Case 27: Treatment Resistant Anxiety Disorder (TR-AD): Gestalt views and SIS Projection

The client is a 50-year-old, married male, working as a schoolteacher, hailing from a middle socioeconomic status, nuclear family presented with a history of anxiety symptoms spanning over three decades. His difficulties began at the age of nine, following an episode of gastrointestinal distress after a meal at a relative’s house. Since then, he developed a persistent fear of vomiting, heightened bodily vigilance, and anticipatory anxiety, which he linked to his grandmother’s history of migraine. During the same period, his sister’s seizures and hospitalization intensified his feelings of helplessness, restlessness, and somatic tension. By late childhood, he exhibited obsessional features, including prolonged bathing, repeated washing, and excessive time spent in the washroom, particularly before examinations or travel. These rituals were accompanied by worry, muscle tension, and fear of losing control in public situations. At around 11 years of age, he developed phobic anxiety, with intense fear of lightning, thunder, and flying cockroaches, leading to avoidance behavior and safety measures such as carrying insect spray. Through adolescence, he reported excessive exam-related worry, irritability, disturbed concentration, and physiological arousal. At the age of 20, he fainted while travelling to college, an event that marked the onset of persistent fears of fainting, autonomic hyper arousal (palpitations, sweating, nausea), and recurrent vomiting sensations. These symptoms were most pronounced in stressful situations, public places, and during examinations or long-distance travel. 

Three months later, in 1994, he consulted a psychiatrist in his hometown and was prescribed medications which provided relief for about three months. As advised, he also sought psychotherapeutic help, where he was recommended relaxation training, cognitive restructuring, and stress reduction. After 3 months of therapy, he reported improvement and subsequently discontinued both medications and the psychological support. Three months later, he experienced symptom relapse, particularly while attending teacher education training. The same psychiatrist prescribed Aripiprazole, which improved his concentration but he was still feeling tense. Discontinuation of medication precipitated withdrawal symptoms, including shivering, palpitations, breathlessness, and nausea which prompted the patient to restart medications. Despite adherence, symptoms persisted. Approximately a decade later, another psychiatrist prescribed Sertraline and Clonazepam. The client reported being “encouraged to marry and seek employment” as part of treatment advice.

He married at the age of 36 on the advice of an astrologer and has remained married for 14 years, with one daughter. Initially, he denied marital problems but later expressed frustration, including reduced intimate relationship over the past five years, attributed partly to diabetes. According to his wife, the client had no observable major difficulties apart from recurrent complaints of underemployment, frequent worry, occasional irritability, lethargy and daytime sleeping during holidays. She also noted his repeated expressions that he could “live a luxurious life if he won the lottery,” indicating dissatisfaction with his socioeconomic status.

Two years prior to referral for psychotherapy, the client consulted a psychiatrist (Dr. V) due to worsening anxiety. While on medication, he denied major sleep disturbances; however, he described occasional morning low mood, feelings of helplessness, and intermittent suicidal thoughts. His predominant concerns revolved around ‘his psychological dependence on benzodiazepines, insomnia, fluctuating anxiety which was work related’. These episodes were marked by nausea, palpitations, shivering, dizziness, restlessness, and impaired concentration during teaching, lasting for hours together. Even minor health issues precipitated these attacks. His medical history was notable for diabetes mellitus, hypertension, and hypercholesterolemia, for which he was on regular treatment. As his symptoms persisted without relief and the difficulty weaning off from the medications remained unresolved, he was referred for psychotherapy.

The Clinical Global Impressions scale (CGI) is a widely used clinician-rated tool with good inter-rater reliability that measures global improvement and treatment response (Guy, 1976), and it has been effectively applied to calculate clinically significant change in routine clinical practice (Kelly, 2010). On CGI, his retrospective score at the time of seeking help 2 years ago was rated as >1 (Kelly, 2010), and at the time of referral and after therapy sessions, his score remained unchanged at >2. This indicates that the client showed minimal to no clinically significant improvement across the course of treatment, suggesting persistence of symptoms and non-responsiveness to appropriate interventions.

Findings and Discussion:

The client gave 72 responses (Set A: 38; Set B: 34) and he perceived 22 responses as “not a pleasing one,” and 3 were described as “pleasant.” The pleasant responses included: Card 5A: “It’s a pleasant picture 1. A bird at the bottom, not a scary one; 2. Symbol of love; 3. Another bird at the top, together, looks like an emblem.” Card 6A: “1. On one side a doll, 2. On the other side is a toy, a pleasant picture.” Card 31B: “Father, mother, boy child and a girl child, this is a pleasing picture.” He gave six “emblem” responses, of which all but one was perceived as unpleasant. A symbolic psychoanalytic interpretation of an emblem views it as a manifestation of unconscious conflicts and desires, stemming from repressed thoughts and early childhood experiences that are indirectly represented by the emblem's imagery. The emblem of its meaning is both the object itself and a substitute for a hidden, unconscious thought or feeling, providing a delayed form of gratification or expression. Additionally, there were 9 Human Movement (M) and 5 Animal Movement (FM) responses, and all were popular responses that ruled out underlying psychotic processes. A few clinically significant responses projected on the Somatic Inkblot Test were interpreted using content analysis, symbolism, and a gestalt perspective by the co-author (BLD), who was blind to the client’s clinical history.

Image A4:  “On the side, one person standing with hands raised. On the other side, a person with anger, harmful person”. The client might be projecting the aggressive behaviour of a person who has raised his hands and need help / support from others. Such situations are often seen in family violence. 

Image A7: “It is exactly like an emblem, upper part is like cashew mango is handing, down part- a labourer (no specific gender mentioned)”. If a male has not perceived a “dancing lady” in this image, it may indicate that the man has traumatic experience from a female. It may further indicate poor interpersonal relationships with his wife and a kind of hatred and aggression towards her. 

Image A9: “On the left side - a lady (Not a pleasing one, scary picture) but not a beautiful woman” Instead of perceiving two persons, male and female, or any two persons, which is a healthy response, in this image, he projected a scary picture of a lady, may indicate hatred and aggression towards his wife. He did not perceive a male figure – a most common response, towards the other side of the image, may indicate his avoidance and psychological separation from his wife.   

Image A16: “Emblem, two birds within the emblem”. Two birds kissing / playing is the normal response in this image, which may indicate a good interpersonal relationship. Normally couples having conflicting relationships may avoid seeing birds kissing or making love. This image may further indicate frustrated love affairs and conflict in love relations. The theme of interpersonal conflict is projected in earlier three images also which must be addressed during therapy sessions.

Image A21:    “Big bird, cannot make out what is next to it” Batman / flying bird and two children is a normal and healthy response in this image, which indicates a good interpersonal relationship with parents/authority figures. The projection of “Big bird” denotes authority/father figure. Avoidance of two babies on either side is a strong indication of conflict with his father particularly during childhood.  The poor relationship with father might have impacted his personality. 

Image A24: “Not clear, two people harassing another person, one is closing the mouth of the other person. The third person is a very hard person who is closing the mouth of the client and is not allowed to express”. The responses indicate feelings of harassment and physical abuse during childhood. Such traumatic memory must be addressed during therapy sessions.  

Image A26:  “Fossils of a creature, died long ago, only head and tail” depressing, not a pleasant one”. The response indicates his pensive mood and a kind of regression where he is feeling that the death might have resolved his present problems. The client must get pharmacological help to address a depressive mood. The therapist must address if the client has witnessed abortion of his wife or some significant family member. 

Image A27:  “It is the aerial view of a cave” Female breast is the most common normal response in this image. The client has avoided perceiving female breasts which may indicate deprivation/ conflict with mother during childhood. Those who lost their mother during childhood, lived away from their parents, or reared by grandparents, often reject this image. Male having poor interpersonal conflict with his wife may also reject the common perception of breast. The perception of CAVE may indicate sexual fantasy and sexual frustration. 

Image A28: “Dropped breasts of a woman, but not a full picture of the woman”. The response may indicate his frustration and hatred towards a female, possibly his wife whom he does not like. 

Image A29:     “Not clear, inside looks tiger like creature”. The perception of tiger in this image may indicate that the client is demanding, dependent with passive aggressive attitude (Schafer, 1954)

Image B1: “Like a nest, young birds opening mouths for food and a bird outside. Looks as if it has come to harm the young birds”. The response indicates his insecurity and craving for affection. It further indicates unpleasant feelings of his childhood because of the harsh attitude of his father, which must be addressed during therapy sessions.  

Image B2: “Two scary creatures. A strong creature forcefully taking away another creature”. The theme of image B1 is projected again in this image which indicates feelings of harassment and insecurity. The therapist must ascertain whether the client had a difficult childhood memory, or it is a development in later life. 

Image B12: “Some bird carrying its prey in the legs, not a pleasing picture” indicates his insecurity towards life and future. Such pathological anatomy responses are often seen in psychotic patients. 

Image B19: “Octopas- disgusting to hold in hands”. Two hearts are the most common normal response in this image. A person having broken love relations, frustrated love affairs or poor interpersonal relationships with his wife often avoids perceiving hearts. The case history also supports this finding.

Image B22: “A person lying down, looking up and stones falling on him”. The response indicates his feelings of helplessness and inability to manage the adverse situations in his favour. It further indicates his depressive mood. 

Image B28: “One woman, standing aloof with her hands but face is not of a human being -not a pleasing picture, It has fox’s face. ‘Fox woman’. Human beings with the head of the fox, a crown present on the head, hands tied, wearing a saree”. The “fox woman” may represent the cunning nature that the client is projecting towards his wife. The fox symbolism is deeply tied to cunning, transformation, and spiritual guidance. The conflict with his mother and his wife has been reported in the case history. Mother hugging/ holding the Child is a most common normal response in this image which reflects a smooth loving relationship with parents, particularly with mother. The client has totally avoided perceiving the child with the mother, which indicates severe conflict with the mother. It may also reflect severe conflict with the mother figure which can be his wife. 

To summarise the responses, it indicates that the client has a high level of frustration and hatred towards a significant woman in his life. Further, it suggests that he has unresolved anxiety, feelings of insecurity and uncertainty, depressive mood, feelings of helplessness and aggressive behaviour. It also indicates that he had a strained relationship with his father. There is evidence that his feelings are being hurt, and he is craving for love and affection. There are also evidences of sexual fantasy, sexual frustration and inadequate love in his interpersonal relationships. The responses also indicated that the client has distorted perception towards his life events.

Discussion:  

Mr. S’s’ long-standing, chronic anxiety symptoms, persisted despite multiple treatment attempts and the CGI score remaining <2 meet the clinical definition of TR-AD (Domschke et al, 2024). This formulation is consistent with definitions of treatment resistance as failure to respond to at least two adequate trials of evidence-based treatments, and the illness course reflects chronic anxiety with periodic exacerbations which are situation/field related.

One of the socio-culturally accepted ‘solution’ to psychological or behavioural problems in India is marriage, often encouraged by close family members and friends. This is reinforced by the prediction of the astrologer (Das et al., 2022).  Although this trend is gradually changing, there remains a widespread belief that marriage has the potential to transform lifestyle and behavior, particularly in the context of mental health difficulties such as addiction or chronic stress. However, clinical evidence suggests that marriage does not resolve underlying psychopathology; individuals who are socially disconnected or resistant to change often continue to struggle despite being married (Chadda & Deb, 2013; WHO, 2022). In the present case, the client’s longstanding difficulties persisted despite marriage, underscoring the need to raise awareness that marriage should not be misconstrued as a “treatment” or primary solution for psychological problems. (Deleted the sentence)

Though the client initially presented as having a good relationship with his wife, as therapy progressed, he revealed frustrations in the marriage and spoke of living with his ‘fantasy girl ‘in his phenomenological world. The blind interpretation of Somatic Inkblot Test responses reiterated the same and probably SIS serves as a diagnostic and therapeutic bridge for clients with non-responsive anxiety by revealing contact disturbances, fostering therapeutic alliance, and offering culturally valid insights into somaticized expressions of distress. This makes SIS a valuable adjunctive tool for assessment and intervention when conventional approaches show limited efficacy. For clients with long-standing or treatment-resistant anxiety, SIS helps uncover symbolic expressions of fear, control, and helplessness, thereby guiding integrative therapeutic strategies such as gestalt interventions, relaxation, or body-focused psychotherapy. Administering SIS to the couple, as reported by Kruthi et al. (2015), might have helped to uncover underlying discrepancies in their relationship or possible sexual conflicts between the couple (Manickam & Suhani, 2013, 2014).

The SIS images may facilitate relational dialogue by supporting contact with the person and enhancing awareness of the ‘contact-full’ self, as emphasized by Finlay (2016) and further reported by Manickam and Dubey (2021). However, the awareness that the client phenomenologically experienced did not help him to work through different figures that came up. Individuals with a ‘fixed gestalt’ may perceive stereotyped responses, indicating their habitual way of perceiving others and the environment. From a gestalt perspective, Engle and Holiman (2002) observed that resistance to awareness serves as a self-protective function, shielding the client from the anxiety that accompanies change. This resistance is often expressed as ambivalence, in which one aspect of the person desires changes while another resists it. Consistent with early Gestalt theory, clients are frequently unaware of such internal conflicts and their impact on relationships with self and others and the environment. As Engle and Holiman (2002) noted, ‘An individual will tend to protect him/herself from harm by avoiding unmanageable levels of anxiety’ (p. 177) and may not want to process.

Treatment-resistant anxiety disorders pose a major clinical challenge, contributing to chronicity, comorbidities, and significant personal and socioeconomic burden (Domschke et al, 2024 ). This highlights the urgent need to identify predictive markers, clarify underlying mechanisms, and develop innovative pharmacological and psychotherapeutic interventions. From a Gestalt therapy perspective, an inpatient setting may be understood as a restricted field, where environmental demands and external stressors are reduced, creating a safer and more contained therapeutic context. This narrowing of the field allows the client to focus on the immediate therapeutic relationship and internal processes without being overwhelmed by the broader life circumstances that maintain anxiety. Within such a structured environment, awareness can be deepened, unfinished business can surface, and new modes of contact can be safely experimented with, thereby enhancing the possibilities for change in treatment-resistant anxiety conditions (Perls, Hefferline, & Goodman, 1994; Parlett, 1991; Yontef & Jacobs, 2014).

Conclusions:

Clinicians need to adopt a phenomenological orientation and remain attentive to identifying disorders that may not commonly surface in routine clinical practice. The presented case along with SIS findings perspectives suggest that for treatment-resistant anxiety, resistance may be best conceptualized as a multilayered phenomenon: (a) a protective boundary process to be respected and explored (Gestalt-experiential stance), and (b) a barrier to unconscious expression that can be loosened through symbolic/projective methods (SIS). Integrating both views allows the therapist to honour the client’s resistances while also providing alternative routes of access to entrenched fears. This dual framing is especially valuable in clients who fail to respond to standard pharmacological or CBT protocols, as it widens the therapeutic toolkit beyond compliance and symptom-reduction models toward awareness, integration, and creative expression.

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