SIS Symbols of PTSD & the Need for Empathy in Therapy

D. Brock, W. A. Cassell, C. Tyrone, C. Maureen,

B. L. Dubey, J. Halia, R. Leigh and S. Laurel

A major underlying aspect of all medical therapies involves the degree of positive empathetic linkage extending from the clinician to the sufferer. This is especially applies for those tormented by recurrent intrusive childhood traumatic memories - the basis of (PTSD). In such situations, the clinician created supportive empathic bond provides an essential foundation of psychotherapy. Moreover when the treatment plan encompasses “Body-Mind-Spirit” theoretical principles, the resultant empathetic bridge optimizes the prognosis. Yet such occupational exposure over time, in vulnerable care providers may induce empathetic “Secondary Traumatization”. This article illustrates typical professional risk factors by presenting a case history study of a victim of PTSD who was traumatized by severe stress throughout childhood and adolescence.

This Somatic Inkblot Series (SIS) clinical case history utilized the SIS- II Booklet version. (In psychologically unstable victims of severe stress, it is prudent to begin assessment with the Booklet projective procedure before introducing the more powerful peering electronic versions.) It involves an intelligent African American middle aged woman who was employed as a medical technician. Her formal diagnostic conditions involved Bipolar Affective Disorder Type II and Posttraumatic Stress Disorder. Her personal problems as subjectively perceived, labeled in the “Brief Health History” form follow: “Weight”, “Depres-sion”, “Hyperactivity”, “Paranoia” and Bulimia”. Her medical outpatient pharmacologic treatment plan involved initiating a therapeutic trial of Lithium to which she responded with mood stabilization. This was supplemented by SIS guided Cognitive -Spiritual Psychotherapy. The latter was empathetically provided by a mature married mature African male. He was selected because of being clinically familiar with “Pandemic” stressful socioeconomic conditions rampart in inner urban areas in too many American cities. He provided personal empathetic support when therapeutically

processing emotionally painful PTSD mem-ories. Moreover at critical times of such memory activated suffering he encouraged her to recall religious supportive spiritual images acquired early in life from an empathetic supportive maternal grandmother.

Case History Summary:

Because of her technical training the suffering woman was familiar with medical history formats. Regarding her genetic background, she indicated that her mother had been diagnosed with Bipolar Affective Disorder. Apparently during either manic periods, or when under the influence of street drugs (i.e. Cocaine, Crack etc.), this parent was both emotionally and physically abusive. According to her grandmother, her mother had repeatedly knocked her unconscious. Moreover she was sexually abused in childhood and adolescence by male cousins. When such traumatic sexual events were reported to her mother, she was ignored. She had no protection from her drug addict father.

With this stressful psychologically impove-rished developmental background, as a girl she

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D. Brock, W.A. Cassell, C. Tyrone, C. Maureen, B.L. Dubey, J. Halia, R. Leigh and S. Laurel, (Corresponding Author e-mail : siswilfredacassell@yahoo.com) SIS Center, Anchorage, Alaska.

Key words: SIS Symbols of PTSD

grew up tending to be moody and socially isolated. When stressed, she would shave her head to make herself emotionally “Feel Better”. Consistent with this as an adult, she habitually had trouble interacting with people in social situations and at work. During initial therapy, she was under scrutiny in her employment for conflict with other staff.

Outside of work, the central positive focus of her personal life was her eighteen old daughter. A few months before evaluation this girl had departed Alaska to attend college. Her loss had provided a major stress for this socially isolated lonely woman.

Stressful Dreams Reported Early in Treatment:

The following are examples of her adult PTSD dreams. Such historical material shaped both the reality imagery content, as well the emotionally disturbing affect linkage of her later life SIS Responses.

“I was hiking with a couple from work and they became angry with me and pushed me down into a snow bank!” Here the dream captured her ongoing stressful situation at work.
“I was with my daughter who was drinking alcohol and became intoxicated”. This reflected her concerns about her daughter's drinking”.
“My mother called me mentally retarded and stabbed me!” This portrayed both psychological and childhood physical abuse perpetrated by her mother”.
“In the nightmare my mother put her hands down inside my pants and it was disgusting!” Here PTSD memories of childhood sexual abuse surfaced in a PTSD affect charged dream.
“I was terrified because rats kept nibbling at my toes!” The place that she lived in as a child was “rat infected”. At night she was terrified that she would be bitten in while sleeping.
“My mother kept telling me to kill myself!” Her

mother's suicidal suggestions constantly plagued her “Nightmares”.

Content Analysis of SIS Projective Assessment:

In assessing the projective SIS data, initial attention will be given to the three responses labeled in the Answer sheet as “Liked Most”. (The affect linkage associated with what was seen follows in capital letters enclosed by brackets).

B27:“Two embryos one is stronger and bound to survive…the other will die”. (“SAD”) Later after responding to the entire 62 “Inkblots”, she elaborated further on her selection by writing “I FEEL LIKE THAT A LOT”

(especially after her daughter left for college). Here the symbolism gives projective awareness to her deep seated depressive feelings involving preoccupation with death and recurrent suicidal impulses. Here the projective data suggested that she was episodically attracted to death as a way of ending her recurrent suffering. This SIS symbolism served as a signal for her psychotherapist to closely monitor the possible need for psychiatric inpatient care.

B15:Her preoccupation with death surfaced symbolically again with SIS structure as follows: “Knives with a herd mentality attacking the loner…I am the loner”. At the end of the viewing procedure, she rationalized her entering therapy as follows: “I want to work on this loner mentality”. Such projected imageryy is consistent with the time persistence of her “SIS Revealed Inner World” by contemplating suicide to escape psychic pain.

B29:“A male shadow in the doorway seen through squinted eyes”. (“ FEAR”) Subsequently she indicated both that both originally as child, and later in her long term

“Nightmares”, she would close her eyes t i g h t l y p r e t e n d t o b e s l e e p i n g ” . Paradoxically, she rated this as “Liked” because it was “Visually accurate”. However, in reality it brought into mental focus “negative” charged affect emotionally painful PTSD memories activated in SIS projective consciousness reminiscent of childhood sexual abuse. Ironically enough, she rationalized these in a denial type mental defense mechanism as a “positive” emotional event!

Next a review will be given of those three SIS scenes, which she considered to be “Least liked”. In rating order these were as follows:

B28: “Child hugging mother…mother trying to be reciprocal”. She indicated that in spite of its favorite first rank position, looking at it made her feel “SAD”. She explained that she liked the scene liked because it reminded her of her love for her daughter who had just departed to attend university. Although they remained in telephonic and e-mail contact, to this lonely woman, this loss represented a severe stressor. This symbolism supported her psychoth-erapist's original impression regarding the role of her daughter's moving as a major determinant of her seeking treatment.

The reader might note the direct emotional Content Validity of this projected symbolism response sequence and the reported clinical history. It is suggested that “The child hugging the mother” signifies her daughter sadly saying goodbye at the Anchorage airport. The “mother trying to be reciprocal” symbolizes herself as a lonely, emotionally distant mother struggling to express love back in return. Later she indicated further the following: “I wish that I had demonstrated my love daughter via hugs more often”.

A30: “A child wearing a mask to appear void of

feelings”. This represented a very direct projection of her affect inhibition as a child for repressing distressing PTSD feelings. Later when elaborating on this response at the end of the viewing, she added the comment “I learned (i.e. as an adult) more facial expression”.

A18:“Labia and vaginal opening”. She immediately wrote “No feelings” and then crossed this statement out. Then she substituted the negative emotional description l inkage as “ GROSS”. Subsequently at the end of the viewing procedure she wrote “I feel very unattractive down below…NERVOUS about what it says about me”. This negative view of her body's sexual structures was consistent with her past abusive history

Next her clinically significant responses to the projective viewing procedure will be presented in order of their presentation as follows:

A1: “An angry rabbit…it reminds me of a movie Danny Darko…no feeling at all”.

This symbolized, in the angry animal image, her long standing repressed rage, which consciously she denied. As a child, as noted with A30, she wore a non-expressive facial “Mask” as her symbolic defense object.

A2: “A dancing juggling hippo…amused”. Here a psychologically safer movement animal response was projected as a defensive strategy over the human figure structure inherent in the stimulus array.

A3:“A person wearing a hat with a gun…menacing…reminds me of Oakland”. Here affect charged childhood stressful traumatic memories from California flooded projective awareness. Her psychotherapist had learned that initially prior to therapy, she had reported experiencing angry “Violent impulses”. Fortunately with therapy she learned some effective techniques for

dealing with anger.

A4: “A deformed butterfly” (“NO FEELINGS AT ALL”). The symbolic imagery here directly in a symbolic projects her own “Body Image”. Her Mental Defense Mechanism involved affect driven perceptual inhibition. Apart from sexual abuse, recall her history as a child, of having been repeatedly knocked unconscious by her mother.

A5:“A child wanting a hug or an angry clown…UNCOMFORTABLE with both”. Here the stimulus array initially triggered childhood unmet needs for positive emotional support from her mother. As indicated, her frustration in not receiving this left her with memories of frustration and symbolically disguised ANGER.

A6: “Someone kicking a Teddy bear”. (“NO FEELINGS”).This again reflected her life style defensive position of blocking affect. Here the symbolism disguised PTSD memories of her mother kicking her.

A7:“A dancing lady wearing a mask under an apple…it is an illusion…she is a lot further back than she appears…my mother

…Distance…but appears closer”. Here again the SIS structure triggered long standing memories of her mentally ill mother “Distant” lacking emotional nurturing.

A8:“A happy person”. (“JEALOUSY”)This response reflected her nonpsychotic (and therefore accurate) reality testing perceptual ability. Here her feelings of “Jealousy” of “Happy” people in social situations spontaneously emerged.

A9:“Love and communication between two adults”. (“FEAR”). Here she correctly recognized the loving positive potential in this SIS scene. Since she is a tragic victim of multiple early life human stressors, such close interpersonal activity was perceived as

highly threatening. Such a response might forewarn her therapist to expect her be e s p e c i a l l y a f r a i d o f e m p a t h e t i c pychotherapeutic intimacy.

A10:“An image of a partial face, nose and above mouth hidden behind paper so I cannot read the entire expression”. (“FEAR”)The fearful imagery brought to the surface of her conscious awareness was symbolized suspicious and paranoid like social fears.

Now several responses will be given for the reader to interpret independently:

A11: “Front of a car or a nose”.

A12: “An ear or an embryo”.

A13: “A hand coming out of fire…overheated (“I HATE”).

A14: “An embryo holding a chess piece or a seal under a buoy”. (“AMUSED”)

A17: “Someone's chest cavity partially skinned to reveal the heart under the ribs…other organs have been removed…interested”.

A21:“An animal smashed by a car on the road…no feelings” or “Such is life or death”.

A24: “Two men wrestling”. (“INTERESTED”)

A25: “Another vagina”. (“NOT INTERESTED”)

A26:“An embryo 8 months??? Malformed or hog tied…my interpretation BOTHERS me”. This once again brings to her conscious awareness the issue of “Deformed” noted earlier regarding her own Body Image. The fact that she became “Bothered” by her projection reflected appropriate awareness of its symbolic connotation.

A27:“Female breast…jealousy because I am flat chested”. Here she revealed previously unexpressed concerns about her feminine Body Image.

A28:“A muscular deformed left leg…or a parasite on someone's leg”. (“I AM UNSURE

OF FEELINGS”). Since she feels psychologically damaged from childhood abuse, she projected this onto her own Body Image. The symbol chosen reflects her past childhood horror.

A29: “A crime in progress…stay inside to avoid crime”. Her stressful memories from her childhood living in a poor area of Oakland California shape and negatively distort her perception.

A31:“One person comforting another or predator feeding on another…my preference over my reality”. This sequence reflects both her intelligence and insight into her PTSD projected responses. Words like “Predator” here and “Parasite” graphically symbolize her imagery.

B2: “A frog ready for dissection…I wish that I were back in school with the knowledge I have today”. This is a positive wish. It opens opportunities for her psychotherapist to empathetically explore more hopeful future life pathways.

B3: “A giant bird with an incredible wing span” (“AWESTRUCK”). Her interest in Nature and Animals represented a psychologically positive trait.

B4: “Adult secrets to a child” (“inappropriate”. Once again her childhood traumatic memories shaped her resent day perception.

B5: “Communication” (“ENVIOUS”). The issue of jealousy of those who are able to socially communicate emerges again like it previously did with A9.

B6: “A crime where only the lower body is found” (“INTERESTED”). Once again her growing up in an inner city violent area shapes her present day perception.

B10: “Mean angry Panda bear distorted”. Here she initially wrote “No feelings” then crossed

this out and inserted the word “FEAR”. Not only did this response reflect her long standing rage, it touched upon her episodic anxiety episodes.

B12: “A seahorse with wings (“INTERESTED. Here her mental defense mechanism of perceptual inhibition protected her from recognizing the SIS embedded figure more suggestive of a man's angry face.

B13: “A house in the shadows…isolation”. This response symbolized her own sense of social isolation.

B17: “I don't know”. She had previously demonstrated a perceptual diathesis to recognize embedded anatomical SIS content. However, here she avoided reference to the heart because of its close linkage to intimate emotions.

B18: “A penis or a crab claw inside of something”. (“NO FEELINGS”). Here she consciously denied any emotional feelings viewing a penis. Yet in view of being the victim of past rapes, her psychological defense mechanisms created the penetrating symbolism projected onto thesis anatomical structure.

B19: “Beginning of a Zygote I assume after love making but the ovum looks sick”. (“UNKNOWN FEELINGS”). Like her ability to recognize embedded SIS anatomical structure, she projected the response “Zygote”. However, the recurrent theme of “Sickness” or distortion of the Body Image surfaced once more in projective awareness.

B22: “A dead person on an autopsy table”. This reflected her past medical training.

B23: “A tic or a spider”.

B24: “Immature lungs”.

B25:“Womb that is glowing…the dark area is the beginning of life”. (“THIS IS SAD”). The symbolism superimposed on the SIS

anatomical structure is strongly colored by her “SAD” view of reproduction and ultimately human life.

B26: Here she wrote labels on the SIS structure as follows: “ovaries, vagina, and uterus” and then in psychological denial wrote (“NO FEELINGS”)

B31: Present Photograph

Most individuals imagine seeing here a family of two adults and two children. Normally, many responders add the descriptive emotional content “HAPPY”. Reflecting her past history of severe abuse and long standing suffering, she wrote “A family of four…SUSPICIOUS…are they happy?”

Discussion:

While empathetic interaction with a suffering person may optimize SIS diagnostic/ therapeutic procedures, over time it may expose the cl inician to “ Secondary Traumatization”. This occupational stressor may be particularly experienced by those treating traumatized children or for adults previously abused in childhood suffering from PTSD. Such SIS psychotherapists are very vulnerable. Repetitive occupational exposure over time may eventually prove “Toxic”. This is due the immense penetrating power of SIS stimulated visual imagery to transmit emotionally charged traumatic memories. The accumulation involves both reality based stressful scenes and by affect reduced disguised defensive symbols.

Over time, the accumulation in the SIS clinician' s memory neurons of such empathetically transmitted suffering may negatively distort the care provider's self-perception of “Body-Mind-Spirit” phenomenon. There may be a tendency for the care provider, to partially react in an analogous fashion to the PTSD victim by Dissociation or “Defensively splitting off awareness from the mind to the body”. When severe, the resulting symptom syndrome may mimic many of the formal diagnostic classification criteria of PTSD. One

example, involves cognitive changes related to trust, intimacy and emotional sensitivity. Such a chronically exposed clinician may during the day experience intrusive thoughts linked to the empathetically transmitted memories. These may then stimulate emotionally disturbing autonomic nervous system arousal. At night during sleep such intrusive material may be incorporated into disturbing dreams. This occupational hazard also applies for therapists lacking SIS projective technology but who do habitually work in psychotherapy by analyzing PTSD dreams. These professionals are also vulnerable to having their memory systems “infected” with a victim's daytime “Flashbacks” and sleep disturbing “Nightmares”.

While the scientific literature is still lacking on this occupational hazard for mental health care providers, one older comprehensive article (Fothergill, A. & Burnard, P., 2004) reviewing the effects of “Compassion Fatigue” in psychiatrists will be briefly summarized. In the United Kingdom, of surveyed psychiatrists 25% reported significant psychological morbidity. Women, who traditionally tend to be more empathetic than men, were more likely to have suffering. The suicide rate was greatest for their medical specialty. Severe stressors involved attempting to care for violent individuals and those suicidal. The authors reported that on an “Impact of Life Scale” the suicidal death of a person under their care was “Equivalent to the death of a parent”.

Finally, it might be noted that the authors in the above review article outlined effective techniques for coping with such stress. These may be professionally relevant for clinicians exposed to SIS magnified Empathic Trauma!

References :

Fothergill A. & Burnard P. (2004) Stress, burnout, coping and stress management in psychiatrists: findings from a systematic review. Int. J. Social Psychiatry 50: 54.

Norfolk, T., Birdi, K., & Walsh, D. (2007). The role of empathy in establishing rapport in the consultation: A new m o d e l . Medical Education , 41 ( 7 ) , 6 9 0 - 6 9 7 . doi:10.1111/j.1365-2923.2007.02789.x

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