Intervention using Somatic Inkblot Test in Sexual Deviance - A Case Study

Shubhika Singh & B. L. Dubey

(SIS Journal of Projective Psychology & Mental Health, (2022):29:1, 51-56).

The Somatic Imagery Test (online version) was administered to a 24-year-old male with complaints of guilt associated to child pornography surfing, porn dependence to fall asleep, depressive features and low self-esteem. The inkblot images were helpful to bring out high level of frustration, interpersonal conflict, sexual preoccupation, and body image issues which supported the client's report and aided the process of psychotherapeutic intervention. 

The Case:

The client is a 24-year-old male, working as a software developer and currently single. He was referred for the main complaints of guilt associated to child pornography surfing, porn dependence to fall asleep, depressive features and low self-esteem. He has undergone 16 sessions of psychotherapy so far and he is feeling better. 

He reported having viewed child porn consciously i.e., out of will a few times and was feeling severe guilt for doing the same. The client watches porn daily at night before sleeping. On probing, the client reported that he is not attracted to underage children but, has built tolerance towards regular porn videos and hence was searching for something new, unusual, and more stimulating. The client also reported having low self-esteem and severe issues regarding his appearance, especially his face. He strongly feels that he is “ugly”. He remembers having a difficult time during 10th to 12th grade in school, being bullied and had no friends. He reported that he could not answer back and felt extremely consumed with himself answering back to the bullies in his head.

During puberty and early adolescence, the client reported being a “pervert” - in his words. On exploration, he reports being a consumer of regular heavy porn usage and his choice of preferred video category was ‘voyeurism’. He also disclosed acting on his voyeuristic desires i.e. putting cameras in girls’ toilets in school, peeking through windows and sneakily watching his mother and aunt bathe or change clothes. He also reports groping or touching inappropriately his younger sister in her sleep. The client has had 2 sexual encounters where both were not up to his satisfaction as he didn’t achieve full erection, and it did not match the images viewed in porn. The client also reported having suicidal ideas as he felt he isn’t a good person and has done something wrong and unacceptable.

Preoccupation with sexual fantasies and curiosity to explore them is common and natural during adolescence and young adulthood. But, when that curiosity and desire begins to affect one’s self concept and interferes in one’s concentration, daily life, and productivity, then, it indicates unhealthy sexual concept. To ascertain his personality and unconscious motives, a projective personality tool - Somatic Inkblot Test (online version, Dubey et al, 2019) was administered and the responses were analyzed using content analysis and psychoanalytic interpretation (Cassell & Dubey, 2003).

Image 1: “I can see the earth, a kid clinging onto that earth on the left and on the right top of the earth I see a kid sitting on that earth which made me a little uncomfortable. I also can see a lady wearing one piece with big breasts resting on Earth. On the top of the earth, I see a plant with peacocks leaves as feathers.” The client’s response of “wearing one piece with big breasts resting on Earth” may indicate his sexual fantasy and sexual preoccupation with females. The “Big Breasts” may also indicate his craving for maternal affection which was confirmed by the client.

Image 2: “At first, I saw a figure of some God flying, probably with Lord Shiva's head. Also, I can see a cross where Lord Jesus was hanged. I can also see a cartoon creature called Samurai jack who is performing some kung-fu stunt. I feel a little positive after seeing this image, which is making me think that yes, I can recover somehow.” The responses of perceiving different God may indicate that the client has religious faith and is seeking spiritual support or divine help in controlling adverse situations that are being faced by him. Often people seek spiritual support to protect ego from breakdown particularly in cases of depression and maladjustment.

Image 3: “On the bottom I can see a fat lady without a head and a hat of a chef who is dancing. I can also see a guy in his night suit dancing without the head. In the middle I can see pink outlined heart. On the top I can see a key of a small toy, or I can see a bat. I don't know, this image somehow depicts that the guy or the woman is happy, but also sad dark clouds are somewhere but this heart is dominating the dark clouds.” The client’s response of “The fat lady without head” may symbolize his wishful thinking to see his mother in pain and suffering. “Key of a small toy” and “bat” might be male phallic symbols, and “sad dark clouds” represent his anxiety. Seeing headless male and female is indicative of his aggressive attitude towards his parents. The client projects aggression towards his parents for their erotic interaction which he had witnessed accidentally during childhood. 

Image 4: “On the right I can see a teddy bear. On the left I can see a guy who is overfilled with joy and playing football which reminds me of a moment in my 8th class where my exams were finished, and I was so happy, playing with my friends. This image also depicts somehow the contrast between happy and sad where the kid on the left is extrovert and happy and the kid on the right is introvert and sad.” The response may indicate his wishful thinking to enjoy like the extrovert boy in the image and feels sad to imagine his home environment. It needs further probing during therapy sessions. A joint therapy session with parents and significant family members will be of great help. 

Image 5: “The guy is dancing in a zig-zag manner or maybe doing some belly- dance. This guy is smiling, has a beard and black hair. Then I thought this is some pregnant lady who is walking with her hands out and what is inside her is the baby. It brought a thought which I had during my 4th year of college when I was into some marijuana stuff as well. On the top I see an apple. Somehow it is just coming to my mind that this apple is bait to this guy who already has a slice of pizza in his belly”. Perception of fetus may indicate intimate relationship with some female. Apple and dancing lady are normal responses to this image. 

Image 6: “At first, I can see a guy on the right and a girl on the left who are talking to each other, and these two red dots depict that they both are sharing their hearts. I don’t know this triggered a thought in my mind where I feel like my whole life would have been different if I was not ugly. Coming back to the image from one perspective it also seems like a spider with two devil eyes.” The response “I feel like my whole life would have been different if I was not ugly” indicates his sense of inferiority regarding his body image/appearance, which is leading him to avoid interaction with others and instead spend more time in viewing pornography. “Spider with two devil eyes” indicates suspicious attitude/ paranoid ideation.

Image 7: “First I saw the letter D. Then I can see a banana on the left bottom inside of that D which is supported by a hand through which an elephant’s trunk is coming out in the opposite direction. On looking closely, I don’t see a banana, I see a brinjal now. In between is red liquid. Now looking a little more closely I can see an ear where the black stuff which I was thinking as a banana now seems like dirt clinging on to the ear and the red part depicts the depth inside that ear. The orange color outside D reminds me of Multani Clay”. The banana and elephant’s trunk may represent male phallic symbol and “the depth inside that ear” may represent female genitalia symbol indicating sexual preoccupation.

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Image 8: “In between is the hand with a wired thumb. It feels like as if this image depicts some sign of a dictatorial political party, probably of Hitler. That small line dividing the palm of the hand into two seems like some scar where the left side of the scar is the mirror image of the right side. Now, I can also see as if this hand is drowning somewhere and is asking for some help. Around the hand are green leaves which I saw in a WHO or a UN sign somewhere. On looking closely into the leaves, I can see people’s heads coming out of it and that hand is asking help from these people, but nobody is helping that hand “. Hitler’s hand indicates authoritarian attitude of the father-figure with whom he appears to have disturbed interpersonal relationship. The other responses indicate the client’s feelings of helplessness. He is aware of his problems for which he is seeking help but is not getting adequate support. The kind of support that the client expects from significant others and even from the therapist must be explored during therapy sessions. 

Image 9: “As if two birds are kissing each other or fighting for food. At the bottom I can see a flowerpot in the shape of a heart with plants coming out of it which further extends with three leaves. On each side are the leaves coming out from the top above the birds. It also seems like an entrance to a wedding ceremony, where on the left half of the heart is the bride and on the right half of the heart is the groom. On the top is the decoration “. Responses indicate wishful thinking to have romantic relationships. It may also indicate conflict in relationship(s). 

Image 10: “This image feels so negative where a fierce animal with sting appears to be coming out of its back and there is a peculiar tail and a head which is eating out the skeleton and trying to reach the heart. The interior of this animal touches the skeletal structure of its ribs inside which is a faded heart. This image feels like some sort of invisible demon has captured our body and is consuming the heart.” The demon may indicate hostility, sadism, and masculine inadequacy in men. The “demon has captured our body and is consuming the heart” may further indicate feelings of helplessness and constant suffering on the part of the client.

Image 11:  “It seems like an image of a girl doing ballet. But now when I look closer, it seems that someone is lying in a bathtub of a heart shape and black blood is coming out of its head, which is spilled around the bathtub.” Denial of perceiving common response of heart in this image indicates interpersonal conflict in romantic relationships which is confirmed from his case history. He had reported how he failed to establish a satisfactory erotic relationship with the opposite gender. 

Image 12: “Two kidneys which are connected to a urinary bladder, but left kidney has extra tube connected to it. On the bottom of the urinary bladder is an outlet which maybe a penis and inside the urinary bladder is the urine collected”. The kidney is normal perception. Other responses indicate sexual preoccupation.

Image 13: “A guy is skydiving with an extra pair of legs which are intertwined with each other with a heart sticker on its costume. On the left is a cupid who is either sitting on a broom or trying to pee. On the right is a kid who is flying with a tail on its rear end. It is difficult to think what those two red dots denote. Upon thinking hard if all of these kids are flying then those two red dots seem like small buildings”. The “cupid trying to pee” indicates sexual preoccupation and release of aggression. 

Image 14: “There is a guy in suit at the bottom with his head cut. There are multiple chests on the top of each other until the mid-point where there is a big belly of some fat guy and now there are many other chests on top of each other with hands coming out at the top. This image now collectively forms a skeleton. It seems to me that legs are necessary for you to stand, and chest is necessary for you to face the world. It all constitutes a backbone.” The perception of backbone towards the end of several responses is normal perception. However, the “fat guy” may symbolize his aggression and hatred towards his classmates bullying him during school days.

Image 15: “On the first glance, it seemed like a vagina with some vaginal ring connected to the bottom and blood coming out of it. On giving it a closer look, I can see an amoeba which has eaten some fish with small legs at the bottom.”  The response “blood coming out of it” may indicate aggression towards females and sexual preoccupation.

Image 16: “It seemed like a vagina with some vaginal ring connected to the bottom and blood coming out of it. On giving it a closer look, I can see an amoeba which has eaten some fish with small legs at the bottom.” Avoiding common response of a fetus may indicate sexual preoccupation and masculine inadequacy.

Image 17: “This image made me a little aroused as what I am seeing is some sort of naked breast coming out of a saree. The abstract drawing is being made from censored nipple of the lady to her shoulder.” The response indicates his repeated sexual preoccupation and sexual fantasy for which he is getting help from his therapist.

Image 18: “There are two faces, one on the left with a side pose seeming sad and that blurriness in that brain makes me feel like that she is too overwhelmed by the feelings and feeling a little foggy mentally. And the guy on the right side has the expression of feeling dumb where he is feeling foggy because he is feeling sleepy. This blue background reminds me of introduction of Ramayana on Door darshan.” The responses indicate feelings of frustration and disturbed interpersonal relationships.

Image 19: “I see the back of the head of a guy and his mask which is purple. This is because the outside world which is the border of this image is also purple, and that mask is what he shows it to the outside world “. The responses clearly indicate his depressive feelings and frustrating interaction with others which the client finds difficult to cope with. 

Image 20: “A guy on the left is sitting on a chair and describing his emotions through his hand gestures to the lady on the right who seems to be his therapist who is noting down his emotions inside a book. And they are inside a bubble where everything that is shared is confidential”. The response indicates his faith in the therapist and at the same time he also wants an assurance of confidentiality from his therapist. Feelings of insecurity and frustration are also indicated through his responses.

Image 21: “On the left I see multiple kind of knives which are moving in a single direction. There are also some straight knives on the right. It feels like they are trying to attack the abstract figure in between. On the top right and bottom are pencil scratches drawn very hastily.” Perceiving knives thrown on abstract figure indicates uncontrolled hostility and aggression.  Pencil scratches drawn hastily also signal the presence of pent-up hostility and frustration. The response seems alarming, and the client should be treated to release his aggression. 

Image 22: “At first glance it felt like I am looking at some greeting card with a heart on it. In between the heart I can see a small mouth who is singing some love song (probably English). This image feels like someone is very happy - enjoying their day, most probably their wedding day.” The response indicates wishful thinking to have a family and desire to live happily. It’s a normal response. 

Image 23: “At first I thought it was a sperm, then a snake which is moving under a stream of water and now I see weird-shaped dick as if someone is squeezing it due to the white line on the top.” The snake which is moving under a stream of water symbolizes erotic interaction and pleasure-seeking projection. However, the “weird-shaped dick” indicates sexual insecurities and failure in establishing smooth erotic relationship, which has been reported by the client.  

Image 24: “Coronavirus” was the first thing that popped up in my head. This image is making me feel uncomfortable as it feels like an earth having the hands of octopus or some organism which we are looking at under a microscope. After giving a close look, I see blue heart in the center that is divided into four. It feels like the heart is trying to recollect some of the good things by capturing small moments which represent small green hearts. But it’s too broken inside and captured by dark thoughts around it.” The broken heart indicates frustrated/broken love affairs/relations. The broken heart inside depicts depressive features. 

Image 25: “It looks like some disinfectant spray gun that is used to kill mosquitoes. It also looks like some old-fashioned gun that has already fired some bullet, and the top of the gun has been destroyed after firing the bullet. On looking more closely, it feels like an arm of a guy has been exploded in a terror attack.” The responses indicate flared-up aggression and frustration. The similar theme was brought on image 21 too. The client needs special attention to address his pent-up aggression which seems to be very alarming. More often, such clients are referred for anger-management treatment. 

Image 26: “Either a guy is dead or is buried somewhere alive and he is letting out some heat through his body. It feels like he is lying alone on his bed, feeling there is nobody in the world who could understand him; there is no point in getting him out of this buried state and do something because it would not matter. No matter how much he tries to prove himself, the world would still judge him on his looks”. The responses clearly indicate his feelings of inferiority towards his appearance and his body-image related insecurities. The feelings of helplessness, hopelessness and depression are brought on the surface. Pent-up aggression and suicidal ideation must be addressed during therapy session.

Image 27: “The kid on the left is still inside the womb and has not been born yet. The kid on the right is unborn kids’ future spirit who is trying to give him some tips about the future. He may be telling him that it is a scary world out there but also preparing him for what is about to come. Future spirit does not want to scare him but just prepare him mentally for what is about to come.” The responses indicate regression as the safer mode of protection in life. His insecurity and challenges faced in life are also projected. It appears as if he has faith in his therapist and hopes for guidance. It further looks like a good prognostic indicator. 

Image 28: “The face of a woman with old-fashioned hair and is sad because she is being beaten by the guy at the bottom. It feels like as if the guy is trying to punch her and she is ready to take that punch.” The client’s response indicates that he has witnessed physical abuse of a female family member by a male and has closely seen the helplessness of the woman in the situation. Witnessing such violence closely also contributes into developing aggressive attitude on the part of the client. Non-perception of child with the mother in the image by the client indicates the presence of conflicts with the mother/maternal figure.

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Image 29: “A guy without a leg who is moving on a side of the street, or the guy is walking heavily, and his half part of the leg cannot be seen, also his face seems like as if he is taking heavy breaths. Also, there is a minor shadow of him at the bottom left. It feels like as if I have opened the door and this guy is standing in front of me looking dumb-faced and does not know what he wants.” The response indicates poor self-image, low self-esteem, and insecurities in life.

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Image 30: “A family portrait where all are trying to pose. Also, a scene of a wedding where kids are holding flowers, and the bride and groom are kissing. Also, it feels like parents are talking to each other and not paying attention to what their kids want. This image felt both positive and negative at the same time.” The responses indicate parental deprivation and sexual preoccupation.  

Conclusion: 

Overall, the client gave more than 50 responses indicating high productivity and average intellectual ability. The responses indicated coherent thinking and ability to meet the demands of the society. However, the protocol revealed high levels of frustration, feelings of insecurity, depressive features, pent-up hostility, and interpersonal conflicts with the opposite gender including the mother. There was also strong evidence of sexual preoccupation. He has also shown anxiety and concerns of body-image and low self-image. The above factors were causing significant distress in the client’s important areas of functioning and needed to be immediately addressed with insight-oriented psychotherapy and pharmacological intervention.

The psychotherapy is in progress with a focus on psychoeducation about healthy sexual arousal, difference between harmful use, dependence, and addiction (in terms of porn surfing) and learning the difference between sexual responses i.e. habitual/ conditioned arousal v/s natural or need-based arousal. Therapy is also focused on finding more than one way of self-pleasure and self-love. Techniques such as deep breathing, grounding exercises, yoga, meditation, cognitive distortions, and Socratic questioning were introduced to address depressive and anxiety symptoms. Extensive work was done to process emotions regarding childhood/adolescent experiences of bullying, sexual exploration, and body image. Habits such as self-compassion and emotional hygiene were introduced to the client to combat low self-image.

The client continues to be in therapy with sixteen therapy sessions completed so far. Therapy has shown a positive outcome and consistent improvement in the client’s wellbeing. Reassessment will be done after 6 months of the termination to find the changes in test responses and to ascertain complete recovery. The outcome of the same shall be reported. 

References:

Cassell, W.A. & Dubey, B.L. (2003). Interpreting Inner World Through Somatic Imagery, SIS Center, Anchorage, Alaska (USA)

Dubey, B.L., Banerjee, P. & Dubey, A. (2019). Inkblot Personality Test -Understanding the Unconscious Mind, Sage Publications Inc. New Delhi.