Case 30: Intervention using Somatic Inkblot Test in Dissociative Disorder
Divyanshi Thakwani & Satyadhar Dwivedi
Dissociative disorders are mental health conditions that involve experiencing a loss of connection between thoughts, memories, feelings, surroundings, behavior and identity. These conditions include escape from reality in ways that are not wanted and not healthy. This causes problems in managing everyday life. The Somatic Imagery Test was administered to a 28-year-old female with complaints of anxiety, episodes of trance and possession, difficulty focusing on her daily routine, recurrent episodes of unconsciousness (4–5 times a day), and an overwhelming sensation of being possessed by a divine force—specifically Maa Durga or Kali. The inkblot images were helpful in eliciting underlying emotional distress, unresolved conflicts, and significant stressors, thereby corroborating the client’s account and aiding the process of psychotherapeutic intervention.
Introduction:
According to the ICD-10, dissociative disorders (also referred to as conversion disorders) involve a disruption or discontinuity in the normal integration of consciousness, memory, identity, perception, motor control, and behavior (World Health Organization, 1992). These disturbances often emerge in response to overwhelming psychological stress or trauma and are not attributable to any known physical or neurological condition. Dissociation commonly occurs in individuals who have experienced early, repeated, or severe interpersonal trauma, such as childhood sexual or physical abuse, especially when it happens during critical developmental periods (Brown, 2002). It is particularly prevalent in those with disrupted attachment, chronic stress, or violations of bodily integrity, leading to a fragmented sense of self and body (Fuller-Tyszkiewicz & Mussap, 2011) Traditionally, these disorders have been examined through the lenses of trauma, stress, and cultural context. However, recent perspectives have begun to highlight the central role of body image and embodiment in the onset and maintenance of dissociative phenomena (Scheffers et al., 2017).
Body image refers to the internalized mental representation of one’s body, encompassing perceptions, beliefs, and emotional attitudes toward its form and function (Cash & Smolak, 2011). When a person develops a deeply negative view of their body, often expressed in feelings like “I feel fat” or intense shame—this disturbed body image disrupts the unified sense of self (Petrucelli, 2016). According to Petrucelli (2016), such negative self-representations are not simply about appearance but also reflect painful internal experiences that the person finds unbearable. In response, the mind may choose to “shut off” or disconnect from these overwhelming emotions through dissociation (Bromberg, 2001). In this protective process, the individual distances themselves from the distress associated with their body image. When the body image becomes distorted by overwhelming negative feelings or shame, the natural integration between what we feel and what we know about our body breaks down. This misalignment makes it difficult for the person to fully experience or regulate their emotions, which in turn can encourage dissociation as a way to cope (Petrucelli, 2016; Bromberg, 2001). Together, these ideas suggest that when an individual’s internal representation of their body is severely disturbed, they may experience a split between their emotional self and their physical self. Dissociation then becomes a defensive strategy to escape the painful reality of a fragmented body image. This understanding helps explain why, for example, people who struggle with intense body shame sometimes experience dissociation, as it allows them to momentarily disconnect from their overwhelming feelings (Petrucelli, 2016; Scheffers et al., 2017; Rudy et al., 2022).
These states may serve as a symbolic expression of internal conflicts, offering psychological relief by shifting control away from the self. As such, assessments that engage the symbolic and projective aspects of the psyche, such as the Somatic Inkblot Series (SIS) can offer valuable insight. These tools may help surface latent conflicts or trauma by bypassing verbal defences and tapping into the unconscious, where dissociative symptoms often originate (Dubey et al., 2019).
About SIS Test:
The Somatic Inkblot Series (SIS) is a structured projective technique designed to explore personality, emotional functioning, and underlying psychological conflicts through spontaneous responses to semi-ambiguous inkblot images. Conceived in 1959 by Professor Wilfred A. Cassell and later expanded in collaboration with Professor Bankey L. Dubey, the SIS was developed in response to the need for a more somatically focused and psychodynamically rich assessment tool (Cassell & Dubey, 2003). Unlike traditional inkblot techniques such as the Rorschach or Holtzman Inkblot Test, which often lack specific anatomical cues, the SIS integrates body and organ-related imagery to facilitate projection of somatic concerns and unconscious material (Cassell, 1989). The test includes three formats—SIS-I (20 cards), SIS-II (a 62-image booklet), and a video version, which enhances relaxation and therapeutic engagement through visual and auditory stimuli (Cassell & Dubey, 2003).
SIS is uniquely suited for populations with limited verbal abilities, such as children, individuals with developmental challenges, or those from different linguistic backgrounds as it relies on imagery rather than text (Cassell & Dubey, 2003). Furthermore, its application spans a wide range of clinical contexts including anxiety, depression, conversion disorders, and even spiritual exploration (Cassell, 1990). Studies have established the reliability and validity of SIS (Dubey et al., 1992; Verma, 1995), its effectiveness in diagnosis (Rathee et al., 1998), and therapy in different clinical conditions (Dubey et al., 2005; Manickam & Dubey, 2021). Overall, the Somatic Inkblot Series offers a dynamic and innovative approach to psychological assessment, allowing practitioners to access the “inner cry” of the suffering individual through a symbolic, visual, and often deeply emotional medium (Cassell, 1989).
The Case:
The client, Miss G, is a 28-year-old female, having completed a B.Sc. in Nursing and currently working as a nurse. She was referred with chief complaints of anxiety, episodes of trance and possession, difficulty focusing on her daily routine, recurrent episodes of unconsciousness (4–5 times a day), and an overwhelming sensation of being possessed by a divine force, specifically Maa Durga or Kali. The symptoms had persisted for the past two months. According to the client, her distress began when she was posted in a rural area for her job, 3 years ago. During this period, she stayed in a rented accommodation where another tenant reportedly became jealous of her. Alongside this, she experienced significant distress regarding her job, as she did not wish to continue her rural posting due to availability of limited amenities. The dissatisfaction with the job and the low salary added to her emotional burden. During her stay, she learned that the tenant’s wife previously suffered from episodes of trance and possession. In a heated conversation, the tenant allegedly threatened her, saying, “I’ll do something to you; you won’t ever recover from it.” Following this, the tenant’s wife fully recovered, and the client started experiencing severe anxiety. Gradually, her anxiety escalated into panic attacks, followed by episodes of trance and possession, wherein she believed that an evil spirit had taken control of her and intended to kill her. She expressed persistent fear, stating, “Evil spirits have possessed me; they want to strangle me. I will only get healed if I take a bath in the Ganga.” Alongside these experiences, she began exhibiting depressive symptoms, including low mood, loss of interest in work, hopelessness, and helplessness.
Her family sought help from various faith healers, but her symptoms persisted. In January 2025, she visited the IMHH, Agra OPD, reporting an increase in the frequency of her dissociative episodes over the past two months, followed by brief periods of unconsciousness. Upon further exploration of her history, the client revealed multiple stressors from her childhood. Her father had married twice, and both wives lived together. She currently resides with both of her mothers. Her father was described as a heavy alcohol consumer, who, under the influence, would engage in frequent conflicts with the client’s biological mother, which the client did not like. Additionally, he had an extramarital affair, further contributing to the client’s stress. Gradually, along with the stress about her job environment, her emotional turmoil manifested in frequent episodes of unconsciousness, occurring 4-5 times daily accompanied by a powerful feeling of being possessed by a deity such as Maa Durga or Kali. The dissociative episodes she experienced began to serve dual functions, both as a maladaptive coping mechanism and a strategy for regaining control. They were negatively reinforced by family dynamics wherein, whenever a fight occurred between her father and mother, the client would dissociate, which would temporarily halt the conflict. Her father would also stop his habitual drinking for a few days to lessen the stress surrounding the client whenever she had these episodes, reinforcing the behaviour further. Additionally, the dissociative episodes were positively reinforced as she began receiving increased care, attention, and emotional support from her family members, meeting her long-standing emotional needs and intensifying the cycle. Thus, in this way dissociation became a perverse strategy for regaining control. Two months ago, she also appeared for the UPPSC nursing exam, and the uncertainty surrounding the results had heightened her panic attacks and dissociative episodes. Each time she experienced these episodes, her voice would deepen, and she would attempt to strangle herself, saying, “I will kill you; you won’t survive.” Preoccupation with supernatural beliefs, possession states, and dissociative symptoms in response to significant stressors can indicate underlying dissociative pathology. When such experiences disrupt one’s daily life, self-concept, and emotional stability, they require thorough clinical assessment and intervention. Given the psychosocial factors contributing to the maintenance of her illness, a structured intervention plan was designed:
Psychological Intervention:
• Psychoeducation: The client was educated about the nature of dissociative disorders and how her symptoms were influenced by stress and reinforced by secondary gains
• Cognitive-Behavioural Therapy (CBT) for Interpersonal Relationships: Therapy sessions focused on helping her develop healthier ways to cope with interpersonal conflicts rather than relying on dissociation.
• Explanation of Reinforcement Mechanisms: It was explained to her how her illness was being reinforced through family dynamics, particularly how her symptoms led to temporary relief from distress (such as her father’s reduced drinking).
• Behavioural Model of Illness: The progression and maintenance of her illness were explained through a behavioural framework, helping her recognize how maladaptive coping mechanisms had developed.
• Pathological Coping Mechanism: The client was encouraged to develop alternative coping strategies to handle stress, such as assertiveness training, relaxation techniques, and problem-solving skills.
Additionally, the Beck Depression Inventory was administered before the intervention, with her scores ranging from 31-40, indicating severe depression. Following the intervention, her scores dramatically reduced to the range of 1-10, indicating no mood disturbance.
This case highlights the complex interplay between family stressors, dissociation, and reinforcement of symptoms through secondary gains. To explore her unconscious conflicts, personality structure, and dissociative tendencies, a projective personality tool—the Somatic Inkblot Test (Cassell, 1990 and Cassell & Dubey, 2003) was administered. The responses were analysed using content analysis and psychoanalytic interpretation (Cassell & Dubey, 2003; Dubey et al, 2019).
The Somatic Inkblot Test provided valuable insights into unconscious conflicts and dissociative processes, enabling a more targeted psychotherapeutic intervention aimed at breaking the reinforcement cycle and fostering adaptive coping mechanisms. The client continues to receive therapy to help her gain emotional resilience and develop healthier ways to navigate family and work-related stressors. A few clinically significant responses, projected on SIS images are interpreted using content analysis, with symbolic and psychoanalytic interpretation being discussed as follows:
Image A5: The client identified the image as “heart and animal,” whereas a typical response would have been “clown” or “happy person.” Because her interpretation deviated from the typical responses, it may indicate her pensive mood and difficulties with self-image.
Image A6: The client projected as “two stands and one ball,” and avoided to perceive the common response “teddy bear.” This may indicate parental deprivation and craving for affection during childhood, which is supported by the case history.
Image A7: The client described the image as “snake,” and avoided perceiving the most common response, namely, “dancing lady.” This may indicate that the person has traumatic experience and severe conflicts in interpersonal relationships. The snake may further indicate conflict in phallic area and disturbed interpersonal relationships. The responses may further indicate potential difficulties with self-image and conformity with group norms.
Image A9: “Two persons - females” is a normal response though avoiding seeing a male and female may indicate poor interpersonal relationship with opposite sex. The avoidance of male figure with female may further bring her hatred and deep-rooted conflicts with males, more likely with father-figures.
Image A12: “A baby in mother's womb” is a typical response. This may indicate her regression to the foetal level. She feels the mother’s womb would have been the safest place, free from all kinds of conflicts which she seems to experience currently.
Image A14: The client did not see anything in this image. Rejection of this image may indicate physical problems and somatic pain, which is confirmed by her case history.
Image A15: She saw “one person’s back” whereas typical responses would have been “stomach; foetus, or bird.” Projecting “back” may indicate her desire to turn her face away from the reality to avoid painful situations.
Image A16: The client saw “lungs and heart” in this image which is a sign of good prognosis. She is likely to experience improvement with psychotherapeutic interventions.
Image A17: “Pelvis” may signify a sense of self and identity, which is very low in this case. In case of a female, it is associated with pleasure, relationships, and emotional flow. It might symbolize difficulty with expressing emotional aspects of life, including intimacy. Further probing during therapy sessions may bring out more unprocessed unconscious material.
Image A21: She saw “vertebrae, spinal cord,” whereas people see “turtle; flying bird; babies on sides” usually. Avoiding to see turtle and babies on the sides, may indicate poor interpersonal relationships with parents particularly during childhood. Often it is seen when father/ father figure is very strict. The case history confirms poor interpersonal relationship of the client with her parents.
Image B17: “Uterus” is atypical response in this image which may indicate her desire to have intimate relationship. She avoided perceiving the common response “heart” which may indicate her conflict and disturbed relationship with her parents/ significant person. Perceiving “heart” most often symbolise intimate relationship.
Image B18: “Male phallic organ” is a normal response on this image. It may indicate healthy erotic imagery. It also suggests no conflict in the sexual area. Snake, spine, missiles and sailing boats in sea/river indicate symbolic Freudian connotation of male sex organ. The response may also indicate her desire of intimate relationship which is a normal response in adults like her.
Image B19: She saw “octopus” and avoided the common response of ‘two hearts’. A person having frustrated love affair/ conflicting relationships may avoid perceiving two hearts on either side. Poor interpersonal relationship with both parents has been highlighted in her case history. The therapist needs to inquire about broken affairs, if any.
Image B 27: The client saw “Two rabbits” in this image and avoided perceiving two “babies” the most common response, which may indicate poor self, low ego strength, and during childhood. Further probing may help to understand if she was an “welcome baby” by the parents and family during her childhood. Two rabbits may also symbolise small children.
Image B 28: She saw an “old person” in this image and avoided “Mother loving the child”, it being the most common response. This may indicate conflict with her mother-figure. The “old person” may symbolise non-supporting / non-helping parents.
Image B 30: The client saw “part of spinal cord” and avoided the most common response of “two ears” or “foetus” which may indicate non - sympathetic and non-receptive behavior of parents and other significant family members. A dissociative patient often seeks attention of close family members and wants them to listen to him/ her.
Discussion:
The inkblot responses revealed repeated misperceptions or rejections of body-related imagery, suggesting a fragmented body schema and discomfort with physical self-awareness. Additionally, inconsistencies in perceiving common human forms and relational figures point toward disturbances in how the client views herself in relation to others—reflecting a fragile self-concept and impaired internalized representations.
Raised in a highly dysfunctional family environment—marked by her father’s alcoholism, polygamous relationships, and chronic inter-parental conflict—the client’s early psychosocial landscape was devoid of emotional safety, consistency, and validation. These adverse experiences severely impaired her capacity to form a stable and cohesive sense of self. The lack of clear attachment figures and the constant exposure to emotionally deregulating circumstances likely disrupted the typical development of body awareness and identity, leading to the distorted imagery seen in the assessment.
Her dissociative symptoms, including trance-like states, loss of consciousness, and identification with deities, appear to be rooted in these unresolved internal conflicts. They functioned as pathological coping mechanisms, providing temporary escape from overwhelming affect but ultimately reinforcing maladaptive patterns of emotional regulation. Notably, her dissociation also served a secondary gain function within her family system, such as temporarily reducing her father's substance use. This dynamic further entrenched the symptoms as functional but resulted in unhealthy strategies for navigating interpersonal stress.
Following this assessment, the client was engaged in 4–5 structured therapy sessions that incorporated psychoeducation, CBT for interpersonal relationships, and explanation of reinforcement mechanisms, along with behavioural and coping-based approaches. These sessions aimed to increase her insight into the stress-dissociation link, reduce reinforcement for maladaptive behaviours, and foster healthier coping mechanisms.
Encouragingly, the client showed substantial clinical improvement, reporting over 80 percent reduction in dissociative episodes and emotional dysregulation. She began to develop greater psychological insight, demonstrated increased emotional expression, and was more willing to engage in interpersonal dialogue without resorting to dissociation. The therapeutic work thus, has laid a strong foundation, but treatment is still in progress, with continued focus on deepening her self-concept, solidifying body-image integration, and building resilience in the face of interpersonal stressors.
In summary, the assessment not only corroborated clinical observations but also illuminated the symbolic and unconscious processes underlying her symptoms. These findings significantly inform both the diagnosis and therapeutic direction, underscoring the need for long-term psychotherapeutic work focused on identity consolidation, emotional regulation, and adaptive interpersonal functioning.
Conclusion:
The Somatic Inkblot images indicated her average productivity and functional intellectual ability, awareness with her surroundings, ego strength maintained, poor interpersonal relationship particularly with parents, healthy erotic imagery and control over impulsive behavior, feeling of deprivation and craving for affection. She was administered five sessions of psychoeducation, CBT to improve interpersonal relationships. The client has shown significant improvement and is continuing psychotherapy.
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