Case 15. SIS-II in a Case of Sex Abuse and Somatic Pain

Miss X, 27 years, unmarried, law graduate, practising as attorney, belonging to high middle-class family, had history of sex abuse at the age of 4 years by a 19-year-old boy, physical relationship with an aged family friend, history of feeling depressed, wish to leave the family and conflicting parental relationship, was given SIS video for understanding her  personality and therapeutic intervention. Interpretation of a few responses found to be quite relevant has been given for understanding the psychology of the case.

A1: She saw ‘A man who looks healthy and majestic but pretty empty inside’ is a direct projection of how she feels empty inside, although she looks normal and healthy on the outside. The fact that she conjures up images of a man rather than of a woman may reflect her sexual identification partially identified with that of her perpetuator.

A3: Many people while viewing this image introduces spiritual connotation with it. Here, she directly projects her feeling of wanting to be free of her past traumatic memories and inner trauma by seeing ‘my soul when will it become free’.

A5: She viewed ‘a lady who is with all her heart celebrating alone’. It is direct projection of same sex identification to the human form. She focuses on the heart because she is introspective and socially withdrawn because of her pain and depression. It may probably also represent a projection of her mother’s image that is critical and non-supporting. Her depression is abnormally high, and she has given lot many responses depicting depression.

A6: ‘A sad teddy bear’ brings back the theme of sadness or depression almost in a perseveratory fashion. In addition, the response has repressive features. She totally avoids reference to the human gestalt and focuses instead in a childlike fashion on a teddy dear.

A10: ‘Blind woman’ is the projection of her psychological blindness associated with her repressing images of her past sexual abuse. She also comments that she is getting impatient and needs therapeutic resolution for her long-standing childhood conflict.

A11: She viewed ‘a needle through the heart—I want to weep but I won’t’. This is a direct projection of an emotional pain and depression, the fact that she conjures up the image of a needle penetrating the heart symbolizes her past sexual penetration and body boundary violation. In commenting on this horrible response, she for the first time acknowledges to the examiner her depression and need for emotional catharsis as well as her inability to do so as without therapeutic assessment.

A12: She viewed ‘can you hear me with your ears and listen with your heart’. With this question, she directly asks the interviewer if she will be heard with empathy and compassion. Previous attempt to share her pain as a child felt on the deaf ears of the parents.

A13: She saw ‘a window hazy with fog with the centre clear, a  handoutstretched asking me to wait. Maybe I should give up’. Here, she continues the theme of her own reluctance to weep and share her pain with the therapist. She has learned from the failure of past attempt to share, which were met with frustration, and further hurt, that the process of attempting to communicate may itself lead to further hurt and rejection.

A11: The hand symbolizes that part of herself that ‘I won’t allow herself to trust the therapy process’. To remove this resistance in therapy, it would be necessary to interpret the symbolic significant of this response in terms of transference. At last, the reference to ‘giving up’ continues the depressive feelings of her helpless.

A14: She saw ‘a dry flower’ in this image. Here, rather than recognizing the anatomical structure, she projects herself in the image as being dead inside.

A18: She viewed ‘a man hanging upside down with smoke bellowing out of his head and waiting to fall through the dark circle into a hole’. Many individuals see anatomical contents here such as the heart or image of sexual intercourse. Because of her sexual trauma and resultant pelvic anxiety, she totally avoided reference of somatic structure in the video image. The defensive material projected symbolizes her severe depressive mood and latent death wishes. At times, she fantasizes running away from her home and escaping from her problems.

A23: She saw ‘looking like a deadly android, resembles a creepy centipede [scary feeling]’. Here, the response is remarkable because of her failure to correctly identify somatic structure, which so clearly depicts spinal column. There are two possible determinants of somatic repression, one relates to her past medical history of having fallen  four years back injuring her tailbone and causing considerable pain. The other relate to phallic connotation of this image. While both hypotheses can lead to heightened body anxiety, symbolic analysis of her defensive imagery suggests that the later determinant is more noticeable that she saw a deadly ardroid resembling creepy centipede which is highly threatening to her. Remember that previously in responding to image, the needle had threatening phallic connotation. A little girl violated by penal penetration will always carry such negative association to phallic imagery.

A31: In Image A31, she viewed ‘a beautiful woman looking at her hazy reflection. She is not sad yet contemplative [feeling confused]’. Here, she avoids reference to central content in A31, which pictorially depicts a man and woman in very close interaction, because this material is highly threatening to her due to her experience with her male perpetuator. The normative content is totally repressed. She defends against this structure by substituting image symbolizing herself in therapy looking at her psychological defence mechanism of denial. The introduction of the idea that the woman is confused symbolized her own confusion and cognitive disarray.

B3 : ‘Two people sitting inside a womb overlooking alter of fire.’ Here, fire signifies life [feeling of wonder]. Was her response on this image, Seeing  two people inside the womb continue the regressive theme previously noted on  A6, the fire denotes her emotional pain. In this essence, rather than associating depressive aspects she introduces the concept of life and wonder. This was positive prognostic implication to therapy and needs to be interpreted to her context. There is hope for recovery if she is willing to share her pain during therapy.

B6: She saw ‘a half statue girdle downwards with some infection around the girdle [feeling of depression]’ in Image B6. Here, she partially picks up the correct anatomical structure referring to the lower abdomen and thigh. However, because of her trauma to related pelvic anxiety, she defends against the specific somatic content by seeing a more abstract image ‘that is, statue girdle’. Here, it is noteworthy that she projects a pathological anatomical response. ‘Infection’ symbolizes her own inhered genitalia. The facts that this image accentuates her feeling of depression in responding to the image indicated that she is grieving the loss of her virginity and body boundary intactness. The assault on a child’s body is not just injurious in a sexual way but when a perpetuator is a close family friend, the overall ego becomes distorted and confused just like she indicated in A31. The other explanation could be her repeated infection in her pelvic region for which she has taken treatment.

B12: She viewed ‘a parrot hanging upside down trying to fly away’. Here again she totally represses the real structure of the image, which dents some man’s facial area and nose. Substituting image of a parrot neutralizes the threat in this image. The fact that the bird is seeing upside down trying to fly away directory symbolizes the childhood feeling of vulnerability and helplessness to avoid her perpetuator.

B16: She saw ‘the centipede is back again. I hate centipede [feeling of filth and dread]’ in image B16. The significance of this response is previously reviewed with A23.

B28: She viewed ‘a person hugging a white coloured pet’. Most individuals who have had experience of positive nurturing mother will see as a woman holding the child. Here, she defends against by avoiding reference to the maternal and female connotation of the adult figures seeing only a ‘person’. Similarly, she avoids reference of the child introducing the image of a pet. Despite this, it should be recognized that of an image which was loving and affectionate. Frequently, when a child has not received maternal love, they will turn to pets to meet the need for aggression. Such individuals with other inkblot tests such as the Rorschach test and the Holtzman test give higher number of animal responses than the human responses.

B30: She saw once again ‘two ears—can you hear me?’ on B30, here like in A12, she directly asks the therapist if her inner cry will be heard and responded to therapeutic alliance and that she is given reassurance that unlike the past when no one has heard her she will be heard with empathy and compassion now. In this sense, her inner cry will be heard, and she will have the helpful therapeutic relationship. Many male therapists because of trust issue prefer to refer such traumatized female patients to a female therapist.

Here, we have presented two cases of clinical interest. Although the subjects of both cases are females, it is important to point out that the problem of inner cry is not only with males or females but human beings in general. It is not limited to any part of the world, society or culture but is universal in nature. The responses to SIS have been successful in identifying the inner cry of the individual, which itself is the first step of therapeutic intervention.

It is important to remember that the projective tests do not have the so-called objective procedure of interpretation. It is the clinician’s acumen, which is necessary to interpret a protocol. In the first case study, it was a denial of the problem initially, but through SIS images and on subsequent enquiry it revealed the roots of the problems, whereas in the second case study, it was the obvious percepts to unstructured stimuli. The Rorschach test was tried in the first case but could not reveal much. It could be since somatic inkblot test is based on the theory of body imagery, whereas Rorschach is largely based on general perception.