAT cards 7GF and 17GF. Perceptions of maternal depression are suggested in her story to TAT card 4, and narratives to the first D-A-P drawing and K-F-D. Anne?s mother and maternal grandmother suffer from depression and anxiety. Her father suffers from BMD, as did Anne?s paternal grandfather. Anna Freud (1981) proposed that innate dispositional factors motivate development and can result in fixation at a particular psychosexual stage. Anne?s tests reveal that she generally tends towards hypersensitivity. All her drawings suggest emotional tendencies and personality imbalance or disorganisation in the form of a neurotic, hysterical personality. Anne has a history of social difficulties (shyness and SAD). She has become even more shy and withdrawn since the onset of OCD. All her drawings contain 1 to 4 indicators of schizoid tendencies. Her first D-A-P drawing and K-F-D indicate hypersensitivity to social opinion, particularly criticism, and she feels frustrated and upset because she cannot always manage to do what people expect. At school she tries to hide her symptoms from teachers and other children and is socially isolated and ridiculed, sometimes missing school. Social isolation, uneasiness, and hostility are indicated in all her drawings, and her story to TAT card 1 implies loneliness. Anne also tries to hide her OCD symptoms at home, and when out in public. Her symptoms wear her out and she is often tired as a result. Conflict between autonomy and compliance with parental and school expectations is indicated in Anne?s narrative to her first D-A-P drawing and story to TAT card 2. Anxiety over parental disapproval is revealed in her story to TAT card 4. All her drawings, especially her K-F-D, suggest that she is overwhelmed by strong dependency needs and feelings of helplessness, suggesting regression to the oral stage of psychosexual development. Anxiety over feelings of helplessness is revealed in Anne?s TAT stories (3BM, 4, 13MF, and 14). Her drawings all suggest autoerotic, narcissistic, exhibitionistic tendencies. These tendencies suggest regession to the oral stage (Freud, 1905b). Anne?s narrative to the first D-A-P drawing suggests dependency in the form of a very oral, concrete need for nurturance. A desire for affection, support, and help is revealed in all her drawings, especially her K-F-D, and her stories to TAT cards 1, 13B, and 14 imply a need to be nurtured and taken care of. Her stories to cards 14 and 19 express a need for reassurance. During testing she occasionally requested reassurance, which is evident in her narratives to the first D-A-P drawing and K-F-D, e.g. ?Must I draw the sweeties?Can I colour in the petals??Do you like the lips??, and ?How much minutes did I take? ?Look at it. How much minutes did I take? Who must I give this to??She?s got funny hair now, look at her. You know why I did her hair like that???. Regression is indicated in her K-F-D and stories to TAT cards 3BM and 13MF. Her K-F-D indicates immaturity, and her TAT stories indicate an average to low level of maturity. According to Freud (1913), some individuals are dispositionally predisposed to developing a particular kind of neurosis (OCD, schizophrenia, hysteria, or paranoia). All Anne?s drawings contain 5 to 7 indicators of schizophrenia/psychosis, 1 to 2 indicators of hysteria, and 2 to 3 indicators of paranoia. Paranoid anxiety is also suggested in her TAT stories (cards 5, 13MF, 14, and 19). All her drawings contain 4 to 7 indicators of organicity. There is a family history of psychopathology. Her father has suffered from OCD from the age of 3 years and suffers from BMD, as did Anne?s paternal grandfather. Anne?s mother and maternal grandmother suffer from depression and anxiety. Anne is thus genetically predisposed to developing psychopathology, particularly OCD and mood disorders, and all the psychoneuroses have manifested to some degree, suggesting a dispositional predisposition to developing all the psychoneuroses. Anna Freud (1981) acknowledged the role of environmental factors such as individual growth patterns and family circumstances in psychological development and psychopathology. All Anne?s drawings and some narratives to her K-F-D reveal a perceived lack of status. Anxiety over family finances is suggested in her narrative to the K-F-D and story to TAT card 13B. A perception of isolation and conflict within her family is indicated in her K-F-D, which also contains more indicators of anxiety than her D-A-P drawings. Communication difficulties in the family are suggested by her TAT stories (cards 4, 6GF, 7GF, 10, and 18GF), and anxiety over perceptions of parental conflict is expressed (cards 4, 6GF, 10, and 13MF). A need to be nurtured and taken care of is revealed in her stories to TAT cards 1, 13B, and 14. There is more tension in the family since the onset of Anne?s OCD symptoms, and she needs more parental attention and tries to involve family members in her rituals. Coping with her leaves her parents feeling more exhausted and frustrated than previously. The figures of all family members in Anne?s K-F-D contain indicators of instability, immaturity, dependency, constriction, and helplessness, and of needing help to cope with one another and the outside world. Freud (1913) acknowledged the role of an external event in triggering the onset of OCD symptoms. The precipitating event for the onset of Anne?s OCD symptoms was starting a new school. She has a history of school-related anxiety, having suffered from SAD when first starting school. School-related anxiety is revealed in her narrative to the first D-A-P drawing and story to TAT card 2. All her drawings contain an indicator of poor school achievement. She has difficulty with handwriting skills and her D-A-P drawings indicate difficulty with reversals and dyslexic tendencies. Her father suffers from dyslexia and had difficulty with reading and writing. Anne has difficulty concentrating in class and displayed some concentration difficulties during testing. Her story to TAT card 1 suggests ADD, and her D-A-P drawings contain an indicator of hyperactivity. All her drawings indicate impulsivity, high energy levels, and excitement. During testing, she displayed highly active behaviour, impulsivity, and high energy levels. Chapter 6 Conclusions 6.1. Conclusions of the Research 6.1.1. Mike?s internal world Mike has adequate contact with reality, but is immature, poorly adjusted emotionally, and has an inadequately integrated ego. He suffers from very high levels of anxiety and his internal world is intensely neurotic because of an unresolved Oedipus complex and a dispositional predisposition to psychopathology, particularly obsessive-compulsive disorder (OCD). He is still in psychotherapy although his OCD symptoms are currently mild. He no longer displays worries about contamination, aggressive or socially unacceptable impulses, or recurrent thoughts or worries about sex/?bad thoughts?, however these fears and impulses persist unconsciously as repressed material. His other symptoms (repeated doubting, ordering, cleaning rituals, observable repeating or counting rituals, mental repeating or counting rituals, and demanding reassurance) remain. Mike suffers from very high levels of anxiety and has a history of anxiety disorders, previously having suffered from separation anxiety disorder (SAD). He has not resolved his Oedipus complex. He is preoccupied and conflicted with sexuality and has infantile, regressed sex drives. He has not relinquished Oedipal phantasies of his mother or identified with his father. He has a history of difficulty controlling his behaviour and emotions, and acts more aggressively since the onset of OCD. He projects his aggression and sexual conflicts on to women, in the form of fears of female aggression and associations of ?badness? and ?dirt? with female sexuality. He transforms his mother and consequently all women into aggressive, domineering, sadistic, and punitive objects by reaction formations. Mike escapes from his feelings of helplessness and isolation and discharges his anxiety and aggressive instincts by using the defenses of projection, reaction formation, undoing, displacement, splitting, intellectualisation, rationalization, fantasy (sometimes disturbing, violent, and highly aggressive in nature), and acting out. He has a harsh superego and directs aggression at himself by some physically self- punishing OCD symptoms and by turning anger in on himself, taking the form of depression. His depression has intensified since the onset of OCD. He has low self- esteem and feelings of inadequacy, which have intensified since the onset of OCD. He has a poor body image and is self-consciousness and insecure over social acceptance and his physical appearance. Although he experiences castration anxiety, he has not identified with his father. He feels ambivalent towards his father and struggles with his sexuality and gender identity. He is both anally and orally- fixated. He is hypersensitive, with a highly sensitive, introverted, shy, withdrawn disposition and hypersensitivity to social opinion, particularly criticism. He has a history of difficulty with social skills due to excessive shyness, which has intensified since the onset of OCD, and suffers from social isolation and ridicule at school. He is embarrassed, ashamed, frustrated, and upset by the way he acts, trying to hide his symptoms from teachers and other children at school and when out in public, and sometimes missing school. He is highly physically sensitive and struggles to physically cope with the demands of his environment and the excessive tiredness caused by his OCD symptoms. He feels isolated within his family, perceiving disconnectedness, communication difficulties, and parental conflict. The precipitating event for the onset of his OCD symptoms was his parents? divorce. He is not close to his brother and although he is close to his sister, there is sibling rivalry. Since the onset of OCD, there has been more tension between Mike and his siblings. He has been diagnosed with attention-deficit disorder (ADD) and testing suggests hyperactive tendencies. He was also diagnosed with tourette?s syndrome (TS), which causes him considerable distress. 6.1.2. Daniel?s internal world Although Daniel has adequate contact with reality and an average level of maturity, he is poorly adjusted emotionally, and has an inadequately integrated ego and a neurotic superego. His personality is imbalanced, neurotic, and hysterical. There is a family history of personality disorders, with Daniel?s sister having been diagnosed with a severe case of borderline personality disorder (BPD). Daniel suffers from very high levels of anxiety. His internal world is highly neurotic, due to an unresolved Oedipus complex and a strong predisposition to developing psychopathology, particularly neuroses, mood disorders, and personality disorders. Although his OCD symptoms are currently mild and he no longer displays symptoms of repeated doubting (fears of his mother?s death) or demanding reassurance that his mother is not going to die, these fears persist as unconscious repressed material. His other symptoms (excessive hand washing, ordering, observable repeating or counting rituals, and mental repeating or counting rituals) remain. Due to his failure to resolve the Oedipus complex, Daniel is preoccupied and conflicted with sexuality and has infantile, regressed sex drives. He is obsessed with his mother?s sexuality and feels ambivalence and considerable aggression towards her. He projects his fear, helplessness, and aggression towards her onto his sister and all women. He thus feels ambivalence and fear towards female sexuality and women, perceiving them as emotionally immature, sick, weak, vulnerable, or dirty objects. Defending against his anxiety takes the form of fears of male aggression towards females. He projects his aggression onto nameless, faceless men, or monsters (such as vampires), sometimes fantasising that he is the omnipotent fantasy hero figure (often in a protective fatherly or husbandly role) that ?saves? the woman from her attackers. He has very high levels of anger and aggression and difficulty with impulse control, and tends to be impulsive, excitable, highly energetic, and overtly aggressive. He has become more aggressive since the onset of OCD. Daniel is experiencing castration anxiety, which he projects onto his environment, perceiving it as an unstable, unreliable, unpredictable, scary, and dangerous place, threatening him with physical injury. However, he has Oedipal fantasy wishes (hero fantasies) of replacing his father as his mother/sister?s protector and mate, indicating that castration anxiety has not eradicated his Oedipal fantasies of eliminating his father and possessing his mother. He experiences Oedipal ambivalence towards his father and has not identified with him. He feels physically inadequate and struggles with his sexuality and gender identity, tending towards homosexuality. He is both anally and orally-fixated. Daniel?s superego is neurotic and he uses the defense of undoing to defend against anxiety generated by guilt. He has low self-esteem, feels inferior (especially physically), and has a poor body image. His endocrine-related growth problem caused him to be physically small and he was bullied at nursery school. He deals with his feelings of inadequacy and consequent aggressive feelings towards himself by projecting his own sense of weakness onto females or fantasy figures (often characters from a movie). He uses fantasy, sometimes violent in nature, to compensate for his feelings of inadequacy and weakness. Daniel?s personality is predominantly extroverted, assertive, ambitious, autonomous, persistent, and forceful. His feelings of inadequacy and weakness result in an intensification of these personality tendencies, so that he behaves in a socially dominant, aggressive, intensely needy, and sometimes manipulative manner, to compensate for these feelings. Since the onset of OCD, these personality tendencies have intensified further. Daniel also turns his anger in on himself, manifesting as depression, which has intensified since the onset of OCD. He escapes from his feelings of helplessness and isolation and discharges his anxiety and aggressive instincts by using the defenses of projection, reaction formation, undoing, blocking, fantasy, intellectualisation, rationalization, displacement, and acting out. Daniel is genetically predisposed to developing psychopathology, and all the psychoneuroses (OCD, schizophrenia, hysteria, and paranoia) have manifested to some degree, suggesting a dispositional predisposition for the development of all the psychoneuroses. His sister has presented with symptoms of all the psychoneuroses. He is dispositionally hypersensitive, both emotionally and physically. He is hypersensitive to social opinion, particularly criticism, and experiences social isolation and poor adjustment at school. He has a history of difficulty with social skills, due to his intense bossiness. He is highly physically sensitive, suffering from an endocrine-related growth problem and asthma. Daniel perceives disconnectedness, a lack of closeness, insecurity, communication difficulties, and instability in family relationships. He perceives a tendency to criticise within the family. Frequent arguing constitutes a part of their communication style. Each family member is perceived as a potential source of conflict, anxiety, or threat to the others and as unstable, dependent, and needing help to cope with one other and the outside world. His mother suffers from depression and Daniel perceives her as unstable, depressed, and as an inadequate nurturer. Daniel?s father presents with bipolar and obsessive-compulsive tendencies. Daniel perceives him as depressed, and as an inadequate provider, protector, and nurturer. Daniel?s sister suffers from bipolar mood disorder (BMD) and BPD, and previously attempted suicide. The precipitating event for the onset of Daniel?s OCD symptoms was his sister?s admission to a mental health centre. He has been exposed to much psychopathology in his family and worries about the health of his parents and sister, fearing their illness, incapacitation, or death, and the economic deprivation thereof for him as a child. One of his first obsessions was repeated doubting (fears of his mother?s death). Daniel?s father is a compulsive spender, which may contribute towards Daniel?s economic anxieties. Daniel?s mother is proud of his intelligence and enjoys doing activities with him, but struggles to cope with her children and attends psychotherapy for support. Daniel needs more parental attention since the onset of OCD and tries to involve family members in his rituals. Coping with him leaves his parents feeling more exhausted and frustrated than previously. There is more tension in the family since the onset of Daniel?s OCD symptoms. Although he is close to his sister, there is sibling rivalry, which has intensified since the onset of Daniel?s OCD symptoms. Daniel was diagnosed with attention-deficit/hyperactivity disorder (AD/HD). He has trouble concentrating in class and tends towards impulsivity, high energy levels, and excitability. 6.1.3. Jane?s internal world Jane has adequate contact with reality but is emotionally unstable and immature. Although she was previously in therapy for OCD and her symptoms are currently mild, all her symptoms (repeated doubting, observable repeating or counting rituals, and demanding reassurance) remain and she suffers from very high levels of anxiety. Her internal world is neurotic because of an unresolved Oedipus complex and a strong predisposition to developing psychopathology, particularly depression and learning disorders. Jane is preoccupied and conflicted with sexuality. She has not identified in an adaptive manner with her mother, or relinquished Oedipal fantasies of her father. She deals with her associated anxiety, aggression, fear, and helplessness by converting her environment into an unhappy, scary place and males into inadequate, aggressive, punitive, threatening objects by reaction formations. She escapes from her feelings of helplessness and isolation and discharges her anxiety and aggressive instincts by using the defenses of projection, reaction formation, undoing, isolation, displacement, intellectualisation, rationalization, fantasy, and acting out. She struggles to control her considerable anger and aggression and tends towards impulsivity and aggression. She suffers from masturbation guilt and blocks her sexual and bodily impulses resulting in moodiness and anxiety. She has identified with her mother but has maladaptive fantasies of replacing her as the mother figure within the family. Jane internalises some of her anger resulting in depression. Her grandfather?s death was the precipitating event for the onset of her OCD symptoms, and continues to contribute towards her depression. She has low self-esteem, feels inadequate (particularly physically) and self-conscious, and has a poor body image. She is dispositionally hypersensitive, shy, introverted, and socially withdrawn and suffers from isolation and loneliness. In addition to her anal fixation, she is orally-fixated. She is genetically predisposed to developing psychopathology and all the psychoneuroses (OCD, schizophrenia, hysteria, and paranoia) have manifested to some degree. Her perceptions of the environment (her family?s economic status, conflict and disconnectedness in her family, instability and inadequacy within the family members, and conflict with her siblings) contribute towards her anxiety. She has developed concentration and short-term memory problems and struggles with mathematics at school. 6.1.4. Anne?s internal world Anne has adequate contact with reality but is immature and poorly adjusted emotionally, suffering from high levels of anxiety, and emotional stress. She experiences some confusion in her thought processes. Her personality is imbalanced, disorganised, neurotic, and hysterical and she has a neurotic superego. Although she was previously in therapy and her OCD symptoms are currently mild, they all remain. They are worries about contamination, cleaning rituals, repeated doubting, ordering, observable repeating or counting rituals, mental repeating or counting rituals, and demanding reassurance. She has a history of anxiety manifesting in anxiety disorders, having been diagnosed with SAD when starting school. There is a family history of anxiety disorders, with her father suffering from OCD and her mother and maternal grandmother suffering from anxiety. Her internal world is neurotic because of an unresolved Oedipus complex and a strong predisposition to developing psychopathology, particularly OCD, mood disorders, and learning disorders. Anne is preoccupied and conflicted with sexuality. Her sex drives are infantile and regressed, and she blocks her sexual and bodily impulses causing anxiety and moodiness. She has ambivalent feelings towards her father, with Oedipal love fantasies of him but also aggression towards him. These aggressive feelings are intolerable and impossible to consciously acknowledge, generating anxiety. She uses reaction formations to counter her anxiety, aggression, and feelings of insecurity and helplessness. In this way she transforms her father into an aggressive, threatening love object, tending to displace her aggression onto the environment, other males, or fantasy figures (such as dragons and monsters) in the form of perceptions of her environment as unpredictable and threatening her with physical injury or attack. Although she has identified with her mother, she experiences Oedipal anger and ambivalence towards her. She uses the defense of undoing to defend against aggressive impulses towards her mother. Some of her first OCD symptoms, which persist, represent a transformation of fears of her own aggression towards her parents. These are repeated doubting (worrying that her parents will die) and demanding reassurance (worrying that bad things are going to happen to her, or to one or both parents). She escapes from her feelings of helplessness and isolation and discharges her anxiety and aggressive instincts by using the defenses of projection, reaction formation, undoing, isolation, displacement, intellectualisation, fantasy, and acting out. She has low self-esteem, feelings of inadequacy, and a poor body image. She is self- conscious and overconcerned with outward appearances. Although she tends towards withdrawal, inhibition, defensiveness, and evasion, and has become more withdrawn since the onset of OCD, she has difficulty controlling her behaviour and emotions. She tends towards impulsivity, emotionality, high energy levels, excitement, and aggression. She has high levels of overt anger and aggression and behaves more aggressively since the onset of OCD, repressing very little of her aggression. She uses aggressive and socially dominant behaviour to compensate for feelings of inadequacy and weakness. She also uses fantasy to defend against feelings of inadequacy. In addition, she turns her anger in on herself, resulting in depression, which has intensified since the onset of OCD. Her mother and maternal grandmother suffer from depression and anxiety, and Anne is aware of her mother?s depression. Her father suffers from BMD, as did Anne?s paternal grandfather. Anne?s is hypersensitive, as she tends to be emotional and has personality tendencies towards imbalance, disorganisation, neurosis, and hysteria. She displays schizoid tendencies, has a history of social difficulties (shyness and SAD), and has become even more shy and withdrawn since the onset of OCD. She is hypersensitive to social opinion, particularly criticism, and gets frustrated and upset because she cannot always manage to do what people expect. She tries to hide her OCD symptoms at home and when out in public, often growing tired as her symptoms wear her out. At school, she tries to hide her symptoms from teachers and other children and is anxious, lonely, socially isolated, and ridiculed, sometimes missing school. The precipitating event for the onset of her OCD symptoms was starting a new school. She has a history of school-related anxiety, having suffered from SAD when first starting school. She has difficulty concentrating in class and tends towards hyperactivity. She struggles to achieve at school, has difficulty with handwriting skills, and displays dyslexic tendencies. Her father suffers from dyslexia and had difficulty with reading and writing. Anne is overwhelmed by strong dependency needs and feelings of helplessness, suggesting regression to the oral stage of psychosexual development. She has a very oral, concrete need for nurturance, and autoerotic, exhibitionistic, narcissistic tendencies. She is preoccupied with body processes, development, and pregnancy. She has a need for affection, care, support, help, and reassurance. She is immature and tends towards regression. Anne is genetically predisposed to developing psychopathology, particularly OCD and mood disorders, and all the psychoneuroses (OCD, schizophrenia, hysteria, and paranoia) have manifested to some degree There is a family history of psychopathology. Her father has suffered from OCD from the age of 3 years and suffers from BMD, as did Anne?s paternal grandfather. Anne?s mother and maternal grandmother suffer from depression and anxiety. Anne perceives isolation and conflict, communication difficulties, and parental conflict within her family. There is more tension in the family since the onset of Anne?s OCD symptoms, and she needs more parental attention and tries to involve family members in her rituals. Coping with her leaves her parents feeling more exhausted and frustrated than previously. Anne perceives all her family members as unstable, immature, dependent, constricted, helplessness, and needing help to cope with one another and the outside world. She suffers anxiety over family finances and her perceived lack of status. 6.1.5. Interpretative themes The analysis revealed some distinct themes in the children studied (see Appendix LL for a diagrammatic representation). 6.1.5.1. Psychological adjustment The analysis reveals that although all the children in the study display adequate contact with reality and are reasonably psychologically stable, they display multiple signs of psychopathology. They are emotionally maladjusted and suffer from very high levels of anxiety and obsessive-compulsivity. Three of the children (Mike, Jane, and Anne) display immaturity and the other child (Daniel) displays an average level of maturity. The two boys (Mike and Daniel) have inadequately integrated egos. The analysis generated insufficient data to assess the ego functioning of the girls. Two of the children (Daniel and Anne) present with personality disturbances (neurotic, hysterical personalities). Mike and Jane have harsh superegos and Daniel and Anne have neurotic superegos. 6.1.5.2. OCD symptoms Most children with OCD have both obsessive and compulsive symptoms (Presta et al., 2003; Robinson, 1998), often presenting with multiple obsessions and compulsions simultaneously (Adams & Burke, 1999). The children in the study all have both obsessive and compulsive symptoms and present with numerous obsessions and compulsions simultaneously. The children in the study share some common OCD symptoms. These are repeated doubting (worrying that someone in the family is going to die/worrying about family finances/worrying whether mother has locked the door and turned the stove off), observable repeating or counting rituals (repetitive counting, counting things, repetitive counting while playing, repeating lines/accents from movies, repeating words/songs, tapping /dragging feet, tapping fingers repetitively, repetitive grunting/sniffing/snorting/coughing/licking of lips, repeated head shaking, avoiding cracks in paving), and demanding reassurance (that nothing bad is going to happen or that nobody in the family is going to die). All the children have previously received psychotherapy for OCD, and Mike is still in therapy. Their symptoms are all currently mild in severity. All the children displayed some of their OCD symptoms during testing. In the case of the girls (Jane and Anne), all the symptoms remain and they are no longer in therapy. In the case of the boys (Mike and Daniel), some symptoms have ceased. However, the boys were both in therapy for longer (at least 2 years and 9 months) than the girls were. Although some of the boys? symptoms have seemingly ceased, the analysis suggests that they continue to exist in the form of repressed material, e.g. Daniel no longer displays the earlier symptoms of repeated doubting (fears of his mother?s death), or demanding reassurance that his mother is not going to die, however analysis indicates that he is preoccupied with fears not only of his mother?s death, but those of his father and sister as well. This finding suggests that OCD obsessions and compulsions persist below consciousness, continuing to affect the individual despite apparent therapeutic progress. Perhaps this explains something of the mechanism of how symptoms alter over time, and how some obsessions or compulsions seem senseless, excessive, and bizarre (Presta et al., 2003), or are paired in ways that evade logical explanation (Adams & Burke, 1999; Dinn, Harris & Raynard, 1999). The original or ?real? obsession becomes repressed and lost to conscious access. This may explain why the initial OCD symptom is often related to the precipitating event, while subsequent symptoms are unrelated to the precipitant and become more generalized (Robinson, 1998). It may also explain the persistent nature of OCD, as it is generally considered a chronic condition (Abramowitz, Moore, Carmin, Wiegartz & Purdon, 2001). These understandings are in keeping with psychodynamic conceptualisations of anxiety as deriving from unconscious conflict between id-driven sexual and aggressive forces that threaten to erupt into consciousness, and the efforts of the superego to keep them repressed (Sadock & Sadock, 2001). When repression breaks down, anxiety is produced, causing the emergence of unconscious intrapsychic defense mechanisms (Sadock & Sadock, 2001). Thus, in the case of OCD, over time the symptoms seem to become further and further divorced from their original, ?real? source, which is obscured due to defensive efforts to keep such unacceptable, anxiogenic material repressed. This relates to Rapoport?s (1990, p. 94) statement about her adult OCD patients, ?But now I know that most of our patients will never find the ?hidden? thought?. 6.1.5.3. Oedipus complex Some of the most striking findings of the study are the high levels of sexual preoccupation and conflict, anger and aggression, and paranoid anxieties about being physically injured and being watched, in all the children. The analysis reveals that the children experience high levels of ambivalence and conflict, due to psychosexual difficulties associated with not having resolved the Oedipus complex. The researcher found psychodynamic explanations of OCD invaluable in understanding these otherwise inexplicable findings. Freud (1905a) conceptualised neurosis as arising from repressed libidinal impulses due to instinctual conflicts around the resolution of the Oedipus complex. The Oedipus complex consists of a significant unconscious psychological developmental challenge for children, in which the child falls in love with the opposite sex parent and wants to eliminate the same sex parent, who is perceived as a rival for the exclusive affections of the same-sex parent (Polansky, 1991). The anxiety generated by the challenges of resolving the Oedipus complex is immense, and prove to be overwhelming for individuals who develop OCD (Stafford-Clark, 1965). A child with OCD is unable to relinquish Oedipal phantasies and libido becomes ?fixated? (stuck) on infantile love objects (Mitchell & Black, 1995). OCD involves regression to the anal-sadistic phase of psychosexual development, in which the child became fixated (Freud, 1913). Fear and helplessness towards the adored parent are transformed by a reaction formation into aggression and omnipotent phantasies and displaced onto all secondary love objects (Stafford-Clark, 1965), resulting in ambivalent feelings of love and hate (Sechaud, 1998). OCD symptoms are defensive reactions to the huge anxiety generated by conflicting impulses, and emerge to prevent or allay fears of harming, contaminating, destroying, or illicitly becoming sexually involved with, the mother or father, or both (Stafford-Clark, 1965). All the children exhibit great difficulty with impulse control, and struggle to control their emotions and behaviour. They experience high levels of anger and aggression, and have become more aggressive since the onset of OCD. Although a small quantity of their aggression is repressed, most is overt and they present with assaultive tendencies. Of particular interest are the considerable levels of anger and aggression experienced by the boys in the study, particularly towards their mothers/women. The boys (Mike and Daniel) have regressed sex drives, with ambivalence and high levels of overt aggression towards their mothers/women, and perceive their mothers/women as emotionally immature. Mike suffers from anxiety over the loss of maternal love and maternal abandonment or rejection, and is obsessed with his mother?s sexuality. By reaction formations and displacement, he transforms his mother, and consequently all women from nurturing, desirable love objects into emotionally immature, stronger, aggressive, dominating, sadistic, and punitive ones. He thus defends against his ?unacceptable? aggression by displacing it onto secondary love objects (women), in the form of fears of female aggression (fears of being dominated and physically mutilated by a woman). He thus experiences fear and ambivalence around female sexuality. One of his first OCD symptoms was demanding reassurance that his mother wasn?t going to die, to the point of suffering from panic attacks, representing a transformation of fears of his own considerable aggression towards his mother. Some of Mike?s first OCD symptoms involved ?bad thoughts? (not wanting to think about sex, or that his mother has sex), worries about contamination (germs from his mother), and compulsions to clean or hand wash. Female sexuality has become associated with ?badness? and ?dirtiness?. He uses the defense of undoing to punish himself for his aggressive impulses. Daniel experiences ambivalence and considerable aggression towards his mother/women, perceiving females as emotionally immature and vulnerable. By reaction formations, Daniel?s feelings of fear and helplessness towards his mother are transformed into aggression, which is displaced onto female sexuality, his sister, and all women. His sister and all women are thus transformed into emotionally immature, sick, weak, vulnerable, or dirty love objects. He defends against his ?unacceptable? aggression by projecting it onto his sister and other women, in the form of fears of male aggression towards females. In these fantasy scenarios, he projects his unacceptable aggressive affects onto nameless, faceless men, or monsters (such as vampires), sometimes casting himself as the omnipotent fantasy hero figure (often in a protective fatherly or husbandly role) who ?saves? the weak, helpless woman from her attackers. He thus feels fear and ambivalence around female sexuality, rooted in obsessions around his mother?s sexuality. Some of his first symptoms were repeated doubting (worrying that his mother would die) and demanding reassurance (that his mother was not going to die). For Daniel, female sexuality has become associated with illness, weakness, and vulnerability. Daniel?s self-punishment also takes the form of self-directed aggression (his OCD symptoms of chewing his clothing, licking his lips repeatedly, and shaking his head over and over again to fall asleep). Daniel?s small physical stature caused him to be bullied at nursery school. He deals with his feelings of inadequacy and consequent aggressive feelings towards himself by projecting his own sense of weakness onto females or fantasy figures (often characters from a movie). The significant male figures in Jane?s life (her father, brother, and cousin) are perceived as threatening and aggressive. She perceives her father as inadequate, critical, and a potential source of anxiety or threat to the other family members. She perceives her relationship with him as distant, but wishes to be closer to him. She perceives her brother as aggressive and there is much dislike, antagonism, and fighting between herself and her brother, causing her sadness and distress. Jane uses reaction formations to counter her feelings of insecurity and defend against aggressive impulses. She thus transforms her father and consequently all males into inadequate, aggressive, punitive, and threatening love objects. She defends against her aggressive feelings towards her father by projecting it onto other males (in the form of her fears of male aggression) and her environment. As a result, she perceives her environment as an unhappy, unstable, sometimes scary place, e.g. her anxieties over being hit by a car and fears of snakes. Some of her first OCD symptoms, which still persist, were repeated doubting (worrying that someone in her family would die) and demanding reassurance that something bad wasn?t going to happen and that nobody in the family was going to die. These symptoms represent a transformation of fears of her own aggression towards her parents. She uses the defense of undoing to defend against her aggressive impulses. Anne has infantile, regressed sex drives and Oedipal love fantasies towards her father. She has ambivalent feelings towards her father, perceiving him as both aggressive and protective. She is anxious about physical safety and fears attack. By reaction formations, she counters her feelings of insecurity by transforming her father into an aggressive, threatening love object. Her aggressive feelings towards her father are intolerable and impossible to consciously acknowledge. She thus displaces and projects them onto the environment, other males, or fantasy figures (such as dragons and monsters), in the form of her fears of physical injury or attack. She consequently perceives her environment as unpredictable and scary. She escapes from her feelings of helplessness and isolation and discharges her anxiety and aggressive instincts by using the defenses of projection, reaction formation, undoing, isolation, displacement, intellectualisation, fantasy, and acting out. She uses aggressive and socially dominant behaviour to compensate for feelings of inadequacy and weakness. Some of her first OCD symptoms, which persist, were repeated doubting (worrying that her parents will die) and demanding reassurance (worrying that bad things are going to happen to her, or to one or both parents). These symptoms represent a transformation of fears of her own aggression towards her parents. Identification with the opposite sex parent emerges with the successful resolution of the Oedipus complex, involving superego formation by incorporating the values, attitudes, and sexual orientation of the same sex parent (Lemma, 2002). In boys, the Oedipus complex is normally resolved through castration anxiety and identification with the same sex parent (Freud, 1925). In girls, the Oedipus complex is normally resolved by abandonment or repression, and identification with the mother (Freud, 1925). Although they experience castration anxiety, the boys in the study feel Oedipal ambivalence towards their fathers. They experience preoccupation and conflict with their gender identity or sexual orientation because, although they express a need for masculine assertiveness, they display strong homosexual tendencies. They have not identified with their fathers (both of whom are also OCD sufferers). Mike has not identified with his father. His feelings toward towards his father are consequently ambivalent. He perceives his father as demasculated and inadequate, but fears punishment from him. He experiences castration anxiety, displacing his aggression, helplessness, and fear onto the environment, which he perceives as harsh, unstable, punitive, and often scary. He has fears of being watched, and unjustly and severely punished (mostly by imprisonment or physical injury). He feels physically inadequate and conflicted about his sexuality and gender identity, tending towards homosexuality and narcissism. He experiences homosexual ambivalence, in the form of both homosexual drives and fears, related to his ambivalent feelings towards his father. His superego is consequently harsh, as revealed by his TAT stories. Daniel experiences Oedipal ambivalence towards his father. Because he has not identified with his father, his superego is neurotic (as revealed by his TAT stories), he feels physically inadequate, and experiences conflict and confusion over his sexuality and gender identity. He tends towards homosexuality and narcissism, and experiences conflict between homosexual drives and fears of homosexual attack. He defends against his feelings of helplessness and inadequacy by masculine strivings for physical strength and power. He experiences castration anxiety, displacing his aggression, helplessness, and fear onto the environment, which he perceives as unstable, unpredictable, dangerous, and scary. He has fears of being physically injured. These anxieties represent a projection of Daniel?s fears of castration. Despite Daniel?s castration anxiety, his TAT stories suggest Oedipal fantasy wishes (hero fantasies) of replacing his father as the protector and mate of his mother or sister, indicating that castration anxiety has not eliminated his Oedipal fantasies of eliminating his father and possessing his mother. A girl suffers from ?penis envy?, in the form of anger towards her mother for not giving her a penis. Penis envy plays a necessary role in loosening the girl?s ties to her mother (her primary love object) and the development of her femininity (Freud, 1925). Her desire for a penis is replaced by the desire to have a child by her father. In this way, her father becomes her love object and she becomes jealous of her mother (Freud, 1925). The girls in the study have ambivalent feelings towards their mothers, as although they have identified with them as females, they have Oedipal fantasies connected with replacing their mother as their father?s mate. They block their sexual and bodily impulses, causing anxiety and moodiness, and experience masturbation guilt. Jane?s feelings towards her mother are ambivalent. She identifies with her mother as a fellow mother figure. She is parentified and has fantasies of replacing her mother as the mother figure within her family. Her assumption of this motherly role towards Mary and Wilson implies ambivalent feelings of love and hate towards her own mother, projected onto Mary and Wilson. Anne has identified with her mother as a female, but feels ambivalent towards her. She experiences Oedipal anger and aggressive impulses towards her mother, and uses the defense of undoing to defend against them. She displays femininity, but also exhibitionistic tendencies and preoccupation with body processes, development, and pregnancy. According to Freud (1923), the superego of individuals with OCD is particularly harsh and feelings of inferiority persist due to a strong sense of guilt, generating anxiety. Mike and Jane have harsh superegos, and Daniel and Anne have neurotic superegos. All the children have low-self-esteem and experience feelings of inadequacy. They are self-conscious, with poor body images. Their dissatisfaction with their bodies stems mostly from feelings of physical inferiority and wishes for physical strength. They experience their world as an unstable and frightening place, and have high levels of anxiety over the prospect of physical injury, or attack. They experience anxiety over social acceptance, and feel socially isolated, lonely or insecure, uneasy, and hostile. They have developmental histories of difficulty with social skills, and are hypersensitive to social opinion, especially criticism. They also display an exaggerated sense of personal responsibility for events around them (such as the wellbeing of their family members, and family finances). These findings are interesting in the light of the theory that OCD symptoms represent gross distortions of adaptive behaviour (Rachman, 1993, as cited in Dinn et al., 1999). According to this theory, the individual feels an exaggerated sense of personal responsibility for events around him, and is hypersensitive to criticism. OCD symptoms emerge partly due to efforts to avoid criticism and gain social acceptance (Rachman, 1993, as cited in Dinn et al., 1999). Because obsessions and compulsions actually generate anxiety (Sadock & Sadock, 2001), it seems then that the OCD symptoms which emerge to counter the anxiety generated by criticism generate even further anxiety for the child, as the child anticipates or receives even further criticism for displaying the symptoms (due to their frequently bizarre, embarrassing, socially unacceptable nature). In this way a feedback loop is created, in which criticism (or fear thereof) generates anxiety in the hypersensitive child, resulting in OCD symptoms, which in turn cause criticism (or fear thereof). 6.1.5.4. Defenses All the children in the study display high levels of defensiveness. They escape from their feelings of helplessness, inadequacy, and isolation, and discharge their anxiety and aggressive instincts by using neurotic defenses characteristic of OCD (undoing and reaction formation). Daniel, Jane, and Anne also use the neurotic defense of isolation. All the children use the defenses of acting out and fantasy (sometimes violent in nature) to compensate for feelings of inadequacy and weakness. They all also use the defenses of projection, displacement, and intellectualisation. Mike, Daniel, and Jane also use the defense of rationalization. 6.1.5.5. Oral fixation The characteristics of the Oedipus complex depend largely on how previous psychosexual developmental stages were resolved by the child (Mitchell & Black, 1995). All the children experience conflict between autonomy and compliance with parental and school expectations. However, their dependency and nurturance needs are overwhelming, resulting in anxiety and feelings of helplessness, suggesting regression to the oral stage of psychosexual development. They perceive the rest of their family members as similarly dependent and helpless. Mike?s experiences strong dependency and nurturance needs and feelings of helplessness. He seems to fulfil a passive, dependent, ?baby? role within his family. Oral and oral incorporative themes related to eating and drinking emerge in his TAT stories, and two of his persistent OCD symptoms have oral features, viz. chewing the clothing he wears and licking his lips repetitively. Despite his assertive, ambitious personality Daniel?s dependency and nurturance needs are very strong, and he reminded the researcher of a needy, greedy child. His bossiness and forcefulness seem to be motivated by a seemingly insatiable need for attention. Oral and oral incorporative themes related to eating and drinking emerge in his stories. There is a family history of alcoholism, with both Daniel?s parents as sufferers. Despite Jane denial of her dependency needs, they are very strong, suggesting regression to the oral stage of psychosexual development. She displays immaturity and tends towards regression. She has a need for support, acknowledgement, nurturing, and reassurance. She uses passivity as a defense, due to fear of her aggressive impulses. Anne displays autoerotic, narcissistic, and exhibitionistic tendencies, and has a very oral, concrete need for nurturance. She displays immaturity and tends towards regression. She has a need for nurturance, affection, support, help, and reassurance. 6.1.5.6. Personality factors An interesting finding of the study is that OCD has had the effect of intensifying the predominant personality tendencies of the children in the study (the very tendencies that have historically caused them social difficulties). The personality styles of three of the four children (Mike, Jane and Anne) tend toward excessive introversion, introspection, shyness, and withdrawal. The other child (Daniel) tends more towards extroversion. The three introverted children have become even more shy and withdrawn (but also more aggressive), and Daniel has become more forward, bossy, and aggressive. The three introverted children have histories of difficulty with social skills due to excessive shyness and withdrawal. They have become even more shy and withdrawn since the onset of OCD and display schizoid tendencies. Their symptoms wear them out and they are often tired as a result. They try to hide their symptoms at home, from their teachers and other children at school, and when out in public. Their emotional adjustment is poor, their maturity levels are relatively low, and they have regressive tendencies. Daniel tends towards an extroverted personality. He has a history of difficulty with social skills due to aggressive, antisocial tendencies (excessive bossiness). He has become even more bossy and forward since the onset of OCD. The analysis suggests that he has an intense, assertive, ambitious, autonomous, persistent, demanding, and forceful personality. His behaviour causes stress for those around him, as he tends to overlook the rights of others. He has become more manipulative, rude, argumentative, demanding and overbearing. Sometimes he even unintentionally hurts others due to his forcefulness. His mother believes that Daniel over-compensates for his small stature by his aggressive behaviour. The analysis indicates that he uses aggressive and socially dominant behaviour to compensate for feelings of inadequacy and weakness. Two of the children (Daniel and Anne) display personality imbalance or disorganisation, tending towards neurotic and hysterical personalities, impulsivity, high energy levels, and excitement. Daniel has a family history of personality disturbance, as his sister suffers from BPD. 6.1.5.7. Psychosocial factors Anna Freud (1981) acknowledged the role of environmental factors such as individual growth patterns and family circumstances in psychological development and psychopathology. Research has revealed that family relationships are often affected in an intensely negative way by a child?s OCD symptoms (Adams & Torchia, 1998, as cited in Adams & Burke, 1999). The children in the study all perceive disconnectedness, conflict, and communication difficulties within their families. They perceive the rest of their family members, as similarly dependent and helpless. There is more tension in their families since they presented with OCD. They need more parental attention, try to involve family members in their rituals, and leave their parents feeling more exhausted and frustrated than previously. Research has established that siblings of children with OCD often also experience substantial stress (Adams & Torchia, 1998; as cited in Adams & Burke, 1999). There is sibling rivalry, in the case of the children with siblings (Mike, Daniel and Jane), and tension has increased between their siblings and themselves since they presented with OCD. Mike feels isolated within his family and is aware of the conflict between his parents. He is not close to his brother and although he is close to his sister, there is sibling rivalry (his sister is perceived as being closer to the parents than Mike). Since the onset of OCD Mike?s siblings feel jealous and neglected because the parents spend extra time with him. They feel embarrassed by his strange behaviour and do not like inviting friends home. Daniel perceives insecurity, unstable relationships, and a lack of closeness within his family. Each family member is perceived as a potential source of conflict, anxiety, or threat to the others and as unstable and needing help to cope with one other and the outside world. Daniel?s self-esteem is especially low within his family context, and he perceives the other family members as lacking in self-esteem. There is a tendency to criticise within the family and frequent arguing constitutes a part of the family?s communication style. Daniel?s mother struggles to cope with her children and is in psychotherapy to support her. She mother suffers from depression and Daniel perceives her as an inadequate nurturer, and as depressed and unstable. Daniel?s father presents with bipolar and obsessive-compulsive tendencies and Daniel perceives him as inadequate as a provider, protector, and nurturer, and as depressed. Daniel?s sister suffers from BMD and BPD, previously attempted suicide, and is withdrawn and exceedingly moody. Daniel has been exposed to a considerable amount of psychopathology in his family environment and worries about the health of his parents and sister, fearing their illness, incapacitation, or death, and the financial impact thereof for him as a child. His father?s compulsive spending may also contribute towards his economic anxieties. Although he is close to his sister, there is sibling rivalry (his sister is perceived as being closer to the parents than Daniel). She has felt jealous and neglected because of the extra time Daniel?s parents spend with him. Jane feels isolated and insecure within her family context, and perceives conflict and a lack of closeness between her parents, and her mother and herself as needing affection. She perceives her social status as unsatisfying, and her parents as emotionally immature, critical, and inadequate as providers. She experiences anxiety over her family?s economic status. One of her first OCD symptoms, which persists, was repeated doubting (worrying about family finances). Jane is not close to her siblings, and perceives much dislike, antagonism, and fighting between her brother and herself. She feels that every member of her family is unstable and needs help to cope with one other and the outside world. Anne perceives isolation and conflict within her family, suffers anxiety over conflict between her parents, and feels a need to be nurtured and taken care of. She is aware of her mother?s depression. She perceives her social status as unsatisfying and experiences anxiety over family finances She perceives all the members of her family members as unstable, immature, dependent, constricted, and as needing help to cope with one another and the outside world. Research has established that children with OCD often experience psychosocial difficulties due to social isolation (Kanner, 1962, as cited in Snider & Swedo, 2000). OCD often affects peer friendships and academic performance in profoundly negative ways (Waters, Barrett & March, 2001). The children in the study all experience psychosocial difficulties and anxiety over social acceptance. They feel socially isolated, lonely or insecure, uneasy and hostile, and are hypersensitive to social opinion, especially criticism. They have long had trouble with social skills, due to their predominant personality characteristics (excessive shyness and withdrawal in the case of the introverted children, and excessive bossiness in Daniel?s case), and have trouble adjusting to school due to their OCD symptoms. Mike is embarrassed and ashamed by how he acts, and experiences social isolation at school. He has difficulty making friends, and is teased and ridiculed due to his strange behaviour. He struggles to physically cope with the expectations of parents and school, consequently feeling frustrated and upset. He sometimes does not want to go to, or misses, school. Daniel has difficulty with social skills due to his aggressive behaviour, which has intensified since the onset of OCD. Jane has trouble making friends at school. Anne has difficulty making friends at school and is lonely. She is teased and ridiculed for her strange behaviour and sometimes does not want to go to, or misses, school. She feels frustrated and upset, as she cannot always meet people?s expectations. 6.1.5.8. Precipitating events Freud (1913) acknowledged the role of an external event in triggering the onset of OCD symptoms. Dinn et al. (1999) proposed a trauma-based aetiological component to OCD. All the children in the study experienced a personally traumatic precipitating event that served as a trigger for the onset of OCD symptoms. The precipitating event for the onset of Mike?s OCD symptoms was his parents? divorce. He has anxiety over the ongoing conflict between his parents and is very aware of the dynamics between them. Daniel?s precipitating event was his sister?s admission to a mental health centre. He is preoccupied with fears of the illness, incapacitation, and death of his sister, as well as his mother and father. One of Jane?s first OCD symptoms, which still persists, was demanding reassurance that nothing bad was going to happen and that no-one in her family was going to die. The precipitating event for the onset of Anne?s OCD symptoms was starting a new school. She has a history of school-related anxiety, having suffered from SAD when first starting school, and continues to suffer from school-related anxiety. 6.1.5.9. Genetic factors and comorbidity According to Robinson (1998) comorbid psychological disorders are reasonably common in children with OCD, especially other anxiety disorders and depressive disorders. Research indicates that there is a high degree of general psychopathology in the families of children with OCD (Dinn et al., 1999), and a strong genetic predisposition for OCD, particularly in first-degree relatives (Robinson, 1998). According to de Silva and Rachman (1998), a review of genetic research suggests that what appears to be inherited is a general emotional oversensitivity (neurotic tendency), which can predispose an individual to developing an anxiety disorder. All the children in the study display high levels of emotional sensitivity. The most frequently reported comorbid disorder with OCD is major depressive disorder (Kaplan & Hollander, 2003). From a psychodynamic perspective, it is understandable that depression is so frequently comorbid with OCD, as the superego of individuals with OCD is particularly harsh Freud (1923). Depression constitutes a form of self-punishment, as it is the turning of anger in on the self (Freud, 1917). The analysis reveals that all the children in the study are suffering from depression, which has intensified since the onset of OCD. Jane has been diagnosed with depression and experiences low physical energy levels and feelings of weakness. Three of the children (Daniel, Jane, and Anne) have family histories of mood disorders (all have at least one depressed parent and two have fathers with bipolar tendencies). These three children display the OCD symptom of repeated doubting (worries about their parents dying and family finances). In their TAT stories, worries about family finances are frequently linked directly to fears of parental abandonment, death or incapacitation (due to the parent being very sad, weak, or ill), and the economic impact this would have on them as children. They perceive all the members of their families as unstable and as needing help to cope with one another and the outside world. Research has shown that OCD is frequently comorbid with a number of childhood- onset conditions, such as SAD (Adams & Burke, 1999). Three of the children (Mike and Anne) have histories of SAD. These two children have family histories of anxiety disorders (both of paternal OCD, and one of maternal anxiety as well). OCD is often comorbid with childhood-onset learning disorders, especially reading disorder, expressive language disorder (Robinson, 1998), nonverbal learning disability (NVLD), AD/HD, and ADD (Adams & Burke, 1999). Research has established that the problems with memory, handwriting, and mathematics experienced by children with OCD are linked to their impaired nonverbal learning abilities (Henin et al., 2001). All the children in the study experience concentration difficulties and present with some disorders or problems with implications for learning and school achievement. Mike was diagnosed with ADD and has hyperactive tendencies and trouble with handwriting skills. Daniel has been diagnosed with AD/HD, and has high energy levels, tending towards impulsivity and excitability. Jane has short-term memory problems and difficulty with mathematics. She has a family history of learning disorders (her brother). Anne tends towards hyperactivity, impulsivity, and excitability, and has high energy levels. She has difficulty with handwriting skills and displays dyslexic tendencies. She has a family history of difficulties with reading and writing, and dyslexia (her father). Other childhood-onset disorders, with which OCD is frequently comorbid include disruptive behaviour disorders (especially conduct disorder) and tic disorders, particularly TS (Robinson, 1998). All the children in the study behave more aggressively since the onset of their OCD symptoms. Mike has been diagnosed with TS, and Daniel exhibits traits of conduct disorder. Anna Freud (1981) explained that innate dispositional factors underlie development, and can result in fixation at a particular pregenital psychosexual stage. Freud (1913) maintained that some individuals are dispositionally predisposed to developing a particular kind of neurosis. Freud (1905a) defined the psychoneuroses as OCD, schizophrenia, hysteria, and paranoia. Analysis reveals that Daniel, Jane, and Anne have tendencies of all the psychoneuroses. 6.2. Research Limitations The present study has various methodological limitations in terms of factors relating to both external and internal validity. These limitations, as they apply to the study, are discussed below. 6.2.1. External validity External validity is defined as the degree to which a causal relationship can be generalized to circumstances other than those experimentally studied or observed (Rosnow & Rosenthal, 1996). Relevant factors to the study include population validity and sampling bias, and third variable effects. a) Population validity and sampling bias A case study approach was employed because it is useful for gathering detailed, subjective data (Babbie & Mouton, 1998), which is useful in addressing the research questions of the study. Non-probability, volunteer sampling is convenient and economical, however generalizability of results to the population is not feasible, as one cannot guarantee that the sample is representative of the population (has population validity) (Rosnow & Rosenthal, 1996). A volunteer sampling method was selected because the study relates to a specific population, and it was only ethically and practically possible to gain access to a sample via non-probability, convenience sampling. A small sample size was selected, as it was more manageable for the purposes of the study. Because only four individuals constitute the sample, the results of the study are not necessarily generalizable beyond the subjects themselves. Although the researcher aimed to use a sample of six individuals, she was only able to gain access to four. The researcher encountered great difficulty in gaining access to subjects. She approached many psychologists, organisations, institutions, and schools. Although some patients or individuals known to these individuals or bodies were generally known for displaying symptoms of OCD, or even as suffering from OCD, they had not officially been diagnosed as such and thus were unsuitable for inclusion in the sample. Some had been diagnosed as suffering from brain damage or from other disorders (such as autism, asperger?s syndrome, ADD, AD/HD, schizophrenia, or TS), while others presented with sub-clinical OCD, or had not been diagnosed with any disorder at all. In addition, the ratio of parents who contacted the researcher, as compared to the quantity of introductory letters distributed, was very poor. The diagnosis of OCD is often overlooked or incorrectly identified by health care professionals (Flament et al., 1988, as cited Robinson, 1998). Banister, Burman, Parker, Taylor and Tindall (1994) explain that qualitative research aims for specificity, rather than to generalize its results. Thus, a small group of subjects was adequate for the purposes of the study, because the study does not aim to generalize its results to the population, but rather to gain a rich, detailed understanding of the inner worlds of the subjects. The researcher considers that this objective was achieved. b) Third variable effects The ?Third Variable Problem? is defined as the issue of whether another variable that is correlated with both X and Y, could be the cause of both (Rosnow & Rosenthal, 1996, p.233). The non-experimental research design of the study introduces this issue as a potentially confounding factor. The study aims to assess the perceptions of children and their parents and, because perceptions are subjective internal experiences subject to constant change, they are subject to distortions in the accuracy with which they are reported. These undetermined third variables cannot be controlled for within the confines of the non-experimental design of the study, and may thus pose a threat to the accuracy of the results of the study. 6.2.2. Internal validity Internal validity denotes factors within the context in which research is performed, which may affect the validity of the research process and its results (Rosnow & Rosenthal, 1996). In terms of internal validity, potentially confounding effects may arise due to experimenter effects, content validity, and self-reported data (Rosnow & Rosenthal, 1996). a) Experimenter effects The researcher is a fundamental part of the qualitative research process and is regarded as the primary data gathering instrument (Babbie & Mouton, 1998; Henning, 2004). Thus, the researcher?s interpretation and understanding of the data generated from the study are integral aspects of the research process, and the results thereof (Banister et al., 1994). It is acknowledged that the data gathering and analysis is contextualised within, and coloured by, the personal perceptions and understandings of the researcher herself. Babbie and Mouton (1998) refer to the importance of the qualitative researcher focusing on establishing rapport and a sense of trust with research subjects, in order to elicit data that is as reliable as possible. The researcher made every effort to establish good rapport with the children studied and their parents, while also attempting to remain as objective as possible. Henning (2004) focuses on the importance of the qualitative researcher providing evidence by integrating her understanding and interpretation of the data with a strong theoretical base. The researcher approached the study from the theoretical base provided by existing research, particularly relating to psychodynamic understandings of OCD and the use of projective methods in assessing the constructs that the study aimed to explore, and to integrate this with her understandings of the data. The biographical questionnaire was analysed using thematic content analysis for the open-ended questions. Content analysis is advantageous in that it results in an output that can be classified, and thus interpreted (Rosenthal & Rosenthal, 1991). However, interpretations must be consistent with the data (Campbell, 1987). Content analysis provided useful data that addressed the research aims. However, content analysis is subject to potential threats to the internal validity (and ultimately, the truth value) of results of the study, due to researcher bias, misunderstandings, and miscommunications affecting the neutrality of the researcher (Rosnow & Rosenthal, 1996). Thus, interpretation of the results of the open-ended questions used in the study may have been subject to interpreter effects. Potential interpreter effects may have emerged from the researcher?s personal experience with individuals who have OCD. It is thus possible that her interpretations of some of the children?s behaviour may have been subject to bias, in terms of the researcher making judgements based on their symptoms as described by the parents in the open-ended questions. Although the researcher has to reply on her own initiative when coding qualitative data (Mason, 1996), Neuman (1997) emphasizes the importance of the integrity of the researcher in making interpretations. Coetzee and Wood (1995) suggest the use of direct quotes from the subject, to enable readers to assist the researcher in maintaining integrity in her interpretations, by allowing her interpretations to be checked and verified. The researcher made use of tape recordings and note taking during testing, and has transcribed the participants? verbalisations and non-verbal behaviour during testing. These are presented in the analysis chapter of the research report, as well as in the appendices containing questions and answers for the drawing tests, and the TAT stories. The researcher has included numerous quotations followed by her interpretations thereof, in the analysis and discussion chapters of the research report. Sarantakos (1998) refers to the usefulness of the researcher presenting notes of his or her direct observations, containing descriptive detail of the subjects, events, and dialogue, as well as personal notes on her feelings and subjective impressions, in the recording of meaningful qualitative data. The researcher recorded such notes and incorporated them in the analysis and discussion chapters of the research report. The psychodynamic theoretical orientation of the researcher and the study may have resulted in bias, in interpreting the data. Although the primary theoretical basis for interpreting and analysing the data was psychodynamic, the researcher has incorporated some theories from other paradigms (such as psychosocial theories) and data generated from research (such as genetic studies) where relevant in the discussion and conclusions chapters of the research report. Copies of the children?s drawings and transcripts of their TAT stories are attached to the research report as appendices for evaluation, to enhance the reliability and validity of data generated by the researcher?s interpretations. b) Content validity Content validity refers to the extent to which a test or questionnaire represents the kind of content it aims to capture (Rosnow & Rosenthal, 1996). In terms of content validity, the rationale behind the use of projective techniques in the assessment of individuals is referred to as ?the projective hypothesis?, which holds that subject responses to the test stimuli or the tester are reflections, or projections, of his or her inner world (Tallent, 1992). The study thus assumes the validity of the projective hypothesis. Four instruments were utilised to gather data in the study. Three of these instruments took the form of projective assessment tests, administered to the children. Thus, the limitations inherent in these projective assessment instruments limit the findings of the study. Although the researcher attempted to consult a wide variety of interpretative systems relating to the analysis and interpretation of Human Figure Drawings, the results of the study are subject to the limitations of the theoretical frameworks used by the authors consulted. These are discussed below. Although Human Figure Drawing (HFD) is widely recognised as representing the drawer?s self-perception, body image, and personality, and is useful as a psychopathological diagnostic indicator to generate hypotheses, some assumptions behind HFD interpretation may lack experimental verification (Machover, 1949, as cited in Tallent, 1992). In this regard, the researcher made an effort to consider the verbalizations of the subjects about their drawings, which Ogden (2001) stipulates as important, together with the hypotheses and signs contained within the drawings, in order to provide further verification and support for any hypotheses generated from analysing the drawings. By making use of a second phase of administration, involving a series of questions about the projective drawing tests, the researcher attempted to triangulate the findings of the drawing analyses with another data source (verbalisations of subjects). However, it is acknowledged that the limitations of the questions asked limit the findings of the study. The research aims to explore the unconscious world of the children in the study, which is a broad, intangible, and elusive subject that no amount of questioning can possibly fully explore. Subjects may not have responded well to particular questions asked. They may have withheld, fabricated, or distorted information vital to the analysis in their answers to questions. Although the TAT is utilised extensively and can generate rich data about an individual, and there is consensus among most experts that sufficient evidence exists as to its content-related validity to support its use in the evaluation of human personality, criterion-related evidence as to its validity has not been easy to document and some experts consider its psychometric properties to be questionable (Kaplan & Saccuzzo, 2001). The fourth data gathering instrument utilised in the study was a biographical questionnaire about the child, which was completed by the parents or guardians of the children. Although the questionnaire is based on the DSM-IV-TR diagnostic criteria for OCD (APA, 2000), as well as data about OCD gathered in the literature review of this study, the limitations of the questions contained in the questionnaire limit the findings of the study. This researcher-designed questionnaire had the inherent advantage of convenience of use, however there are some potential threats to the internal validity (integrity) of research designs containing questionnaires (Rosnow & Rosenthal, 1996). In the context of the study, one needs to consider how useful, appropriate, and valid the questionnaire developed by the researcher is, in exploring the research questions. The questionnaire may not have adequately addressed the research aims, as the questions related to aspects about their children (such as their OCD symptoms) that the parents have insufficient knowledge or memories of. c) Self-reported data Because one of the data collection instruments is a questionnaire for parents, there is an inherent risk that the data gathered may be biased or subject to the effects of decay, due to its self-reported nature (Rosnow & Rosenthal, 1996). The parent questionnaire was answered based on the parent?s perceptions and memories of their child and what specific data they choose to report, which may be limited in accuracy and subject to the effects of decay. The researcher was present when some parents completed the questionnaire and observed that they sometimes had difficulty remembering information, particularly their children?s initial OCD symptoms. 6.3. Avenues for Future Research The researcher recommends that more research be conducted on children with OCD in South Africa. Both qualitative and quantitative studies on OCD and its effects would help to broaden our insight into and understanding of the disorder. Although OCD has a profound effect on the lives of child sufferers and their families, relatively little data has been published on clinical and therapeutic studies of children with OCD (Presta et al., 2003). Clinical studies, particularly ones that are longitudinal in nature, would be useful in gaining further knowledge about the course of OCD and informing mental health professionals on assessing, diagnosing, and treating OCD. 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Presta, S., Marazziti, D., Dell'Osso, L., Pfanner, C., Pfanner, P., Marcheschi, M., Masi, G., Muratori, F., Mucci, M., Millepiedi, S. & Cassano, G.B. (2003). Obsessive-Compulsive disorder in childhood and adolescence. Psychopathology, 36, 55-64. 53. Ramsay, R. & Fahy, T. (1995). Recent Advances: Psychiatry. British Medical Journal, International edition, 311(6998), 167-170. 54. Rapoport, J.L. (1990). The boy who couldn?t stop washing: The experience and treatment of Obsessive-Compulsive Disorder. Cornwall, U.K.: Collins. 55. Rapoport, J.L. (1998). Editorial. Journal of the American Medical Association, 280(20), 1785. 56. Reynolds, C.R. (1978). A Quick-Scoring Guide to the Interpretation of Children?s Kinetic Family Drawings (KFD). Psychology in the Schools, 15(4), 489-492. 57. Richards, A. (Ed.) (1977). On Sexuality: Three Essays on the Theory of Sexuality and other works. London, United Kingdom: Penguin Books. 58. Richardson, J.T.E. (Ed.) (1996). Handbook of Qualitative Research Methods for Psychology and the Social Sciences. Leicester, U.K.: BPS Books. 59. Robinson, R. (1998). Obsessive-Compulsive Disorder Update. Bulletin of the Menninger Clinic, 62(4), A49-A64. 60. Rosario-Campos, M. C., Leckman, J. F., Mercadante, M. T., Shavitt, R. G., da Silva Prado, H., Sada, P., Zamignani, D. & Miguel, E. C. (2001). Adults with early-onset Obsessive-Compulsive disorder. American Journal of Psychiatry, 158, 1899-1903. 61. Rosnow, R.L. & Rosenthal, R. (1996). Beginning Behavioral Research: A Conceptual Primer. (2nd ed.). New Jersey, U.S.A.: Prentice-Hall. 62. Sadock, B.J. & Sadock, V.A. (2001). Kaplan & Sadock?s Pocket Handbook of Clinical Psychiatry. (3rd ed.). Philadelphia, U.S.A.: Lippincott Williams & Wilkins. 63. Sadock, B.J. & Sadock, V.A. (2003). Kaplan & Sadock?s Synopsis of Psychiatry. (9th ed.). Philadelphia, U.S.A.: Lippincott Williams & Wilkins. 64. Sarantakos, S. (1998). Social Research. Basingstoke, U.K.: Macmillan. 65. Sechaud, E. (1998). Neurosis: Psychoanalytical perspectives. Psychologie- Clinique-et-Projective, 4, 5-21. 66. Snider, L.A. & Swedo, S.E. (2000). Pediatric Obsessive-Compulsive disorder. Journal of the American Medical Association, 284(24), 3104-3106. 67. Stafford-Clark, D. (1965). What Freud Really Said. Middlesex, U.K.: Penguin Books. 68. Tallent, N. (1992). The Practice of Psychological Assessment. New Jersey, U.S.A.: Prentice-Hall. 69. Waters, T.L., Barrett, P.M. & March, J.S. (2001). Cognitive-behavioral family treatment of childhood Obsessive-Compulsive disorder: Preliminary findings. American Journal of Psychotherapy, 55(3), 372-387. 70. Zohar, A.H., Pauls, D.L., Ratzoni, G. & Apter, A. (1997). Obsessive-Compulsive disorder with and without tics in an epidemiological sample of adolescents. American Journal of Psychiatry, 154(2), 274-276. APPENDIX A DSM-IV-TR DIAGNOSTIC CRITERIA FOR 300.3 OBSESSIVE-COMPULSIVE DISORDER (OCD) A. Either obsessions or compulsions: Obsessions as defined by (1), (2), (3), and (4): (1) recurrent and persistent thoughts, impulses, or images that are experienced, at some time during the disturbance, as intrusive and inappropriate and that cause marked anxiety or distress (2) the thoughts, impulses, or images are not simply excessive worries about real-life problems (3) the person attempts to ignore or suppress such thoughts, impulses, or images or to neutralize them with some other thought or action (4) the person recognizes that the obsessional thoughts, impulses, or images are a product of his or her own mind (not imposed from without as in thought insertion) Compulsions as defined by (1) and (2): (1) repetitive behaviours (e.g., hand washing, ordering, checking) or mental acts (e.g., praying, counting, repeating words silently) that the person feels driven to perform in response to an obsession, or according to rules that must be applied rigidly (2) the behaviours or mental acts are aimed at preventing or reducing distress or preventing some dreaded event or situation; however, these behaviours or mental acts either are not connected in a realistic way with what they are designed to neutralize or prevent or are clearly excessive B. At some point during the course of the disorder, the person has recognized that the obsessions or compulsions are excessive or unreasonable. Note: This does not apply to children. C. The obsessions or compulsions cause marked distress, are time consuming (take more than 1 hour a day), or significantly interfere with the person?s normal routine, occupational (or academic) functioning, or usual social activities or relationships. D. If another Axis I disorder is present, the content of the obsessions or compulsions is not restricted to it (e.g., preoccupation with food in the presence of an Eating Disorder; hair pulling in the presence of Trichotillomania; concern with appearance in the presence of Body Dysmorphic Disorder; preoccupation with drugs in the presence of a Substance Use Disorder; preoccupation with having a serious illness in the presence of Hypochondriasis; preoccupation with sexual urges or fantasies in the presence of a Paraphilia; or guilty ruminations in the presence of Major Depressive Disorder). E. The disturbance is not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition. Specify if: With Poor Insight: if, for most of the time during the current episode, the person does not recognize that the obsessions and compulsions are excessive or unreasonable. (APA, 2000, pp. 462-463) APPENDIX B INTRODUCTORY LETTER Dear Parents I am an Educational Psychology Masters student at the University of the Witwatersrand. I am conducting research on Obsessive-Compulsive Disorder (OCD) in children, to explore their inner emotional experiences. Your child?s psychologist/psychiatrist kindly agreed to forward this letter to you, on my behalf, as it is unethical for him/her to release your name or contact details to me, because s/he is bound to maintain your confidentiality. I would like to invite your child and yourselves to participate in my study, on a voluntary basis. As I am ethically bound to maintain your confidentiality, your child?s psychologist/psychiatrist will not know whether you have chosen to participate, or not, unless you elect for them to be provided with copies of the data collected from testing your child. If you are interested in participating in my study, please contact me telephonically, for me to explain the aims and procedure of my study in more detail. Briefly, the study involves parents completing a questionnaire about the child, which will take approx. 15 to 30 minutes. I would also like to spend half an hour with yourselves and your child, getting to know you a little better. Thereafter, with your consent and your child?s assent, I will administer three psychological tests to the child: the Draw-A-Person test, the Kinetic Family Drawing test, and the Thematic Apperception Test. For these, I will ask the child to draw pictures, answer questions about them, and make up stories about some picture cards. I will need to be alone with the child, preferably in their home, for up to two hours. If necessary, I may need a second session with the child, of up to one hour. Please note that your contact details and all responses will be treated confidentially. No-one, except my supervisor and I, will have access to them. No identifying data is requested on the questionnaire and pseudonyms will be used in my research report. Your participation in this study is voluntary, and you or your child are free to withdraw, at any stage in the research process. If you are interested in participating in my study, or have any questions, please contact me. My contact details appear below. Thank you for taking the time to read this. Your participation will add value to my study. Yours faithfully Tamarin Epstein Tel: (011) 728-4631 (H) 0823083472 (Cell) APPENDIX C SUBJECT INFORMATION SHEET Dear Parents I am an Educational Psychology Masters student at the University of the Witwatersrand and I am conducting research on Obsessive-Compulsive Disorder (OCD) in children. I am interested in exploring the psychological life of children with OCD, for the purpose of gaining an understanding of the child?s inner emotional experiences. I would like to invite your child and yourselves to participate in my study. If you choose to participate, please complete the attached questionnaire and return it to me, when we meet. The questionnaire will take approximately 15 to 30 minutes to complete. After that, I would like to spend half an hour together with yourselves and your child, to give me a chance to get to know you all a little better. Thereafter, with your consent, and if your child is willing, I will administer three psychological tests to the child: the Draw-A-Person test (D-A-P), the Kinetic Family Drawing test (K-F-D) and the Thematic Apperception Test (TAT). I will ask the child to draw three to four pictures for me and then I will ask some questions about each of them. I will also show the child a selection of picture cards and ask them to make up a story about each one. For this, I will need to be alone with the child, in a quiet room, with a desk or table and chairs, for a time period of up to two hours, at your convenience. I may require an additional session with the child, of up one hour, if the testing is not completed in the first session. I would prefer it if we can arrange for all sessions to take place at home, because I feel this will help your child to feel comfortable and safe. Receipt of your completed questionnaire will indicate to me that I have your permission to use your responses, and your child?s drawings and responses, in this study. Please note that your contact details and all responses will be treated confidentially. No-one, except my supervisor and I, will have access to them. Anonymity is guaranteed, as no identifying data is requested on the questionnaire, and pseudonyms will be used at all times, in my research report. Your participation in this study is entirely voluntary, and you or your child are free to withdraw your consent to participate, at any stage in the research process. Although no individual feedback will be given, a summary sheet of the findings of this study, will be made available to you, on request. Although I don?t anticipate or intend for your child or yourselves to experience any concerns or problems, as a result of participation in the study, should any arise, I can provide your child?s psychologist/psychiatrist with the child?s drawings and stories, with your written consent. The questionnaire provides for you to indicate whether or not you consent to your child?s mental health practitioner receiving this data. S/he will then be in a position to address any concerns, and provide you with the appropriate psychological support. If you have any questions about the study, or any concerns, please feel free to contact me. Yours faithfully Tamarin Epstein Tel: (011) 728-4631 (H) 0823083472 (Cell) APPENDIX D SUBJECT BIOGRAPHICAL QUESTIONNAIRE Date: _______/__________/____________ Day Month Year What age is your child now? ______________ years and _________ months What age was your child when you first noticed symptoms of OCD? ______________ years and _________ months What are the ages of your child?s siblings, if any?________________________________ _______________________________________________________________________ Have any of your child?s siblings been diagnosed with OCD or with any other psychological difficulty? If so, please provide details: ________________________________________ _______________________________________________________________________ Is there a history of OCD or of any other psychological difficulty in the family? If so, please provide details: __________________________________________________________ _______________________________________________________________________ What age was your child when you first sought treatment for his/her OCD symptoms? ______________ years and _________ months What treatment did you first seek for your child? (e.g. paediatrician, dermatologist, dentist, family doctor, psychologist, neurologist, plastic surgeon) __________________________ _______________________________________________________________________ _______________________________________________________________________ What age was your child when you first sought psychological/psychiatric treatment for him/her? ______________ years and _________ months How long has your child received (or did your child receive) treatment from a psychologist/psychiatrist? ______________ years and _________ months What were your child?s first symptoms of OCD that you noticed (please tick as many as apply)? Worries about contamination (e.g. illness, germs, dirt, shaking hands) Please give details:________________________________________________________ ________________________________________________________________________ Repeated doubting (e.g. worrying that someone is going to die, or that the door hasn?t been locked) Please give details:_________________________________________________________ _________________________________________________________________________ Needing to have things in a specific order (e.g. books must be piled up straight) Please give details:__________________________________________________________ __________________________________________________________________________ Aggressive/socially-unacceptable impulses (e.g. wanting to shout out a swear word in a public place, wanting to hit somebody for no apparent reason) Please give details:___________________________________________________________ __________________________________________________________________________ Recurrent thoughts/worries about sex/?bad thoughts? Please give details:___________________________________________________________ __________________________________________________________________________ Cleaning rituals (e.g. excessive hand washing, washing clothes) Please give details:___________________________________________________________ Checking behaviour (e.g. checking the door is locked over and over again) Please give details:___________________________________________________________ __________________________________________________________________________ Observable repeating/counting rituals (e.g. counting to 10 three times in a row, always touching or tapping an object five times, tapping foot a certain number of times, going back and forth through a doorway a certain number of times, turning the light on and off a certain number of times) Please give details:___________________________________________________________ __________________________________________________________________________ Mental repeating/counting rituals (e.g. silently repeating the words of a song/a prayer over and over in his/her head, mentally counting over and over) Please give details:___________________________________________________________ __________________________________________________________________________ Demanding reassurance that e.g. the doors are locked/there isn?t going to be a fire in which the family will die/something terrible isn?t going to happen. Please give details:___________________________________________________________ __________________________________________________________________________ Other Please give details:___________________________________________________________ Do you recall any difficult/traumatic event happening for your child, just prior to the start of his/her OCD symptoms (e.g. moving home, starting school, death of a close family member)? Yes No If YES ? please give details: ____________________________________________________ __________________________________________________________________________ __________________________________________________________________________ How would you describe the severity of your child?s OCD symptoms now? Very severe (debilitating, all aspects of my child?s life are very seriously impaired) Severe (Most aspects of my child?s life are seriously impaired) Moderate (Some aspects of my child?s life are impaired, but not seriously so) Mild (One/two aspects of my child?s life are mildly impaired, but s/he generally copes well with life) None (OCD causes no interference whatsoever in my child?s life) How would you describe your child?s OCD symptoms now (please tick as many as apply)? Worries about contamination (e.g. illness, germs, dirt, shaking hands) Please give details:___________________________________________________________ Repeated doubting (e.g. worrying that someone is going to die, or that the door hasn?t been locked) Please give details:___________________________________________________________ __________________________________________________________________________ Needing to have things in a specific order (e.g. books must be piled up straight) Please give details:___________________________________________________________ __________________________________________________________________________ Aggressive/socially-unacceptable impulses (e.g. wanting to shout out a swear word in a public place, wanting to hit somebody for no apparent reason) Please give details:___________________________________________________________ __________________________________________________________________________ Recurrent thoughts/worries about sex/?bad thoughts? Please give details:___________________________________________________________ __________________________________________________________________________ Cleaning rituals (e.g. excessive hand washing, washing clothes) Please give details:___________________________________________________________ __________________________________________________________________________ Checking behaviour (e.g. checking the door is locked over and over again) Please give details:___________________________________________________________ __________________________________________________________________________ Observable repeating/counting rituals (e.g. counting to 10 three times in a row, always touching or tapping an object five times, tapping foot a certain number of times, going back and forth through a doorway a certain number of times, turning the light on and off a certain number of times) Please give details:___________________________________________________________ __________________________________________________________________________ Mental repeating/counting rituals (e.g. silently repeating the words of a song/a prayer over and over in his/her head, mentally counting over and over) Please give details:___________________________________________________________ __________________________________________________________________________ Demanding reassurance that e.g. the doors are locked/there isn?t going to be a fire in which the family will die/something terrible isn?t going to happen. Please give details:___________________________________________________________ __________________________________________________________________________ Other Please give details:___________________________________________________________ __________________________________________________________________________ Has life changed in your family, since your child started displaying symptoms of OCD? Yes No If YES ? in what way has it changed (please tick as many as apply)? The child needs more of our (parental) attention The child tries to involve us in his/her OCD rituals (e.g. tries to get us to check doors/wash clothes again and again/turn the light on and off for him/her, tries to get us to give him/her special foods, tries to get us to allow him/her longer time periods in the bathroom, give him/her constant reassurance that nothing terrible is going to happen, etc.) There is generally more tension/arguments in the family, than before. The child?s siblings feel jealous/neglected because we spend extra time with the child. There is more tension/arguments between the child and his/her siblings, than before. The child?s siblings don?t like inviting friends home any more/ are embarrassed by their brother/sister?s strange behaviour The child?s siblings are afraid that they might get OCD too. Coping with the child leaves us feeling more exhausted/frustrated than previously. We feel guilty, because we think maybe we have somehow caused, or passed on, OCD, to our child. Other (please specify): _________________________________________________________________ Did/does your child experience any difficulty with any of the following developmental milestones/tasks (please tick as many as apply)? Potty training Handwriting Social skills (e.g. being able to interact well with other children) Mathematics Memory Other (please specify): _________________________________________________________________ Has your child?s temperament and life, especially at school, changed, since s/he started displaying symptoms of OCD? Yes No If YES ? in what way has it changed (please tick as many as apply)? Child?s OCD symptoms wear him/her out and s/he is often tired as a result. Child has become more depressed. Child has become more withdrawn/shy. Child ?acts-up? more than before Child has trouble making friends at school Child tries to hide his/her symptoms from teachers/other children at school Child tries to hide his/her symptoms at home Child tries to hide his/her symptoms, when out in public Child tries to hide his/her symptoms everywhere else, except at home Child?s symptoms are very bad at home, and minimal/none at school Child has developed learning problems at school Please give details:__________________________________________________ Child has trouble concentrating in class. Child?s teacher complains that s/he doesn?t concentrate in class/is disruptive. Child?s school marks have dropped Child is teased/ridiculed at school, because of his/her strange behaviour Child sometimes doesn?t want to go to school/misses school. Child is embarrassed/ashamed by the way s/he acts. Child is frustrated/upset because s/he can?t manage to do what people expect. Child has a low self-esteem. Other (please specify): _________________________________________________________________ Has your child ever been diagnosed by a medical/mental health practitioner with any of the following medical/psychological conditions (please tick as many as apply)? Attention-Deficit Disorder (ADD) Attention-Deficit/Hyperactivity Disorder (AD/HD) Separation Anxiety Disorder Social Phobia Other Phobias (e.g. fear of flying) Tic Disorder (e.g. Tourette?s Syndrome) Depression Other (please specify): _________________________________________________________________ As the legal guardian/s of ____________________________________ (child?s name), I/we hereby consent to the use of the data contained in this questionnaire and gathered from the tests administered to my/our child in the course of this study, to be used for the purpose of the research study. As the legal guardian/s of ____________________________________ (child?s name), I/we hereby consent/do not consent (delete whichever is not applicable) to the provision of my/our child?s drawings and stories from the tests administered to him/her in the course of this study, to his/her mental health practitioner. ___________________________________________________________________ ___________________________________________________________________ Signature/s of guardian/s ___________________________________________________________________ ___________________________________________________________________ Full name/s of guardian/s Thank you for completing this questionnaire. Your participation will add value to my study. APPENDIX E CHILD ASSENT FORM I _________________________________________ (full name) assent to participating in Tamarin Epstein?s research study. ____________________________________________________________ Signature of minor child Assisted by: _____________________________________________________________ Signature of legal guardian/s _____________________________________________________________ Full name/s of legal guardian/s APPENDIX G SUBJECT A (?Mike?) D-A-P 1 QUESTIONS & ANSWERS Q: Let?s give your person a name? A: ?Bean?. Must I write it on top? . Q: What is ?Bean? doing? A: He?s looking. Q: What makes ?Bean? happy? A: Well, because he?s got cool hair. Q: What makes ?Bean? sad? A: Cos he doesn?t have any eyeballs. Q: What does ?Bean? like doing the most? A: Um?going to parties. Q: What does ?Bean? not like doing? A: Um? doing nothing?and running. Q: What is the best thing about ?Bean?? A: Mm?he?s got cool hair. Q: What is the worst thing about ?Bean?? A: That he?s got a pointy nose. Q: If ?Bean? were an animal, what would he like to be? A: Cheetah. Q: Why? A: Cos that?s just what he looks like, if you made him an animal. Q: Would you like to be ?Bean?? A: Not really. Q: What does ?Bean? do on the weekends? A: He parties. Q: Who is ?Bean??s favourite person? A: His best friend. Q: Who is the person ?Bean? doesn?t like? A: His enemy Q: What does ?Bean? do when he?s being good? A: He does, he just sits down. Q: What does ?Bean? do when he?s being bad? A: He, um he?s bashing something. Q: If ?Bean? were invisible, what would he like to do? A: Play pranks on people. Q: Does ?Bean? remind you of anyone? A: No. APPENDIX I SUBJECT A (?Mike?) D-A-P 2 QUESTIONS & ANSWERS Q: Let?s give your person a name? A: ?Shanon? Q: What is ?Shanon? doing? A: She?s standing. Q: What makes ?Shanon? happy? A: Um?dancing. Q: What makes ?Shanon? sad? A: When she doesn?t know what she?s doing. Q: What does ?Shanon? like doing the most? A: Dancing. Q: What does ?Shanon? not like doing? A: Um?she doesn?t like it when her hair gets ugly. Q: What is the best thing about ?Shanon?? A: Her name. Q: What is the worst thing about ?Shanon?? A: Her face?got a funny face. Q: If ?Shanon? were an animal, what would he like to be? A: Dog. Q: Why? A: Cos that?s what she likes. Q: Would you like to be ?Shanon?? A: No. Q: What does ?Shanon? do on the weekends? A: Horse riding. Q: Who is ?Shanon??s favourite person? A: Her friend. Q: Who is the person ?Shanon? doesn?t like? A: Um? the person that doesn?t choose her. Q: What does ?Shanon? do when she?s being good? A: Sleeping. Q: What does ?Shanon? do when she?s being bad? A: Uh??I think party. Q: If ?Shanon? were invisible, what would she like to do? A: Scream?when no-one can hear her. Q: Does ?Shanon? remind you of anyone? A: Yes, a girl at school. APPENDIX K SUBJECT A (?Mike?) D-A-P 3 QUESTIONS & ANSWERS Q: What are you doing? A: Um?standing there. Q: What makes you happy? A: Sleeping. Q: What makes you sad? A: When people ignore me. Q: What do you like doing the most? A: ?Sitting with family. Q: What do you not like doing? A: ?Uh?stuff that makes me boring. Q: What is the best thing about you? A: My hair. Q: What is the worst thing about you? A: ?T.S (Tourette?s Syndrome)?I don?t like it. Q: If you were an animal, what would you like to be? A: A dog. Q: Why? A: Cos dogs are cool. Q: What do you do on the weekends? A: Sleeping and hanging out with friends. Q: Who is your favourite person? A: My friends. Q: Who is the person that you don?t like? A: Um? people that don?t like me. Q: What do you do when you?re being good? A: Mm? just sit around. Q: What do you do when you?re being bad? A: ?When I get hyper. Q: If you were invisible, what would you like to do? A: Mm??call people names. APPENDIX M SUBJECT A (?Mike?) K-F-D QUESTIONS & ANSWERS Q: Can you tell me who each person is, and what they are doing? A: (From left to right): My dad ? he?s laughing at what my mom?s telling him. My mom ? she?s telling my dad something. My sister ? she?s sleeping. Me ? I?m listening to music. Q: What is the one best thing about this family? A: That they?re all doing something. Q: What is the one worst thing about this family? A: That they all doing different things. Q: What things does this family do together? A: They go to the shop. Q: If you could change one thing about this family, what would it be? A: Make my sister stop singing?that?s why I?ve got the headphones on . Q: Who is the favourite person in this family? A: My favourite? My sister. Q: How does everyone in this family get along? A: ?all right. Q: How does your dad feel about himself? A: He feels like he?s the boss of everyone. Q: How does your mom feel about herself? A: My mom feels like she?s making my dad laugh. Q: How does your sister feel about herself? A: She thinks she?s a good singer. Q: How do you feel about yourself? A: Uh??I think I?m tired. APPENDIX N SUBJECT A (?Mike?) TAT TRANSCRIPT AND SHORT FORM FOR RECORDING AND ANALYZING TAT (ADAPTED FROM BELLAK, 1975) TAT Card 1 ?OK, the kid?s bored so that he?s staring at stuff and he wanted to do something, so he found these things. And he wanted to bust something, but it was too hard, so his magic powers broke it and then it smashed in his face ?That?s the end.? Main theme (diagnostic level): Overt aggression and aggression directed back at self, in form of painful punishment. Main hero: Child Main needs and drives of hero: Behavioural needs of child (aggression) Conception of environment as: Punitive Parental figures seen as Punitive Significant conflicts: Between superego and aggression (id) Nature of anxieties: Physical harm/punishment, and being overpowered and helpless. Main defenses against conflicts and fears: Acting-out, fantasy, undoing (aggression is directed back at the self, to undo damage done) Adequacy of superego, as manifested by punishment for crime being: Injury: too severe (harsh superego). Integration of the ego, manifesting itself in: Inadequate hero; unhappy, unrealistic, bizarre outcome; poor drive control; thought processes as revealed by plot being original, inappropriate, concrete and contaminated. Intelligence: High Maturational level: Low TAT Card 2 ?Um?the one person fell down, cos he was too tired. But then he had to do his homework. His sister tried to wake him up, but couldn?t. He got into trouble at school?he fell asleep again and didn?t do his homework again, as he had such a hard day at school.? Main theme (diagnostic level): Child is punished for not being able to physically cope with the demands of environment (school). Main hero: Child Main needs and drives of hero: The need to be taken care of (exhaustion) Conception of environment as: Punitive Contemporary figure (sister) seen as: Trying to help, but unable to. Significant conflicts: Between autonomy and compliance (between own physical abilities and demands of environment). Nature of anxieties: Disapproval, punishment, and being overwhelmed and helpless Main defenses against conflicts and fears: Regression Adequacy of superego, as manifested by punishment for crime being: Getting into trouble: too severe (harsh superego). Integration of the ego, manifesting itself in: Inadequate hero, unhappy and realistic outcome, poor drive control, thought processes as revealed by plot being inappropriate and concrete. Intelligence: High Maturational level: Low TAT Card 3BM ?The guy?s sleeping on the window sill cos it was raining and he didn?t want his head to get wet and he was hiding by the window, cos he didn?t want to get wet. Then his head got mashed and then it rained again and it looked like his whole head was crying.? Main theme (diagnostic level): Child is punished for not being able to physically cope with the demands of environment (rain). Main hero: Child Main needs and drives of hero: The need to be taken care of (kept dry from the rain), and aggression Conception of environment as: Punitive Significant conflicts: Between own physical abilities and demands of environment; between superego and aggression (id) Nature of anxieties: Physical harm, and being overpowered and helpless Main defenses against conflicts and fears: Regression, projection Adequacy of superego, as manifested by punishment for crime being: Injury: inappropriate and too severe (harsh superego) Integration of the ego, manifesting itself in: Inadequate hero; unhappy, unrealistic, bizarre outcome; poor drive control; thought processes as revealed by plot being original, inappropriate, concrete and contaminated. Intelligence: High Maturational level: Low TAT Card 3GF ?The girl?s crying cos she can?t open the gate and cos she cried so loud, it broke the gate and it mashed her fingers and she cried so hard, it mashed her fingers again. And then it broke and she finally got it open and then she stopped crying.? Main theme (diagnostic level): Child is punished for not being able to physically cope with the demands of environment (opening the gate). Main hero: Child Main needs and drives of hero: The need to be taken care of and aggression Conception of environment as: Punitive Significant conflicts: Between own physical abilities and demands of environment, between superego and aggression (id) Nature of anxieties: Injury, and being overwhelmed and helpless Main defenses against conflicts and fears: Regression, acting-out, undoing (aggression is directed back at the self, to undo damage done) Adequacy of superego, as manifested by punishment for crime being Injury: inappropriate and too severe (harsh superego). Integration of the ego, manifesting itself in: Adequate hero; happy and realistic outcome; poor drive control; thought processes as revealed by plot being original, bizarre, inappropriate and concrete. Intelligence: High Maturational level: Low TAT Card 4 ?The woman likes the man but then he?s tryna get away, but then she grabbed him so hard his eyeballs popped out. And then she put them back in cos she thought he might like her again. But then he tried to run away.? Main theme (diagnostic level): Child is dominated and injured by mother- figure, may be repressed aggression towards mother. Main hero: Child Main needs and drives of hero: Autonomy and aggression Conception of environment as: Punitive Parental figure (mother) seen as: Punitive, aggressive, stronger and dominating. Significant conflicts: Between autonomy and compliance; between superego and aggression (id) Nature of anxieties: Physical injury, and being overwhelmed and helpless Main defenses against conflicts and fears: Projection, undoing Adequacy of superego, as manifested by punishment for crime being: Injury: inappropriate and too severe (harsh superego) Integration of the ego, manifesting itself in: Inadequate hero, unhappy and unrealistic outcome, good drive control, thought processes as revealed by plot being original, bizarre, inappropriate and concrete. Intelligence: High Maturational level: Low TAT Card 5 ?A woman opened the door and she saw the flowers were dead, then she went and throwd that out the window. And then the lamp was broken and so she threw that away as well. And then the book came alive and then she threw it out the window. Then she went to hospital and they walked right through her cos she was a ghost.? Main theme (diagnostic level): Mother is frustrated, as she is unable to control her environment. May be repressed aggression against mother. Main hero: Mother (ghost) Main needs and drives of hero: Aggression and the wish to be powerful, seen and acknowledged, and to have control over her environment. Conception of environment as: Uncontrollable Significant conflicts: Between own physical abilities and demands of environment; between superego and aggression (id) Nature of anxieties: Illness/death of mother, and her being overwhelmed and helpless Main defenses against conflicts and fears: Acting-out, undoing Adequacy of superego, as manifested by punishment for crime being: Death: inappropriate, too severe (harsh superego) Integration of the ego, manifesting itself in: Inadequate hero, unhappy and unrealistic outcome, poor drive control, thought processes as revealed by plot being original, bizarre, inappropriate and concrete. Intelligence: High Maturational level: Low TAT Card 6BM ?The guy saw the old woman looking out the window, but then he was a crook so he took something out of her pocket and she shouted and cried and he shot at her. But he missed her and she called the police and the police killed him.? Main theme (diagnostic level): Oedipal - child is punished by father for aggression against mother Main hero: Child Main needs and drives of hero: Behavioural needs (aggression) Conception of environment as: Punishing of aggressive behaviour Parental figures: Mother seems weak and regressed, but is actually powerful. Father powerful. Significant conflicts: Between superego and aggression (id) Nature of anxieties: Disapproval, punishment (castration anxiety), and being overwhelmed and helpless Main defenses against conflicts and fears: Regression, acting-out, undoing Adequacy of superego, as manifested by punishment for crime being: Death: appropriate but severe (harsh superego). Integration of the ego, manifesting itself in: Inadequate hero, unhappy and realistic outcome, poor drive control, thought processes as revealed by plot being inappropriate and concrete. Intelligence: High Maturational level: Low TAT Card 7BM ?The guy with the funny moustache was telling the guy he was getting promoted, but he liked his job and he didn?t want to get promoted. But then the boss got angry and said he was fired. He?d like to whip that moustache off his face, but then he didn?t cos he really got fired.? Main theme (diagnostic level): Child is punished for autonomy, may be repressed Oedipal anger at father. Main hero: Child Main needs and drives of hero: Autonomy and aggression Conception of environment as: Punitive Parental figures: Father seen as punitive Significant conflicts: Between autonomy and compliance, between id and superego Nature of anxieties: Disapproval, punishment (castration anxiety), and being overwhelmed and helpless Main defenses against conflicts and fears: Fantasy Adequacy of superego, as manifested by punishment for crime being: Losing his job: inappropriate and too severe (harsh superego). Integration of the ego, manifesting itself in: Inadequate hero; unhappy and unrealistic outcome; poor drive control; thought processes as revealed by plot being original, bizarre, inappropriate and concrete Intelligence: High Maturational level: Low TAT Card 7GF ?The two friends were fighting, then she looked away. The other one started to say something, but she didn?t care about her. Then, next day, she saw her friend with another friend, then she walked out the door again.? Main theme (diagnostic level): Child is abandoned by mother Main hero: Child Main needs and drives of hero: The need to be taken care of (nurturance/love needs) Conception of environment as: Punitive Parental figures: Mother seen as unnurturing. Significant conflicts: Between nurturance needs and environmental constraints (mother) Nature of anxieties: Loss of love and being deserted Main defenses against conflicts and fears: None Adequacy of superego, as manifested by punishment for crime being: Loss of friendship/love: inappropriate, too severe (harsh superego) Integration of the ego, manifesting itself in: Inadequate hero, unhappy and unrealistic outcome, poor drive control, thought processes as revealed by plot being inappropriate and concrete. Intelligence: High Maturational level: Low TAT Card 8BM ?They were operating on this guy cos they shot at him but then he screamed so hard that the bullet came out. But then they still charged him. But then they made a mistake and still cut him. Then his friends came and pointed to the bullet, but then he made a mistake, cos he was actually the guy that killed him.? Main theme (diagnostic level): Child is physically injured (by himself) and hurt further while incapacitated. Main hero: Child Main needs and drives of hero: The need to be taken care of (nurturance/love needs) and aggression Conception of environment as: Punitive Contemporary figures seen as Helpful (friends), punitive (doctors). Doctors may represent father. Significant conflicts: Between nurturance needs and environmental constraints (father), and between aggression (id) and ego Nature of anxieties: Physical injury Main defenses against conflicts and fears: Regression, undoing Adequacy of superego, as manifested by punishment for crime being: Injury: inappropriate, too severe (harsh superego). Integration of the ego, manifesting itself in: Inadequate hero; unhappy and unrealistic outcome; poor drive control; thought processes as revealed by plot being inappropriate, bizarre, contaminated and concrete. Intelligence: High Maturational level: Low TAT Card 9BM ?Ooh?uh?the guy was in a party, so he went onto stage and jumped into the crowd. Then they stomped on him and he fell asleep and they chucked him in the bin and took his hat off and shoved it in his mouth. Then, they put him back on stage again, but he still smelled of rubbish.? Main theme (diagnostic level): Child is rejected and injured, for wanting to be accepted by his peers, may be repressed homosexual drives and fears. Main hero: Child Main needs and drives of hero: Acceptance, nurturing and self-esteem needs; homosexual drives; aggression Conception of environment as: Punitive Contemporary figures seen as (other men) seen as punitive Significant conflicts: Between homosexual drives and fears, between id and superego. Nature of anxieties: Injury, disapproval, and being overwhelmed and helpless Main defenses against conflicts and fears: Regression, undoing Adequacy of superego, as manifested by punishment for crime being: Injury and shame: inappropriate and too severe (harsh superego). Integration of the ego, manifesting itself in: Inadequate hero, unhappy and unrealistic outcome, poor drive control, thought processes as revealed by plot being original, bizarre, inappropriate and concrete. Intelligence: High Maturational level: Low TAT Card 10 ?The two people were happy to see each other, so then they hugged each other. But the one guy wasn?t the real guy, so he called the police, cos the one guy was a diamond smuggler and he ran away, cos the other guy was lying. But, he told the police the other guy was lying, but then they didn?t believe him, and then he went to prison.? Main theme (diagnostic level): Child is rejected and punished, for trusting another man?s affections, may be repressed homosexual drives and fears. Main hero: Child Main needs and drives of hero: Acceptance, nurturing and self-esteem needs; homosexual drives Conception of environment as: Punitive Contemporary figures seen as (other man, police) seen as punitive. Police may be father-figure. Significant conflicts: Between homosexual drives and fears, between id and superego. Nature of anxieties: Punishment, loss of love, disapproval, and being overwhelmed and helpless Main defenses against conflicts and fears: Undoing Adequacy of superego, as manifested by punishment for crime being: Imprisonment: inappropriate and too severe (harsh superego). Integration of the ego, manifesting itself in: Inadequate hero; unhappy and unrealistic outcome; adequate drive control; thought processes as revealed by plot being bizarre, inappropriate and concrete Intelligence: High Maturational level: Low TAT Card 11 ?OK?there was once a big waterfall with all the birds and a bridge across it. No bird could cross it, but two did, but security cameras saw. But they released a big ball of rocks, so all the birds could cross. But then they took a big rock and put it at that place, cos they?d finished all the food that was behind the waterfall.? Main theme (diagnostic level): Child is afraid of punishment, for autonomy Main hero: Child Main needs and drives of hero: Autonomy and the need to be taken care of (food) Conception of environment as: Punitive Parental figures (security cameras) seen as punitive Significant conflicts: Between autonomy and compliance, between id and superego. Nature of anxieties: Disapproval, punishment and loss of love Main defenses against conflicts and fears: Undoing Adequacy of superego, as Parental disapproval: inappropriate and too manifested by punishment for crime being: severe (harsh superego). Integration of the ego, manifesting itself in: Inadequate hero; unhappy and unrealistic outcome; poor drive control; thought processes as revealed by plot being original, bizarre, inappropriate and concrete. Intelligence: High Maturational level: Low TAT Card 12M ?There was once a sick person and she fell as in the house and the old guy came in to see if she was sleeping. And he waved too hard and hit her, but then she woke up, but too fast, and then mashed her head against his head and then they knocked each other out.? Main theme (diagnostic level): Child is injured, while sick and asleep, by an older man, may be repressed homosexual drives and fears. Main hero: Child Main needs and drives of hero: Homosexual drives; aggression Conception of environment as: Punitive Contemporary figures (other man) seen as punitive Significant conflicts: Between homosexual drives and fears, between id and superego. Nature of anxieties: Injury, and being overwhelmed and helpless Main defenses against conflicts and fears: Regression, undoing Adequacy of superego, as manifested by punishment for crime being: Injury: inappropriate and too severe (harsh superego). Integration of the ego, manifesting itself in: Inadequate hero, unhappy and unrealistic outcome, poor drive control, thought processes as revealed by plot being original, bizarre, inappropriate and concrete. Intelligence: High Maturational level: Low TAT Card 13MF ?OK?the kid was crying cos he saw this woman was sleeping and he told her not to sleep till he got there, cos he wanted to talk to her. But he didn?t want her to talk cos she was too bad. When she was asleep, he mashed her head and she screamed so hard, the book flew out of his hand and she started beating him.? Main theme (diagnostic level): Oedipal child is punished, for trying to kill his mother, because she does not meet his needs and is bad. Main hero: Child Main needs and drives of hero: Oedipal aggression and acquisition needs Conception of environment as: Punitive Parental figures (mother) seen as bad and powerful Significant conflicts: Between superego and aggression (id) Nature of anxieties: Injury, punishment (castration anxiety), disapproval, lack of love Main defenses against conflicts and fears: Regression, acting-out, rationalization, undoing, splitting Adequacy of superego, as manifested by punishment for crime being: Injury: appropriate (adequate superego). Integration of the ego, manifesting itself in: Inadequate hero, unhappy and unrealistic outcome, poor drive control, thought processes as revealed by plot being original, bizarre, inappropriate and concrete. Intelligence: High Maturational level: Low TAT Card 13B ?There was once a boy and he, his parents told him never to go through the door, so he always sat next to the door. But one day, he went out and security cameras saw and he was locked up for not obeying his parents rules, in the prison beyond the door. But he broke even more rules and again and again he got locked up, cos he couldn?t get out of prison to get back behind a door.? Main theme (diagnostic level): Child is imprisoned for autonomy (disobeying his parents). Main hero: Child Main needs and drives of hero: Autonomy versus compliance Conception of environment as: Punitive Parental figures Seen as punitive Significant conflicts: Between superego and autonomy Nature of anxieties: Punishment, disapproval, lack of love, being overpowered and helpless Main defenses against conflicts and fears: Acting-out, undoing Adequacy of superego, as manifested by punishment for crime being: Imprisonment: inappropriate and too severe (harsh superego). Integration of the ego, manifesting itself in: Inadequate hero; unhappy and unrealistic outcome; poor drive control; thought processes as revealed by plot being original, bizarre, inappropriate and concrete. Intelligence: High Maturational level: Low TAT Card 14 ?Once there was a guy that liked looking out the window, cos the room was so dark and he saw light every time he closed the curtains. It was so dark, he fell asleep immediately, but something was at the window and it blew, so there was light. Then, he broke down the curtains, but couldn?t sleep again. He had no choice but to jump out the window and wait for it?s night.? Main theme (diagnostic level): Child commits suicide, to gain autonomy. Main hero: Child Main needs and drives of hero: Autonomy versus compliance, aggression Conception of environment as: Punitive Parental figures Seen as punitive Significant conflicts: Between superego and autonomy Nature of anxieties: Being overpowered and helpless Main defenses against conflicts and fears: Regression Adequacy of superego, as manifested by punishment for crime being: Death: inappropriate and too severe (harsh superego). Integration of the ego, manifesting itself in: Inadequate hero; unhappy and unrealistic outcome; poor drive control; thought processes as revealed by plot being original, bizarre, inappropriate and concrete. Intelligence: High Maturational level: Low TAT Card 17BM ?There was once a guy and he went to prison for no reason, cos they thought he?d killed someone. So, he decided to get out, so he was sliding down a rope. It broke on top cos a policeman cut it, so he falled down. But by the time he hit the ground, all the police had surrounded him. But then they locked him up again.? Main theme (diagnostic level): Child is imprisoned, for trying to gain autonomy. May represent Oedipal fears of father?s retaliation (castration anxiety). Main hero: Child Main needs and drives of hero: Autonomy versus compliance, aggression Conception of environment as: Punitive Parental figures Father seen as punitive Significant conflicts: Between superego and autonomy Nature of anxieties: Being overpowered and helpless Main defenses against conflicts and fears: Undoing Adequacy of superego, as manifested by punishment for crime being: Imprisonment: inappropriate and too severe (harsh superego). Integration of the ego, manifesting itself in: Inadequate hero; unhappy and realistic outcome; poor drive control; thought processes as revealed by plot being original, bizarre, inappropriate and concrete. Intelligence: High Maturational level: Low TAT Card 18BM ?There was once a guy and he liked to sleep because one day, he sleeps too hard, he walked in his sleep and drank a potion and became a giant. So big, it used all his energy and he fell asleep so hard he started walking in his sleep, cos he?d walked so far. He didn?t know why he was like that. Because he was such a big giant, he used up all his energy, so he went small again.? Main theme (diagnostic level): Child fears his own physical weakness and helplessness, possibly Oedipal (castration anxiety) Main hero: Child Main needs and drives of hero: Need for physical strength and size, to gain control over environment Conception of environment as: Uncontrollable Significant conflicts: Between id and ego Nature of anxieties: Being overpowered and helpless Main defenses against conflicts and fears: Regression, fantasy, undoing Adequacy of superego, as manifested by punishment for crime being: Becoming small again: inappropriate and too severe (harsh superego) Integration of the ego, manifesting itself in: Inadequate hero; unhappy and unrealistic outcome; poor drive control; thought processes as revealed by plot being original, bizarre, inappropriate and concrete. Intelligence: High Maturational level: Low TAT Card 19 ?Mm..mm, once there was a dark shadow that kept on hunting the burger in the fridge. The person wanted it, but saw holes in it cos of the shadow. He put cameras in, because he didn?t know what was eating it. He saw holes in it and wanted to find the shadow. He couldn?t find the shadow. The shadow ate the burger and everything that was in the fridge and he couldn?t find it.? Main theme (diagnostic level): Child?s food is eaten by an elusive shadow. May represent Oedipal fears of father (castration anxiety). Main hero: Child Main needs and drives of hero: Oedipal wishes for mother?s nurturance and sexual favours (food) Conception of environment as: Punitive and uncontrollable Parental figures (father) seen as: Punitive, elusive, powerful (father, symbolised by dark shadow); elusive and desirable (mother, symbolised by food). Significant conflicts: Between superego and Oedipal id Nature of anxieties: Being overpowered and helpless, loss of love/nurturance Main defenses against conflicts and fears: Projection, regression Adequacy of superego, as manifested by punishment for crime being: All his food is eaten: inappropriate and too severe (harsh superego). Integration of the ego, manifesting itself in: Inadequate hero; unhappy and realistic outcome; poor drive control; thought processes as revealed by plot being original, bizarre, inappropriate and concrete. Intelligence: High Maturational level: Low APPENDIX P SUBJECT B (?Daniel?) D-A-P 1 QUESTIONS & ANSWERS Q: Let?s give your person a name? A: Let me think, ?Michael?. I can remember when I was 4! I like snakes, animals?and I had a mongoose, but you need a permit. Now, I got a tortoise, but it poo?s a lot! Q: What is ?Michael? doing? A: He?s busy?lemme think, playing mouse, the mouse and the cat. You see, one person?s a cat, the other?s a mouse. You standing in a circle and people all run around. The person becomes a mouse and the person becomes the cat! Q: What makes ?Michael? happy? A: I would say he likes condensed milk, and what makes him happy? Condensed milk. Once 11 is 11, two 11?s are 22,?10 11?s, 110. Can you say the 100 times-table? Researcher: Yes. Daniel: You can?t do it! Time me. 100 times one is 100, and a hundred times 2 is 200, ooh, yeah, well?100 times 3 is 3, 3 hu, 3 hundred. 4 times 100, 400..5 times 100, 500..6 times 100, 600..7 times 100, 700..8 times 100, 800..9 times 100, 900..10 times 100, 1 000. Researcher: Wow! That was quick. You were only 19.37 seconds Daniel: Just to say the hundred times-table! Researcher: And that was hard! Daniel: It?s not! Researcher: Don?t you think so? Daniel: Ja, it?s not. Now what picture can I draw for you? Researcher: OK, but hang on, we haven?t finished answering questions about ?Michael?. Can I ask you more questions? Daniel: Yes. Q: What makes ?Michael? feel sad? A: Mm ?Sad?when one of his pets die. Q: What does ?Michael? like doing the most? A: Mm he likes playing hide and seek. Q: What does ?Michael? not like doing? A: Mm, hmm..sums. Q: What is the best thing about ?Michael?? A: That he?s the oldest in the class, in his class. That?s all, that, that. Also a good thing about him is that ? aah, I can?t say anything. Q: What is the worst thing about ?Michael?? A: Mm that he?s rude. Q: If ?Michael? were an animal, what would he like to be? A: Mm, cheetah. Q: Why? A: Bcos! He can run fast. Next thing is that his favourite animal is a cheetah. Q: Would you like to be ?Michael?? A: No. Q: What does ?Michael? do on the weekends? A: Weekend he likes sleeping over at his friends. Q: Who is ?Michael??s favourite person? A: In his family, or outside his family? His favourite person it?s, uh, Charlie Chaplin?because that?s his favourite actor and he likes him cos of all his jokes and he has like good movies. Q: Who is the person ?Michael? doesn?t like? A: Mm he hates mm lemme think?he hates Melanie. It?s his, it?s a girl in his class. He hates her because she sucks her finger. And she does, and there?s really a girl in my class that does suck her finger and named Melanie. I don?t like her cos she touches us with that spots. Q: What does ?Michael? do when he?s being good? A: Mm?me..err.. he?s listening to his teacher. Q: What does ?Michael? do when he?s being bad? A: Being rude. Q: If ?Michael? were invisible, what would he like to do? A: He would like, er, to run through walls and scare people. Q: Does ?Michael? remind you of anyone? A: Mm?yes. He reminds me of a boy named ?Michael? in my class. I like ?Michael?, he?s one of my friends in my class, 8 years old. APPENDIX R SUBJECT B (?Daniel?) D-A-P 2 QUESTIONS & ANSWERS Q: Let?s give your person a name? A: It, her name, ?Tammy?. She is you. Q: What is ?Tammy? doing? A: She is doing ballet Q: What makes ?Tammy? happy? A: Mm, a Barbie Q: What makes ?Tammy? sad? A: Uh, getting shouted at Q: What does ?Tammy? like doing the most? A: She likes doing?tennis Q: What does ?Tammy? not like doing? A: She does not like doing jump Q: What is the best thing about ?Tammy?? A: That she?s the best, she?s the ballet dancer of the world Q: What is the worst thing about ?Tammy?? A: Mm ?that she that she is uh, a rude girl Q: If ?Tammy? were an animal, what would she like to be? A: She?d like to be a panther. Q: Why? A: Cause she likes black and?the panther?s her favourite animal. Q: Would you like to be ?Tammy?? A: No because she likes panthers. I hate them. She?s a girl and I don?t like being a girl. And?another thing is that she doesn?t wash her hair. Q: What does ?Tammy? do on the weekends? A: She plays at her neighbour?s house Q: Who is ?Tammy??s favourite person? A: Mm ?lemme think, Anne, the ballet teacher Q: Who is the person ?Tammy? doesn?t like? A: Mm, Johnny Depp. Because she doesn?t like boys. Q: What does ?Tammy? do when she?s being good? A: Mm, she?s doing her work, work neatly. Q: What does ?Tammy? do when she?s being bad? A: Not listening to her teacher. Q: If ?Tammy? were invisible, what would she like to do? A: She would like to hide from her mother and go to her friend?s house when she?s not allowed to. Q: Does ?Tammy? remind you of anyone? A: Yes. She reminds me of Melanie. APPENDIX T SUBJECT B (?Daniel?) D-A-P 3 QUESTIONS & ANSWERS Q: What are you doing? A: I am playing hide and seek with my friends. Q: What makes you happy? A: Err?when I see my sister. Q: What makes you sad? A: When one of my pets die. Q: What do you like doing the most? A: Mm, any sums. Q: What do you not like doing? A: Mm?anything?I only like doing?my homework. I just need the toilet again. Can you turn that thing off? Q: What is the best thing about you? A: That I?m the best junior primary hockey player. Q: What is the worst thing about you? A: Mm..that I hate ballet, no no, not that?that I, that I nag a lot. Q: If you were an animal, what would you like to be? A: Mongoose. Q: Why? A: Because they very nice animals. They cute and they run fast. Q: What do you do on the weekends? A: Spend time at my house, play with my neighbour or go to sleep over at my sister or..at my friend?s house. Q: Who is your favourite person? A: Johnny Depp. Because he?s a good actor and I like him very much. Finding Neverland is my favourite movie of his and Charlie and the Chocolate Factory is one of the others I like very much. Q: Who is the person you don?t like? A: Mm uh, lemme think, I do not like what?s his name??.uh?.he?s?what?s that name again? Bill Gates, I hate him?just because I don?t like him. Q: What do you do when you?re being good? A: When I?m good? Mm, I listen to everything I?m told. Q: What do you do when you?re being bad? A: Mm, I don?t listen to anyone and I?m rude. Q: If you were invisible, what would you like to do? A: I?d like to run around invisible, play with my toys. APPENDIX V SUBJECT B (?Daniel?) K-F-D QUESTIONS & ANSWERS Q: Can you tell me who each person is, and what they are doing? A: (From left to right): My dad is eating popcorn with Coke, my mom is watering the garden, my sister is picking flowers and I?m playing with action men. Q: What is the one best thing about this family? A: I can?t answer that (said sharply). Q: What is the one worst thing about this family? A: I also can?t answer that (said sharply). OK, I know the worst thing is that, ok? no the good thing is that we not poor and that we not rich. And the bad thing is well, there is no bad thing. Q: What things does this family do together? A: Err?my sister and me go to movies. The entire family goes to the drive-in and?my mother, me?and my sis, my my family also goes to have dinner with, eh, it?s this place called uh, Flamingas Re, Flamingo?s Restaurant, where we eat ribs. Q: If you could change one thing about this family, what would it be? A: That we had powers. For me, it would be every kind of fire that there is, that includes lava. Err, my sister would be that, OK my father would be?I don?t know what he would be, cos I?or my mother, or well I?d say my mother could be, have water, so she can drown you. My sister would have poison ivy, s?and my father will have?err?thorns. I can burn people, my sister can er poison people, my mother can drown people and my father can kill people, by by stabbing spikes in them. If someone tries to rob them, then or steal us, that?s what we could use to protect ourselves. And I would turn into a wraith. Researcher: A wraith? Daniel: Yes Researcher: What?s a wraith? Daniel: It?s like a dead person, that?s dressed in this black?I?ll get a, I?ll get a toy! I?ll be a wraith, my sister would be invisible woman, my mother would be flexible lady and my father would be?Mr Incredible. Researcher: Wow! Do you like that movie? Daniel: Yes, and Mr Incredible, he has the strength, so he can break through walls, my father. Q: Who is the favourite person in this family? A: That I like? No-one. I like them all. Did you think it would be that? Did you think I?d say that? Cos I love my whole family. Q: How does everyone in this family get along? A: They do get along, but I don?t know how. They just get along. Q: How do you feel about yourself? A: Fantastic. Q: How does your sister feel about herself? A: I don?t know (said very sharply) Q: How does your mom feel about herself? A: No?I don?t know, and my father, no! (said very sharply, before I had finished asking the question). APPENDIX W SUBJECT B (?Daniel?) TAT TRANSCRIPT AND SHORT FORM FOR RECORDING AND ANALYZING TAT (ADAPTED FROM BELLAK, 1975) TAT Card 1 ?There?s this one boy that lived in a forest. He, he, he lived, himself and his sister, and he, and he used to go catch up, he used to go catch birds with his gun, cos he had no toys. So all he had to play with was this gun. And one day, these men tried to attack them, then he shot them. That?s all. After that, they were sent to jail, the men, and he and his sister lived happily ever after. I can make it up quick!? Main theme (diagnostic level): Oedipal ? fantasy wish to take father?s place, as sister?s protector & sexual fantasy of taking sister as mate Main hero: Child Main needs and drives of hero: Aggression, achievement and sexual Conception of environment as: Dangerous, unreliable Parental figures: Father may be symbolised by the men, in Oedipal hero fantasy of killing father Contemporary figures: Sister (perceived as a mate) Significant conflicts: Between superego and aggression, sexual drives & Oedipal needs Nature of anxieties: Economic deprivation, physical injury, loss of love Main defenses against conflicts and fears: Projection, acting-out, fantasy, rationalization Adequacy of superego, as manifested by punishment for crime being: None (inadequate punishment). Integration of the ego, manifesting itself in: Adequate hero; happy and unrealistic outcome; poor drive control; thought processes as revealed by plot being inappropriate and concrete. Intelligence: High Maturational level: Average TAT Card 2 ?There was once, once there was a lady. She had a husband and a daughter. Her daughter had to go live somewhere else, cos the house was getting too small for all of them. And then one day, she found a nice man and they got married. Then she went on to her parents and they got married and lived happily ever after.? Main theme (diagnostic level): Oedipal ? perhaps himself as the fantasy ?nice man?, who married his mother or sister (it is unclear which got married) Main hero: Mother Main needs and drives of hero: Behavioural needs (sexual) Conception of environment as: Unpredictable, but not unfriendly Parental/contemporary figures: Mother/sister perceived as potential sex object; mother unnurturing (sent daughter to live somewhere else) Significant conflicts: Between superego and Oedipal sexual needs Nature of anxieties: Economic deprivation, sexual Main defenses against conflicts and fears: Projection, fantasy Adequacy of superego, as manifested by punishment for crime being: Finding a nice man and getting married (inadequate punishment) Integration of the ego, manifesting itself in: Adequate hero, happy and unrealistic outcome, poor drive control, thought processes as revealed by plot being inappropriate and concrete. Intelligence: High Maturational level: Average TAT Card 3BM ?Once upon a time, there was this boy with his mother. He asked his mother could he get a, live with a, could he get a goat as a pet? Then his mother said no, because you?d wreck the house. Then one day, huh, this goat got lost. He looked after it, but he kept it outside. Then one day, he went in the house and ruined their entire house. And then, he, his mother shouted at the boy and then the goats got sent away.? Main theme (diagnostic level): Aggression, directed at his mother Main hero: Child Main needs and drives of hero: Autonomy vs compliance, aggression Conception of environment as: Unnurturing Parental figures: Mother perceived as punitive, unnurturing Significant conflicts: Between superego and aggression, between environmental constraints (mother) and nurturance needs (a pet is desired to fill nurturance needs); between autonomy and compliance Nature of anxieties: Economic deprivation, nurturance needs (pet to substitute for insufficient maternal nurturance) Main defenses against conflicts and fears: Projection, fantasy, blocking Adequacy of superego, as manifested by punishment for crime being: Boy was shouted at and pet was sent away (adequate) Integration of the ego, manifesting itself in: Inadequate hero, unhappy and realistic outcome, poor drive control, thought processes as revealed by plot being inappropriate and concrete. Intelligence: High Maturational level: Average TAT Card 3GF ?Once upon a time, there was this lady, she had a daughter. One day, her daughter got sick, she fainted and died. Then, er, she was so sad that she, she, that she, er, er, lo, lost all her money cos she didn?t go to work, and d, and that?s the end.? Main theme (diagnostic level): Fears of maternal depression, and resulting physical deprivation. Fear of loss through death (possibly loss of mother/sister). Main hero: Mother Main needs and drives of hero: Need to be taken care of Conception of environment as: Dangerous, unstable, depriving Parental figures: Mother perceived as emotionally unstable Contemporary figures: Girl (sister perhaps): weak and sick, dies. Significant conflicts: Between environmental constraints (mother), and physical and nurturance needs Nature of anxieties: Economic deprivation Main defenses against conflicts and fears: Displacement (of fears of maternal death onto sister) and blocking Adequacy of superego, as manifested by punishment for crime being: Loss of all her money (too severe) Integration of the ego, manifesting itself in: Inadequate hero; unhappy, realistic outcome, poor drive control, thought processes as revealed by plot being appropriate, concrete. Intelligence: High Maturational level: Average TAT Card 4 ?Once upon a time, there was a man named James Bond. He had a wife and one day he had, and he, and he was a spy. And one day, he had to go and er, find, er, he had to go and find Skeleton Jack. He was the robber of the town. Then, he found him and in, he got paid a million Rand and he lived happily ever after!? Main theme (diagnostic level): Hero fantasy around economic ambition (may be similar fears to previous card) Main hero: Child Main needs and drives of hero: Need to be taken care of Conception of environment as: Dangerous Contemporary figures: Skeleton Jack: robber (dangerous) Significant conflicts: Between environmental constraints, and physical needs Nature of anxieties: Economic deprivation Main defenses against conflicts and fears: Fantasy Adequacy of superego, as manifested by punishment for crime being: None Integration of the ego, manifesting itself in: Adequate hero, happy and unrealistic outcome, poor drive control, thought processes as revealed by plot being appropriate and concrete. Intelligence: High Maturational level: Average TAT Card 5 ?Once upon a time, there was this man. His name was?called?James. And then he lived with his maid. And his maid, uh, oh, while it was looking out the window, he asked: What are you looking out the window for? I?m looking if there?s rain. How can you look if there, he said how can you look if there?s rain, y, there?s not even the one cloud in the sky. The, the end.? Main theme (diagnostic level): Fears of maternal depression and consequences thereof (same theme as Card 3GF) Main hero: Child Main needs and drives of hero: To prevent, or foretell, maternal depression (to have control over an unstable environment) Conception of environment as: Foreboding, unstable Parental figures: Mother: depressed, unstable Nature of anxieties: Maternal depression and its consequences Main defenses against conflicts and fears: Fantasy, intellectualisation Adequacy of superego, as manifested by punishment for crime being: None/unknown (story incomplete) Integration of the ego, manifesting itself in: Adequate hero, unhappy and realistic outcome, poor drive control, thought processes as revealed by plot being appropriate, incomplete and concrete. Intelligence: High Maturational level: Above average TAT Card 6BM ?Once upon a time, there was this man. He lived in town, OK? And he was the on?and then one day, these people came in and shot him, then the policeman caught them and they went to jail and the man?survived and then?one day?he died. The end. Quick hey?? Main theme (diagnostic level): Oedipal themes, possibly castration anxiety Main hero: Child Main needs and drives of hero: Aggression Conception of environment as: Dangerous, unstable Parental figures: Father may be policeman, or people who shot the hero Significant conflicts: Between superego and aggression Nature of anxieties: Physical injury Main defenses against conflicts and fears: Fantasy, undoing Adequacy of superego, as manifested by punishment for crime being: None/unknown (story incomplete) Integration of the ego, manifesting itself in: Adequate hero, unhappy and unrealistic outcome, good drive control, thought processes as revealed by plot being inappropriate and concrete. Intelligence: High Maturational level: Average TAT Card 7BM ?Once upon a time, there was this man. He lived with his father. His father was a actor. And then, one day, he, he got fired, his father. Then, he had to, he wanted to, er?go to an army, but he had to look after his father cos he was so old. Then, he?s, to make money, he decided, eh, to be a businessman, and he got 50 Grand. And then his father w, he got well again, and then he went to the army. Finished.? Main theme (diagnostic level): Hero fantasies around economic ambition and aggressive needs Main hero: Child Main needs and drives of hero: The need to be taken care of and aggression (wanting to join army) Conception of environment as: Unreliable, unnurturing Parental figures: Father: old & sick (inadequate) Significant conflicts: Between superego and aggression, and between autonomy and compliance Nature of anxieties: Deprivation Main defenses against conflicts and fears: Fantasy, intellectualisation Adequacy of superego, as manifested by punishment for crime being: Had to look after father and earn the money (too severe) Integration of the ego, manifesting itself in: Adequate hero, happy and realistic outcome, good drive control, thought processes as revealed by plot being inappropriate and concrete. Intelligence: High Maturational level: Above average TAT Card 7GF ?Once upon a time, there was this girl. She was so rich, co, and she lived with her mother. Her mother was the richest person in the world. And, and her name was Veruca Salt (a spoilt, rich girl character, from Johnny Depp?s movie, ?Charlie and the Chocolate Factory?). Then, uh, one day, she was looking, she got a new doll. And she was so happy, then, er, er, it broke, er, in, and then she was so sad that she actually fells down and fainted. The end.? Main theme (diagnostic level): Hero fantasies around economic ambition and nurturance needs Main hero: Child/sister Main needs and drives of hero: Physical needs and nurturance needs Conception of environment as: Unreliable Parental figures: Mother: unnurturing (gave girl faulty gift) Significant conflicts: Between physical and nurturance needs and environmental constraints (mother) Nature of anxieties: Economic deprivation, lack of maternal nurturance Main defenses against conflicts and fears: Fantasy, reaction-formation Adequacy of superego, as manifested by punishment for crime being: New doll broke (too severe) Integration of the ego, manifesting itself in: Inadequate hero, unhappy and unrealistic outcome, poor drive control, thought processes as revealed by plot being inappropriate and bizarre. Intelligence: High Maturational level: Average TAT Card 8BM ?Once upon a time, there was this boy. He, he lived with his father, then he, his father was sleeping and he was awake, then these two men killed his father. Then he had to live by himself, but before the robbers got away, he shot them. The end.? Main theme (diagnostic level): Hero fantasies around economic ambition and Oedipal ambivalence towards father Main hero: Child Main needs and drives of hero: Physical needs, nurturance needs, aggression Conception of environment as: Dangerous, unstable Parental figures: Father: inadequate Contemporary figures: Robbers: aggressive Significant conflicts: Between superego and aggression (Oedipal); between physical and nurturance needs and environmental constraints (father) Nature of anxieties: Physical deprivation, lack/loss of paternal nurturance Main defenses against conflicts and fears: Projection, fantasy, acting-out, undoing Adequacy of superego, as manifested by punishment for crime being: None (inadequate) Integration of the ego, manifesting itself in: Adequate hero, unhappy and unrealistic outcome, poor drive control, thought processes as revealed by plot being inappropriate. Intelligence: High Maturational level: Average TAT Card 9BM ?Once upon a time, there was this boy. His father went to sleep and left the boy all alone. The end.? Main theme (diagnostic level): Fear of paternal death/abandonment Main hero: Child Main needs and drives of hero: Need to be taken care of Conception of environment as: Unstable, depriving Parental figures: Father: inadequate (abandons boy) Significant conflicts: between physical and nurturance needs and environmental constraints (father) Nature of anxieties: Physical deprivation, lack/loss of paternal nurturance Main defenses against conflicts and fears: Displacement Adequacy of superego, as manifested by punishment for crime being: Being left all alone (too severe) Integration of the ego, manifesting itself in: Adequate hero, unhappy and unrealistic outcome, poor drive control, thought processes as revealed by plot being inappropriate and concrete. Intelligence: High Maturational level: Average TAT Card 10 ?I don?t know any story for this one.? TAT Card 11 ?Once upon a time, eh, there was this man. He, he started to go inside the most dangerous cave where there was a dragon. Bu, but then he went inside, it was two bulls and the dragon didn?t eat him because he was special. And, and so he got out safely with bags of gold. End.? Main theme (diagnostic level): castration anxiety, and economic ambition Main hero: Child Main needs and drives of hero: Oedipal wishes, and a need to be taken care of Conception of environment as: Dangerous, unpredictable Parental figures: Father (dragon): inadequate Significant conflicts: Between superego and Oedipal sexual/nurturance needs; between environmental constraints (father) and physical (economic) needs Nature of anxieties: Physical deprivation, physical injury Main defenses against conflicts and fears: Fantasy Adequacy of superego, as manifested by punishment for crime being: None (too lenient) Integration of the ego, manifesting itself in: Adequate hero, happy and unrealistic outcome, poor drive control, thought processes as revealed by plot being inappropriate and bizarre. Intelligence: High Maturational level: Average TAT Card 12M ?Once upon a time, there was this man. He was in bed and he never got out, he was so tired. Then one day, this angel came and blessed him and then he walked again. The end.? Main theme (diagnostic level): Fear of paternal abandonment/death, lack of paternal nurturance Main hero: Child/father (if child, father is fantasised as an angel, who can nurture and cure him; if father, child is fantasy angel, who can cure his father) Main needs and drives of hero: Need to be taken care of Conception of environment as: Unstable and unpredictable Significant conflicts: Between environmental constraints (father) and nurturance needs Nature of anxieties: Lack/loss of paternal nurturance Main defenses against conflicts and fears: Fantasy Adequacy of superego, as None manifested by punishment for crime being: Integration of the ego, manifesting itself in: Adequate hero, happy and unrealistic outcome, poor drive control, thought processes as revealed by plot being appropriate. Intelligence: High Maturational level: Average TAT Card 13MF ?Once upon a time, there was this man. He was a vampire. He married his wife, then one night, he sucked all her blood out and he cried. And then, then he, duh, told the police that someone killed them. The end.? Main theme (diagnostic level): Oedipal wish to have sex with his mother, but knowing that it is socially unacceptable and punishable Main hero: Child Main needs and drives of hero: Oedipal sexual drives, oral aggression Conception of environment as: Not permissive towards his aggression, expecting of higher moral standards Parental figures: Mother: ambivalence towards her Significant conflicts: Between superego and oral aggressive drives Nature of anxieties: Punishment/castration anxiety Main defenses against conflicts and fears: Fantasy, reaction-formation, regression to oral stage, acting-out Adequacy of superego, as manifested by punishment for crime being: Feeling sad (crying) (inappropriate, far too lenient) Integration of the ego, manifesting itself in: Inadequate hero, unhappy and unrealistic outcome, poor drive control, thought processes as revealed by plot being inappropriate and bizarre. Intelligence: High Maturational level: Above average TAT Card 13B ?Once upon a time, there was this boy. He lived by himself in a cottage. The one day, uh, his father found him, then they, then he lived happily ever after with his father.? Main theme (diagnostic level): Wish fulfilment: to be emotionally close to, and acknowledged by, his father Main hero: Child Main needs and drives of hero: Need to be taken care of Conception of environment as: Unpredictable Parental figures: Father: absent, then appears as the rescuer Significant conflicts: Between environmental constraints (father) and nurturance needs Nature of anxieties: Lack of nurturance, physical deprivation Main defenses against conflicts and fears: Fantasy Adequacy of superego, as manifested by punishment for crime being: None Integration of the ego, manifesting itself in: Adequate hero, happy and unrealistic outcome, good drive control, thought processes as revealed by plot being appropriate. Intelligence: High Maturational level: Average TAT Card 14 ?Once upon a time, there was this black man. He was so black that not, even at night you couldn?t see him. Then one day, he came into this room that was just plain white, and he became a human. The end.? Main theme (diagnostic level): Wish fulfilment: to be seen, acknowledged and healed of badness Main hero: Child Main needs and drives of hero: Nurturance needs (love and accepted) Conception of environment as: Unpredictable Significant conflicts: Between environmental constraints and nurturance needs Nature of anxieties: Lack of nurturance Main defenses against conflicts and fears: Fantasy Adequacy of superego, as manifested by punishment for crime being: None Integration of the ego, manifesting itself in: Adequate hero, happy and unrealistic outcome, good drive control, thought processes as revealed by plot being inappropriate and bizarre. Intelligence: High Maturational level: Average TAT Card 17BM ?Once upon a time, there was this man. He was so strong, but he couldn?t break a rope. Then one day, he was climbing up this rope. He, he broke it and he fell down and he became a dwarf. The end.? Main theme (diagnostic level): Wish fulfilment: to be physically strong Main hero: Child Main needs and drives of hero: Nurturance needs Conception of environment as: Unpredictable, dangerous Significant conflicts: Between environmental constraints and nurturance needs Nature of anxieties: Lack of nurturance Main defenses against conflicts and fears: Fantasy, reaction-formation Adequacy of superego, as manifested by punishment for crime being: Becoming a dwarf (too severe) Integration of the ego, manifesting itself in: Inadequate hero, unhappy and unrealistic outcome, poor drive control, thought processes as revealed by plot being inappropriate and bizarre. Intelligence: High Maturational level: Average TAT Card 18BM ?Once upon a time, there was this man. He got kidnapped, then, but he?s, but then he, er, he escaped and he told the police that, that these men took him. And then the, they went to jail and he lived happily ever after.? Main theme (diagnostic level): Fears of attack, of a homosexual nature Main hero: Child Main needs and drives of hero: Homosexual drives Conception of environment as: Unpredictable, dangerous Contemporary figures: Kidnappers: punitive Police: helpful Significant conflicts: Between homosexual drives and fears Nature of anxieties: Injury Main defenses against conflicts and fears: Fantasy, undoing Adequacy of superego, as manifested by punishment for crime being: None Integration of the ego, manifesting itself in: Adequate hero, happy and realistic outcome, good drive control, thought processes as revealed by plot being appropriate. Intelligence: High Maturational level: Average TAT Card 19 ?Once upon a time, there was this woman, who lived in a snow house. She had two children. And the one was named Cinderella. The other one was so rude to her. But then one day, sha, the rude one went down to the ocean and then, the, she fell in the water and drowned. The, the other girl lived happily ever after, in the house?. Main theme (diagnostic level): Feeling that his mother rejects him, and wishes him dead. Drowning may relate to his mother?s depression Main hero: Child Main needs and drives of hero: Need to be taken care of, nurturance Conception of environment as: Unpredictable, dangerous Parental figures: Mother: unnurturing Contemporary figures: Sister: rejoices in his death (selfish, unnurturing) Significant conflicts: Between environmental constraints (mother) and nurturance needs Nature of anxieties: Lack/loss of maternal affection, maternal depression and its consequences; sibling rivalry Main defenses against conflicts and fears: Regression Adequacy of superego, as manifested by punishment for crime being: Death (too severe) Integration of the ego, manifesting itself in: Inadequate hero, unhappy and unrealistic outcome, poor drive control, thought processes as revealed by plot being inappropriate and bizarre. Intelligence: High Maturational level: Average APPENDIX Y SUBJECT C (?Jane?) D-A-P 1 QUESTIONS & ANSWERS Q: What are you doing? A: Standing and looking at the sun. Q: What makes you happy? A: The sun and all the flowers?and I love smelling flowers. Q: What makes you feel sad? A: Um?nothing. Q: What do you like doing the most? A: Drawing and playing and to go?going to Durban. Q: What do you not like doing? A: I don?t like fighting and swearing. Q: What is the best thing about you? A: Playing. Q: What is the worst thing about you? A: Um?uh?nothing. Q: If you were an animal, what would you like to be? A: Tiger. Q: Why? A: Because tigers are strong. Q: What do you do on the weekends? A: I like going to Durban and going?l?lot of places and going to the zoo, going to Mauritius and all that stuff. If you say: let?s go to the zoo; I will?mmm?to the car and get in the car! Q: Who is your favourite person? A: Um, my cousin, Mary. I like my cousin because she plays with me. I drawed a picture like this of her at home and I take it with me when I go somewhere?it sleeps with me. I don?t bath it, because it gets wet. Put it in the shower in a place where it?s not wet and keep on waving to her. Q: Who is the person you don?t like? A: Playing in the street, cars can bump me. Fighting, swearing, hitting her sister. Snakes?yesterday, my sister brought another snake at home, it?s only a toy one and when you put it down, it shakes. Me and my mother scared of it and so my father threw it away. A, b, c, d, e, f, g (sung softly). Q: What do you do when you are being good? A: I takes Mary to shops and she plays and I help with her homework and I take her to sleep and she likes a hug and, when I sleep, I hug her. Sometimes, my brother takes her and he brings her to me and she hugs me. Q: What do you do when you?re being bad? A: I hit her and shout at her. When I shout at her, she cries. I like to draw tears on her and then I?m gonna rub them out. Q: If you were invisible, what would you like to do? A: She would like to scare me and I wouldn?t know where?s Mary. APPENDIX AA SUBJECT C (?Jane?) D-A-P 2 QUESTIONS & ANSWERS Q: Let?s give your person a name? A: Wilson. Q: What is ?Wilson? doing? A: In school. Q: What makes ?Wilson? happy? A: The sun and the Spidermans and butterflies. Q: What makes ?Wilson? sad? A: To fight and be ugly, to swear and he hits, um, his sister. Q: What does ?Wilson? like doing the most? A: Going to school and playing with his sister. Mary is his sister. Q: What does ?Wilson? not like doing? A: Fighting with his sister. But his sister doesn?t like and when Wilson hits his sister, she cries and she hits him back and I shout at them. It makes me angry when they fight, cos some of them get hurt. I like gyming and running with them and I run fast with them and I like to hold their hands and run fast and I just make them open their mouths like they?re laughing. Q: What is the best thing about ?Wilson?? A: I don?t know. Q: What is the worst thing about ?Wilson?? A: Fighting with his sister. Q: If ?Wilson? were an animal, what would he like to be? A: Elephant. Q: Why? A: Cos an elephant makes noise. He likes noise and me and his sister doesn?t like noise. Q: Would you like to be ?Wilson?? A: No. Q: What does ?Wilson? do on the weekends? A: Nothing?I just take him to zoo. My father takes me, Mary and Wilson to the zoo and my brother, my father and my mother?a, b, c, d, e, f, g?(sung softly). Q: Who is ?Wilson? ?s favourite person? A: It?s me. Q: Who is the person ?Wilson? doesn?t like? A: His sister. Q: What does ?Wilson? do when he?s being good? A: I ask my father to take us to MacDonald?s and I take them with and my father takes us. I like going to MacDonald?s cos you play and you have fun and it?s so close to my house, so I can even walk Wilson and Mary there with my brother. Q: What does ?Wilson? do when he?s being bad? A: He shouts at me and I say: Stop it, else you?ll go to bed. And, he likes going to bed, cos it?s so warm in the blankets. In here, it?s cold and I like it cos you get fresh air and all that stuff. Q: If ?Wilson? were invisible, what would he like to do? A: He?d like to call me and he?d like to take his sister to school. Q: Does ?Wilson? remind you of anyone? A: I don?t know. APPENDIX CC SUBJECT C (?Jane?) K-F-D QUESTIONS & ANSWERS Q: Can you tell me who each person is, and what they are doing? A: (From left to right): This is my mother. My mother?s writing. This is my father. This is the chair. I don?t know how to draw a chair. My father, writing. This is me?I am in my reading dress and I?m wearing my boots. I am playing, I?m playing hide and seek and here?s the box which I shake. Q: What is the one best thing about this family? A: I don?t know. Q: What is the one worst thing about this family? A: The worstest thing is?I have no idea. Q: What things does this family do together? A: They mm, like to play and do all that stuff. I forgot? Q: If you could change one thing about this family, what would it be? A: I would change the house and I would change the beds and the dishes and the cars. That?s all. Q: Who is the favourite person in this family? A: Uh, no-one. My favourite is my little cousin, but my cousin?s bigger than me?ten years old and when I go to to see her, I play with her. Q: How does everyone in this family get along? A: Ja?it?s only my brother doesn?t like me and I don?t like him too?must I tell you the name? He?s the worst, worst brother in the world. He makes me so, so sad?cos sometimes I fight with him. Q: How does your mom feel about herself? A: Don?t know how she feels about herself, cos my mother hasn?t told me. I?m gonna ask her. I think she feels so happy. Q: How does your dad feel about himself? A: He thinks happy. Q: How do you feel about yourself? A: I just feel sad?it?s just because a lot of people dying has made me so sad. APPENDIX DD SUBJECT C (?Jane?) TAT TRANSCRIPT AND SHORT FORM FOR RECORDING AND ANALYZING TAT (ADAPTED FROM BELLAK, 1975) TAT Card 1 ?The boy is reading?and, and the boy saw pictures, beautiful pictures?he was gyming before he was reading. He feels sad. I don?t know why.? Main theme (diagnostic level): Depression and loneliness Main hero: Child Main needs and drives of hero: Reassurance and achievement Conception of environment as: Lonely, unsupportive Nature of anxieties: Loneliness and sadness Main defenses against conflicts and fears: Isolation Integration of the ego, manifesting itself in: Inadequate hero, unhappy and unrealistic outcome, good drive control, thought processes as revealed by plot being appropriate and concrete. Intelligence: Average Maturational level: Average TAT Card 2 ?I dunno a story for this one.? TAT Card 3BM ?The lady?s crying.? Main theme (diagnostic level): Depression Conception of environment as: Lonely, unsupportive Nature of anxieties: Loneliness and sadness Main defenses against conflicts and fears: Regression TAT Card 3GF ?The girl?s crying. Maybe she?s fell. She?s gonna tell her mother.? Main theme (diagnostic level): Depression Main hero: Child Main needs and drives of hero: Reassurance Conception of environment as: Unhappy Parental figure (mother) seen as: Nurturing Main defenses against conflicts and fears: Regression Adequacy of superego, as manifested by punishment for crime being: Physical injury (severe) Integration of the ego, manifesting itself in: Adequate hero; happy and realistic outcome; poor drive control; thought processes as revealed by plot being appropriate and concrete. Intelligence: Average Maturational level: Low TAT Card 4 ?The lady?s looking at this man and holding him.? Main theme (diagnostic level): Need for nurturance Main hero: Child Main needs and drives of hero: Reassurance Intelligence: Average Maturational level: Low TAT Card 5 ?The lady opens the door and the lady looks inside when there?s anyone. And she?s gonna get in?she?s gonna find flowers.? Main theme (diagnostic level): Concern over being observed by mother Main hero: Child Main needs and drives of hero: Fears of being observed (possibly related- related or Oedipal fantasy) Conception of environment as: Invasive Parental figure (mother) seen as: Invasive, threatening Significant conflicts: Possibly Oedipal id versus superego Nature of anxieties: Disapproval Main defenses against conflicts and fears: Reaction-formation Intelligence: Average Maturational level: Low TAT Card 6GF ?This other man?s talking to the lady. I don?t know about what.? Main theme (diagnostic level): Distance in relationship with father Main hero: Child Main needs and drives of hero: Emotional closeness to father Parental figure (mother) seen as: Distant Nature of anxieties: Sense of isolation Intelligence: Average Maturational level: Low TAT Card 7GF ?The girl?s sad and the girl?s looking somewhere and the mother?s doing something?writing. The girl?s gonna cry.? Main theme (diagnostic level): Depression Main hero: Child Main needs and drives of hero: To be taken care of, nurtured, and supported Conception of environment as: Unsupportive Parental figures seen as Unsupportive, unreceptive Nature of anxieties: Sadness and loneliness Adequacy of superego, as manifested by punishment for crime being: Ignored by mother (too severe) Integration of the ego, manifesting itself in: Adequate hero; unhappy and realistic outcome; poor drive control; thought processes as revealed by plot being appropriate and concrete. Intelligence: Average Maturational level: Low TAT Card 9GF ?They running away from the water.? Main theme (diagnostic level): Depression Main hero: Child Conception of environment as: Scary Intelligence: Average Maturational level: Low TAT Card 10 ?The lady?s praying and the man?s also praying. They both pray to G-d?for a car.? Main theme (diagnostic level): Physical needs of family Main hero: Parents Main needs and drives of hero: To be taken care of Conception of environment as: Unsupportive Parental figures seen as Dyad; helpless Nature of anxieties: Economic needs of family Main defenses against conflicts and fears: Fantasy Integration of the ego, manifesting itself in: Adequate hero; unhappy and realistic outcome; poor drive control; thought processes as revealed by plot being appropriate and concrete. Intelligence: Average Maturational level: Low TAT Card 11 ?I dunno what?s this. Um, it?s in a bush and there?s a tree there and a way there?someone?s gonna come and someone?s gonna see these? . Main theme (diagnostic level): Fear of being observed, paranoia Conception of environment as: Foreboding, confusing Nature of anxieties: Fear of being observed Main defenses against conflicts and fears: Reaction-formation Integration of the ego, manifesting itself in: Adequate hero; unhappy and unrealistic outcome; poor drive control; thought processes as revealed by plot being inappropriate and concrete. Intelligence: Average Maturational level: Low TAT Card 12F ?This other lady?s talking to her, because she?s sad.? Main theme (diagnostic level): Depression, possibly maternal Main hero: Child/mother Main needs and drives of hero: To be taken care of, nurtured, and supported Conception of environment as: Unhappy Contemporary/parental figures seen as: Supportive, receptive Nature of anxieties: Sadness Intelligence: Average Maturational level: Low TAT Card 13MF ?The man?s crying and the lady?s sleeping. Maybe the man can?t find his shoes or something.? Main theme (diagnostic level): Depression, possibly paternal Main hero: Father Main needs and drives of hero: To be taken care of, nurtured, and supported Conception of environment as: Unsupportive Contemporary figures seen as: Mother seen as unreceptive Nature of anxieties: Sadness, economic concerns Main defenses against conflicts Regression, rationalization and fears: Intelligence: Average Maturational level: Low TAT Card 13B ?The boy?s sitting outside in, by the door and it?s looking. The boy?s looking outside at the sun and the boy?s sad. Maybe, um, someone hit him.? Main theme (diagnostic level): Depression Main hero: Child Main needs and drives of hero: To be taken care of, nurtured, and supported Conception of environment as: Unsupportive/punitive Parental figures seen as Punitive Nature of anxieties: Physical injury, sadness, and loneliness Intelligence: Average Maturational level: Low TAT Card 14 ?The man?the man is looking out of the window?cos he?s looking at the moons and the stars. And he?s seen and he looks at the dark outside. He feels?ah?happy.? Main theme (diagnostic level): Aloneness Main hero: Child Main needs and drives of hero: To be seen and acknowledged Conception of environment as: Happy, but lonely Nature of anxieties: Loneliness Main defenses against conflicts and fears: Reaction-formation Intelligence: Average Maturational level: Low TAT Card 17GF ?The lady?s crying and she?s looking for her house. She?s walking down the stairs.? Main theme (diagnostic level): Depression Main hero: Child Main needs and drives of hero: To be taken care of, nurtured, and supported Conception of environment as: Unstable, confusing Nature of anxieties: Sadness and loneliness Main defenses against conflicts and fears: Regression Intelligence: Average Maturational level: Low TAT Card 18GF ?The lady?s crying and this other lady?s sleeping. And, and the lady?s looking at this other lady and this other lady?s holding this other lady.? Main theme (diagnostic level): Depression Main hero: Child/mother Main needs and drives of hero: To be taken care of, nurtured, and supported Conception of environment as: Unhappy Contemporary/parental figures seen as: Unnurturing Nature of anxieties: Sadness and loneliness Main defenses against conflicts and fears: Regression Intelligence: Average Maturational level: Low TAT Card 19 ?I dunno. What?s this? Um snow. It might be snows there and there?s snow there covering and snow there and it?s raining.? Main theme (diagnostic level): Depression Conception of environment as: Cold Intelligence: Average Maturational level: Low APPENDIX FF SUBJECT D (?Anne?) D-A-P 1 QUESTIONS & ANSWERS Q: What are you doing? A: I?m picking so much flowers. Now, I?m gonna draw another flower . I?m being a flower girl. Q: What makes you happy? A: Sweeties in a bowl. Must I draw the sweeties? Can I colour in the petals? I?m picking the flowers and now I?m eating my sweeties. I?ve got 150 sweets in there, gonna draw 2 bowls, 3 bowls of sweeties. Do you like the lips? Now, I?m drawing teeth and the tongue. Q: What makes you feel sad? A: If Mommy takes my sweets away. Q: What do you like doing the most? A: Drawing. Q: What do you not like doing? A: Going to school. Q: What is the best thing about you? A: The heart. Q: What is the worst thing about you? A: When my mommy?s sad. Q: If you were an animal, what would you like to be? A: Lion, a girl lion. Q: Why? A: Because then, cos my favourite animal?s a lion. Because I?ve seen them a lot and I like how they run. Q: What do you do on the weekends? A: Baking with my Auntie Joan and Lauren, going to Lauren?s house and my friends? houses. Q: Who is your favourite person? A: Mommy and Daddy. And Betty, my nanny. Q: Who is the person you don?t like? A: Josephine, my grandpa?s maid. Because, I don?t know why. Q: What do you do when you are being good? A: Do everything that my mommy says. Q: What do you do when you?re being bad? A: Don?t do what my mommy says?and my daddy. Q: If you were invisible, what would you like to do? A: Give people a fright. APPENDIX HH SUBJECT D (?Anne?) D-A-P 2 QUESTIONS & ANSWERS Q: Let?s give your person a name? A: Daddy. Q: What is ?Daddy? doing? A: He?s being a flower boy?la, la, la. Q: What makes ?Daddy? happy? A: Um um ?just G-d. Q: What makes ?Daddy? sad? A: Um?no G-d. Q: What does ?Daddy? like doing the most? A: Being, mm, being with me. Q: What does ?Daddy? not like doing? A: Not being with me and not working. Q: What is the best thing about ?Daddy?? A: His hair, cos I like what his hair looks like. Q: What is the worst thing about ?Daddy?? A: Um, how, um, how he, he bee?s ugly?that?s it. Q: If ?Daddy? were an animal, what would he like to be? A: A lion. Q: Why? A: Because it?s his favourite animal. Me and my daddy have the same favourite animal. Q: Would you like to be ?Daddy?? A: Um, a lion? No! Cos I don?t wanna be a boy, cos boys fight too much. Q: What does ?Daddy? do on the weekends? A: Mm, not work. Q: Who is ?Daddy?s??s favourite person? A: Um, me and Mommy. Q: Who is the person ?Daddy? doesn?t like? A: I don?t know. Q: What does ?Daddy? do when he?s being good? A: Being nice to people. Q: What does ?Daddy? do when he?s being bad? A: Not be nice. Q: If ?Daddy? were invisible, what would he like to do? A: Give people a shock. APPENDIX JJ SUBJECT D (?Anne?) K-F-D QUESTIONS & ANSWERS Q: Can you tell me who each person is, and what they are doing? A: (From left to right): This one?s Daddy, holding hearts. This one?s me, holding stars and butterflies. This one?s Mommy, holding flowers. I?ll give Mommy a bigger, smiley face . Q: What is the one best thing about this family? A: That we holding something nice. Q: What is the one worst thing about this family? A: The worstest thing is?I have no idea. Nothing?actually, um, when I get punishment. I?m just doing hair now . She?s got funny hair now, look at her. You know why I did her hair like that? Cos I wanna decorate it with hearts . Daddy?s got curly hair. Q: What things does this family do together? A: Feed their animals, like Catty and Doggy. Q: If you could change one thing about this family, what would it be? A: Um?being poor?nothing else. Q: Who is the favourite person in this family? A: Me! Q: How does everyone in this family get along? A: Well . Q: How does your dad feel about himself? A: Feels nice about himself. Q: How does your mom feel about herself? A: Nice. Q: How do you feel about yourself? A: Nice. APPENDIX KK SUBJECT D (?Anne?) TAT TRANSCRIPT AND SHORT FORM FOR RECORDING AND ANALYZING TAT (ADAPTED FROM BELLAK, 1975) TAT Card 1 ?Is this a girl or a boy? It?s a girl! I?m still thinking about the story . I?m thinking. I think I came up with a idea . This little girl was watching TV and it was a cartoon. That?s all it is. Here?s your card back.? Main theme (diagnostic level): Need for nurturance Main hero: Child Main needs and drives of hero: Need for nurturance Nature of anxieties: Sense of loneliness Intelligence: High Maturational level: Average TAT Card 2 ?That?s a girl here and she?s going to school. She?s taking all her books for activities?but she doesn?t want to go to school. That?s it.? Main theme (diagnostic level): School-related anxiety Main hero: Child Conception of environment as: Unhappy Parental figures seen as Potentially punitive Significant conflicts: Between autonomy and compliance Nature of anxieties: Parental disapproval, and anxieties related to school Integration of the ego, Adequate hero; unhappy, realistic outcome; manifesting itself in: good drive control; thought processes as revealed by plot being appropriate, and concrete. Intelligence: High Maturational level: Average TAT Card 3BM ?OK?this lil girl was brushing her teeth and after she brushed her teeth, she went to bed and dreamed of a horrible dream, and after the horrible dream, she felt better, cos it was the morning. And she said: No, no. Finished!? Main theme (diagnostic level): Oral aggression Main hero: Child Main needs and drives of hero: Behavioural needs of child (aggression) Conception of environment as: Unpredictable and scary Significant conflicts: Between superego and aggression (id) Nature of anxieties: Being overpowered and helpless. Main defenses against conflicts and fears: Displacement and undoing (aggressive feelings/thoughts are directed back at the self); regression. Adequacy of superego, as manifested by punishment for crime being: Nightmare (too severe). Integration of the ego, manifesting itself in: Adequate hero; happy, realistic outcome; poor drive control; thought processes as revealed by plot being original, inappropriate, and concrete. Intelligence: High Maturational level: Average TAT Card 3GF What is this one?I don?t know what it is. What was your story, if you had to do the activity? I?m gonna test you after. What can I use to do it? This girl was hanging on the pole and she was going somewhere?that?s it. Main theme (diagnostic level): Depression (?The girl was hanging on the pole and she was going somewhere?) Main hero: Child Main defenses against conflicts and fears: Controlling, displacement Integration of the ego, manifesting itself in: Adequate hero; unrealistic outcome; poor drive control; thought processes as revealed by plot being inappropriate and concrete. Intelligence: High Maturational level: Average TAT Card 4 ?The man and lady are fighting. He?s angry with her and she said no fighting, and she?s sad. But, now she?s happy again.? Main theme (diagnostic level): Parental conflict Main hero: Child Main needs and drives of hero: May be projection of child?s aggression and ambivalence (Oedipal) Conception of environment as: Ambivalent, conflicted Parental figures seen as Conflicted Significant conflicts: Between superego and aggression (id) Nature of anxieties: Disapproval, and being overpowered and helpless. Main defenses against conflicts and fears: Projection, acting-out, undoing Adequacy of superego, as Sadness (severe) manifested by punishment for crime being: Integration of the ego, manifesting itself in: Inadequate hero; happy, unrealistic outcome; poor drive control; thought processes as revealed by plot being appropriate and concrete. Intelligence: High Maturational level: Low TAT Card 5 ?There?s flowers in the room and the lady?s checking that everything?s OK. Finished.? Main theme (diagnostic level): Checking (may be compulsive checking) Main hero: Mother Parental figures (mother) seen as Invasive/obsessive Nature of anxieties: Anxiety over being observed by mother Main defenses against conflicts and fears: Projection (perhaps of own compulsive checking) Integration of the ego, manifesting itself in: Adequate hero; happy, realistic outcome; poor drive control; thought processes as revealed by plot being stereotyped, appropriate, concrete and incomplete Intelligence: High Maturational level: Low TAT Card 6GF ?The lady?s trying to read, but the man?s trying to talk with her.? Main theme (diagnostic level): Communication difficulties between parents Main hero: Child/mother Main needs and drives of hero: Perhaps repressed aggression towards father Parental figures seen as Disconnected from each another Main defenses against conflicts and fears: Projection Intelligence: High Maturational level: Average TAT Card 7GF ?The little girl?s got a doll?a baby doll?and her mommy?s trying to talk to her, but she?s too angry to talk to her mom. That?s all.? Main theme (diagnostic level): Passive-aggression directed at mother Main hero: Child Main needs and drives of hero: Behavioural needs of child (aggression) Parental figures seen as Infuriating Significant conflicts: Between superego and aggression (id) Nature of anxieties: Anger at mother Main defenses against conflicts and fears: Isolation Integration of the ego, manifesting itself in: Inadequate hero; unhappy, unrealistic, outcome; poor drive control; thought processes as revealed by plot being appropriate and concrete Intelligence: High Maturational level: Low TAT Card 9GF ?The girl and her mommy are on holiday, running on the beach?they gonna build sand castles! Like I?at the beach, I love that and swimming!? Main theme (diagnostic level): A sense of connectedness with mother Main hero: Child Conception of environment as: Nurturing Parental figures (mother) seen as Nurturing Integration of the ego, manifesting itself in: Adequate hero; happy, realistic outcome; good drive control; thought processes as revealed by plot being original, appropriate and concrete. Intelligence: High Maturational level: Average TAT Card 10 ?The mommy and daddy were fighting, but now they made-up and they hugging. Finished.? Main theme (diagnostic level): Conflict and ambivalence, between parents Main hero: Parents Parental figures seen as Conflicted Nature of anxieties: Conflict between parents Main defenses against conflicts and fears: Acting-out, and undoing Intelligence: High Maturational level: Average TAT Card 11 ?There?s an angry dragon in the jungle and he?s looking for something to fight with. Maybe another animal.? Main theme (diagnostic level): Aggression, projected onto father Main hero: Dragon (father) Main needs and drives of hero: Behavioural needs of child (aggression) Parental figures (father) seen as Angry and aggressive Significant conflicts: Between superego and aggression (id) Nature of anxieties: Physical harm/attack Main defenses against conflicts and fears: Acting-out, fantasy, projection Adequacy of superego, as manifested by punishment for crime being: None (inadequate). Integration of the ego, manifesting itself in: Inadequate hero; bizarre outcome; poor drive control; thought processes as revealed by plot being original, appropriate, and concrete. Intelligence: High Maturational level: Low TAT Card 12F ?This old lady is very old and the young lady is a princess.? Main theme (diagnostic level): Feeling of disconnectedness from mother Main hero: Child Main needs and drives of hero: Nurturance Parental figures (mother) seen as: Distant Intelligence: High Maturational level: Low TAT Card 13MF ?The lady?s sleeping, maybe she?s dead and he?s killed her. But, he?s sorry that he did that and he?s crying now. But, she?s not really dead.? Main theme (diagnostic level): Aggression and ambivalence towards mother (Oedipal) Main hero: Father Main needs and drives of hero: Aggression, projected onto father Conception of environment as: Unpredictable, confusing Parental figures (father) seen as: Aggressive, threatening, ambivalent Significant conflicts: Between superego and aggression (id) Nature of anxieties: Physical harm/punishment, and being overpowered and helpless. Main defenses against conflicts and fears: Acting-out, fantasy, undoing, projection, regression Adequacy of superego, as manifested by punishment for crime being: Sadness (inadequate) Integration of the ego, manifesting itself in: Inadequate hero; unhappy, unrealistic, bizarre outcome; poor drive control; thought processes as revealed by plot being inappropriate, concrete and contaminated. Intelligence: High Maturational level: Low TAT Card 13B ?The little boy?s poor and he doesn?t have anywhere else to live?but, only in a shack, where there?s no food to eat even. That?s all.? Main theme (diagnostic level): Economic and nurturance concerns Main hero: Child Main needs and drives of hero: Need to be taken care of Conception of environment as: Depriving Nature of anxieties: Economic and nurturance concerns Main defenses against conflicts and fears: Projection Intelligence: High Maturational level: Average TAT Card 14 ?The man is checking before he puts on the alarm. It?s night time and he?s gonna turn the alarm on, before he goes to sleep. He should put it on, hey?? Main theme (diagnostic level): Anxiety/Paranoia (fears of darkness/attack) Main hero: Father Main needs and drives of hero: Fear of physical injury, and of being overwhelmed and helpless; need to be taken care of Conception of environment as: Scary Parental figures seen as Protector, although inadequate Nature of anxieties: Night time fears Intelligence: High Maturational level: Average TAT Card 17GF ?There?s a big, old building and a bright sun. The lady?s watching the river and she?s really worried. That?s it.? Main theme (diagnostic level): Anxiety and depression Main hero: Child Conception of environment as: Distressing Main defenses against conflicts and fears: Isolation Intelligence: High Maturational level: Average TAT Card 18GF ?The ladies are fighting with each other, but they are very, so sad for being fighting. Cos they don?t like to be ugly.? Main theme (diagnostic level): Ambivalence and aggression, possibly in relationship with mother (Oedipal) Main hero: Child Main needs and drives of hero: Oedipal aggression and ambivalence towards mother Parental figures seen as Ambivalent Significant conflicts: Between superego and aggression (id) Nature of anxieties: Maternal punishment and disapproval Main defenses against conflicts and fears: Acting-out, undoing Adequacy of superego, as manifested by punishment for crime being: Feeling sad (adequate) Integration of the ego, manifesting itself in: Adequate hero; happy, realistic outcome; poor drive control; thought processes as revealed by plot being appropriate, and concrete. Intelligence: High Maturational level: Average TAT Card 19 ?This, this is overseas, where it?s snowing and really cold. I think there?s a monster outside?I think they scared of the monster, so they staying inside. That?s a good idea, don?t you think?? Main theme (diagnostic level): Fear of attack Main needs and drives of hero: Need to be taken care of Conception of environment as: Scary Nature of anxieties: Physical harm, and being overpowered and helpless. Intelligence: High Maturational level: Average APPENDIX LL INTERPRETATIVE THEMES Hypersensitive child Emotionally oversensitive Neurotic predisposition Intense personality Trigger event EXCESSIVE ANXIETY OCD Social isolation Comorbid disorders Depression & learning problems Low self- esteem Genetic predisposition to psychopathology (especially depression and anxiety disorders and/or OCD) Family difficulties Emotional immaturity (oral and anal fixation, poor impulse control) Failure to resolve Oedipus complex Regressed sex drives & conflict with sexuality Aggressive impulses Aggression Emotional maladjustment Disturbed superego (harsh or neurotic)