Case 24: Somatic Inkblots Imagery in Transsexual—a Case Study

Transgender is a general term applied to a variety of individuals, behaviours, and groups involving tendencies to vary from culturally conventional gender roles. Transgender is the state of one’s gender identity (self-identification as woman, man, neither or both) not matching one’s ‘assigned sex’ (identification by others as male, female or intersex based on physical characteristics).‘Transgender’ does not imply any specific form of sexual orientation and such people may be identified as heterosexual, homosexual, bisexual or asexual (Layton 1966). 

The word transsexual, on a scale called the ‘Benjamin Scale’ defines different levels of intensity of transsexualism, namely ‘transsexual (nonsurgical)’, ‘true transsexual (moderate intensity)’ and ‘true transsexual (high intensity)’. Many transsexuals believe that to be a true transsexual, a person needs to have a desire for surgery, however, it is notable that Benjamin’s moderate intensity ‘true transsexual’ needs either estrogen or testosterone medication as a ‘substitute’ for or preliminary to operation (Benjamin 1966). 

In addition to the larger categories of transgender and transsexual, there is a wide range of gender expressions and identities which are contrary to the mainstream male–female binary. These include cross-dressers, transvestites, etc. The current definitions of transgender include all transsexual people, although this has been criticized. Intersex people have genitalia and other physical characteristics that do not conform to strict definitions of male and/or female, but they are not necessarily transgender, since they do not disagree with their assigned sex at birth. 

<Level B>Case Mr X 

Mr X, 30 years, male, unmarried, Bengali speaking was referred by a physician to a private psychiatric hospital in Calcutta for multiple symptoms. The main complaints of the patient were gender identity crisis, too much interest in sex-changing surgeries, feelings of being harassed by teasing of peers in childhood, attempted suicide (thrice), unpleasant past experiences, disturbed sleep, distress in working conditions, poor job satisfaction, lack of peace/low mood, anger/irritation, worry about future and low self-esteem. He has severe depression, hopelessness and frustration towards future life. 

His father died in early childhood and he was brought up by his mother in his maternal uncle’s house. He is the only child and has good relationship with his mother. His mother is a working woman and is unable to spend enough time with him. Others in the family are not that much cooperative. Most of the people used to tease him for his sexual orientation by telling him that he looks more like a girl than a boy. He was also teased by his schoolteachers and friends on his sexual orientation. He was abused sexually by a few known friends initially but later he had consensual passive homosexual involvement with them several times. His friendships break up easily causing him to often have relationship crisis. 

The SIS-II was administered to him following the standard procedure (Cassell and Dubey 2003) for understanding his personality profile and unprocessed unconscious material needs to be addressed during psychotherapy. He was motivated and cooperative during testing. The clinically significant responses on SIS-II are discussed ahead: 

A1: He perceived ‘butterfly’ in this image which is not a common response. The butterfly may indicate feminine outlook and interest in feminine objects. 

A2: He saw ‘heart’ in this image which is an atypical response that may depict body imagery and to some extent signs of tension and anxiety. 

A3: ‘Cloud’ may indicate his free-floating anxiety. 

A4: Perceiving ‘chocolate’ in this image may suggest regression to childhood and feministic attitude. 

A5: He has viewed ‘birds’, whereas human figure is the most common response which he has avoided. This probably indicates his disturbed interpersonal relationship with others. 

A6: Perceiving ‘toy’ may again bring the theme of Image A4 and his regression to childhood to avoid problems as an adult. 

A7: ‘Apple’ is a normal response. 

A8: He has perceived ‘planet’ though male sex organ is the most common response on this image. Avoiding male sex organ may indicate his deep-rooted sexual conflict which could be due to faulty gender perception or disturbed sexual role as passive homosexuals. 

A9: He viewed ‘two insects’, whereas two human beings—a male and a female—is the common response on this image. Avoiding two persons may again indicate disturbed interpersonal relationships particularly between male and female. 

A10: ‘Eyes’ is generally perceived normal response on this image. 

A11: ‘Meat (chicken)’ is a passive, aggressive response which may indicate helplessness, frustration and depression. The dead chicken (meat) may also be taken as strong indication of suicidal tendency, which the patient has already tried thrice. 

A12: Perceiving ‘eyes’ on this image may indicate his suspicious attitude towards others which needs to be addressed during his therapy sessions to explore the possibilities of paranoid tendency, if any at this stage. He is unable to continue friendship with anyone which might be an early indication of some serious pathology. 

A16: ‘Small sparrows’ is a beautiful response though most people perceive it as two birds. ‘Small sparrows’ may again indicate his regression to childhood where he feels comparatively more secure. 

A17: ‘Cage’ may indicate his feeling of helplessness and inability to come out of his present situations. 

A21: He perceived it to be a ‘star fish’. Though a tortoise/a big man with two babies are the common responses on this image, avoiding two babies and big man may indicate his perpetuator who had forced sexual abuse during childhood. 

A22: ‘Star fish, sea fish’ might indicate his conflicts with gender role as the common response on this image is spinal column which represents male phallic organ—a conflicting area of the patient. 

A23: He perceived ‘scorpio’ which is a painful insect though spinal column is a common response and avoiding this response indicates his conflicts regarding male sexuality which is the main problem of the patient. 

A24: ‘Leg joint’ is a normal response on this image. 

A25: ‘Female sex organ’ is a normal response on this image. Perceiving female sex organ might indicate his wishful thinking to identify this image as his own body part by taking help of surgery. 

A26: ‘Babies in pregnancy’ is a normal response on this image. 

A27: ‘Female breast’ is a normal response on this image. It may indicate his good interpersonal relationship and closeness with his mother. 

A31: ‘Two faces’ is a normal response on this image though a male and a female have been a better response. Avoiding male and female may also indicate his gender role conflict. 

B3: He has perceived ‘clouds’ on this image though people talking is the common perception. The clouds may indicate his tension and free-floating anxiety. 

B8: He has perceived ‘nose’ on this image which may be an indicator of homosexuality. 

B14: He has perceived ‘water’ on this image though this is a rare response which may represent anxiety and insecurity. 

B16: He viewed ‘scorpion’ on this image which may repeat the theme of his perception on Image A23. The spinal cord is a common response on this image and avoiding this probably indicates his conflicts regarding male sexuality. 

B18: He has perceived ‘insect’ instead of a ‘male phallic organ’ which is the most common response on this image. Avoiding perceiving the male sex organ and perceiving it as an insect may indicate his conflict in the male phallic region. 

B19: ‘Sun’ is a normal response on this image but avoiding two hearts (either side of the sun) may indicate frustration and his conflicts in interpersonal relationship. 

B22: He perceived ‘frozen man’ which is a very depressive response. The therapist must take note of this during therapy session to address severe depressive contents with the help of antidepressant drugs and psychotherapy. This may also indicate severe suicidal ideation. 

B27: ‘Twins’ is a normal response on this image. 

B28: ‘Mother with a baby’ is a normal response on this image. It further indicates his close relationship with his mother. 

B31: ‘Family’ is a normal response on this image. 

As all the SIS responses indicate that he has contact with reality, has moderate ego strength and is free from psychotic ailments (no psychotic features). However, he has shown severe suicidal tendency, poor interpersonal relationships, conflict in the sexual area and gender role with marked depression and frustration. He was treated with the help of drugs and psychotherapy with significant improvement. 

<Level B>Discussion 

Most suicidal individuals when asked by a clinician will report their suicide ideation. Yet, while this emphasizes the importance of detailed enquiry, some individuals successfully hide plans to end their lives. These maybe highly impulsive, yet lethal. For example, early in my first year of psychiatric training in a military hospital, involved a Korean combat veteran who was under my care. Eventually, he improved sufficiently as to no longer appear clinically depressed. Since he denied suicide ideation, my supervising treatment team had judged him safe for his first weekend pass. However, according to nursing reports, his wife rejected him in a phone conversation claiming that she was ‘too busy’ to get him. A few minutes later he impulsively leapt from a hospital window killing himself! 

While I was still dealing with his loss, two days later another veteran jumped to his death from the window of a medical ward. Previously in the hospital, it had been many months since such suicides had occurred. In retrospect, it appeared that this second veteran also had been depressed with undetected suicidal intensions. This object lesson suggested that for certain vulnerable suggestive individuals, suicide may sometimes have a psychologically ‘infectious copycat’ quality. It was for this reason that immediately after the tombstone inscription, student readers were forewarned. 

Predicting suicide in an individual clinical case poses challenges. Most screening questionnaires have definite limitations. They tend to rely on some form of self-reporting by the individual being screened for dangerous impulses. For example, a motivated suicidal person who has previously denied such intent in clinical interviews may well recognize what the test administrator is assessing and consequently falsify answers. 

While this type of falsification may occur in a deceptive individual when reporting responses on the SIS Booklet answer sheet and during the subsequent detailed enquiry, escaping detection is less likely because of the depth revealing power of symbolic projection. Except for B15 (i.e., sharp objects, knives, etc.), B21 (i.e., a gun) and B22 (a dying person’s body and spirit), which were purposely designed to access suicidal/homicidal impulses, the visualization of ‘weapons’ on the remaining images, or the body of a suicide victim should arouse alarm signals. Such responses signal the need for close observation by the treatment team, as well as concerned family members. 

Denial mental mechanisms maybe still more effectively circumvented by the revealing significance of highly morbid symbolic responses portraying open wounds, dying, etc. For example, the response ‘blood’ may indicate otherwise unreported psychotic features. If such pathologic material is seen, the clinician would be well advised to ascertain if the responder had similar ‘nightmares’ with such symbolic imagery. ‘Dream scenes in which the content explicitly portrays suicide of any characters should alert the interviewer to otherwise denied ambivalent suicidal ideations of the dreamer. The person should be considered suicidal if the dream content relates to a suicide scene, only if the individual has not been stressed by such a self-inflicted death of a friend, family member or other psychologically significant individual’. This is because such dreams may reflect a form of loving spiritual communication between the grieving person and the deceased. Otherwise, the individual’s involuntary flood of self-directed violent impulses may be conceptualized as quite comparable to perceived violence from other people or life threatening external traumatic events which activate PTSD imagery during sleep. 

In all honesty, the clinical cases presented merely outline response patterns for clinical consideration as warning signals. No statistical studies have been completed with the SIS, or  any of the other tests purported to effectively identify deep-seated fluctuating suicide impulses. SIS researchers are invited to contemplate the almost impossible task of securing valid data baselines preceding the suicide. 

Recall that modern astronomers now scan the mysterious cosmos with multiple technologies. In an analogous fashion, for a reality-based ‘picture’, SIS students need training to view their projective data within the context of all other relevant scientific methods. 

The paper was designed for training students in SIS technology for detecting, otherwise unreported, suicidal/homicidal ideation with the help of responses projected on Somatic Inkblots Images. Four clinical cases were presented in a case study mentioned in this chapter(Case 11. Assessing  Suicidal/ homicidal impulses with the SIS) to illustrate how SIS technique brings to the surface psychopathology of violent behaviour. A trained SIS psychotherapist can reactivate such imagery under reduced anxiety conditions, thereby enabling psychotherapeutic management and neutralization of dangerous impulses. 

<Level A>Overview of Clinical Cases 

We have tried to emphasize with the help of several international clinical cases, the true universal application of projective testing, particularly inkblots images (the Rorschach, Holtzman and SIS), as a tool for personality assessment, diagnostic evaluation and therapeutic aid. These findings apply to professionals working with suffering souls across a wide spectrum of ages from children, adolescents, and trough out the various stormy passages of an adult’s life. Most of the psychologists are using inkblot procedure as an ‘objective test’ and follow a procedure (such as Klopfer, Beck, Exner, Piotrowski and Rapaport) heavily loaded with indices-based interpretation. While these psychological instruments represent a significant step beyond non-projective tests, since emphasis is placed on numerical calculation, they emerged as a protest against the rigid framework and numerical calculation of forced choice questionnaires involving choosing choices such as ‘Yes or No, True or False, Agree, Disagree or Can’t decide’. 

Modern diagnostic classification systems for mental disorders represent a significant step forward regarding facilitating treatment planning. Historically, these evolved from the international scientific teamwork of psychiatrists, psychologists and clinical investigators. As new findings appear, especially about the less scientifically based personality disorders, these data will be incorporated into psychiatric nomenclature. 

As might be expected, unravelling nature’s complex hidden body–mind–spirit functioning frequently seems like a formidable clinical task. There are many significant variables, which can make what to some diagnosticians seem simple, yet to others, infinitely more complex. Complexity can arise from multiple idiosyncratic case history including genetic factors, age, sex, socio-economic status, cultural differences, etc. 

For severe chronic forms of mental illness, for example, the schizophrenic disorders, the medical model has been proven clinically valuable. For these, their biological roots have been explored by a variety of scientifically based evidence studies. Examples include investigations concerning genetics, epidemiological prevalence, neurophysiologic functioning, psychopharmacology, etc. 

Normally for such disorders, standardized interview techniques which focus on classical symptoms patterns, family history, mental status examination, etc.,  enable a trained clinician to rapidly establish a working diagnosis, a meaningful initial treatment plan and the prognosis. Yet, frequently in the early stages of suspected psychosis, psychological testing may be required for diagnostic clarification. Often as well, there may be other indications for such assessment: for example, to assess cognitive improvement from antipsychotic medication, to detect unreported suicidal/homicidal ideation, to make a valid judgement to establish level of care, etc. If somatic delusions are present, the SIS may be particularly helpful in cognitive psychotherapy for reality testing, patient body gestalt education. Moreover, projective testing can facilitate the early detection of recurrence, when paranoid fears of medication side effects lead to unreported non-compliance. 

In addition, there are many other mental disorders having psychotic and/or severe affective disturbances. These pose similar diagnostic problems, perhaps often better conceptualized for management purposes utilizing the medical model. One important example that fits well into the above conceptual framework throughout the world is BAD. However, medical interviewing to elicit symptoms/signs in a ‘cook book’ fashion has definite limitations. Many of these are quite comparable to those associated with ‘question and answer’ scored non-projective tests. 

Clinical interviewing blends the art and science of human interaction. It involves a two-person communication system. The professional questions the other, while monitoring non-verbal clues as to the verbally hidden nature of the suffering individual’s body–mind–spiritual status. Normally, this approach works relatively well. However, it only reveals verbally to the clinician what the sufferer consciously can recall from memory storage. Thus, it is subject to limitations, like the limited number of words to describe distraught emotions. Material may be held back and not reported for reasons of social acceptability, fearing ‘looking crazy’, etc. 

Despite these, the traditional clinician’s diagnostic interview approach is normally adequate. In comparison with the projective tests under review, it may be compared to a pathologist examining a microscopic slide through a low power microscope. Using this analogy, the various projective procedures presented in this book are analogous to the more powerful electronic microscopes available. Of these, the SIS specially patterned inkblot structure was designed to stimulate imagery pertinent to that experienced by those experiencing tormented mental states. They can access directly, or through symbolism, clinically relevant data inaccessible with interviews. 

Several of the clinical cases illustrate how the innovative technology with the electronic mesmerizing forms of the SIS accentuates the pulling power for the clinicians. Historically, it might be recalled that in the early Rorschach day, psychoanalysts explored the use of Rorschach content in therapy (Schaefer 1954). While Wayne Holtzman scoring system focused on 22 indices, remarkably, in his book, a central case history illustrated content analysis. Later, Paul Lerner published a book entitled Psychoanalytic Theory and the Rorschach which failed to generate much interest. Perhaps this was because it was based more on index-based scoring than symbolic content. While using mathematical summations on the surface appear more scientifically valid, what emerges resembles the superficial psychological data derived from use of questionnaires. In his book, Psychological Testing, 1982, Anastasi claimed that inkblot projective testing often revealed the subjective world of the examiner more than the subject, without truly appreciating the clinical merit. It should be remembered that projective tests emerged as a protest against the rigid framework of so-called objective tests. It is erroneous in many instances, with the Rorschach and Holtzman to refer to the index data as ‘projective’ since they reflect primarily the optics/cognition of vision rather than deep-seated memories and subjective perceptions. Perhaps it might be useful for illustration purposes to extend the analogy to modern astronomical technology like the Hubble telescope. This has enabled astronomers to view new aspects of the cosmos to which they were previously blind. Some of their observations have represented enormous steps of scientific value that enabled them to extend the boundaries of existing knowledge. Others have simply been mind-boggling and presented challenges that ultimately involve attempts to scientifically understand the understandable, like what spiritually predated the ‘Big Bang’. 

With the electronic forms of the SIS, prior presentation of mesmerizing electronic audio/visual stimuli hypnotically bypasses psychological defences, thereby reducing neural inhibitions to memory. Without inhibiting effects of the clinician’s presence, this enables the viewer to look back into events from years before, quite analogous to the way modern astronomers view light from ancient cosmic events. When the inkblots containing clinically relevant suggestive structure flow in and out of the viewer’s field of vision for recording on an answer sheet, it is much like an inner cosmic experience. Since these are written down on an answer sheet-like hypnotic writing, deeper memories can more readily be documented. After the viewing process, relaxing audio and nature scenes can serve as a robotic technique to desensitize the viewer to those memories linked with disturbing affect prior to travelling out of the inner world into the external reality of the clinician’s office. 

Like with Hubble, what is seen in the multiple projected responses, as illustrated with the clinical cases outlined in this chapter, normally goes beyond that revealed by clinical interviews. Moreover, they more readily lend themselves to blending diagnostic/psychotherapeutic processes. 

Projective procedures are essential for those who have appreciation and reverence for the hidden mysteries of the body–mind–spirit. These techniques can uncover deeper dimensions than non-projective tests. The latter only access the surface of psyche suffering. Their mathematical rating scales are prone to create an intellectualized barrier between clinician and client. All readers interested in the depth revealing power of the Rorschach, Holtzman and SIS will be exposed to the psychologically toxic occupational exposure to secondary empathetic discomfort. It is predicted that most will find the risk/benefits rewarding.