Case 25: The Use of the Rorschach, SIS-I and SIS-II in Releasing Somatic Grief
SIS (SIS-I and SIS Video) and the Rorschach test were administered to a 42-year-old female patient (named X in the Case discussion). SIS and the Rorschach were able to bring out her inner cry and depressive contents related to her father’s death due to cancer and her own recovery after cancer. SIS images have been found to be powerful media to take the person back in time and creating hypnotic-like effect, helping the person in catharsis and finally proving to be an effective therapeutic tool. Responses given by the patient on the Rorschach and the SIS-I and SIS-II Video are interpreted using content analysis and psychoanalytic interpretations.
The subject of death has been explored from several standpoints (Kubler-Ross 1969). When a parent dies, the psychological impact normally is very great (Myers 1986). Sometimes, the grief may be prolonged over the course of several years (Doka 1989), resulting in major depression and various conversion reactions involving the experience of somatic pain.
There are many stages in the grief process. One involves the appearance of the deceased person’s body or aspects of the body in the subject’s dreams (Von Franz 1984). This is one way for the subject to experience spiritual and psychological contact with that individual and to deny the pain of the loss so that sleep can occur. The dreamer, when awake, realizes that it is ‘just a dream’, and will then feel the emotional discomfort and continue in the normal grieving process. Occasionally—especially at night—the images of the deceased will spill over into conscious awareness in the form of hallucinations when the deceased person appears as a ghost-like figure and sometimes talks. Lay people refer to these hypnologic phenomena involving images of the departed loved one as ‘ghost’.
Images of the deceased person’s body may be projected onto inkblots (Cassell 1980) and video stimuli having human and anatomical content. This process will be illustrated by presenting the case history of a woman who had lost her father several years ago resulting in depression and who required antidepressant medication. Psychologically, she closely identified herself with him in her own body gestalt. She had developed painful somatic symptoms in her chest, mimicking those which he had experienced in dying lung with cancer.
A transcript of a video interview with this grieving person is given as follows:
Dr B: I appreciate your coming here today and could you tell us a little bit about the extent of your depression and how it relates to your father’s death and so on?
Dr X: Miss him. I could always talk to him. He made me feel good. And even now I sometimes still feel it was my fault that he was sick.
Dr B: What was his sickness? Could you tell us?
Dr X: He had cancer and it went into his bones and then he died shortly after we got back. We were gone when we found out that he had cancer. And we got back to home in Aug 1982, and it just wasn’t my father.
Dr B: Yeah.
Dr X: He had changed quite a bit from the chemotherapy and that.
Dr B: What were the changes you saw in your father with this cancer and how did that impact you at the time?
Dr X: Well, when I first saw him, he was sitting in the corner of my mother’s kitchen; he was just a little thin old man with hardly any hair. He couldn’t talk because he’d had a couple of strokes and he had a hard time with that.
Dr B: How old was he at the time?
Dr X: He was 56.
Dr B: So that must have been hard for you to see that?
Dr X: Especially when I saw him the summer before and he was very weak. We had gotten closer and I guess I could just talk to him.
Dr B: Could you tell us if you had images of your dad in dreams?
Dr X: Yes, he looked like my father and not like this person that I saw when we came back.
Dr B: How would you feel when you saw your father the way he used to be in your dreams?
Dr X: Secure.
Dr B: Yeah, you loved your dad. And then when you’d wake up how would you feel when you realized it was just a dream?
Dr X: I would feel very upset, when I woke up and found that he wasn’t there, that was the dream and that the dream I have of being with him was real.
Dr B: Did you ever have visual experiences or sense his presence in the waking state?
Dr X: Yes, sometimes I’ve walked through the malls and might have gotten a glimpse of someone, a gentleman walking or shopping, and I would have to look again because I thought it was my father.
Dr B: Yes, I appreciate your sharing. I know it’s very painful. It will help to continue in getting some of the grief out. One of the things we noticed was when you looked at these inkblots, you saw things resembling your father. And at this time, I am going to have Dr Dubey go over the results of the Rorschach test with certain cards, so I’d appreciate if you would share your experience with him as well. OK, thank you!
Dr D: I would like to know little more about the responses on Rorschach cards that you have already seen. On Card #II you saw something like ‘cancer cells….’
Dr X: It’s just.
Dr D: Would you like to tell something more about it?
Dr X: It just reminds me of the cancer cells eating him up inside and he is having a hard time not being able to speak because of the strokes.
Dr D: I’m sorry. Does it remind you of something else?
Dr X: Just the cancer and the blood. Wondering where the blood went because my father was cremated.
Dr D: On Card #VIII you perceived ‘there is an arm in the centre and there are two persons grabbing and pulling me down’. Would you please tell little more about this?
Dr X: They were my son and my mother, you know it just feels like I try to talk to my mother and I try to do what she wants me to do and I try to please her and to please my son too and I can’t do it. I’m having a hard time.
Dr D: Yes. Of the two persons, one is your mother and the other one your son, is that so? And are they helping each other?
Dr X: Well, my son, he tries sometimes. He sticks up for me when he knows I’m being pushed into a corner. He has this feeling. My mother, I love her, but I have a hard time getting her to stand by me.
Dr D: Maybe it reminds you that when you really needed her help she was not that helpful?
Dr X: She thinks it’s all in my head.
Dr D: Take care. On Card IX you saw ‘a person hiding behind and feeling ashamed like me’. What makes you feel like ashamed?
Dr X: I’m just ashamed of myself because I can’t seem to do what everybody wants me to do and like I said before, I feel responsible for my father’s death. For being bad when I was younger. And I just don’t want anybody to see….
Dr D: So you think yourself as a bad girl and your father was being punished for your mistakes.
Dr X: You see, I came up here. We were in the States and I came up the summer before for vacation. I was under a doctor’s care there and I was having some problems and I didn’t spend the time I wanted to with him then. And we were getting closer and closer together and I had to leave. It was recommended by a doctor that I go back to be with my doctor there, so I had to cut my trip short and leave him before we really got a chance to get a lot of things said.
Dr D: On Card X you perceived ‘this is an explosion. There is something coming out of mind’. What makes you to think like that?
Dr X: It makes me think of me. I keep a lot of things inside. I don’t yell that much at my son. I just let things that happen to me to myself and then when it reaches a certain point, I just lose it. And I try to talk and explain what’s going on and I can’t because I’m so nervous and crying and then when it’s over I feel ashamed. I feel like I’ve done something wrong.
Dr D: And by seeing ‘something is coming out’ might be giving a sort of release, release of tension.
Dr X: By not keeping it in anymore. By finally saying something to someone. Like I say I have a hard time because I just start crying and shaking and I can’t get it out. I just sometimes feel like I want to explode because I can’t take any more.
Responses on other cards of the Rorschach were normal and clinically not relevant for interpretation.
Dr D: Let us review your response on the SIS-I. You have selected Card #20 as the most threatening image to you. And on this card, you have perceived, ‘it’s like death coming to me. May hurt me’.
Dr X: It’s just coming to get me. I think about it a lot and I, like I say, I’m afraid of dying. And it’s coming.
Dr D: Are you still so much afraid that it might come at any time and it may hurt you?
Dr X: I’m afraid that it’s gonna come very soon and I worry about my son when it happens and my husband but mainly my son. I don’t feel I have done very well as far as health goes this year and I’m scared. I don’t want to die right now.
Dr D: On Card #12 you have seen ‘blood’. May be the card is of red colour and probably this red colour reminds you of blood. Would you like to share your feelings?
Dr X: It’s mine, my father’s; you know everything. All the problems that I’ve had where I’ve lost blood and my father losing all his blood somewhere and it’s just all together.
Dr D: Please take care. On Card #18 you have viewed ‘the gate of hell’. Would you like to tell about this gate of hell?
Dr X: Well, it just looks like the gate of hell. The teeth are the gates that are opening that you walk through. The eyes are watching you to make sure that you do come. It’s like it’s waiting for me. That’s where I’m going to go because I wasn’t good.
Dr D: Yeah. Is it the whole image or just the eyes watching you and waiting for you?
Dr X: It’s the mouth opening and as I go through closing in on me.
Dr D: Does it still remind about your father?
Dr X: I’m afraid that’s where my father is.
Dr D: On Card #5, you said ‘pain’. What sort of pain?
Dr X: It’s the pain eating inside. The pain that my father felt. The pain that I feel when I need him and he’s not there.
Dr D: Can you imagine this red spot inside?
Dr X: It’s like a disease.
Dr D: What disease?
Dr X: Cancer.
Dr D: Yeah.
Dr X: I’m scared of cancer. I had it once before, got over it but it kind of. It’s like, first they said the cancer is looking good, that it was getting smaller and then suddenly, he started getting bone pain and it was in his bones.
Dr D: It’s very painful to think of your father and his disease. This is Card #6. Right here you have perceived ‘a child in tension’. Can you tell more about this child?
Dr X: Well, the child is used to having just a mother around and now he had to learn that the mother has met someone and that they are going to be husband and wife and that the mother must build her life around the husband and the child doesn’t understand it because he had always had the mother’s attention.
Dr D: Does this child remind you of anything?
Dr X: My son.
Dr D: Yeah.
Dr X: Yeah, it was just him and I for quite a while and then I met my husband and I tried to please, you know my son and my husband. It was hard. My son needed to build his life around us and you know we had problems because I would be upset when my husband would punish him. I would say things in front of my son.
Dr D: Just to save him?
Dr X: Yeah, and I shouldn’t have. I should have known. I just wanted my son to grow up and be loved. You know he deserves that.
Dr D: Yeah, and now the last image, Card #19. Here you saw ‘something is dying’. What is that?
Dr X: It’s like the slow death my father had. I mean it was fast, but yet it was slow and painful. A person or thing is just lying there helpless and not being able to move or say anything. Occasionally, he opens his eyes, looks around and sees that the family is there with him. There is nothing he can do, he tries to speak but cannot, and just slowly starts dying.
Dr D: Take care. Would you like to review some of your responses on SIS Video? In Image A2 you perceived ‘a bad life with lots of uncertainty’. Would you like to tell about this?
Dr X: I don’t know what’s going to happen next. And it has been a bad life, maybe not for me, but I have put my husband through an awful lot and my son. Insecurity had made me afraid that my husband would find someone else. Someone, who is better for him; I give everything I have, but sometimes I don’t feel that it’s enough.
Dr D: On next Image #A3 you saw ‘it’s flower and beautiful’ but later you said that it’s a flower with roots and an insect is eating the roots.
Dr X: That’s what it looked like.
Dr D: Would you please elaborate little more?
Dr X: It’s just that there are some things that are beautiful and some people that want to destroy them. And my husband is a very good man and sometimes I feel that I am dragging him down. So I feel like I’m the beetle eating the roots because I kind of affected his career also.
Dr D: It is very painful. Let’s go ahead on Image A13. You have seen ‘man’s hand reaching for help’.
Dr X: My father reaching from the pits of hell. My father wasn’t a bad man, but he had problems and….
Dr D: Did he get the help he needed?
Dr X: Sometimes.
Dr D: On A21 you have seen ‘a man is being torn apart by sickness’. Who is that man?
Dr X: My father being torn apart with cancer.
Dr D: You perceived on A26 ‘baby trapped in a ball and that baby is not able to come out’. Will you please like to describe about this?
Dr X: I had to have a hysterectomy because I had cancer and my sister was pregnant and she didn’t want to have any more children and she went and had an abortion.
Dr D: Take care. In Image B2 you have seen, ‘cancer eating up all good cells’. So again, you are thinking….
Dr X: My father.
Dr D: Let’s proceed to Image B3. You perceive ‘two people, man and woman sitting in a house on fire’.
Dr X: It’s, I don’t know, it just looked like that two people were sitting there and they really didn’t realize what’s going on around them.
Dr D: And **in Image B9, you have seen ‘bad lungs’. What do you mean by bad lungs?
Dr X: My father had lung cancer and the last chest x-ray that he had didn’t look too good and it just scares me.
Dr D: I am sorry.
Dr X: ‘Because I don’t want to die of cancer. I don’t want to go like my father did.
Dr D: On B20. You saw ‘brain covered with bad cells’. What is that?
Dr X: Cancer cells in the brain.
Dr D: Last image on SIS Video B22, you saw ‘a man lying down with a bad pain’.
Dr X: Intense pain. Fire in his stomach. It just looked like that his stomach was on fire.
Dr D: Can you tell more about this?
Dr X: It was like fire, you know the smoke and uh the pain and my father were hurting very badly in the hips and around there.
Dr D: Hope it has helped you in releasing lots of emotions and sad feelings.
Dr X: Well they are.
Dr D: How do you feel after taking the test?
Dr X: Drained. Sometimes better. And then sometimes it just brings up memories of watching my father die in the hospital. Because we didn’t leave his side until the end. Because my husband was stationed in the States. And I was in and we found out we were coming back. Just before we left I was in a PI ward in Virginia and they were trying to help me. They were trying to help me to get, I guess, get ready for what I was going to see. It was a really big change and….
Dr D: It’s very painful.
Dr X: I guess nobody could prepare you for that. But then when he went in the hospital the last time, I stayed there day and night, all his kids did. We slept on the floor and in the hallway. We all stayed there with my mother until it was over.
Dr D: Thank you for sharing your feelings with me. We’ll be meeting again.
Dr B: Dr D, thank you very much for the sensitive and probing interview with Mrs. X. It seems we have a powerful approach with the combination of the Rorschach and the SIS (card form and then the video). As I indicated to you, a sensitive, caring psychologist and a patient with enough ego strength that she can face pain even though the grief goes back several years and is very intense. I wanted to ask you some questions in terms of how you feel the Rorschach and the SIS helped us clinically. And especially as it relates to therapy. As you know I have been very interested in a content analysis approach. I had the privilege years ago of working with Professor Seymour Fisher on the Rorschach and SIS anatomical responses presented by people who had somatic symptoms. Ultimately, I realized that we needed projective stimuli with more anatomical content and so on and have been stimulated originally by reviewing some of Dr Schafer’s work on the psychoanalytic content analysis and others more recently like Lerner (1991). It was fascinating for me to realize that you had met Piotrowski towards the end of his life and that he himself was interested in psychoanalytic content analysis. Could you share about that please, especially in terms of Mrs X’s responses?
Dr D: I use both the tests, SIS and Rorschach, clinically. The SIS provides more vital information and it is a quick test for diagnosis and screening. The SIS is backed by theories of body symbolism and inner cry (Cassell 1980). The theories are very impressive and exciting. About 40 per cent of cases in hospitals, particularly in psychiatric set-up, have psycho manifestation and the causes are psychological in nature.
Dr B: Exactly. A lot of people cannot verbalize their emotional issues and tend to somatize. In medical set-up, physicians and nurses who focus on the physical symptoms do not imagine the impact of such emotional issues. Many either do not have time or the training to work on the psychological issues is not adequate.
Dr D: So the test is very helpful in detecting the psychological problems, the inner cry of the patient as in the case of Mrs. X. The medicine (antidepressant) may help her in managing physical symptoms and SIS images will help her in processing deep-rooted emotional trauma. Her problem is probably because of her psychological/emotional attachment with her father, which she is unable to resolve after his death.
Dr B: The antidepressant medicine helps her to feel better symptomatically. The symptoms are removed and so on, but it doesn’t get to the core difficulty, the grieving process and her irrational thoughts.
Dr D: Exactly. As you have noticed that the SIS images have created hypnotic-like effect and she started verbalizing with her inner cry. It helps in understanding the psychopathology of the case and releases tensions of the person undergoing the test. And you could notice her face; she was feeling released and cheerful.
Dr B: She got relief. As time goes on, in my own career, I have really moved from an interest in the diagnostic aspects to the therapeutic and I am much more interested in the techniques that help people, which release feelings and help them understand themselves.
Dr D: Many psychologists working in educational institutions and not really trained in handling patients/clinic population do not believe much in inkblot procedure. They believe more in questionnaires because they do not require any training and sophistication in interpretation.
Dr B: That’s right. It’s also true in this country that some of the authorities who give seminars on Rorschach do not see a broad range of patients anymore. They are so removed that they’re missing some of the richness of clinical work. I wonder if we could go through at this time and have you comment on some of the specific colour responses. Please begin with her Rorschach responses and then SIS.
Dr D: All four Rorschach Cards #II, VIII, IX and X were very informative and effective in this case.
Dr B: Yes.
Dr D: She was very upset while viewing chromatic cards.
Dr B: They carry the punch in terms of the affect.
Dr D: She was unable to control her emotions and all through she was sobbing. She was crying like a child during the interview session.
Dr B: Yes. So she really went back in time to the original loss of the father. So this pulled her back and facilitated release of the pent-up grief.
Dr D: Right. And it is difficult to score such responses under closed scoring categories. For example, on Rorschach Card #VIII, she says ‘I feel like as I am in the centre and two persons are pulling me from each other, and that one side is my mother and on the other side my son’. Such responses can be interpreted only by using content analysis.
Dr B: Correct.
Dr D: And this is how the clinician can hear the inner cry of the suffering individuals.
Dr B: It makes it more real when you have a stimulus than just talking in generalities in an interview.
Dr D: Exactly. And on Rorschach Card #IX again she perceived ‘a person hiding behind and feeling ashamed like me’. This is true projection, which one can never imagine on questionnaires.
Dr B: Yes.
Dr D: And such feeling that ‘I have let them down, especially my father’. ‘I feel like I am a bad girl and my father is being punished because of me’, is common in paranoid schizophrenics. However, such responses are possible due to excessive unreleased grief and feelings of guilt.
Dr B: Right.
Dr D: And based on such responses she cannot be categorized with paranoid symptoms.
Dr B: That’s right.
Dr D: Such responses can be explained only through psychoanalytic interpretation.
Dr B: Yes.
Dr D: She felt that as a child it was her duty to help her father whom she could not do and because of this she is calling herself a bad child.
Dr B: So it is very important that the therapist ultimately go back and make these interpretations.
Dr D: Exactly, this is what Dr Piotrowski (1985) explained me during my visit to his home at Logan’s Square, Philadelphia in July 1985. He explained that do not give more emphasis on indices such as M, FM, C, Popular and Form and try to understand the meaning behind the responses given by the subjects.
Dr B: Yes.
Dr D: Because after all, what is the purpose of psychological tests? It is only to understand the psychopathology of the patient.
Dr B: We want information which is clinically relevant to the therapy process.
Dr D: Exactly, and that is why out of 62 images of SIS, I was interested only in a few images giving more clues.
Dr B: Right. What is your feeling about rating the images for their degree of threat and then starting with those that are most threatening?
Dr D: The images rated as most threatening helped in understanding the psychopathology of the case. Such images depict specific body percept and traumatic situation which the patient has experienced in past. In fact, it is not the 10 cards of Rorschach, or 20 cards of SIS-I or 62 images of SIS-II but the three most threatening images which will provide you signals to peep into the inner self of the subject.
Dr B: Yes.
Dr D: Maybe out of 20 cards you are interested only in five or six cards for depth interview/analysis.
Dr B: Excuse me. In the book Body Symbolism (Cassell 1980), the last chapter deals with death anxiety. And characteristically, as you know, people deny death as an issue. And we have a technique here on some of those death-related cards you can introduce it clinically and deal with it.
Dr D: Yes, she has projected the fear of death by giving responses such as ‘Gate of Hell’ on Card #18. Further she said, ‘I have to go inside—my father has already gone inside’. One can see the sort of fear and insecurity in her.
Dr B: There’s a lot of rage associated with this. Part of the problem with her is that she hasn’t gotten in grips with her anger for her father for leaving and the way he died and some of the old childhood problems as well.
Dr D: And on Card #19 she said, ‘I’m going to die, and my father died and may be in the near future something is going to happen to me’.
Dr B: Would you be concerned about suicidal ideation with her in view of this death preoccupation?
Dr D: Well, she has maintained ego strength and is attached with her son and husband, because of this the chances of suicide are very less.
Dr B: Yes.
Dr D: She is aware of her medical profile. Her strength is still her consideration and caring attitude towards her family.
Dr B: Yes. She has also a positive relationship with her husband and other people who love her.
Dr D: And if the person has gone through such traumatic experiences, such responses are but natural.
Dr B: Thank you for your most interesting comments. What would you recommend in terms of someone considering the use of the SIS as opposed to existing techniques including non-projective tests?
Dr D: While taking the questionnaire, you are forced to choose yes or no, true or false, agree or disagree. Most of the time, these questionnaires have cultural influence. Contrary to this you are free to project your feelings and emotions on inkblot tests. SIS is the latest and most powerful amongst the inkblot tests.
Dr B: Yes.
Dr D: And in fact, in one of my studies, I tried to find out correlation between Rorschach and SIS, it turned to be quite low, reason being the Rorschach measures the basic personality and is used as diagnostic test. The SIS is a projective instrument and an aid to psychotherapy. It helps in understanding the psychopathology of the case. It further helps to peep into the inner deep and hearing the inner cry of the suffering individuals and you can get more information, which is not possible through other tests. The SIS is not against the Rorschach test, but it is a further extension of the Rorschach test. The SIS was also tried in India during selection and was found to be a successful instrument in getting the right man on job.
Dr B: Yes.
Dr D: So the SIS covers both the aspects, diagnostic as well as therapeutic. The best part of SIS-II and video is its self-administration. It can also be administered in group. It reduces test’s anxiety because the subject is alone while taking the test. It helps in true projection. The test can be taken even at home or while waiting for your turn in the clinic. And because of these qualities, it is the best projective test.
Dr B: And there are variations in the use of SIS test. For example, currently I am interested in administering the procedure at bedtime and seeking at what extent some of the images are picked up in the individual’s dreams by doing the interpretation of dream work the following morning.Well, thank you very much. Dr D, your comments have been most helpful, and I have learned a great deal from you in terms of your own experience with the SIS and sometimes one can get too close to a procedure, but I think it has been very helpful and thank you.
We’ve had the opportunity to look at an individual who has lost her father and see how this has affected her responses to the Rorschach and the SIS both in the card form and the video. Hopefully this material, as time goes on, may be brought up in therapy in ways, which will help her express the inner cry and further move ahead in resolving the blocked grief. As an experienced clinician might well imagine, it is not just a matter of prying at the pain to release feelings. In addition, there needs to be definitive cognitive therapy in terms of helping her deal with some irrational thinking that she has relative to her pathological guilt. Similarly, she needs further insight into how the sympathetic identification with her father’s deteriorating body image contributed to her converting the diseased anatomical imagery into repressed affect, leading to physical symptoms of chest pain and marked cancer phobia.