Case 22: SIS Imagery in Depression with Somatization—Therapeutic Intervention
This case illustration involves a 28-year-old engineering graduate severely depressed woman with multiple somatic symptoms. These included a sensation of heaviness in her head, various discomforts throughout her body and a year’s duration of ‘falling unconscious’. Psychosocial history revealed several significant stressors. The onset of her complaints occurred after her marriage, two years back, when she moved into her in-law’s home. She complained that her mother-in-law was too controlling: ‘Nobody can do anything without her permission. She used to shout at me for small things; she says that I am nothing except my education. She is very dominating and expects that everybody does things, the way she wants’.
Gradually, she started avoiding her abusive mother-in-law, yet she could not avoid her completely. After several episodes of verbal abuse, she began to subsequently imagine persistently hearing her critical voice and persistently feeling anxious retreating to her room. Gradually, she developed more problems. She began experiencing fainting spells and claimed that she used to be ‘unconscious for long periods’. Things got even worse after she gave birth to a child, when her mother-in-law took over total care of her infant. After the first year she could assume some responsibility for the child. Yet her confidence for providing adequate care was very low, consequently her anxiety increased, so did her fainting.
The SIS-II Booklet was administered to uncover psychopathology and as a basis for developing a language for more effective psychotherapy. The significant responses are analysed and discussed ahead:
A1: 1. Looks like an elderly man without head. (This response is a symbolic projection of her weakness and lack of social power in dealing with her mother-in-law’s domination.)
A2: 1. Puppy pushing a piggy. (Here, the ‘puppy’ symbolizes herself attempting to overcome and push out of the way her mother-in-law, to assume care of her own child.)
2. Two persons making whirlpool. (This symbolizes her struggle not to be pulled down in a fainting spell by her socially stronger mother-in-law.)
A3: 1. Looks like a shroud, a magician trying to do some magic. (This may indicate that someone is trying to dominate her.)
A4: 1. Lord Ganesha. (This image of a God-like elephant headed God having a large trunk and big mouth depicts in symbolic form her domineering verbally abusive mother-in-law.)2. Little birdie saying bye. (A symbolic portrayal of her losing attachment with her child.)
A5: 1. A bat flying … Vulture flying… Heart carried by both. (This portrays the vulnerability that she feels. She has a feeling of love for her child in her heart but senses him distancing.)
A6: 1. A sweet teddy bear. (This reflects her positive feelings for her child that she is so desperately trying to care for.)
2. Ball hitting a wicket. (Indicates aggressive contents.)
A7: 1. Lady dancing. (It is a normal response indicating wishful thinking to lead a happy life.)2. Two snakes grabbing food. (May indicate erotic conflict and aggression.)
3. Man throwing a big stone. (This suggests her feeling of being a victim. Quite possibly her husband supported his mother in her criticisms.)
A8: 1. Something hanging in space is leading to darkness. (Here, the ‘darkness’ symbolizes her depression.)
A9: 1. Two persons drifting apart. (This depicts her feeling of separation, perhaps from her husband.)
2. One picture looking like a dragon. (This is a symbolic representation of her relationship with her dominating mother-in-law.)
A10: 1. A picture of a lady with burnished eyes and is crying. (This is a direct projection of her ‘inner cry’. This symbolism provides an important interview lead for her psychotherapist in assisting her to express dysphoria and grief.)
A11: 1. A crow hanging downwards. (Like in A8, this indicates her sense of isolation and depression.)
2. Liver. (As part of her withdrawal from her stressful social environment, she has focused on her own body as a psychological object. Minor body sensations are now experienced as conversion pain and weakness.)
3. Flying dragon. (This represents a symbol of her mother-in-law.)
A12: 1. Small baby. (Her longing for her child is reflected in this response.)
2. Jesus Christ. (Her extreme sense of suffering and betrayal maybe causing her to identify with religious symbolism of being abandoned and crucified. Alternatively, this can reflect her reaching out to God for help.)
A13: 1. A hand being surrounded by small insects. (This symbolizes the ever-present stinging criticisms that she is bombarded with on a daily basis.)
2. Human brain. (No doubt her social stressors are flooding her mind, making her more conscious of her thinking. This plus her headaches are determinant of this anatomical response.)
A14: 1. Water being spilled in a pit through a pipe. (This depicts her perception that everything has gone out of her control.)
A15: A baby hanging and being engulfed in darkness. (Her stress has caused her to mentally regress, feel helpless and at times faint. She is engulfed in a psychological sea of dark depressive emotions. Not only does she need psychotropic medication, she also requires psychotherapy, both individual and family involvement is indicated.)
A16: 1. Two birds playing. (In spite of her hopelessness, she still clings to the notion that everything will work out in the future in her marriage).
2. Plant growing. (She has benefited from her initial psychotherapy and sense personal growth occurring.)
A18: 1. A wolf being surrounded by two big dragons. (This response symbolizes her family situation involving the mother-in-law and one other controlling person. The family psychotherapist needs to ascertain the identity of the other ‘dragon’. Perhaps her critics have depicted her as wicked wolf eating their resources.)
A19: My head is aching while watching this picture. (While the symbolism described above has served to defend her from facing directly her family stressors, eventually the release of the stressful underlying imagery triggered one of her main somatic symptoms.)
A21: A starfish … Small baby and another baby crawling. (Taking care of her child is on her mind).
A22: 1. A monster with heads joined and a horn coming out of it with claws. (This again symbolizes her threatening family situation.)
2. Two baby elephants. (Again, the heightened awareness of ‘baby’ imagery.)
A23: 1. An Alligator. (A threatening image depicting her fear of being harmed and being attacked.)
2. Small birdies sitting one over the other on a pot being balanced on a stick. (Her interest in her child causes her in this response to see ‘small birdies’.)
A24: 1. A set of babies being held by someone. (Baby imagery continues to flood projective awareness.)
2. A monster with fire in his hand towards left. (Another response like in A22.)
3. A big lizard. (Like A23)
A25: 1. Like a candle’s flame. (This might indicate her repressed conflict in erotic area.)
2. An owl looking scary. (This indicates her feeling of insecurity and suspicion.)
3. Lizards. (Erotic connotation is projected through this response. The therapist should explore this area during therapy.)
A26: 1. An elephant resting. (Normal response)
A27: 1. A cave. (This might indicate her conflict in erotic area.)
2. Volcano bursting. (She feels like bursting from the tremendous flood her ‘inner cry’ attempting to surface.)
3. A cat holding something long like a snake in its mouth. (Disguised sexual feelings.)
A28: 1. A wolf standing behind a tree. This again symbolizes her threatening family situation.)
A29: 1. A deep groove beside a flat hilltop.
2. A crow in search of food. (This indicates her insecurity.)
A30: A human skull. (Normal response)
A31: 1. A boy with a cap is running.
B1: 1. A cloud of gas looking like an octopus.
2. A man falling with high speed.
B2: A monster running after snatching a kid. (A direct portrayal of her mother- in-law taking her child.)
B3: 1. Two persons watching horror movie in cinema hall.
B4: 1. A dead female (female ghost/witch) with bloody eyes and mouth and no nose. (On the basis of this death symbolism, it is important for the clinicians providing care to check for unreported suicidal ideation.)
B5: A man and a woman sitting on chairs in a tent with some hanging lamps.
B7: 1. A leaf being eaten by small insects. (Indicates her helplessness.)
2. A flower garland. (Normal response)
B9: Human kidney turned upside down with bladder upwards. (Normal response)
B10: A kid hiding from a dragon between two big wild leaves.
B11: 1. Two men with big nose and wounded forehead. (This depicts in symbolic form conflict at home, possibly between male figures over the child’s care. The wound may again relate to her headache, now activated by the stress of the test procedure.)
2. A hat. (Normal response)
B12: 1. A cruel magician with a big nose ring.
2. Dragon holding a kid’s head. (By now the reader can interpret this symbolic material consistent with the above formulation.)
B13: 1. A giant robot. (This may indicate authoritarian figure with aggressive contents.)
2. Hawan kund. (This may depict her feeling of being burned or sacrificed by the family.)
3. Lord Ganesha. (This may indicate her spiritual strength while feeling helpless.)
B15: 1. Fire crackers. (This may indicate her aggression and hostility.)2. Many grasshoppers and spade-like knives attacking someone and the person trying to protect himself with his rod. (At this point in the protocol, hopefully the reader has learned to interpret the reoccurring symbols depicting her stressors.)
B17: A burning heart and flames coming out of it. (The symbol of a ‘burning heart’ may be translated by her psychotherapist during therapy to more effectively release her ‘inner cry’ than traditional language for suffering).
B18: A big anaconda-like snake in sea trying to pass through a groove. (This may indicate her insecurity.)
B19: 1. Sun being broken into pieces. (This indicates her depressive contents.)
2. Insects trying to enter moon. (The insects may connote her mother-in-law who is intruding in her life.)
B20: Human brain, small insects eating it. (Here, the ‘insects’ symbolize her threatening thoughts and upsetting emotions impinging upon her consciousness.)
B21: A leaf. (Normal response)
B22: 1. A man sleeping and lost in his dreams. (This may indicate her wishful thinking to have good time.)
2. A man drowning in water but protected by a shield. (Prior to initiating treatment, she had a depressive sense of hopelessness. However, now she is hopeful about the future, now protected by the ‘shield’ of her psychotherapist.)
B23: A big spider falling from the wall with a broken stick in its two legs. (Another threatening symbol. She senses a feeling of having a mental ‘breakdown’.)
B24: 1. Aladdin’s lamps in water. (This may indicate her wishful thinking that some spiritual power may help her in improving her present condition.)
2. A saint standing on a flying carpet. (This indicates her feeling to flee from the present environment.)
B25: 1. Future being seen in a magic bowl. (Feeling of insecurity and depressive contents.)2. Fire burning in a cave. (This might indicate her repressed conflict in erotic area.)
B26: Leopard and a ghost. This may indicate her insecurity and fear of being tortured by her mother-in-law.)
B27: A newly born child and another foetus. (Normal response)
B28: An old lady thinking and looking scary. (Here, the symbolism again refers to her dominating mother-in-law.)
B29: A man running towards light. (In spite of all her stressors, at a deeper level of awareness now that she has initiated treatment, she has hope—symbolized by moving towards ‘light’.)
B30: 1. Right and left ear closed in a glass bowl. (Normal response)
2. A man coming out of right ear. (While she has no overt psychotic clinical features, this response has a bizarre quality.)
B31: A happy family—ma, pa, two kids. (This response, like B29, again points to a positive prognosis.)
It is evident that many of her SIS projective responses reflected the severe extent of her depression. The symbolic imagery revealed in a disguised form her family stressors and her ‘inner cry’. Even though she was an adult, her mother-in-law’s criticisms greatly undermined her sense of confidence. It is understandable that her extreme vulnerability led her to somatize her feelings and imagine ‘fainting’. Yet her initial response to early psychotherapy had begun to restore her image as being a competent mother who cares for her child. The rich and graphic SIS symbols now need to be effectively translated into the language of psychotherapy making up for the paucity of words to describe emotions.