Case 20: Assessing Suicidal/Homicidal Impulses with the SIS
I have an obsession with death… Death is very intriguing… It’s one of the only great mysteries of man that has never been solved… And it’s just my mind travels on a parallel… Well it really doesn’t travel on a parallel… But it’s like my mind wants to question death… It’s like… it’s almost like it wants to experience it but yet it doesn’t. —JF
After reading about the above quotation describing a suicidal youth’s ‘obsession’ with death, are you beginning to feel a little anxious? As a thinking member of the Homo sapiens species, with a time-limited body, your emotional discomfort is understandable. It means that your optic nerves are transmitting neural impulses containing language symbols to your brain’s visual areas. This is presently enabling your central nervous system to interact with your various memory pathways. Remarkably enough, in some mysterious body–mind–spirit realm, you may begin to ‘think’. The subject involves SIS material that even experienced mental health professionals may find anxiety provoking. After all, epidemiologic studies have always indicated that our profession has high rates of suicide.
Having the ability and opportunity to think about the subject of death is both good news and bad news for you! The former is that you are in the minority of humans with enough neural endowment and education to cognitively process complex symbolic information. The latter is that you will be visually exposed to potentially emotionally upsetting SIS imagery projected by psychiatrically hospitalized suicidal/homicidal Alaskan native males.
While this should stimulate the cognitive centres in your brain, it can arouse secondary empathetic pain in your heart. Moreover, as you read this article, it may also stimulate you to think about your own mortality. In 1973, an anthropological professor of mine, Ernest Becker, wrote a Pulitzer Prize winning book titled The Denial of Death. His thesis was that apart from employing reassuring religious doctrine, most individuals use the mental mechanism of denial in philosophically contemplating their body’s fateby contrast, like the above cited suicidal youth, many mentally disturbed Alaskan natives are preoccupied with their death.
As a clinically relevant background, perhaps it might prove of interest to briefly review the special historical, cultural and socio-economic background features of Alaska. It was purchased from Russia in 1857 for approximately seven million dollars. At the time, most Americans considered this an outlandish price in labelling it as ‘Seward’s Folly’. It has turned out to be just the opposite since the state is a major supplier of natural resources.
Unfortunately, these developments have not always benefited Alaskan natives. Starting with the Russian occupation, foreigners began imposing their values and undermining those of the Alaskan natives. For example, the newly acquired territory was divided up by the various Christian churches. The authoritarian missionaries, priests and educators then became the powerful figures in the remote communities. They taught the children that their native religion was based upon superstition and ‘the work of the devil!’
As the acculturation experience shattered existing related support systems and the integrity of families, a series of predictable public health problems resulted. In schools, children were informed by the outsiders that their difficulties were due to their inferior culture. Moreover, they were punished for speaking in their native language. Eventually, the acculturation stress caused them to self-medicate with alcohol. In some northern villages, upwards of 60 per cent of infants born show evidence of a fetal’s alcohol-induced organic brain impairment. Adolescent Alaskan native males have the highest rate of suicide in USA, a country where someone commits suicides every twenty minutes. Four cases with SIS analysis are presented ahead (Cassell, 2005).
<Level B>Case Studies of Suicide Survivors
<Level C>Case I
The first is a 31-year-old Alaskan native who entered marital counselling with his wife. He had been intermittently suicidal since childhood. When he completed the SIS-II Booklet, a flood of emotionally painful traumatic memories surfaced.
In rating the SIS responses for anxiety/threat, he selected A4 as the most threatening. Here, he split the gestalt of the figure. He projected a childhood memory on the left portion as himself. On the right, he visualized an image of his ‘monster dad’.
In the detailed enquiry with great anguish, he indicated that the latter reminded him of his abusive ‘birth dad’. He gave the following associations: ‘he always beat me up… I was so small, and he was so huge… I really felt inferior!’ At the age of seven, he was placed in a foster home to protect him from his biological parents. During this period, he had PTSD dreams reliving the earlier series of traumas. To him, the SIS-stimulated image of the ‘monster dad’ recalled his childhood PTSD dream symbols.
He selected SIS B15 as the second most upsetting one. He imagined this to represent ‘a window that cuts my arm!’ This brought memories back of an earlier suicide attempt. Because of extensive blood loss, he had almost succeeded. A large scar on his right wrist was consistent with his story. At that time, he was under the influence of alcohol. He had gone into a jealous rage, triggered by learning that his wife had an affair with a Caucasian oilfield worker. She viewed him with a better economic future and more socially powerful, hence more sexually arousing.
The third most troublesome SIS inkblot was B22. He indicated that this reminded him of ‘evil spirits!’ It recalled ‘the enemy trying to put dirty thoughts into his head at night’ and ‘dirty pornographic movies that I replay in my mind’. He indicated that when he had trouble finding meaningful employment as a teenager, he got money as a male prostitute from paedophiliac Alaskan tourists.
Next, his responses to the three SIS inkblots that evoked positive feeling will be reviewed. At the top of the list was A6 which he saw as ‘a kind boy’. He gave associations which reflected childhood wish fulfilment fantasies and day dreams of having a close relationship with his father. However, in the interview, he quickly reverted to negative memories about his father: ‘he never provided me a father image… Sometimes I get sad and cry thinking about him, but I cannot raise him from the dead’.
His next favourite was A10. This brought back fond memories of ‘looking through the rear window of my 1976 Chevy Monza’. Initially, his emotions were positive when recalling fun times with the car. However, they soon became negative as he remembered eventually losing the vehicle when he could no longer compete with younger native male prostitutes.
His third favourite SIS-stimulated projective scene was evoked with A9. He imagined it to represent himself happily dancing with his wife.
Certain other responses to the SIS-II booklet provide a projective window for revealing the past mental interplay between his intense suicidal and homicidal impulses:
A3: ‘The inner man of me.’
A8: ‘Me standing inside my own eyeball looking over my nose towards my wife.’ (This symbolized his jealousy and paranoia-like suspicions.)
A13: ‘Someone drowning.’ (This symbolized him a few years back in an unsuccessful suicide attempt.)
A15: ‘My kneecap dislocated.’ (He had sustained multiple severe injuries from placing himself at high risk self-injurious behaviours.)
A17: ‘A mad wet cat coming inside out of the rain.’ (Here, he projected his inner murderous impulses onto the figure of a cat.)
A18: ‘My broken heart when my wife forced me to leave.’
A19: ‘When I am drunk looking through a wine glass and everything is fuzzy.’
B8: ‘Me looking through a telescope or a gun at the man walking towards my wife.’ (Instead of cutting on himself, he almost shot the man!)
B18: ‘An oriental dagger with blood on it.’
<Level C>Case II
The second case involves a seventeen -year-old adolescent (JF) who reported being obsessed with death. He was admitted to a psychiatric hospital because of severe suicidal ideation. Like the older native man discussed above, he too had a history of severe abuse as a child.
In viewing the SIS-II Video, he rated A30 as the most upsetting inkblot. It reminded him of the past: ‘my mother when she is pissed at someone’. She suffered from severe mood swings and rage reactions.
The next most threatening was A31. This stimulated memories of stressful scenes of his parents fighting. The third most disturbing imagery was evoked by A13. Here, he saw ‘a hand and arm area with a cut on it’. He said that the scene was ‘very scary!’. It triggered memories of few years back when he had first tried to kill himself.
His three favourite SIS inkblots were as follows:
B28: ‘A mother hugging her child.’ It reminded him of the few times that his mother was able to act in a loving fashion.
B31: ‘A happy family.’
A6: ‘Me at the age of eight.’ Here, he envisioned the background figure as ‘a teddy bear’. However, his positive emotions quickly left. He soon was speaking about memories of when his mother was highly abusive.
Certain of the other, SIS inkblots evoked material relative to his suicidal history. These were as follows:
A2: ‘Blood on the floor when I was in the third grade.’ In describing this scene, he became very emotionally upset:
‘My father called me at night and told me to immediately run and get the police. When I was running downstairs to go outside, I looked and saw my mother with a knife cutting deep wounds into her wrist. Blood was squirting out onto her arms and legs. There was a puddle on the floor. It was very, very frightening.’
Following this, he had recurrent anxiety-laden PTSD dreams reflecting in content and affecting his SIS-triggered imagery.
A4: ‘A leech crawling over a puddle of blood.’
A5: ‘My mother when I was six shouting at me.’
A7: ‘A neon sign for a night club.’ Here, he failed to visualize a woman’s gestalt because of his PTSD-induced aversion to female body imagery.
A10: ‘An evil person!’ His self-concept of irrationally blaming himself as a child for his mother’s mood disorder.
A16: ‘A crying person.’ This depicted him at the age of eight, sad, alone and crying by himself at night.
A17: ‘A couple of dragons devouring a heart!’ A horrible scene consistent with the symbols in his PTSD dreams.
A20: ‘An upside-down person with huge feet.’ Like the older native man, he too had frequently engaged in high-risk suicidal behaviour. Shortly before hospitalization, driving while intoxicated at a high speed, he had almost been killed.
A25: ‘A valley and an ugly vagina!’
A28: ‘A bloody arm… like mine was at the age of 14!’
B1: ‘All consuming flames that consume everything.’ This reminded him how once he had almost set his bedroom on fire.
B2: ‘A headless person that has been ripped apart!’ This reminded him of his violent video and computer games.
B15: ‘A shattered window.’ This recalled the shattered window of the truck that he recently had rolled.
B19: ‘A heart eating sea urchins.’
B21: ‘An exploding battery.’
B22: ‘A person’s spirit leaving his body.’ This suggested his suicidal overdose of pills that had precipitated his recent hospitalization. He exclaimed ‘I didn’t want to feel more pain!’
<Level C>Case III
The third case involved a youth who had been hospitalized because of serious suicidal ideation. He had a long history of psychological and physical abuse by his stepfather. He suffered from related PTSD nightmares and rage reactions.
While viewing the SIS-II Video, he selected A25 as the most threatening inkblot. Here, he conjured up an image of ‘a large predator fish or animal which had the capacity to hurt you!’ It recalled traumatic memories of his abusive stepfather.
The second most threatening SIS inkblot was A18. This was simply too anxiety provoking for the traumatic memory to fully register in conscious awareness. The best he could do was report, ‘it is the shape that bothers me’. He was clearly quite disturbed in seeing it again in the detailed enquiry.
The third most threatening SIS inkblot was B3. He said that this resembled ‘a mask!’. His associations revealed a degree of paranoid ideation: ‘I do not like faceless people and not being able to see their eyes!’
Next attention will be directed to certain other responses which appeared to have clinical significance:
A3: ‘A bomb blowing up… maybe a pipe bomb.’ When asked to expand on this, he indicated that it reminded him of ‘a terrorist attack’. He appeared to be fascinated by news accounts of terrorism. He claimed that he had just read the biography of the mail bomber Ted Kozinski. He reported that frequently when he felt angry, that he fantasied about blowing up people. He quickly added ‘I would never do it!’. His response revealed the close approximation in his mind between suicidal and homicidal impulses. Troubled and angry young people like him could be vulnerable to terrorist propaganda. If they were living in certain war-torn cultures, possibly they could easily be manipulated into becoming ‘suicidal bombers’.
A31: He saw ‘two people yelling at each other with a red haze in the head area’. Here, it is significant that he focused on the ‘red’. This was consistent with the rage in his parent’s long-term marital battles. When their anger was directed to him, he would feel alternatively fear, rage and then sadness.
B7: He saw ‘A gas mask’. In speaking about this, he revealed a series of fantasies about being a warrior, soldier, etc., and participating in war. These thoughts were constantly activated when he played electronic war games which can inflame aggressive impulses (Cassell and Dubey, 1998).
B19: It was ‘a broken heart trying to catch the little hearts in tentacles.’ Here the symbolism reflects a mixture between his sad suicidal feelings and his violent homicidal aggressive ones. In speaking about this impulse battle, he emphasized that he no longer could cry. The last time that he had this healthy release for his pent-up frustrations was at the age of seven after his stepfather had abused him. Since this traumatic event, he had dissociated himself from his PTSD pain. While this defence mechanism protected him from inner cry, over time it provided the fuel for his destructive fantasy life.
B27: It seemed to represent ‘twins in their mother’s womb—one bad and one good’. Here the symbolism depicted the two aspects of his evolving adolescent personality. Clearly the ‘bad’ reflected his destructive side.
<Level C>Case IV
The last illustrative case involved a man who had several violent features in common with the first case. He had been episodically suicidal and had survived two serious overdoses. He also had intermittent jealous rage reactions related to his wife’s infidelity and murderous impulses to kill her.
Certain SIS II Booklet responses captured his suicidal/homicidal ideation:
A4: ‘A mad cat!’ This represented the projection of his own rage onto the image of a cat. Prior to hospitalization, when raging about his wife’s unfaithfulness he had killed cats.
A7: ‘A mad female teacher with an apple!’ He claimed that his wife had anger problems and was threatening him.
A27: ‘A woman’s breast being cut by glass!’ Here again the symbolism depicts the murderous impulses that he had chosen to deny, when questioned as part of a standard mental status examination.
Unfortunately, after discharge he failed to have follow-up treatment. Eventually he killed her. Three years later when incarcerated for murder, reflecting his anger and regret for having acted on his unreported homicidal impulses, he selected the scene evoked by B15 as the one that bothered him the most. It may be recalled that this stimulus array was designed to evoke violent fantasies. In the retest situation, he imagined this to represent ‘knives with broken glass!’.
In recent years, American mental health practitioners have seen more violent behaviour. At times, there appears to be almost an infectious and theatrical quality with violence. This applies to both suicidal and homicidal violent behaviours. The former has been studied under the name ‘suicide contagion’ (Davidson and Gould 1989; Gould and Davidson 1988). This refers to the process by which exposure to the suicide or suicidal behaviour of one or more person influences other to attempt or commit suicide. The effect appears to be strongest in adolescents (Gould et al. 1990; Phillips and Carstenson 1988).
An example of the theatrical quality of violence occurred in one northern village recently when an adolescent Alaskan Native youth set the stage for murdering the school principal. He created an audience by boasting in advance to his peers. He informed them exactly where, when and how he was going to commit the murder. On the specified day, he had an appreciative audience of youths when he shot the victim.
As is frequently the case in the United States of America , his photograph and life story were widely circulated in the media. Since murderers have the highest status in any criminal system, this immediately made him a hero with his peers. No doubt, the publicity had some economic value to the owners of the various media enterprises, though unfortunately, it had the potential for educating others concerning the status value of ‘copy cat murder’!
It is amazing how some adolescents can impulsively kill, without an ounce of empathy for their victim. Several years ago, I evaluated such a cold-blooded youth. The crime scene involved him being in the back seat of a taxi with his peers. When the driver wanted to get paid a few dollars for the ride, he put a gun to the back of his head. Reportedly, the terrified victim begged for his life pleading: ‘Don’t shoot! I’m a married man with a wife and children!’ The youth shot him! During psychiatric examination he denied remorse.
Sometimes adolescents murder and then kill themselves. American-Indian adolescents who live on reservations have comparably high rates of violence than their Alaskan counterparts. Recently, such a Minnesota youth went on a school shooting spree. This mass murderer watched a popular movie which provided the format for the ‘copy cat’ violence. While the hero in this film served as a role model, this also points up to the infectious quality of aggression.
The teenager had communicated significant suicidal/homicidal ideation to certain interested peers through the Internet e-mail. Youths who are experiencing suicidal/homicidal impulses now can share and mutually fuel their violent fantasies through the Internet blog groups as well. The technology has also given rise to a new form of abuse referred to as cyberbullying. Adolescents are particularly vulnerable to this and there are now Web resources for those victimized (e.g., www.bullying.org and www.netbullies.com).
American surveys reveal that a high number of young people report having violent fantasies. Yet most mass murders are not committed by adolescents of minority groups. If there is a common denominator in epidemiologic terms, they are much more likely to be perpetrated in society by humans with male gonads.
Before digressing much further, a brief review historically will be presented concerning how the SIS conceptually evolved as a PT for assessing violent impulses. The background is presented in Cassell’s book Body Symbolism (Cassell 1980). The original research began in 1959 with a clinical investigation of the body image problems in women with excessive facial hair (hirsutism). It became apparent that there was a need for alternative assessment techniques, apart from standard interviews. PTs appeared to have promised for investigating the subjective manner, whereby somatic symptoms are experienced in various medical disorders.
This led Cassell to work with Seymour Fisher, who in association with Sidney Cleveland had originally developed two Rorschach measures of body awareness: The Barrier and Penetration Scores (Fisher and Cleveland 1958). In examining Rorschach responses, the possibility presented itself that certain anatomical responses might reflect somatic symptom-related health concerns. As an outgrowth of this, Cassell created the Body Interior Awareness Index (Cassell 1964) and employed this concept in subsequent studies (Cassell 1965, 1969, 1971, 1972).
During this early period of introduction, Cassell observed that many students at Syracuse University projected broken, mutilated and violated anatomical responses. In 1962, he began consulting in the student health infirmary at the university. Consequently, he became familiar with their many stressors, including the ongoing Vietnam conflict. In addition, he had the opportunity to work with George Stern, a social psychologist, in conducting health surveys revealing high rates of psychological morbidity. He realized that it was a mistake to solely relate their pathological anatomical responses to body image disturbances and medical symptoms. It seemed more reasonable to conceptualize certain disturbed Rorschach somatic imagery, as reflecting various forms of mental suffering, including unreported suicidal/homicidal fantasies (Cassell 1977, 1979).
This conceptual model played an important role in the subsequent design of SIS stimuli. For SIS-I, the embedded inkblot material in Card XVIII and XX incorporates structure capable of stimulating the projective release of violent imagery from the viewer’s brain memory systems. For SIS-II, the same principle provided the impetus for designing images B15, B21 and B22. Work to date has demonstrated how this added structure has increased the projective pulling power of the SIS. However, they have added more occupational hazard by exposing the examiner to a higher degree of secondary empathetic trauma.
The four case histories in the present study serve to illustrate how the SIS can provide important information regarding violent fantasies (Cassell and Dubey 1998; Cassell et al. 2002). The direct and symbolic imagery projected can provide new insights enriching those obtained with standard clinical interviews. Members of this society are challenged to pursue this promising line of scientific investigation. We also must learn how to more effectively incorporate its spiritual applications into clinical practice (Cassell et al. 1997, 2001). Perhaps we may improve in therapeutically communicating with suffering individuals like JF:
’ Clearly his ‘obsession’ goes far beyond reality-based cognitive psychotherapy and atheistic scientific interpretation. It demands a religious response consistent with his native culture and SIS body–mind–spirit theory. This could provide the support of an empathetic bridge reaching beyond biological death into the realm of eternal spirituality.