The case examines how SIS and Rorschach imagery project with past painful body events. The three tests were administered, and the interpretation of the tests is discussed at length. An adult female was referred to a internist for pain management by a physician. She had a history of severe recurrent migraine headaches. The referring physician was concerned about her intake of analgesic medication (Demerol). It was the internist’s impression that she was experiencing psychological stress because she had moved to a new state. When initially interviewed, she said that her painful headaches indeed seemed worse ever since she moved to a new place. She, however, denied mental problems. Mental status examination revealed an intelligent, middle-aged woman with some hysterical features but who was essentially intact. She showed no gross evidence of thought disorder and denied auditory hallucinations. Initial diagnostic impression was conversion hysteria with migraine headaches exacerbated by the stress of moving to a new place. The treatment plan specified psychotherapy to improve her coping skills and to reduce stress, and hypnotherapy for pain control. She avoided the spinal content, instead seeing a ‘screw on top of an awl’, a disguised phallic symbolism. Moreover, she may have repressed the spine as well. She did not want to be independent and stand on her own. An awl is a tool to make holes in leather or wood. Finally, near the top, she projected another eye, perseverating this theme.

B17: She gave a normal response ‘a wrench’. Her second association, ‘a carnivorous sea creature’, reflected symbolically her negative view of phallic imagery. An oral aggressive quality is clear.

B19: She saw ‘a sunny day or intense passion’. This is a positive response associating the sun with warmth and emotion. She expressed herself as the one who is capable of passion generally but not directly or overtly sexual; love more than sex.

B20: Mostly, this is seen as the brain but she saw ‘an atomic explosion’. Her defensive symbolism served to repress her brain, an area she associated with her inner turmoil.

An atomic explosion suggests the magnitude of her rage as in A18. Her second level of imagery came closer to reality structure in that she saw ‘a wig on a Styrofoam headstand with a rose attached’. She allowed herself to see a head but not a brain. Her dream content suggested some degree of splitting that subjectively noted her anxious brain fixation. Her response to B4 evidenced a cognitive disorder. Her response to B21 was consistent with her aggressive feeling and previously detected catharsis of guns.

B12: She saw ‘a gun that has exploded’.

B22: She saw ‘a person dead in the middle of the road’. It was consistent with the theme of body destruction and helplessness.

B23: Instead of seeing anatomical chest structure, she saw ‘a ladybug, she has broken the rifle of a would-be killer’. The response of a diminutive female figure (ladybug) with the power to break an attacker’s rifle (phallus?) is a strongly defensive symbolism. It reinforces the optimism and positive orientation of a rifle.

B24: She saw ‘a curly moustache’ initially and secondly ‘a two-headed snake’. Her first response to a masculine structure may symbolize her perpetrator. It may also symbolize the male genitalia, the moustache as pubic hair and the nose as penis. This seems likely since the next association was to a snake, a well-established phallic symbol.

B25: She saw ‘an eagle with a crystal body and snakes at the end of its wings trying to see the future in the crystal. It looks like a baby eagle’. The baby eagle signifies regression. She lived at home and was never separated from her family. The snake imagery from B24 continues the phallic imagery. Metaphorically, this may be a variation of the Little Red Riding Hood theme of the virgin in the forest⎯a baby bird with the snake near at hand on its very wingtips.

B27: Evoked a typical response. In the first hypnotherapy session, she proved to be an excellent subject. She was able to learn and apply relaxation techniques and imagery to reduce her headaches. Over the next several months, there was a dramatic reduction in her pain and need for emergency room visits. However, as her treatment progressed, her case became much more complex. Following the first hypnotherapy session, she recalled a long and traumatic period in her childhood involving sexual abuse by her father. She also became aware of amnesic episodes when she would suddenly find herself outside a bar dressed in provocative clothing. Eventually, she reported being aware of voices in her head telling her to do socially unacceptable things. At that moment, her voice and behaviour changed, adopting one of several multiple personalities. In one therapy session she suddenly spoke in a deep, threatening masculine voice as she assumed the identity of one of her early male abusers. Eventually, she recalled a history of terrifying child abuse in a religious cult where she said she witnessed human sacrifice, mutilation and burning of babies. She was administered the Rorschach followed by the 20 cards of SIS-I. Her Rorschach responses were as follows:

Card I: ‘A face with eyes and nose. Part of this smile is covered by a black mask.’ Here content analysis revealed that she has internalized the image of a masked man. Historically, this represented the male leader of the cult who abused her in her childhood.

Card II: ‘It’s a face. Above the eyes are red figures. The head must be hurting. He is shouting out in pain.’ The person perceived represented a direct projection of one of her male altar personalities who experienced the painful headaches.

Card III: ‘It’s the figure of a person with long black arms. His head is split in two. The eyes are covered with dark sunshades’. In this response sequence, she continued to project one of her male personalities. Seeing the head split in two was interpreted as a direct reference to the ‘splitting’ intensity of her headaches at a somatic level. At a psychic level, it reflected ego splitting one of her male personalities.

Card IV: ‘Just a very dark looking mask.’ Here, she was able only to see blackness with weak, undifferentiated mask-like form.

Card V: ‘A butterfly. Black. Sad to see a butterfly all black.’ These are popular response but with added depressive content mirroring her own feelings of sadness and depression.

Card VI: ‘Two persons sitting with backs turned against each other. Above their heads is another butterfly.’

Card VII: ‘Two elephant faces not looking at each other. Above their heads is another butterfly’.

Card VIII: ‘Two pink cats walking down. Blue butterfly with square wings’.

Card IX: ‘Two narrow eyes being hidden by pink, blue and orange masks. The eyes are sad. He wants out.’ The theme of a masked person recurs with added content, suggesting depression and a wish to escape or relieve the depression. It represented one of her repressed personalities that was sad for lack of expression in her behaviour. She responded in a brooding, threatening masculine voice.

Card X: ‘Every object has a partner, two of everything.’ Aspects of the inkblot are personified and split in two. Her responses to the 20 SIS-I cards are as follows:

Card 1: ‘A spook with distorted eyes. Face of animal with eyes and horns. Red looks like birds.’ The spook represents the face of a past abuser. She was afraid of birds. In a phobic way, she insisted upon the removal of a picture of an eagle from the interviewer’s office.

Card 2: ‘Somebody’s head has been cut off. Somebody laughing, a get-even type of laughter’. She viewed a mutilation scene involving the motive of revenge. This is consistent with childhood cult abuse and certain of her murderous personalities.

Card 3: ‘Two people. A man and a woman. The red blotches represent pain, close to the chest and heart, hurting pain’. Her perception of the red central objects as pain close to the chest and heart represent a direct projection of her own conversion pain, related more to her chest than her head.

Card 4: ‘A person, probably a male, and a red apple’. She again projected male identification. For her, female body images were to be avoided because of their threatening association to her long childhood history of sexual abuse.

Card 5: ‘A swimming turtle, two dots, little children and a heart.’ These are unremarkable responses.

Card 6: ‘An animal trapped in an enclosure. It can’t get out. A person standing on a heart.’ The reference to a trapped animal reflected a statement of how she felt when multiple personalities spoke to her in her head.

Card 7: ‘An animal sitting with feet. A llama. The heart is red. Some poor animal hurting.’ She projected her pain onto the image of the animal hurting.

Card 8: ‘Seahorses’. ‘A ribcage and heart’. A heart split in two instead of one. Her reference to the ‘heart split in two’ described her own mental splitting.

Card 9: ‘Two masses, inside, joined by something in common. The bottom looks like a knife.’ She repressed the anatomical content because for her urogenital imagery was especially threatening. Her projection of the response ‘knife’ is clinically significant. Prior to viewing the SIS image, she had awakened from sleep on one occasion with a knife in her hand. She was completely unaware of how or why she picked it up. During this phase, several of her personalities were both suicidal and homicidal.

Card 10: ‘Lips, red running from lips a snake.’

Card 11: ‘Red colours’.

Card 12: ‘Someone trapped in a red mask. Two faces on side, one angry, the other dazed.’ Her responses continued the theme of being trapped and masked. She projected anger onto one face and confusion on the other.

Card 13: ‘A beetle chopping away.’

Card 14: ‘A dark demon with two eyes (top). A tiny cross at the bottom. A face with no eyes or eyebrows.’ Because of the past sexual abuse, she repressed vaginal imagery. Non-anatomical symbolism defended against this aspect of herself and involved negative connotations. The dark demon symbolizes certain of her personalities, which act out sexually. After such episode, she would find herself standing outside a bar ‘dressed like a hooker’ and be entirely amnesic about her sexual behaviour. Another of her personalities was flirtatious and would attract a large following of men at cocktail parties.

Card 15: ‘Little faces staring up at each other. Eyes. The base support (bottom).’ She repressed the spinal content because of the association of the spine with sexual activity during intercourse. Non-anatomical defensive material represents projecting of the faces of her multiple personalities.

Card 16: ‘A face with two eyes and a nose.’

Card 17: ‘A skeleton part. The vertebrae and pelvic area. There is also a face with white eyes and a mouth.’ She added the comment: ‘I don’t like it. It makes me depressed.’

Card 18: ‘Mountain cliffs and a man looking over people standing.’ The people standing reflect her multiple personalities.

Card 19: ‘Masks, carnival, Halloween.’ The mask theme continues. She introduced the concept of Halloween, with implications of monsters, ghosts, frightening costumes and a cult ritual holiday she may have associated with her traumatic ritual abuse as a child.

Card 20: ‘The Devil himself, eyes and horns, the mouth wide open like he wants to say something or scream at someone.’ One of her inner personalities represented the Devil. It was his screaming at her that frequently produced her headaches. The Rorschach and 20-card SIS were later re-administered. The second administration of Rorschach yielded the following responses

Card I: ‘Pumpkin face, Halloween type faces. I like it. Feels like I’m being laughed at. A bad feeling of being watched. I see two birds on either side of a pumpkin face.’ At this stage of therapy, she was working through her incest trauma.

Card II: ‘Face of a man. Eyes are red, mouth white as if opened, tongue hanging out—it’s red.’ Her responses again reflect a threatening man’s face. It was reasonable to postulate that it represented the face of the perpetrator of her incest trauma, her father or other adult male cult members.

Card III: ‘Two female images each holding on to someone’s head. Looks as if they’re pulling on the head. Looks like a red heart or two hearts joined between the females. On each side of the female’s head are red falling objects, falling down.’ She avoided male content, possibly defensively because of how males have been threatening to her. ‘Pulling on the head’ may reflect a past abuse or it could depict the psychic forces splitting her personality and figuratively pulling her head apart.

Card IV: ‘At first I see a monster face coming towards me, black and scary. Next, I see two boot-type shoes on either side of a common object.’ At this stage of her therapy, her multiples were closer to the surface. In the projective test situation, she was unable to view the stimulus objectively. It became animated and moved towards her like in dream imagery. Her ego was less intact and she was moving into a border-line or psychotic state as the terrible extent of her past abuse was beginning to emerge. In retrospect, this reminds of Freud’s original comments about analysing a patient with hypochondriacal abdominal pains. When terrible problems come into consciousness, he mused philosophically that it might be more humane not to pursue psychoanalysis and leave the patient with less physical suffering, the lesser of two evils.

Card V: ‘Black butterfly, but I also see two objects joined in the middle each wanting to pull away.’ This represents a direct projection of her early splitting of her terrible past from memory.

Card VI: ‘The smaller object at top has to pull the two larger objects on the bottom. Both two larger objects are joined in the middle by a common body. The object on top would like to be rid of its companions.’ The theme of splitting continued with symbolic representation of the great psychic tension it caused.

Card VII: ‘Two Indian-type girls looking at each other. They each have one feather on their head. They are balancing on the edge of butterfly wings. They don’t want to be together.’ The theme of splitting continued.

Card VIII: ‘I see two pink rats walking over on three sets of objects or bodies. In the bottom object I see a scary yellow gold face.’ The ‘set of bodies’ reflects the early stage of her ego breaking into multiple personalities.

Card IX: ‘I don’t like this picture, it frightens me. It’s all messed up like me.’ She acquired more insight into the extent of her past trauma and resultant psychopathology.

Card X: ‘Everything in this picture is connected by some common link. I see different objects like two grey insect-type objects at the top looking angrily at each other. Two blue spiders. Two green seahorses. I see blue in the middle, a pelvic-type skeleton. There is, however, in the middle an orange wishbone-type object. Everything’s very scattered.’ This response symbolized the anger and conflict between her inner psyche structures. After taking the Rorschach, she completed the 20-card SIS-I for the second time and these were her responses.

Card 1: ‘Distorted face, twisted white eyes, crooked, two red hens, and the face is sad.’ This response parallels her earlier response.

Card 2: ‘I see red lips, laughing man at bottom holding his arms wide open. Looks like a bird flapping wings at top of picture.’ She failed to make a gestalt of the inkblot configuration. The splitting reflected inner psychic fragmentation. The theme of being laughed at or tormented continued.

Card 3: ‘Two objects, one man, the other female, red hearts in between the two, sharing.’ This response was more positive. The couple was sharing and there was less pain consistent with less conversion pain.

Card 4: ‘Red apple at top, male figure at bottom, the male is smiling.’ She failed to recognize the female figure, consistent with a poor feminine identity and low self-esteem. She was more comfortable talking with men than women. As therapy progressed, it became apparent that her mother knew of the long-standing sexual abuse. She recalled hearing her mother’s footsteps near her bedroom door when her father was abusing her.

Card 5: ‘Looks like a black turtle with red heart, two infants on either side. The one on right is upside down. Two red dots above the turtle look like red eyes.’ She continued to p euphonize her reaction to red colour. Eyes are consistent with her paranoia.

Card 6: ‘Bottom is a heart, red, with a red man walking on it. Two doves connected or trapped that can’t get out or escape. Two reds on top are eyes looking at me.’ These responses projected two of her inner personalities seeking expression. The paranoid theme continued.

Card 7: ‘Large red heart surrounding in the neck of a llama that’s all dark.’ This response reflected her clinical improvement. At this stage of her therapy, she experienced less physical pain and wasn’t taking analgesic medication as frequently.

Card 8: ‘Two dark seahorses eating on someone’s heart. This response reflected the degree of suffering from her childhood history of abuse.

Card 9: ‘Two bodies connected to a lower body with a knife at the end of lower body.’ She repressed male imagery because of its threatening qualities. The knife refers to human sacrifice by the religious cult.

Card 10: ‘Red lips at the top, blood running from lips onto a foreign object.’ This represented a more direct association to her emphasis on red.

Card 11: ‘Looks like lower intestines, red, on fire, pain.’ This reflected her long history of lower gastrointestinal symptoms.

Card 12: This card evoked no response.

Card 13: ‘In the centre I see a black scary object looking at me.’ This response associated with one of her internalized ‘bad’ objects.

Card 14: ‘A little girl in the centre with arms open.’ She repressed the female genitalia, the area of her past trauma. It showed age regression to the time of the incestuous abuse.

Card 15: ‘Looks like stacks of bones, a spine?’ She had less anxiety and appropriately identified the spine. Experience with a variety of clinical populations suggests that there is less somatic repression and less conversation pain as a person focuses from body to psychic conflicts.

Card 16: ‘Two faces, dog faces, sticking their tongues out at each other.’ This symbolized aggressive feelings.

Card 17: ‘Black atomic cloud with a sad face, with white in it.’ This response reflected hostility and sadness.

Card 18: ‘Scary face with mouth wide open.’ This symbolizes a threatening internalized object.

Card 19: ‘I see a face again with long eyebrows, mouth open, coming from behind two human-type objects trying to hide.’ Threat theme continued.

Card 20: ‘This is also a scary, angry face, with mouth wide open. There is a wishbone above the head.’ It is more of the threat theme. Four years later she was again given the SIS-II booklet form. It was apparent that her headaches were not migraines but rather conversion phenomena arising from a conflict between her various personalities and emergence of past traumas to full consciousness. Viewing certain SIS images precipitated and intensified her head pain. She saw A5 as ‘a monster with giant arms, a heart with a cloud above. It makes my head hurt and gives me an uncomfortable feeling.’ On A10 she responded: ‘It makes my head hurt. It’s a face. I see eyes and it leaves me with a painful feeling.’ For Image B11, she projected ‘a nose with sinus pain’. She repressed the picture of the brain on B23. Onto this painful region, which she perceived as the nerve centre of her mental conflicts, she substituted ‘an atomic bomb explosion’. Symbolically, this reflected her terrible past traumatic neurosis. Despite earlier brain repression, on B30 she saw ‘a brain divided up’, directly associating her multiple personalities. Also relative to her multiple identities was her response to A13 as ‘lots of hands reaching up for help’ and A14 as ‘monsters fighting over a heart’, the effect of her destructive personalities. On A18 she saw ‘a skeleton skull with the devil inside, scary’. In a follow-up interview, she recalled this was a direct projection of ‘the evil one’, one of her more powerful identities. On A24 she saw ‘a group of people with arms connected’. In the detailed enquiry, she related these to a group of five inner personalities who had gotten together to fight the evil one. Some responses related to her trauma and sexual anxiety. Instead of seeing a woman on A7, she saw ‘a man with an apple above his head’. On A20, depicting kidneys and male urogenital system, she repressed the male sexual content and saw instead ‘two lima beans attached by a hair’. For the spinal picture in A23, she refused to respond and said only that she didn’t like what she saw. She related A14 to the ritual abuse by family members and others in the cult: ‘The foetus, someone killing the baby’. She saw A27 as ‘a cut-off breast’. A partial determinant of her response to A14 was that she tried to abort her youngest child at four months’ pregnancy. This occurred after her father, in a jealous rage, told her he didn’t want her to be pregnant by anyone else. Some of her responses reflected somatic concerns about areas other than the head. To A28 she responded: ‘muscle tendon in pain’. For B13, which depicts the female pelvis, she saw ‘three growths on the stomach’ referring to colitis. This involved excruciating recurrent abdominal pain with diarrhoea. It felt like her ‘insides were on fire’. For B17, which lacks somatic structure, she saw ‘a heart’ relating to palpitations experienced when she was upset. Interestingly, the responses to the videotape version of SIS-II images accessed much earlier traumatic memories. B24 elicited memory of a burning baby. She recalled that as a child, she had witnessed cult ritual mutilation, murder and burning of babies. The video evoked more painful somatic symptoms (e.g., headache) and was more psychologically threatening than the SIS-I, the SIS booklet and the Rorschach.