In this case history study, the SIS Video, Rorschach Inkblot Test and figure drawing tests were administered to a teenage girl who was admitted to a psychiatric hospital in Boston for treatment of major depression and dissociative disorder. She had history of suicidal ideation and self-mutilation of her left wrist and forearm. The relaxing instructions in the video and the hypnotically present healing flowers may have facilitated neural extinction of the terrifying hallucinations intruding upon her consciousness. The figure drawing and content analysis of SIS and Rorschach may provide useful aids to supplement standardized clinical interviewing techniques. The case has been discussed in detail (Cassell, Schaeck and Mohn, 2002).The study of hallucinatory phenomenon has been long proven of interest. If there is a common clinical bias in evaluating hallucinations, it is the assumption that these perceptual disturbances are evidence of abnormalities in brain chemistry. There is a great deal of supporting evidence for this viewpoint, especially in those with disease of the central nervous system or toxic conditions involving the brain (e.g., chemical-induced hallucinatory states). This case history presentation explores the notion that when there is no clear evidence of neurological dysfunction, the clinician may glean important diagnostic information and novel therapeutic leads by exploring the symbolism in the hallucinations.
Prior to admission, the patient (her fictitious name S) had experienced severe suicidal ideation with plans involving a variety of suicidal behaviours such as overdosing, slitting her throat and electrocution. Her usual behaviour involved self-mutilation of her left wrist and forearm. While she had experienced suicidal ideation from the time she was severely abused by the violent biological father, her pattern of mutilation had only started after she had been removed from high school seven months back by her mother and stepfather. Even though she had been made to do homeschool, she retained communication with a teacher who had been especially supportive of her interests in drama and writing. When she revealed to him her suicidal thoughts, he contacted mental health services who referred her for hospitalization. Her parents initially refused to accept the fact that she hallucinated and was a danger to herself.
During the initial psychiatric evaluation, she reported that she had previously drawn a coloured representation of a reoccurring violent visual hallucination. This was a threatening man with a knife in his hand. Her representation of the figure revealed that he had cut his wrists. Red blood poured from the wounds. When asked to recall who he reminded her of, she said that it reminded her of her abusive biological father. Upon detailed questioning about her drawing, she told the interviewer that the eyes resemble ‘mine’.
She was selected for this illustrative case study because she provided a unique opportunity to examine hallucinatory symbolism prior to psychotropic medication. Because she was quite intelligent, she was an excellent candidate for the illustration purposes. She was intelligent with excellent writing skills in poetry and drama. Previously when enrolled in school, she had demonstrated her ability of effective communication in school drama activities. However, consistent with her long-standing dissociative symptoms, she had extremely limited concern in the expression of personal feelings. Further relevant clinical history will be provided subsequently in connection with her projective test results.
On the second day of hospitalization, she was administered the video version of the SIS. The image that she rated as most threatening was B1. A transcript of the detailed enquiry is as follows:
Dr B: Now we’re going to go to B1. On the answer sheet, you indicated that it frightened you and made you think that something was trying to bring you down. And you saw ‘a claw reaching out from the depths to drag you down’. Do you want to say more about that?
S: No. (This projective response incorporates an image of a ‘claw’ which in disguised form symbolizes the hallucinatory figure’s knife.)
Dr B: When… when have you felt that way? That something’s dragging you down?
S: A lot of times. Like when I do theatre, and someone isn’t so accepting about it. That kind of drags me down (her parents were adamantly against such activities).
Dr B: Do you think that image—that person in the hallucination brings you down?
S: Yeah.
Dr B: Yeah. Tell, tell me about that. In what way does he bring you down?
S: He shows me the way that—a path that he chose (suicide by cutting his wrists), I suppose, that is also a path that I’ve—I’ve considered. And the fact that it scares me kind of brings me down.
Dr B: And he chose what path?
S: Suicide.
Dr B: In what way have you considered suicide?
S: Slitting my wrist the same—same way he did (it will be shown in her free associations to subsequent SIS images). S had been severely traumatized by her biological father and had partially identified with his violent personality. This identification was reflected in her comments about the eyes in the figure resembling her own. Next, her associations to SIS B21 will be explored for symbolic content. She had rated this image as the third most threatening.
Dr B: Okay. For B21 you said: ‘Anything that hurts nature angers me’. Okay. It angers me too. And you see…
S: ‘An oil rig digging into the beautiful earth to suck her dry’ (here, the symbolism again relates to self-mutilation with the ‘earth’ symbolizing her body).
Dr B: Especially the beauty in Alaska, right?
S: Yes. Oh. And—and just the fact that something can damage that is upsetting. (Here, she totally avoids the imbedded structure of a handgun and substitutes an image of an oil rig digging into the beautiful earth. Again, this depicts the knife in the hand of the hallucinatory figure. The power of this symbol to emerge in projective consciousness is immense. No recognition of the gun takes place, yet a few minutes earlier in viewing A11, consistent with her violent impulses, she had projected the response ‘gun’.) The next response that warrants projective analysis was produced regarding her viewing B22. Here, she envisioned a ‘person sleeping with dreams so disturbing it causes them illness’. Consistent with this, in association with the visual hallucinations of a figure with a threatening knife; she had recurrent post-traumatic dreams in which a similar figure slashed his own wrists and then chased her.
In this regard, the violent hallucinations simply reflected a spillover into conscious awareness of the violent night-time imagery and emotions. Sometimes, the violence in dreams was directed at her friends as illustrated in her response to SIS B22.
Dr B: Then B22. ‘A person sleeping with dreams so disturbing it caused an illness’. And what does that recall?
S: Myself.
Dr B: What way are your dreams disturbing?
S: They’re horribly violent.
Dr B: What sort of violent images come to mind?
S: One I have, I recall a lot, a friend of mine is dying because a bowling ball fell on his head.
Dr B: What were the images like in the dream?
S: They were real looking. What do you mean? I’m sorry.
Dr C: Well, what did you see with it? Did you see the ball hit his head? Was there blood?
S: Yes, there were bones and blood and…
Dr B: And how did it affect you in the dream, emotionally?
S: It hurt. I mean I cried, and I was…
Dr B: It was horrible wasn’t it?
S: Yeah.
Dr B: And you wake up feeling how?
S: ‘Helpless’. This brings to mind those theoreticians who conceptualize of certain depressions as resulting from ‘learned helplessness’).
Dr B: How long does that feeling last in the morning?
S: It lasts throughout the day.
Dr B: Colours the whole day, right?
S: Yeah.
(Even though this was a horribly disturbing dream, she still was able to recall it, since it was much less anxiety provoking than her terrifying dreams of the knife threatening hallucinatory figure).
Next attention will be given to her reaction to B15, the only SIS image that had embedded structure of knife-like sharp objects.
Dr B: Okay. B15 ‘Knives being thrown at someone to cause them more pain’. What does that recall?
S: Me.
Dr B: In what way you?
S: Because sometimes the pain that I feel—it feels like somebody’s taking a knife and stabbing me (here, she compares her somatic pain in terms of a knife stabbing her).
Dr B: Where do you feel it in your body?
S: In my stomach and in my ribs and my heart (diagnostic medical studies had not revealed any physical problems to account for her discomfort. Consequently, it was assumed that they represented conversion reaction symptoms related to her dissociative disorder).
Dr B: What does your stomach feel like at that point?
S: Oh, it feels horrible. It’s… it’s just… burning and it’s… I don’t know. It’s just sharp pain.
Dr B: And then your heart, what does it feel like?
S: Same thing.
Next, the detailed enquiry regarding SIS Images A10 and A12 will be explored in terms of their related body symbolism.
Dr B: Right. And A10?
S: I don’t know. It just looked like somebody who is sad and in pain.
Dr B: Does it remind you of the pain that you have?
S: Yeah.
Dr B: What’s the pain like that you have inside?
S: It’s hurtful.
Dr B: And where do you feel that?
S: Everywhere.
Dr B: Yeah. More in your chest or just everywhere?
S: Sometimes.
Dr B: What’s your chest feel like?
S: It feels like sharp shooting… Well, it feels like somebody’s stabbing me.
Dr B: A12 what does this recall?
S: An ear with blood in it. (The blood response projected here is quite consistent with knife bleeding.)
As will be shown subsequently, S was a victim of severe childhood, psychological, physical and sexual abuse. Associated with the resultant traumatic events, she had blocked from conscious awareness many of the events along with their related painful affects. Consciously, when triggered by current stressful life events, these were experienced as somatic pain.
Next, her response to B27 will be outlined.
Dr B: B27. ‘Self-reflection. Evil, but completes half versus a pure, but damaged half’. And what does it recall?
S: It brings to mind myself and… and like the darker half winning over the better half.
Dr B: What is the lighter part of you like?
S: What do you mean?
Dr B: The good part.
S: What is it like?
Dr B: Yeah.
S: Happy.
Dr B: And then the darker part, what it’s like?
S: Controlling, dominating, hurtful.
In interpreting the symbolic significance of human content in visual hallucinations, it may be inferred that the figure represents an aspect of the person’s own self. For Stephanie, the male figure of the hallucination symbolized both her father and her violent tendencies. The latter resulted from her learning aggressive behaviour from her abusive father (i.e., mutilating her wrists). Of course, genetic factors may also be determinants.
Next, historical information of childhood trauma follows regarding her associations to A22.
Dr B: A22. ‘Someone moving to destroy or damage someone’. What that recalls?
S: The way people are affected by certain things.
Dr B: Hm hm. When you were young, were you exposed to too much violence or hurt?
S: Yeah.
Dr B: What was it like?
S: Hard. It was painful.
Dr B: Who was hurting?
S: My dad for the most part.
Dr B: In what way did he hurt you?
S: He would hit us and throw us against the wall and stuff. (Her mother reported sexual abuse, although at this stage in her psychotherapy with her female therapist she was amnesic to this early trauma.)
Next, her comments about A18 are relevant to understanding how the dissociation process fragmented her personality.
Dr B: Hm. A18. ‘Someone captured inside a prison they created for themselves.’ What does that make you think of?
S: Me.
Dr B: In what way you?
S: Because I have problems with communication. And it seems that I just have barriers that I put up.
Next her discussion in relation to B4 throws light on her distorted cognition presented in her mutilation poem below:
My Scars
These scars upon my wrist
Are beautiful to me
What the world looks at with shame
I view with joy and pride
These scars upon my wrist
are mine I put them there
They are some gift
That no one can take away
These scars upon my wrist
Are my reminders Proof
that I can feel happiness
Despite all the sorrow that consumes me
These scars upon my wrist
That you look upon with disgust
Could someday be owned by you
Could someday bring pride and joy to you
Could someday be scars upon your wrist.
Dr.B:: B 4. “ A reflection of a person’s true self without the mask they present” And what does that recall?
S: Me. (Before exploring further her associations, perhaps it might be helpful to consider two drawings that she made for her female psychotherapist. One drawing was of a flower depicting her exterior self. The other presents a troubled interior with a peace symbol that is burning, above it are tear drops symbolizing her sadness and inner cry.)
Dr B: What way does that reflect you and your mask?
S: Because one of the images is a lot uglier than the other one.
Dr B: Uh-huh. In what way do you have an ugly image?
S: That would be the image that I don’t present. It’s distorted over things that have happened.
Dr B: Such as?
S: Such as my dad being mean, or something as little as J leaving (one of the losses that precipitated her current depression was J’s moving away. They then communicated frequently by e-mail. Eventually, S shared her mutilation secret with J. J, in turn, then sent her the drawing presented in figure, indicating that she too found ‘peace through cutting).
Dr B: Hm. And so that person is a person who’s feeling what?
S: Pain.
Dr B: Pain. Yeah. And how about hurt and anger too?
S: Yeah.
Dr B: What’s the anger aspect?
S: The anger at themselves.
Dr B: And how does that relate to your wanting to cut on you?
S: One of the reasons I cut myself is the anger that I feel towards myself.
Dr B: What affect does it have when you see your blood during cutting?
S: It feels like something is being released.
Dr B: Hm hm.
S: Something being set free.
Dr B: Somehow, there’s some emotional release with it?
Next, her response to B20 depicting a human brain portrays her distorted cognitions and auditory hallucinations.
Dr B: B20. ‘Someone’s brain destroyed in parts.’ What does that recall?
S: Me.
Dr B: In what way do you feel your brain is destroyed at times?
S: My lack of concentration now. And my inability to recall things that happened to me three days ago. In dissociative disorder, amnesia is a common symptom relating to overriding attempts of her mental defence system to obliterate emotional suffering.
Dr B: Right. And when you have these visions what—how does that feel in your brain?
S: It feels damaged.
Dr B: And then the visions you… you see things, and… and do you hear things at times as well?
S: Yeah.
Dr B: What do you hear?
S: Jumbled noises.
Dr B: I see. And how do those affect you emotionally?
S: They kind of throw me off and upset me for a bit, until I can like try and regain myself.
Dr B: Can you ever make out the voices, whether they are of a man or a woman, you know?
S: It just sounds like everybody is jumbled. (These auditory hallucinations are of concern. They could indicate that she was suffering from the early stages of one of the schizophrenic disorders.) Next, her responses to B29 and B30 are of interest because they provide an opportunity to assess, through the mechanism of projection, how her hallucinations affect her. This additional aid in assessment was clinically important. Initially, neither her mother nor her stepfather would believe her or the hospital staff that she was truly hallucinating.
Dr B: B29. ‘Someone is running away from fear.’ What does that recall?
S: Me. I run from everything.
Dr B: When do you feel fear and anxiety?
S: A lot of times. Just out of the blue, sometimes, I’ll be really scared and—and when I hallucinate, I feel scared and just—yeah.
Dr B: B30. ‘Two ears each hearing something differently.’ And what does that recall? (This depiction of human ears is particularly useful. It enables those suffering from auditory hallucinations the opportunity to communicate about their suffering. The material which follows more sharply brings into clinical focus her dissociated mental processes).
S: Everybody. Everybody seems to hear something different than everybody else. And sometimes they hear two different things that weren’t even intended and…
Dr B: Do you ever hear things like that are confusing in your head?
S: Yeah.
Dr B: Tell us about it.
S: Sometimes I – I – I hear things telling me what a bad job I’m doing, and everything.
Dr B: Put down things?
S: Yeah.
Dr B: How does that affect you?
S: Really bad. It makes me feel weak.
Dr B: Do you ever hear things telling you to hurt yourself?
S: No. (Here she reveals [by elimination of suicidal voices] that it is primarily the visual hallucinations which contribute to her mutilating behaviour.)
S:: was tested with Rorschach one week after admission when she was still hallucinating. The report read as follows:
<Block Quote Begins>
Her responses to the Rorschach cards were scored with the Exner scoring technique. Mostly her responses were scored within normal parameters. At the time of this assessment, she appeared somewhat depressed, but not necessarily suicidal. She did, however, appear susceptible to episodes of affective disturbance that may involve features of worthlessness and confusion. She tends to make decisions based on how she feels rather than on what she thinks, although she tends to be confused and uncertain about how she feels much of the time. She appeared to be experiencing considerable emotional stress that was interfering with pleasure in life and making her susceptible to becoming even more depressed and anxious.
<Block Quote Ends>
The contents of her responses were interesting and seemed related to the contents of her hallucinations and dreams. One perception was of a ‘horrible, ugly giant with big, mean hands and huge feet’. She described another as something ‘rough on the edges like something that’s been cut up’. Another was a ‘scary face with an evil horrible grin with awful sharp teeth’. These references were consistent with hallucinations featuring a man with a knife, cutting himself and threatening to cut her’. She was subsequently interviewed by Dr B, 30 days after her admission. She was asked the question: ‘Did you see anything in any of the cards which reminded you of the figure in your visual hallucinations?’
S: Yes (selecting Card II), I see his face. There are his eyes (pointing to the blank space under the upper red colours).
Dr B: Can you say anything more?
S: Yes, he is frowning.
Dr B: How does that make you feel?
S: Lonely.
Dr B: What does the red on top resemble?
S: It looks like he is crying. His eyes are red.
Assessing the symbolic significance of hallucinations poses serious methodological challenges. Ideally, the clinical investigator should attempt to obtain valid and reliable data at the time the subject is experiencing a hallucination. These data could be compared with projective responses in the non-hallucinatory state. While this may have appeal to those who champion scientific rigour, like dreams, hallucinatory episodes are constantly in flux. Moreover, because of a variety of complicating factors, not the least of which is the individuals’ confused cognitive state and inability to clearly demarcate boundaries between actively psychotic and dormant psychotic conditions, such rigourous comparison is not always practical. In addition, the prime emphasis must always be on therapeutic issues. This case study has many limitations, active psychotherapy was going on over the course of treatment and psychotropic medication levels were being brought up to therapeutic levels.
Despite such limitations, perhaps a general observation can be made which could provide guidelines for future clinical investigators. In the absence of clear-cut neurological illness, it may be hypothesized that direct and/or symbolic information can be gleaned by the assessing hallucinations. In assessment, PTs like figure drawing, and content analysis of the SIS and Rorschach stimuli may provide useful aids to supplement standardized clinical interviewing techniques.
In this case history study, the SIS-II Video was used on the second day of hospitalization when the hallucinations were frequent and intensely threatening. When Stephanie viewed the video, the SIS evidence of their presence was only symbolically inferred from two of the three images that she rated as the most threatening: Images B1 (‘a claw reaching from the depths to drag you down’) and B21 (‘an oil rig reaching into the beautiful earth to suck her dry’). While at the time, these were rated as quite disturbing, it could have been potentially much more disruptive to her fragile cognitive state if her mental processes had not employed symbolic defensive overlays blocking the intruding hallucinatory imagery of ‘the man with a knife’. Moreover, the relaxing instructions in the video and the hypnotically present healing flowers may have facilitated neural extinction of the terrifying hallucinations intruding upon her consciousness.
One week later, she was responding well to treatment. Self-mutilation impulses and visual hallucinations were infrequent, yet her ‘Rorschach responses’ showed content consistent with the face of a threatening man. However, no specific enquiry was done concerning what she recalled from the facial responses. A month later in treatment, when she was given an opportunity to view all Rorschach plates laid out on a table in response to a specific enquiry she spontaneously indicated that the imagery evoked by Card II resembled the hallucinatory man’s sad face with reddened eyes. Consistent with her clinical improvement, there was no reference to his cutting behaviour, blood, etc., and he seemed much less threatening.
In psychotherapy the following day, she was asked why she thought that he was sad. She said that she did not know why. When asked if she felt sad, she immediately answered in the affirmative. Two days before, she had been crying profusely and was ‘red eyed’ herself. As indicated earlier, hallucination represented a composite image of her abusive biological father and her own dark side.
As she got in better touch with her sadness and emoted during therapy sessions, the visual hallucinations stopped. The imagery was replaced by her sensing the psyche presence of the man standing behind her. In a paranoid way, she imagined him to be contemplating and touching her shoulder in what she feared would be in a menacing fashion. However, she envisioned that he no longer had a knife in his hand. Currently, there was a reduction in her suicidal ideation and impulses to mutilate her wrists.
Her improvement was reflected in her writing a poem after a few weeks of therapy. The poem is given below.
You constantly ask me
What it is I want
Well, now I will tell you
I want more than I deserve
I want to be inspired
And to cry because I am so truly thrilled to be alive
A reason to keep up the fight
To put the knife down
Or the extra pills up
To actually beg to live another day
I want to never worry about acceptance
To know that people love me
And to accept that it is not important to understand why
You asked me what I want
But it isn’t easy to say
I want a lot
Though it doesn’t always feel like enough
The only thing that I can tell you
With absolute certainty
Is that I want more than I deserve.
Finally, in considering the significance of hallucinations whose etiology is primarily not neurological, it might be useful to consider certain psychological origins of their symbolism. Like many other adolescents who have experienced severe childhood trauma and developed dissociative disorder, Stephanie’s mental defence system became disrupted. Thus, she suffered from a breakdown of the usually integrated functions of consciousness, memory, identity and perception.
The latter disturbances involved both the outer world and of her body image. She had been depressed for years and long had experienced suicidal ideation. Death in her fantasies provided her a way out of her painful existence. Her self-mutilation impulses were first acted upon when she was taken out of school. For her, this was a devastating attack on her fragile sense of identity. It shut off her outlet regarding drama and writing—all things that her parents despised. Not being able to express her rage directly to them, she acted out her anger on her body. When she found the act of bloodletting giving her an emotional release, she developed an almost addictive behaviour to this.
Her Internet friends reinforced this maladaptive self-abusive behaviour—as illustrated by the friend who sent her the ‘peace through cutting’ drawing the figure. She also had so-called friends in cyberspace with suicidal behaviours that also had eating disorders. Consistent with familiarity to the latter, she responded to A7 as follows: ‘someone trying to deal with an eating problem, trying to make healthier choices’. In the initial enquiry, she denied having this problem herself. However, in the second month of therapy, she finally revealed that after listening so much to their fears, she too had become concerned about her body image. Since self-destructive behaviours can sometimes be readily transmitted from one person to the next, her Internet ‘chat room’ was a highly dangerous place for this suggestible adolescent girl. This case illustrates why the 21st-century clinicians need to enquire into the Internet activities in exploring determinants of violence.
The relaxing instructions in the video and the hypnotically present healing flowers may have facilitated neural extinction of the terrifying hallucinations intruding upon her consciousness. The projective instruments may provide useful aids to supplement standardized clinical interviewing techniques.