PTSD and ‘Unfinished Business: Can SIS images lead to Re-experiencing and Gestalt Closure?

L S S Manickam and Bankey L. Dubey

(SIS Journal of Projective Psychology & Mental Health, (2021):28:1, 58-62).

Animal attacks on human beings are a rare phenomenon and those who are living in the forest buffer zone areas are at greater risk. In this paper we present the report of a 21-year-old unmarried lady who was exposed to the mutilated body of her father who was killed in a tiger attack and was diagnosed as having post-traumatic stress disorder. The relational dialogue with her using Somatic Inkblot Test (SIS-II) is described and an analysis of her responses are provided, which led her to being free from her embodied disturbances. Using SIS projective images may facilitate the ‘contact-full, dialogical-relational nature of gestalt work’ and can help in processing the painful ‘unfinished business’ caused by a traumatic event.

Tiger attacks are considered as stray incidents and as accidents that are caused in the interface between people and animals living in buffer zones. As per the official report, India has recorded 113 human casualties/deaths due to tiger attacks from 2013-14 to 2016-17 and 1224 casualties/deaths due to elephant attacks during the same period (Government of India, 2017).  The trauma and panic it can cause on the survivors vary from region to region. The Post Traumatic Eco-Stress Disorders (PTESD) of the ‘tiger widows’ of Sunderbans, West Bengal (Chowdhury et al 2013) and the impact of tiger attacks on the people are documented both from qualitative and quantitative perspectives. The prominent among the reactions is the stigma with which the women continue to live and are marginalized due to the cultural belief system the community holds towards them (Chowdhury et al 2014). They are being perceived as ‘one who eats her husband’ and they are seen as ‘inauspicious and evil’ and as a result are isolated, branding them as people with ‘divine curse’ from the community which puts them into economic hardships in addition to the psychological trauma. 

The probable consequences the tiger attack can have on their children and grandchildren make the women more vulnerable. The male children, having to discontinue their schooling, often take up a vocation at a young age, mostly that of their fathers and on the other hand the girl children suffer being outcasted, leading to low prospect of marriage and sexual exploitation (Chowdhury et al 2014). In Karnataka, 5 deaths were reported due to tiger attacks in the year 2013-2014 and it is not known how it has impacted the survivors (Government of India, 2017). 

Unfinished business means the need for oneself to ‘complete the incomplete’ and there are several of them which an individual needs to work with. From a gestalt therapy perspective, the manifestation of PTSD may be viewed as ‘unfinished businesses’ related to the traumatic event that one was exposed to (Cohen, 2003).  There need not be a temporal relationship with the traumatic event and the manifestation of the unfinished business. Greenberg, et al, (1993) observed that unfinished business can be arising from, “…traumatic, stress-inducing situations or victimization experiences involving tragic loss, violent death, disaster or abuse” (p. 242). The symptoms of PTSD seemed to demonstrate two processes. Apart from an attempt to ‘assimilate an experience that is impossible to assimilate’ there is also an ‘expression of an underlying organismic need to finish some unfinished aspect of the trauma’. It may well be understood as the, ‘repeated unsuccessful attempts at completion of the contact cycle or the experience cycle (Cohen, 2003).  

The contact cycle as described by Zinker (1977) and modified by Clarkson,(1989) involves the process of sensation, awareness, mobilization, movement or action, contact, satisfaction, resolution/closure, and final stage being withdrawal after which the individual is free for another sensation to take on in the fertile void. In other words, a healthy organism processes the organismic need in this process of figure formation and ‘destruction’. Another viewpoint raised by Melinck and Nevis (1988) on the process of resolving the unfinished business in relation to PTSD suggest that the symptoms manifest as a result of the inability of an individual to ‘absorb and digest an experience’ and prevent disengagement. Probably, the PTSD symptoms are a manifestation due to the incomplete contact cycle leading to demobilization. 

The therapeutic usefulness of SIS-II (Cassell, 1990, Cassell and Dubey, 2003) was documented in relation to somatoform disorder (Manickam & Suhani, 2003) and to psychogenic cough (Manickam, et al, 2013). The SIS test was found to be an effective therapeutic tool in working with persons who had post-traumatic stress disorder (Cassell, 2006; Cassell et al, 1999, 2014; Cassell and Dubey, 2010, 2017). The present casestudy illustrates how working through SIS-II images from a gestalt therapy perspective hadhelped a person to unravel the unfinished business, get over the fixed gestalt, make the contact cycle complete and promoted a gestalt closure.

Case Report:

A 20-year-old unmarried lady educated up to higher secondary and homemaker, hailing from a joint family living in the suburban area near the forest consulted the Department of Psychiatry, JSS Medical College Hospital, Mysuru. Three months prior to her consultation she had ‘hyperventilation’ and was admitted and treated elsewhere symptomatically when the symptom first occurred. She continued to have mild disturbance on and off, and on the day of consultation, she had exacerbation of the symptoms of ‘hyperventilation’ which lasted for about 1 hour and the family members took her to the hospital. Investigations did not show any physical cause for the manifestation of the symptoms. 

There was a temporal relationship between the present reemergence of her symptoms and a family conflict that was going on between her grandmother and other members in the family. During this time, she overheard her grandmother expressing that she had not been given adequate care by the family members and expressed that she would go out and end her life. This reminded the patient of her grandfather who died in a tiger attack prior to the onset of her initial symptoms. 

Three months before the visit to the clinic, her 54-year-old grandfather, a farmer while tending his cattle close to the forest, was apparently attacked by a tiger and dragged him away. Only the head and the limbs of her grandfather were intact, and the torso was consumed by the animal that attacked him. She happened to see the body of the grandfather when it was brought home. The next day she developed anxiety and palpitation and was feeling extremely tired, whenever she remembered her grandfather. This continued, on and off, till her present consultation. Around this time, 4 other tiger attacks and 3 related deaths were reported from the same area within a span of 6 months, and it created panic among the people living in the buffer zones of the forest area.

Her father died of cancer two years before her clinical visit. There was no other significant family history. She was reported to have good interpersonal relationships with family members and was dependent on them and had difficulty in making decisions on her own. Based on the history, clinical evaluation and investigations, she was diagnosed as having PTSD (ICD-10, F43.1). In order to aid the psychotherapeutic process, SIS-II (Cassell, 1990) with 62 images was administered to her.

Findings and Discussion:

There were 69 responses on SIS II which indicate her high imaginative capacity, high productivity and high level of functioning intelligence. It also indicates active involvement and interaction with the outer world. She gave 12 Most Typical and 22 typical responses which indicate coherent, logical thinking and an ability to keep up with the demands of society.  Often such individuals exhibit conventional ways of thinking and good interpersonal relationships.

There were 17 Human Movement (M) responses, and only 2 Animal Movement (FM) responses. A high number of Human Movement responses with high percentage of H and MT responses are associated with high fantasy, creativity, active involvement and good interpersonal relationships. The high M is also correlated with introversive style of personality. There were 12 Animal responses and 3 Animal detail (Ad) responses which indicates her frustration, immature thinking, aggressive attitude and suppressed hostility which need to be addressed during therapeutic intervention. The seven anatomical responses are indicative of preoccupation with somatic symptoms.  There were no pathological signs and it validates the fact that clinically there were no persecutory ideas or delusions expressed by the person.  

1. Psychodynamic interpretation of the responses:

A few significant responses are interpreted using content analysis:

A3 (Image 2 of SIT): “Looks like a ghost. It was in the news that the ghost was walking on the street”. This might indicate the scary feeling of past trauma and fear of death.

A7 (Image 5 of SIT): “Doll”. Dancing lady is the most common response on this image which she avoided to perceive. This may indicate that the happiness from her life has apparently gone away. It might be the impact of trauma which she has undergone in the past.

A9 (Image 6 of SIT): “Two birds”. Instead of perceiving male and female, or any two persons on this image, she has viewed it as “two birds”, which may indicate poor interpersonal relationship with the opposite gender.

Image A14: “A person standing in a boat in a sea” indicates her pensive mood and desire to be away from her family. 

A21 (Image 13 of SIT): “A man with long clothes trying to scare” may indicate fear from authority figure/father-figure. This is confirmed from her family case history. She has also avoided perceiving two human children which may indicate disturbed interpersonal relations with the father/authority figure.

A23 (Image 14 of SIT): “scorpion” a pain inflicting insect. Normally people perceive it as “spine”. This might be due to the spinal injury that happened to the grandfather during the tiger attack or sexual conflict. Females with sexual trauma may reject this image because it symbolizes the male phallic region. 

A25 (Image 15 of SIT): “May be eyes” which appears to be a symbolic representation of female genitalia- a normal response.  The eye may also indicate suspicious attitude and paranoid ideation which must be kept in mind when she gets back to therapy session.

A27 (Image 17 of SIT): “Jog falls – water flowing” and avoided the common response Breast. It clearly indicates conflict with mother-figure which was supported by her response on image B28 where she has avoided perceiving “mother and child”. “The waterfall –water flowing” is also a symbolic representation of satisfying erotic desires.

A30: A ghost mask. (ghost) may indicate timidity, paranoid tendency and concealment of true self.

A31 (Image 18 of SIT):  A boy and girl talking to each other may indicate her desire to have loving relations. 

Image B1: “A person standing and watching a waterfall”. The theme of image A27 is brought back which indicates a symbolic representation of satisfying erotic desire.  

Image B2: “A person on fire” may indicate her distress and painful situations of the past. This distress must be addressed during long term therapeutic intervention. 

Image B6: “An owl is standing” may indicate inadequacy and negativism.

B27 (Image 27 of SIT): of SIS-II): “A doll telling something to another doll” may indicate sharing of very personal feelings to some very close friend. This may also indicate that the client wants to share her personal thoughts and feelings with the therapist.

B28 (Image 28 of SIT): of SIS-II): Mother loving the child is the common response. Instead of mother and child, she has perceived it as “man” and “monkey” which may indicate conflict with mother.  

B31 (Image 30 of SIT): of SIS-II): “Children playing the train game”. A family of father, mother and two children is the most common response on this image. It indicates a smooth relationship among family members and happy childhood with parents. Rejection of this theme may indicate poor interpersonal relationships between parents and children or among close family members.

1. Gestalt therapy perspective of the responses:

A content and ‘process’ analysis of her responses to the perceptual sensation provided by the images suggests that the individual was moving through the contact/experiencing cycle which Clarkson (1989) described while she was taking the SIS test. In the initial phase, she gave 5 responses related to ghosts and masks that suggested her awareness about the unfinished event (A3 ‘Looks like a ghost. It was in the news that the ghost was walking on the street’; A, 24, ‘Mask’; A 26, A 30, ‘A ghost mask’). Apart from these, there were responses of disfigured person or person in distress like heartbeat, (A20), ‘A man with long clothes trying to scare’ [A-21] and ‘As if someone is coming’ (A-4); A person is standing in a boat in a sea (A-14). It appeared that the ‘deceased person’ was the response in several images, which was like an ‘exposure’ and re-experience to her. Her response in the second set B1, ‘A person standing and watching a waterfall’ and B2 ‘Person on fire may indicate the inner turmoil or the ‘unfinished business’ that were expressed during the middle phase of the administration which may have mobilized her towards making the contact.

As she moved further, she viewed image B-4, as ‘Somebody is saying something to a child’; B-5 ‘Somebody is teaching something to someone’; B-12, ‘A person standing on a tree’ suggesting that she has mobilized herself to the final contact or the closure. The response on B-29, ‘A man walking on one leg’, is a “most typical response” and is congruent with her being in contact with herself. The ending responses on B-31, ‘Two people folding their hands’ suggest satisfaction. Another response on B-31, “Children playing the train game” may indicate the gestalt closure occurring and the person withdrawing from the contact and being in the phase of fertile void (Clarkson,1989) for further sensation/figure to emerge.

The only image that she rejected was B18, which may indicate sexual conflict, which the unmarried client avoided to share further in the initial phase of the therapy. The denial of typical sexual responses on sex cards may also be an indication of sexual conflicts that the individuals may have (Manickam & Suhani, -2014). Since the disturbance with which the person consulted has come to a closure, it may be taken up when it comes as a ‘figure’ for her. In our cultural contexts women especially from rural areas do not give ‘permission for themselves’ to seek professional help, when they experience sexual disturbance and it stays as ‘unfinished business’ for them and often develop ‘somatic complaints’ to reach the helping professional at a later stage (Manickam, 2020). Unless the therapists are sensitive enough, the women do not get the due consideration to explore their sexual problems (Manickam, 2019). 

The interpretation of the responses from a psychodynamic perspective suggests that she needs long term therapeutic engagement and SIS has brought out the areas that require further exploration and process.

From a gestalt perspective, it is evident that the SIS images help the process of relational dialogue in contacting the person and in turn helps one to become aware of ‘fully in contact’ with oneself (Finlay, 2016). It was also interesting to see that the person who had the ‘fixed gestalt’ wherein the projections have become ‘a fixed way of seeing the other’ was found to be evolving as the person progressed through seeing the ‘creative images’ of Somatic Inkblot Test and led to change. The client was free of the symptoms by the end of the session and was symptom free during the follow up period. Since SIS images have been effectively used to study the therapeutic change, (Mishra et al 2020), it may be worth administering to the same person after an appropriate interval to see the types of responses that are likely to emerge and its relation to the clinical status.

Conclusion:

Post-traumatic stress disorder related to tiger attack and the administration of SIS-II assumes importance since the process of administration itself has led to therapeutic change.  From a psychodynamic perspective, there are several unconscious processes that came up that need to be addressed during a longer duration of therapy. Though a single case report does not give us sufficient data to generalize, it would be interesting to ‘experiment’ from a gestalt perspective how the widows of those who died out of tiger attack in Sunderbans and who had PTSED (Chowdhary et al, 2013) would respond to the SIS images and work through the unfinished business which in turn can be therapeutic. The potential of SIS images to evoke ‘re-experiencing’ (Cohen,2003) that can lead to gestalt closure may be further explored through well-designed randomized controlled studies involving more participants and the results may help draw more meaningful conclusions that can be generalized.

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