Efficacy of Somatic Inkblot Test (Online version) in Clinical Cases
Ankush Aneja, Anand Dubey & Bankey L. Dubey
Projective tests open a window into the inner depth of the unconscious and help in accessing the suppressed and repressed material causing undesirable behavior, unlike the Questionnaire and Rating Scale method. This suppressed and repressed material is brought to the surface in the form of responses and dreams and needs symbolic interpretation and introspection. This paper highlights the efficacy of Somatic Inkblot Test – online version (Dubey et. Al., 2019, Dubey & Dubey, 2021) in two cases: first is a case of major depressive disorder (single episode, mild severity, with anxious distress-mild severity-Code: DSM-5, 296.21), and second is a case of Somatic Symptom Disorder, having mild, predominant pain, with panic attack (Code: DSM-5, 300.82)
Case 1.
The Index Client is a 35-year-old para-medical professional, she is a college graduate, single and lives in an urban Indian joint family. Her family consists of her elder parents, a younger brother and his wife and a younger sister. She complains about insomnia, suicidal thoughts, irritability, loss of interest in professional work, night-time crying, feelings of aloofness and depressive mood. These symptoms have been ongoing for the past four to five months. She was administered the Somatic Inkblot test on September 1, 2022.
The client reports of a distressed and disturbed family environment, frequent financial arguments between her brother and mother, internal family conflict between “brother’s wife” and the rest of the family. As per the client, her tension and stress got compounded by the loss of her older sister and confidante to a medical illness. The client also reported the failure of a nine-year romantic and physical relationship with a male co-worker. The client had hidden this relationship from her family and chose to reveal it to her younger sister after the breakup. Her sister chose to share this secret with her parents even though the client had requested privacy in the matter. The client's family, though upset with her decisions nonetheless provided her with emotional support and encouragement to help her move on and address her mental health issues. The client reports feeling fine till April 2022.
The client started feeling sad all day and stopped taking care of herself and was no longer interested in routine home chores. She even stopped spending time with her 3-year-old nephew who was very close to her. She also reported loss of appetite even to the food of her choice. She has lost about 3 Kilogram since then. She stopped visiting her workplace in June 2022 and was advised to start work or resign. She started keeping distance from her colleagues and friends even on social media because she was feeling irritated, annoyed, tense, and restless even on petty things. Finally, she lost her job. She has joined another hospital and has been working since August 2022.
In the month of July, she started feeling discomfort in lower abdomen and fear of having pain from an Ovarian Cyst for which she consulted a Gynecologist. After investigation, the Doctor diagnosed it as a case of “hydrosalpinx” and advised that it may affect her pregnancy in future if remain untreated. She has not reported any injury, serious illness, seizures, use and abuse of substance. She has not reported suspicion and any kind of hallucination.
Provisional Diagnosis: Major depressive disorder, single episode, mild severity, with anxious distress-mild severity. Code: 296.21 (DSM-5)
Her responses on 30 images of online SIT are interpreted following content / psychoanalytic interpretation (Cassell & Dubey, 2003; Dubey, et al, 2019; Phillips & Smith, 1953; Schafer, 1954).
Image 1: “I see a dog”. The response indicates passive dependency with aggression.
Image 2: It looks like a “Jesus’ cross”. It may indicate innocence and denial of guilt as defense against superego conflict (Schafer, 1954). It further indicates that the person is seeking spiritual support to control the adverse situation she is facing and to save her ego from breakdown particularly in cases of depression and maladjustment.
Image 3: It looks like a “Smiling person”. It may indicate her happy mood.
Image 4: “Person wants to play with a sad teddy”. Sad teddy bear may indicate her unhappy childhood. Sad Teddy bear may represent the client herself, and her depressive childhood. Special note regarding inquiry of any traumatic experience during childhood may be further conducted during therapy sessions.
Image 5: I see “A Lady dancing and an Apple”. Both responses are the most common perceptions and indicate
her happy mood.
Image 6: Her response on this image was “A boy likes a girl, and the girl does not like the boy”. It may indicate a conflicting relationship between a male and a female. It looks like her own projection of a conflicting relationship with her male partner.
Image 7: I see a “Fetus”. Normally people see an ear on this image and the “fetus” may indicate her anxiety and
fear of pregnancy.
Image 8: Looks like “A hand is coming out after breaking the ice. Also there looks like many small pigs”. It indicates her suffering and her efforts to escape from this suffering. Many small pigs may indicate her timidity, dependency, passive-receptive attitude, rejection of adult role and sign of fertility.
Image 9: She saw “Two happy penguins”. It indicates her wishful thinking to have a happy life with her friend which looks far away from the present reality.
Image 10: I see a “A lady's body with a broken heart”. Heart is a natural symbol of Interpersonal relationship;
however, broken heart indicates broken love relations, which is confirmed from her case history.
Image 11. Looks like “Lizard's mouth on the top and a dog”. Image of lizard and dogs indicates a conflicting relationship, it might be about her own love relationship. Mouth of Lizard may indicate male phallic symbol and libidinal conflict (Schafer, 1954).
Image 12: “Two ovaries with blocked urethra”. This response may indicate a kind of fear that the fallopian tube is blocked to control pregnancy. This could also indicate her fear of blocked urethra, after using fertility pills to control pregnancy, which she shared during inquiry.
Image 13: “A happy God gives his love and blessings to his male and female children”. This may indicate
seeking spiritual help to resolve her issues.
Image 14: Looks like a “spinal column”, is a normal response.
Image 15: “Female phallic organ” may indicate healthy body imagery.
Image 16: It looks like “Two babies in the womb and blessing to each other”. It indicates her wishful thinking
to get blessings to have a good interpersonal relationship with her boyfriend.
Image 17: “A half-naked breast”. It indicates active phallic content and her involvement and fantasy in erotic
relationship.
Image 18: “Two young people talking against each other”. It may indicate their conflict and disturbed interpersonal relationship particularly with her boyfriend. A couple/male and female talking is the common response in this image.
Efficacy of SIT in Clinical Cases: 33
Image 19: “A lady loves her child”. It indicates a smooth interpersonal relationship with her mother and a kind of tension with father or father figure. Normally people perceive a father in this image, which she has avoided; this may indicate her poor relationship with father. This could also be due to the poor relationship with her boyfriend.
Image 20: “A couple chatting”. It may indicate her wishful thinking, to have a good interpersonal relationship
with her friend.
Image 21: Looks “Too many sharp objects”. This may indicate her passive aggression.
Image 22: I see “A lovely heart which diminishes his color and shape”. It Indicates her frustration and anxiety in her relationship.
Image 23: “A penis inserted in some lake full of waves”. It may indicate her fantasy and active erotic
involvement.
Image 24: It looks like “Heart within ovum which is broken and too much sperm wants to enter in that heart. The responses may indicate active erotic involvement and a desire to become mother. The broken heart clearly indicates a broken love relationship.
Image 25: It looks like “A gun with defective head”. This may indicate her passive aggressiveness and withdrawal from the situation. She might not be in a position to express her aggression towards her boyfriend.
Image 26: “A dead man's soul is coming out”. It is a normal response in this image.
Image 27: “A child talking with an unborn child”. It may indicate a kind of regression where she feels she was much better and secure while in the mother’s womb.
Image 28: It looks like “A lady loves her child”. It’s a normal response indicating a loving relationship with her
mother.
Image 29: “A man who has lost half of his leg and is still running”. This may indicate her ego strength to save her from breakdown after such odd happenings. It is also a sign of good prognosis. Psychotherapy works better with such clients.
Image 30: Looks like “A happy couple kisses each other with their two children” It may indicate her memory of a happy childhood with her parents.
Indices based Quantitative Analysis:
The Indices’ based interpretation is more like counting the number and percentage of responses and their ratios. The high and low percentages have been interpreted ahead:
Her total number of responses (R= 46) indicates high productivity and functioning intelligence. The high percentage of Human responses (H= 17, 36.96%) may indicate her smooth interpersonal relationship with other people. It is also an indicator of high self-esteem and good interpersonal skills. High percentage of Human responses are observed in team-makers and normal subjects. The moderate number of Most typical responses (MT= 12) further supports the contention of high Human percentage and indicates coherent, logical thinking and an ability to keep up with the demands of society. The person with 12 MT responses may agree with others after little persuasion and can change their opinion easily. They also show good adjustment in most of the situations. Very low percentage of Animal responses (A= 5, 10.87%) may indicate withdrawal from the surroundings, aloofness, loneliness, and isolated outlook towards life. Such people may behave in an egocentric manner and invite tension. Often such persons may exhibit frustration and suppressed aggression. The Anatomical responses (At = 11, 23.91%) are slightly more than average range but normal for the persons belonging to the discipline of physiology / medical sciences. The Typical responses: 17 (36.95%) are in normal range. The high Movement responses (M= 18, 39.13%) supports the contention of high Human responses and indicates her active involvement and creativity. The percentage of Sex response (Sex= 3, 6.52%) Hostility Aggression (HAS=0), Depression (D= 3), and Paranoia (P=0), are within normal range. Other indices are found within normal range.
The qualitative / Psychoanalytic interpretation:
The qualitative/psychoanalytic interpretation gives emphasis on projection, symbolism, and content analysis. Overall, the responses given by the client indicate the presence of good Interpersonal relationship with her mother (Image 19/28). Her responses on Image 3/5/15/29 indicate her healthy body imagery. She is happy with her body imagery and able to protect herself and her ego strength. She has a desire to keep a happy life and it is a sign of good prognosis. Her responses on Image 2/8/13 indicates that she is seeking spiritual support to control the adverse situation and resolve issues which she is facing presently. Her spiritual bent saves her ego from breakdown. Small pigs indicated her timidity and her weakness to face reality. She has projected suppressed aggression towards someone (Images 1/21/25), perhaps her boyfriend, which must be addressed during therapy sessions. Her response on Image 4 indicates that the projection of the sad teddy bear is her own perception of depressive childhood. It seems pertinent to inquire any traumatic experience if she can recollect during childhood particularly before the age six years during the therapy sessions. Her responses on Image 6/10/11//24 indicate a conflicting relationship between her and her partner/friend. Perceiving the heart is a natural symbol of good Interpersonal relationship, however, a broken heart indicates broken love relations or a kind of frustration which she has shared while talking about the broken relationship with her boyfriend. The responses also projected active erotic involvement and a desire to become mother. Her response on Image 12 indicates a kind of fear that the fallopian tube is blocked. This might be because of the use of fertility pills to control pregnancy, which she has shared during inquiry. Her responses on image 15/17/23 may indicate her active involvement and fantasy in sexual relationship. Her responses on Image 9/16/30 are indicative of her wishful thinking to have a happy life and happy family. She also feels neglected by her father. The Somatic Inkblot images brought on surface her frustration, suppressed aggression, erotic conflict, and depressive contents. Her spiritual bent and positive look towards life is a positive sign of good prognosis.
Case 2:
The Client is a 16-year-old female, unmarried, studying in 11th standard, belonging to urban family of middle socio-economic status, referred by her treating general physician for psychological help and psychotherapy, with major complaints of pain in lower abdomen and excessive worry about the illness for the last seven months. She took an online Somatic Inkblot test on 28 January 2022.
The client reported that on 26th June 2021, she went to attend the birthday party of one of her female friends. There were two couples, her female friend with her boyfriend and another couple. They consumed alcohol and booked three separate rooms in a hotel. She was surprised to see the ex-boyfriend of her female friend (celebrating her birthday), knocking at her door. She invited him inside her room. They sat for a while and shared a cigarette, after which they came close to each other and had an intimate relationship. The client pushed him away after some time, and shouted at him, asking him to leave the room. He left the room after which she started sobbing and called her friend to drop her home. She stays with her maternal grandfather because her mother is a divorcee. On the chatting platform, the next morning, she received an apology from the boy with clarification that all that happened was because of her consent. After that she started feeling pain in her lower abdomen. She informed her mother about the incident and pain in stomach for which she advised her to meet a professional nurse who is a good friend of her mother. Next morning, she met the Nurse and shared all that happened in the night because she was afraid of getting pregnant. She was advised to take a contraceptive pill to avoid risk of pregnancy. She did not get any relief and visited another doctor who advised ultrasound and other investigations, which turned out to be normal. She could still feel pain for which the doctor started treating her for gastrointestinal problems.
She was hospitalized for two days for the treatment of stomach pain before the “Unit test examination of school”. The treating doctor advised her mother to take help from a psychiatrist because they did not find any reason for her pain.
Efficacy of SIT in Clinical Cases: 35
Provisional Diagnosis: Somatic Symptom Disorder, mild, with predominant pain, with panic attack (Code: 300.82).
Her Responses on Somatic Inkblot test have been interpreted following content / psychoanalytic interpretation:
Image 1: Looks like a “A monkey”. The response monkey symbolizes ambivalence towards domineering father, (domineering authority), antisocial personality (psychopathy), derisive attitudes and ineffectuality (Phillips & Smith, 1953). This may also project the domination of her perpetuator.
Image 2: “A boy sitting over someone’s head” may be the direct projection of domination and overpowering of the perpetuator.
Image 3: “A person dancing and a heart”, indicates her ego strength, good interpersonal relationship, and happy
mood.
Image 4: “Teddy bear”. It is a normal response, indicating her happy childhood.
Image 5: Looks like “A clever man dancing and an apple”. Instead of seeing a woman dancing, she has seen a dancing man. The clever man may represent her perpetrator who is feeling happy and enjoying. If a female is unable to perceive a dancing lady, it may indicate that the happiness from her life has gone away.
Image 6: “Two women” may indicate good interpersonal relations.
Image 7: Looks like “A mouse”. The mouse may represent “cautious interpersonal relations, lethargy, and
timidity (Schafer, 1954).
Image 8: “Hand - must be in some kind of suffering”. She wanted to share her suffering and needed help from
the therapist. This is also a sign of good prognosis.
Image 9: I see “a heart between two animals”. Two birds interacting / playing is the normal response. Persons having conflicting relationships with opposite sex often do not see birds playing/ interacting. She has projected her hatred and frustration towards the perpetuator.
Image 10: “Skeleton”. She has avoided perceiving hearts, which may indicate her frustration in a relationship.
The skeleton may also indicate somatic anxiety.
Image 11: “Dear”. She avoided perceiving “heart”; another common perception on this image may indicate frustration with depressive contents. The theme of images 9, 10, 11 is projected on this image, strongly indicating somatic anxiety.
Image 12: I see “Trees within the Lungs”. Kidney/Lungs is the most common normal response to this Image.
Seeing trees within lungs may indicate tension and anxiety.
Image 13: “A huge man in black clothes dancing with 2 children”. Huge man in black clothes symbolizes an authoritarian father. She left her father’s home after the divorce of her mother; she has no contact with her father. It may also indicate her wishful thinking of having a good relationship with her father.
Image 14: “Utensils piled up”. Rejection of spinal column may indicate physical injury to the spine or sexual
conflict. Females with sexual trauma may reject this image because it symbolizes male phallic region.
Image 15: Looks like “Fish mouth with a church sign”. The fish mouth symbolizes erotic content. Female phallic organ is the common response in this image. The Church may indicate spiritual support to resolve her conflict. It may also indicate her guilt feelings and spiritual support.
Image 16: “A baby girl who is crying”. Fetus is a common normal response. The “baby girl crying” may be the
reflection of her suffering and fear of pregnancy. This may also indicate her pensive mood.
Image 17: “Someone is trapped”. The response may indicate a feeling of being trapped and helpless. Breast is the most common normal response in this image. Rejection of breast may indicate deprivation/ conflict with her mother during childhood. Those who lost their mother during childhood, lived away from their parents, or reared by grandparents, often reject this image. A female having sexual trauma may also reject this image. She has left her father’s home and stayed with her maternal grandpas for many years.
Image 18: “A woman and a man with brains''. The brains may indicate arguments and conflict between father and mother, which the client has witnessed during her childhood.
Image 19: “Two people.” Normally people perceive father and son- a healthy response. Avoiding perceiving a father may indicate her deep-rooted conflict with her father which should be addressed during therapy sessions. Such feelings, if not addressed, may lead to hatred towards male partners in future.
Image 20: Looks like “Two people are sitting and having conversation” is a normal response. It may also
indicate her smooth relationship with others.
Image 21: I see “knives” may indicate aggression.
Image 22: “Heart” is a normal response and sign of healthy body imagery and good interpersonal relationship.
Image 23: “Water waves with a fish”. It is Freudian symbolism indicating active erotic involvement. It should
be addressed during therapy sessions.
Image 24: I see “Broken Earth with heart”. The response may indicate frustration and a broken love
relationship.
Image 25: “Gun” may indicate passive aggression.
Image 26: “A person lying down with thoughts”. Normal response Image 27: “A baby seeing his reflection” looks like a normal response.
Image 28: “A mother with baby hugging” indicates a caring mother with a very happy interpersonal relationship.
Image 29: “A sad man is kicking something” may indicate her pensive mood and aggressive behavior. This
may also indicate her revenge to punish the perpetuator.
Image 30: “Fourpeople holding each other, two adults and two small”. She failed to perceive “A family of father, mother and two children'.' The most common response in this image may indicate poor interpersonal relationships between parents and children or among close family members. The theme of conflict with the father shown on image 19 is supported by her response in this image also. This should be addressed during the therapy session.
Indices based Quantitative Analysis:
Her total number of responses are R = 40, indicating high productivity and functioning intelligence. The presence of a high percentage of Human responses 17 (42.5%) (more than 25 %) may indicate that the person can maintain a smooth interpersonal relationship with others. The low number of Animal 6 (15%) responses may restrict outlet of aggression. The Most Typical responses (MT=11) are just on the border. Such people show poor adjustment. Often, they invite conflict because they are misunderstood by others. The Anatomical responses: 6 (15%) are within normal range. The preponderance of more than 10 percent of other contents 11 (27%) may indicate anxiety. It may also be an indicator of evading reality and psychological disturbances. She has avoided perceiving male or female phallic contents which may be because of her traumatized encounter. A high number of Movement responses are associated with high fantasy, creativity, functioning intelligence, and active involvement. High M response is also correlated with an introverted personality. Her score on Depression scale (D=3) may indicate mild depressive symptoms. Other scores on PAS, HAS, Paranoia are within normal range.
Efficacy of SIT in Clinical Cases: 37
The qualitative / Psychoanalytic interpretation:
Overall, the SIT responses indicate good interpersonal relationships with mother-figure and colleagues (images 18/20/28), She has projected libidinal conflict, somatic anxiety, sexual assault, and repugnant emotion (Images 2/7/10/14/16). Poor interpersonal relationship with father, parental deprivation, family conflict or family disintegration, authoritarian parenting is reflected (Images 13/19/30). Her responses also indicate loss of happiness from life, sufferings, feeling of helplessness and sexual assault. She finds herself in a situation that she is unable to cope with and attempts to seek spiritual support (Image 5/8/15/17). She has also projected desires to have intimate relations, conflicting relationships with partner/friend, and frustration in broken love relationships (Image 9/23/24).
Conclusion:
The interpretation of indices-based analysis and content analysis does not go hand to hand. The indices could indicate basic personality of the person whereas content analysis/ psychoanalytic interpretation brought to the surface her suffering and repressed unconscious materials needed for processing during therapy sessions. Both cases are advised to undergo at least 10-15 sessions of psychotherapy. The first case has reported significant improvement after 4 sessions of psychotherapy. The second case has reported improvement after 3 sessions of psychotherapy.
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