Case 19: Cognitive Behaviour Therapy with the SIS in Body Phobia

Although not formally recognized in any existing diagnostic manual, ‘body phobia’ represents a clinically definable and treatable condition. In 1976, it first occurred to me that this symptom pattern might possibly be worthy of formal recognition. At that time, a small series of case studies were initiated. 

For illustration purposes, one will be outlined. It utilized an early 12-card form of the SIS called ‘A Projective Test of Body Awareness’. It involved a 29-year-old professional engineer who had initially been referred by his family physician for treatment of depression. During his evaluation, it was noted that a major stressor was his fear of losing his wife. Their marital relationship was characterized by communication conflicts at all levels. 

In rating his responses in a hierarchy of threat, he selected Card 2 as the most threatening. He initially had responded: A woman with a big mouth … the black is the hair…. When elaborating further, he quickly became angry and felt like tearing up the card. He revealed that it strongly reminded him of his mother’s highly critical nature and the verbal abuse he suffered as a child. Eventually, he became tearful as the projective scene activated painful emotions associated with these memories. 

Initially, it seemed problematic to determine the mental mechanisms by which this oral imagery got transferred or projected onto the image of his wife’s body. It was partially clarified as a result of a subsequent interview with a female member of the treatment team. He reluctantly reported to me that he did not feel comfortable in talking to her. The reason was that he could not take his attention off her mouth. He was embarrassed and puzzled to admit that the therapist’s lips resembled his mother’s. The treatment team then realized that this distorted transference reaction was partially mediated through symbolic body imagery. 

The threatening nature of this symbolism was also evident in his selecting Card 10 as the next most upsetting one. Consistent with the above outlined transference hypothesis, he imagined seeing the following scene: ‘Lips and pictures taken by the subject from the air (referring to the lower aspect of the card)’. 

Here, it is evident that initially the threatening maternal oral image intruded upon conscious awareness. This triggered psychological defences of spatial withdrawal enabling him to mentally distance from unresolved childhood PTSD memories of verbal abuse. Focusing on the SIS inkblot as ‘a photo’ taken from a great distance facilitated the repressive perceptual inhibition and resultant threat reduction. 

The third most emotionally arousing situation involved his viewing Card 4. Once again, he became quite disturbed in visualizing imagery of a ‘woman’ with its concomitant traumatic memories. This additional projective clue signified a new evident response pattern. 

At this point in the evaluation, it seemed that for him maternal originated female body symbolism can stimulate confused memories of love–eroticism, fear–hate, etc. These had strongly shaped his lifelong perceptions, especially distorting his interaction with females. 

As might be expected, some of this confusion had been historically transferred of the developmental years to his perception of his own body. Consistent with this projection onto his own body gestalt, his response to the upper object in Card 4 was ‘penis’. This abnor mal visualization in close SIS proximity to potentially erotic arousing female imagery reflected his heterosexual phallic dysphoria. 

His high degree of ambivalence about genital sexuality was illustrated by his response to an original SIS card which clearly depicted the outline of the human body with reddish lungs-like internal organ and a sexually ambiguous pelvic area. 

Clinical trials indicated that it simply had too much structure to effectively serve as a projective stimulus. Most viewers perceived it as ‘the outline of a man’s body showing lungs’. For historical background interest, it is noteworthy that only a small minority perceptually inhibited the somatic content and projected other than human or anatomical responses. All suffered from severe conversion pain syndromes now categorized in modern diagnostic nomenclature as somatization disorder. 

This man responded as follows: ‘a man … also the picture of the vagina (pointing to the pelvic region) … and a penis (pointing to the white background between the lung-like objects in the chest)’. Here, it is noteworthy that an image of the vagina first intruded into projective awareness. This response indicated that his negative feelings about a woman’s oral region had been displaced downwards to the female pelvic region. It was understandable that vaginal intercourse with his wife was associated with more emotional pain than pleasure. 

At last, it might be noted that in a similar fashion as his response to Card 4, visualizing a ‘penis’ in the white background between the lungs-like organ representations was highly abnormal. It provided additional projective evidence of phallic dysphoria. 

Overall in analysing the significance of the above outlined sexually ambivalent imagery, it was hypothesized that he may have primarily identified with his aggressive mother’s female body. Thus, it appeared that the characteristics projected onto his own body gestalt during psychosexual development may have been unduly bisexual. 

<Level B>Treatment Plan 

These projective data were helpful in developing a comprehensive multidimensional treatment plan. This necessarily included antidepressant medication, cognitive psychotherapy, couple psychotherapy and sexual counselling. The additional dimension to be presently illustrated was behaviour therapy. 

To set the stage for the latter, he received four separate training sessions in Jacobson relaxation. When he demonstrated relative competence with this procedure, desensitization sessions were scheduled. In the initial clinical trial, after inducing Jacobson relaxation, the SIS cards were exposed to him by presenting them in an ascending order of threat. Initially, the viewing time of 5 seconds was used, followed by a relaxation period of 20 seconds. 

An attempt at measuring his level of arousal was made by asking him to use a subjective scale as follows: This ranged from 0 representing the psyche condition of feeling free of emotional discomfort to 100—the greatest dysphoria ever remembered. In the initial phase, he rated his feelings as 0. In viewing the 12-card series, his arousal level gradually rose to an estimated rating of 20–25 seconds. However, with the last one (Card 2), his rating jumped to 50. 

After a five-minute relaxation period, the procedure was repeated but in a modified fashion by increasing both the exposure time and the relaxation period to 30 seconds. Also, he was given the opportunity of rejecting any card before 30 seconds, if the viewing proved too upsetting. This time his arousal level only reached 20. However, to accomplish this, he rejected Cards 2 and 5, after only brief exposure. 

One week later, the above procedure was repeated with a further modification. On this occasion, he was instructed to view each SIS inkblot but only to the degree of sensing some minor degree of arousal. Under these desensitization conditions, he rated all cards as 0 with the exceptions of Card 5 (15–25), Card 4 (10–15) and Card 2 (0–10). 

The next week, the procedure was repeated for a final desensitization treatment session. By this time, he was relatively comfortable in viewing all cards. 

<Level B>Discussion 

Clinically, this behavioural therapy was associated with reduction in his anatomical image dysphoria. Moreover, there was a temporal correlation with improvement in his psychological and sexual intimacy with his wife. Consequently, it appeared that he had benefited from this SIS-assisted behavioural therapy. Of course, in such a multidimensional complex treatment programme, it is virtually impossible to sort out efficacy for one modality. Clearly, more sophisticated research designs are required to follow the encouraging clinical leads evolving such pilot studies. 

In contemplating future investigations, it might be helpful to conceptualize further about the possible mental mechanisms underlying body phobia disorder. During critical periods of psychosexual development, it appears that childhood exposure to stressful situations can distort anatomical imagery. In this condition, the threat primarily involves exposure to sensations and emotionally charged images of the body, rather than external physical objects. The resultant concomitant affect can strongly shape perception and cognition, as well as ultimately behaviour. Depending upon the individual’s genetic diathesis, this sequence can play a major underlying psychophysiologic role in symptom formation including sexuality. 

An example of this complex process was presented. The subject had a childhood history involving a relatively weak father figure, exposure to a verbally abusive mother and resultant distortions in body imagery. Eventually in his marriage, these played an underlying role in his multiple communication and sexual problems. The presenting problem as labelled by his family physician was ‘major depression’—a medically valid symptom, complex and socially acceptable label for seeking therapy. However, it turned out to be much more complex. Apart from being clinically depressed, based on the original SIS assessment, it appeared that problems related to sexuality needed to be resolved. 

Consistent with such complexity, evaluators of SIS anatomical responses are advised to keep in mind the following principle. Distorted body image affects and its cognitive misinterpretation, not only can relate to the suffering person’s own body gestalt but also that of psychologically significant others. This is essentially a ‘dehumanizing’ conceptual model. During extreme psychological stress in childhood, anxiety reducing dissociative defences become activated. In such situation, the child may sense leaving the body only to view it from an imaginary safer distance. Frequently, victims may perceive their perpetrator’s body in a concrete and primitive manner. Such distortions as illustrated in the above case study can underlay a variety of clinical problems. One involves the victim’s tendency to sexually identify with the perpetrator’s body gestalt. 

Historically, conceptualizing about such cases provided my original insights into the importance determining the original somatic focus of projected anatomical responses. These not only can reflect altered awareness levels for the assessed individual’s own body but also that of other psychologically significant people. Frequently, the detailed enquiry will throw light on the image’s original reference. Sometimes for clarification purposes, other techniques should be employed to clarify the root source. With children, sand tray with figurines and art therapy involving human figure drawings can assist in the interpretative process. Other approaches include verbal association tests with key anatomical words, analysing the body symbolism in dream imagery, and, as an additional example, measuring organ-specific physiologic activity as it relates to sensory feedback awareness. 

Finally, from the historical standpoint, it is noteworthy that this early work also established the importance of establishing an operational plan utilizing projective data reflecting the hierarchy of organ dysphoria. This facilitates the introduction of a SIS behavioural therapy programme that may provide additional therapeutic potency.